"Freud and I had a falling

out over the concept of

penis envy. He thought it

should apply only to women."

--Woody Allen

Chapter 9

Sexual and Gender Identity Disorders

Dale L. Johnson

Freud was right about some things, and his argument that sex was involved in all neurotic disorders, and, for that matter, just about everything else, was probably right. He was the first to call attention to the central role sex plays in social life. Without a sexual interest, why bother with other people, they certainly are the source of much trouble. But the sex drive heightens social interest and brings people together in the complex organizations we call societies. Freud also pointed out that there is nothing simple about sex and there are a great many ways to make sex troublesome.

This section of our course deals with two main areas of sexual trouble: sexual abnormalities and sexual dysfunctions.

Gender Identity Disorders

Transexualism

The transsexual is a person who is dissatisfied with his or her genital sex and wishes to be the other sex, and has been this way for at least two years. It is the female who feels she is really male, or the male who feels he is really female. Typically, they dress in the clothing of the other sex.

Since this is so obviously wrong, isn't it delusional? No, the person feels like a member of the opposite sex, but knows she or he is not. It would be delusional if a person with male genitalia said he was a woman.

Treatment

Sex assignment surgery is possible. The textbook describes the process. There are hospitals where this is done, but one leader in the field, Johns Hopkins, has stopped doing this kind of surgery. The found counseling was more satisfactory.

Transvestic Fetishism

It is important to distinguish this from transsexualism. In transvestic fetishism the person is sexually aroused by dressing in the clothes of the opposite sex. The person who does this has no feeling of that he is a person of the opposite sex. I once had a patient who revealed that she had been puzzled to find her clothes had been rearranged in her closet. This happened several times and finally she saw her husband wearing her clothes. She was shocked and they had a big shouting match about it, but when it was apparent that he was aroused by cross-dressing, and was a better lover, she happily accepted the arrangement.

Paraphilias

The term means a deviation (para) in what one is attracted to (philia). Actual behavior is not necessary to fit the classification; imagery is sufficient. It may be multiple. It may be part of another disorder; e.g., alcoholism. It may involve non-consenting partners, in which case it is illegal. Paraphilias almost always occur in males. The major paraphilias are described in the textbook.

Causes

The major single cause is that a child or adolescent has an experience that is sexually arousing and has satisfying consequences. This is followed by the discovery that this type of sexual experience is more satisfying than more conventional heterosexual experience. For many people who prefer paraphiliac experiences, there is also the element of excitement. Voyeurs, for example, find that secretly looking at other people is exciting because they might be caught and he harmed. This is certainly a major part of the exhibitionist's interest.

A few years ago a young woman joined the department of psychology faculty. I met her on campus and asked how she liked UH so far. She said it was just fine except she had been flashed twice in one week. Once when a man in the athletic dormitory raised the shade as she passed and exposed his genitals. The second time was when she was in the library, late in the afternoon when not many students were there, and a man dropped his pants and shorts in front of several women. In neither case was the flasher caught, but in both instances the flasher risked being caught and publicly humiliated or charged with a crime. They took the risk because exhibitionism was exciting and sexually arousing for them.

Paraphilial behaviors are maintained by fantasy accompanied by masturbation. The behaviors are repeated many times. This is the private world of the paraphiliac. Only rarely does this behavior enter the public world. When it does it ceases being private and acceptable and becomes public and unacceptable by society.

Treatment

The treatments for the paraphilias are all behavioral and cognitive today. Psychodynamic treatments have not been successful. Cognitive therapy and behavior therapy are the treatments that have been found to be most effective. Details appear in the textbook. Table 10.6 shows the effectiveness rates for these therapies. They are very high, but note that multiple offenders and those with very unstable backgrounds do not fare well. Obviously, treatments do not fit all people equally well and some more severe cases may need special treatment. In general, however, psychosocial and drug treatments are so effective that only a few men relapse.

The concern with returning sex offenders to the community is not entirely unrealistic, mainly because the treatments mentioned in the textbook are not widely available. Most offenders receive individual or group counseling, and the effectiveness of these treatments is either low or untested. Few criminal justice treatment programs use best methods. Instead, they spend vast amounts of money on relocation programs, violate the rights of offenders who have served their sentences, and offer little protection to the public. There should be a public outcry about this, but people are ignorant about what can be done.

Rape

The causes of child molestation and rape are largely unknown. It is fairly clear that these are men who are impulsive, absorbed by sexual thoughts and promiscuous behavior and are "emotionally callous toward women." (R. Knight, Brandeis University). Many offender has attention deficit disorder as children.

One line of treatment is to medicate these men with anti-androgens such as Depo-provera. The FDA has not approved the use of these drugs with sex offenders and so the forced administration of the drugs raises legal and ethical issues. The drugs were once used for birth control by women, but the increased risk of cancer has led to their rejection. The drugs reduce testosterone and related sex-drive and interest.

CBT is also used to redirect sex thoughts and to teach self-management techniques. One study showed a 41% decrease in repeat offenses after CBT.

A 25-year follow-up of 7,275 sex offenders who were treated with CBT. Failure rates were disappointingly high with 20% of rapists and 16% of homosexual pedophiles committing repeat crimes. Nevertheless, the large majority were not repeat offenders.

Sexual Dysfunction

Sexual functioning problems are very common and are one source of other problems. Many people who have paraphiliac behaviors, for example, are unhappy with their sex lives, whether hetero- or homo-. Sexual relations in themselves are fairly simple; if they hadn't been our species would have expired in East Africa 3 million years ago. What makes the sexual relationship complicated is that people want to enjoy sex, and quite often they do not.

The textbook is excellent on the types of sexual dysfunction and treatments. One theme stands out. The resolution of sexual dysfunctions often depends on improving communication between partners. The other theme is that successful treatment makes use of behavioral methods. Psychotherapy alone does not yield effective outcomes.

Homosexuality

In the DSM-I and DSM-II homosexuality was a psychiatric disorder. Now it is not. In 1980, when the DSM-III was being developed the American Psychiatric Association was asked to decide, was homosexuality a disorder or not? The psychoanalytically-affiliated psychiatrists were adamant that it was, but others said it was not. No one could pin down any specific behaviors, apart from the type of sexual relationship, that could be used to define the "disorder." The association decided the matter by taking a vote and the result was that homosexuality is not a disorder.

Several things paved the way for this decision. One was the work of work of psychologist, Evelyn Hooker. She asked a large number of Rorschach test (inkblot) experts if they could identify homosexuality using the Rorschach. All said they could. She then tested a number of men in the San Francisco Bay area, straight and gay, and presented the inkblot results to the experts in pairs, one gay, one straight. She asked the experts to sort them into two piles. They did and they said they were confident that they had made accurate decisions. In fact, they did no better than chance. The Rorschach did not help them identify which men were homosexual and which were heterosexual. This was a devastating defeat for those who believed in a "homosexual personality" because the Rorschach was then held in such high esteem.

Research on homosexuality virtually came to a halt about 20 years ago when a stellar committee on research asked for a moratorium on research in this area. They said it was unproductive, chiefly because it was nearly impossible to define "pure" homosexuality. Some people had sex and sexual interests only with the opposite sex and some had these behaviors and interests only with the same sex, but a large number were, at various times in their lives, bisexual. Also, what is homosexual behavior? For men is penetration required to meet the definition, or would mutual masturbation suffice? What about women?

A few years ago there was excitement in the gay world when LeVay found brain differences between gay and straight men. He reported differences in a part of the hypothalamus. Other researchers have challenged his findings, but the issue is not settled. His findings seem reasonable. Ask why should a person have heterosexual drives? No one is trained to have them. They just appear. This suggests some kind of DNA-directed brain organization and functioning that precedes learning.

The possibility of some form of brain functional difference seems necessary to deal with these different orientations. As the textbook points out, there is some evidence for a genetic basis for sexual orientation. Perhaps the genetic basis is even stronger than the social basis. Freudian psychologists argued for years that homosexual behavior arose from conflicted mother-child relationships. They urged patients to spend years in analysis to work through these conflicts, with no success. I recall, while in Topeka and associated with the Menninger School of Psychiatry, being a bit amused to know of psychoanalysts who were gay and apparently functioning well, but still worrying about their relationship with their mothers. Years of analysis had had no effect on that worry.

A recent review of the genetics and brain involvement in homosexuality reveals the complexity of the issue. A very large (4,900) study of Australian twins found some evidence for significant heritability of homosexuality, but the effect was stronger for women (50-60%) than for men (30%)(Kirk, 2000, Behavior Genetics, 30, 345-356. A similar study in the USA found similar results (Kendler, 2000, American Journal of Psychiatry, 157, 1843-1846). The search for the gene or genes involved has not been productive.

Research using brain imaging and hormones has yielded results that also point to an involvement of biology in the development of homosexuality, but none of the effects are strong. Reviewers of this research quite consistently point to a multi-factorial development process in which psychosocial factors are important.

But there are new developments. What about finger length? Did you think of that? It seems that the length of fingers of lesbians is longer than that of their straight sisters. In short, their hands are more masculine (Breedlove, Nature, about March 30, 2000). Researcher hypothesized that these women were subjected to more fetal androgen than heterosexual women. These analyses do not work for gay and straight men.

* * *

Some time ago I ran across this father's statement in the New York Times. I copy it here without comment.

My Daughter is a Lesbian

Robert A Bernstein

”Typically the parent of a gay child passes through successive stages of shock, disbelief, sorrow, and sooner or later, acceptance. For many of us, however, there is yet another phase: outrage against society's stereotypical thinking that would relegate our gay loved ones to second-class citizenship.

Some of us have a dream. It is that millions of angered parents will coalesce in a powerful crusade for societal change.

For the moment, we remain a puny David in a mismatch with a homophobic Goliath. Millions of Americans live in daily terror lest disclosure of their sexual orientation deprive them of jobs, promotions, housing, and a variety of social and political advantages.

Stereotypes shun logic and reason and at least temporarily can block the natural flow of parental affections. But the primal instinct to love and protect one's young, however latent, embodies an immense potential for social reform.

My daughter is a lesbian. She is also the light of my life, a warm and talented young woman whose joyous spirit helps brighten the lives of others. Ironically, she is now an even better person for having learned to live honestly and openly in a hostile society.

My own path to activism was charted by an organization called P-Flag, an acronym for Parents and Friends of Lesbians and Gays. It is essentially a support group, a sort of alchemist of the soul that converts bereaved parents into active agents of acceptance. It leads us gently through the thickets of wrong-headed conventional wisdom and back to where we belong--at our children's sides.

Among other things, we learn that we did not "cause," and our children did not "choose" their homosexuality--that sexual orientation, like warts or perfect pitch, is a matter of biological roulette. We also learn that a much maligned "life style' of the average gay person is about as lurid as our own, centered on such mundane matters as jobs, friends, hobbies, and church. The gay community, as it turns out, contains about the same proportion of saints to rascals as any other.

The political potential of these parental conversions was brought home to me on a march on Washington for lesbian and gay rights last August. My daughter's mother and I were among the marchers, with other members of P-Flag. We made up a relatively tiny contingent, a grizzled crew of a few hundred parents in a sea of mostly youthful people variously estimated at from 200,000 to 600,000 people.

Dramatically, however, this token symbolic presence touched off a stirring in the crowd that soon grew to a thunderous roar of cheers and applause that followed us all the way down Pennsylvania Avenue--a measure, surely, of the yearning of the young people for the support and understanding of their own parents.

But that yearning cannot be any stronger than the potential of their parents' reciprocal affections. It was after the march, as I pondered the strength of the parent-child bond and the sheer numbers of homosexual Americans, that I could envision the doom of homophobia's reign.

It is estimated that there are upward of 25 million gay people, who by definition, started out with some 50 million parents. Sooner or later, a large portion of those parents will want to enlist in the crusade for their children's dignity. When that happens, a significant slice of the nation's voters fired by familial bonds will be dedicated to the most basic of freedoms: the right to be what one is."