paraphilias and gender identity [Autosaved] - Copy (2)-1.pptx

Paraphililas
Gender identity
Sexual perversions

1. Paraphilias and gender identity disorders

2. paraphilias Paraphilias ( Sexual Deviations or Perversions ): paraphilia is a greek word. “ para ” means next to and “ philia ” means love. Etymological definition of paraphilias is next to or along side of love. Its an intense and persistent sexual interest other than sexual interest in genital stimulation or preparatory fondling with phenotypically normal, physically mature ,consenting human partners.

3. History RichardvonKrafft-Ebing (1840-1902) left us his book Psychopathia Sexualis who first identified paraphilias . The book, first published in 1886 , features 200 case studies to know more about fetishism, sadism, masochism, homosexuality, nymphomania, necrophilia, pederasty, coprophilia , bestiality, transvestism, exhibitionism and incest. This highly influential psychiatric text laid the groundwork for the development of research and treatment in this area that has taken place over the past century.

4. Sigmund Frued : Individuals would progress towards “normal” heterosexuality unless prevented. He saw all paraphilias as infantile, that is, not mature sexual behavior . Wilhelm Stekel’s Patterns of Psychosexual Infantilism came from this perspective. Homosexuality, sadism, zoophilia,and many others were included in his examples

5. Nosology Paraphilias have been included sinceDSM I under the category of sexual deviation. In DSM-II sexual deviations were classified with the personality disorders. DSM III changed the nomenclature of these behaviors from sexual deviation to paraphilia . Paraphilias were classified as psychosexual disorders, which included gender identify disorders, psychosexual dysfunctions, and ego- dystonic homosexuality.

6. The DSM-IV-TR re classified transvestism from a disorder of gender identity to a paraphilia called transvestic fetishism.

7. Epidemiology GenderRatio : Paraphilias are predominantly male sexuality disorders. Except for sadism and masochism, the paraphilias are almost never diagnosed in females. Nonparaphilic Populations: 61.7% - initiating young girl into sexuality. 33% - rapping adult women. 11.7% - masochistic fantasies.

8. 5.3% - having sex with an animal. 3.2% - initiating a young boy into sexuality. 42 % - voyeurism. 35% - frottage. 8% - obscene telephone calls. 5% - coercive sexual activity. 3% - sexual contact with girls under 12 yr of age 2% - exhibitionism.

9. Crossing over: Individuals with paraphilias “crossover” from one paraphilia behaviour to another. paraphiliacs tend to cross over between touching and non touching of their victims, between family and non family members, between female and male victims, and to victims of various ages.

10. Etiology Biological theory: Neuro anatomical and neuro imaging studies of sex offenders, indicates that congenital or acquired brain damage are overrepresented. Some pedophilic perpetrators show structural impairment of brain regions critical for sexual development. Subtle defects in the right amygdala might be implicated in the pathogenesis of paraphilias .

11. Monoamine hypothesis: monoamine hypothesis for the pathophysiology of paraphilic disorders was first articulated by Kafka(1997). dopamine, norepinephrine , and serotonin serve a modulatory role in human and mammalian sexual motivation. Pharmacological agents that affect monoamine neurotransmitters can have facilitative and inhibitory effects on sexual behavior .

12. paraphilic disorders have Axis I comorbid associations with nonsexual psychopathologies that are associated with monoaminergic dysregulation . pharmacological agents that enhance central serotonergic function ameliorate paraphilic sexual arousal and behavior .

13. Psychosocial factors : According to psycho analytic model paraphilias occur because of fixation at earlier level of psychosexual development. The difference between one paraphilia to other is method chosen by person to cope with the anxiety caused by the threat of castration by father and separation from the mother.

14. Failure to resolve the oedipal crisis results in improper choice of object for libido cathexis . 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.

15. Fetishism is an attempt to avoid anxiety by displacing libidinal impulses to inappropriate objects. Persons with pedophilia and sexual sadism have a need to dominate and control their victims to compensate for their feelings of powerlessness during the oedipal crisis.

16. Persons with sexual masochism overcome their fear of injury and their sense of powerlessness by showing that they are impervious to harm. The first shared sexual experience can be important . Molestation as a child can predispose a person to accept continued abuse as an adult or, conversely, to become an abuser of others.

17. DSM V PARAPHILIAS The activity must be the sole means of sexual gratification for a period of 6months and cause “marked distress or interpersonal difficulty ”. The categories of paraphilic behavior are exhibitionism, fetishism, frotteurism , masochism, pedophilia , sadism, transvestic fetishism, and voyeurism. Paraphilias not otherwise specified(NOS).

18. FETISHISM F65.0 Individuals who achieve sexual gratification with the use of objects, most commonly women’s undergarments, shoes, stockings, or other clothing items, suffer from fetishism. Fetishists often collect the object of their sexual gratification . It is exclusively described in men and often exists with other paraphilias .

19. Fetishistic transvestism F65.1 The wearing of cloths of the opposite sex principally to obtain sexual excitement. Fetishistic articles are not only worn ,but worn also to create the appearance of the opposite sex. Usually more than one article is worn and often complete outfit and wig. Clear association with sexual arousal and strong desire of removing cloths once orgasm occurs.

20. Exhibitionism F65.2 A recurrent or persistent tendency to expose the genitalia to strangers or to people in public places. Sexual excitement occurs at the time of exposure and the act is commonly followed by masturbation. It is almost entirely limited to heterosexual males who expose o females. If the witness appears shocked, frightened the exhibitionist’s excitement is heightened.

21. Voyeurism F65.3 Voyeurism ( scopophilia ) is a recurrent or persistent tendency to look at people engaging in sexual or intimate behaviour such as undressing. It is usually followed by masturbation. It is carried out without observing people being aware.

22. Paedophilia F65.4 A sexual preference for children , usually prepubertal or early pubertal age. Some paedophilias are attraced only to girls, others are only to boys and others are interested in both the sexes. Men who retain a preference for adult sex partners but because they are chronically frustrated in achieving appropriate contacts,habitually urn to children as substitute. Men who sexually molest their own prepubertal children approach other children as well, which is indicative of paedophilia.

23. 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. When a perpetrator is a late adolescent involved in an ongoing sexual relationship with a 12- or 13-year-old, the diagnosis is not warranted.

24. Sadomasochism F65.5 A preference of sexual activity that involves bondage or the infliction of pain or humiliation. If the individual prefers to be the recipient of such stimulation this is called masochism; if the provider ,sadism. Masochism takes its name from the activities of Leopold von Sacher- Masoch , a 19 th century Austrian novelist. His characters derived sexual pleasure from being abused and dominated by women. The onset of the sadism is usually before the age of 18 years, and most persons with sexual sadism are male.

25. Multiple disorders of sexual preferenceF65.6 Sometimes more than one disorder of sexual preference occur in one preference and none has clear precedence. The most common combination is fetishism, transvesitism and sadomasochism.

26. Other disorders of sexual preferenceF65.8 This classification includes various paraphilias that cause personal distress and that have been acted upon for 6 months that do not meet the criteria for any of the previously mentioned categories. TELEPHONE AND COMPUTER SCATOLOGIA . Telephone scatologia is characterized by obscene phone calling and involves an unsuspecting partner. Tension and arousal begin in anticipation of phoning; the recipient of the call listens while the telephoner (usually male) verbally exposes his preoccupations or induces her to talk about her sexual activity. The conversation is accompanied by masturbation, which is often completed after the contact is interrupted.

27. Computer scatalogia : Persons also use interactive computer networks, sometimes compulsively, to send obscene messages by electronic mail and to transmit sexually explicit messages and video images. Because of the anonymity of the users in chat rooms who use on-line or computer sex (cybersex) allows some persons to play the role of the opposite sex . It represents an alternative method of expressing transvestic or transsexual fantasies. A danger of on-line cybersex is that pedophiles often make contact with children or adolescents who are lured into meeting them and are then molested.

28. Frotteurism : It 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.

29. ZOOPHILIA : In zoophilia, animals—which may be trained to participate—are preferentially incorporated into arousal fantasies or sexual activities, including intercourse, masturbation, and oral–genital contact. Zoophilia as an organized paraphilia is rare. For many persons, animals are the major source of relatedness, so it is not surprising that a broad variety of domestic animals are used.

30. Asphyxiophilia (autoerotic asphyxiation): This is the practice of achieving or heightening sexual arousal with restriction of breathing. Necrophilia : It is an obsession with obtaining sexual gratification from cadavers. Most persons with this disorder find corpses in morgues, but some have been known to rob graves or even to murder to satisfy their sexual urges.

31. COPROPHILIA AND KLISMAPHILIA: Coprophilia is sexual pleasure associated with the desire to defecate on a partner, to be defecated on, or to eat feces ( coprophagia ). coprolalia : compulsive utterance of obscene words (coprolalia). These paraphilias are associated with fixation at the anal stage of psychosexual development. klismaphilia : The use of enemas as part of sexual stimulation’ Urophilia : a form of urethral eroticism, sexual pleasure is associated with the desire to urinate on a partner or to be urinated on.

32. PARTIALISM : Persons with the disorder of partialism concentrate their sexual activity on one part of the body to the exclusion of all others. Mouth–genital contact—such as cunnilingus (oral contact with a woman’s external genitals), fellatio (oral contact with the penis),and anilingus (oral contact with the anus). Mastutrbation : Masturbation can be defined as a person’s achieving sexual pleasure which usually results in orgasm—by himself or herself . Masturbation is abnormal when it is the only type of sexual activity performed in adulthood if a partner is or might be available, when its frequency indicates a compulsion or sexual dysfunction,

33. The techniques of masturbation vary in both sexes and among persons. The most common technique is direct stimulation of the clitoris or penis with the hand or the 􀉹 ngers . Indirect stimulation can also be used, such as rubbing. against a pillow or squeezing the thighs. Men and women have been known to insert objects in the urethra to achieve orgasm. The hand vibrator is now used as a masturbatory device by both sexes.

34. Good prognostic factors Poor prognostic factors Only one paraphilia Normal intelligence. Absence of substance abuse. Absence of nonsexual antisocial personality traits. Successful adult attachment. Early age of onset. High frequency of acts. No guilt or shame about the act. Substance abuse.

35. Treatment Five types of psychiatric interventions are used to treat persons with paraphilic disorder External control : prison is an external control mechanism for sexual crimes that usually does not contain a treatment element. When victimization occurs in a family or work setting, the external control comes from informing supervisors, peers, or other adult family members of the problem. Reduction of sexual drives : Antiandrogens, such as cyproterone acetate and medroxyprogesterone acetate may reduce the drive to behave sexually by decreasing serum testosterone levels to subnormal concentrations.

36. Treatment of comorbid conditions: Cognitive behavioural therapy : It is used to disrupt learned paraphilic patterns and modify behavior to make it socially acceptable. The interventions include social skills training, sex education, cognitive restructuring (confronting and destroying the rationalizations used to support victimization of others), and development of victim empathy

37. Insight-oriented psychotherapy : It is a long-standing treatment approach. Patients have the opportunity to understand their dynamics and the events that caused the paraphilia to develop. In particular, they become aware of the daily events that cause them to acton their impulses . Treatment helps them to deal with life stresses and enhances their capacity to relate to a life partner. psychotherapy allows patients to regain self-esteem and to approach a partner in a more normal sexual manner.

38. GENDER IDENTITY DISRDERS

39. Gender identity disorders Sex and gender often used interchangeably .sex refers to the status of biological variables that can be described as either male typical or female typical in normatively developed individual. gender identity: term coined by Robert Stoller in the mid 20 th century refers to the sense one has of being male or female, which corresponds to the patients anatomical sex. Transgender: the term coined by Virginia Prince Refers to people who lived full – time in gender that was not the one that usually went with their genitals.

40. 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 other sex. Transexual : Refers to an individual who has , or plans to, employ hormonal or surgical means to modify the body so that it conforms to one’s experienced gender.

41. History In 19 th and early 20 th centuries many theorists routinely conflate homosexuality with transgender identities as a frame of reference. Karl Ulrichs - some men were born with a women’s spirit trapped in their bodies. He believed these men constituted a third sex and named them urnings . Until middle 20 th century transgender presentations were usually classified as “psychopathological”.

42. krafft-Ebing’s Psychopathia Sexualis documented cases of those born and assigned to one sex and living as members of other sex. Magnus Hirschfeld first distinguished the desires of homosexuality from those of transsexuaism . Magnus Hirschfeld was a sexologist in the early 20th century. He was also  “a pioneering advocate for transgender people. As early as 1910 he had written  The Transvestites , the first book-length treatment of transgender phenomenon. The distinction is accepted after contribution from Benjamin, Money, Stoller and Green .

43. john Money proposed and developed several theories and related terminology, including gender identity. Money believed that parental attitudes and rearing practices had a strong effect on gender identity. He also established the Johns Hopkins Gender Identity Clinic . The hospital began performing sexual reassignment surgery in 1966. He received the Magnus Hirschfeld Medal in 2002 .

44. Robert Stoller is credited with introducing the concept of gender identity into both psychoanalytic and and psychiatric literature. He believed that childhood family dynamics were responsible for causing adult transsexualism . He was influenced by separation- individuation theories. Gender dysphoria in prepubescent boys was a developmental arrest due to an excessively close gratifying mother and infant symbisos that prevented him to separating from his mother’s female body and feminine behaviour.

45. Richard green Richard green served DSMIII subcommitee on psychosexual disorders that recommended including the diagnosis of transexualism and GID childhood in DSMIII .

46. NOSOLOGY Gender identity disorders were first introduced in DSM III criteria. They were included in the category of psychosexual disorders along with paraphilias and sexual dysfunctions. DSM-III-R gender identity disorders were placed in the section on disorders usually first evident in infancy, childhood, or adolescence In DSM-IV, gender identity disorders were placed in a separate section called sexual and gender identity disorders. In DSM -V the term gender identity disorders is replaced by gender dysphoria .

47. DSM-III and DSM-III-R also classified adult gender identity patients by their sexual orientation The heterosexual subtype was attracted to a person of the other genetic sex, the homosexual subtype to a person of the same genetic sex, and the asexual subtype to neither. DSM-IV continued the subtype classifications and added bisexuality but coded the individuals as attracted to males, females, both,or neither, without calling the attraction homosexual or heterosexual.

48. scales Gender identity /gender dysphoria Questionnaire for adults & adolescents-Female assigned gender at birth . Genderqueer identity scale GQI.

49. ICD 10 In ICD-10 gender identity issues appear under Disorders of Adult Behavior and Personality in the category Gender Identity Disorders (F64). It include five diagnoses: Transsexualism (F64.0), Dual-role transvestism (F64.1), Gender identity disorder of childhood (F64.2), Other gender identity disorders (F64.3), Gender identity disorder, unspecified (F64.4).

50. ICD 11 In ICD11 GID of Childhood renamed as Gender Incongruence of Children while transsexualism renamed as Gender Incongruence of Adolescents and Adults. Both the diagnosis will be removed from the mental and behavioural section of ICD and will be part of new section entitled conditions related to Sexual health.

51. EPIDIOMOLOGY Children: Cross - gender behaviours were reported before 3 years of age. referred clinically - boys younger than 12 yr – desire to be other sex was 10% where as in girls the prevalence 5%. Sex ratio of children referred for gender dysphoria is 4 to 5 boys for each girl.

52. Adults : Prevalence 1 in 11,000 in male – assigned and 1 in 30,000 in female – assigned people. Sex ratio of gender dysphoria in adults 3 to 5 male patients for each female patient. overall prevalence is more in males it may because there is greater social acceptance of birth – assigned female dressing as boys than birth – assigned male dressing and behaving as female.

53. ETIOLOGY Biological factors: Initially the resting state of fetal tissue is female. Male is produced only when there is ‘Y’ chromosome and androgens are introduced. maleness and masculinity depends on fetal and perinatal androgens. Sex steroids influence the expression of sexual behaviours ie . Testosterone increases libido and aggressiveness in women , and oestrogen can decreases libido and aggressiveness in men. Testosterone affects brain neurons that contribute to the masculinization of brain in such areas as hypothalamus.(brain organization theory).

54. Cross gender identification results from brain – limited form of intersexuality . In transgender individuals some brain regions or circuits that are involved in gender identity differ between cisgender men and women. The size of a small area of the bed nucleus of the stria terminalis (BNST) was same in male-to-female transsexuals as in non- transsexual females. chromosomal variations are uncommon in transgender population. Identical twins have shown some pairs that are concordant for transgender issues and others are not so affected. Handedness is manifest during the first trimester of pregnancy , and it is related to prenatal sex steroid levels. transgender persons are likely to be left handed.

55. Male – female transsexuals had a significant excess of maternal aunts to uncles. It is because of genomic imprinting . Model of permissive biological effects Biology plays a permissive role by providing the neural machinery through which gender identity is inscribed by formative experiences. A permissive role could also include delimiting the development stage during which the relevant formative experiences must occur.

56. Psychosocial factors Sigmund Freud believed that gender identity problems results from conflicts experienced by children with in the oedipial triangle. Conflicts are influenced by both family events and children’s fantasies. Mother – child relationship in the first year of life plays an important role in establishing gender identity. Mother normally facilitate their children’s awareness of, and pride in their gender. Gender identity can also triggered by a mother’s death, extended absence or depression. Presence of father normally helps in seperation - individuation process.

57. Verbal labelling( eg as a boy or girl) and non verbal gender -cuing (mannerisms, colthing , hair style)of children by parents and others in their social environment , shaping of gender by positive and negative reinforcement and explicit statements of gender –role expectations. Learning theory postulates that children may be rewarded or punished by parents and teachers on the basis of gender behaviour, thus influencing the way children’s express their gender identities .

58. Autogynephilia in natal males: two major developmental pathways leading to gender dysphoria in male to female adult transsexuals. Homosexual transsexuals are effeminate, gender atyical natal boys who are attracted to partners of their own natal gender. Gynephilic transsexual who are attracted women, usually not overtly gender atypical as children ,who often spend much of their lives in relationship with women.

59. Transsexualism F64.0 Desire to live and be accepted as a member of the opposite sex. It is usually accompanied by a sense of discomfort with one’s anatomical sex and a wish to have hormonal treatment and surgery to make one’s body as congruent as possible with preferred sex. Transsexual identity should have been present persistently for at least 2 yrs. It must not be a symptom of another mental disorder, such as schizophrenia or associated with any intersex,genetic or `

60. Dual-role transvestism F64.1 wearing of cloths of the opposite sex for part of the individual’s existence in order to enjoy the temporary experience of membership of the opposite sex. Without any desire for a more permanent sex change or associated surgical reassignment. No sexual excitement accompanies it.

61. Other gender identity disorder F64.8 It can be used in cases where the presentation causes clinically significant distress or impairment but does not meet the full criteria for gender dysphoria . If this diagnosis is used the clinician records the specific reason that the full criteria were not met

62. Gender identity disorder of childhood F64.2 Usually first manifest during early childhood(before puberty ). Characterized by persistent and intense distress about assigned sex, together with a desire to be of other sex . There is persistent preoccupation with the dress or acivities of opposite sex. In both the sexes, there may be repudiation of the anatomical structure of their own sex . They deny being disturbed by it, although they may disturbed by conflicts with the expectations of their family and peers.

63. Gender identity disorder, unspecifiedF64.9

64. ICD 11 Gender Incongruence of Childhood: It is characterized by a marked incongruence between an individual’s experienced/expressed gender and the assigned sex in prepubertal children . it must be manifested by the following three indicators: ( 1) a strong desire on the child’s part to be a different gender than the assigned sex, or insistence that he or she is a gender different from one’s assigned gender; ( 2) a strong dislike on the child’s part of his or her sexual anatomy or anticipated secondary sex characteristics.

65. 3 )Make-believe or fantasy play, toys, games, or activities and playmates that are typical of their experienced rather than their assigned sex . In addition, the incongruence must have persisted for about 2 years so the diagnosis cannot be made before approximately age 5 . The diagnosis can only be assigned to children before puberty.

66. Incongruence (GI) of Adolescence and Adulthood : It is characterized by a marked and persistent incongruence between an individual’s experienced gender and the assigned sex. The diagnosis cannot be assigned prior to the onset of puberty. a strong dislike or discomfort with one’s primary and/or secondary sex characteristics due to their incongruity with the experienced gender; ( 2) a strong desire to be rid of some of all of one’sprimary and/or secondary sex characteristics due to their incongruity.

67. strong desire to be rid of some of all of one’s primary and/or secondary sex characteristics due to their incongruity . a strong desire to have the primary or secondary sex characteristics of the experienced gender; and a desire to be to live and be accepted) as a person of other sex.

68. scales Gender identity /gender dysphoria Questionnaire for adults & adolescents-Female assigned gender at birth . Genderqueer identity scale GQI.

69. Treatment Prepubescent children: Work with children with GD can be considered to follow one of three approaches, None of these approaches entail hormonal or surgical interventions . The first approach focuses on working with the child and caregivers to lessen gender dysphoria and to decrease cross-gender behaviors and identification. This approach is based upon the assumption that the child’s self-esteem can be best served by improved social integration, including positive relationships, with same-sex peers. Critics of this approach have likened it so-called sexual orientation conversion efforts (SOCE) or reparative therapies of homosexuality .

70. Second approach(Dutch approach): It is to remain neutral with respect to gender identity outcome and to not target gender identity and gender atypical behaviors for change. The goal is to allow the developmental trajectory of gender identity to unfold naturally without pursuing or encouraging a specific outcome. This approach entails combined child, parent and community-based interventions to support the child in navigating the potential social risks. This approach is This approach aims to avoid damaging the child’s self-esteem by risking conveying to him/her that his/her likes and dislikes , behaviors and mannerisms are somehow intrinsically wrong.

71. A third approach entails affirmation of the child’s cross-gender identification by mental health professionals, family members and others . The rationale for supporting transition before puberty is GD can be identified so that primary caregivers and clinicians may opt to support early social transition . The APA Task Force on Treatment of GID published in 2012 identified the major tasks for mental health professionals working with children referred for gender concerns . These include accurately evaluating the gender concerns that precipitated the referral; accurately diagnosing any gender identity related disorder in the child according to the criteria of the most current DSM;

72. accurately diagnosing any coexisting psychiatric conditions in the child, as well as problems in the parent–child relationship , and recommending appropriate treatment; Providing psychoeducation and counseling to the caregivers about the range of treatment options and their implications; providing psychoeducation and counseling to the child appropriate to his or her level of cognitive development ; engaging in psychotherapy with the appropriate persons, such as the child and/or primary caregivers, or to make appropriate referrals for these services

73. Adolescents: Adolescents with recent onset should be screened carefully to detect emergence of the desire for gender transition in the context of trauma , for any disorders such as schizophrenia, mania or psychotic depression that may produce gender confusion. along with psychotherapy, puberty blocking medications can be used. GnRH agonists that can be used to temporarily block the release of hormones that lead to secondary sex characteristics, Giving adolescents and their families time to reflect on the best options moving forward. WPATH SOC v 7, genital surgery should not be carried out until patients reach the legal age of majority to consent to medical proceduresand have lived continuously for at least 12 months in the gender role.

74. Adults: Treatment of adults who identify as transgender may include psychotherapy to explore gender issues, hormonal treatment, and surgical treatment. Hormonal and surgical interventions may decrease depression and improves quality of life. Mental health treatment: Because poor treatment and medicalization of transgender people by mental health providers leads to decreased interest in mental health care. Some mental health providers are specializing in working with transgender population and engage them in psychotherapy.

75. Hormones : In FTM hormone treatment is primarily accomplished with testosterone. It is usually taken by injection every week or every other week. Initial changes include secondary sexual characterstics , including beard growth and male distribution of body hair, and coarsening of the facial features and skin, increased acne, muscle mass, and libido, as well as cessation of menses. Subsequent, and more permanent, changes include deepening of the voice, increased body hair, and enlargement of the clitoris. Monitoring includes hemoglobin / hematocrit ,LFT, monitor for cholestrol and screening for diabetes . Testosterone increases risk of lipid abnormalities and diabetes, polycythemia , weight gain,acne balding ,sleep apnea and future fertility may be affected.

76. In MTF may take estrogen , testosterone-blockers, or progesterone, often in combination. These hormones can cause softening of the skin and redistribution of fat, as well as breast growth. There maybe decreased body hair, decreased sex drive as well as erections and ejaculations. There is no change in voice, as testosterone has permanently altered the vocal cords, and many women seek out voice coaching. Monitoring of BP ,LFT, lipid levels, prolactin levels. Those on estrogen should avoid cigarette smoking, as the combination can lead to increased risk of blood clots. There is increased risk of prolactinomas , venous thrombosis, gallstones , hypertriglyceridemia , cardiovascular diseases and permanent sterility takes place. Physical changes occur over the course of 2 years.

77. Scrotoplasty : placement of testicular implants, is another way to create male-appearing genitalia. Phalloplasty : It is the creation of a penis, is less commonly performed It is expensive, involves multiple procedures, requires donor skin from another part of the body, and has limited functionality. Bottom surgery for women is vaginoplasty , also known as Sex Reassignment Surgery (SRS). In this procedure, the testicles are removed, the penis is reconstructed to form a clitoris, and a vagina is created.

78. surgery Fewer people undergo gender-related surgeries . The most common type of surgery for both trans-men and trans-women is “ top surgery ,” or chest surgery. FTM may have surgery to construct a male contoured chest. MTF may have breast augmentation. “Bottom surgery ” is less common. FTM may have a metoidioplasty , in which the clitoris is freed from the ligament attaching it to the body, and tissue is added, increasing its length and girth.

79. Some women may have orchiectomies , In this procedure, the testicles alone are removed. facial feminization surgeries that alter the cheeks, forehead, nose, and lips to create a more feminine facial appearance.

80. Sex reassignment surgery Sex reassignment surgery(SRS) Gender reassignment surgery /gender confirmation surgery . includes a range of surgeries that transforms the sex organs from male to female, and transforms the physical appearance of a transgender person . Before undergoing sexual reassignment surgery, the patient will begin with hormone treatment for 1 year prior to the surgery.

81. In MTF For patients with a long penis, the surgery is performed with penile skin inversion, the technique involves inverting the penis and removing the erectile tissue and skin, which is then used to create a labia and inverted into the pelvic tissue. The urethra is shortened to fit into place with the female anatomy. For patients with a medium sized penis, the penis is also inverted, however this is combined with a scrotal skin graft. The hair from the scrotum is removed using laser hair removal techniques. The skin graft is used to create the vagina. For patients with a shorter penis, the surgery is performed with a penile skin inversion, in combination with a sigmoid colon graft. The surgery involves taking a section of the sigmoid colon and using it to construct the vaginal opening

82. In FTM two main types of surgery are phalloplasty and metoidioplasty . phalloplasty :It is generally performed in 2 or 3 stages. The first stage involves performing a hysterectomy, removing the ovaries and extending the urethra. Grafts are then taken from the arm or abdomen which is used to construct the phallus (penis ). A scrotoplasty is then performed where by the labia majora are joined together to insert testicular implants. The urethra is then connected to the penis in the final stage and any necessary surgery to correct deformities of the penis is performed. It may be necessary to wait 4 to 6 months between each stage of surgery that i

83. Metoidioplasty is a less complicated procedure than a phalloplasty The penis that is created is significantly smaller than the penis size which can be achieved with a phalloplasty . Once the patient starts taking hormones, this increases the size of the clitoris which is then used to construct a penis . The procedure separating the clitoris from the labia minora and cutting the ligament in order to create the penis . The difference between these two procedures is the size of the penis, after phalloplasty , it is likely that the penis can be used for penetration however, after metoidioplasty ,  this is not usually possible.

84. REFERENCES Kaplan & Sadock’s Comprehensive textbook of psychiatry 10 th edition. Synopsis 11 th ediion . ICD 10 DSM V Tasmann 4 th edition.

85. Thank you