Paraphilias

Gender Dysphoria
Dr Humaira Naz
 https://www.youtube.com/watch?v=32TSeU6pjXs
• Mr. J comes from a middle-class household with no history of trauma or
substance use. He does not report any symptoms consistent with anxiety, but
discloses a history of sexual preoccupations. Mr. J says that during
adolescence he developed a predilection for observing others engage in
sexual activity. In his late teens, he began following couples to their homes in
the hope of witnessing sexual intimacy. In the rare instance that his
voyeuristic fantasy comes to fruition, he achieves sexual gratification he is
incapable of experiencing otherwise. Mr. J notes that he has not yet been
caught through self pleasure but he expresses concern and embarrassment
related to his actions. He concludes by noting that he seeks help because the
frequency of this behavior has steadily increased.
Paraphilias
 These disorders are characterized by intense sexual urges, fantasies or
behaviors that involve:
 Nonhumans
 Children
 Nonconsenting adults
 corpses,
There are also specific paraphilias that are generally better described
as preferential sexual interests than as intense sexual interests.
An individual’s pattern of paraphilic interests is often
reflected in his or her choice of pornography
Paraphilias

 According to the DSM-5 TR, paraphilias should be diagnosed only when the
urges, fantasies, or behaviors last at least 6 months
 For most paraphilias, the urges, fantasies, or behaviors
must also cause great distress or interfere with one's
functioning
 Some people with one kind of paraphilia display others as
well
 Relatively few people receive a formal diagnosis, but
clinicians suspect that the patterns may be quite common
Theoretical view

 Psychodynamic view argues that the paraphilias are defensive processes –

Paraphilias protect against repressed fears –A person with a paraphilia is
fearful of heterosexual relationships
 Behaviorists argue that the paraphilia represent classical conditioning of
sexual arousal that has gone awry Biological: Role of testosterone is unknown
• Psychological factors are thought to play a major role, especially events in
childhood that led the individual to associate sexual pleasure with a specific
event or object.
• Often, a child who is the victim or observer of inappropriate sexual behaviors
- including online, learns to later imitate the behavior.
• Other causes include childhood sexual abuse, substance abuse,
hypersexuality, exhibitionism, and a history of antisocial behavior and sexual
anxiety.
biological factors

• Genetics
• brain injury,

hormonal imbalance,
Paraphilias

 Although theorists have proposed various explanations for paraphilias, there is

little formal evidence to support them

 None of the treatments applied to paraphilias have

received much research or been proved clearly
effective
 Psychological and sociocultural treatments have been
available the longest, but today's professionals are also
using biological interventions
Fetishistic Disorder

 The key features of fetishistic disorder are recurrent intense sexual urges, sexually arousing
fantasies, or behaviors that involve the use of a nonliving object, often to the exclusion of all other
stimuli

 The disorder, far more common in men than women, usually begins in
adolescence
 Almost anything can be a fetish
 Researchers have been unable to pinpoint the causes of fetishistic disorder

 Psychodynamic theorists view fetishes as defense mechanisms, but

therapy using this model has been unsuccessful
Fetishistic Disorder

 Behaviorists propose that fetishes are learned through classical conditioning

 Fetishes are sometimes treated with aversion therapy,
or covert sensitization
 Another behavioral treatment is masturbatory
satiation, in which clients acts to boredom while
imagining the fetish object
 An additional behavioral treatment is orgasmic
reorientation, a process which teaches individuals to
respond to more appropriate sources of sexual
stimulation
Transvestic Disorder

 Also known as transvestism or cross-dressing

 Characterized by fantasies, urges, or behaviors involving dressing in the clothes
of the opposite sex in order to achieve sexual arousal
 The typical person with transvestism is a heterosexual male who began cross-
dressing in childhood or adolescence
 Transvestism is often confused with gender dysphoria (transsexualism), but the
two are separate patterns
 The development of the disorder seems to follow the behavioral principles of
operant conditioning
Exhibitionistic Disorder

 Characterized by arousal from the exposure of genitals in a

public setting
 Also known as “flashing”
 Sexual contact is rarely initiated nor desired
 Usually begins before age 18 and is most common in males
 Treatment generally includes aversion therapy and
masturbatory satiation
 May be combined with orgasmic reorientation, social skills
training, or cognitive-behavioral therapy
 Voyeuristic Disorder

 Characterized by repeated and intense sexual urges to observe people

as they undress or to spy on couples having intimacy
 The person may masturbate during the act of observing or while
remembering it later
 The risk of discovery often adds to the excitement .
The ratio of voyeuristic behavior in men to women was
approximately 2:1
 Many psychodynamic theorists propose that voyeurs are seeking power
 Behaviorists explain voyeurism as a learned behavior that can be traced
to a chance and secret observation of a sexually arousing scene
Frotteuristic Disorder

 A person who develops frotteuristic disorder has recurrent and intense

fantasies, urges, or behaviors involving touching and rubbing against a
nonconsenting person
 Almost always male, the person fantasizes during the act that he is having a caring
relationship with the victim
 Usually begins in the teen years or earlier
 Acts generally decrease and disappear after age 25
Pedophilic Disorder

 Characterized by fantasies, urges, or behaviors involving

sexual activity with a prepubescent child, usually 13 years of
age or younger
 Some people are satisfied with child pornography
 Others are driven to watching, fondling, or engaging in
sexual intercourse with children
 Evidence suggests that two-thirds of victims are female
 People with pedophilic disorder develop the disorder in adolescence

 Some were sexually abused as children

 Most are immature, display distorted thinking, and have
an additional psychological disorder
 Most people with pedophilic disorder are imprisoned or forced into treatment

 Treatments include aversion therapy, masturbatory

satiation, orgasmic reorientation, and treatment with
antiandrogen drugs
 Cognitive-behavioral treatment involves relapse-
prevention training, modeled after programs used for
substance dependence
Sexual Masochism Disorder

 Characterized by fantasies, urges, or behaviors

involving the act or the thought of being
humiliated, beaten, bound, or otherwise made to
suffer (engage in, such as restraints or restriction,
discipline, spanking, slapping, sensory deprivation
)
 Most masochistic fantasies begin in childhood and
seem to develop through the behavioral process
of classical conditioning
Sexual Sadism Disorder

 A person with sexual sadism finds fantasies, urges, or behaviors involving the thought or act of
psychological or physical suffering of a victim sexually exciting

 Named for the infamous Marquis de Sade (French writer, libertine,

political activist and nobleman best known for his libertine novels and
imprisonment for sex crimes, blasphemy and pornography)
 People with sexual sadism imagine that they have total control over a
sexual victim
Sexual Sadism

 Sadistic fantasies may first appear in childhood or adolescence

 Pattern is long-term
 Appears to be related to classical conditioning and/or modeling
 Psychodynamic and cognitive theorists view people with sexual sadism as
having underlying feelings of sexual inadequacy
 Biological studies have found signs of possible brain and hormonal
abnormalities
 The primary treatment for this disorder is aversion therapy
Treatment

 Most cases of paraphilia are treated with counseling and therapy to help
these people modify their behavior.
 Medications may help to decrease the compulsiveness associated with
paraphilia and reduce the number of deviant sexual fantasies and behaviors.
 In some cases, hormones are prescribed for individuals who experience
frequent occurrences of abnormal or dangerous sexual behavior. Many of
these medications work by reducing the individual's sex drive
 Aversion therapy and satiation are effective for several of the paraphilias
 Aversion therapy and satiation are effective for several of the paraphilias
Gender Dysphoria

 Gender is used to denote the public, sociocultural (and

usually legally recognized) lived role as boy or girl,
man or woman, or other gender.

 Gender identity is a category of social identity and

refers to an individual’s identification as male, female,
 Gender assignment refers to the assignment as male or
female. This occurs usually at birth based on
phenotypic sex and, thereby, yields the birth-assigned
gender, historically referred to as “biological sex” or,
more recently, “natal gender.” (DSM 5 TR
Gender Dysphoria

 According to current DSM-5 criteria, people with this

disorder persistently feel that they have been assigned
to the wrong biological sex, and gender changes would
be desirable
 The DSM-5 categorization of this disorder has become
controversial in recent years
 Many people believe that transgender experiences
reflect alternative – not pathological – ways of
experiencing one's gender identity
 Others argue that gender dysphoria is, in fact, a
medical problem that may produce personal
unhappiness
 Gender dysphoria— the discomfort one
experiences because their outward appearance
and the way they are perceived do not align
with their gender identity.
 The current term is more descriptive than
the previous DSM-IV term gender identity
disorder and focuses on dysphoria as the
clinical problem, not identity per se.
Diagnostic Features

 A strong desire to be of the other gender or an insistence that one

is the other gender (or some alternative gender different from
one’s assigned gender).

 . In boys (assigned gender), a strong preference for cross dressing

or simulating female attire; or in girls (assigned gender), a strong
preference for wearing only typical masculine clothing and a strong
resistance to the wearing of typical feminine clothing.
 A strong preference for cross-gender roles in make believe play or fantasy
play.

 4. A strong preference for the toys, games, or activities stereotypically

used or engaged in by the other gender.

 5. A strong preference for playmates of the other gender.

 In boys (assigned gender), a strong rejection of typically
masculine toys, games, and activities and a strong avoidance of
rough-and-tumble play; or in girls (assigned gender), a strong
 rejection of typically feminine toys, games, and activities.
 A strong dislike of one’s sexual anatomy. A strong desire for the
primary and/or secondary sex characteristics that match one’s
experienced gender.
 B. The condition is associated with clinically significant distress
or impairment in social, school, or other important areas of
functioning.

 The “posttransition” specifier may be used in the context of

continuing treatment procedures that serve to support the new
gender assignment.
 The specifier “with a disorder/difference of sex
development” should be used in the context of individuals
who have a specific and codable disorder/difference of sex
development documented in their medical record.:\
 (historical terms hermaphroditism and
pseudohermaphroditism.
 DSDs include somatic intersex conditions such as
congenital development of ambiguous genitalia,
 congenital disjunction of internal and external sex
anatomy (e.g., complete androgen insensitivity
syndrome),
 incomplete development of sex anatomy (e.g., gonadal
agenesis),
 sex chromosome anomalies (e.g., Turner syndrome;
Klinefelter syndrome),
  Transsexual, a historic term,
 Transgender refers to the
denotes an individual who
broad spectrum of
seeks, is undergoing, or has
individuals whose gender
undergone a social
identity is different from
transition from male to
their birth-assigned gender.
female or female to male,
which in many, but not all,
cases also involves a
somatic transition by
gender-affirming hormone
treatment other gender
affirming surgery
(historically referred to as
sex reassignment surgery).
 Epidemiology
 Gender dysphoria occurs around puberty or even much later in life

 In children, sex ratios of individuals assigned male at birth to individuals

assigned female at birth range from 1.25:1 to 4.3:1

 in adolescents and young adults than individuals assigned male at birth.

In adults, estimates generally suggest more individuals assigned male at
birth seek gender-affirming treatment, with ratios ranging from 1:1 to
6.1:1 in most studies in the United States and Europe.
 Among adolescents, the highest rate of suicide attempt is among
transgender young men, followed by those defining themselves as neither
male nor female.
Gender Dysphoria

 Many clinicians suspect biological – perhaps genetic or prenatal

– factors
 Abnormalities
in the brain, including the
hypothalamus are a potential link
Gender Dysphoria

 To more effectively assess and treat those with the disorder,

clinical theorists have tried to distinguish the most common
patterns of gender dysphoria:
 Female-to-male
 Male-to-female: Androphilic Type
 Male-to-female: Autogyneophilic Type

 (Comer, 2012)
Female-to-Male Gender Dysphoria
 People with a female-to-male gender dysphoria pattern are
born female but appear or behave in a stereotypically
masculine manner from early on—often as young as 3 years
of age or younger.
 As children they always play rough games or sports, prefer
the company of boys, hate “girlish” clothes, and state their
wish to be male. As adolescents, they become disgusted by
the physical changes of puberty and are sexually attracted to
females.
 However, lesbian relationships do not feel like a satisfactory
solution to them because they want other women to be
attracted to them as males, not as females.
 Male-to-Female Gender Dysphoria:
Androphilic Type
 People with an androphilic type of male-to-female gender dysphoria are
born male but appear or behave in a stereotypically female manner from
birth. As children, they are viewed as pretty, and gentle; avoid rough
games; and hate to dress in boys’ clothing.
 As adolescents, they become sexually attracted to males, and they often
come out as gay and develop gay relationships (the term “androphilic”
means attracted to males).
 But by adulthood, it becomes clear to them that such gay relationships do
not truly address their gender dysphoric feelings because they want to be
with heterosexual men who are attracted to them as women.
Male-to-Female Gender Dysphoria:
Autogynephilic Type
 People with an autogynephilic type of male-to-female gender
dysphoria are not sexually attracted to males; rather, they are
attracted to the fantasy of themselves being females (the term
“autogynephilic” means attracted to oneself as a female).
 Like males with the paraphilia transvestic fetishism persons
with this form of gender dysphoria behave in a stereotypically
masculine manner as children, start to enjoy dressing in female
clothing during childhood, and, after puberty, become sexually
aroused when they cross-dress
 Also, like males with transvestic fetishism, they are attracted
to females during and beyond adolescence. However, unlike
individuals with transvestic fetishism, these persons have
fantasies of becoming female that become stronger and
stronger during adulthood. Eventually they are consumed with
the need to be female.
 In short, cross-dressing is characteristic of both men with the
paraphilia transvestic fetishism and men with this type of male-
to-female gender dysphoria. But the former individuals cross-
dress strictly to become sexually aroused, whereas the latter
develop much deeper reasons for cross-dressing, reasons of
gender identity.
Associated Problems

 Gender dysphoria is associated with high levels of

stigmatization, discrimination, and victimization, leading to
negative self-concept, increased rates of depression,
suicidality, and other mental disorder co-occurrence,

 school dropout, and economic marginalization, including

unemployment, with attendant social and mental health
risks, especially in individuals who lack family or social
support.
 Many adults with GD receive
psychotherapy
 Some adults with this disorder
change their sexual
characteristics by way of
hormones; others opt for sexual
reassignment (sex change)
surgery