Module 11: Sex and Gender Identity Disorders

Question 1

Sexual dysfunctions

Answer 1

Sexual issues that are associated with clinically significant distress and experienced for more than 6 months

Question 2

What are sexual dysfunctions characterized by?

Answer 2

Disturbances in a person’s ability to respond sexually or experience sexual pleasure

Question 3

Sexual dysfunctions consist of…

Answer 3

clinically significant issues with desire, interest, arousal, orgasm, genito-pelvic pain and penetration

Question 4

What happens if someone has a comorbid with a non-sexual mental disorder?

Answer 4

If the presence of the non-sexual mental disorder can explain the sexual dysfunction that that is the diagnosis, and only diagnosis that should be made.

Question 5

Diagnoses of a sexual dysfunction also requires that…

Answer 5

issues better explained by a medical condition or domestic violence, or severe partner distress or other stressors are ruled out.

However, sexual dysfunctions may be diagnosed as being due to the use of medications and/or substances

Question 6

DSM-5 sexual dysfunctions are organized into 4 main categories:

Answer 6

1) Desire/interest dysfunctions, which describes issues with sexual fantasies and the wish to engage in sexual activity
2) Arousal dysfunctions, which are characterized by concerns related to the subjective feelings of sexual pleasure and associated with psychological changes (e.g., erection)
3) Orgasm dysfunctions, which are problems with the timing of the release of sexual tension
4) Genito-pelvic pain/penetration disorder (GPPD), which describes issues that prevent vaginal penetration (e.g., pain, anxiety about penetration).

It is important to note that these are highly comorbid, especially for women.

Question 7

When is onset “lifelong”?

Answer 7

When a sexual dysfunction appears to have always been present; if the sexual dysfunction appeared after a period of non problematic experiences then the onset would be considered “acquired”

Question 8

Context is specified as “situational” when…

Answer 8

the sexual dysfunction is restricted to certain types of stimulation, situations, or partners, whereas a “generalized” dysfunction indicates that the dysfunction occurs in all experienced circumstances

Question 9

In the case of PE, how would severity be designated?

Answer 9

mild - ejaculatory latency between 30-60 seconds
moderate - ejaculatory latency between 15-30 seconds
Severe- ejaculatory latency within 15 seconds or prior to the start of sexual activity

Question 10

Distress Severity

Answer 10

Can be designated as mild, moderate, severe and should be documented for all sexual dysfunctions, except for premature ejaculation (PE).

Question 11

Sexual desire disorders affect?

Answer 11

15-25% of men and women under 60
40-50% of men and women over 60

Question 12

Does DSM-5 consider desire dysfunctions and arousal dysfunctions as distinct?

Answer 12

desire dysfunctions and arousal dysfunctions are distinct for men (i.e., there are separate diagnosis for HSDD and ED), but this distinction is not made for women.
Based on research that women experience a higher amount of overlap in perceptions of sexual desire and arousal than men and that parallel criteria for HSDD in men and women do not accurately represent women’s experiences with sexual desire, thereby leading to over diagnosis to HSDD in women.

SIAD replaces the HSDD for women,

Question 12

HSDD

Answer 12

Hypoactive sexual desire disorder

A desire/interest sexual dysfunction disorder for males

Question 13

SIAD

Answer 13

Sexual Interest/arousal disorder

A desire/interest sexual dysfunction disorder for females

Question 14

What sexual dysfunctions are under the orgasm category?

Answer 14

Delayed ejaculation (DE) - Male
premature ejaculation (PE) - Male
Orgasm disorder (OD) - Female

Question 14

When is the diagnoses of HSDD made?

Answer 14

when a client describes persistent or recurrent deficient (or absent) sexual/erotic thoughts or fantasies and desire for sexual activity

Question 15

SIAD is characterized by at least 3 out of these 6 symptoms

Answer 15

absent/reduced
1) interest in sexual activity
2) sexual/erotic thoughts or fantasy
3) sexual excitement/pleasure during sexual activity in almost all, or all (75-100%) sexual encounters
4) Sexual interest/arousal in response to any internal or external sexual/erotic cues
5) Genital/nongenital sensations during sexual activity (75-100% of encounters)
6) no-reduced initiation of sexual activity and typically unreceptive to a partners attempts

Question 16

A diagnoses of ED is made when at least one of the following 3 symptoms are experienced on all or almost all (75-100%) sexual encounters

Answer 16

Marked difficulty in obtaining or maintaining an erection
Marked decrease in erectile regidity

Question 17

What is the prevalence of ED?

Answer 17

1-10% under the age of 40
2-15% age 40-49
10-25% age 50-59
20-40% age 60-69
50-100% age 70 and olrder

Question 18

Orgasmic Disorders consist of

Answer 18

OD in women
DE and PE in men

Question 19

OD is characterized by at least one of the following symptoms in at least 75-100% of encounters

Answer 19

marked delay in
marked infrequency of
or absence of orgasm and markedly reduced intensity of orgasm sensation

OD affects approx 16-25% of women, some cases reporting higher rates for women over 50

Question 20

GPPPD

Answer 20

Genito-pelvic pain disorder is restricted to only females.

Diagnosis involves persistent or recurrent difficulties with at least one of the following:
1) vaginal penetration during intercourse
2) marked vulvovaginal/pelvic pain during vaginal intercourse of penetration attempts
3) marked fear/anxiety about vulvovaginal/pelvic pain in anticipation, during or as a result of vaginal penetration
4) marked tensing of tightening of the pelvic floor muscles during vaginal penetration

Prevalence of 10-28%. But specific rates depend on type of condition (e.g., pelvic pain, vulvodynia)

Question 21

Sexual functioning is a complex biopsychosocial process

Answer 21

Biological factors: general physical health, specific health conditions, medications/treatments, diet, exercise, sleep, alcohol/drug use

Psychological: anxiety, and depressive symptoms, stress, and coping skills

Social: Individuals’ experience with their family, peer, sexual partners and larger context within how/where they were raised. Historical factors can influence current sexual function.

Question 21

What is the main technique to asses and diagnose sexual dysfunctions?

Answer 21

Clinical Interview

Question 22

What medications can impact sexual functioning?

Answer 22

Antidepressants, anti psychotics, and anti-hypertensives can detrimentally affect sexual functioning.

Question 23

Male sexual dysfunctions

Answer 23

Hypoactive Sexual Desire Disorder
Erectile Dysfunction
Delayed Ejaculation
Premature Ejaculation

Question 24

HSSD Etiology

Answer 24

Sexual desire is a subjective state that includes psychological, physiological, affective and cognitive components to initiate and maintain sexual behaviour.
It is linked to sexual arousal and comprises of 3 biopsychosocial elements:
1) Drive (biological component)
2) Motivation (psychological component)
3) Wish (cultural component)

Early studies on etiology focused on role of hormones (androgens), ended up being nonlinear and therefore is clear that other factors than hormones play a role in experiencing desire.

HSSD has been associated with biological factors such as aging, medical conditions, and psychotropic and other medications.

Psychosocially - mental health problems like anxiety, depression, PTSD, alexithymia, the presence of other sexual dysfunctions and the lack of erotic thoughts and presence of sexually dysfunctional beliefs have been associated with low desire.

Question 25

ED Etiology

Answer 25

Associated with numerous biological factors such as neurogenic (spinal cord injury), peripheral (sensory neuropathy due to diabetes), endocrinology, efferent (due to radical pelvic surgery), vasculogenic (artery, venous).

ED is a well established predictor of cardiovascular disease.

Antidepressants, cigarette smoke, alcoholism and use of recreational drugs, systemic diseases and general ill health (obesity, hypertension) are associated with ED.

As well as anxiety and depression and lower relationship happiness.

Cognitively men with ED tend to make more internal and stable causal attributions for sexual events than do men without ED.

Question 26

DE etiology

Answer 26

Delayed ejaculation is associated with genetic factors, congenital anatomical factors (wolffian duct abnormalities), neurogenic causes (multiple sclerosis), infections/inflammation (prostatitis), endocrine issues (hypergonadism) and medications (SSRI’s).
Fear (pregnancy, loss of control, intimacy), autosexual orientation (preference for masturbation to partnered activity)

Question 27

PE Etiology

Answer 27

Premature ejaculation can include genetics, anxiety, faster reflexes involved in ejaculation, prostatic inflammation/infection, sexual conditioning (masturbating quickly and efficiently), low frequency of ejaculation, younger age, erectile disorder, greater capacity for partial erection, greater prevalence of hyperthyroidism, and life stressors such as relationship or work dissatisfaction.

Question 28

Female sexual dysfunctions

Answer 28

Sexual Interest/Arousal Disorder
Orgasmic disorder
Genito-pelvic pain/penetration disorder

Question 29

Female Sexual Interest/Arousal Disorder (SIAD)

Answer 29

• SIAD are among the most frequent reasons for seeking sex therapy

A result for hypofunctional excitation, hyperfunctional inhibition, or both.

-Lower estrogen levels in menopause

-Evidence is mixed between oral contraceptives and link to lower desire

-Activation and inhibition of the sympathetic nervous system is linked to physiological sexual arousal

-Societal pressures may contribute to SIAD

-Childhood victimization has adverse effects on internal sexual scripts and later sexual function

-Cognitive distraction, negative sexual attitudes, performance anxiety, and body image concerns direct attention away from erotic cues and can interfere with arousal and desire,

-Depressive symptoms and low self esteem are also correlated with SIAD

-Feelings of over-familiarity, institutionalization of marriage and desexualization of roles in relationship were reasons women expressed low desire.

-In quantitative research, sexual difficulties in the partner, poor sexual compatibility and relationship dissatisfaction are linked with SIAD.

Although there is evidence that relational factors better account for women’s low desire then biomedical, the scarcity of studies cannot confirm causality.

Question 30

Orgasmic disorder etiology

Answer 30

hypofunctional excitation

hyperfunctional inhibition

illnesses that cause damage to the blood vessels or nerves (diabetes, hypertension, smoking, spinal cord injury, pevlic surgery, rectal cancer), pelvic floor dysfunction

Antidepressants, mood stabilizers

Inadequate, erotic stimulation during partnered sexual activity or negative evaluation of the stimulus or context (relationship factors) are the most common causes of OD

Question 31

GPPPD etiology

Answer 31

resulting from either Physical or psychological factors

Physical such as endometriosis, interstitial cystitis, lichen sclerosis, and other genital infections as well as events such as childbirth and menopause.

Provoked vestibulodynia (VPD) an acute recurrent pain localized in the vulvar vestibule is the most frequent cause in premenopausal women.

Psychosocial processes also play a role in the onset and maintenance of GPPPD

Childhood victimization is a major determinant

Anxiety and depression have been found to be robust affective precursors, consequences and maintenance factors

Cognitive factors are associated with greater pain intensity and sexual dysfunction, and include pain catastrophizing, hypervigilence to pain, lower pain self-efficacy, negative attributions about the pain, perceived injustice, negative cognitions about penetration, pain acceptance and self-compassion.

Avoidance of pain and sexual activity is the core behavoural factor that may exacerbate GPPPD

Distal interpersonal factors that play a role in GPPPD include intimacy, romantic attachment, ambivilance over emotional expression, and sexual communication

Question 32

retrograde ejaculation

Answer 32

sperm travels to bladder instead of out of penis

Question 33

Sexual dysfunction interventions

Answer 33

Both medical and psychological interventions exist for treatments and a combination of both has been shown to be more successful than one type of treatment alone.

Note that medical treatments tend to differ based on the sexual dysfunction but psyhcological treatments tend to highlight similar techniques and skills

Question 34

HSDD Treatment

Answer 34

two sometimes overlapping categories: sex therapy and pharmacotherapy

Sex therapy for men with HSDD include:
-decreasing inhibitory (distracting thoughts, performance anxiety)
-increasing excitatory (sexual fantasies, focusing on pleasure)
Using sensate focus and increasing knowledge about sexual techniques and pleasure/eroticism

Men with androgen deficiency who recieve testosterone replacement improves sexual function

Question 35

Erectile Disorder Treatment

Answer 35

First line option is pharmacological - PDE5 inhibitors are the treatment of choice.
Side effects include headache, flushing, dyspepsia, and nasal congestion and cannot be taken with certain other medications due to fatal interactions (e.g., nitrates).
Some form of sexual arousal is needed for PDE5 inhibitors to work.

Second line treatment choices:
- intercarvernosal injections (inject erectogenic drugs into penis, erection ocurs within 10 minutes and side effects include mild pain and priaprism)
-transurethral therapy (injection of erectogenic drug in the form of a pellet into the urethra, side effects include penile and/or urethra pain, syncope and priaprism) which lead to predictable erections for a period of time.

Non-pharmacological treatments include vacuum constrictive devices (mechanical and “cold” in terms of sensation), penile prosthesis (surgical implantation of semirigid or inflatable - a last resort treatment due to damages and complications) , and sex or couple therapy .

Question 36

Psychological intervention is often recommended for ED for three main reasons

Answer 36

1) Lack of negative physical side effects
2) the reestablishment of sexual functioning
3) the increase of sexual satisfaction beyond symptom reduction

Question 37

Delayed Ejaculation Treatment

Answer 37

Usually medical if acquired or lifelong. Some off label medications treat this condition.

If lifelong and congenital abnormalities are ruled out and off-label med’s are unsuccessful or declined then psychological intervention targeting multiple areas specific to the client (lack of sexual knowledge, fear of getting pregnant) can be useful.
Sensate focus can be useful in reducing performance anxiety and maximizing pleasure, masturbation retraining can be beneficial. Reducing the amount of masturbation is also recommended.

Question 38

Premature Ejaculation (PE)

Answer 38

Local topical anesthetics
SSRI;s off label
tramadol
PDE5 inhibitors
alpha-adrenegic blockers

Some experts recommend that all men experiencing PE should psychological intervention, which include:
-education to dispel myths about ejaculatory latency time
-strategies to increase latency time and gain confidence in sexual performance
-decrease performance anxiety
-modify rigid sexual repertoires
-increase intimacy
-address maintaining factors in the relationship
-increase effective communication
-Tackle thoughts and feelings that interfere with sexual function

Question 39

SIAD Treatment

Answer 39

To date most couple used psychological interventions
Two medications are now approved in the U.S FDA:
1) Flibanserin; premenopausal women, taken nightly and not mixed with alcohol
2) Bremolanotide; injection prior to sexual activity

CBT improves women’s sexual desire, but not satisfaction - although one study suggested that including the partner in the CBT may be helpful with this

Mindfulness based group therapy appears promising for sexual desire, satisfaction and functioning

Question 40

Orgasmic disorder Treatment

Answer 40

Education about women’s sexual response and sexual anatomy, directed masturbation, sexual skills training, and sensate focus in order to generalize newly learned skills to partnered sexual activity.

CBT sex therapy interventions - medium effect in improving women’s orgasmic capacity and satisfaction. Psychological interventions are effective in helping women achieve orgasmic success, whether secondary or primary,

Question 41

GPPPD Treatment (Genito-pelvic pain/penetration disorder)

Answer 41

Often receive first line medical treatment, which can include topical applications and oral medications.
Most common - topical lidocaine, tricyclic antidepressants - however recent guidelines suggest lack of evidence in their efficacy and point towards psychological interventions and pelvic floor physical therapy as the best approach.

CBT generally focuses on reducing pain, improving sexual function as well as relationship satisfaction by targeting the cognitive, behavioural, and affective and relationship factors associated with GPPPD

CBT has been shown superior to first line topical application.
Multimodal physical therapy showed consistent effectiveness

Question 42

Sexual dysfunctions are most often treated with 2nd and 3rd generation CBT’s. Hypothesized mechanisms of change and targets of intervention include:

Answer 42

1) reconceptualizing sexuality as a relational phenomena where both members of a couple function as a team to improve their sexual well-being
2) Facilitating intimacy
3) reducing sexuality-related anxiety
4) promoting communication of sexual needs and preferences
5) fostering self-efficacy

Question 43

Sexual dysfunctions are highly comorbid with other mental health and medically relevant conditions - what comorbidities are common?

Answer 43

mood disorders with sexual dysfunctions

In men, depression associated with high risk of ED

In women, depression and anxiety were both related to GPPPD

45% of women with GPPPD report cormorbid pain condition

Male partners of women with GPPPD report increased rates of psychological distress, ED, and decreased sexual satisfaction

Women with SIAD report more depressive symptoms and anxiety

Question 44

Agender

Answer 44

refers to someone who has no gender. It can be an identity (e.g., I am agender) or refer to someone’s existence (e.g., this person has no gender, and so is agender).

Question 45

All gender

Answer 45

This refers to inclusiveness of all gender expressions and identities

Question 46

Androgynous

Answer 46

This refers to people, experiences, and/or expressions that involve both femininity and masculinity, a mix of them, neither of them, or something in between.

Question 47

Assigned Sex / Assigned Female / Assigned Male

Answer 47

These are terms that identify the gender people were assigned or designated at birth apart from their current gender. These terms can be useful because they can avoid essentializing people by their birth-assigned gender/sex and are thus more accurate than terms like biological female/male, genetic male/female, natal female/male. However, in the absence of a compelling reason to use these terms for identification and/or grouping purposes, they can be problematic because they still put birth assignment ahead of current gender and thus can end up essentializing people by birth-assigned gender/sex after all.

Question 48

Autogynephilia:

Answer 48

This is a contested term in academic circles, and widely disliked and disagreed with within trans communities. Autogynephilia is hypothesized as a paraphilia (see ‘paraphilias’ for more), and used to refer to transgender women whose birth-assigned sex was male and who are aroused at the thought of themselves as a woman; autogynephilia posits this arousal as the reason for transition. The term is used by a small group of people, including researchers, clinicians, and/or transgender women, but is otherwise seen as offensive and reflecting a pathologizing and stigmatizing framework. This concept also overlooks the arousal of many different kinds of people who may feel good about a gendered aspect of their identity or presentation.

Question 49

Bigender/Bi Gender

Answer 49

This refers to people who identify with both a feminine and masculine gender, move between masculine and feminine gender-typed behavior depending on context, express a distinctly feminine and distinctly masculine persona, and/or have two separate genders in one body.

Question 50

Cisgenderism

Answer 50

This refers to the belief/ideology/framework that assumes gender (and/or sex, sometimes intertwined) to be assigned at birth, and that this is right, natural, universal, healthy, acceptable, and inherent to human existences. This often has the effect of delegitimizing people’s own understandings of their bodies and genders. Cisgenderism includes laws, structures, relations, concepts, and utterances that naturalize cisgender with the implicit and/or explicit othering, stigmatizing, pathologizing, and/or discriminating against transgender and non-cisgender people. Cisgenderism is closely related and to and sometimes used synonymously with cissexism (see next).

Question 51

Cissexism

Answer 51

This refers to the belief/ideology/framework that assumes that cisgender is the only and/or right form of gender and/or sex. It involves prejudice, stereotyping, and/or discrimination against people with transgender identities, backgrounds, and/or experiences. Cissexism can be understood in relation to sexism, with sexism negatively impacting women, and cissexism negatively impacting people with trans identities, backgrounds, and/or experiences. Cissexism is closely related to and sometimes used synonymously with cisgenderism (see previous).

Question 52

FTM / F2M / FtM

Answer 52

This refers to the direction of transition in men, i.e., from “female” (assigned at birth) to “male”. It is used by some people, but also seen as outdated and potentially reflective of a biomedical or even pathologizing framework

Question 53

Gender Binary / Binary Gender (or Sex Binary / Binary Sex)

Answer 53

Some people (and this can include some trans and some cis people) see a gender binary with either women/girls and men/boys as the only options. This is often based (explicitly or implicitly) on ideas of a sex binary, with only female and male categories. Some people do not see the world as divided into men/boys/males and women/girls/females, but do experience their own gender and/or sex as binary (and this can include some trans and some cis people).

Question 54

Intersex

Answer 54

This term refers to people who are seen as having bodies (anatomical, reproductive, physiological, genetic, etc.) that do not fit into binary female or male expectations, apparent at birth and/or in later development. It also can include a degree of unwanted and/or unconsented to medical attention or intervention, especially within childhood, that may or may not have been kept secret from the individual. Intersex can be an identity and/or refer to a set of experiences, and can also refer to political mobilization. People who identify as intersex can also identify as cisgender or transgender, or neither. And the term can sometimes be used to refer to the experience, bodies, existence, condition, or diagnosis in addition to an identity.

Question 55

Gender majority

Answer 55

This refers to those who see themselves or are seen as existing within cultural norms for their gender, any gender, and/or a gender binary, usually cisgender, and do not experience stigmatization, marginalization, and/or restriction of rights on this basis. It is not necessarily a numerical term referring to frequency but, instead, refers to a sociocultural position in cultures relative to those who have restricted access to mainstream and/or normative power structures.

Question 56

Framings - cause

Answer 56

Because trans and transgender experiences, identities, and existences were historically studied as a disease, researchers were interested in its causes, in part to understand ‘abnormal’ gender or to help inform insights about ‘normal’ gender. Accordingly, many people are rightly suspicious about research into the ‘causes’ of being transgender, since this was part of a project that saw being transgender as a disease and abnormality. And, since impact matters at least as much as intent, many people’s concerns will not be eliminated by statements or professions of non-transphobia or ’trying to help’.

Question 57

Framings - choice

Answer 57

Transgender existences are highly stigmatized in most cultures, including Western ones where some rights for transgender people exist, but those rights are often transient or not fully implemented. Part of this stigmatization includes suggesting that being trans is a choice or lifestyle, but there is nothing inherently stigmatizing about choosing; instead, the language of choice is often used as a part of stigmatizing or marginalizing rhetoric. It is important to avoid reifying the link between choice and stigma by suggesting that choice is impossible or unlikely or by using choice alongside other stigmatizing arguments. And, many if not the majority of trans people experience their need to transition outside a choice framework and instead as a need, and it is critical to reflect and respect that.

Question 58

Gender dysphoria

Answer 58

This refers to a diagnostic label from the American Psychiatric Association’s fifth/2013 edition of the Diagnostic and Statistical Manual of Mental Disorders in which a person must be experiencing a marked difference between their expressed/experienced gender and the gender assigned to them at birth for at least six months, and it must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. In children, there must be a desire to be the ‘other’ gender that is present and verbalized. Many researchers, clinicians, and trans individuals view this language as pathologizing and problematic, and many others do not.

Question 59

Framings - Kink

Answer 59

(see also paraphilia) Historically, and more limited at present, being trans (usually using the language of transsexual) was seen as related to an error or atypicality of gender and sexuality, since the two were seen as intertwined. This means that transgender people were often treated by those who saw their existences as a kink, or who saw attraction to transgender people as a kink. Health practices have generally moved well beyond this framework, which is very much seen as outdated and extremely offensive. While this may relate in some way to the stigmatization of kink, it more relates to the generally inaccurate outdated/offensive framing of being trans as a sexual rather than gender issue. It is important to not add to the stigmatization of kink when clarifying why being trans is not and should not be framed as a kink issue.

Question 60

Transgender and gender nonconforming (TGNC)

Answer 60

Although many of the more nuanced experiences of identifying
as transgender remain obscured, there is growing recognition among researchers, clinicians, trans activists, and their allies that gender is multidimensional and not binary

Question 61

Transgender-affirmative cognitive behavior therapy (TA-CBT

Answer 61

TA-CBT is a version of CBT that has been adapted to
ensure practitioners recognize specific sources of stress among TGNC individuals
and also to deliver CBT content within an affirming and trauma-informed framework

Question 62

TGNC individuals experience disproportionate rates of psychological distress such as

Answer 62

suicidality, depression, and anxiety, compared with their cisgender counterparts. 17–20 Growing research highlights particularly high rates of suicidality among TGNC individuals.

-found that 54% of participants had experienced suicidal ideation and
28% had previously attempted suicide.
-Even higher rates of attempted suicide (45%) were found among respondents (aged 18–24 years) in the National Transgender Discrimination Survey.
-emerging research suggests that lifetime prevalence rates of nonsuicidal self-injury are also notably high (42%) among transgender adults in the United States.

Question 63

What is critical for providing culturally informed mental health care to TGNC individuals?

Answer 63

Understanding the effects of posttraumatic stress disorder (PTSD) and other trauma-related disorders.

Preliminary evidence indicates that transgender persons who have been exposed to violence
and other traumatic events experience high levels of posttraumatic symptoms.

Moreover, gender nonconformity in childhood is associated with greater exposure
to potentially traumatic events and the subsequent development of PTSD.

Controversy persists in that many TGNC individuals show symptoms consistent with a
PTSD diagnosis, but they are exposed to events that do not meet the definition of
trauma in the Diagnostic and Statistical Manual of Mental Disorders

Question 63

What is the core behavioural factor that may exacerbate symptoms of GPPPD?

Answer 63

Avoidance of pain and penetration

Question 64

What are distal COGNITIVE factors in sexual dysfunctions?

Answer 64

Social pressure
Value discrepancies between partners (type and frequency)
Work dissatisfaction/stress
Cultural/religious related norms

Question 65

What are distal AFFECTIVE factors in sexual dysfunctions?

Answer 65

Childhood trauma and associated difficulties with trust and intimacy, as well as an insecure attachment style

Question 66

Social connectedness with the transgender community may be facilitated through the use of

Answer 66

Information and communication technologies (ICTs).

ICTs (eg, transgender-specific YouTube channels or Facebook groups) are frequently used to obtain transgender-specific knowledge (eg, understand transgender identities or locate trans-affirming doctors)
and to connect with other transgender individuals, when it is unsafe to be “out” in their physical environments.

Question 67

Social connectedness

Answer 67

-Can foster resilience
-and with the broader transgender community contributes to increased comfort with a per-
son’s transgender identity and better behavioral health
-represents an important component of affirmative
interventions for TGNC individuals

Question 68

TRANSGENDER-AFFIRMATIVE CLINICAL APPROACHES

Answer 68

-make known, an affirming clinical position that recognizes all experiences of gender as equally healthy and valuable
-must acknowledge and counter the oppressive contexts of the lives of TGNC individuals
-attend to policies regarding access to services based on gender identity versus assigned sex at birth and the use of gender-neutral rest-rooms, the development of transgender-inclusive promotional materials (eg, pamphlets, Web pages), and the use of inclusive language on intake and other forms of documentation
-how gender inclusivity at the moment of first contact with their clients.
-Unconditional positive regard for the diversity of transgender identities and expressions that is integrated throughout all interactions with transgender individuals is perhaps the most fundamental component of a transgender-affirmative (TA) clinical practice
-clinicians must diligently engage in self-exploration regarding their personal gender-related attitudes, beliefs, and biases
-Interventions attending to the specific needs of transgender individuals should be implemented and practiced with competency, and this requires clinicians who are committed to developing
transgender-specific knowledge and skills.

Question 69

TA-CBT is a version of CBT that has been adapted to ensure:

Answer 69

1. An affirming stance toward gender diversity
2. Recognition and awareness of transgender-specific sources of stress (eg, trans-phobia, gender dysphoria, systematic oppression)
3. The delivery of CBT content within an affirming and trauma-informed framework

Question 70

Given the traumatic experiences often precipitated by minority stress among
TGNC individuals, a critical component of TA-CBT is?

Answer 70

that it is grounded in an understanding of the pervasiveness and consequences of transgender stigma and preju-
dice

Question 71

From a CBT perspective, embracing a trans-affirming worldview can decrease…

Answer 71

troubling emotional responses (eg, shame, anxiety) and subsequent maladaptive
behavioral responses

Question 72

Components of Transgender-affirmative Cognitive Behavior Therapy

Answer 72

-Assessment and case conceptualization
-Self-regulation
-Psychoeducation
-Modifying negative thinking
-Behavioral activation

Question 73

TA-CBT Assessment and case conceptualization

Answer 73

-understanding the clients’ presenting issues within the context of early learning experiences, because these lead to the development of core beliefs that may contribute to and/or exacerbate current problems.

-During the early phases of assessment and case conceptualization in TA-CBT it is important
to explore clients’ early experiences of recognizing and understanding their own gender identity.

-During assessment and case conceptualization, clinicians should explore clients’ thoughts and beliefs about their transgender identities and experiences through sensitive and affirming questions.

• it is important to explore transgender-specific stressors across multiple domains of life (e.g, family, school/work, sexuality, spiritual life), as well as during the various phases of transitioning/living authentically (eg, pretransition, transition, or posttransition).

-It is important to remember that not all gender-diverse clients want to transition or seek services related to transitioning

Question 74

TA-CBT Self-regulation

Answer 74

it is important that clinicians help clients achieve a relaxed body and mind before they begin to
recount traumatic experiences. Strategies for teaching clients to self-regulate may
include deep breathing, progressive muscle relaxation, or mindfulness.

Only when clients achieve a relaxed body and mind can they safely explore potentially traumatic
histories that may be contributing to presenting clinical issues.

Question 75

TA-CBT Psychoeducation

Answer 75

There are 2 primary goals of the psychoeducational component in TA-CBT:

1. To help clients develop a basic understanding of the theoretic underpinnings of
   cognitive behavioral approaches to promoting health and well-being through an
   introduction to the cognitive model; that is, the relationship between thoughts,
   emotions, and behaviors
2. To help clients to understand the potentially traumatic impact of transphobic
   discrimination and prejudice and its contribution to feelings of distress

Psychoeducation component provides the opportunity for clients to identify and explore painful and traumatic effects of discrimination, victimization, and violence within a supportive and safe environment.

clients can begin to move away from a view of themselves as abnormal, weak, or disordered toward a more accurate view of themselves as ordinary individuals navigating exceptionally stressful and often traumatic circumstances.

Question 76

TA-CBT Modifying negative thinking

Answer 76

A critical component of most CBT interventions is to identify and modify automatic
thoughts, as well as related intermediate and core beliefs, through the use of a variety
of effective strategies.

One strategy that may be particularly important for transgender individuals is to evaluate the intermediate and core beliefs underlying their
negative automatic thoughts within a transgender-affirming context.

Question 77

Intermediate beliefs

Answer 77

Intermediate beliefs are
defined as conditional rules, attitudes, and assumptions, often unspoken, that significantly affect the way in which individuals respond to life’s challenges and stressors

Question 78

cognitive reactions are often referred to as

Answer 78

Automatic thoughts

Question 79

Automatic thoughts

Answer 79

are described as words, phrases, or images that spontaneously
occur in an individual’s mind in response to specific situations and circumstances