Gender Dysphoria

In DSM-5, there is a new classification for the DSM-IV-TR “Sexual and Gender Variants” referred to as
Gender Dysphoria. This reflects a change in the way these diagnostic groups are defined. The
phenomenon of “gender incongruence” is emphasized instead of “cross-gender identification” that
was emphasized in DSM-IV Gender Identity Disorder. We will examine two general categories: the
paraphillias and gender identity disorders.

The Paraphilias:
People with paraphilias have recurrent, intense sexually arousing fantasies, sexual urges, or
behaviors that generally involve (1) nonhuman objects, (2) the suffering or humiliation of oneself or
one’s partner, or (3) children or other nonconsenting persons.

Paraphilias have challenged authors of past DSM editions for two main reasons.

First, some paraphilias—especially pedophilia—are widely considered pathological even if the

paraphilic individual does not experience distress. For example, consider a pedophile who has
molested children but does not feel guilty.

Most people believe that such a man has a mental disorder. In the past, pedophilia has been
diagnosed even in the absence of distress.

A second challenge has been that some other categories of paraphilias may be compatible with
psychological health and happiness. For example, some men who have a foot fetish are comfortable
with their sexual interest and even find willing partners who happily indulge them, while some
others feel substantial shame and guilt .

Individuals with paraphilias may or may not have persistent desires to change their sexual
preferences. Because nearly all such persons are male

The DSM-5 recognizes eight specific paraphilias:

(1) fetishism

(2) transvestic fetishism

(3) voyeurism

(4) exhibitionism

(5) sexual sadism

(6) sexual masochism

(7) pedophilia

(8) frotteurism (rubbing one’s genital area against a nonconsenting person)

Several Different Paraphilic Disorders

1.Fetishist Disorder:
With fetishism, a person has recurrent and intense sexual arousal from inanimate objects or
nongenital body parts. Fetishism can be harmless. It’s only classified as a disorder when it causes
significant distress or causes some form of harm and occurs for at least six months. Some common
fetishes include undergarments, feet, rubber and leather items.

DSM Criteria:

A. Over a period of at least 6 months, recurrent and intense sexual arousal from either the use of
nonliving objects or a highly specific focus on nongenital body part(s)

B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in
social, occupational, or other important areas of functioning.

C. The fetish objects are not limited to articles of clothing used in cross-dressing (as in transvestic
disorder) or devices specifically designed for the purpose of tactile genital stimulation (e.g., vibrator).

Transvestic Disorder
A person who is sexually aroused by cross-dressing may have transvestic disorder. For it to be
regarded as a disorder, the urges or behaviors must have been recurrent, intense, and present for at
least six months. While people who cross-dress do not necessarily have a disorder, a person with
transvestic disorder experiences significant distress or impaired functioning.

A. Over a period of at least 6 months, recurrent and intense Sexual arousal from crossdressing, as
manifested by fantasies, urges, or behaviors.

B. The fantasies, sexual urges, or behaviors cause clinically Significant distress or impairment in
social, occupational, or Other important areas of functioning.

Voyeuristic Disorder
Voyeuristic disorder causes a person to have intense and recurrent urges to watch a non-consenting
person engage in sexual activity. Voyeuristic disorder causes significant distress and can limit a
person’s ability to function. Voyeuristc disorder is more common amongst men than women.

A.Over a period of at least 6 months, recurrent and intense sexual arousal from observing an
unsuspecting person who is naked, in the process of disrobing, or engaging in sexual activity, as
manifested by fantasies, urges, or behaviours.

B. The individual has acted on these sexual urges with a nonconsenting person, or the sexual urges
or fantasies cause clinically significant distress or impairment in social, occupational, or other
important areas of functioning.

C. The individual experiencing the arousal and/or acting on the urges is at least 18 years of age.
Exhibitionistic Disorder
People with an exhibitionistic disorder experience recurrent and intense arousal from the exposure
of their genital to an unsuspecting person. They may become distressed and unable to function
properly due to their urges or have acted on these urges with a non-consenting person. On the other
hand, exhibitionism isn’t a paraphilic disorder, which is simply the desire to expose your genitalia to
a consenting party for the purpose of sexual arousal

A.Over a period of at least 6 months, recurrent and intense sexual arousal from the exposure of
one’s genitals to an unsuspecting person, as manifested by fantasies, urges, or behaviours.

B. The individual has acted on these sexual urges with a nonconsenting person, or the sexual urges
or fantasies cause clinically significant distress or impairment in social, occupational, or other
important areas of functioning.

Sexual Sadism Disorder

Sexual sadism involves inflicting physical or psychological pain on another person to achieve sexual
gratification. It’s important to distinguish between sexual sadism disorder, a paraphilic disorder, and
sadistic sexual behaviour, which is not. It’s normal for mild sadistic sexual behavior to occur between
two adults who consent. With sexual sadism disorder, for at least six months the sadistic sexual
urges cause significant distress, impairment or the individual has acted on these urges with a non-
consenting person.

Criteria:

A.Over a period of at least 6 months, recurrent and intense sexual arousal from the physical or
psychological suffering of another person, as manifested by fantasies, urges, or behaviours.

B. The individual has acted on these sexual urges with a nonconsenting person, or the sexual urges
or fantasies cause clinically significant distress or impairment in social, occupational, or other
important areas of functioning.

Sexual Masochism Disorder

Sexual masochism is a form of paraphilia, but most people who have masochistic interests do not
meet clinical criteria for a paraphilic disorder, which require that the person's behavior, fantasies, or
intense urges result in clinically significant distress or impairment. The condition must also have
been present for ≥ 6 months.

People with sexual masochism generally openly acknowledge their interest in, or participation in,
masochistic sexual activities. The term BDSM (bondage-domination-sadism-masochism) is an
encompassing descriptive term that includes sexual masochists who do, or do not, meet clinical
criteria for a diagnosis of sexual masochism disorder.

A. Over a period of at least 6 months, recurrent and intense sexual arousal from the act of being
humiliated, beaten, bound, or otherwise made to suffer, as manifested by fantasies, urges, or
behaviours.
B. The fantasies, sexual urges, or behaviours cause clinically significant distress or impairment in
social, occupational, or other important areas of functioning.

Pedophilic Disorder:
Pedophilia is sexual attraction to children. According to the DSM-5, a person with pedophilic disorder
must have felt intense and recurrent sexual urges, behaviors, and fantasies toward prepubescent
children for at least six months. A vital component of the condition is that it must bring significant
distress or impairment to a person with it. It’s important to note that acting on sexual attraction to
children is a crime.

A. Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual urges, or
behaviors involving sexual activity with a prepubescent child or children (generally age 13 years or
younger).

B. The individual has acted on these sexual urges, or the sexual urges or fantasies cause marked
distress or interpersonal difficulty.

C. The individual is at least age 16 years and at least 5 years older than the child or children in
Criterion A.

Frotteuristic Disorder
A person with frotteurism is excited by touching or rubbing their genitals against another’s in a
sexual manner without the other person’s consent. It’s a rare type of paraphilia, and much research
still needs to be done to understand it. According to the DSM-5, for a person to be diagnosed with
frotteuristic disorder, they must have experienced an intense and recurrent urge to rub their genitals
against a non-consenting party to achieve sexual gratification for at least six months. This must have
caused significant distress or impairment, or the individual must have acted upon this urge.

A. Over a period of at least 6 months, recurrent and intense sexual arousal from touching or rubbing
against a nonconsenting person, as manifested by fantasies, urges, or behaviours.

B. The individual has acted on these sexual urges with a nonconsenting person, or the sexual urges
or fantasies cause

clinically significant distress or impairment in social, occupational, or other important areas of

functioning.

Causes :
It’s a little unclear what exactly causes paraphilic disorders. Scientists and researchers suspect that a
combination of neurobiological, genetic, developmental, behavioral, and interpersonal factors play a
role. In a 2019 study on paraphilic disorders, researchers observed that people with paraphilic
disorders have elevated levels of serotonin and norepinephrine and decreased levels of a metabolite
of dopamine called dihydroxyphenylacetic acid (DOPAC).

Paraphilic disorders have a variety of complicated origins, many of which include biological,
psychological, and environmental elements. It’s crucial to remember that each instance is unique
and that the precise etiology is yet unknown. The following are a few possible risk factors for
paraphilic disorders:

 Biological Factors:

 Neurobiological Differences: Differences in brain structure or function, including

alterations in neural circuits related to sexual arousal and regulation, may play a
role.

 Hormonal Influences: Hormonal imbalances or abnormalities during development

may contribute to atypical sexual interests.

 Psychological Factors:

 Early Childhood Experiences: Traumatic experiences, abuse, or neglect during early

childhood may influence the development of paraphilic disorders.

 Personality Factors: Certain personality traits, such as impulsivity or sensation-

seeking, may increase the risk of developing paraphilic disorders.

 Cognitive Factors:

 Cognitive Distortions: Distorted thought patterns or beliefs related to sex and

relationships may contribute to the development or maintenance of paraphilic
interests.

 Psychosocial Factors:

 Environmental Influences: Exposure to specific environmental factors, such as a

permissive or overly restrictive sexual environment during childhood, may
contribute.

 Social Learning: Observational learning and modeling of atypical sexual behaviors

within one’s social or familial context may play a role.

 Genetic Factors:

 Family History: Some studies suggest a potential genetic component, as individuals

with a family history of paraphilic disorders or related mental health conditions may
be at a higher risk.

 Neurodevelopmental Factors:

 Disruptions in Neurodevelopment: Factors that disrupt normal neurodevelopment

during critical periods may influence the development of atypical sexual interests.

 Substance Use:
  Substance-Induced Factors: Substance use or abuse, especially during critical
developmental stages, may contribute to the development or exacerbation of
paraphilic disorders.

 Social and Cultural Influences:

 Cultural and Societal Factors: Cultural attitudes, societal norms, and the availability
of specific stimuli in the environment may influence the development of paraphilic
interests.

Symptoms of Paraphilic Disorders

Atypical and strong sexual desires or activities that defy social norms and may cause distress or harm
to the individual or those involved are characteristics of paraphilic disorders. Depending on the
particular form of paraphilia, symptoms of paraphilic disorders might vary, however, they often
consist of the:

 Intense Sexual Arousal:

 Individuals with paraphilic disorders experience strong and persistent sexual arousal
in response to atypical stimuli, fantasies, or behaviors.

 Recurrent and Intense Fantasies:

 Persistent and intrusive sexual fantasies involve a specific paraphilic focus, often
causing distress due to their frequency and intensity.

 Compulsive Urges and Behaviour:

 A strong and recurrent urge to engage in paraphilic behavior, which may lead to
impulsive and compulsive actions.

 Impaired Control:

 Difficulty controlling or resisting the urges to engage in paraphilic behaviors, despite

potential legal, social, or personal consequences.

 Distress or Impairment:

 The paraphilic interests or behaviors cause significant distress to the individual or

impair their ability to function in daily life, maintain relationships, or fulfill societal
obligations.

 Legal and Social Consequences:

 Engagement in paraphilic behaviors may lead to legal consequences, such as arrests

or legal actions, and social consequences, including damaged relationships or social
isolation.

 Interference with Daily Life:

 Paraphilic symptoms may interfere with various aspects of daily functioning,

including work, social interactions, and personal relationships.

 Duration and Persistence:

  The symptoms persist for an extended period, typically six months or longer, and are
not limited to a specific life stage (e.g., adolescence).

 Co-occurring Mental Health Issues:

 Individuals with paraphilic disorders may experience co-occurring mental health

issues, such as depression, anxiety, or substance use disorders.

 Risk of Harm to Others:

 In some paraphilic disorders, there is an increased risk of harm to others, either

directly through non-consensual actions or indirectly through legal consequences.

Treatment of Paraphilic Disorders

The treatment of Paraphilic Disorders involves a comprehensive and individualized approach, often
addressing biological, psychological, and social factors. The primary goals of treatment are to
manage distress, reduce harmful behaviors, and improve overall well-being. Here are common
components of the treatment for paraphilic disorders:

 Psychotherapy:

 Cognitive-Behavioral Therapy (CBT): CBT is often used to address distorted thought

patterns, manage impulsivity, and develop healthier coping strategies. Specific
modalities, such as relapse prevention and social skills training, may be
incorporated.

 Aversion Therapy: This approach involves associating the paraphilic behavior with
unpleasant stimuli to reduce its appeal. However, it should be used cautiously and
ethically.

 Mindfulness-Based Therapies: Techniques such as mindfulness meditation may help

individuals become more aware of their thoughts and impulses, promoting better
self-regulation.

 Pharmacotherapy:

 Selective Serotonin Reuptake Inhibitors (SSRIs): Medications like SSRIs may be

prescribed to reduce obsessive-compulsive symptoms and manage impulsivity.
These medications can also address co-occurring conditions like depression and
anxiety.

 Antiandrogen Medications: In some cases, medications that reduce testosterone

levels may be considered to decrease sexual drive and fantasies. However, these
medications come with potential side effects and ethical considerations.

 Group Therapy:

 Group therapy provides a supportive environment where individuals with paraphilic

disorders can share experiences, learn from others, and develop interpersonal skills.

 Psychoeducation:
  Providing education about the nature of paraphilic disorders, their impact, and
treatment options can help individuals and their families understand and cope with
the condition.

 Relapse Prevention:

 Developing strategies to prevent relapse is crucial. This may include identifying

triggers, creating a relapse prevention plan, and learning coping skills to deal with
stress and challenging situations.

 Family Therapy:

 Involving family members in the therapeutic process can enhance understanding

and support, contributing to the individual’s overall well-being.