CONCEPTS OF GENDER DYSPHORIA____(3).pptx

Gender dysphoria

1. GENDER DYSPHORIA; PARAPHILIC DISORDERS IN CHILDREN AND ADOLESCENTS Presenter : Dr. Venkata Rahul Kumar Moderator : Dr. Hrishikesh Giriprasad sir

2. DEFINITIONS SEX : represents physical differentiation as male/female i.e. biological status indicated by external anatomy of genitilia , presence of gonads and chromosomal analysis etc . GENDER : represents psychological recognition of self, sense of being male or female

3. Gender identity results from an almost infinite number of cues derived from.. Experiences with family members, teachers, friends etc Parenteral and cultural attitudes Infants external genitilia Genetic and hormonal influences Gender identity is fixed in most persons by 2 – 3 years

4. G ender identity : Sense one has of being male or female, which corresponds most often to the person’s anatomical sex . Gender expression : refers to the way in which one presents to the world in a gendered way Sexual orientation : refers to the types of people towards which one is sexually attracted. It describes the object of persons’s sexual impulses; homosexual, heterosexual, bisexual etc Biological sex : is the one that is assigned during birth

5. GENDER DYSPHORIA Gender dysphoria express their discontent with their assigned sex as a desire to have the body of the other sex or to be regarded socially as a person of the other sex It is psychological distress that results from an incongruence between one’s sex assigned at birth and one’s gender identity Gender Identity disorder (DSM 4) changed to Gender Dysphoria (DSM 5 ) Code in DSM 5 : 302.85 ( adults and adolescents), 302.6 ( children) Code in ICD 10 : F64.1 , F64.2 In ICD 11 : included under BLOCK L 1 HA 6 – Gender Incongruence ( HA60, HA 61)

6. The term “ TRANSGENDER ” refers to a person whose sex assigned at birth (i.e. the sex assigned by a physician at birth, usually based on external genitalia) does not match their gender identity (i.e., one’s psychological sense of their gender ) They are called by various names such as kinner , hijra , aravani , jogta etc in various cultures in India Not all transgenders have gender dysphoria Transgender people are a diverse group: T ranssexuals : These are those who want to have the body of another sex. Genderqueer : T hose who feel they are between genders, of both genders, or of neither gender. Crossdressers : Those who wear clothing traditionally associated with another gender, but who maintain a gender identity that is the same as their birth assigned gender

7. Epidemiology Prevalance : 1 in 11,000 for male assigned 1 in 30,000 for female assigned Acc. to DSM 5, prevalance : 0.005 to 0.014% Parents can observe cross gender behaviours as early as 3 years, but usually m ost children with gender dysphoria are referred for clinical evaluation in early grade school years Researchers have observed that many children considered to have shown gender nonconforming behavior do not grow up to be transgender adults C onversely many people who later come out as transgender adults report that they were not identified as gender nonconforming during childhood

8. ETIOLOGY BIOLOGICAL FACTORS : Sex steroids infuence the expression of sexual behavior in mature men or women; that is, testosterone can increase libido and aggressiveness in women, and estrogen can decrease libido and aggressiveness in men. But masculinity, femininity, and gender identity may result more from postnatal life events than from prenatal hormonal organization BRAIN ORGANIZATION THEORY refers to masculinization or feminization of the brain in utero. Testosterone affects brain neurons that contribute to the masculinization of the brain in such areas as the hypothalamus; controversial issue Genetic causes of gender dysphoria are under study but no candidate genes have been identified

9. PSYCHOSOCIAL FACTORS : Sigmund Freud believed that gender identity problems resulted from conflicts experienced by children within the Oedipal triangle . Whatever interferes with a child’s loving the opposite-sex parent and identifying with the same-sex parent interferes with normal gender identity development. Devaluing, hostile mothering Can be triggered by mother’s death, extended absence or depression, to which a young boy may react to totally identifying with her by becoming a mother to replace her

10. Differential Diagnosis Centain transgenders , Gender unconformating people ; they may not have any distress Delusional thinking in Schizophrenia Body dysmorphic disorder : usually patient has distress on a particular body part rather than whole body of opposite sex Transvestic disorder (paraphilia)

11. CO-MORBIDITY : Higher rates of Depressive disorders Anxiety disorders Impulse control disorders This is likely to be related to stigma faced by these children related to their gender behaviours and identities There are also reports that those diagnosed with gender dysphoria are more likely than others to fall on the autism spectrum

12. Treatment PSYCHOTHERAPIES HORMONES SURGERIES Colloboration of psychiatrists, endocrinologists, surgical specialists working as a team i s necessary CHILDREN : Individual, family, group therapies that guide children in exploring their gender interests and identities ADOLESCENTS : In addition to psychotherapy, determine if puberty blocking medications (such as GnRH agonists) should be a consideration

13. The usual protocol for the management of a transsexual condition is hormone therapy, followed by, or simultaneously with, facial hair electrolysis and Reassignment surgery. Studies have shown that many transsexuals have benefited from such reassignment surgery, if patients properly selected and carefully managed Before starting administration of hormone therapy, following criteria should be met – 1 . Patients age must be 18 years or above . 2 . In depth knowledge of what hormones can achieve medically, their social benefits and risks . 3 . A documented real - life experience of at least 3 months prior to the administration of hormones. A period of psychotherapy of a duration specified by the mental health professional after the initial evaluation (usually a minimum of 3 months) should be given

14. Hormones For Transgender man : Testosterone by injections, weekly or biweekly Testosterone causes Increased acne, muscle mass Increased libido Cessation of mensus Deepening of voice Increased body hair Enlargement of clitoris S/E may include : increased RBC, leading to stroke altered cholesterol levels; DM, lipid abnormalities

15. For Transgender Woman : Estrogen testosterone blockers Progesterone These cause : Softening of skin Redistribution of fat Breast development No change in voice ( as testosterone has permanantly altered vocal cords) Avoid smoking (combination may lead to increased clot formation) Chances of increased prolactin levels Permanent sterility occurs : reproductive counselling

16. Before undertaking a SRS( SEX REASSIGNMENT SURGERY), a firm diagnosis for the transsexual condition must be established. The criteria for these are: 1 . A sense of discomfort and inappropriateness about one's sex. 2 . A wish to be rid of one's genitalia and the desire to live life as a member of the opposite sex. 3 . This discomfort/disturbance has been continuously present for a minimum of 2 years and is not limited to a period of stress. 4 . An absence of physical intersex or genetic abnormality . 5 . Absence of a mental disorder such as schizophrenia Before undergoing SRS, referral letters from mental health professionals are essentially required to treating physician regarding hormonal therapy and surgeries

17. Surgery Two types : Top surgery(m/c) Bottom surgery(less common) Top surgery : it is chest surgery Transgender man want male contoured chest Transgender female want breast augmentation Bottom surgery : Transgender male : metoidioplasty , sacroplasty , phalloplasty Transgender woman : vaginoplasty or sex reassignment surgery (SRS), may go for orchidectomies F acial feminization surgeries that alter the cheeks, forehead, nose, and lips to create a more feminine facial appearance Transgender male rarely undergo facial surgeries

18. MEDICOLEGAL CONSIDERATIONS FOR TRANSGENDERS

19. TRANSGENDER PERSONS (PROTECTION OF RIGHTS) ACT, 2019 ; 5 th december 2019 An act to provide for protection of rights of transgender person and their welfare It has 9 chapters Chapter 6, section 15 describes about medical care facilities : (b) appropriate government…. To provide for medical care facility including sex reassignment surgery and hormonal therapy (c) pre treatment and post treatment counselling (d) health manual related to SRS in accordance with world professional association for transgender health guidelines (g) comprehensive insurance schemes etc

20. The problems faced by transgenders were brought to notice of government in 2013 In this regard a meeting was organised by M inistry of Social Justice and Empowerment n august 2013 to discuss about issues related to transgender community The report of the committee is submitted to Ministry of Social J ustice and Empowerment in january 2014 Report consists 13 chapters Chapter 10 includes access to health care; General Health Services (Physical / Mental), and Gender Transition Services (including Sex Reassignment Surgery)

21. INTERSEX CONDITIONS CONGENITAL ADRENAL HYPERPLASIA : Chr : 46XX Overproduction of adrenal androgens Virilization of female fetus High rates of bisexual or homosexual behaviours were reported ANDROGEN INSENSITIVITY SYNDROME Chr : 46XY Testicular feminisation Tiussue cells unable to use testosterone or other androgens produced Appears as normal female at birth and raised as GIRL. Cryptorchid testes are seen

22. TURNER SYNDROME : Chr : 45X Female genitilia , short, webbed neck, shield shaped chest Dysfunctional ovaries : require estrogen for normal development of secondary sexual characters KLINEFELTER’S SYNDROME : Chr : 47XXY appears as males, tall Excessive gynacomastia in adolescence Rudiment testes without sperm production Higher rates of gender dysphoria reported

23. 5 – ALPHA REDUCTASE DEFICIENCY : Conversion of testosterone to dihydroxytestorterone Prevents virilization Affected person appears to be female TREATMENT : Intersex conditions should be addressed as early as possible, so that the entire family can regard the child in a consistent, relaxed manner . This is particularly important because intersex patients may have gender identity problems because of complicated biological influences and familial confusion about their actual sex

24. PARAPHILIAS Paraphilias or perversions are sexual stimuli or acts that are deviations from normal sexual behaviours , but are necessary for some persons to experience arousal and orgasm D eviant fantasy or impulse has been expressed behaviorally The paraphiliac person’s sexuality is mainly restricted to specific deviant stimuli or acts . Persons that occasionally experiment with paraphilic behaviour, but are capable of responding to more typical erotic stimuli , are not seen as having paraphilic disorders.

25. The major functions of human sexual behavior are : to assist in bonding to create mutual pleasure in cooperation with a partner to express and enhance love between two persons to procreate. Paraphilic disorders entail divergent behaviours in that those acts involve aggression , victimization, and extreme one-sidedness . The behaviours exclude or harm others and disrupt the potential for bonding between Persons Moreover , paraphilic sexual scripts often serve other vital psychic functions. They may assuage anxiety, bind aggression, or stabilize identity .

26. DSM-5 lists : Pedophilia Frotteurism Voyeurism Exhibitionism Sexual Sadism Sexual Masochism Fetishism Transvestism Others

27. EPIDEMIOLOGY Paraphilias are practiced by only a small percentage of the population, but the insistent, repetitive nature of the disorders results in a high frequency of such acts. Thus , a large proportion of the population has been victimized by persons with paraphilic disorders Among legally identified cases of paraphilias , pedophilia is most common Of all children, 10-20 % have been molested by age 18 years Of adult females, 20% have been targets of exhibitionism and vouyerism

28. Paraphilias seems to be largely male conditions . Fetishism almost always occurs in males More than 50 percent of all paraphilias have their onset before age 18. Patients with paraphilia frequently have three to five paraphilias , either concurrently or at different times in their lives Sadism and masochism are underreported. Sadism usually comes into notice in cases of rape, brutality or lust murder

29. Frequency of Paraphilic Acts Committed by Patients with Paraphilia Seeking Outpatient Treatment

30. ETIOLOGY PSYCHOSOCIAL FACTORS : According to classical psychoanalytical model, persons with a paraphilia have failed to complete the normal developmental process toward sexual adjustment Method chosen by a person (usually male) to cope with the anxiety caused by the threat of castration by the father and separation from the mother T he resulting behaviour provides an outlet for the sexual and aggressive drives that would otherwise have been channelled into normal sexual behaviour TRANSSEXUALISM AND TRANSVESTIC FETISHISM : involves identification with the opposite-sex parent instead of the same-sex parent

31. EXHIBITIONISM AND VOYEURISM : may be attempts to calm anxiety about castration because the reaction of the victim or the arousal of the voyeur reassures the paraphilic person that the penis is intact FETISHISM is an attempt to avoid anxiety by displacing libidinal impulses to inappropriate objects PEDOPHILIA AND SEXUAL SADISM : may have a need to dominate and control their victims to compensate for their feelings of powerlessness during the oedipal crisis SEXUAL MASOCHISM : overcome their fear of injury and their sense of powerlessness by showing that they are impervious to harm or MASOCHIST directs the aggression inherent in all paraphilias toward herself or himself.

32. Other theories attribute to early experiences that condition or socialize children into committing a paraphilic act Molestation as a child can predispose a person to accept continued abuse as an adult or, conversely, to become an abuser of others . Also , early experiences of abuse that are not specifically sexual, such as spanking, enemas, or verbal humiliation, can be sexualized by a child and can form the basis for a paraphilia The onset of can result from persons’ modeling their behaviour on the behaviour of others who have carried out paraphilic acts , mimicking sexual behaviour depicted in the media, or recalling emotionally laden events from the past, such as their own molestation .

33. BIOLOGICAL FACTORS : several extensive studies have shown these organic findings in paraphilic disorders : 74 percent with abnormal hormone levels, 27 percent with hard or soft neurological signs 24 percent with chromosomal abnormalities 9 percent with seizures 9 percent with dyslexia 4 percent with abnormal EEG studies 4 percent with major mental disorders 4 percent with mental handicaps Psychophysiological tests have been developed to measure penile volumetric size in response to paraphilic and nonparaphilic stimuli

34. EXHIBITIONISM (302.4; F65.3) Exhibitionism is the recurrent urge to expose the genitals to a stranger or to an unsuspecting person . Sexual excitement occurs in anticipation of the exposure, and orgasm is brought about by masturbation during or after the event . In almost 100 percent of cases, those with exhibitionism are men exposing themselves to women Specifiers added in DSM 5 for arousal from exposing genitals : to prepubertal children to physically mature individuals or to both prepubertal children and physically mature individuals

35. FETISHISM (302.81; F65.0) In fetishism the sexual focus is on objects (e.g., shoes, gloves, pantyhose, and stockings) that are intimately associated with the human body, or on nongenital body parts( partialism ) Usually, the disorder begins by adolescence, although the fetish may have been established in childhood. Once established , the disorder tends to be chronic Sexual activity may be directed toward the fetish itself (e.g., masturbation with or into a shoe), or the fetish may be incorporated into sexual intercourse (e.g., the demand that high-heeled shoes be worn).

36. FROTTEURISM ( 302.89; F65.81) Frotteurism is usually characterized by a man’s rubbing his penis against the buttocks or other body parts of a fully clothed woman to achieve orgasm. At other times, he may use his hands to rub an unsuspecting victim. The acts usually occur in crowded places, particularly in subways and buses . Those with frotteurism are extremely passive and isolated, and frottage is often their only source of sexual gratification .

37. PEDOPHILIA ( 302.2; F65.4) Pedophilia involves recurrent intense sexual urges toward, or arousal by, children 13 years of age or younger, over a period of at least 6 months . Persons with pedophilia are at least 16 years of age and at least 5 years older than the victims . Usually involves genital foldling or oral sex Although most reported cases are girls, offenders aften say when they touch a child, 60% are boys DSM 5 added specifiers : sexually attracted to males sexually attracted to females sexually attracted to both

38. POCSO Act, 2012. Protection of children from sexual offences Act This Act has been amended on 6th August’2019 and came into effect frpm 16th august 2019 If an attempt or commission of sexual assault/offence/harassment happens against a child (male or female) under the age of 18 years, then such cases are filed under POCSO Act, 2012 Some of the key points of this Act are : It covers all children below the age of 18 years It is a gender neutral Act Provides child friendly processes for reporting, recording and trial keeping best interest of child as top priority Burden of proof is on the accused in cases of penetrative sexual assault, aggravated penetrative sexual assault, sexual assault and aggravated sexual assault Makes reporting of child sexual abuse cases mandatory

39. POCSO Act, 2012 Where to file a complaint and to whom (process of filing a complaint regarding the offences ) : To report the offences : If any person, including child, has any doubt that such offence can happen or has the knowledge that such offence has been committed, can give the information to the following authorities : Special Juvenile Police Unit formed in all police stations Local police In every report : A written report shall be filed The report should be read out to the person filing the report Entry of the report in the register of police unit

40. SEXUAL MASOCHISM ( 302.83; F65.51) persons with sexual masochism have a recurrent preoccupation with sexual urges and fantasies involving the act of being humiliated, beaten, bound, or otherwise made to suffer Specifier added : with Asphyxiophilia ; also called autoerotic asphyxiation, this is the practice of achieving or heightening sexual arousal with restriction of breathing More common among men than women 30% also have sadistic fantasies Named after Leopold von Sacher-Masoch

41. SEXUAL SADISM ( 302.84; F65.52) R ecurrent and intense sexual arousal from the physical and psychological suffering of another person . Onset usually before 18 years and almost all of them are male According to psychoanalytic theory , sadism is a defense against fears of castration; persons with sexual sadism do to others what they fear will happen to them and derive pleasure from expressing their aggressive instincts Named after Marquis de Sade Lust Murders : some sadistic rapists kill their victims after having sex with them

42. These lust murderers may have underlying schizophrenia or brain trauma John Money lists five contributory causes of sexual sadism: hereditary predisposition Hormonal Malfunctioning pathological relationships a history of sexual abuse the presence of other mental disorders

43. VOYEURISM ( 302.82; F65.3) Voyeurism, also known as Scopophilia , is the recurrent preoccupation with fantasies and acts that involve observing unsuspecting persons who are naked or engaged in grooming or sexual activity. Masturbation to orgasm usually accompanies or follows the event. The first voyeuristic act usually occurs during childhood, and the paraphilia is most common in men . When persons with voyeurism are apprehended , the charge is usually loitering

44. TRANSVESTISM ( 302.3; F 65.1) Previously : Transvestic Fetishism F antasies and sexual urges to dress in opposite gender clothing as a means of arousal and as an adjunct to masturbation or coitus . F etishism is added if the patient is aroused by fabrics, materials, or garments A utogynephilia is added if the patient is sexually aroused by thoughts or images of himself as a female.

45. Other Specified Paraphilic Disorder (302.89; F65.89) Telephone And Computer Scatologia : obscene phone calls Necrophilia : obtaining sexual gratification from cadavers Partialism : concentrate their sexual activity on one part of the body Zoophilia : animals are incorporated into arousal fantasies or activities Coprophilia : desire to defecate on partner Klismaphilia : desire to use enemas as sexual stimulation Urophilia : desire to urinate on partner

46. TREATMENT Five types of psychiatric interventions are used to treat persons with paraphilic disorder and paraphilic interests external control reduction of sexual drives treatment of comorbid conditions (e.g., depression or anxiety) cognitive- behavioral therapy dynamic psychotherapy.

47. References Synopsis 11 th Edition Diagnostic And Statistical Manual; DSM 5 Image From Https://Www.Genderbread.Org/Resource/Genderbread-person-v4-0 THE TRANSGENDER PERSONS (PROTECTION OF RIGHTS) ACT, 2019 ACT NO 40 OF 2019[5th December, 2019.] Report Of Expert Committee On Issues Related To Transgender Person, 2014 Https://Www.Wpath.Org Original Research Article : Transsexualism And Sex Reassignment Surgery – Arising Medicolegal Issues; Richa Gupta1 Et Al The Protection Of Children From Sexual Offences( pocso ) Act, 2012