Sexuality and Gender Identity Disorders

SEXUALITY GENDER DYSPHORIA & SEXUAL DISORDERS DR. FORRY J. BEN PSYCHIATRIST – KIUTH Common myths regarding Sex Morality of sex Male arousal Female orgasm The ‘gay’ question OUTLINE • SEXUALITY • DEFINITIONS • CURRENT TRENDS • LATEST UPDATES • CONTROVERSIES • GENDER IDENTITY DISORDERS • CONCEPTS • EPIDEMIOLOGY • DIAGNOSIS • MANAGEMENT • SEXUAL DISORDERS • SEXUAL RESPONSE CYCLE • EPIDEMIOLOGY • DIAGNOSIS • MANAGEMENT SEXUALITY - Definition • The sum of a person's sexual behaviors and tendencies, and the strength of such tendencies • Unfolds in adolescence…….evolves throughout life • Private and Complex and Dynamic • Nature vs Nurture Clinical correlates of sexuality • Sexual identity ‘disorder’ • Sexual dysfunction • Disorder vs Paraphilia NB: Pts may dwell on nonsexual complaints hoping the doctor will ask about their sexual life SEXUALITY • Sexual identity ‘disorder’ • Personal sense of self attained by end of adolescence • X-terized by self-labels • Gender identity • Tranvestism vs Transexualism • Sexual orientation • Fear of being gay or lesbian • Sexual intention • Autoerotic asphyxiation • Violent sexual fantasies SEXUALITY – Current Trends • 4 determinant elements etiologically • Biological…..hormonal imbalance • Psychological…..childhood trauma • Interpersonal….personality traits • Sociocultural concepts of normality and morality • Prone to short and long-term changes • Age related • Hormonal based • Globalization trend SEXUALITY – Latest Updates • Classification of sexual orientation • Heterosexuality • Autoerotism • Homosexuality • Asexuality • Gymnophobia • Erotophobia • Philophobia • Bisexuality SEXUALITY • Special considerations in Dx and Mx • Lifelong/primary vs Acquired/secondary • Persistent vs Situational • Specific vs Global • Disorder-oriented vs Etiology-focused • Biological • Psychological Remember • Sociocultural 4P’s • Interpersonal Benefits of SEX beyond reproduction Health benefit of sex Relieves stress Health benefit of sex Contd. Boosts the immune system by Ig A Health benefit of sex Contd. Improves CVS ( Lower BP) Health benefit of sex Contd. Self esteem Health benefit of sex Contd. Improves intimacy with partner Health benefit of sex Contd. Reduce pain (+) oxytocin Health benefit of sex Contd. Risk of prostate cancer Health benefit of sex Contd. Strengthens pelvic muscles Health benefit of sex Contd. Promotes good sleep Health benefit of sex Contd. Improves the sense of smell Health benefit of sex Contd. Improves urinary bladder control SEXUALITY – Controversies • Biological basis of sexuality • Psychological influences • Sociocultural constraints • ‘rule of excesses’…..Hedonism • Global trends • LGBTQ Lobbying and Advocacy • Future consequences SEXUALITY – Homosexuality • Romantic or sexual desire for individuals of same sex • Latent homosexual tendencies…….i.e. ‘in the closet’ • Not a disorder but variant • Epidemiology unknown • Subjectivity of research methods • <10% in both sexes • ~10% of every species • Unknown/Unclear etiology….childhood trauma • Prepubertal and pubertal same-sex exploratory activities • Common • Not indicator of latent homosexuality • Associated mental disorders • MDD and Adjustment disorder SEXUALITY – The “Gay” course… • From retrospective data on homosexual men • In childhood 1. Feminine gender role & related behavior 2. Childhood trauma 3. High frequency of cross-gender identification • Thus is homosexuality due nature or nurture • Inborn Vs learned behavior GENDER – Concepts • Masculine or feminine sense that normally corresponds to the anatomical sex (Kaplan & Sadock’s synopsis of psychiatry). • Category to which an individual is assigned by self or others, on the basis of sex (Stedman’s Medical Dictionary). • The state of being male or female chiefly in cultural or social contexts (Concise Oxford English Dictionary). • Gender identity; psychological state reflecting one’s sense of being male or female. GENDER • Gender identity crystallizes in most persons by age 2 or 3 years • Usually corresponds to biological sex (male vs female) • Masculine vs Feminine vs ‘Common’ vs ‘Neuter’ i.e. the gender of nouns • Develops from a multitude of cues from parents & the culture • These are in of themselves reactions to the genitalia of the progeny • Gender Identity Disorders • ‘Culturocentric’ i.e. Culture bound/specific • Linked to improving SOL Transsexualism & Transvestitism in the world • Queen Hatshepsut became Pharaoh • Sekhet in ancient Egypt • Muxes in Mexico • ‘two spirit’ in native Americans • Fa’Afafines in Samoa • Hijras in Bangladesh, India and Pakistan • Sekrata in Madagascar • Kathoey in Thailand • The highest numbers of sex reassignment surgery globally • In Precolonial Uganda; Bunyoro and Teso ??? (Encyclopedia of Africa by A. Appiah & H.L Gates) GENDER DYSPHORIA • Formally Gender identity disorder (G.I.D) in DSM IV-TR was transsexualism in early versions of the DSM. • Subjective feeling that they were born the wrong sex thus distress • Affective &/or cognitive discontent • They may; 1. dress as the opposite sex 2. take sex hormones or 3. undergo sex change operations. • It is associated with an increased incidence of major depression, anxiety disorders and suicide. GENDER IDENTITY DISORDERS – Epidemiology • 1 in 30,000 men • 1 in 100,000 women • More common in men than women (1 : 3 – 5) • No direct research studies • Subjectivity of research methods • Sociocultural constraints GENDER IDENTITY DISORDERS – Diagnosis GENDER IDENTITY DISORDERS DIAGNOSIS AND DSM-IV-TR CRITERIA (Simplified) 1. A strong and persistent cross-gender identification 2. Persistent discomfort with his or her sex or sense of inappropriateness in the gender role of that sex 3. Clinical distress or impairment in social, occupational, or other important areas of functioning GENDER IDENTITY DISORDERS – Transvestitism • Transvestite • One who dresses in clothes of the opposite sex (DSM-IV-TR) • A G.I.D if transient & related to stress • Tension relief • Sex excitement sometimes • Anxiety reduction • May have fantasies (in whole or in part) but only act on them when stressed • A paraphilia if not stress related (transvestic fetishism)- sex excitement GENDER IDENTITY DISORDERS – Management • Special considerations • Focus on pt • Treat as ‘couple’ • Nonjudgmental • Empathy • Fact based and openness • Therapy, family involvement for younger patients • Possibly sex reassignment by hormonal and surgical techniques for adults GENDER IDENTITY DISORDERS • Treatment models • Compliant • Aversive • Compliant • Hormone therapy • Sex Reassignment Surgery • Aversive • Anxiety and Depression management • Treat the delusional thinking • Aversion therapy, Behavioral therapy, Hypnosis • Systems therapy, Interpersonal therapy GENDER IDENTITY DISORDERS – Prognosis • Children with gender identity disorders • Few become transsexual • Few want to change their sex • Determinants of prognosis 1. Age of onset 2. Intensity of symptoms 3. Comorbidity e.g. depression Hopeless about obtaining sex reassignment either by hormones or surgery 4. Self mutilation e.g. penectomy “Forcing the surgeon to deal with his problem” and not a suicide attempt SIDENOTE Hermaphroditism; Ambiguous genitalia; and Gender Identity G.I.D……..N.O.S 38 • Reserved for individuals who don’t fit above criteria • Include individuals with; • Intersex conditions & gender dysphoria • Transient stress-related cross-dressing behavior • Persistent preoccupation with castration or penectomy (without desire to acquire the sex x-tics of the other sex) SEXUAL DISORDERS DR. FORRY J. BEN PSYCHIATRIST – KIUTH …………………SCIENTIA POTENTIA………………… OUTLINE • DEFINITIONS • HISTORY TAKING • SEX CYCLE • CLASSIFICATION OF SEXUAL DISORDERS • EPIDEMIOLOGY • DIAGNOSIS • MANAGEMENT DEFINITIONS • Sex • The physiologic and psychological processes within an individual which prompt behavior related to procreation or erotic pleasure • Erotic • Lustful; relating to sexual passion; able to produce sexual arousal • Lust • Strong sensuous and passionate desire • Synonyms • Coitus, Copulation, Consummation, Cunnilingus, Fellatio, Fornication, Intercourse, Masturbation, Buggery, Sodomy Normal sexual behavior • Brings pleasure • Self and partner • Stimulation of primary sex organs • Including coitus • Devoid of • Inappropriate feelings of guilt or anxiety • Not compulsive • Societal understanding of normal sexual behavior • Inconstant • Varies from era to era • Reflects cultural mores of the time Hormones and Sexual Behavior • Testosterone increases libido in both men and women • Estrogen is a key factor in the lubrication involved in female arousal and may increase sensitivity in the woman to stimulation • Progesterone mildly depresses desire in men and women as do excessive prolactin and cortisol • Oxytocin is involved in pleasurable sensations during sex and is found in higher levels in men and women following orgasm. It reinforces pleasurable activities Physiological Responses • Psychosexual development • Psychological attitudes toward sexuality • Attitudes toward one's sexual partner These 3 are Directly involved with and Affect human sexual response Physiological Responses • William Masters and Virginia Johnson • Increasing levels of vasocongestion and myotonia (tumescence) • Subsequent release of the vascular activity and muscle tone as a result of orgasm (detumescence) Sexual Stimulation: Foreplay . Psychological Stimulation -use of smell, taste, hearing, sight or fantasy . Physical Stimulation- use of touch pressure or bodily contact 1. Erogenous zones 2. Kissing 3. Breast

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