NB12-6 - Gender Dysphoria, Sexual Dysfunctions, and Paraphilic Disorders

Question 1

What are the diagnostic criteria for Gender Dysphoria(GD) (formerly gender identity disorder, aka transgender or transsexual)?

Answer 1

A marked incongruence, for at least 6 months, between a person’s assigned gender and their experienced gender, resulting in clinically significant distress or functional impairment.

Question 2

What is thought to be the etiology of GD? How is GD treated?

Answer 2

Altered androgen exposure during critical periods of in-utero development

GD isn’t treated, the distressing symptoms that go along with it are managed by allowing the individual to live their chosen lifestyle, giving them hormone therapy to postpone puberty or have them differentiate into their chosen gender, and sex reassignment surgery once they are adults.

Question 3

What is a sexual dysfunction? List and describe the dysfunctions we need to know.

Answer 3

Sexual dysfunctions are problems related to the normal sexual response cycle that persist for at least 6 months and cannot be explained by a medical condition.

• Female Sexual Interest/Arousal Disorder
• Female Orgasmic Disorder
• Genito-Pelvic Pain/Penetration Disorder (GPPPD) - difficulties with vaginal penetration or the experience of pain during intercourse/penetration attempts
• Male Hypoactive Sexual Desire Disorder
• Erectile Disorder
• Premature/Delayed Ejaculation

Question 4

What are the specifiers used for sexual dysfunctions and what are the common causes?

Answer 4

When diagnosing sexual dysfunctions it’s important to use as many specifiers as you can such as generalized, situational, life-long, and acquired.

Typically the causes are psychological. A medical condition may co-exist but insufficiently explain the symptoms

Question 5

How should a physician perform a sexual dysfunction assessment?

Answer 5

1. Routinely take a sexual history concerning gender, sexual preference, and sexual function
2. If sexual dysfunction is acknowledged, consider whether the symptoms are related to medication, substance use, a medical condition, or aging
3. Be familiar with tests to differentiate a psychiatric vs organic basis for sexual problems

Question 6

List the examples of sexual dysfunction treatments we need to know.

Answer 6

To increase libido and responsiveness - dual sex therapy which involves sensate focus exercises (romantic activity during date night but no sex)

To slow ejaculation - squeeze technique (squeeze glans penis), start & stop technique (partner ceases stimulation to reduce pleasure), SSRIs

Question 7

Describe the overall treatment strategy for sexual dysfunctions.

Answer 7

PLISSIT

• Permission - ask about sex life
• Limited Information - provide basic sex education and correct misconceptions
• Specific Suggestions - provide specific suggestions
• Intensive Therapy - refer on if the above steps fail to resolve the issue

Question 8

What is a paraphilia?

Answer 8

A paraphilia is an intense and deviant sexual interest lasting for at least 6 months. Deviant is defined as a sexual interest other than for genital stimulation or preparatory fondling with phenotypically normal, physically mature consenting human partners.

Question 9

What is a paraphilic disorder?

Answer 9

A paraphilia is a disorder if any of the following three conditions occur:

If an individual:

• Acts on the urge with a non-consenting person
• Acts on the urge with a consenting person (or object) and the actions cause significant distress/functional impairment
• Does NOT act on the urge but the urge causes significant distress/functional impairment

Question 10

List the paraphilic disorders we need to know.

Answer 10

• Exhibitionistic disorder
• Fetishistic disorder
• Frotteuristic disorder
• Pedophilic disorder
• Sexual masochism disorder
• Sexual sadism disorder
• Transvestic disorder
• Voyeuristic disorder

Question 11

Answer 11

Yes

Even though she is not acting on her fantasies, it concerns her enough that she is seeking psychological help.

Question 12

What is exhibitionism?

Answer 12

Sexual arousal from exposing genitals to an unsuspecting stranger

Question 13

What is voyeurism?

Answer 13

Sexual arousal from observing an unsuspecting person either naked, in the process of disrobing, or engaging in sexual activity. Patient must be at least 18 years old

Question 14

What is fetishism?

Answer 14

Sexual arousal from nonliving objects or a highly-specific sexual focus on a non-genital body part.

Note - devices specifically designed for genital stimulation don’t count as a fetish

Question 15

What is transvestism?

Answer 15

Sexual arousal by cross-dressing

Question 16

What is frotteurism?

Answer 16

Sexual arousal from touching or rubbing against a non-consenting person

Question 17

What is sexual sadism and masochism?

Answer 17

Sexual Sadism - sexual arousal from causing psychological/physical suffering of another person

Sexual Masochism - sexual arousal from receiving psychological/physical suffering

Question 18

What is pedophilia?

Answer 18

Sexual arousal by a prepubescent child (usually < 13)

Perpetrator must be at least 16 AND at least 5yrs older than the child.

Question 19

Answer 19

B

Question 20

Answer 20

B

Question 21

What is the etiology of paraphilias?

Answer 21

Multi-factorial and largely unknown but there are suggested influences:

• Abnormal testosterone levels
• Frontal lobe dysfunction and serotonin dysregulation affecting impulse control
• Classical conditioning (from childhood)

Question 22

What are the treatment options for paraphilic disorders?

Answer 22

• Behavioral Therapy
  
  • Aversion Therapy - while engaging/fantasizing about one’s paraphilia, an actual/imagined noxious stimulus is applied to the patient, or imagined by them (covert sensitization)
• Medication
  
  • Antidepressants like SSRIs can be used to reduce libido/obsessions and control impulses
  • Anti-androgens (chemical castration) like Depo-Provera can be given to men to lower testosterone levels

Question 23

Answer 23

B