Chapter 10: Sexual Functioning and Gender Identity

Raskin explores sexual functioning, paraphilias, and gender identity from historical, biological, psychological, and sociocultural perspectives. The chapter begins with case examples of individuals struggling with low desire, erectile dysfunction, premature ejaculation, sexual pain, paraphilic urges, and gender incongruence. Basic terms are clarified, including sex, gender, gender identity, sexual orientation, heterosexism, and coming out, emphasizing the role of cultural values and shifting norms. DSM-5-TR and ICD-11 classify sexual dysfunctions into desire/arousal disorders (e.g., female sexual interest/arousal disorder, male hypoactive sexual desire disorder, erectile disorder), orgasmic disorders (e.g., female orgasmic disorder, premature and delayed ejaculation, anorgasmia), and sexual pain disorders (genito-pelvic pain/penetration disorder, sexual pain-penetration disorder). Paraphilic disorders such as exhibitionism, voyeurism, fetishism, frotteurism, sadism, masochism, pedophilia, and transvestism are examined, alongside debates about pathologizing common sexual interests. Gender dysphoria (DSM) and gender incongruence (ICD) are presented as diagnoses for distress over assigned versus experienced gender, raising debates about stigma, gatekeeping, and the role of gender-affirming care. ICD-11 additionally recognizes compulsive sexual behavior disorder (CSBD). Historical perspectives trace the medicalization of sexual deviance from biblical prohibitions, Tissot’s eighteenth-century condemnation of masturbation, and Krafft-Ebing’s Psychopathia Sexualis, to 20th-century sexology and the removal of homosexuality from DSM. Influential research includes Kinsey’s sexuality surveys, the Hite and Janus Reports, and Masters and Johnson’s sexual response cycle. Biological perspectives highlight hormones like testosterone and estrogen, neurotransmitters such as dopamine, norepinephrine, and serotonin, and medications including sildenafil, flibanserin, and bremelanotide. Genetics, brain imaging, prenatal hormones, evolutionary theories, and immune system research further illuminate sexuality and gender identity. Psychological perspectives explore psychodynamic accounts of unconscious conflict and perversions as hostile fantasies, CBT interventions such as sensate focus, stop-start and squeeze techniques, pelvic floor rehabilitation, covert sensitization, and masturbatory satiation, as well as transgender-affirmative CBT and experiential sex therapy. Sociocultural perspectives emphasize the New View campaign’s critique of medicalized female sexuality, the controversies over gatekeeping in transgender healthcare, systemic oppression, and cultural diversity in defining sexual problems. Service user perspectives include programs for sexual offenders (relapse prevention, RNR model, good lives model) and advocacy groups supporting transgender and LGBTQ individuals. Systems perspectives frame sexual difficulties within couple and family dynamics, while closing reflections emphasize that ideas about sexuality are socially constructed, fluid, and historically contingent.