Sexual and Gender Identity Disorders ?>

Sexual and Gender Identity Disorders

Sexual and Gender Identity Disorders


Introduction

History

The study of sexual deviancy began just before the turn of the 20th century as the taboo of discussing sexuality was beginning to lift. Early pioneers included Richard von Kraff-Ebing, Albert Moll, August Forel, Iwan Bloch, Magnus Hirschfield, Havelock Ellis, and Sigmund Freud. Their work was not well accepted, and they were regarded with disdain.

Several psychiatric concepts were prominent at this time. One of them was a constitutional predisposition of unknown origin called degeneration, which refers to an innate neurologic weakness that is transmitted with increased severity to future generations and produces deviations from the norm. Masturbation was blamed for a list of diseases including insanity, suicide, self-mutilation, and tuberculosis. The law of association of ideas suggests that when sex and another experience occur, one stimulus sets off the other.

Ellis worked against the prudish view of sex that existed at the time, and he advocated the decriminalization of homosexuality. Freud wrote on fetishism, masochism, and the theory of perversions. These early investigators of sexual deviation provide an important principal: “Not only must the act be studied, but also the person. The personal roots of deviance spring from an interaction of the individual’s biological nature and his early life experiences.”

Disorders of human behavior remain difficult to understand, identify, and treat. Few data are available, too much of our knowledge is based on speculation and unsupported theory, and societal stereotypes influence our perceptions. Good science-based research remains difficult, and monetary, ethical, and legal concerns complicate such research.

Paraphilias

Sexual deviation is a term applicable to a subclass of sexual disorders termed paraphilias. Paraphilias are associated with arousal in response to sexual objects or stimuli not associated with normal behavior patterns and that may interfere with the establishment of sexual relationships. In modern classification systems, the term paraphilia is preferable to sexual deviation because it clarifies the essential nature of this group of behaviors (ie, arousal in response to an inappropriate stimulus).

The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR), the prevailing resource for diagnostic criteria of paraphilias, describes the essential feature of paraphilias as recurrent, intense, sexual urges and sexually arousing fantasies generally involving nonhuman objects, the suffering or humiliation of oneself or partner, or children or other nonconsenting persons. The DSM-IV-TR describes 8 of the more commonly observed paraphilias and makes reference to several other examples. People who experience one paraphilia may also experience other paraphilias, although the paraphilia may occur as an isolated event. Commonly, people who manifest paraphilias also exhibit personality disorders, substance abuse problems, or affective disorders.

Prevalence

Paraphilias are rarely diagnosed in clinical settings. Large commercial markets in paraphiliac pornography and paraphernalia are testaments that prevalence is high. Pedophilia, voyeurism, and exhibitionism are the most commonly observed behaviors in clinics that specialize in paraphilia treatment. Sexual masochism and sexual sadism are much less commonly observed. Approximately half of patients observed in clinics for treatment of paraphilias are married.

Differentials

Nonparaphiliacs may describe nonpathological use of sexual fantasies, behaviors, or objects as stimuli for sexual excitement.

In patients with mental retardation, paraphilia should be distinguished from dementia, personality change due to general medical condition, substance intoxication, manic episode, or schizophrenia in which judgment, social skills, or impulse control are compromised.

When appropriate, public urination should be distinguished from exhibitionism.

Exhibitionism

The DSM-IV-TR diagnostic criteria for exhibitionism are as follows:
The patient reports recurrent, intense, sexual urges and sexually arousing fantasies related to exposing the genitals to a stranger. Symptoms must be present for at least 6 months.
The patient experiences significant distress or impairment in social, occupational, or other important areas of functioning because of the fantasies, urges, or behaviors.

Generally, no attempt at further sexual activity with the stranger occurs, although a desire to shock the stranger sometimes exists or the exhibitionist may have a fantasy that the observer will become sexually aroused. Onset usually occurs in persons younger than 18 years but may occur later. The disorder causes significant stress or impairment in social, occupational, or other important areas of functioning. In 1975, Rooth classified 2 types of exhibitionism: Type I is the inhibited flaccid exposer, and type II is the sociopathic exposer who may have a history of other conduct. About half of adult women have witnessed indecent exposure sometime in their lives.

Exhibitionists, whether timid or brash, feel dominated by women and resent it. By exposing themselves, exhibitionists turn the table on women, dominating rather than being dominated. Exhibitionists view this act as making women their helpless victims, rather than being helpless before them. Some researchers have suggested that exhibitionists have a fragile sense of masculinity. Threats to masculinity are countered by demonstrations of manliness.

Exhibitionists have difficulty relating to women as whole people. Rather, women are present merely to provide both gratification and proof against castration. Many exhibitionists are very prudish with their wives. They go to great efforts to never look at their wives or be seen by them in the nude. Intercourse tends to be rigid and conventional.

Common to all exhibitionists is some abnormality in handling aggression and hostility. On the one hand, they must keep their anger under tight control, yet on the other hand they may become tyrannical with their family because they feel safe from retaliation.

Male genital exhibitionism is an indicator of future sexual offenses in some individuals. In a 1980 longitudinal study, Bluglass found that 7% of exhibitionists were later convicted of contact sexual offenses, including rape.

Genital exhibitionism is rare among women. This has been explained by the differences between the sexes in the development of the castration complex and the absence of a reassuring effect from showing a penis because of anatomic differences in women. Eber in a 1977 report and Kohut in a 1978 report view female exhibitionism as a disorder of bodily narcissism.

Presentation to physicians is common and may result from a sense of guilt and an inability to control the behavior. Sometimes the behavior is revealed as the result of a criminal offense. More serious underlying pathology is suggested when preferred scenes include defecation or small children.

Fetishism

The DSM-IV-TR lists the following diagnostic criteria for fetishism:
The patient experiences recurrent and intense sexual urges and sexually arousing fantasies involving the use of nonliving objects by themselves. Symptoms must be present for at least 6 months.
The patient experiences significant distress or impairment in social, occupational, or other important areas of functioning because of the fantasies, urges, or behaviors.
The fetishes are not limited to articles of female clothing used in cross-dressing (transvestic fetishism) or devices designed for genital stimulation (eg, vibrators).

Common fetishistic objects include female underwear; rubber, plastic, or leather garments; specific articles of clothing such as shoes or boots; and bodily items such as hair, odors, or feces. The disorder is more common among males than females. Prevalence is unknown. It can often be traced from adolescence and usually persists.

In the context of psychoanalytic theory, in a 1996 publication Greenacre associates fetishism with a severe castration complex in males and a more complicated and less readily recognized set of relational reactions in females. For men, the fetish serves a defensive function, a reinforcing adjunct for a penis of uncertain potency. The fetish serves to increase the efficiency of the penis, which does not perform well without it. In women, fetishism is less common, largely because of anatomic differences that allow women to conceal inadequate sexual response more readily than men. Women can develop symptoms more comparable to male fetishism when the illusion of having a phallus has gained sufficient strength to approach delusional proportions. This occurs in rare cases in which severe disturbances in the sense of reality exist.

Treatment of the specific condition (fetish), rather than the primary underlying disorder (eg, organic pathology, personality disorder) generally is unsuccessful. A variety of treatment approaches have been tried, such as aversive conditioning, cognitive therapy, and psychotherapy.

Frotteurism

The DSM-IV-TR lists the following diagnostic criteria for frotteurism:
The patient experiences intense, recurrent, sexual urges and sexually arousing fantasies involving touching and rubbing against a nonconsensual person. Symptoms must be present for at least 6 months.
The patient experiences significant distress or impairment in social, occupational, or other important areas of functioning because of the fantasies, urges, or behaviors, or the patient has acted on the sexual urges.

Frotteurs typically act out their fantasies in crowded places (eg, public transportation vehicles, busy sidewalks), which allows for escape; the frotteur can claim that the touching was accidental. The frotteur rubs his genital area against the (usually female) victim’s thighs or buttocks, or the frotteur fondles a woman’s genitalia or breasts with his hands. While committing the act, the offender typically fantasizes about an exclusive, caring relationship with the victim.

Most acts occur in perpetrators aged 15-25 years, after which frequency gradually declines. Frotteurism has been noted to be equally common among older, shy, inhibited individuals. Fantasies of frotteuristic behavior without action have been reported as a stimulant to sexual arousal.

Voyeurism

The term voyeurism, from the French word meaning to see, refers to the fairly common desire to view nudity and acts of coition. Differentiating innocent enjoyment of nudity from behavior that is similar but deviant in other circumstances can be difficult.

The DSM-IV-TR diagnostic criteria for voyeurism are as follows:
The patient has recurrent and intense sexual urges and sexually arousing fantasies involving the act of observing an unsuspecting person who is naked, in the process of disrobing, or engaging in sexual activity. Symptoms must be present for at least 6 months.
The patient experiences significant distress or impairment in social, occupational, or other important areas of functioning because of the fantasies, urges, or behaviors.

When severe, the act of peeping constitutes the exclusive form of sexual activity. Onset usually is in persons younger than 15 years, and the disorder tends to be chronic. The wide extent of voyeuristic tendencies in the general population is evidenced in the common desire to indulge in exploitative activities such as live shows and pornography.

Pedophilia

The essential features of this disorder as described by the DSM-IV-TR include the following:
The patient reports recurrent and intense sexually arousing fantasies, sexual urges, or behaviors involving sexual activity with a prepubescent child or children, generally aged 13 years or younger.
Pedophiles must be aged 16 years or older and be at least 5 years older than the victim.
The disorder causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
The clinician should specify if the person is attracted to males, females, or both; if the acts are limited to incest; and if the patient is attracted to children only (exclusive type) or both children and adults (nonexclusive type).

While female pedophiles are considered to be rare, discrepancies between the numbers of male and female offenders are tied to sexual stereotypes. Masculinity connotes sexual qualities, while femininity connotes maternal qualities and nurturance. When a female pets a child, she is nurturing. When a male pets a child, he is molesting. The majority of men who have had sexual contact with a woman when they were boys viewed it positively rather than negatively. Consequently, these acts were probably unreported. In one study, 16% of college males and 46% of prisoners reported having had sexual contact with older females, and half of the encounters involved intercourse. Mean age of males at the time of sexual contact was 12 years, and the females with whom they were involved were aged 20-30 years.

Many pedophiles have a personal history of unstable parent-child relationships as children and sexual abuse. The majority of pedophiles have a clear sexual preference. The undifferentiated or bisexual group accounts for only 5-25% of pedophiles. Most studies indicate that 60-90% of incidents of abuse involve girls.

Great variation exists among men who use children sexually. One third to one half prefer children as sexual partners. Others are attracted to children but act on their impulses only under stress. Some, who typically are younger than 30 years, are sociosexually underdeveloped, lack age-appropriate experience, and have feelings of shyness and inferiority. Unable to attain adult female contact, they continue prepubescent sexual patterns. Amoral delinquent youths (younger than pedophiles proper), lacking control when aroused, use whoever is close at hand. Patients with the situational type of pedophilia have no special preference for children, although they have sexual contact with children because of convenience or coincidence. Contact typically is brief and nonrecurrent. A residual category of offenders includes people with mental retardation, psychosis, alcoholism, senility, or dementia.

Approximately 37% of sexual assault victims reported to law enforcement agencies were juveniles ( <18 y); 34% of all victims were younger than 12 years. One in 7 victims is younger than 6 years. Forty percent of offenders who victimized children younger than 6 years were juveniles ( <18 y).

Sexual masochism

The essential features of this disorder as described by the DSM-IV-TR include the following:
The patient reports recurrent and intense sexual urges and sexually arousing fantasies involving the act (real, not simulated) of being humiliated, beaten, bound, or otherwise made to suffer. Symptoms must be present for at least 6 months.
The fantasies, urges, or behaviors cause significant distress or impairment in social, occupational, or other important areas of functioning.

Masochistic acts commonly involve a wide range of activities, such as restraint, blindfolding, beating, electrical shock, cutting, piercing, and humiliation (eg, being urinated or defecated on, forced to bark, verbally abused, forced to cross-dress). Some sexual masochists inflict pain through self-mutilation, and some engage in group activity or use services provided by prostitutes.

Hypoxyphilia is a dangerous form of masochism that involves sexual arousal by oxygen deprivation achieved by means of chest compression, noose, ligature, plastic bag, mask, or chemicals. Oxygen deprivation may be accomplished alone or with a partner. Data from the United States, England, Australia, and Canada indicate that 1-2 deaths per million population are reported each year.

Some sexually masochistic males also exhibit fetishism, transvestic fetishism, or sexual sadism. Masochistic sexual fantasies are likely present in childhood. Masochistic activities commonly begin by early adulthood, tend to be chronic, and the same act is generally repeated. Some individuals increase the severity of the act over time, which may lead to injury or death.

In 1926, Sadger observed a common association between homosexuality and masochism. In a 1977 report, Spengler found that 38% of exclusive homosexuals were sadomasochists, which provides some support for Sadger’s observation.

Ritualized behavior is a noted feature of masochistic scenes; the slightest deviation from the script may result in failure to achieve the desired result. This feature is also viewed as a mechanism through which the masochist maintains control.

Sexual sadism

The DSM-IV-TR diagnostic criteria for sexual sadism are as follows:
The patient reports recurrent and intense sexual urges and sexually arousing fantasies involving the act (real, not simulated) in which the psychological or physical suffering (including humiliation) of one person is sexually arousing to another person. Symptoms must be present for at least 6 months.
The fantasies, urges, or behaviors cause significant distress or impairment in social, occupational, or other important areas of functioning.

Sadistic fantasies or acts may involve activities such as dominance, restraint, blindfolding, beating, pinching, burning, electrical shock, rape, cutting, stabbing, strangulation, torture, mutilation, or killing. Sadistic sexual fantasies are likely present in childhood. Onset of sadistic activities commonly occurs by early adulthood, and it tends to be chronic.

Some individuals do not increase the severity of their sadistic acts; however, severity of the sadistic acts does usually increase over time. When practiced with nonconsenting partners, the activity is likely to be repeated until the perpetrator is apprehended. When sexual sadism is severe and associated with antisocial personality disorder, victims may be seriously injured or killed.

No clear lines divide sexual sadism and sexual masochism, and the predispositions are often interchangeable. The conditions may coexist in the same individual, sometimes in association with other paraphilias. This relationship is supported by the finding that those who entertain masochistic fantasies also engage in sadistic fantasies. In the context of psychoanalytic theory, Panken in a 1973 publication does not find that the conditions coexist in an individual and claims that the dynamics are different.

Transvestic fetishism

Transvestic fetishism is defined by DSM-IV-TR diagnostic criteria as follows:
The patient is a heterosexual male who has recurrent, intense, sexually arousing fantasies, urges, or behaviors involving cross-dressing. Symptoms must be present for at least 6 months.
These fantasies, urges, or behaviors cause significant distress or impairment in social, occupational, or other important areas of functioning.
If gender dysphoria is present, it should be specified.

Fetishistic transvestism is essentially unheard of in females. Women may cross-dress, but no literature (English) describes cross-dressing females who become sexually excited by the activity.

Other paraphilias

Sexual arousal may be obtained from a wide array of additional behaviors. Some are provided with the assistance of prostitutes, others find willing partners when needed. Other paraphilias include the following:
Scatologia (obscene phone calls)
Necrophilia (corpses)
Partialism (exclusive focus on part of body)
Zoophilia (animals)
Coprophilia (feces)
Klismaphilia (enemas)
Urophilia (urine)

Gender Identity Disorder

The DSM-IV-TR diagnostic criteria for gender identity disorder (transsexualism) include strong and persistent cross-gender identification that extends beyond a desire for a perceived cultural advantage.

In children, gender identity disorder is defined by 4 or more of the following characteristics:
Desire to be the other sex
Preference for cross-sex roles in play or preference for cross-dressing
Persistent fantasies of being the other sex
An intense desire to participate in stereotypical games and pastimes of the other sex
Strong preference for playmates of the other sex

Boys have an aversion to their penis or testes, a belief the genitals will disappear, an aversion to rough-and-tumble play, and a rejection of male toys. Girls have a rejection of urinating in the sitting position, an assertion that they will grow a penis, an assertion that they do not want to grow breasts or menstruate, and an aversion toward normative feminine clothing.

Adolescents and adults may experience the following:
Desire to be the other sex
Frequent passing as the other sex
Desire to live or be treated as the other sex
Conviction that the person has the typical feelings and reactions of the opposite sex
Persistent discomfort with his or her sex or sense of inappropriateness in the gender role of that sex

Adolescents and adults may have a preoccupation with getting rid of primary and secondary sex characteristics, and they may believe that they were born as the wrong sex.

People with gender identity disorder do not have a concurrent physical intersex condition. Patients report significant distress or impairment in social, occupational, or other important areas of functioning.

For sexually mature patients, the clinician should specify if the patient is sexually attracted to females, males, both, or neither.

Prevalence

No recent epidemiologic studies have determined the prevalence of gender identity disorder. In Europe, 1 per 30,000 adult males and 1 per 100,000 adult females seek sexual reassignment surgery (SRS).

Differentials

The differential diagnosis should include nonconformity to stereotypical sex role behaviors, transvestic fetishism, gender identity disorder not otherwise specified (with a concurrent congenital intersex condition), and schizophrenia.

Proposed parental factors

Rooted in psychoanalytic theory, in a 1968 publication Stoller describes a typical background from which a male transsexual might emerge. A woman whose mother did not encourage her daughter’s femininity grows up and marries a passive man for a relationship that is unsatisfactory for both but is often lasting. This depressed woman has a male child. A blissful symbiosis is established between mother and son. The father does not try to break the symbiosis and tends to stay away from home. Excessive physical and emotional closeness to the mother for too long leads to feminine identification and behaviors that secretly please the mother, who reinforces these behaviors. Stroller views this nonconflictual learning process as similar to imprinting. In contrast, he views homosexuality and transvestism as end results of defense against the trauma of dangerous and painful interpersonal relationships.

In a 1974 publication, Person and Ovesey postulate a different, yet still psychosocial, etiology based on a study of 10 primary transsexuals (individuals with gender identity disorder). Although all 10 envied girls and engaged in cross-dressing behavior starting at the age of 3-10 years, none believed he was a girl and 9 gave no history of feminine behavior. They were loners, with few age mates of either sex, and they had feelings of anxiety, depression, and loneliness. They were asexual and loathed their male characteristics. Their wish to be female was based on a fantasy of symbiotic fusion with the mother as a way to deal with extreme separation anxiety, thus falling diagnostically in the borderline spectrum of disorders.

Stoller describes the psychoanalytic etiology of female transsexualism as unclear but postulates some preliminary findings. Neither the mother nor father of the girl has a gender disorder. The mother is unable to function in the first months or year of her daughter’s life because of deep depression (paranoia or physical illness in fewer cases). The child knows the mother is present but beyond emotional reach. The father does not minister to his wife; rather, he has the daughter minister to her. These transsexual females are described as vigorous, ungraceful, and unattractive in infancy. The father engages his daughter in activities that interest him, thus promoting masculine behavior. By the age of 4-5 years, she is already yearning to have the anatomic insignias of maleness, born out of pain and conflict from premature maternal separation. Note that these ideas are postulated but data are unavailable.

Retrospective studies in adult transsexuals show differences in recalled child-rearing patterns between transsexuals and normative groups. Male-to-female transsexuals characterized their fathers as less emotionally available, less warm, more rejecting, and overcontrolling. Female-to-male transsexuals characterized both parents as more rejecting and less emotionally warm, but they only characterized their mothers as more overprotective than their female controls did.

Biological factors

Biomedical research of transsexualism has investigated several areas. Girls with congenital adrenal hyperplasia (CAH), a condition causing prenatal exposure to a relatively high level of androgens, were examined to determine if male gender identity developed even if XX chromosome individuals were raised as females. A few such cases have been reported. In most cases, however, girls assigned and raised consistently as girls do not become transsexuals.

Transsexualism was not observed in males or females exposed to progestogens in utero, which might have antiandrogenic or androgenic qualities, nor was it found upon exposure to estrogenic drugs, such as diethylstilbestrol (DES). Nevertheless, some atypical aspects of gender role behavior have been observed.

In 1983, Dörner and colleagues found male-to-female transsexuals, like females, show a rise in luteinizing hormone (LH) levels after estrogen stimulation as a consequence of prenatal exposure to imbalanced sex steroid levels. The opposite occurred in female-to-male transsexuals. Other studies that used more rigorous endocrine methodology were unable to replicate this study’s findings.

Several hypothalamic nuclei in humans have been reported to be sexually dimorphic with respect to size and/or shape: a sexually dimorphic nucleus (SDN) of the preoptic area of the hypothalamus (SDN-POA61), 2 cell groups in the anterior hypothalamus (isonicotinic acid hydrazide [INAH]-262-64 and INAH-362), the darkly staining posteromedial component of the bed nucleus of the stria terminalis (BNST-dspm), and the suprachiasmatic nucleus (SCN) and the central subdivision of bed nucleus of the stria terminalis (BSTc). These sex differences in the hypothalamus are believed to underlie sex differences in gender identity, reproduction, and sexual orientation. Clearly, more solid well-designed research into the biology of these disorders is needed.

Assessment

Paraphilias

Multiprofessional assessment may be helpful, particularly when paraphilias result in criminal behavior. Assessment should include psychiatric history, psychosexual history, full standardized neuropsychological testing, behavioral analysis, physiological measurements, and risk assessment (for future offenses). Assess medical health (including brain), attitude toward offense, attitude toward victim, social stressors, substance abuse, and treatment recommendations.

Gender identity disorder (transsexualism)

Transsexualism is not a homogeneous phenomenon. Diagnosis is complicated because the results of psychological testing are not conclusive. Some individuals distort information to gain access to SRS. Diagnosis, therefore, needs to be extensive and, subsequently, is a time-consuming process.

Standards of care of the International Harry Benjamin Gender Dysphoria Association outline a 2-phase diagnostic process for patients seeking SRS treatment:
Phase I: A formal diagnosis is made using DSM or International Classification of Diseases (ICD) criteria. Risk factors are estimated to ensure the individual can tolerate the life changes that SRS will bring.
Phase II: The ability to live in the desired sex role is tested because the individual must live permanently in the desired sex role. The family is informed, and the patient’s name is changed. Assessment of whether to administer hormone therapy is made. Psychotherapy is required.

Diagnostic procedures for adolescents seeking SRS include all of the above as well as the following:
The patient must show lifelong cross-gender identity that increased at puberty.
Serious psychopathology must be absent.
The person must be able to function socially without significant problems.

Preliminary follow-up observations include the following:
Heterosexual transsexuals appear to have poorer outcomes than homosexual transsexuals.
Gender-confused individuals (patients who do not meet the full criteria for transsexualism), transvestites, effeminate homosexuals, older individuals, and those resisting transsexualism generally have poorer post-SRS functioning.
Patients who have undergone female-to-male SRS tend to do better than male-to-female SRS individuals.
Treatment

Paraphilias

A wide variety of people manifest various paraphilias. The level of severity, distress, and impairment (up to and including criminal behavior) resulting from these disorders also are highly variable. Consequently, treatment options vary and must take into account the specific needs of each individual case.

Treatment options may include psychotherapy, individual psychotherapy, group therapy, marital therapy, and family therapy. Cognitive behavioral therapy may be used with a 7-step approach, as follows:
Aversive conditioning with ammonia or (masturbatory) satiation
Confrontation of cognitive distortions (especially effective in groups)
Victim empathy (show videos of victims and consequences to victims)
Assertiveness training (social skills training, time management, structure)
Relapse prevention (identifying antecedents to the behavior [high-risk situations] and how to disrupt antecedents)
Surveillance systems (family associates who help monitor patient behavior)
Lifelong maintenance

Pharmacotherapy may also be used.
Antiandrogens (to lower sex drive)
Medroxyprogesterone acetate (Provera) – 10 mg bid, double dose every 3 days up to 200 mg/d; maintain for 1 mo and adjust prn
Leuprolide acetate (Lupron) – IM

Selective serotonin reuptake inhibitors (SSRIs) may be prescribed to treat associated compulsive sexual disorders and/or to gain benefit from libido-lowering sexual side effects. Higher doses than are typically administered for depression are usually used.
Sertraline (Zoloft) – 150-200 mg/d
Fluoxetine (Prozac) – 20-80 mg/d
Fluvoxamine (Luvox) – 200-300 mg/d
Citalopram (Celexa) – 20-80 mg/d
Paroxetine (Paxil) – 20-60 mg/d

Gender identity disorder (transsexualism)

Psychological intervention may be beneficial. Individual treatment focuses on understanding and dealing with gender issues. Group, marital, and family therapy can provide a helpful and supportive environment.

Hormone therapy may also be necessary. In male-to-female individuals, original sex characteristics can be suppressed by luteinizing hormone–releasing hormone (LHRH) agonists, progestational compounds (eg, medroxyprogesterone acetate), spironolactone, flutamide, and cyproteronacetate. In male-to-female individuals, breasts, increased body fat, and a more feminine body shape can be promoted by ethinyl estradiol (0.1-0.5 mg/d) and conjugated estrogen (7.5-10 mg/d). In female-to-male individuals, facial and body hair promotion may be achieved with testosterone cypionate (200 mg IM every 2 wk).

Speech therapy may help male-to-female individuals use their voice in a more feminine manner.

Pharmacotherapy may be necessary for patients with comorbid psychiatric diagnoses. Approximately 50-70% of individuals with gender identity disorder manifest concurrent DSM-IV-TR axis II disorders, most commonly in Cluster B (eg, histrionic, borderline, antisocial, schizoid). They may also experience symptoms of depression, anxiety, or psychosis. Medications may include antidepressants, anxiolytics, and antipsychotics.

Patient and family education

As mentioned previously, neither paraphilia nor transsexualism is a homogeneous phenomenon. Furthermore, considerable variability exists within both categories. Nevertheless, a number of issues can be constructively discussed with patients and, when appropriate, with family members. The goal should be to enhance understanding about the issues being faced and the options available to address them.

In cases of paraphilia where significant potential for negative consequences to others poses genuine concern (eg, pedophilia, sexual sadomasochism), the need for long-term therapy and monitoring must be emphasized. Partners, family, and friends should be encouraged to understand the continuing potential for harm and their responsibility to take the necessary steps to protect themselves and others who may be at risk. Warning signs and coping strategies should be discussed and formulated.

When counseling individuals with gender identity disorder, patients should be educated about the differences between true transsexualism and other gender disorder issues such as transvestic fetishism, nonconformity to stereotypical sex role behaviors, gender dysphoria, and homosexuality. Patients and their families need to be educated about the complexities of these issues, the enduring nature of these disorders, and the challenges that gender disorders typically present. Treatment options should be discussed. When SRS is being considered, point out that the procedure does not produce a trouble-free life. Additionally, work and social adjustment issues need to be discussed, and plans for how to address these concerns need to be developed. The importance of continuing family support and understanding should also be addressed. Finally, the need for long-term therapy and social support should be discussed and encouraged when appropriate.

Outcome And Prognosis

Paraphilias

Paraphilias may occur in isolation. Partners, family, and friends may never know that the person is affected. A paraphilia may exist as a discrete anomaly in an otherwise stable personality. More commonly, paraphilias coexist with personality disorders, substance abuse, anxiety disorders, or affective disorders. Limited knowledge and explanation exists as to why some people act on deviant urges and others do not. Persons with personality disorders who exhibit problems with self-esteem, anger management concerns, difficulty delaying gratification, poor ability to empathize with others, and faulty cognitions are particularly vulnerable. Predicting treatment outcomes is difficult. Long-term treatment gains appear to require approaches that address the underlying dynamics that go beyond the simple paraphilia itself. Treatment and prognosis need to be based on individual assessment.

Specific paraphilias

Exhibitionism: When sociopaths are excluded, group therapy with adults has been effective in improving social skills and providing support against additional offenses. Group therapy has been effective with shy inhibited adolescents, but not compulsive instinct-ridden adolescents. Individual psychotherapy has been helpful with many exhibitionists. Unfortunately, exhibitionism has one of the highest recidivist rates of all sexual offenses.

Fetishism: While it often begins in adolescence, fetishism usually persists. Treatment of the specific fetish rather than the primary underlying dynamic has not been very promising. Behavioral techniques show some promise, particularly when aided by adequate follow-up.

Pedophilia: Many abusers have had sexual fantasies about children for a long time. Consequently, this can be very difficult to change. The physician can attempt to reduce the intensity of pedophiliac fantasies and develop coping strategies for the abuser. The abuser must be willing to recognize that a problem exists and be willing to participate in treatment. This is not always the case. Dynamic psychotherapy, behavioral techniques, chemical approaches, and surgical interventions yield mixed results. Lifelong maintenance may be a pragmatic and realistic approach.

Sexual sadomasochism: Unfortunately, a person with sexual sadomasochism rarely presents for treatment until someone becomes an unwilling partner or is injured. The seriousness and intensity of these behaviors often increase over time. Prognosis varies depending on the depth of the underlying dynamics (especially poor when sociopathy is involved) and the motivation of the patient.

Gender identity disorder (transsexualism)

Existing case reports do not indicate that psychotherapy produces complete and long-term reversal of cross-gender identity. Transsexuals are not a homogeneous group. Some transsexuals do not show severe psychopathology. SRS may be a viable treatment solution for some. Satisfactory results are reported in 87% of male-to-female and 97% of female-to-male SRS patients.

Factors associated with relatively poor SRS postoperative functioning include transvestitism, effeminate homosexuality, SRS performed late in life, bad surgical results, suicidal intentions, inadequate social functioning, loss of work and family, noncooperative attitude toward clinicians, and enduring resistance towards being transsexual.

Outcome studies suggest that transsexuals without severe psychopathology are better off when treated promptly after diagnosis. Transsexuals with severe psychopathology, who are not homosexual, or those who have a late-onset gender identity disorder should not necessarily be excluded from SRS; however, they require more care and extensive evaluation and therapeutic support before SRS is deemed viable.

Controversies

Paraphilias

Historically, 2 forms of physical treatment have been used. Both pose ethical questions.

Psychosurgery using stereotaxic tractotomy and limbic leucotomy may be performed. This is an invasive irreversible procedure that was used on a small number of subjects, primarily in Germany. Some success is reported in treatment of pedophilia, hypersexuality, and exhibitionism. Given the emotional, physical, and intellectual adverse effects, as well as available pharmacologic interventions, this procedure is not likely to be widely used. Bilateral orchidectomy (castration) has been used since the 19th century in Europe and America, although not in Western Europe since the 1970s. Pharmacologic interventions provide a reversible alternative, given negative adverse effects of the procedure (eg, weight disturbance, gynecomastia, hot flashes, osteoporosis and bone pain in elderly patients, depression).

Pharmacologic interventions used to suppress sexual behavior have included the major tranquilizers, estrogens, progestogens, LH-releasing analogue, antiandrogens, and SSRIs.

These treatments may offer genuine help to a variety of paraphiliac disorders; however, numerous adverse effects have been reported. Additionally, ethical, medical, and legal questions have been raised regarding issues of informed consent, including patients in hospital and prison settings.

Gender identity disorder (transsexualism)

Negative attitudes toward SRS appear to be changing among professionals, and scientific interest is increasing. Nevertheless, SRS does not promote a trouble-free life. Psychotherapy post-SRS may substantially improve overall outcome.

Controversy exists over whether adolescents should be allowed to pursue SRS. Many countries deny SRS to adolescents; however, early treatment may be beneficial in adolescents whose secondary sex characteristics have not yet fully developed (eg, facial hair, lowered voice, breast development). Parental involvement and approval is essential.

Postoperative complications can occur. In persons who undergo male-to-female SRS, the vagina can scar and become shorter and narrower, requiring additional surgery. Bouts of recurring cystitis are common. In persons who undergo female-to-male SRS, considerable scarring may occur from breast tissue removal. Additionally, surgical complications from phalloplasty (construction of scrotum with plastic testicles and a penislike appendage) are not uncommon.

Keywords

paraphilia, exhibitionism, fetishism, frotteurism, voyeurism, pedophilia, sexual masochism, sexual sadism, transvestic fetishism, transsexualism, sexual reassignment surgery, SRS, sexual deviancy, arousal in response to an inappropriate stimulus, hypoxyphilia, scatologia, obscene phone calls, necrophilia, partialism, zoophilia, coprophilia, klismaphilia, urophilia, sexual identity disorders, gender identity disorders

Leave a Reply

Your email address will not be published. Required fields are marked *