Chapter 14: Sexual and Gender Identity Disorders
• Sexual and Gender identity disorders: In DSM-IV, disorders comprising
the paraphilis, sexual dysfunctions, and gender identity disorders.
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
• According to the DSM criteria, someone who has repeatedly had sec with
young children but is not distressed or impaired cannot be diagnosed as
• 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
• 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 regular basis.
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 pedophile’s desires.
• 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
• 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 the
• 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
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
• 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
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
• 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