(11-9-05)
- Sexual Dimorphism, Gender, & Gender Identity Disorders
- Sexual Dysfunctions
- Paraphilias
- HIV/AIDS
- Sero-discordant: adj. Of a relationship involving one HIV-positive and one HIV-negative partner.
Sexual Dimorphism, Gender, & Gender Identity Disorders
(10-29-07)
- Sexual Dimorphism
- Chromosomal Sex
- Gonadal Sex
- Hormonal Sex
- Internal Morphologic Sex
- External Morphologic Sex
- Assigned Sex
- Incongruity Syndromes–physical intersex condition
- Adrenogenital Syndrome
- Progestin-Induced Hermaphroditism
- Androgen-Insensitivity Syndrome (Testicular Feminization)
- Turner’s Syndrome
- Gender
- Gender Role Behavior
- Gender Identity
- Gender Disorder
- strong & persistent cross-gender identification
- persistent discomfort with his/her sex or gender role of that sex
- transexualism
- transvestism
- sexual orientation
- First transsexual operation reported by F.Z. Abraham in 1930’s
- Hamburger in 1953 reported case of Christine Jorgensen
- James Morris: Jan Morris Conundrum
- Richard Raskin: Renee Richards
- Controversies
- The primacy of Assigned Sex:
- John Money & June Doe
- Behavioral treatments for gender disorder:
- Lovaas & Craig
- Functional Criterion
- Sociological & Tolerance Criterion
- Lovaas & Craig
- The primacy of Assigned Sex:
Paraphilias
(10-26-09)
Assessment
“What is the total number of behaviors in a week that culminate in orgasm?” (Maxmen & Ward, 1995, p. 325), Kinsey referred to this as the individual’s “total sexual outlet”; Maxmen and Ward note that only 5% of men have an outlet of 7 or greater, while the majority of men with paraphilic disorder have persistent hypersexual desire and tie or exceed this number.
“What are the different ways that you become aroused to the point of orgasm?” (Maxmen & Ward, 1995, p. 325), eliciting an honest answer to this question will reveal paraphilias and related behavior (promiscuity, dependence on pornography, and compulsive masturbation). Morrison (1995) discusses interviewing on sensitive topics, including a client’s sexual life.
Paraphilia [para: “beyond” or “along side of”; philia: “love”]: sexual deviations
Ford, C.S. & Beach, F.A. (1951). Patterns of Sexual Behavior. New York: Harper.
“sexual disorders characterized by persistent and intense fantasies or desires, usually for nonhuman objects; for sexual activities involving pain, domination or submission; or for nonconsenting partners, such as young children.” (Weiner & Rosen, 1999, p. 421)
“a paraphilia is the involuntary and repeated need for unusual or bizarre imagery, acts, or objects to induce sexual excitement.” (Maxmen & Ward, 1995, p. 324)
Weiner and Rosen suggest that it is: “the repetitive and persistent character of the sexual fantasies or urges” which uniquely define paraphilias (p. 421); they note that these disturbances are sometimes referred to as disorders of sexual compulsivity or impulsivity.
Paraphilias usually interfere with interpersonal relationships “or normal pair bonding” to some degree (Weiner & Rosen, 1999, p. 421); “The essential disorder is in the lack of capacity for mature and participating affectionate sexual behavior with adult partners.” (Meyer & Seitsch, 1996, p. 154)
A distinction may be made between “victimless” paraphilias and those involving victimization of a nonconsenting partner; this validity of distinction has been questioned
legally paraphilias are usually prosecuted as “sex crimes”, adjudicated offenders are referred to as “sex offenders”, and there may be reporting requirements for both clients and therapists significantly different than those which usually exist for mental health cases
Although DSM-IV bases subclassification of paraphilia on the stimulus/activities found to be sexually arousing, some research suggests many paraphilic individuals engage in multiple forms of deviant sexual behavior: Abel, Becker, Cunningham-Rathner, Mittelman, & Rouleau (1988) reported that less than 10% of their patients had a single paraphilia, approximately 20% had two paraphilic diagnoses, 32% had three or four diagnoses, and 38% had engaged in five or more concomitant paraphilic behaviors; other investigators have reported high rates of multiple paraphilias (see Weiner & Rosen, 1999)
Individuals with paraphilias do not usually seek treatment or disclose information voluntarily; the reported prevalence data is viewed by everyone as a small fraction of the actual level of behavior
Most paraphilias are predominantly male disorders, the age of onset is often prior to age 18, and individuals often report high frequencies of behavior over time
- Exhibitionism
- as with all paraphilias, prevalence figures are highly suspect; but appears to be a common sexual offense
- not all cases are harmless
- prevalence may decline past 40 years of age, possibly associated with the general reduction of impulsiveness reported with advancing age
- almost exclusively male clinical population, onset usually prior to age 18, approximately 1/3 never married and high reported rates of unsatisfactory interpersonal relationships in samples
- Voyeurism
- “scopophilia” or “scoptophilia”
- “An essential feature is the lack of awareness in the victim being observed, in contrast to consensual forms of voyeurism, such as occurs in sex clubs and X-rated movies.” (Weiner & Rosen, 1999, p. 425)
- Fetishism
- “partial fetishism” refers to using the fetish object for stimulating arousal
- “complete fetishism” requires use of the fetish object to achieve orgasm
- “Partialism” is a fetish behavior involving intense erotic attraction to specific parts of the body, to the exclusion of sexual interest in the partner or the partner’s body as a whole [Paraphilia NOS in DSM-IV]
- Frotteurism
- usually begins in adolescence and may decline after age 25 (Abel & Osborn, 1992)
- Sexual Sadism & Masochism
- autoerotic asphyxiation
- 28% of subscribers to sadomasochistic magazines found to be female (Breslow, Evans, Langley, 1985)
- Transvestite Fetishism
- cross dressing for sexual arousal, may be associated with either masturbatory or heterosexual activity
- not diagnosed when cross dressing occurs exclusively during a gender identity disorder
- not diagnosed when motivation for cross dressing is not sexual in nature
- heterosexual males may cross dress without arousal
- homosexual males may cross dress for entertainment purposes
- homosexual males may cross dress to attract heterosexual clients
- cross dressing for sexual arousal, may be associated with either masturbatory or heterosexual activity
- Paraphilias NOS
- coprophilia: smearing feces
- klismaphilia: self-administering enemas
- mysophilia: lying in filth
- partialism: exclusive focus on parts of the body
- zoophilis: sexual activity with animals
- necrophilia: having sex with a corpse
- telephone scatologia: making lewd telephone calls
- urophilia: urinating on others or being urinated on
Pedophilia
- a focus of erotic attraction or interest upon prepubescent children
- Pedophilia does not follow a single pattern (Finkelhor & Arraign, 1986; see also Weiner & Rosen, 1999)
- homosexual/heterosexual
- incestuous/nonincestuous
- penetrative/nonpenitrative sex
- sadistic physical harm/incidental physical harm
- some cases of sexual abuse of children by adult females have been reported
- Course is often chronic
Child Sexual Abuse (not exactly the mirror image of pedophilia)
- The prevalence of child sexual abuse is unknown, in 2000 child sexual abuse comprised approximately 10% of the officially reported child abuse cases and approximately 88,000 substantiated or indicated cases were found (Putman, 2003). Only about half of victims found in community surveys had disclosed to anyone (Putman, 2003).
- Females are at higher risk for child sexual abuse (2.5 to 3 times greater risk than boys); males account for 22-29% of victims (Putman, 2003); risk rises with age, physical disabilities, absence of a parent. A step-father in the home doubles the risk for girls. Socioeconomic status, race, and ethnicity have not been found to be significant risk factors (but may relate to likelihood of reporting and symptom expression). Intergenerational transmission of child sexual abuse appears less than that seen for physical abuse. (Putman, 2003)
- A number of child and adult psychiatric disorder have been associated with childhood sexual abuse, including depression, sexualized behavior, neurobiological sequelae (Putman, 2003)
- “As a group, individuals with histories of CSA, irrespective of their psychiatric diagnosis, manifest significant problems with affect regulation, impulse control, somatization, sense of self, cognitive distortions, and problems with socialization. Many of these processes are believed to have developmentally sensitive neuronal and behavioral periods related to brain maturation and early caretaker interactions” (Putman, 2003, p. 273)
- Pelcovitz et al. (1997) recommended a proposed diagnosis of Disorders of Extreme Stress Not Otherwise Specified (DESNOS)
- “(1) altered affect regulation such as persistent dysphoria, chronic suicidal preoccupation, and explosive or inhibited anger; (2) transient alterations of consciousness, such as flashbacks and dissociative episodes; (3) altered self-perceptions including helplessness, shame, guilt, and self-blame; (4) altered relationships with others, such as persistent distrust, withdrawal, failures of self-protection, and rescuer fantasies; (5) altered systems of meanings, including loss of sustaining faith, hopelessness, and despair; and (6) somatization (Herman, 1992).”
- Not all sexually abused children have emotional and behavioral sequelae, up to 40% present with no symptoms (Putman, 2003), 10% to 20% of these may deteriorate over the next 12 to 18 months. Long term deterioration (“sleeper effect”) is poorly understood and not well predicted by family-environmental and abuse-related variables (Putman, 2003)
Abuse
- Consequences:
- Jackson, Philp, Nuttall, & Diller (2002) suggest that mild TBI may be a “hidden consequence” for many battered women. In a sample of 53 battered women, they found 92% reporting having received blows to the head and 40% reporting loss of consciousness; and found a significant correlation between reported frequency of being hit in the head and postconcussive symptoms.
- Partner Abuse
- A history of early behavior problems was the developmental anticedent of partner abuse most consistently identified in multivariate analyses by Magdol, Moffitt, Caspi, & Silva (1998)
- In a primary care setting Oriel & Fleming (1998) found prevalence rates of mild violence (6-11%) and severe violence (3-4%) reported by males. Self-reported symptoms of depression, drinking more than two drinks on average, and any history of abuse as a child increased a man’s probability of violence from a baseline of 7% to 41% if all three risk factors were present. Witnessing parental violence and living with children from a partner’s previous relationship were also associated with violence.
Adolescent Sex Offenders
- Ryan et al. (1996) analyzed data from more than 1,600 juveniles in 30 states referred for sexual offense; found 27.8% identified with three or more nonsexual offenses.
- Butler & Seto (2002) recommend distinguishing between adolescent sexual offenders with and without criminal histories of non-sexual offenses
- conduct disorder subtype
- nonconduct disorders subtype (possibly with more deviant sexual interests)
- Multiple victims may be associated with greater risk of recividism of sexual offenses (Rasmussen, 1999)
- Adult dangerous sexual offenders usually commit their first offense during adolescence, and usually have 2 to 5 times as many reported offenses than those apprehended for (Groth, Longo, & McFadin, 1982)
Stress Reactions
Sexual dimorphism
(10-22-07)
Levels of sexual dimorphism
female | male | indeterminate | |
| chromosomal | XX | XY | 45 XO; 47 XXX; 47 XYY; etc. |
| gonadal | ovaries | testes | undifferentiated |
| hormonal | low androgenshigh estrogens | high androgenslow estrogens | low levels of sexual steroids; or high levels of androgens in genetic female |
| internal morphologic sex | fallopian tubes, uterus, vaginal sheath | vas defeferens, seminal vesicles, ejaculatory ducts | hermaphroditism; or undifferentiated; or female in genetic male |
| external morphologic sex | external labia | penis, scrotum | “blurred” genitalia; true hermaphroditism very unusual–same anlage |
| assigned sex | “girl” | “boy” | “?” |
Example for a case of Turner’s syndrome
| female | male | indeterminate | |
| chromosomal | XX | XY | 45, XO |
| gonadal | ovaries | testes | undifferentiated |
| hormonal | low androgenshigh estrogens | high androgenslow estrogens | low levels of sexual steroids |
| internal morphologic sex | fallopian tubes, uterus, vaginal sheath | vas defeferens, seminal vesicles, ejaculatory ducts | normal female |
| external morphologic sex | external labia | penis, scrotum | female genitalia |
| assigned sex | “girl” | “boy” | “girl” |
| secondary sexual characteristics | female pattern body hair; breast development | male pattern body hair; facial hair; deeper voice | little without hormone supplimentation |