Disorders of Sex

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Disorders of Sex Gender

• Psych 251
• October 2, 2003

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dynamics of sexuality

• experiences of sex and desire are mediated by
  biology, our personal psychologies, and cultural
  values and norms
• sexual desire is often construed as unruly
• our desires may catch us by surprise, differ from
  how we think about our selves consciously
• social and psychological structures are created
  to keep unruly sex in control
• designations of disordered sexuality or gender
  may be one such form of control

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Sexual and Gender Identity Disorders listed in
the DSM-IV

• Sexual Dysfunctions--problems with desire,
  arousal, and orgasm
• Sexual Desire Disorders, Sexual Arousal
  Disorders, Orgasmic Disorders, Sexual Pain
  Disorders
• Paraphilias--problems with whom or what you are
  sexual
• Exhibitionism, Fetishism, Frotteurism,
  Pedophilia, Sexual Masochism, Sexual Sadism,
  Transvestic Fetishism
• Gender Identity Disorders--problems with your
  gendered self

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sexual values

• before 1973, the DSM listed homosexuality as a
  sexual disorder
• ones sexual desire may cause individual
  distress, but where do we locate the source of
  this distress?
• disorders we will discuss today are deemed
  pathological, in part, because of our values
  about what constitutes good and appropriate
  sexual behavior
• What are contemporary cultural attitudes about
  good and appropriate sex?

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dominant sexual values expectations

• sex is important and ought to occur
• sex should be orgasmic
• sex should be limited to involvements between 2
  adults
• not children
• not inanimate objects or parts of people
• whatever your assigned gender, you should feel
  like that gender

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Sexual Dysfunctions

• disorders in which people can not respond
  normally in key areas of sexual functioning
• typically very distressing
• make it difficult or impossible to enjoy sexual
  intercourse
• often lead to sexual frustration, guilt, loss of
  self-esteem, and interpersonal problems
• quite common as many as 31 of men and 43 of
  women suffer from such a dysfunction during their
  lives

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common male sexual dysfunction

• male erectile disorder
• definition failure to attain or maintain an
  adequate erection
• frequency 10 of men increases to 15 at age
  60 1/2 of all men experience some erectile
  difficulty at least some of the time
• treatment focus on reducing the mans
  performance anxiety, increasing his stimulation,
  or both

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male erectile disorder

• treatment techniques
• sensate focus exercises--partners focus on the
  sexual pleasure that can be achieved by exploring
  and caressing each others bodies, without
  demands to have intercourse or reach orgasm
• tease technique--partner caresses, but if man
  gets an erection, partner stops caressing him
  until he loses it (reduces pressure to perform)
• Viagra--biological approach increases blood flow
  to penis

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common female sexual dysfunction

• female orgasmic disorder
• definition inability to achieve orgasm despite
  adequate stimulation
• frequency 25 of women suffer from 10 or more
  of women today have never had an orgasm (either
  alone or during intercourse) another 10 rarely
  have orgasm
• half of all women experience orgasm in
  intercourse at least fairly regularly

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treatment techniques

• directed masturbation training
• a woman is taught step-by-step how to masturbate
  effectively and eventually to reach orgasm during
  sexual interactions
• highly effective over 90 of women learn to have
  an orgasm during masturbation about 80 during
  caressing by their partners about 30 during
  intercourse
• hormone therapy also being used increasingly

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theoretical perspectives sexual dysfunctions

• psychodynamic
• tend to explain through the presence of
  unresolved sexual issues from childhood
• will understand manifest problem as representing
  a solution or an attempt to cope with earlier
  difficulty
• ex male erectile disorder as cure for guilt
• focus on meanings of sexuality for person
• particularly unconscious meanings for example,
  conflicts about intimacy, merger or boundary
  issues

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cognitive behavioral models

• cognitive
• focus on the self-talk accompanying sexual
  dysfunction
• therapist might help patients examine and change
  beliefs about sexuality that are interfering with
  sexual arousal and pleasure
• behavioral
• sexual problems as learned through accidental
  pairings or patterns of reinforcement
• treatment such as pause procedure (for
  premature ejaculation) creates new associations

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medical views

• assumption of physiological incapacity unless
  proven otherwise
• health, age, medications, hormones, etc. may all
  influence sexual desire and arousal
• ex drop in testosterone can affect sex drive in
  both men and women shifts in estrogen during
  menstrual cycle can cause fluctuations
• medical assessment will look for possible
  contributing factors such as hormonal
  imbalances, vascular problems, damage to the
  nervous system, effects of medications or
  substance abuse

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evaluation biological or psychological?

• measuring sexual arousal during sleep
• during REM sleep, men typically get erections and
  women lubricate, as many as 2 to 5 times a night
• snap gauge may be used to assess whether or not
  man experienced an erection during sleep
• behavioral assessment
• global--occurs in all contexts (intercourse and
  masturbation)
• situation-specific--ex occurs with wife, but not
  mistress

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cultural milieu

• although we appear, in the media and pop culture,
  to be sexually explicit and obsessed, many people
  are quite reserved when talking about sexual
  issues
• even with sexual partners or therapists
• masculinity is often defined in phallic terms
• when men experience sexual disorders, may feel
  that manhood itself is under attack
• sexual scripts may place undue pressure on men to
  perform

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cultural milieu female desire

• desire and pleasure are often left out of our
  formal, approved discourses of sexuality--particul
  arly for girls
• sexual scripts suggest that males should take the
  lead in sexual acts, that sex is driven by and
  about male sexual desire
• sexual desire of girls and women presented as
  optional for sexual acts
• 1/4 of adolescent girls who have had sex say it
  was voluntary, but unwanted

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not talking about female desire consequences

• failure to address desire is implicitly shaming
• females may feel desire, but not know how to
  enact it
• girls not told anywhere that they might like,
  want, need, seek out, or enjoy sexual activity
• without recognition of their desire, it is
  difficult for females to become agents of their
  own desire
• taught to be objects of others desire
• becomes difficult to recognize and articulate
  what one does and does not want sexually

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Disorders of Gender Identity

• degree to which individuals challenge our gender
  categories varies
• some feel relatively comfortable within existing
  categories, others chafe within societys
  definitions and expectations but do not question
  their core gender identity
• gender identity disorders are diagnosed when
  individuals feel that they fundamentally do not
  belong in the categories they have been assigned

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GID DSM-IV diagnostic criteria

• A. A strong and persistent cross-gender
  identification.
• B. Persistent discomfort with his or her sex or
  sense of inappropriateness in the gender role of
  that sex.
• C. The disturbance is not concurrent with a
  physical intersex condition.
• D. The disturbance causes clinically significant
  distress or impairment.

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Transsexualism

• ones psychological experience of gender
  conflicts with ones biological sex
• may feel that a horrible mistake has been made
  that you were assigned the wrong sex
• experience is one that is usually psychologically
  and socially quite painful
• often experience depression and have thoughts of
  suicide
• may be preoccupied with getting rid of primary
  and secondary sexual characteristics and
  acquiring the characteristics of the other sex

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• in order to correct for this mistake,
  transsexuals may attempt to live their lives in
  accord with their internal gender
• may engage in cross-dressing
• have a sex change operation, etc.
• others may become transactivists--fighting for
  the rights of transgendered individuals and/or
  advocating for changes to our dichotomous gender
  system

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gender sexual orientation

• more common among males than females
• FTM--female to male
• MTF--male to female (men outnumber women by
  around 2 to 1)
• ideas about why this might be?
• sexual orientation
• MTF--substantial numbers are sexually attracted
  to males, females, both, or neither
• FTM--virtually all are sexually attracted to
  females, although some exceptions exist

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not to be confused with...Transvestic Fetishism

• transvestic fetishism--cross-dressing adopted as
  a means of achieving sexual arousal
• almost always a heterosexual man
• retains a clear sense of himself as a man
• excitement is about being a man wearing a womans
  clothing
• behavior may be secretive or shameful
• etiology not unusual to find examples in history
  of cross-dressing behavior being encouraged or
  rewarded during childhood

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controversy transsexualism as disease

• psychopathology?
• diagnosis from DSM-IV is necessary for insurance
  reimbursement
• experience is one that often creates
  psychological pain and difficulty
• life style?
• If I want my nose done, its a nose job. If I
  want my breasts done, its a boob job. But if I
  want my groin done, suddenly I have a mental
  disease. (Riki Ann Wilchins)

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cultural problems with gender?

• others locate the disease within our cultures
  approach to gender
• criticize the ways in which
• gender is overly emphasized
• gender roles and categories are enforced too
  rigidly
• categories of gender are falsely constructed as
  binary
• expectations of congruence between biological
  appearance of sex and gender roles is overly
  valued

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sex-reassignment surgery

• some transsexual adults change their sexual
  characteristics by means of hormone treatments
  and feel that this is sufficient
• for others, this is not enough, and they elect
  for sex-reassignment surgery
• surgery is usually preceded by
• one to two years of hormone therapy
  participation in extended counseling or
  psychotherapy taking steps in order to live life
  fully as the opposite of ones biological sex

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• approximately 1,000 sex change operations are
  performed each year in the US (top, bottom,
  and face may all be involved)
• complications
• surgery and treatment do not often lead to
  cosmetically or functionally adequate genitalia
• individuals may have
• scarring
• on-going need for medical treatment
• loss of sexual arousal
• difficulty with orgasm

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Long-Term Psychological Outcomes

• results not clear or definitive
• some studies show improvement in self-esteem
  post-surgery with people functioning well for
  years after
• other studies show
• problem outcomes longer term
• initial acceptance diminished over time
• psychiatric distress increased following loss of
  ones genitals

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Is surgery an appropriate treatment for
transsexualism?

• different positions
• humane solution giving transsexuals what they
  want
• drastic nonsolution for a largely psychological
  problem
• subjecting bodies to mutilation in order to
  conform to cultures rigid gender requirements

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Gender Identity Disorder in Childhood

• like adults, feel uncomfortable with assigned sex
  and yearn to be members of the opposite sex
• developmental course childhood pattern usually
  disappears by adolescence or adulthood
• research findings for boys
• about 3/4 of boys with GID report a homosexual or
  bisexual orientation later in development,
  without continuing GID symptoms

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• most of the remainder report later heterosexual
  orientation without continuing GID symptoms
• a small percentage of adolescents and adults
  request sex-reassignment surgery or live as
  transgenderists
• conclusion transsexual adults may have had a
  childhood gender identity disorder, but most
  children with a gender identity disorder do not
  become transsexual adults