SEXUAL AND GENDER IDENTITY DISORDERS

Paraphilia means “abnormal or unnatural attraction”. The sexual relationships of these people differ from normal individuals in regard to their preferred sexual objects or in the ways they relate to those objects. Their sexual activities revolve around the themes of: 1. Objects or non-human animals 2. Humiliation or suffering of the patient or partner 3. Non-consenting persons, including children

The most common parphilias in descending order are Pedophilia, Exhibitionism, Voyeurism, and Frotteurism.

In many patients, the paraphilic behavior may be present much of the time, though other patients may indulge in it only occasionally (when under stress). Almost all paraphilia patients are male. Most fantasize sexual contact with their victims.

Paraphilia is not diagnosed if someone is merely sexually excited by images and ideas such as women’s panties and bras, but do not act on their ideas and are not distressed by them.

Most paraphilias begin during adolescence. This is also the time when people begin to discover and explore their sexuality; teenage boys in particular typically experiment with a variety of sexual behaviors.

Terminology of Paraphilias

1. Exhibitionism The patient has urges to expose the genitals to a stranger who does not expect it.

2. Fetishism The patient has sexual urges related to the use of inanimate objects.

3. Frotterism The patient has urges related to rubbing the genitals against a person who has not consented to this (commonly done in a subway or crowded transportation area).

4. Pedophilia The patient has urges involving sexual activities with children.

5. Sexual Masochism The patient has sexual urges related to being injured, bound, or humiliated.

6. Sexual Sadism The patient has sexual urges related to inflicting suffering or humiliation on someone else.

7. Transvestic Fetishism A heterosexual man has sexual urges related to cross-dressing.

8. Voyeurism The patient has urges related to viewing some unsuspecting person disrobing, naked, or engaging in sexual activity. 2

9. Paraphilia Not Otherwise Specified There are quite a few paraphilias that are not widely practiced or that have received too little clinical attention to be assigned their own DSM_IV code. They include sexual urges involving dead people, animals, feces, urine, enemas, and making obscene phone calls.

PEDOPHILIA

The term means “love of children”. This is the most common paraphilia that involves actual sexual contact. Although estimates vary, it is thought by the age of 18, up to 20% of American children have been sexually molested in some way. The perpetrator is usually a relative, friend, or neighbor, not a stranger. The vast majority of pedophiles are men, but Pedophilia has been occasionally reported in women; however, adequate studies are lacking.

The types of acts vary. Some pedophiles will only look; others want to touch or undress a child. But most acts involve oral sex or touching of the genitals of the child or perpetrator. In cases other than incest, most pedophiles don’t require actual penetration. When they do, however, they may use force to achieve it. Victim are usually age 12 or under.

The behavior usually begins in later teenage years, though some pedophiles do not start until midlife. It may be more common among persons who were themselves abused as children. Once pedophilia has begun, it tends to run a chronic course. It is believed that up to 50% of pedophiles use alcohol as a prelude to their contacts with children.

Pedophiles, like other paraphilic individuals, develop a degree of cognitive distortion about their activities: they tell themsleves that sexual experience is important for children’s development or that children enjoy it. Most pedophiles do not force their attentions on children, but depend on guile, friendship, and persuasion. A number of studies suggest that children who are lonely or otherwise uncared for may be at special risk for accepting the advances of a pedophile.

Overall, around 15-25% of those convicted re-offend within a few years of their release from prison. Men who prefer boys are about twice as likely to re-offend as are those who prefer girls.

Criteria for Pedophilia · Repeatedly for at least six months, the patient has intense sexual desires, fantasies, or behaviors concerning sexual activity with a sexually immature child (usually 13 or under) · This causes clinically important distress or impairs work, social, or personal functioning. · The patient is 16 or older and at least five years older than the child.

FETISHISM

A fetish was an idol or other object that had magical significance. In the context of sexual activity, it refers to something that excites an individual’s sexual fantasies or desires. Such objects typically can include underwear, shoes, stockings, and other inanimate objects. Bras and panties are the most common objects used as fetishes.

Some people collect great numbers of their preferred fetishes; some may resort to stealing (from 3 stores or clotheslines) to get them. They may smell, rub, or handle these objects while masturbating, or they may ask sex partners to wear them. Without a fetish, such a person may be unable to get an erection.

The onset of Fetishism is usually in adolescence, although many patients report similar interests even in childhood. Although some women may show a degree of Fetishism, nearly all fetishists are men. The disorder tends to be a chronic condition.

Criteria for Fetishism: · Repeatedly for at least six months, the patient has intense sexual desires, fantasies or behavior concerning the use of inanimate objects (such as shoes or underwear). · This results in clinically important distress or impairs work, social, or personal functioning. · The objects are not used solely in cross-dressing and are not equipment intended to stimulate the genitals (such as a vibrator).

TRANSVESTIC FETISHISM

Transvestic fetishists are defined as hetersexual males who cross dress in order to achieve sexual excitement; they experience frustration when this behavior is interfered with. Some men will do it only occasionally, while alone; others frequently go out in public. Some limit it to underwear; others get dressed up completely. Many will masturbate or have intercourse when they cross dress. They may fantasize about themselves as girls and keep a collection of female clothing, often wearing it under their normal attire.

The onset of transvestic fetishism is usually during adolescence, or even in childhood. Most of these individuals were not effeminate boys. Like other types of Fetishism, this behavior often gradually replaces normal sex. Through videos, magazines, or personal interaction, there may be considerable involvement in the transvestite culture. A small number of these men gradually feel increasingly comfortable dressed as women and become transsexual.

Criteria for Transvestic Fetishism: · Repeatedly for at least six months, a heterosexual male has intense sexual desires, fantasies, or behavior concerning cross-dressing. · This causes clinically important distress or impairs work, social, or personal functioning.

GENDER IDENTITY DISORDER

Patients with gender identity disorder feel intensely uncomfortable with their own biological sex. Some actually detest their own genitalia. They wish to live as members of the opposite sex, and many of them do take on dress and mannerisms of the opposite sex. Cross-dressing is a common first step toward a complete gender change. Next, they may request to take hormones to suppress menstruation, enlarge their breasts, or otherwise change their body appearance or functioning.

A few persons with this disorder are so uncomfortable with their sex that they request sex reassignment surgery. Although many patients who have such surgery are reportedly satisfied and live contentedly in their new gender, some ultimately request to be changed back. 4

GID, which is also known as trans-sexualism, is one of the more recently described disorders in the DSM_IV. Until the 1950s, clinicians did not even recognize that people existed who were so intensely uncomfortable with their biological sex. It was only the widespread publicity that occurred in 1952 when Christine Jorgensen received sex reassignment surgery in Denmark and emerged as a woman that this disorder became generally acknowledged.

GID is rare (3 of every 100,000 males; 1 of every 100,000 females). It begins in childhood and appears to be chronic. Many male patients have low sex drive; if they have sex at all, most prefer other men. Nearly all affected women are sexually attracted to women.

It is far more common for boys with gender disturbance to grow up to become homosexual than to develop GID;

Other Individuals in the News for this disorder: Renee Richards– was a physician. After surgery became a seeded women’s tennis player.

Criteria for Gender Identity Disorder: · The patient strongly and persistently identifies with the other sex. This is not simply a deisre for a perceived cultural advantage of being a member of the other sex. In adolescents and adults, this desire may be manifested by any of the following:  Stated desire to be the other sex  Often passing as the other sex  Wish to live or be treated as the other sex  Belief that the patient’s feelings and reactions are typical of the other sex.

· There is strong discomfort with the patient’s own sex or a feeling that the gender role of that sex is inappropriate for the patient. This is shown by symptoms such as:  Preoccupation with hormones, surgery, or other physical means to change one’s sex characteristics.  Patient’s belief in having been born the wrong sex. · The patient does not have a physical intersex condition. · These symptoms cause clinically important distress or impair work, social, or personal functioning.

EATING DISORDERS

Primary Eating Disorders:

Each of the primary eating disorders is defined by abnormal eating behaviors, and they have a number of other features in common. Patients in both groups may binge and purge with laxatives. Both conditions are encountered mainly in girls and young women; onset is usually during the patient’s teens. Anorexia Nervosa is less common than is Bulimia Nervosa, but the overall prevalence of both may be increasing.

1. Anorexia Nervosa Despite the fact that they are severely underweight, these patients see themselves as fat. Severe weight loss (body weight reduction of 15% or more), refusal to gain weight, and a distorted body image characterize Anorexia Nervosa. About 5% of individuals will die 5

of complications from this disease.

2. Bulemia Nervosa These patients eat in binges, then prevent weight gain by self-induced vomiting, purging, and exercise. Although appearance is important to their self-evaluations, these patients do not have the body image distortion characteristic of Anorexia Nervosa.

3. Eating Disorder Not Otherwise Specified Use this category for disorders of eating that do not meet the criteria for either Anorexia Nervosa or Bulimia Nervosa.

OTHER CAUSES OF ABNORMAL WEIGHT AND APPETITE

Mood Disorders Patients with depression can experience either anorexia with weight loss or increased appetite with weight gain.

Schizophrenia and Other Psychotic Disorders Bizarre eating habits are occasionally encountered in psychotic patients.

Somatization Disorder Complaints of marked weight fluctuation and appetite distrubance may be encountered in these patients.

Simple Obesity This is not a DSM-IV diagnosis. But emotional problems that contribute to the development or maintenance of obesity can be coded as a Psychological Factor Affecting Medical Condition.

SLEEP DISORDERS

Dyssomnias A patient with a dyssomnia sleeps too little, too much, or at the wrong time. But the sleep itself is pretty normal.

Insomnia Is often a symptom; sometimes it is a presenting complaint. It is imperative that the clinician evaluate whether another mental disorder or a general medical condition is the cause of the insomnia.

Hypersomnia Although the term means that a person is sleeping too much, it indicates drowsiness at a time when the patient should be alert. Sleep apnea commonly results in excessive daytime sleepiness.

Sleeping at the Wrong Times In two sleep disorders, sleep itself is pretty normal, but it occurs during times when the patient should be awake.

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Narcolepsy Sleep intrudes into wakefulness, causing patients to fall asleep almost instantly. In extreme cases, this may happen even when they are standing up. Their sleep is brief but refreshing. They may also have sleep paralysis, sudden loss of strength (cataplexy) and hallucinations as they fall asleep or awaken.

Circadian Rhythm Sleep Disorder Three types of mismatches between someone’s environment and biological clock have been described: Shift Work, Jet Lag, and Delayed Sleep.

SOMATOFORM DISORDERS

It has been recognized for a long time that physical symptoms and concerns about health can have emotional origins. Somatoform disorders have symptoms that are typical of somatic (bodily) diseases. Several sorts of problems can suggest a somatoform disorder. These include: · Pain that is excessive or chronic · Conversion symptoms · Chronic, multiple symptoms that do not seem to have an adequate explanation · Complaints that do not improve, despite the use of treatment that helps most patients · Excessive concern with health or body appearance

Patients with somatoform disorders have usually been evaluated for somatic disease. These evaluations often lead to testing and treatments that are expensive, time-consuming, ineffective, and sometimes dangerous. Such treatment only reinforces the patient’s fearful belief in some non-existent general medical condition.

These patients are not faking their symptoms, as in Factitious Disorder, or consciously pretending to be ill, as in Malingering. Somatoform patients often believe that they have something seriously wrong; this belief can cause them enormous anxiety and impairment.

Terminology:

Somatization Disorder Multiple, unexplained symptoms (including pain and mood symptoms) characterize this disorder found almost exclusively in women.

Conversion Disorder These patients complain of isolated symptoms that seem to have no physical cause.

Pain Disorder The pain in question has no apparent physical or physiological basis, or it far exceeds the usually expectations, given the patient’s actual physical condition.

Hypochondriasis An otherwise healthy patient who has the unfounded fear of a serious, often life-threatening illness such as cancer or hear disease may warrant this diagnosis.

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Body Dysmorphic Disorder Physically normal patients believe that parts of their bodies are misshapen or ugly. Somatization Disorder Patients with this disorder have a pattern of multiple physical and emotional symptoms that lasts for many years. The symptoms affect various areas of the body and must include, at a minimum, symptoms from these groups: pain, gastrointestinal, sexual, and pseudoneurological.

The disorder begins early in life, usually in the teens or early 20s, and can last for many years– perhaps the patient’s entire lifetime. There is a strong tendency for this disorder to run in families.

Hypochondriasis People with this disorder experience physical sensations such as cough, skipped heartbeats, or minor pain, physical abnormalities (sore, or a mole) and other vague symptoms as evidence of some serious illness. This belief persists despite medical evidence and reassurance. When it is suggested that these patients do not have a serious disease, they may become outraged and reject the idea of a mental health consultation.

Many patients go from doctor to doctor in the effort to find someone who will relieve them of the serious disorders they are sure they have.

Body Dymorphic Disorder Patients with this illness are concerned that there is something wrong with the shape or appearance of a body part. Most often this involves breasts, genitalia, hair, or the nose or some other portion of the face. The ideas these patients have about their bodies are not delusional, they are overvalued ideas. The disorder can be devastating.

Conversion Disorder Conversion symptoms are more likely to be found in patients who are medically unsophisticated and in countries where medical practice and diagnosis are still emerging. It is usually a disorder of young people and is more common among women than men. Especially susceptible are relatively uneducated people from low socioeconomic groups.

Conversion symptoms are also called pseudoneurological because they resemble genuine sensory or motor symptoms, but they do not usually conform to the anatomical pattern that would be expected for a condition with a well-defined physical cause.

Common conversion symptoms involving the senses include blindness, deafness, double vision, and hallucinations. Examples of motor deficits that are conversion symptoms include impaired balance or coordination, weak or paralyzed muscles, lump in the throat or trouble swallowing, loss of voice, and retention of urine.

FACTITIOUS DISORDER

Factitious means that something does not occur naturally. In the context of mental health patients, it means that a disorder looks like a real disease, but isn’t. Patients accomplish this by simulating symptoms (making complaints of pain) of physical signs (warming a thermometer in coffee or submitting a urine specimen that has sand in it). Sometimes they will complain of psychological symptoms including depression, hallucinations, delusions, anxiety, suicidal ideas, 8 and disorganized behavior.

Patients do not behave this way for material gain (such as insurance payments); but because they wish to occupy the sick role. These patients need the feeling of being cared for or of tricking medical personnel. They manufacture physical and psychological symptoms in a way that they claim they cannot control.

Patient’s symptoms can be very dramatic, with outright lying about the severity of the distress. The overall pattern of signs and symptoms is generally not typical for the alleged illness, and some patients change their stories upon retelling. They may undergo many procedures which may be painful and dangerous in order to continue in the sick role.

Once hospitalized, the patients complain bitterly and often, argue frequently with staff members, and have few visitors, if any. They usually stay only a few days and leave against medical advise once their tests prove negative. Many travel from city to city for medical care. The most persistent confabulators are said to have Munchausen Syndrome, named for the fabled Baron von Munchausen who told outrageous lies about his adventures.