In-Depth Notes on Gender Dysphoria and Related Disorders

Gender Dysphoria

• Definition: Discomfort or distress caused by a discrepancy between an individual’s gender identity and their sex assigned at birth. It often becomes apparent in childhood or adolescence.

• Key Characteristics:

  • Persistent, strong identification with the gender different from assigned sex.

  • Possible experiences of shame, embarrassment, social isolation, and discrimination.

  • Important to note that this is a difference, not a disorder.

Diagnostic Criteria for Gender Dysphoria

For Children:

• Strong ambition to be of a gender opposite to the sex assigned at birth.

• Strong preference for wearing clothing of the opposite gender.

• Preference for playing with children of the opposite gender.

• Dislike of one’s sexual anatomy.

• Ambition for traits that match experienced gender.

For Adolescents and Adults:

• Identical ambitions to those for children but may also include:

  • Rejection of masculine or feminine toys/activities.

  • a general feeling aligned with the emotions of the opposite gender.

  • A desire to be treated as the opposite gender.

  • Ambition to remove or prevent development of primary/secondary sex traits inconsistent with their experienced gender.

Considerations for Alleviating Gender Dysphoria

• Living Role Affirmation: Discuss living part-time or full-time in a gender role consistent with gender identity.

• Social Affirmation: Use of preferred pronouns.

• Medical Affirmation: Consider using hormones or gender-affirming procedures to change sex characteristics.

• Psychotherapy: Explore gender identity and expression.

• Legal Affirmation: Change name and gender on identification documents.

Gender Reassignment “transition”

• Definition: Individuals identifying with a gender opposite or incongruent with their sex assigned at birth.

  • Transgender Woman (MtF): Born with male genitalia, identifies as female.

  • Transgender Man (FtM): Born with female genitalia, identifies as male.

  • Nonbinary: Gender identity does not fall strictly within male or female categories.

  • AMAB - Assigned male at birth

  • AFAB= Assigned female at birth

Steps for Transition

1. Psychotherapy: Help individuals prepare for the transition process.

2. Living as Desired Gender: Trial living period (~1-2 years) to ensure readiness.

3. Hormone Therapy: Use of hormones for gender affirmation.

4. Surgical Intervention: Surgical options available for further alignment of physical traits with gender identity

5. Hormonal therapy to suppress undesired physical characteristics and elicit desired sexual characteristics

6. Hormones: diminish facial hair and enlarge breasts, or to alter one’s voice; this may be the last step for many people.

7. Surgical intervention to alter the person’s secondary sex characteristics to match those of the identified gender

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Impulse Control Disorders (ICDs)

• Definition: Decreased ability to resist impulses, leading to specific acts.

• Characteristics: Tension builds until action is taken, which can be impulsive or planned.

Types of ICDs:

1. Intermittent Explosive Disorder: Episodes of aggression, often disproportionate to provocation.

2. Kleptomania: Compulsion to steal, deriving gratification from theft of items of little value.

3. Pyromania: Compulsion to set fires for emotional gratification.

4. Gambling Disorder: Preoccupation with gambling despite negative consequences.

5. Trichotillomania: Compulsive hair pulling for tension relief.

Interventions for Impulse Control Disorders

1. Develop tension reduction and stress control strategies.

2. Promote healthier, less maladaptive responses to stress.

3. Explore feelings associated with impulses (shame, fear, guilt).

4. Educate on consequences of impulsive behavior.

5. Explain how drugs/alcohol can increase impulsivity.

6. Group therapy can benefit pathological gamblers.

7. Provide support for cosmetic issues arising from trichotillomania.

Psychopharmacology for ICDs

• Medications Used:

  • Antidepressants

  • Mood stabilizers

  • Naltrexone

  • Lithium

  • Atypical antipsychotics

Paraphilic Disorders

• Definition: Involve deviations from socially acceptable sexual behavior, causing distress or harm.

• Key Issues: Stigma, embarrassment may cause reluctance to seek help.

  1. The incidence of paraphilias is difficult to measure because stigma, potential for embarrassment, and other concerns cause reluctance to disclose this information. Divergent religious and cultural beliefs have created conflict within our society about how to define appropriate sexual behavior.

  2. Paraphilic disorders are defined in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) as paraphilias that cause distress, risk of harm, or actual harm to oneself or others (APA, 2013). Paraphilic disorders involve a preoccupation with sexual fantasies and related urges and behaviors that focus on nontraditional or socially unacceptable sexual “targets,” such as children, animals, or objects. Persons with these disorders may or may not act on their fantasies and urges; enacting such fantasies can involve criminal acts.

  3. Paraphilic, and especially pedophilic, offenders can harm or kill their victims, and even when the victim is physically uninjured, there is often significant, protracted, and sometimes disabling psychological damage. Survivors are at increased risk of disorders such as PTSD, depression, anxiety, deliberate self-harm, dissociation, and substance abuse disorders. Families, loved ones, and the general community are often traumatized and left unable to trust others or feel fully secure

     

Causes:

1. Biological: Brain function/structure differences.

2. Psychological: Attachment issues during childhood.

3. Behavioral: Learned responses.

4. Exclusion of Medical Causes: Must eliminate other possible medical or psychiatric causes.

   • Biological Factors

     The causes underlying paraphilic disorders have not yet been determined. Some researchers believe pedophilia should be viewed somewhat as a neurodevelopmental disorder because structural and functional differences in the frontal, temporal, and limbic regions of the brain have been observed (Tenbergen et al., 2015). Traumatic brain injuries and dementia may also be associated with impulsive behavior, behavioral disinhibition, and inappropriate sexual behavior (De Giorgi & Series, 2016; Sadock et al., 2015).

   • Psychological Factors

     A failure to develop appropriate attachments in early childhood, resulting in inadequate or inappropriate attachments at later developmental stages, may contribute to paraphilic disorders. Another theory is that the disorders are learned responses to inappropriate sexual role models. One’s own sexual victimization may contribute to paraphilic disorders, particularly those associated with sexual offenses; 30% to 60% of pedophiles were themselves sexually abused as children. Funding entities and research institutions, perhaps because of the controversial aspects of these disorders, are sometimes reluctant to support research related to the causes and treatment of paraphilic disorders, limiting our understanding (Tenbergen et al., 2015).

   • The diagnosis of these disorders first requires eliminating all other medical and psychiatric causes of the behavior in question (e.g., criminal intent, mania, dementia, substance abuse). Paraphilic disorders do not involve psychotic features, and most have their onset during adolescence. Most people with paraphilic disorders are male, and diagnosis requires that the features must have been present for at least 6 months

     

Effects:

• Distress, shame, guilt, and indifference.

Treatments:

• Individual or group therapy

• Cognitive Behavioral Therapy (CBT)

• Medication (e.g., antidepressants)

Types of Paraphilic Disorders

1. Fetishistic Disorder: Unusual preoccupation with objects/activities for sexual gratification.

2. Exhibitionistic Disorder: Arousal from exposing genitals to an unsuspecting person.

3. Frotteuristic Disorder: Arousal from rubbing against unsuspecting others in public places.

4. Pedophilia: Sexual activity with prepubescent children, causing significant distress.

5. Sexual Masochism/Sadism: Gratification from inflicting or receiving pain/humiliation.

6. Transvestic Disorder: Deriving pleasure from dressing as the opposite gender.

7. Voyeuristic Disorder: Deriving pleasure from observing others in sexual situations.

8. Fetish-

Self-Care for Nurses

• Acknowledge personal biases.

• Practice objectivity in approaches to care.