Psychiatry 714: Paraphilic Disorders & Gender Dysphoria

• Basic Psychiatry 714 discusses paraphilic disorders and gender dysphoria.
• Maritza Santiago M.D., a Child and Adolescent Psychiatrist, leads the discussion.

General Objective

• Students will learn to diagnose paraphilic disorders, including:
  • Voyeuristic
  • Exhibitionistic
  • Frotteurism
  • Sexual masochism
  • Sexual sadism
  • Pedophilic
  • Fetishistic
  • Transvestic disorder
• Students will learn to diagnose gender dysphoria in children, adolescents, and adults.
• Students will learn to recommend initial treatment interventions applicable to general medical practice.

Specific Objectives

• Students will learn to describe the epidemiology, biological factors, and psychosocial effects of gender dysphoria.
• Students will learn to diagnose gender dysphoria based on diagnostic criteria.
• Students will learn to describe clinical features, course, and prognosis of gender dysphoria disorders.
• Students will learn to formulate treatment recommendations for patients with gender dysphoria disorders.
• Students will learn to deine the term "paraphilia".
• Students will learn to diagnose a patient with a paraphilic disorder based on clinical presentation and DSM 5 diagnostic criteria.
• Students will learn to describe the management of paraphilic disorders.

Terminology Review

• Cisgender person: A person whose gender identity matches their sex assigned at birth.
• Transgender person: A person whose gender identity does not align with the sex they were assigned at birth.
• Nonbinary person: A person whose gender identity is not exclusively male or female, utilizing terms like gender nonconforming or gender-diverse.
• Genderfluid person: A person whose gender identity changes over time or at different times.
• Sex: A person's biological and anatomical status assigned at birth, which can be male, female, or intersex.
• Sexual orientation: A person's physical, romantic, sexual, and emotional attraction to others.
• Gender identity: A person's internal sense of being male, female, both, or something else, usually acquired by the age of 3.
• Gender expression: A person's outward presentation of their gender identity through appearance, dress, and behavior.

Gender Dysphoria

• Gender dysphoria refers to the distress accompanying an individual's sense of incongruence between their gender experience and assigned gender.
• DSM-III and IV defined this as transsexualism or gender identity disorder, highlighting the discordant gender identity.
• DSM-5 moved towards depathologizing discordant gender identity, focusing on clinically significant distress or dysfunction alongside discordance.
• The DSM-5-TR diagnosis reflects a clinical reality where patients experience unhappiness due to the discordance between their bodies and sense of self.
• Surgical and hormonal interventions are not perfect solutions.

Epidemiology

• Gender dysphoria has an estimated prevalence of approximately 4.6 per 100,000, likely an underestimate.
• Studies focusing on individuals receiving hormone therapy, gender-affirming surgery, or with transgender diagnostic codes reported a prevalence of 7 to 9 per 100,000 people.

Diagnostic Criteria: Gender Dysphoria in Children

• Marked incongruence between experienced/expressed gender and assigned gender for at least 6 months, with at least six of the following:
  • Strong desire to be of the other gender.
  • In boys, preference for cross-dressing; in girls, preference for masculine clothing and resistance to feminine clothing.
  • Strong preference for cross-gender roles in play.
  • Strong preference for toys/activities stereotypically used by the other gender.
  • Preference for playmates of the other gender.
  • In boys, rejection of masculine toys/activities; in girls, rejection of feminine toys/activities.
  • Strong dislike of one's sexual anatomy.
  • Strong desire for primary/secondary sex characteristics matching experienced gender.
• Condition is associated with clinically significant distress/impairment in social, school, or other areas of functioning.

Disorders of Sex Development

• With a Disorder/Difference of Sex Development condition is also included.
• Congenital adrenal hyperplasia and androgen insensitivity syndrome are examples.
• In Classic CAH, female infants may be diagnosed at birth due to ambiguous genitalia.
  • They still have normal internal female organs
• Male infants with classic CAH may appear normal at birth with an enlarged penis, showing rapid growth and early puberty signs after infancy.
• Undiagnosed infants with Classic CAH may suffer from weight loss, vomiting, dehydration, diarrhea, changes in body chemistry, shock, heart problems, and coma.
• Androgen Insensitivity Syndrome: People are genetically male but their bodies can't respond to androgens, possibly leading to mostly female external sex characteristics.

Diagnostic Criteria: Gender Dysphoria in Adolescents and Adults

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

Diagnostic Clarifications

• Specify if there's a disorder or difference in sex development like congenital adrenal hyperplasia or androgen insensitivity syndrome.
• Specify if posttransition, the individual has transitioned to living full-time in the experienced gender and had gender-affirming medical procedures or hormone treatment. -Examples of gender-affirming medical procedures/treatment include:
  • Breast augmentation surgery and/or vulvovaginoplasty in an individual assigned male at birth
  • Transmasculine chest surgery and/or phalloplasty or metoidioplasty in an individual assigned female at birth

Clinical Findings

• Gender dysphoria typically begins in childhood.
• In boys, early signs include overidentification with the mother, overtly feminine behavior, disinterest in male pursuits, and relationships with girls.
• Girls may show tomboyish behavior, however is more acceptable.
• Young children may show distress when told they are not "really" the other gender.
• Adolescents/adults are more likely to experience distress, mitigated by supportive networks, with impairment ranging from school refusal to social avoidance.

Comorbidity

• Individuals with gender dysphoria are more likely to experience mental health issues, such as anxiety, depression, and substance abuse.

Outcome

• Rule out other causes of gender dysphoria when diagnosing, such as a desire to change gender due to schizophrenia.
• A desire to change one's anatomical gender might be part of a complex delusion in a person with schizophrenia.
• A meta-analysis showcased that mental health was lower in the transgender community vs the controls.
• Quality of life can significantly improve following cross-sex hormonal treatments.

Treatment

• Many individuals with gender dysphoria seek hormonal therapy and gender reassignment surgery, also called gender confirmation surgery.
• Transitioning from male to female involves:
  • Hormones (estradiol, progesterone) to develop secondary female characteristics.
  • Laser treatment/electrolysis for hair removal.
  • Surgery to remove testes/penis and create an artificial vagina (vaginoplasty).
• Female-to-male transition involves:
  • Mastectomy, hysterectomy, and oophorectomy.
  • Testosterone to develop muscle mass and deepen the voice.
  • Construction of an artificial penis.

GENDER

• Affirming Therapy
• A therapeutic stance focuses on affirming a patient’s gender identity.
• Trauma: discourage and be hostile, which creates physical and psychological effects.
• Shame leads to anxiety.
• Depression of those who suffer from repeated trauma.
• Self-harm: high levels of ideation, and about 50% have attempted suicide.
• Violence: Victims of hate crimes, with at least 25% reporting an attack.
• Sexuality: Placed in discrete "boxes" regarding sexual orientation.
• Medical treatment: Understanding where they fit on the gender spectrum.

Paraphilic Disorders

• Focuses on the diagnosis

Paraphilia

• Is sexual arousal from the following
  • Sexual masochism disorder
  • Voyeuristic disorder
  • Transvestic disorder
  • Pedophilic disorder
  • Frotteuristic disorder
  • Exhibitionistic disorder
  • Fetishistic disorder
• Paraphilias involve:
  • atypical sexual stimulation from objects, situations, and/or targets,
  • Some which seem unusual but without a paraphilic disorder.
• Paraphilic disorders involve:
  • recurrent and intense sexual arousal" from an anomalous preference.
  • A person has acted upon the urges.
  • The urges have caused stress or impairment.
• A paraphilic disorder must last at least 6 months.

Voyeuristic disorder

• Over 6 months, recurrent, intense sexual arousal from observing a person nude, disrobing, and also their activities.
• Specifiers
  • Controlled environment for restricted behavior.
  • Full remission is not acting on non-consenting urges.
• Voyeurism often starts before the age of 15.

Exhibitionistic disorder

• Over 6 months, there is a recurrent and intense sexual arousal from genitals towards a unsuspecting person.
• The person has urges with a non-consenting person.
• The sexual urges or fantasies cause clinically significant distress or impairment in social
• Specification includes
• Individuals living in institutional or settings.

Frotteuristic disorder

• Has arousal from touching or rubbing against a non consenting person over the course of 6 months.
• The person acted on urges on a non consenting person as the sexual urges has impairment.
• Controlled environment means that there is typically impairment.
• This behavior occurs in crowded places for a quick escape, and is commonly seen in the 25-15 group.

Sexual Masochism Disorder

• Over a period of 6 months with humiliation, beaten, and bound as manifested by fantasies to urges.
• Must specify if related to a restricted breathing.
• Clinical significance is if a person with a sexual urge has clinically impairment.

Sexual Sadism

• There is a physical and physiological component when someone is suffering.

Pedephilia

• Can be attracted to males, females, or both.
• 13 years older
• At least 8 years old
• Do not include in late adolescence involved in an ongoing sex relationship
• They many experience a emotional cognitive affinity
• Comorbidity includes
  • depressive
  • bipolar
  • anxiety disorders
  • antisocial personality disorder

Fetishistic disorder

• There is a high focus on the genitals which is manifested by fantasizes.
• Individuals that engage has impairment in social functioning and there is a specific environment.
• Clinical significance is if there is any distress in social environment.
• Present with issues from a younge age and developing from adolescence.
• Diverse stimuli from stimuli.
• Course is usually chronic for this disorder.

Transvestic disorder

• Clinically cause signifiant distress or impairment in social
• Fantasies , sexual, urges that can cause clinical environment
• Also there is a with fetishism if Sexually aroused by thoughts
• The presence includes that behavior signifies the presence of distress disorder.

Epidemiology

• The DSM5 is new and they don't know how the new concept works
• In addition, paraphilias or disorders usually don't get a response from the patients , due to associate illegal implications and societal stigma
• Exhibitionism
• Only 18% are women and the rest are usually friends of the family and relatives

Etiology

• Krafft ebing, a vienness compiled the first systematic count of paraphilias in his book The book Is called psychopathy sexuals.
• Freud thought that sexual deviations result from failure

Factors that add to Parafillia

• Social learning
• Biological process from genes contributed to pedophilism
• They all can play a role

Treatment

• Cognitive behavior therapy has been helpful
• Relaxation can help due the anxiety and stress
• Satiation and boring the patient with his own deviant fantasies
• Masturborty can help generate arousal to non deviancy
• Social learning can help better with other appropriate partners
• The couple therapy can be helpful for those in committed relationship
• No FDA approved but
• Ssris
• Naltrexone

FDA

• Can use:
• Medoxyprogesterone
• Leupromide
• But doesn't have Gnaditopium
• Helps with trip but not in United States.