PA R A P H I L I C D I S O R D E R

AND GENDER DYSPHORIA

M A N D A L , A J AY K U M A R
4TH MEDICAL STUDENT
GULLAS COLLEGE OF MEDICINE
 OBJECTIVES
• Introduction

• EPIDEMIOLOGY-Prevalence & sex ratio

• ETIOLOGY- biological ,psychosocial and Psychological aspect

• Diagnostic Criteria

• Course and prognosis

• Differential Diagnosis

• Treatment
 PARAPHILIC DISORDERS
 Paraphilias(perversions) are sexual stimuli or acts that are deviations
from normal sexual behaviors but are necessary for some persons to
experience arousal(Imagination) and orgasm.

 According to the Diagnostic and Statistical Manual of Mental Disorders:

paraphilic disorder is reserved for those cases in which a
sexually deviant fantasy or impulse has been expressed
behaviorally.
• Paraphilic disorders can range from nearly normal behavior to behavior
that is hurtful only to a person's self and partner and finally to behavior that
is deemed destructive to the community at large.

• DSM-5 lists: Pedophilia, frotteurism, voyeurism,exhibitionism, sexual

sadism, sexual masochism, fetishism and transvestism Paraphilias
diagnosed.
• A paraphilia is clinically significant if the person has acted on these
fantasies.

• when the fantasy has not been acted upon, the term paraphilic
disorder should not be applied.
• A special fantasy with its unconscious and conscious components is the
pathognomonic element of the paraphilia with sexual arousal and orgasm
being associated phenomena that reinforce the fantasy or impulse.
EPIDEMIOLOGY:

• Paraphilia's are practiced by only a small percentage of the population.

• Pedophilia is most common in children among age 18. Because a child is

the object and the act is taken more seriously.

• As usually, the paraphilias seem to be largely male conditions. More than 50

percent of all paraphilias have their onset before age 18.
• DSM-5 suggests the paraphilia designation be reserved for those ages 18 and
occasional experimentation in adolescence.
ETIOLOGY
Psychosocial Factors:

Although recent developments in psychoanalysis place more emphasis on

treating defense mechanisms than on oedipal traumas.

psychoanalytic therapy for patients with a paraphilia remains consistent with

Sigmund Freud's theory.

The onset of paraphilic acts can result from persons modeling their behavior on
the behavior of others who have carried out paraphilic acts and mimicking sexual
behavior.
 BIOLOGICAL FACTORS

• Several studies have identified abnormal organic findings in persons with

paraphilias includes positive organic findings included:
74 % with abnormal hormone levels
27 % with hard or soft neurological signs
24 % with chromosomal abnormalities
9 % with seizures and dyslexia
 And 4 % with abnormal electroencephalography (EEG) studies and major
mental disorders.

• Psychophysiological tests have been developed to measure penile

volumetric size in response to paraphilic and non-paraphilic stimuli.
The procedures may be of use in diagnosis and treatment.
 DIAGNOSIS AND CLINICAL FEATURES:
• In DSM-5, the criteria for paraphilic disorder requires the patient to have
experienced intense and recurrent arousal from their deviant fantasy for at
least 6 months and to have acted on the paraphilic impulse.

• The fantasy distressing the patient contains unusual sexual material that is
relatively fixed and shows only minor variations.

• Arousal and orgasm depend on the mental elaboration, if not the behavioral
playing out of the fantasy. Sexual activity is makes use of degraded objects.
 EXHIBITIONISM:
• Is the recurrent urge to expose the genitals to
a stranger or to an unsuspecting person.
Sexual excitement occurs in anticipation of the
exposure and orgasm is brought about by
masturbation during or after the event.

• In exhibitionism, men is exposing themselves

to women. And men unconsciously feel
castrated and impotent.
 FROTTEURISM:
• Is usually characterized by a man's rubbing
his penis against the buttocks or other body
parts of a fully clothed woman to achieve
orgasm.
• The acts usually occur in crowded places,
particularly in subways and buses.
 FETISHISM:
• Is the sexual focus is on objects (e.g.,
shoes, gloves, pantyhose, and stockings)
that are intimately associated with the
human bod or on non-genital body parts.
Usually the disorder begins by
adolescence.
• Sexual activity may be directed toward
the fetish itself (e.g., masturbation with
or into a shoe). The disorder is almost
exclusively found in men.
 PEDOPHILIA :
• Pedophilia involves recurrent intense sexual urges toward children 13 years of
age or younger over a period of at least 6 months.
• Persons with pedophilia are at least 16 years of age and at least 5 years older
than the victims.
• Most child molestations involve genital fondling or oral sex.
• Vaginal or anal penetration of children occurs infrequently except in cases of
incest.
• Although most child victims coming to public attention are girls.
• According to DSM-5 the diagnosis of pedophilic disorder are sexually
attracted to males, sexually attracted to females or sexually attracted to both.
 SEXUAL MASOCHISM :

• Persons with sexual masochism have a

recurrent preoccupation with sexual urges and
fantasies involving the act of being humiliated,
beaten, bound, or otherwise made to suffer.

• Can lead to serious injury and death (especially

in the case of hypoxyphilia)

• 20:1 males: females.

 SEXUAL SADISM:
• As the recurrent and intense sexual arousal
from the physical and psychological suffering
of another person.

• A person must have experienced these

feelings for at least 6 months.

• The onset of the disorder is usually before

the age of 18 years and most persons with
sexual sadism are male.
VOYEURISM(SCOPOPHILIA):

• It is the recurrent preoccupation with fantasies and

acts that involve observing persons who are naked
or engaged in grooming or sexual activity.

• Masturbation to orgasm usually follows the event.

• The first voyeuristic act usually occurs during

childhood and is most common in men.
TRANSVESTISM:
• Is described as fantasies and sexual urges to dress in
opposite gender clothing as a means of arousal and as
an adjunct to masturbation or coitus.

• The diagnosis is given when the transvestic fantasies

have been acted upon for at least 6 months.

• Begins in childhood or early adolescence. As years

pass, some men with transvestism want to dress and
live permanently as women. Very rarely, women want
to dress and live as men( as gender dysphoria).
OTHER SPECIFIED PARAPHILIC DISORDER
TELEPHONE AND COMPUTER SCATOLOGIA
• Telephone scatologia is characterized by obscene phone calling and involves
an unsuspecting partner.
• Tension and arousal begin in anticipation of phoning.
• The conversation is accompanied by masturbation which is often completed
after the contact is interrupted.
• Persons also use interactive computer networks to send obscene messages by
electronic mail and to transmit sexually explicit messages and video images.
• An alternative method of expressing sexual fantasies.
 ZOOPHILIA
• In zoophilia, animals-which may be trained to participate-are preferentially
incorporated into arousal fantasies or sexual activities(intercourse,
masturbation and oral-genital contact).
• However, a predilection for animal contact is probably present in opportunistic
zoophilia.

NECROPHILIA
• Necrophilia is an obsession with obtaining sexual gratification from cadavers.
Most persons with this disorder find corpses in morgues but some have been
known to rob graves or even to murder to satisfy their sexual urges.
 PARTIALISM
• Persons with the disorder of partialism
concentrate their sexual activity on one part of
the body to the exclusion of all others.

• Mouth-genital contact-such as cunnilingus

(oral contact with a woman's external
genitals), Fellatio (oral contact with the
penis) and anilingus (oral contact with the
anus )-is normally associated with foreplay.

• It is also known as oralism.

 COPROPHILIA AND KLISMAPHILIA
• Is sexual pleasure associated with the desire to defecate on a partner; to be
defecated on or to eat feces (coprophagia).
• These paraphilias are associated with fixation at the anal stage of
psychosexual development.
• Similarly, klismaphilia, the use of enemas as part of sexual stimulation and is
related to anal fixation.
UROPHILIA
Aform of urethral eroticism and is interest in sexual pleasure associated with
the desire to urinate on a partner or to be urinated on.
In both men and women, the disorder may be associated with masturbatory
techniques involving the insertion of foreign objects into the urethra for
sexual stimulation.
 MASTURBATION
• Masturbation is a normal activity that is common in all stages of life from
infancy to old age, but this viewpoint was not always accepted.
• The techniques of masturbation vary in both sexes and among persons.
• The most common technique is direct stimulation of the clitoris or penis
with the hand or the fingers.
• Indirect stimulation can also be used such as rubbing against a pillow or
squeezing .
HYPOXYPHILIA
Isthe desire to achieve an altered state of consciousness secondary to
hypoxia while experiencing orgasm. Persons may use a drug (e.g., a
volatile nitrite or nitrous oxide) to produce hypoxia.
 DIFFERENTIAL DIAGNOSIS :
• Paraphilic activity most likely begins during adolescence. Some paraphilias
(especially the bizarre types) are associated with other mental disorders, such as
schizophrenia.
• Brain diseases can also release perverse impulses.

COURSE AND PROGNOSIS:

• The difficulty in controlling paraphilic disorders rests in the fact that it is hard for
people to give up sexual pleasure with no assurance that new routes to sexual
gratification will be secured.
• A poor prognosis for paraphilic disorder is associated with an early age of
onset, a high frequency of acts, no guilt or shame about the act and substance
abuse.
• The course and the prognosis are better when patients have a history of coitus in
addition to the paraphilia, and when they are self-referred rather than referred by a
legal agency.
 TREATMENTS:
• Five types of psychiatric interventions are used to treat persons with
paraphilic disorder:
A. External control
B. Reduction of sexual drives
C. Treatment of comorbid conditions (e.g., depression or anxiety)
D. Cognitive-behavioral therapy
E. Dynamic psychotherapy.
• Drug therapy including:
A. Antipsychotic or antidepressant medication used for treatment of
schizophrenia or depressive disorders (if the paraphilia is associated).
B. Antiandrogens(cyproterone acetate and medroxyprogesterone
acetate)may reduce the drive to behave sexually by decreasing serum
testosterone levels to subnormal concentrations.
C. Serotonergic agents such as fluoxetine have been used with limited
success in some patients with paraphilia.
The interventions include social skills training, sex education, cognitive
restructuring (confronting and destroying the rationalizations) and
development of victim empathy.
 GENDER DYSPHORIA
• The term gender dysphoria appears as a
diagnosis for the first time DSM-5to refer to
“those persons with a marked
incongruence between their experienced or
expressed gender and the one they were
assigned at birth.”

• It was known as gender identity disorder in

the previous edition of DSM.
• Gender identity: the sense one has of being
male or being female which corresponds,
normally, to the person's anatomical sex.

• The affective component of GID is gender

dysphoria, discontent with one's designated
birth sex and a desire to have the body of
the other sex, and to be regarded socially as
a person of the other sex.

GENDER IDENTITY DISORDER

• Transgender is a general term used to refer to those who identify with
a gender different from the one they were born with(sometimes referred
to as their assigned gender).

• Genderqueer those who feel they are between genders, of both

genders, or of neither gender.

• Crossdressers who wear clothing traditionally associated with another

gender, but who maintain a gender identity that is the same as their
birth assigned gender known as cross dressers.
 EPIDEMIOLOGY
• Most children with GD are referred for clinical evaluation in early grade
school years.
• GID(transexualism in older version of DSM)
• Gender identity becomes fixed in most persons by age 2 or 3 years.
• The sex ratio of referred children is 4 to 5 boys for each girl.
• DSM-5 reports a prevalence rate ranging
 from 0.005 to 0.0 1 4 percent for Male.
And 0.002 to 0.003 percent for female.
• Overall the male to female dysphoria is higher than female to male
dysphoria.
 ETIOLOGY
A. BIOLOGICAL FACTORS
• Resting state of tissue in mammals is initially female & as fetus develops, a
male is produced only if androgen is introduced by Y chromosome.

• maleness and masculinity depend on fetal and perinatal androgens.

• Testosterone can increase libido and aggressiveness in women and

estrogen can decrease libido and aggressiveness in men.

• Masculinity, femininity, and gender identity result more from postnatal life
events
B. PSYCHOSOCIAL FACTORS

 Children usually develop a gender identity consonant with their sex of

rearing (also known as assigned sex).

 The formation of gender identity is influenced by the interaction of

children's temperament and parents' qualities and attitudes.

 Sex- role stereotypes are the beliefs, characteristics and begaviours of

individuals cultures that are deemed normal and appropriate for boys and
girls to possess.
• Sigmund Freud believed that gender identity problems resulted from
conflicts experienced by children within the Oedipal triangle.
• In his view, these conflicts are fueled by both real family events and
children’s fantasies.

• Whatever interferes with a child’s loving the opposite-sex parent and

identifying with the same-sex parent, interferes with normal gender identity
development.
• Since Freud, psychoanalysts have postulated that:

Mother and child relationship - relationship in the first years of life is

paramount in establishing gender identity. During this period, mothers
normally facilitate their children’s awareness of their gender.
Separation individualization process- The separation– individuation
process is unfolding.Which results from shifts between a desperate infantile
closeness and a hostile, devaluing distance.
Role of mother- devaluing, hostile mothering can result in gender problems
triggered by a mother’s death, extended absence or depression.

Abused child- Some children are given the message that they would be more
valued if they adopted the gender identity of the opposite sex. Rejected or
abused children may act on such a belief.

Father’s Role - The father’s role helps the separation–individuation process in

early year. In absence, mother and child may remain overly close. For a girl,
the father is normally the prototype of future love objects; for a boy, the
father is a model for male identification.
 DIAGNOSIS AND CLINICAL FEATURES
DSM-5 Diagnostic Criteria for Gender Dysphoria
A. Differential Diagnosis of Children
 A definite difference between experienced/expressed gender and the one assigned at
birth of at least 6 months duration. At least six of the following must be present:
 Persistent and strong desire to be of the other sex or insistence that they belong to
the other sex

 In males a strong preference for cross-dressing and in female children a strong

preference for wearing typical masculine clothing and dislike or refusal to wear typical
feminine clothing
 Fantasizing about playing opposite gender roles in make-belief play or activities
 Preference for toys, games, or activities typical of the opposite sex.
 Preference for playmates of the other sex
  Rejection of toys, games and activities conforming to one’s own sex. In boys avoidance
of rough-and-tumble play and in girls rejection of typically feminine toys and activities
 Dislike for sexual anatomy. Boys may hate their penis and testes and girls dislike
urinating sitting.
 Desire to acquire the primary and/or secondary sex characteristics of the
opposite sex.
 The gender dysphoria leads to clinically significant distress and/or social, occupational
and other functioning impairment. There may be an increased risk of suffering distress
or disability. The subtypes may be ones with or without defects or defects in sexual
development.
DIFFERENTIAL DIAGNOSIS OF ADOLESCENTS AND ADULTS

•A definite mismatch between the assigned gender and

experienced/expressed gender for at least 6 months duration as
characterized by at least two or more of the following features –
 Mismatch between experienced or expressed gender and gender
manifested by primary and/or secondary sex characteristics at puberty
 Persistent desire to rid oneself of the primary or secondary sexual
characteristics of the biological sex at puberty.
 Strong desire to possess the primary and/or secondary sex
characteristics of the other gender
 Desire to belong to the other gender
  Desire to be treated as the other gender
 Strong feeling or conviction that he or she is reacting or feeling in
accordance with the identified gender.
 The gender dysphoria leads to clinically significant distress and/or social,
occupational and other functioning impairment. There may be an
increased risk of suffering distress or disability.
 The subtypes may be ones with or without defects or defects in
sexual development
 COURSE AND PROGNOSIS
A. CHILDREN
 Begin to develop a sense of their gender identity around age 3 . At this
point they may develop gendered behaviors and interests and some may
begin to express a desire to be another gender(Transgender).

 Where many children diagnosed with gender dysphoria begin to show

increased levels of anxiety related to anticipated changes to their bodies.

 Children diagnosed with gender dysphoria show higher rates of depressive

disorders, anxiety disorders and impulse-control disorders.
B. ADULTS:

 As adults recall the continuous development of transgender identity since

childhood.

 Some have periods of hiding their gender identity, many entering into
stereotypic activities and employment in order to convince themselves and
some do not have gender nonconforming identities.

 Some people identify as gay, lesbian, or bisexual before coming out as

transgender.

 Adults diagnosed with gender dysphoria show higher rates of depressive

disorders, anxiety disorders, suicidality and self-harming behaviors, and
substance abuse.
 TREATMENT
A. IN CHILDREN
• Children with GID affects the direction of subsequent sexual orientation.

• The treatment of GID in children is directed largely at developing social

skills and comfort in the sex role expected by birth anatomy.

• No hormonal or psychopharmacological treatments for GID in childhood

have been identified.
B. IN ADOLESCENTS
• Puberty-blocking medications are gonadotropin-releasing hormone
( GnRH) agonists that can be used to temporarily block the release of
hormones that lead to secondary sex characteristics and giving
adolescents and their families time to reflect on the best options moving
forward.
• Are felt to be safe
C. ADULTS
• Adult patients coming to a gender identity clinic usually present with
straight forward requests for hormonal and surgical sex reassignment.

• No drug treatment has been shown to be effective in reducing cross-

gender desires.
 HARMONAL TREATMENT
• Hormone treatment of transgender men is primarily accomplished with
testosterone(usually taken by injection every week).
• Transgender women may take estrogen, testosterone-blockers or
progesterone(often in combination).
• Cross-sex steroid hormones affect general body fat and muscle distribution
as well as promote breast development in patients born male.
SURGICAL TREATMENT
• The most common type of surgery for both trans-men and trans-women is
"top surgery," or chest surgery.
• Transgender men may have surgery to construct a male-contoured chest.
• Trans-women may have breast augmentation.
• Phalloplasty(the creation of a penis, is less commonly performed because it is
expensive).
• Vaginoplasty(Sex Reassignment Surgery)-In this procedure, the testicles are
removed and the penis is reconstructed to form a clitoris, and a vagina is created.

UNSPECIFIED GENDER DYSPHORIA

The International Statistical Classification of Diseases and Related
Health Problems (ICD- 1 0) include five diagnoses:
a. Transsexualism
b. Dual-role transvestism
c. Gender identity disorder of childhood
d. Other gender identity disorders
e. Gender identity disorder, unspecified.
A.TRANSSEXUALISM:

Desire to live and be accepted as a member of the

opposite sex, usually accompanied by the wish to
make one's body as congruent as possible with one's
preferred sex through surgery and hormonal treatment.

B.DUAL-ROLE TRANSVESTISM:
Wearing clothes of the opposite sex in order to experience
temporarily membership of the opposite sex.
 INTERSEX CONDITIONS

• Intersex conditions in which

persons are born with anatomies
that do not correspond with
typical male or female bodies.

• Is usually congenital involving

chromosomal, morphologic and
genital anomalies. FIGURE-Turner's syndrome
 TREATMENT OF INTERSEX CONDITIONS
Management of intersex can be categorized into one of the following two:
A. Treatments : Restore potential functionality – generally undertaken before age 3.

B. Enhancements : Give the ability to identify with“mainstream”- breast enlargement

surgery.

 It is easier to assign a child to be female than to assign one to be male, because male-to-
female genital surgical procedures are far more advanced than female-to-male procedures.

 The exact procedure of the surgery depends on what is the cause of a less common body
phenotype in the first place. There is often concern as to whether surgery should be
performed at all.

 The goal of treatment is to have genitals concordant with chromosomal, biological,

physiological, and other genetic antecedents, thus allowing the development of a person with
healthy gender identity.
 Transvestic Disorder
Is defined as a period of at least 6 months of recurrent and
intense sexual arousal from cross-dressing that causes
clinically significant distress or impairment.

Cross-dressing can coexist with paraphilias, such as sexual

sadism, sexual masochism, and pedophilia.

A cross-dresser is a person who has an apparent gender

identification with one sex but who wears the clothing of the
opposite sex. Cross-dressers may not identify with opposite
gender & do not adopt behaviors of the opposite gender and
generally do not want to change their bodies medically.
The disorder is most common among female impersonators.
The prevalence of transvestic disorder is unknown. It is more common in
males and extremely rarely diagnosed in females, most likely due to
comparable societal acceptance of women dressing in male-typical
clothing.
TREATMENTS:
A combined approach using psychotherapy and pharmacotherapy is often
useful in the treatment of cross-dressing.
Medications as Antianxiety and antidepressant agents is used to treat the
symptoms as cross-dressing can occur impulsively such as fluoxetine
(Prozac).
PREOCCUPATION WITH CASTRATION
• The category of preoccupation with castration is
reserved for men and women who have a persistent
preoccupation with castration or penectomy without a
desire to acquire the sex characteristics of the opposite
sex.

• They are clearly uncomfortable with their assigned sex

and their lives are driven by the fantasy of what it would
be like to be a different gender.

• They may be asexual and lack sexual interest in either

men or women.
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