Psychiatry 714: Paraphilic Disorders & Gender Dysphoria

• Basic Psychiatry 714 covers paraphilic disorders and gender dysphoria.
• The objective is to diagnose paraphilic disorders and gender dysphoria, and recommend initial treatment.

Specific Objectives

• Describe the epidemiology, biological factors, and psychosocial effects of gender dysphoria.
• Diagnose a patient with gender dysphoria based on diagnostic criteria.
• Describe clinical features, course, and prognosis of gender dysphoria.
• Formulate treatment recommendations for gender dysphoria.
• Define paraphilia.
• Diagnose a patient with paraphilic disorder based on 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; can be male, female, or intersex.
• Sexual orientation: Physical, romantic, sexual, and emotional attraction to others.
• Gender identity: Internal sense of being male, female, both, or something else, usually acquired by age 3.
• Gender expression: Outward presentation of gender identity through appearance, dress, and behavior.

Gender Dysphoria

• Gender dysphoria is the distress accompanying incongruence between experienced gender and assigned gender.
• DSM-III and IV: transsexualism (transition from one gender to another) and gender identity disorder indicated the clinical problem was the discordant gender identity.
• DSM-5 moved towards depathologizing discordant gender identity, focusing on clinically significant distress or dysfunction.
• The DSM-5-TR diagnosis reflects a subset of patients with unhappiness related to the discordance between their bodies and sense of self.
• Surgical and hormonal interventions are not always perfect.

Epidemiology of Gender Dysphoria

• The estimated prevalence of gender dysphoria is approximately 4.6 per 100,000 but is likely an underestimate.
• Prevalence is reported as 7 to 9 per 100,000 people in studies including individuals who received hormone therapy, gender-affirming surgery, or had diagnostic codes documenting being transgender.

Diagnostic Criteria: Gender Dysphoria in Children

• A marked incongruence between experienced/expressed gender and assigned gender, of at least 6 months' duration, is required.
• Manifested by at least six of the following (one of which must be Criterion A1):
• Strong desire to be of the other gender or insistence on being the other gender.
• In boys, strong cross-dressing preference; in girls, wearing only 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.
• 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 and school.

Specifiers for Gender Dysphoria

• With a disorder/difference of sex development (e.g., congenital adrenal hyperplasia, androgen insensitivity syndrome).

Classic CAH (Congenital Adrenal Hyperplasia)

• In many cases, female infants are diagnosed at birth because they have ambiguous genitalia.
• They still have normal internal female organs.
• Male infants may appear normal or have an enlarged penis.
• Untreated CAH in infants can lead to weight loss, vomiting, dehydration, changes in the body, shock, heart problems, and coma
• Boys with classic CAH grow rapidly and show signs of early puberty.

Androgen Insensitivity Syndrome

• This affects sexual development before birth and during puberty.
• People are genetically male.
• Bodies are unable to respond to androgens, male sex hormones.
• May have female external characteristics or signs of both male and female development.

Diagnostic Criteria: Gender Dysphoria in Adolescents and Adults

• Marked incongruence between experienced/expressed gender and assigned gender is required.
• Duration of at least 6 months.
• Manifested by at least two of the following:
  • Marked incongruence between experienced gender and primary/secondary sex characteristics.
  • Strong desire to be rid of one's sex characteristics.
  • Strong desire for the 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 and occupational areas.

Specifiers and Additional Information

• Specify if there is a disorder/difference of sex development.
• Specify if posttransition where one has transitioned to full-time living in the experienced gender, undergone gender-affirming procedures, or hormone treatments.
• Examples:
  • Breast augmentation surgery and/or vulvovaginoplasty for assigned males at birth
  • Transmasculine chest surgery and/or phalloplasty or metoidioplasty for individuals assigned female at birth

Clinical Findings: Gender Identity

• The disorder usually begins in childhood.
• In boys: overidentification with the mother, feminine behavior, little interest in male pursuits & peer relationships primarily with girls
• Girls: tomboyish behavior, but this is often more accepted in society.
• A very young child may intensely cry when parents tell them that he or she is not "really" a member of the other gender.
• Adolescents and adults are more likely to experience distress, but the distress tends to be mitigated by supportive family and friends.
• Impairment can vary from school refusal in children to avoiding social activities in adolescents and adults.

Comorbidity

• Individuals with gender dysphoria are more likely to experience mental health problems, such as anxiety, depression, and substance abuse.
• Rule out other potential causes of gender dysphoria, such as schizophrenia.

Outcome

• Mental health quality of life was found to be lower in the transgender population.
• Mental health quality of life was found to significantly improve following cross-sex hormonal treatment

Treatment

• Individuals seek hormonal therapy and gender reassignment surgery (gender confirmation surgery).
• Transition from male to female:
  • Hormones (estradiol, progesterone) to promote the development of secondary female characteristics.
  • Laser treatment and electrolysis.
  • Surgery to remove testes and penis, creating an artificial vagina (vaginoplasty).
• Female-to-male patient:
  • Mastectomy, hysterectomy, and oophorectomy.
  • Testosterone will help develop muscle mass and deepen the voise
  • Artificial penis constructed.

Gender Affirming Therapy

• Therapeutic stance that focuses on affirming a patient's gender identity and does not try to "repair" it.
• Trauma: Hostility towards gender diversity leads to repeated trauma.
• Shame: Feeling flawed/different leads to shame.
• Depression: Sufferers of repeated trauma may have higher levels of depression.
• Self-harm: High levels of suicidal ideation are seen, with 50% attempting suicide.
• Violence: Victims of hate crimes at least 25% have reported being attacked
• Sexuality: Those living on more diverse gender spectrums are placed into discrete "boxes".
• Medical Treatment: exploring the pros and cons of hormone interventions is important.

Paraphilias

• Paraphilias involve sexual arousal to atypical objects, situations, and/or targets.
• Some paraphilias do not meet the criteria for a paraphilic disorder simply because they are unusual
• Paraphilic Disorder: Having a recurrent and intense sexual arousal, acted on the urges and the urges have caused significant distress.

Diagnostic Criteria: Voyeuristic Disorder

• Over 6 months, recurrent and intense sexual arousal from observing an unsuspecting person naked or engaging in sexual activity.
  • Individual has acted on the sexual urges with a nonconsenting person, or the urges or fantasies cause clinically significant distress.
• The individual experiencing the arousal and/or acting on the urges is at least 18 years of age.
  • Controlled Enviornment: This specifier is applicable for where opportunities to engage in voyeuristic behavior are restricted.
  • Full Remission: The individual has not acted on the urges with a nonconsenting person, and there has been no distress or innparment for at least 5 years.

Additional Information for Voyeurism

• Voyeurism is often an expression of sexual curiosity in adolescents and usually has an onset before age 15.
• Individuals often use binoculars and mirrors for a better view.
• Some may record a person to rewatch later.
• Individual can use cameras, hack into video cams, and use a phone to take pictures of video of someone having sexual relations.

Diagnostic Criteria: Exhibitionistic Disorder

• Over 6 months of recurrent and intense sexual arousal from exposure of one's genitals to an unsuspecting person.
• The individual has acted on urges with a nonconsenting person, or urges cause clinically significant distress.
• Specify whether:
  • Sexually aroused by exposing genitals to prepubertal children, physically nature adults;
  • A specifier is primairly applicable where opportunities to expose one's genitals are restricted.
  • The individual hasn't acted on the urges with a nonconsenting person for at least 5 years.

Additional Information for Exhibitionistic Disorder

• This accounts for about one-third of the sexual offenders referred for treatment.
• The person will typically masturbate when exposing genitals.
• Differential Diagnoses: manic episode, major neurocognitive disorder, sexual preference may increase the change sexual recidivism.

Diagnostic Criteria: Frotteuristic Disorder

• Over a period of at least 6 months, recurrent and intense sexual arousal from touching or rubbing against a nonconsenting person.
• Specify if:
  • In a controlled environment where restricted from rubbing against a nonconsenting person.
  • In full remission: no urges with a non consenting person for at least 5 years.

Additional Information for Frotteuristic Disorder

• The behavior tends to occur in crowded places such as a subway car.
• Most commonly occurs in 15- to 25-year age group.

Diagnostic Criteria: Sexual Masochism Disorder

• Over 6 months, recurrent sexual arousal from being humiliated, beaten, bound, or made to suffer.
• The fantasies, sexual urges, or behaviors cause distress or impairment.
• Specify if:
  • With asphyxiophilia: where practice of sexual arousal related to the restriction of breathing exists.
• Specify if:
  • In a controlled environment where living in institutional or restricted from masochistic behaviors.
  • In full remission where a lack of distress or impairment over a 5 year period.

Diagnostic Criteria: Sexual Sadism Disorder

• Over 6 months, recurrent sexual arousal from physical or psychological suffering of another.
• The individual has acted on these urges with a non consenting person where clinical distress exists.
• In a controlled environment with opportunities restricted to sadistic sexual behaviors. -In full remission in absence of distress of impairment for over a 5 year period.

BDSM

• Broad term that refers to restraints or restrictions, discipline, spanking etc. Individuals are at risk for accidental death while practicing asphyxiophilia or other autoerotic procedures

Diagnostic Criteria: Pedophilic Disorder

• Over 6 months, recurrent sexually arousing fantasies, urges, or behaviors with prepubescent children (generally age 13 or younger).
• The individual is at least 16 years and 5 years older than the child.
• An individual in late adolescence inolving sexual relations with a 12 or 13 year old isn't considered.
• Specify whether:
  • Exclusive type (attracted only to children)
  • Nonexclusive type
  • Sexually attracted to males/females/both including incest.

Additional Information for Pedophilic Disorder

• Individuals with pedophilic disorders may experience emotional and cognitive affinity and congruence with children.
• Adult men may became aware of the sexual interest in children around puberty.

Diagnostic Criteria: Fetishistic Disorder

• Over 6 months of recurrent, intense sexual arousal either from nonliving objects or a highly specific focus with fantasies, urges, or behaviors.
  • No the fetish objects are not limited to articles of clothing with tactile genital stimulation.
• Specify the nonliviling objects.
• Specify that there are restrictive environments or full remission.

Additional Information for Fetishistic Disorder

• This disorder is not often diagnosed in children; but where interests are reported they are present from a young age
• Patients will commonly recall an initial sexual preoccupation with the fetish object developing in adolscence
• The object is the subject of fantasies during masturbation.
• Sex with the object may be uncommonduring teen where the patient is unable to engage with their parnters sexually withoiut the object.
• Course is chronic fluctuations in intensity are common

Diagnostic Criteria: Transvestic Disorder

• Over 6 months, recurrent and intense sexual arousal from cross-dressing with impulses or behaviors.
• Specify if:
• With fetishim when sexual arousal exists with fabrics.
• While autogynephilia exists.
• IN restrcited in restrcitve enviroenemnt.

Additional Information for Transvestic Disorder

• The pattern of behavior "purging and aequisiton" often signifies the presence of distress in individuals with this disorder.
• IT's often found in other paraphilias.

Epidemiology

• Where DSM5 is novel of paraphilic disorders, epimemiological date does not exist.
• Paraohilias are are reported by undrerreported by patients.
• Majority or individuala swith paraphilic disorders are with men.

Ethiology

• Combination or neurobioligcal, interpersonal and cognitive play a role.

• Krafft Ebing compiled sexual dviations in psychophathhia sexualis.

  Paraphilic Disorders -Cognitive Behavioral therapy can be uses for restructuring.

  • Relazation training can preceed anxiety and stress
  • Masturbatory santation helps for deviant fantasies.

FDA Approved

There are nos FDA approved and naltrexone have uses with used with medroxyprosterong and testoterone with drugs like tilriptorelin but unavailable.