chapter 10- gender and sexuality disorders

gender identity

psychological sense of being male or female

• for most people this is consistent with their physical or genetic sex

gender dysphoria

people who experience significant personal distress or impaired functioning as a result of conflict between their biological sex and their gender identity

• previously called gender identity disorder

gender roles

societal expectations of behaviors for men and women

features of gender dysphoria

• transgender identity (not all people have gender dysphoria)

• often begins in childhood

• bit more common in boys than girls but by adolescence it evens out

• can come in different forms

  • may end before adolescence with children becoming more accepting of either their biological sex or transgender identity

  • it may persist into adolescence or adulthood as they continue to struggle with transgender identity

  • many transgender people suffer from depression as a result from the stigma

gender confirmation surgery

• male to female surgery is more successful

• hormone treatments promote growth of secondary sex characteristics

• can reach orgasm but cannot conceive children

psychodynamic theorists perspectives of gender dysphoria

• close mother son relationships

• empty relationships with parents

• or fathers who were absent or detatched

learning theorists perspective on gender dysphoria

father absence in case of boys

biological perspecitives of gender dysphoria

• result of variations in male sex hormones acting upon the developing brain during prenatal development

• disturbance in the endocrine environment during gestation leads the brain to become differentiated with respect to gender identity in one direction while the genitals develop normally in the other direction

• we lack direct evidence of abnormal hormonal balances during prenatal development

sexual dysfunctions prevalence

• women 40-45%

• men 20-30%

lifelong vs acquired classification of sexual dysfunctions

lifelong: cases that have existed for the individuals lifetime

acquired: begin following a period of normal functioning

situation vs generalized classifications of sexual dysfunctions

situational: problems occur in some situations but not others

generalized: problems occur every time the individual engages in sexual activity

sexual dysfunctions

persistent problems with sexual interest, arousal, or response

three genral sexual dysfunctions categories

1. Disorders involving problems with sexual interest, desire, or arousal

2. disorders involving problems with orgasmic response

3. problems involving pain during sexual intercourse or penetration (in women)

when making sexual dysfunctions diagnosis clinicans must determine

• problem is not due to use of drugs or meds

• not due to medical conditions

• not due to severe relationship stress

• disorder must cause significant levels of personal distress or impairment in daily functioning

disorders of interest and arousal

• male hypoactive sexual desire disorder MHSDD

• female sexual interest/arousal disorder FSIAD

• erectile disorder ED

male hypoactive sexual desire disorder (MHSDD)

persistently have little, if any, desire for sexual activity or may lack sexual or erotic thoughts or fantasies

female sexual interest/arousal disorder (FSIAD)

experience either a lack of or a greatly reduced level of sexual interest, drive or arousal

• may have problems becoming sexually aroused, may lack feelings of sexual pleasure or excitement that normally accompany sexual arousal

• clinicians do not agree on criteria for determining the levels of sexual desire considered normal

• may weigh factors in reaching diagnosis such as lifestyle, sociocultural, quality of relationship, clients age

erictile disorder (ED)

men with persistent erectile difficulties

• may have difficulty achieving an erection or maintaining an erection to the completion of sexual activity or have erections that lack the rigidity needed to perform effectively

• occasional problems in achieving or maintaining erection are common due to factors such as fatigue, alcohol, or anxiety with anew partner

  • if he becomes worried about his sexual ability, the more likely he is to suffer from performance anxiety

orgasm disorders

• female orgasmic disorder

• delayed ejaculation

• premature ejaculation

female orgasmic disorder

type of sexual dysfunction involving persistent difficulty achieving orgasm despite adequate arousal

female orgasmic disorder diagnosis

• marked delay in reaching orgasm or an infrequency or absence or orgasm

• must be present for 6 mo or longer

• symptoms must cause a significant level of distress

• symptoms occur on all or almost all occasions of sexual activity

delayed ejaculation

persistant or recurrent delay in achieving orgasm or inability to achieve orgasm despite arousal

• formerly called male orgasmic disorder

delayed ejaculation features

• little attention in clinical literature

• most men with this problem are able to ejaculate though masturbation but have difficulty with a partner

premature ejaculation

type of sexual dysfunction involving a pattern of unwanted rapid ejaculation during sexual activity

premature ejaculation features

• involves recurrent pattern of ejaculation occurring within about one minute of vaginal penetration and before the man desires it

• perceive a lack of control over ability to delay ejaculation

• occasional experiences of rapid ejaculation is not considered abnormal → only when problem becomes persistent and causes emotional distress or relationship problems that a diagnosis is rendered

genito-pelvic pain / penetration disorder

women who experience sexual pain and/or difficulty engaging in vaginal intercourse or penetration

genito-pelvic pain / penetration disorder features

• pain cannot be explained by an underlying medical condition and is believed to have a psychological component

• some cases involve vaginismus

• condition in which muscles surrounding the vagina involuntarily contract whenever vaginal penetration is attempted, making intercourse painful

• not a medical condition, but a conditioned response in which penile contact with the woman’s genitals elicits an involuntary spasm of the vaginal musculatur

psychological perspectives of sexual dysfunctions

• physically or psychologically traumatic sexual experiences may lead to sexual contact producing anxiety

• performance anxiety

• learning skills

• Relationship problems

physically or psychologically traumatic sexual experiences may lead to sexual contact producing anxiety

• conditioned anxiety resulting from a history of sexual trauma may lead to problems with sexual arousal or achieving orgasm or may lead to pain in women during penetration

• also may experience flashbacks of abuse

• may develop other psychological problems that frequently co-occur with sexual dysfunctions especially depression and anxiety

  • emotional disorders may contribute to sexual problems in some cases or result from them in others

performance anxiety

represents an excessive concern about the ability to perform successfully

• can develop when people experience problems performing sexually and begin to doubt their abilities

• their attention is focused on how their bodies are responding to sexual stimulation, and seem more like spectators rather than participants

• plagued by disruptive thoughts

• in western cultures, there is a deeply ingrained connection between a man’s sexual performance and his sense of manhood → leads to lack of self esteem and even depression

learning skills

sexual fulfillment is based on sexual skills, and are acquired through

opportunities for new learning

• Albert Ellis points out underlying irrational beliefs and attitudes can contribute to sexual dysfunctions

  • we must have the approval at all times of everyone who is important to us

  • we must be thoroughly competent at everything we do

  • if we cannot accept the occasional disappointment of others, we may catastophize the significance of a single frustrating sexual episode

relationship problems

• can contribute to sexual dysfunctions, especially when they involve long-simmering resentments and conflicts

• other stressful life events can take a toll on sexual desire

biological perspectives of sexual dysfunctions

• low testosterone levels and disease can dampen sexual desire and reduce responsiveness

• women who have ovaries / adrenal glands removed may also have lower sexual desire

• cardiovascular problems involving blood flow can cause erectile disorder

  • ED is linked to obesity because of this

• men with diabetes mellitus also have risk of ED

• ED and delayed ejaculation may also result from multiple sclerosis

  • other forms of nerve damage can do this

• ED is associated with large waist, physical inactivity, and drinking too much alcohol (or not drinking at all) → factors link to high cholesterol

• antidepressants can also effect orgasmic response

  • some medical drugs used to treat high blood pressure and high blood cholesterol levels can interfere with erectile response

sociocultural perspectives on sexual dysfunctions

• women being told sex is a duty and not for pleasure can lead to sexual anxieties

• in many Hispanic cultures, the Marianismo stereotype which is derived from Virgin Mary, is where the ideal women “suffers in silence” as she submerges her needs and desires to those of her husband and children

• Dhat Syndrome: indan cultural belief that links the loss of semen to a draining of the man’s life energy (an irrational fear of loss of semen, can develop ED in fear about wasting precious seminal fluid

contemporary treatment of sexual dysfunctions

• most contemporary sex therapists assume that sexual dysfunctions can be treated by directly modifying a couple’s sexual interactions

• Masters and Johnson (1970) uses cognitive behavioral techniques in a brief therapy format to help individuals enhance their sexual competencies (sexual knowledge and skills) and relieve performance anxiety

low desire treatment for SD

• sex therapist help people rekindle their sexual appetites through masturbation exercises → when working with couples, therapists prescribe mutual pleasuring exercises that the couple can perform at home

• when lack of desire results from depression, the treatment focuses on treating the underlying depression

• medical treatment to treat testosterone can increase sexual interest in both men and women → have serious implications such as liver damage or prostate cancer in men

disorders of sexual arousal treatment SD

masters and johnson recommend sensate focus exercises for couples with performance anxiety → nondemanding sexual contacts and learn to pleasure each other and be pleasured by following and giving verbal instructions by guiding each other’s hands → after several sessions, direct massage of genitals is included

disorders of orgasm treatment SD

• women with orgasmic disorders most often harbor underlying beliefs that sex is dirty or sinful; they feel anxious about sex and have not learned what arouses theme

• treatment includes modification of negative attitudes towards sex

• when disorder stems from relationship, relationship is enhanced in treatment

• whether or not relationship problems are involved, masters and johnson preferred to work with the couple and first used sesate focus exercises to lessen performance anxiety, open channels of communication, and help couple acquire sexual skills

• most widely used behavioral approach for treating premature ejaculation is stop-start or stop and go technique → helps delay ejaculation

genital pain disorders treatment

• treatment usually involves medical intervention to determine and treat any underlying physical problems such as UTIs

• vaginismus may be treated with use of behavioral methods, including relaxation techniques and gradual exposure method which desensitizes vaginal musculature to penetration over the course of a few weeks by having the women insert fingers or plastic dialators

• psychotherapy is also used to help women with sexual trauma

biological treatments of sexual dysfunction

• viagra and cialis increase blood flow to help with ED

• combining viagra with psychotherapy can be more effective than medication alone

• SSRIs can help men with early ejaculation

paraphilia

unusual or atypical pattern of sexual attraction that involves sexual

arousal in response to atypical stimuli

paraphilic disorder

paraphilia must cause personal distress or impairment in important areas of daily functioning

OR

involve presently or in the past in which satisfaction of the sexual urge involves harm or risk of harm

types of paraphilias

• exhibitionism

• fetishism

• transvestism

• voyeurism

• frotteurism

exhibitionism

characterized by strong and recurrent urges, fantasies, or behaviors of exposing one’s genitals to unsuspecting individuals for the purpose of sexual arousal

• person typically seeks to surprise, shock, or sexually arouse the victim → victims are almost always women

exhibitionism features and prevelence

• victims are told to act like nothing is going on, and leave the scene

• a lot of men who engage in exhibitionistic acts do so as a means of indirectly expressing hostility towards women

• men tend to be shy, lonely, dependent, lacking in interpersonal skills and may have had difficulty interacting with women

• 4% of men and 2% of women report exposing their genitals for sexual arousal

fetishism

recurrent, powerful sexual urges, fantasies, or behaviors involving inanimate objects

• origins of fetishism can be traced to early childhood → most individuals with a rubber fetish were able to first recall a fetishistic attraction sometime between ages 4 and 10

transvestism

refers to individuals who have recurrent and powerful urges, fantasies, or behaviors in which they become sexually aroused by wearing clothing of the other sex

• most men who have this paraphilia are heterosexual

voyeurism

involves strong, and recurrent sexual urges, fantasies, or behaviors in which a person becomes sexually aroused by watching unsuspecting people, generally strangers, who are naked, disrobing, or engaged in sexual activity

frotteurism

recurrent, powerful sexual urges, fantasies, or behaviors in which a person becomes sexually aroused by rubbing against a nonconsenting person or touching a nonconsenting person

pedophilia

recurrent and powerful sexual urges, fantasies, or behaviors involving sexual activity with children

pedophilia diagnosis

person must be atleast 16 yrs olf and 5 yrs older than the child

pedophilia features

• most cases involve men

• pedophiles can be attracted to either purely children or both children and adults

  • some men limit their sexual activity to their family members, others exclusively attack outside the family

• not all pedophiles molest children and not all child molesters are pedophiles

• most of the men who are pedophiles are not creepy men who hang around school yards, but distinguished, law abiding citizens in their 30s or 40s

origin of pedophilia

• complex and varied

• some cases fit the stereotype of shy, passive, socially inept and isolated man who is threatened by relationships with adult women turn to children

• some cases, men try to recapture the excitement from sex during their adolescence with children

effects of pedo sexual abuse on children

• 8% of adult males and 20% of adult females reported some form of sexual

abuse before the age of 18

• 30% of girls and 15% of boys

• sexual abuse can inflict great psychological harm

  • may suffer from anger, anxiety, depression, eating disorders, inappropriate sexual behavior, aggressive behavior, drug abuse, suicidal behavior, PTSD, low self esteem, sexual dysfunction, and feelings of detatchment

  • memory and cognitive functioning

  • younger children sometimes react with tantrums or agressive / antisocial behavior, while older children tend to develop substance abuse problems

  • abused children may also show regressive behaviors, such as thumb sucking

Sexual Masochism

involves strong and recurrent sexual urges, fantasies, or behaviors in which a person becomes sexually aroused by being humiliated, bound, flogged, or made to suffer in other ways

sexual masochism features

• urges are either acted on or causes significant personal distress

• in some cases, some may not reach sexual gratification in the absence of pain or humiliation

• most common in men, but found in women

• some cases involve mutilating oneself, most involve with other partners who are sadistic

• hypoxyphila: type of masochism in which a person becomes sexually aroused by being deprived of oxygen

sexual sadism

invovles strong and recurrent sexual urges, fantasies, or behaviors in which a person becomes sexually aroused by inflicting physical or psychological pain, humiliation, or suffering on another person

sexual sadism features

• most people with this paraphilia involves lovers with masochistic interests or prostitutes who are paid to play the role

• small minority stalk and assault nonconsenting victims

  • sadistic rapists fall into this group → most rapists do not become sexually aroused when inflicting pain

sadomasochism

refers to a practice of mutually gratifying sexual interactions with both sadistic and masochistic acts → clincial diagnosis of sadism or masochism is not brought here unless these cause personal distress or impact a persons ability to function

psychological perspectives on paraphilic disorders

• psychodynamic: paraphilias as defenses against leftover castration anxiety from the phallic period of psychosexual development

• castration anxiety: unconscious fear that the father will retaliate by removing the penis motivates the boy to give up yearnings for his mother and identify with aggressor

  • failure to resolve conflict may lead to castration anxiety as an adult → leads men to displace his sexual arousal onto “safer” sexual activities such as sexual contact with undergarnments

learning theorists on PD

explain paraphilias in terms of conditioning and observational learning

• some object or activity becomes associated with sexual arousal, then gains the capacity to elicit sexual arousal

• orgasm in the presence of the object reinforces the erotic connection

• meaning of stimuli plays primary role

• family relationships may also play role → some men were punished by being humiliated by being dressed in girls clothing, leading to transvestism

biological perspectives on PD

• men with paraphilias have evidence of higher than average sex drives, higher frequency of fantasies, and shorter refractory period

• some professionals may apply some cases of paraphilia as hypersexual arousal disorder

• differences in brainwaves in men with paraphilias compared to those who do not → when using pedophiles, brain activity was so different professionals could identify nearly 100% of them

• John Money → love map

  • lovemap determines the types of stimuli and activities that become sexually arousing

  • in paraphilias, love map becomes distorted by early traumatic experiences

treatment of paraphilic disorders

• psychoanalysis

• CBT

  • adversive conditioning: induce negative emotional response to unacceptable stimuli or fantasies → works, but questions remain in how long lasting effects can be

  • convert sensitization: variation of aversive conditioning in which paraphilic stimuli are paired with aversive stimuli in imagination → benefits maintained for men with exhibitionism but few with pedophelia

  • social skills training

• biomed therapies

  • SSRI

  • antiandrogen drugs lower testosterone lvls