516 CHAPTER 11
Summary of
Gender Identity Disorder
Gender identity disorder is characterized by
a persistent cross-gender identification that
leads to chronic discomfort with one’s biologi-
cal sex. Symptoms of gender identity disorder
often emerge in childhood, but most children
diagnosed with the disorder no longer have the
disorder by the time they are adults. However,
most adults with gender identity disorder re-
port that their symptoms began in childhood.
In children, symptoms of gender identity
disorder include cross-dressing, engaging in
other-sex types of play, choosing other-sex
playmates, and even claiming to be the other
sex. In adults, symptoms include persistent
and extreme discomfort from living publicly as
their biological sex, which leads many to live
(at least some of the time) as someone of the
other sex.
Criticisms of the diagnostic criteria in
DSM-IV-TR for this disorder point to the overly
narrow concept of gender and appropriate be-
havior (particularly for males) and the ambig-
uous requirement about distress. With gender
identity disorder, the person’s distress often
arises because of other people’s reactions to
the cross-gender behavior.
Some brain areas in adults with gender
identity disorder are more similar to the cor-
responding brain areas of members of their
desired sex than to those of their biological
sex. Results from animal studies suggest that
one explanation for this disorder is that pre-
natal exposure to hormones causes the brain
to develop in ways more similar to the other
sex, although the sexual characteristics of the
body are unchanged. Beyond symptoms that
are part of the diagnostic criteria for the dis-
order, no psychological or social factors are
clearly associated with the disorder.
Treatments may target neurological (and
other biological), psychological, or social
factors. Treatments that target neurological
and other biological factors include hormone
treatments and sex reassignment surgery.
Treatments targeting psychological factors
include psychoeducation and helping the pa-
tient choose among gender-related lifestyle
options and problem solve about potential
diffi culties. Treatments that target social fac-
tors include family education, support groups,
and group therapy.Thinking like a clinician
When Nico was a boy, he hated playing with the
other boys; he detested sports and loved play-
ing with the girls—playing “house” and “dressup”—except when the girls made him dress up
as “the man” of the group. Sometimes he got
to be the princess, and that thrilled him. As a
teenager, Nico’s closest friends continued to
be females. Although Nico shied away from
playing with boys, he felt himself sexually at-
tracted to them. To determine whether Nico
had gender identity disorder, transvestic fe-
tishism, or no gender or sexual disorder, what
information would a clinician want? What spe-
cifi c information would count heavily? Should
that fact that Nico is attracted to males affect
the assessment? Why or why not?Summary of
The Paraphilias
Paraphilias are characterized by a predictable
sexual arousal pattern regarding “deviant”
fantasies, objects, or behaviors. Paraphilias
can involve (1) nonconsenting partners or chil-
dren (exhibitionism, voyeurism, frotteurism,
and pedophilia), (2) suffering or humiliating
oneself or one’s partner (sexual masochism
and sexual sadism), or (3) arousal by nonhu-
man objects (fetishism and transvestic fetish-
ism). To be diagnosed with a paraphilia, either
the person must have acted on these sexual
urges and fantasies, or these arousal patterns
must cause the patient signifi cant distress.
Assessments of paraphilias may involve
the use of a penile plethysmograph to deter-
mine the sorts of stimuli that arouse a man, as
well as self-reports of arousing stimuli and re-
ports from partners and from the criminal jus-
tice system for those apprehended for sexual
crimes.
Criticisms of the DSM-IV-TR paraphilia
classification include the following: What is
determined to be sexually “deviant” varies
across cultures and over time; the diagnos-
tic criteria are overly broad and thereby lead
clinicians to group together very different
disorders; and the criteria do not address the
ability to control the paraphilic urges.
Research shows that paraphilias share
similarities with OCD. Additional possible
contributing factors include classically condi-
tioned arousal and the Zeigarnik effect.
Most frequently, men who receive treat-
ment for paraphilias because they were or-
dered to do so by the criminal justice system.
Treatments that target neurological factors
decrease paraphilic behaviors through medi-
cation; however, although the behaviors may
decrease, the interests often do not. Treat-
ments that target psychological factors are de-
signed to change cognitive distortions about
the predatory sexual behaviors, especially thefalse belief that the behavior is not harmful
to the nonconsenting victims. A goal of such
treatments is to change sexual arousal pat-
terns using behavioral methods, as well as to
prevent relapse. Although social factors may
be the target of treatment for sex offenders,
they have not generally been successful.Thinking like a clinician
Ben was getting distracted at work because he
kept fantasizing about having sexual relations
with young boys. He’d think about a neigh-
bor’s son or a boy in an advertisement. He
hadn’t done anything about his fantasies, but
they were getting increasingly harder to turn
off. According to DSM-IV-TR, what paraphilic
disorder, if any, does Ben have? On what is
your decision based? If Ben wasn’t getting
distracted by his fantasies, would your diag-
nosis change or stay the same, and why? Do
you think that illegal acts (such as child sex
abuse or sexual acts with nonconsenting indi-
viduals) should be part of the DSM criteria, as
they presently are? Explain your answer. What
treatment options are available to Ben?Summary of
Sexual Dysfunctions
Sexual dysfunctions are psychological dis-
orders marked by problems in the human
sexual response cycle. The response cycle
traditionally has been regarded as having
four parts: excitement, plateau, orgasm, and
resolution—but it is now commonly regarded
as beginning with sexual attraction and de-
sire. Sexual dysfunctions fall into one of four
categories: disorders of desire, arousal, or-
gasm, and pain. The dysfunctions may be
situational or generalized and may arise from
neurological (and other biological) factors,
psychological factors, or a combination of fac-
tors. However, to be classifi ed as dysfunctions
they must cause signifi cant distress or prob-
lems in the person’s relationships.
Each sexual dysfunction involves cogni-
tive, emotional, and neurological (and other
biological) components to varying degrees;
the DSM-IV-TR diagnostic criteria, however,
generally focus on neurological and other bio-
logical components.
Various factors contribute to sexual dys-
functions. Neurological (and other biologi-
cal) factors include disease, illness, surgery
or medications, and the normal aging pro-
cess. Psychological factors are divided into
predisposing, precipitating, and maintain-
ing factors. Social factors include the quality
of the partners’ relationship, the partner’sSUMMING UP
Sf
up” exceptwhenthegirlsmade him dress up falsebelief that thebehaviorisnot harmfull