Paraphilic Disorders and Gender Dysphoria

• The lecture covers paraphilic disorders and gender dysphoria, aiming to equip students with diagnostic and treatment skills applicable in general medical practice.
• Students are expected to describe epidemiology, factors, effects, clinical features, course, prognosis of gender dysphoria; diagnose gender dysphoria based on criteria and formulate treatment recommendations
• Students will define paraphilia, diagnose paraphilic disorders based on clinical signs and DSM 5 criteria, and describe their management.

Terminology

• Cisgender: Gender identity aligns with sex assigned at birth.
• Transgender: Gender identity doesn't align with sex assigned at birth.
• Nonbinary: Gender identity isn't exclusively male or female.
• Genderfluid: Gender identity changes over time.
• Sex: Biological/anatomical status 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/neither, typically acquired by age 3.
• Gender expression: Outward presentation of gender identity via appearance/dress/behavior.

Gender Dysphoria

• Refers to distress from incongruence between experienced gender and assigned gender.
• DSM-III/IV: Included transsexualism and gender identity disorder, highlighting discordant gender identity.
• DSM-5: Moved towards depathologizing discordant gender identity, focusing on clinically significant distress/dysfunction.

Epidemiology of Gender Dysphoria

• Estimated prevalence rate: 4.6 per 100,000, likely an underestimate.
• Prevalence in individuals receiving treatment: 7-9 per 100,000.

Gender Dysphoria Diagnostic Criteria in Children

• Marked incongruence between experienced/expressed gender and assigned gender for at least 6 months.
• Manifested by at least six indicators, wherein one must be a strong desire for the other gender,
• Indicators include: preference for cross-dressing, cross-gender roles, stereotypically other-gender activities, playmates of the other gender.
• There can be rejection of typical toys and dislike of one's sexual anatomy.
• There will be a desire for sex characteristics matching experienced gender.
• This is associated with clinically significant distress or impairment.

Gender Dysphoria Diagnostic Criteria in Adolescents and Adults

• A marked incongruence between experienced/expressed gender and assigned gender, of at least 6 months' duration, as manifested by at least two indicators.
• Indicators: incongruence between experienced gender and sex characteristics, desire to remove sex characteristics, desire for the sex characteristics of the other gender, desire to be the other gender, desire to be treated as the other gender.
• There could be conviction of feelings/reactions aligning with with gender identity.
• Causes distress or impairment.

Specify if

• With a disorder/difference of sex development (e.g., congenital adrenal hyperplasia, androgen insensitivity syndrome).
• Posttransition: When the individual has transitioned to full time living.
• The individual has undergone medical procedures or regular treatments.
• These include hormone or gender reassignment surgery.
• Regular treatments include breast augmentation surgery, and/or vulvovaginoplasty.
• Transmasculine individuals might pursue chest surgery, and/or phalloplasty or metoidioplasty .

Clinical Findings with Gender Identity

• Typically begins in childhood.
• Boys: May overidentify with the mother, have feminine behavior, dislike male pursuits/sports, and prefer girls as peers.
• Girls: May show tomboyish behavior.
• Young children show distress on the subject of gender.
• Adolescents/adults: Distress is seen more often especially impairment from school refusal to social isolation.

Comorbidity

• There is a higher chance for experiencing mental health problems like anxiety, depression, and substance abuse
• Distinguish gender dysphoria from other potential causes like schizophrenia.

Outcomes

• A meta-analysis showed mental health/ Life quality being lower in the transgender population.
• Cross-sex treatment was proven to improve mental health and quality of life.

Gender Dysphoria Treatment

• Many seek hormone therapy and gender confirmation surgery.
• Male-to-female: Involves estrogen, progesterone and remove the testes and penis, to create an artificial vagina.
• Female-to-male: Involves mastectomy, hysterectomy, oophorectomy, to develop muscle mass and artificial penis.

Gender Affirmation

• Focuses on affirming gender identity rather than "repairing" it.
• It acknowledges trauma being caused by gender diversity being discouraged.
• Associated with shame, and anxiety due to the feeling of being different
• Often involves depression, self harm and suicidal thoughts
• Violence and hate crimes are also connected.
• Those on a more diverse spectrum are still placed in "boxes".
• Requires exploring medical/ hormonal options.

Paraphilic Disorders Diagnosis

• Paraphilic disorders will involve sexual masochism disorder, voyeuristic disorder, transvestic disorder, pedophilic disorder, frotteuristic disorder, or exhibitionistic disorder.

Paraphilias

• Involve persistent, recurrent sexual interests, urges, fantasies, or behaviors of marked intensity.
• Involve atypical objects activities or situations.
• Involve sexual arousal to atypical objects, situations, and/or targets (eg, children, corpses, animals).

Paraphilic Disorder

• Requires recurrent and intense sexual arousal from anomalous preference.
• The person must act on urges causing distress and impairment in social, occupational, or other important areas.
• Duration must last at least 6 months.

Diagnostic Criteria: Voyeuristic Disorder

• Recurrent, intense sexual arousal from observing an unsuspecting person.
• Must last at least 6 months.
• The individual has acted on urges or fantasies, causing distress or impairment.
• Individual must be 18 or older.
• Must specify if in a controlled environment or in full remission.

Voyeurism

• Often an expression of sexual curiosity in adolescents, typically starting before age 15.
• Involves using binoculars/mirrors for better viewing.
• The individual may record to be rewatched later.
• Hack into video cams and use a phone to take pictures, especially of someone undertaking sexual relations.

Diagnostic Criteria: Exhibitionistic Disorder

• Recurrent, intense sexual arousal from exposing one's genitals to an unsuspecting person, for at least 6 months.

• The individual has acted on the feelings and sexual urges, if not, it causes clinically significant distress.

• Specify if sexual acts/urges is performed on other prepubertal and/or and physically mature individuals.

• Specify if in a controlled environment or in full remission.

• Exhibitionism accounts for about one-third of sexual offenders in treatment. Those with this disorder often masturbates.

• Is a precondition for exhibitionistic disorder,

• Is linked to risk factors of antisocial history, antisocial personality disorder, alcohol misuse.

Diagnostic Criteria: Frotteuristic Disorder

• Recurrent, intense sexual arousal from touching/rubbing against a nonconsenting person for at least 6 months.

• The individual has acted on these sexual urges/fantasies causing significant distress.

• Specify if in a controlled environment or in full remission.

• It tends to occur in crowded places, where the individual can escape readily, for example, subway car.

• The person will rub his or her genitals and other private parts (breasts) against the other person without their consent

• It occurs most commonly in the 15- to 25-year-old age group.

Diagnostic Criteria: Sexual Masochism Disorder

• Recurrent, intense sexual arousal from being humiliated, beaten, bound, or otherwise made to suffer for at least 6 months.
• Causes clinically significant distress or impairment.
• With asphyxiophilia: If the individual restrict breathing for sexual arousal.
• If in a controlled environment or in full remission.

Diagnostic Criteria: Sexual Sadism Disorder

• Recurrent, intense sexual arousal from physical suffering of another person for at least 6 months.

• The individual has acted on nonconsenting person.

• Causes Clinically significant distress.

• Being in a controlled environment or full remission must be specified.

• Not everyone engaged in BDSM has the disorder.

• Bondage-domination-sadism-masochism refers to restraints/restrictions, discipline, spanking, sensory deprivation, and dominance-submission role-play.

• Engaging in masochistic behavior are at risk for accidental death while practicing asphyxiophilia or other autoerotic procedures

Diagnostic Criteria: Pedophilic Disorder

• Diagnosed with recurrent, intense sexually arousing fantasies or urges, after at least 6 months
• Involves sexual activity with a prepubescent child/children generally 13 or younger.
• Must be at least age 16 years, and 5 years older than the child.
• Specify if is an exclusive/nonexclusive type, specifying for particular sex and/or incest.
• May experience emotional/cognitive affinity with children which has been referred to as emotional congruence
• Can be connected to mental health issues such as substance abuse, depressive, bipolar, anxiety, antisocial disorder
• Typically linked to individuals who are family friends or family.

Diagnostic Criteria: Fetishistic Disorder

• It involves recurrent and intense sexual arousal from either nonliving objects.
• It can involve a focus on nongenital body part(s), spanning at least 6 months.
• Causes stress or impairment in occupational and social sectors.
• It would typically involve an object used during cross dressing or articles for tactile stimulation.
• The target object for sex is specified.
• Controlled environments of full remission must be specified.
• Is not diagnosed during children and adolescence.
• Level of the stress in this case depends on the nature of distress

Diagnostic Criteria: Transvestic Disorder

• Diagnosed when recurrent and intense sexual arousal from cross-dressing spans over 6mo period.

• Causes impairment or distress.

• With fetishism: When sexually aroused by fabrics, materials, or garments.

• Controlled environment vs. not in controlled environment is specified

• “Purging and acquisition” highlights distress.

• The most frequent paraphilias: is fetishistic sexual and masochistic behaviors.

Epidemiology

• Because the DSM-5 diagnostic concept of paraphilic disorders is new, epidemiological data do not yet exist.
• Rates range between 3% to 7% in adult populations.
• Most are usually men (1-5%).
• Pedophilic offenders: Are usually family.

Paraphilic Disorders: Etiology

• Krafft-Ebing thought that they were hereditary
• Freud: They result from developmental failures in childhood
• Learning is also linked.
• Linked to various genetic factors contributing to the development of pedophilia and pedophilic disorder(COMT Val.

Paraphilic Disorders Treatment:

• Cognitive-behavioral therapy: Restructures wrong cognitions.
• Relaxation training, masturbatory satiation and conditioning, covert sensitization.
• Couples therapy of social skills training.

Medical/Surgical Treatment for Paraphilic Disorders

• Off-label SSRIs and naltrexone: For deviant fantasies and behaviors.
• Medroxyprogesterone and leuprolide (Off-label) to reduce serum testosterone and lower sex drive.
• Triptorelin is effective and used.