Chapter 14: Sexual and Gender Identity Disorders
• Sexual and Gender identity disorders: In DSM-IV, disorders
comprising the paraphilis, sexual dysfunctions, and gender
Gender Identity Disorder
Characteristics of Gender Identity Disorder
• People with gender identity disorder (GID), sometimes referred
to as transsexualism; feel deep within themselves, usually from
early childhood, that they are of the opposite sex. They have an
aversion to same-sex clothing and activities. The evidence of
their anatomy – normal genitals and the usual secondary sex
characteristics, such as beard growth for men and developed
breasts for women – does not persuade them that they are what
others see them to be. A man can look at himself in a mirror, see
the body of biological man, and yet personally experience that
body as belonging to a woman. He may try to pass as a member
of the opposite sex and may even want to have his body
surgically altered to bring it in line with his gender identity.
• Levine stated that the majority of GID cases are diagnosed as
GIDNOS (gender identity disorder not otherwise specified). That
is, the person has symptoms that meet much of the description
of GID, but there are some unique features that do not fit the
precise criteria of GID.
• GID in a child is usually recognized by parents when the child is
between two and four years old.
• Zucker conducted a chart review that identified several factors
associated with the decision to seek a clinical assessment. These
factors include (1) a belief that the behaviour was no longer a
phase that the child would grow out of; (2) a threshold violation
(i.e., a boy wanting to cross-dress at nursery school, not just at
home); (3) belief that the child was experiencing intense distress
about being a boy or girl; and (4) concerns about potential or
actual rejection by peers.
• Boys with GID have been rated more attractive than control
children, and girls with GID as less attractive.
Therapies For Gender Identity Disorder
• Sex-reassignment surgery is an operation in which the existing
genitalia are altered to make them more like those of the
opposite sex. The first sex-reassignment operation took place in Europe in 1930.
• In DSM-IV-TR the paraphilias are a group of disorders involving
sexual attraction to unusual objects or sexual activities that are
unusual in nature. In other words, there is a deviation (para) in
what the person is attracted to (philia)
• According to the DSM criteria, someone who has repeatedly had
sec with young children but is not distressed or impaired cannot
be diagnosed as having pedophilia.
• Fetishism involves a reliance on an inanimate object for sexual
arousal. The person with fetishism, almost always a male, has
recurrent and intense sexual urges toward non-living objects,
called fetishes, and the presence of the fetish is strongly
preferred or even necessary for sexual arousal to occur.
• When a man is sexually aroused by dressing in women’s
clothing, although he still regards himself as a man, the term
Transvestic fetishism, or transvestism, applies. The extent of
transvestism varies from wearing women’s underwear under
conventional clothing to full cross-dressing.
• The term autogynephilia was coined by Ray Blanchard at the
Clarke Instiute in Toronto to refer to a man’s tendency to
become sexually aroused at the thought or image of himself as a
woman. Blanchard noted that autogynephilia is typically, but not
always, found in association with transvestism.
• Transvestic fetish usually begins with partial cross-dressing in
childhood or adolescence. Transvestites are heterosexual, always
males, and by and large cross-dress episodically rather than on a
Pedophilia and Incest
• According to the DSM, individuals who practice pedophilia
(pedos, Greek for “child”) are adults who derive sexual
gratification through physical and often sexual contact with
prepubescent children unrelated to them. DSM-IV-TR requires
that the offender be at least 16 years old and at least five years
older than the child. • A minority of pedophiles, who might also be classified as sexual
sadists or anti-social (psychopathic) personalities, inflict serious
bodily harm on the object of their passion. These individuals,
whether psychopathic or not, are perhaps best viewed as child
rapists and are different from pedophiles in that they wish to
obtain sexual gratification.
• Incest refers to sexual relations between close relatives for
whom marriage is forbidden.
• First incest is by definition between members of the same family.
Second, incest victims tend to be older than the victims of
• The term gynephile refers to an adult who is incestuous with a
child in the absence of a mature, adult sex partner.
• Men who molest children unrelated to them are sexually aroused
by photographs of nude children. Men who molest children within
their families show more arousal to adult heterosexual cues.
• Plethysmograph measures have been described as “phallometric
tests” and they have been used to identity males-both adults
and adolescents with pedophilic interests.
• Although phallometric testing is used routinely with sex
offenders, concerns have been raised about the reliability and
validity of these measures. In particular, Marshall and Fernandez
express concern about the demonstrated ability of some people
to fake their response when being measured.
• Seto and Lalumiere developed a brief measure known as the
Screening Scale for Pedophilic Interest (SSPI) and have shown
that this screening instrument is quite successful in
distinguishing pedophilic child molesters and non-child molesters
who have abused older victims.
• A study of pedophiles by Blanchard et al. are associated with
greater interest in boys and in younger children in general.
• Child sexual abuse: Sexual abuse of children that involves direct
physical contact, such as pedophilia or incest.
• Voyeurism involves a marked preference for obtaining sexual
gratification by watching others in a state of undress or having
sexual relations. If it occurs by videotaping another person, it is
called electronic voyeurism.
• In voyeurism, there is seldom contact between the observer and
Exhibitionism • Exhibitionism is a recurrent, marked preference for obtaining
sexual gratification by exposing one’s genitals to an unwilling
stranger, sometimes a child. It typically begins in adolescence.
As with voyeurism, there is seldom an attempt to have actual
contact with the stranger. Sexual arousal comes from fantasizing
that one is exposing he or from actually doing so, and the
exhibitionist masturbates either with fantasizing or even during
the actual exposure. In most cases, there is a desire to chock or
embarrass the observer.
• Frotteurism involves the sexually oriented touching of an
unsuspecting person. The frotteur may rub his penis against a
woman’s thighs or buttocks or fondle her breasts or genitals.
These attacks typically occur in places that provide an easy
means of escape, such as a crowded bus sidewalk.
Sexual Sadism and Sexual Masochism
• A marked preference for obtaining or increasing sexual
gratification by inflicting pain or psychological suffering (such as
humiliation) on another is the key characteristic of sexual
sadism. A marked preference for obtaining or increasing sexual
gratification through subjecting oneself to pain or humiliation is
the key characteristic of sexual masochism.
• One particularly dangerous form of masochism, called
hypoxyphilia involves sexual arousal by oxygen deprivation,
which can be achieved using a noose, a plastic bag, chest
compression, or a chemical that produces a temporary decrease
in brain oxygenation by peripheral vasodilation.
• Occasionally, sadists murder and mutilate; some are sex
offenders who are imprisoned for torturing victims, mostly
strangers, and deriving sexual satisfaction from doing so.
Paraphilias Not Otherwise Specified
• As necrophilia (sex with dead people), zoophilia (bestiality),
telephone scatalogia (repeated urge to make obscene phone
calls), and coprophilia (the use of feces for sexual excitement.
• The person with a paraphilia is seen as someone who is fearful of conventional heterosexual relationships, even of heterosocial
relationships that do not involve sex.
• Castration anxiety leads the exhibitionist to reassure himself of
his masculinity by showing his manhood (genitals) to others; it
results in the sadist dominating others.
• As the overwhelming majority of people with paraphilias are
male, there has been speculation that androgen, the principal
male hormone, plays a role. Because the human fetus begins as
a female, with maleness emerging from later hormonal
influences, perhaps something can g wrong during fetal
development. Findings of hormonal differences between normal
people and people with paraphilias do not show elevated levels
of testosterone among those with paraphilia.
Therapies for the paraphilias
• As we have seen with substance abusers, sex offenders often
lack the motivation to try to change their illegal behaviour.
Undermining their motivations for treatment are such factors as
denial of the problem, minimization of the seriousness of their
problem, a belief that their victims will not be credible witnesses,
and the confidence that they can control their behaviour without
professional assistance. Some blame the victim – even a child –
for being overly seductive. Such people are frequently judged to
be inappropriate for treatment programs, for when they do
become involved, they frequently drop out. There are several
methods to enhance their motivation to commit to treatment.
1. The therapist can empathize with the offender’s reluctance to
admit that he is an offender, thereby reducing the
defensiveness and hostility.
2. The therapist can point out to the offender the treatment that
might help him control his behaviour.
3. Having elaborated on the possible benefits of treatment, the
therapist can implement a paradoxical intervention by
expressing doubt that the person is motivated to enter into or
continue in treatment, thereby challenging him to prove
wrong the therapist who has been resisting.
4. The therapist can explain that there will be a
psychophysiological assessment of the client’s sexual arousal,
the implication being that the client’s sexual proclivities can
be revealed without his admitting to them. Behavioural Techniques
• Looking to experimental psychology for ways to reduce these
attractions, researchers fixed on aversion therapy. Thus, a boot
fetish would be given shock (on the hand or feet) or an emetic (a
drug that produces nausea) when looking at a boot, a
transvestite when cross-dressing, a pedophile when gazing at a
photograph of a nude child, and so on.
• Another method is called satiation; with this method, the man
masturbates for a long time, typically after ejaculating, while
fantasizing out loud about his deviant activity.
• Orgasmic reorientation has been employed to help the client
learn to become more aroused by conventional sexual stimuli. In
this procedure, clients (again, most of whom are men) are
confronted with a conventionally arousing sti