Paraphilic Disorders and Gender Dysphoria

• The presentation covers paraphilic disorders and gender dysphoria
• The objective is to enable students to diagnose patients with these conditions and recommend initial treatment

Specific Objectives

• Describe the epidemiology, biological factors, and psychosocial effects of gender dysphoria
• Diagnose gender dysphoria based on diagnostic criteria
• Describe the clinical features, course, and prognosis of gender dysphoria
• Formulate treatment recommendations for gender dysphoria
• Define paraphilia
• Diagnose paraphilic disorders based on clinical presentation and DSM 5 criteria
• Describe the management of paraphilic disorders

Terminology

• Cisgender: Gender identity matches sex assigned at birth
• Transgender: Gender identity does not align with sex assigned at birth
• Nonbinary: Gender identity is not exclusively male or female
• Genderfluid: Gender identity changes over time
• Sex: Biological and anatomical status assigned at birth (male, female, or intersex)
• Sexual orientation: Physical, romantic, sexual, and emotional attraction to others
• Gender identity: Internal sense of being male, female, both, or neither, usually acquired by age 3
• Gender expression: Outward presentation of gender identity through appearance and behavior

Gender Dysphoria

• Refers to distress from incongruence between experienced gender and assigned gender
• DSM-III and IV referred to transsexualism and gender identity disorder
• DSM-5 moved towards depathologizing discordant gender identity, focusing on clinically significant distress or dysfunction
• The DSM-5-TR diagnosis of gender dysphoria reflects a subset of patients with unhappiness tied to the discordance between their bodies and their sense of self

Epidemiology of Gender Dysphoria

• Estimated prevalence is approximately 4.6 per 100,000, likely an underestimate
• Studies including individuals receiving hormone therapy, gender-affirming surgery, or transgender diagnostic codes report a prevalence of 7 to 9 per 100,000

Diagnostic Criteria for Children

• Marked incongruence between experienced/expressed gender and assigned gender for at least 6 months
• Manifested by at least six of the following, including Criterion A1:
  • Strong desire to be of the other gender
  • Preference for cross-dressing or simulating female attire (boys) or wearing only masculine clothing (girls)
  • Preference for cross-gender roles in play
  • Preference for toys/activities stereotypically used by the other gender
  • Preference for playmates of the other gender
  • Rejection of typical masculine toys/activities (boys) or feminine toys/activities (girls)
  • Dislike of one's sexual anatomy
  • Desire for primary/secondary sex characteristics matching experienced gender
• The condition is associated with clinically significant distress or impairment in social, school, or other areas

Sex Development Disorders

• Congenital adrenal hyperplasia and androgen insensitivity syndrome are examples
• Female infants may be diagnosed with ambiguous genitalia but have normal internal female organs
• Male infants may appear normal, but boys may show rapid growth and early puberty
• Untreated CAH can lead to weight loss, vomiting, dehydration, and other severe symptoms
• Androgen insensitivity syndrome affects sexual development before birth and during puberty
• People with androgen insensitivity syndrome are genetically male but may have mostly female external sex characteristics

Diagnostic Criteria for Adolescents and Adults

• Marked incongruence between experienced/expressed gender and assigned gender for at least 6 months
• Manifested by at least two of the following:
  • Incongruence between experienced/expressed gender and primary/secondary sex characteristics
  • Desire to be rid of primary/secondary sex characteristics
  • Desire for the primary/secondary sex characteristics of the other gender
  • Desire to be of the other gender
  • Desire to be treated as the other gender
  • Conviction of having typical feelings/reactions of the other gender
• The condition is associated with clinically significant distress or impairment in social, occupational, or other areas

Specify Gender Dysphoria

• With a disorder/difference of sex development
• Posttransition: The individual has transitioned to full-time living in the experienced gender

Clinical Findings of Gender Dysphoria

• The disorder usually begins in childhood
• Early features in boys include overidentification with the mother and overtly feminine behavior
• Girls may show tomboyish behavior, which draws less attention
• Young children may show distress when told they are not "really" the other gender
• Adolescents and adults are more likely to experience distress, often mitigated by support

Comorbidity and Outcome of Gender Dysphoria

• Individuals may also experience anxiety, depression, and substance abuse
• Need to rule out other potential causes
• Changing one's anatomical gender might be part of a complex delusion in a person with schizophrenia
• Those seeking treatment found to have lower quality of life compared to controls
• Cross-sex hormonal treatment improves mental health quality of life

Treatment Options for Gender Dysphoria

• Hormone therapy and gender reassignment surgery (gender confirmation surgery)
• Male-to-female transition:
  • Hormones (estradiol, progesterone) to promote the development of secondary female characteristics
  • Laser treatment and electrolysis for hair removal
  • Surgery to remove testes/penis and create an artificial vagina (vaginoplasty)
• Female-to-male:
  • Mastectomy, hysterectomy, and oophorectomy
  • Testosterone to develop muscle mass and deepen the voice
  • Artificial penis construction

Gender Affirming Therapy

• Therapeutic stance that affirms a patient's gender identity
• Aims to avoid messages and behaviors that are hostile to gender diversity
• Addresses trauma, shame, and depression
• Addresses higher levels of suicidal ideation

Paraphilic Disorders Diagnosis

• Voyeuristic disorder
• Exhibitionistic disorder
• Frotteuristic disorder
• Sexual masochism disorder
• Sexual sadism disorder
• Pedophilic disorder
• Fetishistic disorder
• Transvestic disorder

Paraphilias

• Persistent and recurrent sexual interests, urges, fantasies, or behaviors of marked intensity involving atypical objects, activities, or situations
• Involve sexual arousal to atypical objects, situations, and/or targets
• Some paraphilias do not rise to the level of a paraphilic disorder

Paraphilic Disorder

• Requires a recurrent and intense sexual arousal from the anomalous preference
• Requires the person has acted on the urges and the urges have caused significant distress or impairment
• Must last at least 6 months

Voyeuristic Disorder Diagnostic Criteria

• Recurrent and intense sexual arousal from observing an unsuspecting person who is naked, disrobing, or engaging in sexual activity for at least 6 months
• The individual has acted on these sexual urges with a nonconsenting person
• The individual experiencing the arousal and/or acting on the urges is at least 18 years of age
• Voyeurism often an expression of sexual curiosity in adolescents
• Specify if:
  • In a controlled environment
  • In full remission

Exhibitionistic Disorder Diagnostic Criteria

• Recurrent and intense sexual arousal from exposure of one's genitals to an unsuspecting person for at least 6 months
• The individual has acted on these sexual urges with a nonconsenting person
• The urges cause clinically significant distress or impairment in social, occupational, or other areas of functioning
• This disorder accounts for about one-third of sexual offenders referred for treatment
• Antisocial history, antisocial personality disorder, alcohol misuse, and pedophilic increase risk
• Differential Diagnosis: manic episode, major neurocognitive disorder, intellectual developmental disorder
• Specify whether sexually aroused by exposing genitals to prepubertal children, physically mature individuals or both
  • In a controlled environment
  • In full remission

Frotteuristic Disorder Diagnostic Criteria

• Recurrent and intense sexual arousal from touching or rubbing against a nonconsenting person for at least 6 months
• The individual has acted on these sexual urges with a nonconsenting person
• Behavior tends to occur in crowded places, and involves rubbing the genitals against another person or touching their genitals/breasts
• Frotteurism occurs mostly in the 15- to 25-year age group
• Differential Diagnosis: manic episode, major neurocognitive disorder, intellectual developmental disorder
• Specify if:
  • In a controlled environment
  • In full remission

Sexual Masochism Disorder Diagnostic Criteria

• Recurrent and intense sexual arousal from being humiliated, beaten, bound, or otherwise made to suffer for at least 6 months
• The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning Specify if:
  • With asphyxiophilia
  • In a controlled environment
  • In full remission

Sexual Sadism Disorder Diagnostic Criteria

• Recurrent and intense sexual arousal from the physical or psychological suffering of another person
• The individual has acted on these urges with a nonconsenting person Specify if:
  • In a controlled environment
  • In full remission
• Individuals engaging in masochistic behavior are at risk for accidental death

Pedophilic Disorder Diagnostic Criteria

• Recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving sexual activity with a prepubescent child (generally age 13 or younger) for at least 6 months
• The individual has acted on these sexual urges, or the sexual urges or fantasies cause marked distress or interpersonal difficulty
• The individual at least 16 y.o. and at least 5 years older than child Specify whether:
  • Exclusive type (attracted only to children)
  • Nonexclusive type
  • Specify if:
  • Sexually attracted to males, Sexually attracted to females, Sexually attracted to both
  • Specify if:
  • Limited to incest

Pedophilia

• Individuals may experience an emotional and cognitive affinity with children, sometimes referred to as emotional congruence with children
• Psychatric comorbidity of pedophilic disorder includes substance use disorders
• Many become aware during puberty

Fetishistic Disorder Diagnostic Criteria

• Recurrent and intense sexual arousal over a period of at least 6 months
• Arousal is from either the use of nonliving objects or a highly specific focus on nongenital body parts
• Clinical significant distress or impairment of functioning

Fetishistic Disorder

• Not common in adults
• In early adulthood

Transvestic Disorder Diagnostic Criteria

• Recurrent and intense sexual arousal from at least 6 months from cross-dressing
• Specifiy if:
  • With fetisihism - If aroused by fabrics, or garments
  • With autogynephillia - if aroused by thoughts or images of self as a woman Specify if:
  • In a controlled environment
  • In full remission
• Transvestic disorder is often found in association with other paraphilias

Epidemiology of paraphilic disorders

• Diagnostic concept of paraphilic orders is new and epidemiological orders don't exist
• Tend to be underreported by patients because of societal stigma
• Majority of individuals with paraphlic disorders are men

Paraphilic Etiology

• Combo of neurobiological, interpersonal, and cognative processes
• Freud thought sexual deviations resulted from failures of developmental processes

Paraphilic Disorder Treatment

• Cognitive-behavioral therapy
• Relaxation training
• Masturbatory satiaion
• Convet self sensitization
• Masturbatory conditioning

Paraphilic Pharmacological Treatment

• SSRIs and naltrezone, or Medroxy progesterone and Leuprolide