Gender Dysphoria: Study Notes

Paraphilic Disorders

• Paraphilias are considered "atypical sexual behaviors."
• DSM 5 requires an intense, persistent sexual interest other than sexual interest in genital stimulation or preparatory fondling with phenotypically normal, physically mature, consenting human partners to diagnose.
• Diagnosis requires both the presence of paraphilic urges and the existence of distress, dysfunction, and/or acting on the urges, for 6 months or more.
• Paraphilic interests can be exclusive or non-exclusive.
• Paraphilia is necessary but not sufficient for a diagnosis.
• Some paraphilias are generally harmless, while others violate laws.
• Canadian law does not prosecute voyeurism directly; instead, voyeurs are prosecuted under trespassing, indecent exposure, or public acts laws.
• Paraphilias are believed to occur mostly in males, but they may be overlooked in females.
• Knowledge of atypical behaviors comes from individuals who seek treatment or have been apprehended.
• DSM 5 outlines eight paraphilic disorders: voyeuristic, exhibitionistic, frotteuristic, sexual masochism, transvestic, sexual sadism, fetishistic, and pedophilic.

Exhibitionism

• Involves powerful, persistent urges and fantasies related to exposing genitals to unsuspecting individuals.
• Almost exclusively affects males and victims are typically female.
• Onset can be as early as 13, and usually declines after age 40.
• Typically, fantasies involve having sex with the female victim.
• It is believed an exhibitionist misinterprets a female’s response of shock or fear as sexual interest.
• A Canadian survey of 238 exhibitionists revealed that 0.5% sought an expression of fear from their victims, nearly 20% wanted no reaction, and 35% wanted the victim to have sexual intercourse with them.
• Obscene phone calls (scatologia) is not a specific category in the DSM 5; those who make obscene phone calls may experience significant distress and impairment.
• The caller is almost always male, and the victim is almost always female.
• Those who make obscene phone calls experience sexual arousal during the act; women doing so are more often motivated by anger.
• Individuals usually masturbate during or after making the call.

Fetishism

• Mild fetishes are relatively common
• DSM 5 classifies it as sexual urges focused on a non-genital body part (partialism), an inanimate object, or other stimulus, plus acting out urges, fantasies, or behaviours for at least 6 months causing distress or impairment.
• It cannot be an article of clothing associated with crossdressing or a sexual stimulation device, i.e., a vibrator.
• Almost any object can be a fetish and be used for sexual gratification in the absence of a partner.
• Approximately 75% are heterosexual and almost exclusively men.
• Object fetishes can be divided into two categories: media and form.
• “Media” fetishes focus on the material an object is made from, either hard (latex, leather, rubber, etc.) or soft (silk, lace, fur, etc.).
• “Form" fetishes focus on the shape of the object.
• Canadian Air Force colonel D. Russell Williams had a fetish.

Transvestism

• Involves recurrent and intense sexual arousal from cross-dressing, as manifested by fantasies, urges, or behaviors.
• Must result in significant distress or impairment.
• Can involve fetishism aroused by the fabric, materials, or garments.
• Can involve autogynephilia which is sexual arousal to thoughts or images of himself as a woman.
• Is almost exclusively in males, usually heterosexual, married, and from traditional families.
• Survey studies eliminate drag queens and entertainers, finding that about 87% are heterosexual, 60% are married, 65% are university graduates, and 93% prefer to completely crossdress.
• Some studies indicate the transvestite is often the eldest child, but information can be hard to obtain.

Frotteurism

• Involves recurrent and intense sexual arousal from touching (toucherism) or rubbing against a nonconsenting person.
• Must result in significant distress or impairment.
• Takes place on crowded buses, trains, subways, etc.
• Usually brief, and then the frotteurist masturbates with fantasies of consensual sex.

Voyeurism

• Involves recurrent, powerful sexual urges and related fantasies involving watching unsuspecting people, generally strangers, who are undressed, disrobing or engaging in sexual activity.
• Scoptophilia refers to the sexual pleasure that is derived from observing sexual acts and genitals.
• Canadian Criminal Code has no explicit provision against voyeurism; offenders are charged with trespassing at night, loitering, etc.
• Age of onset is usually before 15 years old.
• May or may not be dangerous.
• Involves entering the confines of a building or drawing attention of the subject to the fact that they are being watched.

Sexual Dysfunction

• Persistent or recurrent difficulties in becoming sexually aroused or reaching an orgasm (for 6 months).
• Clinically significant distress and disturbance in a person's ability to respond sexually or to experience sexual pleasure.
• Includes sexual desire disorders, sexual arousal disorders (females - interest/arousal disorder), orgasmic disorders, and genito-pelvic pain/penetration disorder.
• Varies along two dimensions: acquired or lifelong, generalized or situational.
• Sexual problems tend to be multi-causal.
• Sexual Response Cycle (W. Masters, & V. Johnson, 1966) categorized physiological sexual response into four phases based on their observations and measurements.
• Four phases indicate different levels of physiological arousal and involve vasocongestion which is the swelling of the genitals with blood, and myotonia which is muscle tension.

Sexual Desire Disorders

• Must be persistent, recurrent, and distressing (min of 6 months).
• Only women are described as having sexual interest/arousal disorder
• Low sexual desire is usually acquired and situational, whereas generalized, lifelong HSD is rare.
• For some, it can be a result of sexual desire discrepancy that is not a sexual disorder but a relationship problem.
• Women with sexual interest/arousal disorder report dissatisfaction with unresolved relationship problems and greater dissatisfaction with the relationship overall.
• Some possible causes of low desire include unresolved relationship problems, hormone deficiencies (testosterone), high prolactin, depression, antidepressant medication, anxiety, exhaustion, sleep deprivation, medical or thyroid problems, other medications, and age-related health issues.

Sexual Arousal Disorders

• Female Sexual arousal disorder indicates an inability to attain or maintain vaginal lubrication.
• This involves a persistent inability to attain or maintain vaginal lubrication.
• Can be caused by low estrogen levels, relationship problems, sexual trauma, or ineffective sexual stimulation.
• Male Erectile Disorder (aka erectile dysfunction, ED) is the inability to achieve or maintain an erection sufficient for penetrative intercourse to the satisfaction of both partners for a period of no less than 6 months.
• Occasional problems in achieving or maintaining an erection is relatively common and much more so among order men.
• Can be caused by performance anxiety
• Achieving and maintaining an erection depends on the PNS whereas ejaculation depends on the SNS.

Orgasmic Disorders

• Involves difficulty achieving an orgasm or achieving an orgasm too quickly that causes clinically significant distress.
• Female Orgasmic Disorder is recurrent difficulty having an orgasm or reduced orgasm intensity during almost all sexual activity
• Male Orgasmic Disorders can manifest as Delayed Ejaculation which is the inability to have an orgasm or the orgasm is greatly delayed, even though he has an erection and adequate stimulation
• Must be persistent or recurrent and cause significant distress, is usually acquired and situational, is more common among older males, and is often a result of medications such as antidepressants and antipsychotics.
• Premature (early) Ejaculation is the inability to control to his or his partner's satisfaction when he ejaculates
• Intra-vaginal ejaculatory latency (IELT) is when the man ejaculates within 60 seconds of penetration, 75% of the time for a min of 6 months
• This must result in distress and dissatisfaction
• Affects 1-3% of the male population; although a much higher percentage report poor ejaculatory control

Premature (early) female Orgasm

• Described as the inability to control to her or her partner's satisfaction when she has an orgasm that results in distress, and persists for a min of 6 months, however, this diagnosis doesn't exist in the DSM.
• Faking an orgasm is also not included in the DSM
• Surveys ask, "Have you ever faked an orgasm?"
• Up to 75% of women and 20% of men say yes
• 75% of women who fake an orgasm report faking more than 50 time
• Types of Sexual Dysfunctions
• Genito-pelvic Pain Penetration Disorder (aka sexual pain disorder)
• Dyspareunia is a medical term for painful intercourse
• Males often experience medical causes such as phimosis, paraphimosis, Peyronie's disease
• Females experience a lack of lubrication where deep pain may be caused by health or medical problems like endometriosis, PID, among others.
• Usually a combination of physical and psychological factors Vaginismus is when one experiences strong involuntary contractions of the muscles in the outer third of the vagina; reflexive response cause by a fear of penetration

Therapies/Treatment

• Sensate focus exercise which is a non-demanding, touching exercise Premature ejaculation Prolonging intercourse – frequent ejaculation, female-superior position, stop-start technique Erectile dysfunction which reduces anxiety/performance anxiety Sensate focus exercises Vaginismus/Dyspareunia Determine cause Self-awareness exercises, use of plastic dilators