Sexual & Gender Identity Disorders

Sexual & Gender Identity DisordersSexual 2/9/2010 Disorders

Question: What is different between men and women in their sexual response cycles? Sexual & Gender Identity A.A.EngorgementEngorgement of genitals during arousal Disorders B.B.NippleNipple erection C.C.IncreaseIncrease in respiration during arousal Jack Krasuski, MD D.D.RefractoryRefractory period after orgasm American Physician Institute for Advanced Professional Studies [email protected]

Question: Which of the following Question: The most prevalent male statements regarding paraphilias is sexual disorder is which of the true? following? A.A. Paraphilias are found equally among men and A.A. Premature ejaculation women B.B.Erectile dysfunction B.B.Paraphilias usually do not cause distress C.C.The paraphilia of fetishism involves watching C.C.Orgasmic disorder naked people D.D. Hypoactive sexual desire disorder D.D. Paraphilias can benefit from treatment

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Question: A 22 year old woman presents to clinic with the complaint that she doesn’t want to have sex with her Question: When the outer third of the vagina boyfriend because it seems “disgusting.” She has had three previous relationships end because of her refusal to spasms during sexual intercourse in a manner have sex. She does, however, wish to have close that prevents intercourse or causes pain, this is companionship and is disappointed by her breakups most likely a manifestation of which disorder? precipitated by her feelings toward sex. Her most likely diagnosis is? A.A. Anorgasmia B.B. Dyspareunia A.A. Hypoactive Sexual Desire Disorder B.B. Dyspareunia C.C. Sexual Disorder NOS C.C. Sexual Aversion Disorder D.D. Somatization Disorder D.D. Female Orgasmic Disorder E.E. Vaginismus E.E. Female Sexual Arousal Disorder 5 6

Question: Male Erectile Disorder is Question: Cognitive distortions associated with disturbance in which present in pedophiles are likely to stage of the sexual response cycle? include versions of all of the following except? A.A. Desire A.A. Sex is a sign of love and mutuality B.B. Arousal B.B. I am guiding the child to mature relations C.C. Orgasmic C.C. Children are sexual beings too D.D. Resolution D.D. Sexual impulses are controllable E.E. Recurrence E.E. Adults have a right to have sexual relations with whom they choose 7 8

Question: A 22 year old biological male presents to clinic, stating, “I’m transgender and need to be cleared Lecture Agenda by psychiatry to begin receiving hormone therapy.” He endorses having feelings that he’s ‘a woman trapped in a man’s body’ for as long as he can remember. Despite The sexual response cycle this, he does not wish to undergo sex reassignment Sexual Dysfunctions surgery. His most likely diagnosis is? Paraphilias

A.A. Gender Identity Disorder Gender Identity Disorders B.B. Gender Identity Disorder NOS C.C. Transvestic Fetishism, With Gender Dysphoria D.D. Sexual Dysfunction NOS E.E. Sexual Orientation Disorder

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Sexual Response Cycle Desire Stage

Linear Stage Theory Cycle Theory Sexual drive/libido Desire Stage Emotional closeness, Motivation/desire to have sex Arousal Stage sexual arousal, and Involves sexual fantasies sexual desire form a Orgasmic Stage Lasts for minutes to hours to days reinforcing cycle Resolution Stage More consistent with female sexual response

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Arousal Stage Orgasmic Stage

Psychological and physiological Peaking of sexual pleasure ––EjaculationEjaculation stimulation Rhythmic contraction of perineal muscles Penile erection / vaginal lubrication & Involuntary pelvic thrusting engorgement Involuntary contractions of anal sphincters Nipple erection in both sexes Increase in heart rate, blood pressure, and Blood pressure and pulse increase acutely respiration in both sexes Lasts 55--1515 seconds Stage of sexual activity Obligatory refractory period in men Lasts minutes to hours Women can have multiple orgasms

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Resolution Stage Sexual Dysfunctions DSM-IV Sexual Desire Disorders Sexual Pain Disorders Disgorgement of blood from genitaliagenitalia—— Hypoactive Sexual Desire Dyspareunia detumescence Disorder Vaginismus Sexual Aversion Disorder Sexual Dysfunction Due Sense of wellwell--beingbeing and relaxation Sexual Arousal Disorders to GMC Refractory period in men for minutes to Female Sexual Arousal SubstanceSubstance--InducedInduced hours Disorder Sexual Dysfunction Male Erectile Disorder No refractory period in women Sexual Dysfunction NOS Orgasmic Disorders Female Orgasmic Disorder Male Orgasmic Disorder 15 16 Premature Ejaculation

Sexual Dysfunctions: Subtypes Diagnosis: Clarification

Onset Biological Factors (GMC / Substance) Lifelong Type Vs. Acquired Type Psychological Factors Context Generalized Type Vs. Situational Type Etiologic Factors

Due to Psychological Factors Sexual Sexual Sexual Dysfunction - Dysfunction - Dysfunction - Due to Combined Factors: Psychological plus Due To Due To Due to GMC GMC or substance Psychological Combined Or Substance Factors Only Factors Induced 17 18

Sexual Dysfunction: Sexual Dysfunction: Biological Psychosexual Factors Factors Psychiatric disorders GMC Neuro, Endocrine, Vascular Stress Medications Relationship conflicts Antihypertensives, Chemotherapeutic agents, CNS Abuse / Trauma (current or past) medications Physical Substances Emotional Alcohol and other drugs Sexual Biological Correlates Age and gender 19 20

Hypoactive Sexual Desire Disorder Hypoactive Sexual Desire Disorder

Sexual Desire Disorder Features DSMDSM--IVIV Diagnosis Common in marriage: 35% women; 16% men Deficiency or absence of sexual fantasies and desire HSDD: 75% of women treated for any sexual disorder for sexual activity Biological factors: low testosterone Marked distress or interpersonal difficulty Psychological factors: stress, depression, anxiety Relational factors: conflict, perceived level of partner’s Not better accounted for by another Axis 1 disorder, libido and sexual satisfaction Substance or General Medical Condition Differential Types Secondary to drugs / meds, a GMC Lifelong Vs. Acquired Depressive and anxiety disorders Generalized Vs. Situational Sexual Aversion Disorder, Erectile Dysfunction 21 Due to Psychological or Combined Factors 22

Hypoactive Sexual Desire Disorder: Sexual Aversion Disorder

Treatment Sexual Desire Disorder Assess for any GMC / Substance Factor DSMDSM--IVIV Diagnosis Therapy Persistent & recurrent aversion to and avoidance of genital contact with a sexual partner Couples Therapy / Sensate Training Sexual opportunity creates anxiety & fear Psychoeducation Marked distress or interpersonal difficulty Medications Not better accounted for by another Axis 1 disorder, Testosterone: for men and women SubstanceSubstance--InducedInduced or General Medical Condition Bupropion Types Erectile Dysfunction Meds: for men and women Lifelong Vs. Acquired, Generalized Vs. Situational, Due to Psychological OR Combined Factors 23 24

Sexual Aversion Disorder Sexual Aversion Disorder: Treatment Features Psychological Factors: childhood or current Assess for any GMC / Substance Factor sexual abuse, stress, fatigue, specific fears Relational Factors: poor relationship, poor sexual Therapy technique of partner CBT Differential Diagnosis Treat any comorbid PTSD, depression Hypoactive Sexual Desire Disorder (CBT, IPT, Psychodynamic Therapy) Vaginismus, Dyspareunia Sensate Training Sexual Pain Due GMC Psychoeducation Undiagnosed STD Vulvar vestibulitis: chronic pain syndrome Couples Therapy

25 Vulvodynia: Chronic discomfort: burning, itching 26

Female Sexual Arousal Disorder Female Sexual Arousal Disorder

Sexual Arousal Disorder Etiologic Factors DSMDSM--IVIV--TRTR Diagnosis Physical Factors Persistent or recurrent inability to attain or maintain Vascular, neurologic, Diabetes Mellitus an adequate lubrication / swelling Response Stress and fatigue Marked distress or interpersonal difficulty Psychosocial Factors Not better accounted for by another Axis 1 disorder, Childhood abuse, fatigue, stress, poor relationship SubstanceSubstance--InducedInduced or General Medical Condition Treatment Types Assess for any GMC / Substance Factor Lifelong Vs. Acquired, Generalized Vs. Situational, Couples Therapy / Individual Therapy Due to Psychological OR Combined Factors Erectile dysfunction meds for women? 27 28

Male Erectile Disorder Erectile Dysfunction: GMC Factors Sexual Arousal Disorder DSMDSM--IVIV--TRTR Cardiovascular disease Diabetes mellitus Inability to attain / maintain adequate erection Atherosclerotic Multiple sclerosis Marked distress/interpersonal difficulty disease Spinal cord injury Not better accounted for Axis I, Substance or GMC Renal disorders (CRF) Types Psychotropic Liver disease medications Lifelong Vs. Acquired, Generalized Vs. Situational, Due to Psychological OR Combined Factors (Cirrhosis) Prostrate surgery Features Malnutrition 1010--25%25% of all men experience at some point

29 >50% of men presenting with sexual dysfunction 30

Erectile Dysfunction: Treatment Female Orgasmic Disorder Erectile Dysfunction Meds Sildenfil (Viagra) 25 to 100 mg Orgasmic Disorder Vardenafil (Levitra) 2.5 to 20 mg (lasts a day) DSMDSM--IVIV--TRTR Tadalafil (Cialis) 5 to 20 mg (lasts 3 days) Persistent delay or absence of orgasm after a Mechanism of Action / Adverse Effects normal sexual excitement stage Prevent degradation of cGMP, ↑↑ nitric oxide which relaxes Marked distress or interpersonal difficulty smooth muscle in penis, increasing blood flow Not better accounted by Axis I, Substance, Headaches, nausea, upset stomach & muscle aches GMC Other interventions Types Alprostadil, placed directly into urethra with a syringe Lifelong Vs. Acquired, Generalized Vs. Situational, Due to Psychological OR Combined Factors 31 Penile prosthesis / Vacuum pump devices 32

Female Orgasmic Disorder Male Orgasmic Disorder Features Orgasmic Disorder More prevalent in younger / less experienced DSMDSM--IVIV--TRTR women Persistent delay or absence of orgasm following normal More often Lifelong than Acquired sexual excitement phase Once capacity to orgasm develops it is rarely lost Not reasonable for age or stimulation Marked distress or interpersonal difficulty Substances commonly contribute to Acquired Type Not better accounted for by Axis I, Substance, GMC Treatment Types Assess for any GMC / Substance Factor Lifelong Vs. Acquired, Generalized Vs. Situational, Due to Improved sexual technique of partner Psychological OR Combined Factors Masturbatory / Sensate training 33 34

Male Orgasmic Disorder Premature Ejaculation Features Orgasmic Stage Disorder Generalized or ... DSMDSM--IVIV--TRTR Persistent or recurrent ejaculation with minimal Situational: with certain partners only OR when sexual stimulation before, on, or shortly after vaginal with a partner vs. masturbating penetration Substances commonly contribute to acquired type Before ejaculation desired May present as infertility / concealed from partner Marked distress or interpersonal difficulty Treatment Not better accounted by Axis I, Substance, GMC Assess for any GMC / Substance Factor Types Couples Therapy / Individual Therapy Lifelong Vs. Acquired, Generalized Vs. Situational, 35 36 Due to Psychological OR Combined Factors

Premature Ejaculation Dyspareunia (Not Due to GMC) Features Sexual Pain Disorder 25% of married men DSMDSM--IVIV--TRTR ndnd 22 most common disorder in men seeking help for Genital pain associated with sex in men or sexual problems women No corresponding disorder in women Causes distress or interpersonal difficulty Treatment Not due to Vaginismus, GMC, or substance “Squeeze method” Types SSRI medications: Paroxetine 20 mg/day Local anesthetic: 1% dibucaine ointment applied to Lifelong Vs. Acquired, Generalized Vs. penis Situational, Due to Psychological OR Combined 37 38 Factors

Dyspareunia: Features Dyspareunia: Treatment Assess for any GMC / Substance Factors Features Therapy Much more common in women Pelvic muscle relaxation Often starts due to physical factors CBT focuses on contributing beliefs Can then develop psychogenic overlay Sensate Training / Psychoeducation / Couples Psychological Contributors Therapy Childhood abuse Somatic Treatments Believing sex is immoral / vulgar / shameful If vestibulodynia, nerve resection Fearing that sex is painful Change of lubricants: waterwater--based,based, not oil--basedoil based

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Vaginismus (Not Due To GMC) Vaginismus: Features

Sexual Pain Disorder Features DSMDSM--IVIV--TRTR Conditioned reflex of pubococcygeus muscle Involuntary spasm of the outer third of the vagina Not under conscious control that interferes with penile insertion or intercourse Feedback loop can lead to worsening Causes distress or interpersonal difficulty May be unexpected to young women Not Somatization Disorder or GMC Psychological Contributors Lifelong Vs Acquired Childhood abuse Acquired: postpost--childbirth,childbirth, pelvic surgery, sexual Believing sex is immoral / vulgar / shameful or physical assault Fearing that sex is painful

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GMCs Contributing to Vaginismus: Treatment Dyspareunia & Vaginismus Assess for any GMC / Substance Factors Provoked vestibulodynia: increased pain Somatic Treatments sensitivity due to nerve remodeling Use of vaginal dilators of increasing size Inflammation or infection Botulinum toxin injection when refractory Injuries to genital area Therapy Allergy or sensitivity to contraceptive creams, Progressive muscle relaxation latex in condoms CBT focuses on contributing beliefs Inadequate vaginal lubrication Sensate Training / Psychoeducation / Couples Deep pain: endometriosis, pelvic adhesions, cysts Therapy 43 44

Substance-Induced Sexual Sexual Dysfunction Due to GMC Dysfunction Female Hypoactive Desire Disorder Due to ... Specifiers Male Hypoactive Desire Disorder Due to ... With Impaired Desire Male Erectile Disorder Due to ... With Impaired Arousal With Impaired Orgasm Female Dyspareunia Due to ... With Sexual Pain Male Dyspareunia Due to ... With Onset During Intoxication Other Female Sexual Dysfunction Due to ... Sexual Dysfunction NOS Other Male Sexual Dysfunction Due to ...

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Antidepressants: Sexual Adverse Sexual Dysfunction: General Effect Profile Principles of Treatment Antidepressant Mechanism Relative Risk Assessment Bupropion Dop / Nor ++ Couple’s attitude about sexual behavior Mirtazepine Ser / Nor ++++ Ability to communicate Duloxetine Ser / Nor ++++ Review of sexual functioning Venlafaxine Ser / Nor ++++ Therapy Fluoxetine SSRI +++ Address relationship problems Psychoeducation Citalopram SSRI +++ Graded assignments to improve sexual technique +++ Sertraline SSRI Sensate training Paroxetine SSRI ++++ CBT to address contributing beliefs 47 48

Paraphilias: Overview Paraphilias: Disorders Culturally inappropriate or dangerous patterns of Exhibitionism: exposing genitals to stranger sexual arousal Voyeurism: observing others’ sexual activities Sexual fantasies, urges, behaviors involving Fetishism: use of inert objects Abnormal expression of sexual gratification Transvestic Fetishism: crosscross--dressingdressing NonNon--humanhuman objects or nonnon--humanhuman animals Sexual Sadism: inflicting suffering / humiliation Suffering or humiliation of self or one’s partner Sexual Masochism: being humiliated, beaten, Children or nonnon--consentingconsenting person bound or made to suffer Cause marked distress / interpersonal difficulty / Frotteurism: rubbing against nonnon--consentingconsenting impaired functioning person Last longer than 6 months Pedophilia: sex with a prepubescent child 49 50

Paraphilias: Features Pedophilia: DSM-IV Diagnosis Almost always males At least 6 months of urges, fantasies, or behaviors involving sexual activity with a Masochism 20:1 Male:Female child or children (generally age ≤≤ 13) Other paraphilias with even higher ratio Person has acted OR urges / fantasies cause Dependent on cultural norms marked distress / interpersonal difficulty Homosexuality no longer a disorder Person is at least age 16 and at least 5 years Masturbation not sanctioned older than child Differ in level of egoego--dystoniadystonia Specifiers: May act on urges or not Sexually attracted towards males, females, or both Often comorbid with other paraphilias Exclusive (only attracted to children) or Deviant and nonnon--deviantdeviant behaviors co--existco exist nonexclusive 51 52

Pedophilia: Features of Perpetrators Pedophilia: Features of Perpetrators Exclusive (7%) versus NonNon--exclusiveexclusive (93%) Exclusive: “true pedophiles” with deviant sexuality Behavior usually egoego--syntonicsyntonic Nonexclusive: opportunistic with disinhibition Psychological Defenses / Cognitive Distortions Incest only versus broader circle of victims Rationalization, minimization, normalization ~ 90% selfself--identifyidentify as heterosexual Cycle of violence > 90% are male 4040--100%100% of perpetrators abused as children 0.40.4--4%4% of convicted pedophiles are female But childhood abuse neither necessary nor sufficient for pedophilia to develop 50% used alcohol at time of crime

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Pedophiles: Cognitive Distortions Features of the Victimized Children

Sex is sign of love and mutuality 50% boys | 50% girls Guiding child to mature relations 1010--20%20% of children molested by 18 years Children are sexual beings Most molestations: genital fondling or oral Sexual impulses are uncontrollable sexsex Sexual entitlement bias

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Paraphilias: Psychosocial Treatment Pedophilia: Treatment A Relapse Prevention Model Features of Effective Treatment Cognitive Restructuring LongLong--termterm Individual / group ––cuttingcutting through the denial MultiMulti--modal:modal: Psychosocial & Meds Skill Training CourtCourt--mandatedmandated Social, assertiveness, empathic skill training Treatment Goals Behavioral Interventions Reduce pedophilic sex drive Generate arousal to nonnon--deviantdeviant themes through Increase inhibition to pedophilic behaviors masturbation Increase ageage--appropriateappropriate sexual & affiliative Covert sensitization: pair unpleasant images or behavior averse consequences with pedophilic scenes 57 58 Plethysmographic biofeedback

Paraphilias: Medication Treatment Paraphilias: Features of Poor Prognosis

Meds to reduce testosterone / sex drive: Early age of onset Antiandrogens / opiate antagonists High frequency of acts Medroxyprogesterone Lack of guilt Leuprolide: LH releasing hormone agonist Antisocial personality traits Naltroxene: opiate receptor antagonist Presence of substance abuse Meds to reduce impulsiveness: SSRIs Fuoxetine, Sertraline, Fluvoxamine

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Paraphilias: Features of Good Prognosis Gender Identity Disorder: DSM-IV (AKA Transsexualism, Transgenderism)

Presence of single paraphilia A.A. Strong crosscross--gendergender identification Normal intelligence Stated desire to be opposite sex, preference for crosscross-- dressing, preference for crosscross--sexsex roles, desire to playplay Absence of substance abuse stereotypical games of other sex, and play with members Absence of antisocial personality traits of opposite sex History of normal intercourse in addition to B.B. Dissatisfaction with one’s biological sex paraphilia Preoccupation with getting rid of one’s primary and secondary sex characteristics, belief one was born the When selfself--referredreferred (rather than by legal wrong sex agency) C.C. Distress or Impairment

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Gender Identity Disorder: Specifiers Gender Identity Disorder Code Features GID in Children Relatively rare; Starts in childhood GID in Adolescents or Adults Males overover--identify,identify, display feminine behavior with little interest in male pursuits Specify (for sexually mature individuals) Tomboyishness present in young transsexual girls Sexually attracted to males Differential Diagnosis Sexually attracted to females Schizophrenia: delusion Sexually attracted to both Transvestic fetishism: for sexual arousal; most Sexually attracted to neither crosscross--dressersdressers do not wish to switch gender Borderline Personality Disorder: generalized

63 64 identity confusion present

Gender Identity Disorder: Standards Gender Identity Disorder: Treatment of Care Psychotherapy Pretreatment evaluation Three parts to treatment PostPost--treatmenttreatment therapy for adjustment 1.1. Psychiatric pretreatment assessment & Skill training to ‘pass’ as new gender ongoing psychotherapy Biological Males 2.2. Hormone therapy Estradiol/progesterone --breastbreast enlargement 3.3. Sex reassignment surgery Orchiectomy and penectomy Vaginoplasty Biological Females Testosterone to develop muscle mass Mastectomy, oopherectomy & hysterectomy 65 66 Metoidioplasty or phalloplasty

GID: Role of Psychiatrist Gender Identity Disorder NOS 1.1. To accurately diagnose the individual's gender disorder 2.2. To diagnose and treat any coco--morbidmorbid psychiatric conditions Intersex conditions 3.3. To educate about range of treatment options and their implications Congenital adrenal hyperplasia or partial 4.4. To provide psychotherapy androgen insensitivity syndrome 5.5. To ascertain eligibility /readiness for hormone and surgical therapy Plus gender dysphoria 6.6. To make formal recommendations to medical and surgical colleagues Transient stressstress--relatedrelated cross--dressingcross dressing 7.7. To document pt’s relevant history in a letter of recommendation behavior 8.8. To be a colleague on a team of professionals with interest in GID Persistent preoccupation with castration / 9.9. To educate family members, employers, institutions about GID penectomy without desire to acquire 10. To be available for followfollow--upup of previously seen gender patients characteristics of other sex

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Question: What is different between Question: Which of the following men and women in their sexual statements regarding paraphilias is response cycles? true?

A.A. Paraphilias are found equally among men and A.A.EngorgementEngorgement of genitals during arousal women B.B.NippleNipple erection B.B.Paraphilias usually do not cause distress C.C.IncreaseIncrease in respiration during arousal C.C.Paraphilias such as fetishism involve watching D.D.RefractoryRefractory period after orgasm naked people D.D. Paraphilias can benefit from treatment

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Question: A 22 year old woman presents to clinic with Question: The most prevalent male the complaint that she doesn’t want to have sex with her boyfriend because it seems “disgusting.” She has had sexual disorder is which of the three previous relationships end because of her refusal to following? have sex. She does, however, wish to have close companionship and disappointed by her breakups A.A. Premature ejaculation precipitated by her feelings toward sex. Her most likely B.B.Erectile dysfunction diagnosis is? C.C.Orgasmic disorder A.A. Hypoactive Sexual Desire Disorder D.D. Hypoactive sexual desire disorder B.B. Dyspareunia C.C. Sexual Aversion Disorder D.D. Female Orgasmic Disorder E.E. Female Sexual Arousal Disorder 71 72

Question: Male Erectile Disorder is Question: When the outer third of the vagina associated with disturbance in which spasms during sexual intercourse in a manner that prevents intercourse or causes pain, this is stage of the sexual response cycle? most likely a manifestation of which disorder? A.A. Desire A.A. Anorgasmia B.B. Arousal B.B. Dyspareunia C.C. Orgasmic C.C. Sexual Disorder NOS D.D. Resolution D.D. Somatization Disorder E.E. Recurrence E.E. Vaginismus

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Question: A 22 year old biological male presents to Question: Cognitive distortions clinic, stating, “I’m transgender and need to be cleared present in pedophiles are likely to by psychiatry to begin receiving hormone therapy.” He include versions of all of the endorses having feelings that he’s ‘a woman trapped in a man’s body’ for as long as he can remember. Despite following except? this, he does not wish to undergo sex reassignment surgery. His most likely diagnosis is? A.A. Sex is a sign of love and mutuality B.B. I am guiding the child to mature relations A.A. Gender Identity Disorder C.C. Children are sexual beings too B.B. Gender Identity Disorder NOS C.C. Transvestic Fetishism, With Gender Dysphoria D.D. Sexual impulses are controllable D.D. Sexual Dysfunction NOS E.E. Adults have a right to have sexual E.E. Sexual Orientation Disorder relations with whom they choose 75 76

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