Chapter 14: Sexuality and Gender CYU

1. Gender Dysphoria & Treatments

Characteristics

  • DSM-5: Gender Dysphoria = distress from incongruence between assigned sex and experienced gender.

  • Not just cross-gender identification → must cause significant distress/impairment.

Treatments

  • Gender-affirmation surgery (more common M→F). Best outcomes when: stable mental health, adapted to new role ≥1 yr, realistic expectations, psychotherapy.

  • Behavioural/psychotherapy efforts: focus on support, adaptation, exploring identity; historically aimed at “altering” identity but now focus on reducing distress.

2. Paraphilias: Definitions & Etiologies

Definition: Sexual attraction to unusual objects/activities.

  • Must last ≥6 months, cause distress/impairment.

Types

  • Fetishism: arousal from inanimate objects (shoes, underwear).

  • Transvestic disorder: arousal from cross-dressing (usually heterosexual men).

  • Pedophilia: sexual gratification with prepubescent children; offender ≥16 & ≥5 yrs older than child.

  • Incest: sexual relations between close relatives; most common father–daughter or sibling.

  • Voyeurism: arousal from watching unsuspecting others undress/have sex.

  • Exhibitionism: exposing genitals to strangers.

  • Frotteurism: touching/groping unsuspecting people.

  • Sexual sadism: arousal from inflicting pain/humiliation.

  • Sexual masochism: arousal from receiving pain/humiliation.

  • Other specified: necrophilia, zoophilia, coprophilia, etc.

Etiologies

  • Psychodynamic: unconscious conflicts, fixation at pre-genital stages.

  • Behavioural/cognitive: childhood abuse, poor social skills, distorted thinking.

  • Biological: androgen levels, prenatal hormone disturbances, altered brain activity (frontal/temporal regions).

3. Treatments for Paraphilias

  • Behavioural: orgasmic reorientation (shift arousal to appropriate stimuli).

  • Cognitive: challenge cognitive distortions, empathy training, relapse prevention (like substance use).

  • Biological: anti-androgen drugs (to reduce sex drive).

  • Most promising = CBT-based approaches + relapse prevention.

4. Impact of Incest, Pedophilia, & Rape

On Victims

  • Effects: anxiety, depression, low self-esteem, conduct disorder, PTSD, suicide attempts.

  • High prevalence: ~27% girls, 5% boys report CSA.

On Rapists

  • Rapists: high hostility to women, low empathy, low self-esteem, poor social skills.

  • Recidivism predicted by psychopathy + past sexual deviance.

Treatments

  • Victims: rape crisis centres, hotlines, CBT, trauma-focused therapy.

  • Rapists: cognitive restructuring, empathy training, group therapy, sometimes biological treatments.

5. Sexual Dysfunctions: Four Categories

  1. Sexual Desire Disorders

    • Hypoactive desire (low fantasies/urges).

    • Sexual aversion disorder (rare, not in DSM-5).

  2. Sexual Arousal Disorders

    • Female arousal disorder (20%).

    • Male erectile disorder (3–9%).

    • Hypersexuality (“sex addiction”) not DSM-5.

  3. Orgasmic Disorders

    • Female orgasmic disorder (16–46%).

    • Male delayed ejaculation (3–8%).

    • Premature ejaculation (up to 40% men).

  4. Sexual Pain Disorders

    • Dyspareunia (pain with sex).

    • Vaginismus (spasms preventing intercourse).

6. Maintaining Variables & Historical Antecedents

  • Current maintaining variables: performance anxiety, cognitive distortions, poor communication, ongoing stress, relationship conflict.

  • Historical antecedents: early traumatic sexual experiences, strict/repressive family attitudes, negative conditioning.

7. Therapies for Sexual Dysfunctions

  • Gradual exposure: sensate focus, nonthreatening touch → builds comfort.

  • Education: anatomy, normal sexual response.

  • Anxiety reduction: directed masturbation, relaxation.

  • Couples therapy: improve communication, resolve conflict.

  • Medical procedures: PDE5 inhibitors (Viagra), hormone therapy, surgical options

DEFINITIONS

Term

High-Yield Definition

Accommodation

The cognitive process of modifying existing schemas to incorporate new events and new information.

Acquaintance (date) rape

Forcible sex with someone known (often on a date).

Assimilation

The cognitive process of incorporating new information and new events into existing schemas.

Child sexual abuse

Sexual abuse of children (e.g., pedophilia, incest).

Delayed ejaculation

Male difficulty reaching orgasm (fear, anxiety, etc.).

Dyspareunia

Painful/difficult intercourse (infection, injury).

Exhibitionism

Sexual arousal from exposing genitals to strangers.

Fear of performance

Anxiety about sexual behaviour → dysfunction.

Female orgasmic disorder

Delay/absence of orgasm despite adequate stimulation.

Female sexual interest/arousal disorder

Inability to maintain arousal/lubrication or enjoy sex.

Fetishism

Sexual arousal from inanimate objects.

Forced rape

Sexual activity forced on another; includes statutory rape.

Frotteurism

Sexual arousal from rubbing against unsuspecting people.

Gender dysphoria

Distress from mismatch between sex & gender identity.

Gender identity disorder

Old DSM term; dropped to reduce stigma.

Hypersexual disorder

Compulsive sexual behaviour (“sex addiction”); not DSM-5.

Hypoactive sexual desire disorder

Low/absent sexual fantasies and urges.

Incest

Sexual relations between close relatives (father–daughter, siblings).

Male erectile disorder

Persistent inability to attain/maintain erection.

Medical forensic exam

Collecting evidence after alleged sexual assault.

Orgasmic reorientation

Behaviour therapy to redirect arousal to normal stimuli.

Paraphilias

Sexual attraction to unusual objects/activities.

Pedophilia

Sexual urges toward prepubescent children.

Premature ejaculation

Ejaculation too quickly for mutual satisfaction.

Sensate focus

Masters & Johnson: non-intercourse touch to reduce anxiety.

Sensory-awareness procedures

Focus on sensations/feelings to enhance experience.

Sex-reassignment surgery

Surgery to align anatomy with gender identity.

Sexual aversion disorder

Avoidance of nearly all genital contact.

Sexual dysfunctions

Inhibited phases of normal sexual response cycle.

Sexual masochism

Sexual arousal from receiving pain/humiliation.

Sexual sadism

Sexual arousal from inflicting pain/humiliation.

Sexual value system

Individual’s beliefs about acceptable sexual activities.

Spectator role

Over-focusing on performance → blocks natural response.

Statutory rape

Sex with minor below legal age of consent.

Transsexualism

Strong belief in being opposite sex; transition desired.

Transvestic disorder

Sexual arousal from cross-dressing with distress/impairment.

Vaginismus

Involuntary vaginal spasms preventing penetration.

Voyeurism

Arousal from watching others undress/have sex (non-consenting).

CASE STUDIES / STUDENT PERSPECTIVES / HISTORY

Case / Topic

High-Yield Takeaways

Peeping William (Voyeurism case)

Lonely, timid, insecure man; early voyeuristic fantasies (sister); stress + alcohol worsened urges; arrest after peeping; behaviour = irrational/self-destructive → classic voyeurism pattern.

Joan/John (David Reimer)

Penis destroyed at birth → reassigned female (Joan) by John Money; raised as girl but showed male behaviours; rejected estrogen/surgery at 14; reverted to male (John). Shows strong biological influence on gender identity. Later suicide.

Canadian Reassignment Case (Bradley et al.)

Boy reassigned female after burn injury; still identified as female as adult, though with masculine traits/bisexuality. Suggests biology + environment interact, but outcome not always like Joan/John.

Child Sexual Abuse (CSA) – Police Data

62% victims <18; 30% <12; mostly female victims by known perpetrators (friends, family). Boys = 31% of victims <12. Pedophilia & incest = CSA. Mandatory reporting in Canada.

CSA Prevalence in Students

19% women, 9% men reported CSA (Finkelhor 1979). Meta-analysis: ~20% women, ~8% men before 18. Global prevalence: 127/1000; girls 2.5× more likely. CSA linked to PTSD, dropout, shame, self-blame. Resilience better with self-compassion & adaptive coping.

Neuroimaging & Sexual Disorders

Erotic stimuli activate reward system (hypothalamus, amygdala). Men > activation in thalamus/hypothalamus. Women = nonspecific genital response. Pedophiles: abnormal frontal/temporal activity, addicted-like patterns; strong brain activation to nude children → distinct neural signature.

Canadian Research – Sex Offender Recidivism

Incest offenders = lower recidivism. Rapists & exhibitionists = higher recidivism. Predictors: young, single, prior offences, antisocial traits, sexual deviance. Sexual deviance strongest predictor. Psychopathy predicts general violence more than sexual reoffense.

Established Risk Factors (Hanson & Yates 2013)

Sexual deviance (preference for children, paraphilias). Lifestyle instability (delinquency, antisocial PD). Social problems (hostility to women, poor intimacy). Treatment issues (dropout, noncompliance). Young age.

Treatment Outcomes (Canada)

Mixed results; CBT + hormonal/medical effective, non-behavioural ineffective. Meta-analysis: untreated recidivism 17.5% vs. treated 11.1%. Psychopathic offenders may misuse therapy → caution.