1. Sexual and Gender
Identity Disorders
Kellie Cooper, Heather Munsche, Danielle
Painter, & Lisa Zbizek-Nulph

2. • Gender Identity Disorder (Heather)
• Sexual Pain Disorders
-Dyspareunia
• Sexual Arousal Disorder (Kellie)
-Female Sexual Arousal Disorder
-Male Erectile Disorder
• Orgasmic Disorders
-Premature Ejaculation
• Paraphilias
-Pedophilia
Overview

3. DSM-IV-TR:
• Core Criteria in DSM includes:
• Cross-gender identification
• Desire to live as member of the other sex
• Sense of inappropriateness in the gender role belonging to one’s
natal sex
• Discomfort about one’s assigned sex
• Desire to have sex characteristics of the other sex
• Discomfort about one’s anatomic sex
• Wish to get rid of one’s natal sex characteristics
Gender Identity Disorder

4. • GID vs. Transgender
• Current formulation – wish to completely alter body (complete
sex reassignment) option for having diagnosis
• Inability of current criteria to capture spectrum of
gender variance phenomena
• Dichotomous rather than dimensional idea of gender
• Netherlands – 10% asked for partial medical treatment
• Risk of unnecessary physical examinations-C
• Gender dysphoria occurs in people with DSD (disorders of sex
development) as well
Criticisms of DSM-IV-TR

5. • Necessity of D criterion – impairment or distress
• Many with GID have psychiatric problems but why?
• Social stigma role
• Many with GID function well but still desire reassignment
• If not distressed, do not qualify for Dx, ineligible for sex reassignment
• Diagnosis still applies to post-operative individuals
• Pathologized for life – should exclude those no longer gender
dysphoric

6. • Rename: Gender Dysphoria
• More neutral connotation
• New diagnostic indicators (Only 1 for Dx)
• Strong sense of discomfort with the gender role associated with one’s
assigned gender
• Strong discomfort with one’s primary and/or secondary sex
characteristics, because they do not match one’s gender identity
• Strong desire for primary and/or sex characteristics that match one’s
gender identity
• Distress causes by a strong desire to live in the gender role of the other
gender and/or to be perceived by others as a member of the other gender
(or some alternative gender different from one’s assigned gender)
• Distress caused by a strong identification with the other gender (or some
alternative gender different from one’s assigned gender)
Recommendations

7. • GID could be understood as CNS-limited form of DSD
without involvement of reproductive tract
• There may be genetically based systemic sex-hormone
abnormalities that do not cause abnormalities of the
reproductive anatomy but nevertheless influence brain &
behavior
• Some feel that (Gender Identity Variation) is completely
biologically-bounded
• Is it “natural” to want to take functioning anatomy and replace it with
characteristics of the other gender and impose infertility?
• Most treatment involves hormones & surgery, not
psychotherapy
Or…depathologize completely

8. • http://www.youtube.com/watch?v=_Wh6NecfMiE
• Currently:
-Criteria are worded differently for boys and girls
-Requires statement that he or she wants to be other gender
Childhood GID

9. • Leave criteria as are (change some wording)
• Shows discriminative validity
• Why not: ability to make Dx in absence of repeated verbal statements that one
wishes to be the other sex
• Tighten criteria so A has to include all 5 parameters
• Some kids might want to be the other sex but don’t verbalize it, would lead to
social problems
• Eliminate criteria of specific behaviors – new set of criteria focusing on
different manifestations of gender dysphoria
• Zucker recommends 2 – may decrease number eligible for Dx.
Combine A & B criteria. Desire to be of the other sex necessary for
diagnosis. Lower bound duration criterion of 6 months.
• Would alert clinician it is not a transitory thing
Recommendations-Child

10. Dyspareunia

11. DSM-IV-TR: • C. The person is at least age 16
years and at least 5 years older
• A. Over a period of at least 6
than the child or children in
months, recurrent, intense
Criterion A
sexually arousing fantasies,
sexual urges, or behaviors • Specify if:
involving sexual activity with • Sexually Attracted to Males
a prepubescent child or • Sexually Attracted to Females
children (generally age 13 or • Sexually Attracted to Both
younger)
• Specify if:
• B. The person has acted on
• Limited to Incest
these sexual urges, or the
sexual urges or fantasies cause • Specify if:
marked distress or • Exclusive Type (attracted only
interpersonal difficulty to children)
• Nonexclusive Type
Pedophilia

12. Arguments for change:
• Diagnostic criteria
based on guesswork • Studies that have investigated
• Field trials for DSM-III these criteria found them to be
included 3 patients “mediocre or poor”
• Paraphilias not included (Blanchard, 2011)
in field trials for DSM-
III-R or DSM-IV
Paraphilias

13. Proposed Changes:
• All Paraphilic Disorders now include two new
specifiers: In a Controlled Environment and In
Remission
• Rename Paraphilias chapter Paraphilic
Disorders
• Pedophilic Disorder - addition of a Hebephilic
Subtype
Paraphilias

14. Criticism 1: Response:
• Remove “sexual acts” • “repeated sexual acts
from Criterion A involving children are
• First and Frances (2008) practically indispensable as a
argue that sexual acts diagnostic sign of
alone then cause pedophilia” (Blanchard,
professionals to diagnose a 2009)
person with a mental • Sometimes this history is the only
thing we can use in diagnosing
disorder without other • Can’t rely on self-report
evidence
• “blurs the distinction
between mental disorder
and criminality”
Pedophilia

15. Criticism 2: • Response:
• Criterion A too vague • Go back to DSM-III
• What constitutes • “the act or fantasy of
recurrent? engaging in sexual
• What constitutes activity with prepubertal
intense? children is a repeatedly
preferred or exclusive
method of achieving
sexual excitement”
• But how do you assess
preferences?
Pedophilia

16. Criticism 3:
• Need more research
• Why 6 months for time
in this area!
interval?
Pedophilia

17. Criticism 4: Response:
• How do we distinguish • Specify a # of
between pedophile and occurrences during a
child molester? time period and use as a
• Not one in the same cutoff
• Child molester could = • Actually has empirical
antisocial PD + support
opportunity • 61% w/ sexual offense of
3 or more children had
greater penile tumescence
to pictures of children
• 42% of 2 or more
• 30% of 1 or more
Pedophilia

18. Criticism 5: Response:
• Should we account for • Specify acute or
difference between chronic
person offending
against 1 child versus
many?
Pedophilia

19. Criticism 6:
• Wording in Criterion B
makes it seem necessary Response:
to be distressed or • DSM-5 could distinguish
impaired by pedophilia between paraphilias and
to have disorder paraphilic disorders
• DSM-IV-R has added
societal impairments to
solve this
• Is this sufficient? What if
person doesn’t act on
feelings and doesn’t
impact community?
Pedophilia

20. Criticism 7: Response:
• Snyder, 2000 found the
• Should there be a
average age of sex
diagnostic category for
victims is 14 – in
those interested
pubescent range (as
primarily in pubescent
cited in Blanchard,
individuals?
2009)
• AKA Hebephilia • But is this
pathological?
• From an evolutionary
point of view - NO!
(Blanchard, 2010)
Pedophilia

21. • A. The person is equally or more attracted sexually to children under the age
of 15 than to physically mature adults, as indicated by self-report, laboratory
testing, or behavior.
• B. The person is distressed or impaired by these attractions, or the person has
sought sexual stimulation from children under 15 on three or more separate
occasions.
• C. The person is at least 5 years older than the child or children in Criterion
A.
• Specify if:
• Sexually attracted to Children younger than 11 (Pedophilic Type)
• Sexually attracted to Children Age 11-14 (Hebephilic Type)
• Sexually attracted to Both (Pedohebephilic Type)
• Specify if:
• Sexually attracted to Males
• Sexually attracted to Females
• Sexually attracted to both
Proposed Criteria for Pedophilic
Disorder

22. • The APA draft guidelines for making changes to DSM-V:
• (1) to distinguish between psychiatric syndromes for purposes of guiding the most effective treatment
and management;
• (2) to reduce confusion of syndromes with each other;
• (3) to take into account co-morbid symptoms which affect the outcome of treatment
in the most effective manner; (4) to facilitate ease of use and promote clinical utility;
(5) to demonstrate validity on as many levels as possible.

23. Approved Changes:
• Paraphilias chapter renamed Paraphilic
Disorders
Paraphilias

24. • 163. Zucker KJ. The DSM Diagnostic Criteria for Gender Identity Disorder in Children.
Archives of Sexual Behavior, 2010; 39:477-498.
• 164. Cohen-Kettenis PT, Pfäfflin F. The DSM Diagnostic Criteria for Gender Identity Disorder
in Adolescents and Adults. Archives of Sexual Behavior, 2010; 39:499-513.
• 165. Meyer-Bahlburg HFL. From Mental Disorder to Iatrogenic Hypogonadism: Dilemmas in
Conceptualizing Gender Identity Variants as Psychiatric Conditions. Archives of Sexual
Behavior, 2010; 39:461-476.
• 176. Drescher J. Queer Diagnoses: Parallels and Contrasts in the History of Homosexuality,
Gender Variance, and the Diagnostic and Statistical Manual. Archives of Sexual Behavior,
2010; 39:427-460.Blanchard, R. (2011). A brief history of field trials of the DSM diagnostic
criteria for paraphilias [Letter to the Editor]. Archives of Sexual Behavior, 40, 861-862.
• Blanchard, R. (2009). The DSM diagnostic criteria for pedophilia. Archives of Sexual
Behavior, 39, 304-316.
• Blanchard, R. (2010). The fertility of hebephile and the adaptationist argument against
including hebephilia in DSM-5. Archives of Sexual Behavior, 39, 817-818.
References