Sexual and Gender Identity

What is “Normal” Sexual Behavior?  Three categories:

 Sexual dysfunctions:  Problems in normal sexual response cycle that affects sexual interest, arousal, and response

 Gender-identity issues:  Incongruity or conflict between one’s anatomical sex and one’s psychological feeling of being male or female  Controversial regarding whether “gender dysphoria” should be considered mental health problem (Note: I do not consider it is – the problem is in society)

 Paraphilic conditions/disorders:  Sexual urges and fantasies about situations, objects, or people that cause significant distress to self or others

What is “Normal” Sexual Behavior?

 Difficult to distinguish between “abnormal” behavior and non-harmful variations reflecting personal values and preferences that are different from social norms

 Definitions vary widely and influenced by both moral and legal judgments

 Difficult when comparing across cultures or across social contexts and time periods

Study of human sexuality:

• Freud made discussion of sexual topics more acceptable by incorporating sex (libido) as important part of his theory

• Contemporary understanding of human sexual physiology, practices, and customs:

 Research work of Alfred Kinsey, William Masters and Virginia Johnson, and The Janus Report  Although controversial, these studies dispelled myths and provided clearer evidence on human sexuality

Sexual response cycle (four stages):

• Appetitive phase

• Arousal phase

• Orgasm phase

• Resolution phase

What is Appetitive phase:

 Characterized by person’s interest in sexual activity

What is Arousal phase:

 May follow or precede appetitive phase

 Heightened when specific and direct sexual stimulation occurs

 Various physical changes occur (e.g., heart rate, blood pressure, and respiration increase)

What is orgasm phase?

 Characterized by involuntary muscular contractions throughout body and eventual release of sexual tension

What is Resolution phase?

 Characterized by relaxation of body after orgasm

 Heart rate, blood pressure, and respiration return to normal

Sexual Dysfunctions

• Disruption of any part of normal sexual response cycle that affects sexual interest, arousal, and/or response

   To be diagnosed, condition must be recurrent and persistent

   DSM-5 requires presence of symptoms at least 6 months and should consider:

  • Frequency, chronicity, subjective distress, and effect on other areas of functioning

     DSM-5 diagnosis for sexual dysfunction is NOT appropriate when relationship problems, mental disorders, or significant stressors play a role

     Dysfunctions can be lifelong, acquired, generalized, or situational

Sexual Interest/Arousal Disorders

 Problems related to appetitive and arousal phases

 Characterized by lack of sexual interest/arousal over prolonged period of time

 Male hypoactive sexual desire disorder

• Little or no interest in sexual activities

 Female sexual interest/arousal disorder

• Little or no interest, or diminished arousal to sexual cues

 40-50% of sexual difficulties involve deficits in interest

The types of Sexual Interest/Arousal Disorders

Erectile disorder:

• Inability to attain or maintain erection sufficient for sexual intercourse 3 and/or psychological arousal during sexual activity

• Distinguishing between biological and psychological causes has been difficult

• Primary erectile dysfunction: Individual has never been able to successfully have intercourse

• SECONDARY erectile dysfunction: Individual has had at least one successful instance of intercourse

What are the types of Orgasmic Disorders?

Female orgasmic disorder:

Delayed ejaculation

Premature ejaculation

Genito-pelvic pain/penetration disorder: Dyspareunia/Vaginismus

Female orgasmic disorder is?

 Persistent delay or inability to achieve orgasm despite receiving stimulation adequate in focus, intensity, and duration after entering the excitement phase

Delayed ejaculation is?

Persistent delay or inability to achieve orgasm after excitement phase has been reached and sexual activity adequate in focus, intensity, and duration

Premature ejaculation is?

 Distressing and recurrent pattern of having orgasm with minimal sexual stimulation before, during, or shortly after penetration

 Most common sexual dysfunction in men (21-33%)

Genito-pelvic pain/penetration disorder is?

Involves physical pain or discomfort associated with intercourse/penetration

 Dyspareunia:  Recurrent or persistent pain in pelvic region during intercourse

 Vaginismus:  Involuntary spasm of outer third of vaginal wall – prevents or interferes with sexual intercourse

Aging, Sexual Activity, and Sexual Dysfunctions

 Aging is a significant predictor of changing sexual functioning

 Physiological aspects are evident in the neural, endocrinological adjustments related to aging process and relationship changes

Research findings of over 3,000 57–85-year-olds:

 Sexual activity declines with age

 Women far more likely to report less sexual activity at all ages 4

 Among sexually active people, 50% report at least one bothersome sex problem

• Most frequent problems in women:

  • Low sexual interest/desire, problems with lubrication, inability to climax

• Most frequent problems in men:

  • Erectile difficulties

Effects of aging on sexuality:

 Estrogen levels drop in women

 Prostate problems increase in men

Aging, Sexual Activity, and Sexual Dysfunctions

 Increased risk for illnesses as people age that can affect sexual performance and interest

 Medical procedures can help minimize effects of organically based problems

AARP survey:

 Relationships more important than sex

 Sexual activity affected by “partner gap”

 Despite health-related declines in sexual activity, 64% of men and 68% of women with sexual partners are satisfied with their sex lives

The Janus Report:

 Sexual activity of people ages 65 and older declined little from that of 30- and 40-year-olds

 Ability to reach orgasm and have sex diminished little

 Unchanged desire to continue relatively active sex life

Multipath of sexual Dysfunctions Biological

• Biological dimension:

 Levels of testosterone (low) or estrogens (high) linked to lower sexual interest in men and women, and erectile difficulties in men

 Medications used to treat medical conditions affect sex drive

 Alcohol as leading cause of disorders

 Illnesses and other physiological factors 5

 Amount of blood flow into genital area

Multipath of sexual Dysfunctions Psychological

• Psychological dimension:

 Predisposing or historical factors

 Current problems and concerns

 Presence of anxiety disorders

 Performance anxiety and spectator role

 Role of early sexual experiences

 Situational or emotional anxiety for women

 Negative thoughts and dysfunctional beliefs

Multipath of sexual Dysfunctions Social/ Socicultural

• Social dimension:

 Social upbringing and current relationships

 Strict religious upbringing

 Traumatic sexual experiences

 Relationship issues often forefront of sexual disorders

• Sociocultural dimension:

 Sexual behavior and functioning influenced by gender, age, cultural scripts, education level, country of origin

 For example, women:

• Are capable of multiple orgasms

• Entertain different sexual fantasies

• Have a broader arousal pattern to sexual stimuli

• Are more attuned to relationships in sex encounter

• Take longer than men to become aroused

 Gender role expectations

 Homophobia/transphobia affecting sexual issues among LGBTQ+ individuals

Treatment of Sexual Dysfunctions Biological/ Non medical

Biological interventions:

 Hormone replacement

 Special medications or mechanical means

• Vacuum pumps, suppositories, penile implants

 For ED, injecting medication into penis

 Oral medications (Viagra, Levitra, Cialis) are alternative to injection therapy

Specific nonmedical treatments: 6

 Female orgasmic dysfunction:

• Masturbation most effective for women

 Early ejaculation:

• Petting and stopping

• “Squeeze Technique”

 Vaginismus:

• Training vaginal muscles

Treatment of Sexual Dysfunctions Psychological

Psychological treatment approaches:

 Include following components:

 Education

• Replace myths and misconceptions with facts

 Anxiety reduction

• Desensitization or graded approaches

 Structured behavioral exercises

• Tasks that gradually increase amount of sexual interaction

 Communication training

• Teach appropriate ways of communicating sexual wishes and strategies for resolving conflicts

Gender Identity Issues

“Gender dysphoria”:

 “Incongruence” between a person’s anatomical sex and her/his/their gender identity, or self-identification as male or female

 Not the same as sexual orientation

• Transgender individuals can be gay, straight, bisexual, or asexual

 Individuals experience strong and persistent gender “incongruence” from early age

 NOTE: I do not consider gender identity-related “disorders” as clinical or mental health disorders. Instead, the “disorder” is located within societal intolerance and inflexibility regarding gender roles and identities (transphobia).

Paraphilic Disorders

 Sexual disorders lasting at least six months:

 During which person has either acted on, or is severely distressed by, recurrent urges or fantasies involving:

• Nonhuman objects

• Nonconsenting others

• Real or simulated suffering or humiliation

 Diagnosed only when paraphilia harms, or risks harming others and is acted on

 Can have multiple paraphilic disorders

 More common in men than women

Paraphilic Disorders Involving Nonhuman Objects is?

 Fetishistic “disorder”:

• Extremely strong sexual attraction/arousal and fantasies involving inanimate objects (e.g., shoes or undergarments) (Note: I do not consider this condition a clinical problem unless it poses harm to others)

• Must cause significant distress to self and/or others

• Most common in men

• Rare among women

 Transvestic “disorder”:

• Intense sexual arousal obtained through cross-dressing (Note: I do not consider cross-dressing a clinical problem)

• Most individuals who “cross-dress” are exclusively heterosexual

• Prevalence higher among men than women (although cross-dressing among women are more accepted by society)

Paraphilic Disorders Involving Nonconsenting Persons is?

 Exhibitionistic disorder:

• Urges, acts, or fantasies of exposing one’s genitals to strangers, intent to shock

 Voyeuristic disorder:

• Urges, acts, or fantasies involving observation of an unsuspecting person disrobing or engaging in sexual activity

 Frotteuristic disorder:

• Recurrent/intense sexual urges, acts, or fantasies of touching or rubbing against a nonconsenting person

 Pedophilic disorder:

 Adult obtains erotic gratification through urges, acts, or fantasies involving sexual contact with a child (generally under age 13)

 Diagnosis requires that individual be at least 16 years old & at least 5 years older than victim

 Most people who act on pedophilic urges are friends, relatives, or acquaintances of their victims

 Effects of sexual abuse can be lifelong; physical symptoms of victims:

• Urinary tract infections, poor appetite, headaches

 Incest considered a form of pedophilia:

• Sexual contact between people too closely related to marry legally

• Nearly universally taboo in society

• Victims often feel guilty and powerless

  • High rates of drug abuse

  • Sexual dysfunction

  • Mental health problems

Paraphilic Disorders Involving Pain or Humiliation

 Sexual sadism disorder:

• Sexual urges, fantasies, or acts associated with inflicting physical or psychological suffering on others

 Sexual masochism disorder:

• Sexual urges, fantasies, or acts associated with being humiliated, bound, or made to suffer

Most sadomasochists engage is what?

both submissive and dominant roles

 Many engage in spanking, whipping, & bondage

 Most do not seek harm or injury, but find sensation of helplessness appealing

 S&M often involves mutual consent

 Considered deviant when pain, either inflicted or received, is necessary for sexual arousal  Early life experiences may underlie some cases of S&M

Etiology and Treatment of Paraphilic Disorders Biological

Biological factors:

 Conflicting findings regarding genetic, neurohormonal, and brain anomaly explanations

 Men may be biologically predisposed to pedophilia

 Deficits in brain activation and less white matter

Treatment:

 Weakening or eliminating sexually “inappropriate” behaviors through processes such as extinction or aversive conditioning

 Acquiring or strengthening sexually “appropriate” behaviors

 Developing effective social skills

 Aversive behavior rehearsal for exhibitionism

Etiology and Treatment of Paraphilic Disorders psychuchological

Psychological factors:

 Psychodynamic theories:

• Unconscious childhood conflicts

• Castration anxiety due to unresolved Oedipus complex

What is rape?

 Sexual aggression/violence involving sexual activity (oral-genital sex, anal intercourse, vaginal intercourse) performed against a person’s will through use of force, argument, pressure, alcohol or drugs, or authority

 Even though rape is not considered mental disorder, it’s a very serious societal problem and an epidemic

 Most victims of rape know their rapist

Prevalence of rape:

 1/4 girls and 1/6 boys sexually assaulted before age 18

 1/6 women and 1/11 men raped after age 18

 Rates among lesbians and bisexual women are equal to or greater than those reported by heterosexual women

Characteristics of rapists:

 Create situations in which sexual encounters may occur

 Misinterpret friendliness as provocation and protest as insincerity

 Manipulate victims into sexual encounters with alcohol (70%) or other drugs

 Attribute failed attempts at sexual encounters to perceived negative features of targeted person  Come from environments of parental neglect or physical or sexual abuse

 Initiate coitus earlier in life than those who are not sexually aggressive

 Have more sexual partners than those who are not sexually aggressive

90% of rapists attack persons of same race/skin color

Date rape, or acquaintance rape:

Accounts for many rapes among young women 10

 Between 8-25% of female college students report having “unwanted sexual intercourse”

 Many victims reluctant to report rape

Effects of rape:

Rape trauma syndrome:

• Includes psychological distress, phobic reactions, and sexual dysfunction (consistent with PTSD)

Two phases:

 Acute phase: Disorganization

• Feelings of self-blame, fear, depression

 Long-term phase: Reorganization

• Lingering fears/phobic reactions, difficulty resuming sexual activity/enjoyment

Etiology of rape:

Power, Anger, and Sadistic rapist

 Power rapist: 55% of rapists

• Compensate for feelings of personal/sexual inadequacy by trying to intimidate victims

 Anger rapist: 40% of rapists

• Angry at women in general

 Sadistic rapist: 5% of rapists

• Derives satisfaction from inflicting pain

• May torture or mutilate victims

More facts of rape

 Rape has more to do with power, aggression, and violence than sex

 Some research findings suggest rape is partially sexually motivated:

• Most rape victims are in their teens or 20’s

• Most rapist name sexual motivation as primary reason for actions

• Many rapists have multiple paraphilias

   Media portrayals of violent sex reflect/affect societal values concerning violence against women

   “Cultural spillover” theory:

  • Rape is high in environments that encourage violence

  • U.S. has highest rape rate among countries reporting rape statistics

Treatment for rapists:

Conventional treatment:

•  Imprisonment has been main form of “treatment,” but it is really punishment as it offers little or no treatment

Behavioral treatment for sexual aggressors:

• Assess sexual preferences/measure erectile responses to different stimuli

• Reduce deviant interests through aversion therapy

• Orgasmic reconditioning/masturbation training to appropriate stimuli

• Social skills training to increase interpersonal competence

Controversial treatments:

 Surgical castration

• Used in Europe

• Low relapse rates

 Chemical therapy

•  Usually use of Depo-Provera

•  Reduces self-reports of sexual urges in pedophiles (i.e., psychological desire)

•  Does not reduce genital arousal (erectile capabilities)

Contemporary Trends & Future Direction

 DSM-5 has made “clearer” distinction between paraphilias and paraphilic disorders

• May change societal views on sexual behaviors that are not harmful to others

• Gender dysphoria may eventually be removed as psychiatric diagnosis (let’s hope this will be sooner than later)

 Sweden has removed transvestism, fetishism, and sadomasochism from list of mental illnesses