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Chapter 10.pdf

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Psychology 2030A/B
David Vollick

Abnormal  Psychology  Chapter  10:   Sexual  Disorders  and  Gender  Identity  Disorder     Introduction   • Three  kinds  of  sexual  behaviour  meet  this  definition  of  impairment   • In  gender  identity  disorder,  a  person  experiences  psychological   dissatisfaction  with  his  or  her  biological  sex   • Sexual  dysfunction  find  it  difficult  to  function  adequately  while  having  sex   • Paraphilia,  the  relatively  new  term  for  sexual  deviation,  includes  disorders  in   which  sexual  arousal  occurs  primarily  in  the  context  of  inappropriate  objects   or  individuals     What  is  Normal?   • The  sexual  risks  taken  by  university  students,  other  young  adults,  and   adolescents  remain  alarmingly  high  despite  the  well  publicized  AIDS   epidemic  and  the  high  rates  of  other  STDs   • Three  recent  Canadian  surveys  suggest  that  about  1/3  of  adolescent  males   and  about  ¼  of  adolescents  report  two  or  more  sexual  partners  in  a  year     Gender  Differences   • Although  both  men  and  women  tend  toward  a  monogamous  pattern  of  sexual   relationships,  gender  differences  in  sexual  behaviour  do  exist,  and  some  of   them  are  quite  dramatic   • Much  higher  percentage  of  men  than  women  report  that  they  masturbate   • The  frequency  of  masturbation  was  also  greater  for  men  than  for  women   • Endorsement  of  many  types  of  sexual  fantasy  was  significantly  higher  for   men  than  women   • The  only  fantasy  endorsed  more  often  by  women  involved  dressing  in  erotic   garments   • Men  also  reported  fantasizing  more  frequently  than  women   • Casual  premarital  sex,  with  men  expressing  a  far  more  permissive  attitude   than  women  do   • An  impressive  series  of  studies  has  assessed  gender  differences  in  basic  or   core  beliefs  about  sexual  aspects  of  ourselves   • These  core  beliefs  about  sexuality  are  referred  to  as  “sexual  self-­‐schemas”   and  the  findings  echo  those  of  a  study  conducted  a  decade  earlier   • Women  tend  to  report  the  experience  of  passionate  and  romantic  feelings  as   an  integral  part  of  their  sexuality  as  well  as  an  openness  to  sexual  experience   • However,  a  substantial  number  of  women  also  hold  an  embarrassed,   conservative,  or  self-­‐conscious  schema  that  sometimes  conflicts  with  more   positive  aspects  of  their  sexual  attitudes   • Men  evidence  feelings  of  power,  independence,  and  aggression  as  part  of   their  sexuality,  in  addition  to  being  passionate,  loving,  and  open  to   experience   • Men  do  not  generally  possess  negative  core  beliefs  reflecting  self-­‐ consciousness,  embarrassment,  or  feeling  behaviorally  inhibited   • The  double  standard  has  disappeared,  in  that  women,  for  the  most  part,  no   longer  feel  constrained  by  a  stricter  and  more  conservative  social  standard  of   sexual  conduct     Cultural  Differences   • The  Sambia  in  Papu  New  Guinea  believe  semen  is  an  essential  substance  for   growth  and  development  in  young  boys  of  the  tribe   • They  also  believe  semen  is  not  produced  naturally;  that  is,  the  body  incapable   of  producing  it  spontaneously   • Therefore,  all  young  boys  in  the  tribe,  beginning  at  approximately  age  seven,   become  semen  recipients  by  engaging  exclusively  in  homosexual  oral  sex   with  teenage  boys   • Only  oral  sexual  practices  are  permitted;  masturbation  is  forbidden  and   totally  absent   • Heterosexual  relations  and  even  contact  with  the  opposite  sex  are  prohibited   until  the  boys  become  teenagers   • Munda  of  northeast  India  require  adolescents  and  children  to  live  together,   but  in  this  group  both  male  and  female  children  live  in  the  same  setting   • The  sexual  activity,  consisting  mostly  of  petting  and  mutual  masturbation,  is   all  heterosexual   • Acceptable  perceived  ages  for  both  men  and  women  were  significantly   younger  in  Sweden,  but  few  other  differences  existed,  with  one  striking   exception   • What  is  normal  sexual  behaviour  in  one  culture  is  not  necessarily  normal  in   another,  and  the  wide  range  of  sexual  expression  must  be  considered  in   diagnosing  the  presence  of  a  disorder     The  Development  of  Sexual  Orientation   • Reports  suggest  that  homosexuality  runs  in  families  and  concordance  for   homosexuality  is  more  common  among  monozygotic  twins  than  among   dizygotic  twins  or  natural  siblings   • This  finding  is  associated  with  differential  exposure  to  hormones  early  in  life,   perhaps  before  birth  and  the  actual  structure  of  the  brain  might  be  different   in  homosexuals  and  heterosexuals     • A  recent  finding  also  suggests  possible  biological  contributions  to  sexual   contribution   • Another  report  suggests  a  possible  gene  for  homosexuality  on  the  X   chromosome   • There  is  now  strong  evidence  accumulated  that  genes  do  influence  sexual   orientation,  although  specifically  which  genes  contribute  to  their  remains   unknown   • Investigators  fell  back  on  a  model  in  which  genetic  contributions  to   behavioural  traits  and  psychological  disorders  come  from  many  genes,  each   making  a  relatively  small  contribution  to  a  vulnerability   • This  generalized  biological  vulnerability  then  interacts  in  a  complex  way  with   various  environmental  conditions,  personality  traits,  and  other  contributors   to  determine  behavioural  patterns   • We  also  discussed  reciprocal  gene-­‐environment  interactions  in  which  certain   learning  experiences  and  environmental  events  may  affect  brain  structure   and  function  and  genetic  expression   • Most  theoretical  models  outlining  these  complex  interactions  for  sexual   orientation  imply  that  many  pathways  to  the  development  of  heterosexuality   or  homosexuality  may  exist  and  that  no  single  factor,  biological  or   psychological  can  predict  the  outcome   • It  is  likely  too  that  different  types  of  homosexuality  with  different  patterns  of   etiology  may  be  discovered   • Bem  proposed  that  we  inherit  a  temperament  to  behave  in  certain  ways  that   later  interacts  with  environment  factors  to  produce  sexual  orientation   • Bem  has  some  evidence  that  gay  men  and  women  feel  more  different  from   their  same  sex  peers  than  do  heterosexual  men  and  women,  but  little  direct   evidence  indicates  this  feeling,  in  turn,  determines  sexual  attraction   • What  is  important  for  our  purposes  is  that  this  theory  combines  biological   and  psychological  or  environmental  variables,  and  suggests  how  they   interact  to  form  sexual  orientation     Gender  Identity  Disorder   • The  essence  of  your  masculinity  or  feminity  is  a  deep  seated  personal  sense   called  gender  identity   • This  sense  of  the  self  as  male  ore  female  is  typically  consolidated  by  age  3-­‐4   • Gender  identity  disorder  is  present  if  a  person’s  physical  gender  is   inconsistent  with  that  person’s  sense  of  identity   • People  with  this  disorder  feel  trapped  in  a  body  of  the  wrong  sex   • Gender  identity  disorder  must  be  distinguished  from  transvestic  fetishism,  a   paraphilic  disorder  in  which  individuals,  usually  males,  are  sexually  aroused   by  wearing  articles  of  clothing  associated  with  opposite  sex   • The  primary  purpose  of  cross-­‐dressing  is  sexual  gratification   • In  the  case  of  gender  identity  disorder,  the  primary  goal  is  not  sexual  but   rather  the  desire  to  live  life  openly  in  a  manner  consistent  with  that  of  the   other  gender   • Gender  identity  disorder  must  also  be  distinguished  from  intersex   individuals,  who  are  actually  born  with  ambiguous  genitalia  associated  with   documented  hormonal  or  other  physical  abnormalities   • Finally,  gender  identity  disorder  must  be  distinguished  from  the  homosexual   arousal  patterns  of  a  male  who  sometimes  behaves  effeminately  or  a  woman   with  masculine  gestures   • Note  also  that  gender  identity  is  independent  of  sexual  arousal  patterns   • Gender  identity  disorder  is  relatively  rare   • In  some  cultures  individuals  with  mistaken  gender  identity  are  accorded  the   status  of  shaman  or  seer  and  treated  as  wisdom  figures     Causes   • Research  has  yet  to  uncover  any  specific  biological  contributions  to  gender   identity  disorder,  although  it  seems  very  likely  that  a  biological   predisposition  will  ultimately  be  discovered   • Slightly  higher  levels  of  testosterone  or  estrogen  a  certain  critical  periods  of   development  might  masculinize  a  female  fetus  or  feminize  a  male  fetus   • Variations  in  hormonal  levels  could  occur  naturally  or  because  of  medication   that  a  pregnant  mother  is  taking   • However,  scientists  have  yet  to  establish  a  link  between  prenatal  hormonal   influence  and  later  gender  identity,  although  it  is  still  possible  that  one  exists   • Structural  differences  in  the  area  of  the  brain  that  controls  male  sex   hormones  have  been  observed  in  individuals  with  male  and  female  gender   identity  disorder  with  the  result  that  the  brains  are  comparatively  more   feminine   • But  it  isn’t  clear  whether  this  is  a  cause  or  an  effect   • At  least  some  evidence  suggests  that  gender  identity  firms  up  between  18   months  and  3  years  of  age  and  is  relatively  fixed  after  that   • But  studies  suggest  that  pre-­‐existing  biological  factors  have  an  impact   • It  has  also  been  suggested  that  a  parent’s  preference  for  a  girl  or  a  boy  might   influence  how  a  child  is  raised  within  the  family  with  respect  to   encouragement  or  discouragement  of  gender-­‐stereotypic  behaviours  in  the   child   • There  is  no  evidence  that  mothers  of  boys  referred  for  gender  identity   problems  wanted  a  girl  more  than  control  mothers   • However,  there  is  evidence  that  the  maternal  wish  for  a  girl  is  greater  when   the  older  children  are  all  male  and  that  gender  dysphoria  in  feminine  male   adults  is  more  common  in  men  who  grew  up  with  several  older  brothers   • Other  factors,  such  as  excessive  attention  and  physical  contact  on  the  part  of   the  mother,  may  also  play  some  role,  as  may  lack  of  male  playmates  during   the  early  years  of  socialization   • The  most  likely  outcome  of  effeminate  behaviour  in  a  boy  in  childhood  is  the   development  of  homosexual  preferences,  but  even  this  particular  sexual   arousal  pattern  seems  to  occur  exclusively  in  only  approximately  40%  of   feminine  boys     Treatment:  Sex  Reassignment  Surgery   • At  present  the  most  common  decision  is  to  use  sex  reassignment  surgery  to   alter  the  anatomy  physically  to  be  consistent  with  the  identity   • To  qualify  for  surgery  at  a  reputable  clinic,  individuals  must  live  in  the   opposite-­‐sex  role  for  1-­‐2  years  so  they  can  be  sure  they  want  to  change  sex   • They  also  must  stable  psychologically,  financially,  and  socially   • Approximately  7%  of  sex  reassignment  cases  later  regret  surgery   • This  regret  is  unfortunate,  because  the  surgery  is  irreversible   • A  controversial  issue  in  Canada  has  been  whether  sex  reassignment  surgery   should  be  a  publically  funded  medical  procedure   • The  treatment  of  this  issue  varies  by  province  and  territory     Treatment:  Treatment  of  Intersexuality   • Surgery  and  hormonal  replacement  therapy  have  been  standard  treatment   for  many  intersex  individuals  born  with  physical  characteristics  of  both  sexes   • In  some  instances  doctors,  on  observing  anatomical  ambiguity  after  birth,   treat  it  as  an  emergency  and  immediately  perform  surgery   • Health  professionals  may  want  to  examine  very  closely  the  precise  nature  of   the  intersex  condition  and  consider  surgery  only  as  a  last  resort  –  and  only   when  they  are  quite  sure  the  particular  condition  will  lead  to  a  specific   psychological  gender  identity     Treatment:  Psychosocial  Treatment   • In  some  clinics,  therapists,  in  cooperation  with  their  clients,  attempt  to   change  gender  identity  itself  before  considering  surgery   • However,  some  individuals  request  psychosocial  treatment  before   embarking  on  a  treatment  course  leading  to  surgery,  usually  because  they   are  in  great  psychological  distress  or  because  surgery  is  immediately   unavailable   • The  issue  of  whether  gender  identity  disorder  in  children  should  be  treated   has  been  hotly  debated   • On  one  side  of  the  issue  they  express  concern  that  considering  gender   identity  disorder  in  children  a  mental  disorder  may  contribute  to  social   stigmatization  of  these  children   • On  the  other  side  of  the  argument  is  that  without  treatment,  children  with   gender  identity  disorder  are  socially  ostracized  and  that  the  condition  is   associated  with  considerable  pain  and  suffering  and  should  be  taken   seriously   • Psychosocial  treatment  at  the  Toronto  clinic  combines  the  involvement  of   parents  in  treatment,  the  discouragement  of  the  child’s  cross-­‐gender   behaviour,  and  the  promotion  of  opportunities  for  the  child  to  develop  same-­‐ sex  friendships  and  skills     Sexual  Dysfunctions:  Clinical  Descriptions   • Sexual  dysfunction  –  inability  to  become  aroused  or  reach  orgasm  seem  to  be   as  common  in  homosexual  as  in  heterosexual  relationships   • The  three  stages  of  the  sexual  response  cycle  –  desire,  arousal,  and  orgasm  –   are  associated  with  specific  sexual  dysfunctions   • In  addition,  pain  can  become  associated  with  sexual  functioning,  which  leads   to  additional  dysfunctions   • However,  two  disorder  are  specific  sex:  premature  ejaculation,  and   vaginismus   • Sexual  dysfunctions  can  be  either  lifelong  to  acquired   • Acquired  refers  to  a  disorder  that  begins  after  sexual  activity  has  been   relatively  normal   • In  addition,  disorders  can  either  be  generalized,  occurring  every  time  the   individual  attempts  sex,  or  at  certain  times,  but  not  with  other  partners  or  at   other  times   • Finally,  sexual  dysfunctions  are  further  specified  as:   1. Due  to  psychological  factors   2. Due  to  psychological  factors  combined  with  general  medical  condition   • The  human  sexual  response  cycle:   1. Desire  Phase:  sexual  urges  occur  in  response  to  sexual  cues  or   fantasies   2. Arousal  Stage:  A  subjective  sense  of  sexual  pleasure  and  physiological   signs  of  sexual  arousal   3. Plateau  Phase:  brief  period  of  time  before  orgasm   4. Orgasm  Phase   5. Resolution  Phase:  decrease  in  arousal  occurs  after  orgasm     Sexual  Desire  Disorders:  Hypoactive  Sexual  Desire  Disorder   • A  person  with  hypoactive  sexual  desire  disorder  has  little  or  no  interest  in   any  type  of  sexual  activity   • It  is  very  difficult  to  assess  low  sexual  desire,  and  a  great  deal  of  clinical   judgment  is  required   • You  might  gauge  it  by  frequency  or  sexual  activity  or  you  might  determine   whether  someone  ever  thinks  about  sex  or  has  sexual  fantasies   • Problems  of  hypoactive  sexual  desire  disorder  used  to  be  presented  as   marital  rather  than  sexual  difficulties   • In  many  clinics  it  is  the  most  frequent  presenting  complaint  of  women;  men   present  more  often  with  erectile  dysfunction   • For  men  prevalence  increases  with  age,  for  women  it  decreases  with  age   • Noted  that  patients  with  this  disorder  rarely  have  sexual  fantasies,  seldom   masturbate,  and  attempt  intercourse  once  a  month  or  less     Sexual  Desire  Disorders:  Sexual  Aversion  Disorder   • Sexual  aversion  disorder,  in  which  even  he  thought  of  sex  or  a  brief  casual   touch  may  evoke  fear,  panic,  or  disgust   • In  some  cases,  the  principal  problem  might  actually  be  panic  disorder  in   which  the  fear  or  alarm  response  is  associated  with  the  physical  sensations   of  sex   • In  other  cases,  sexual  acts  and  fantasies  may  trigger  traumatic  images  or   memories  similar  to  but  perhaps  no  as  severe  as  those  experienced  by  people   with  PTSD     Sexual  Arousal  Disorders   • Disorders  called  male  erectile  disorder  and  female  sexual  arousal  disorder   • The  problem  here  is  not  desire   • Many  individuals  with  arousal  disorders  have  frequent  sexual  urges  and   fantasies  and  a  strong  desire  to  have  sex   • Their  problem  is  in  becoming  aroused:  A  male  has  difficulty  achieving  or   maintaining  an  erection,  and  a  female  cannot  achieve  or  maintain  adequate   lubrication     • The  man  typically  feels  more  impaired  by  his  problem  than  the  woman  does   by  hers   • Inability  to  achieve  and  maintain  an  erection  makes  intercourse  difficult  or   impossible   • Women  who  are  unable  to  achieve  vaginal  lubrication,  however,  may  be  able   to  compensate  by  using  a  commercial  lubricant   • In  women,  arousal  and  lubrication  may  decrease  at  any  time  but,  as  in  men,   such  problems  tend  to  accompany  aging   • Studies  indicate  that  sexual  satisfaction  and  occasional  sexual  dysfunction   are  not  mutually  exclusive  categories   • The  prevalence  of  erectile  dysfunction  is  startlingly  high  and  increases  with   age     Orgasm  Disorders:  Inhibited  Orgasm   • An  inability  to  achieve  an  orgasm  despite  adequate  sexual  desire  and  arousal   is  commonly  seen  in  women  but  inhibited  orgasm  is  relatively  rare  in  men   • An  inability  to  reach  orgasm,  or  female  orgasmic  disorder  is  the  most   common  complaint  among  women  who  seek  therapy  for  sexual  problems   • The  problem  is  equally  present  in  different  age  groups,  and  unmarried   women  were  1.5  times  more  likely  than  married  women  to  experience   orgasm  disorder   • In  diagnosing  this  problem,  it  is  necessary  to  determine  whether  the  women   “never  or  almost  never”  reach  orgasm   • Men  seldom  seek  treatment  for  this  condition   • In  the  most  usual  pattern  ejaculation  is  delayed;  this  is  called  retarded   ejaculation   • Occasionally  men  experience  retrograde  ejaculation,  in  which  ejaculatory   fluids  travel  backward  into  the  bladder  rather  than  forward   • This  phenomenon  is  usually  due  to  the  effects  of  certain  drugs  or  a  coexisting   medical  condition  and  should  not  be  confused  with  male  orgasmic  disorder     Orgasm  Disorders:  Premature  Ejaculation   • A  far  more  common  male  orgasmic  is  premature  ejaculation,  ejaculation  that   occurs  well  before  the  man  and  his  partner  want  it  to     • The  frequency  of  premature  ejaculation  seems  to  be  quite  high   • It  is  very  difficult  to  define  “premature”.  An  adequate  length  of  time  before   ejaculation  varies  fro  individual  to  individual   • Some  survey’s  indicate  typically  climax  no  more  than  one  or  two  minutes   after  penetration,  compared  with  seven  to  ten  minutes  in  individuals  without   this  complaint   • The  work  of  Grenier  and  Byers  suggests  that  men’s  self-­‐identifying  with   premature  ejaculation  had  3  components:  a  behavioural  component,  an   emotional  component,  and  an  efficiency  component   • Although  occasional  early  ejaculation  is  perfectly  normal,  serious  an   consistent  premature  ejaculation  appears  to  occur  primarily  in   inexperienced  men  with  less  education   • Although  premature  ejaculation  is  typically  seen  in  young  men,  the  majority   of  men  consulting  physicians  about  erectile  disorder  are  between  40  and  64   years  of  age     Sexual  Pain  Disorders   • In  the  sexual  pain  disorders,  intercourse  is  associated  with  marked  pain   • For  some  men  and  women,  sexual  desire  is  present,  and  arousal  and  orgasm   are  easily  attained,  but  the  pain  of  intercourse  is  so  severe  that  sexual   behaviour  is  disrupted   • This  subtype  is  named  dyspareunia,  which,  in  its  original  Greek,  means   “unhappily  mated  as  bed-­‐fellows”   • Dyspareunia  is  diagnosed  only  if  no  medical  reasons  for  pain  can  be  found,  It   can  be  very  tricky  to  make  this  assessment   • Found  that  the  degree  of  dyspareunic  pain  in  women  is  associated  with   depressive  and  anxious  symptoms   • Research  also  suggests  that  women’s  dyspareunia  is  associated  with  marital   adjustment  problems  and  with  hostility  and  psychotic  symptoms   • In  the  commoner  vaginismus,  the  pelvic  muscles  in  the  outer  third  of  the   vagina  undergo  involuntary  spasms  when  intercourse  is  attempted   • The  spasm  reaction  of  vagimus  may  occur  during  any  attempted  penetration,   including  a  gynecological  exam  or  insertion  of  a  tampon   • Although  vaginismus  is  considered  a  sexual  pain  disorder,  the  experience  of   pain  is  not  necessary  for  the  diagnosis  in  the  DSM     Assessing  Sexual  Behaviour   • The  assessment  if  sexual  behaviour  has  three  major  aspects:   1. Interviews  –  usually  supported  by  numerous  questionnaires  because   patients  may  provide  more  information  on  paper  than  in  a  verbal   interview   2. A  through  medical  evaluation  –  to  rule  out  the  variety  of  medical   conditions  that  can  contribute  to  sexual  problems   3. Psychophysiological  assessment  –  to  measure  directly  the   physiological  aspects  of  sexual  arousal     Psychophysiological  Assessment     • Many  clinicians  assess  the  ability  of  individuals  to  become  sexually  aroused   under  a  variety  of  conditions  by  taking  psychophysiological  measurements   while  the  patient  is  either  awake  or  asleep   • In  men,  penile  erection  is  measured  directly,  using  for  example,  a  penile   strain  gauge   • As  the  penis  expands,  the  strain  gauge  picks  up  the  changes  and  records   them  on  a  polygraph   • Patients  are  often  not  aware  of  these  more  objective  measures  of  their   arousal;  their  awareness  differs  as  a  function  fo  the  type  of  problem  they   have   • Penile  rigidity  is  also  important  to  measure  in  cases  of  erectile  dysfunction,   because  large  erections  with  insufficient  rigidity  will  not  be  adequate  for   intercourse   • The  comparable  device  for  women  is  a  vaginal  photoplethysmograph  which   is  smaller  than  a  tampon,  is  inserted  by  the  woman  into  her  vagina   • A  light  source  at  the  tip  of  the  instrument  and  two  light-­‐sensitive   photoreceptors  on  the  sides  of  the  instrument  measure  the  amount  of  light   reflected  back  from  the  vaginal  walls   • The  amount  of  light  passing  through  them  decreases  with  increasing  arousal   • Because  erections  most  often  occur  during  REM  sleep  in  physically  healthy   men,  psychophysiological  measurement  of  nocturnal  penile  tumescence   (NPT)  was  in  the  past  used  frequently  to  determine  a  man’s  ability  to  obtain   normal  erectile  response   • If  he  could  attain  normal  erections  while  he  was  asleep,  the  reasoning  went,   then  the  causes  of  his  dysfunction  were  psychological   • An  inexpensive  way  to  monitor  nocturnal  erections  is  for  the  clinician  to   provide  a  simple  “snap  gauge”  that  the  patient  fastens  around  his  penis  each   night  before  he  goes  to  sleep   • If  the  snap  gauge  has  come  undone  he  has  probably  had  a  nocturnal  erection   • But  this  is  a  crude  and  often  inaccurate  screening  device  that  should  never   supplant  medical  and  psychological  evaluation   • Finally,  we  now  know  that  lack  of  NPT  could  also  be  due  to  psychological   problems,  such  as  depression,  or  to  a  variety  of  medical  difficulties  that  have   nothing  to  do  with  physiological  problems  preventing  erections     Causes  of  Sexual  Dysfunction   • Usually  a  patient  referred  to  a  sexuality  clinic  complains  of  a  wide   assortment  of  sexual  problems,  although  one  may  be  of  most  concern   • We  discuss  the  causes  of  various  sexual  dysfunctions  together,  reviewing   briefly  the  biological,  psychological,  and  social  contributions  and  specifying   casual  factors  thought  to  be  associated  exclusively
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