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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