Sexual Dysfunctions And Gender Dysphoria

MODULE 1-
Introduction to sexuality:
Human sexuality is the way people experience and express themselves sexually. This
involves biological, erotic, physical, emotional, social, or spiritual feelings and behaviors.
The biological and physical aspects of sexuality largely concern the human reproductive
functions, including the human sexual response cycle.

Someone's sexual orientation is their pattern of sexual interest in the opposite or same sex.
Physical and emotional aspects of sexuality include bonds between individuals that are
expressed through profound feelings or physical manifestations of love, trust, and care. Social
aspects deal with the effects of human society on one's sexuality, while spirituality concerns
an individual's spiritual connection with others. Sexuality also affects and is affected by
cultural, political, legal, philosophical, moral, ethical, and religious aspects of life.

MODULE 2-
Gender Dysphoria:
The term gender dysphoria appears as a diagnosis for the first time in the fifth edition of the
Diagnostic and Statistical Manual of Mental Disorders (DSM-5) to refer to those persons
with a marked incongruence between their experienced or expressed gender and the one they
were assigned at birth. It was known as gender identity disorder in the previous edition of
DSM.

Persons with 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. The
term transgender is a general term used to refer to those who identify with a gender different
from the one they were born with. There are those who want to have the body of another sex
known as transsexuals; those who feel they are between genders, of both genders, or of
neither gender known as genderqueer; and those who wear clothing traditionally associated
with another gender, but who maintain a gender identity that is the same as their birth-
assigned gender known as crossdressers. Transgender people may be of any sexual
orientation. For example, a trans gender man, assigned female at birth, may identify as gay
(attracted to other men), straight (attracted to women), or bisexual (attracted to both men and
women).
Gender Dysphoria in Children-

The DSM-5 defines gender dysphoria in children as incongruence between expressed and
assigned gender, with the most important criterion being a desire to be another gender or
insistence that one is another gender. Many children with gender dysphoria prefer clothing
typical of another gender, preferentially choose playmates of another gender, enjoy games
and toys associated with another gender, and take on the roles of another gender during play.
For a diagnosis to be made, these social characteristics must be accompanied by other traits
less likely to be socially influenced, such as a strong desire to be the other gender, dislike of
one's sexual anatomy, or desire for primary or secondary sexual characteristics of the desired
gender. Children may express a desire to have different genitals, state that their genitals are
going to change, or urinate in the position (standing or sitting) typical of another gender. It is
notable that characteristics used to diagnose children with gender dysphoria must be
accompanied by clinically significant distress or impairment on the part of the child, and not
simply on the part of the adult caregivers, who may be uncomfortable with gender
nonconformity.

DSM-5 Diagnostic criteria- Gender Dysphoria in Children

A. A marked incongruence between one's experienced/expressed gender and assigned gender,

of at least 6 months' duration, as manifested by at least six of the following (one of which
must be Criterion A 1 )

1. A strong desire to be of the other gender or an insistence that one is the other
gender (or some alternative gender different from one's assigned gender).
2. In boys (assigned gender), a strong preference for cross-dressing or simulating
female attire; or in girls (assigned gender), a strong preference for wearing only
typical masculine clothing and a strong resistance to the wearing of typical feminine
clothing.
3. A strong preference for cross-gender roles in make-believe play or fantasy play.
4. A strong preference for the toys, games, or activities stereotypically used or
engaged in by the other gender.
5. A strong preference for playmates of the other gender.
 6. In boys (assigned gender), a strong rejection of typically masculine toys, games,
and activities and a strong avoidance of rough-and-tumble play; or in girls (assigned
gender), a strong rejection of typically feminine toys, games, and activities.
7. A strong dislike of one's sexual anatomy.
8. A strong desire for the primary and/or secondary sex characteristics that match
one's experienced gender.

B. The condition is associated with clinically significant distress or impairment in social,

school, or other important areas of functioning.

Specify if: With a disorder of sex development (e.g., a congenital adrenogenital disorder such
as congenital adrenal hyperplasia or androgen insensitivity syndrome).

Course and Prognosis-

Children typically begin to develop a sense of their gender identity around age 3. At this
point they may develop gendered behaviors and interests, and some may begin to express a
desire to be another gender. It is often around school age that children are first brought for
clinical consultations, as this is when they begin to interact heavily with classmates and to be
scrutinized by adults other than their caregivers. Some children who will later identify as
transgender as adults do not show behaviors consistent with another gender at this age. Some
say later that they worked hard to appear stereotypical to their assigned gender, whereas
others deny being able to recall gender identity concerns. Approaching puberty, many
children diagnosed with gender dysphoria begin to show increased levels of anxiety related to
anticipated changes to their bodies. Children diagnosed with gender dysphoria do not
necessarily grow up to identify as transgender adults. Those children who do identify as
transgender as adults have been shown to have more extreme gender dysphoria as children.
Many studies show increased rates of gay and bisexual identity among those who were
gender nonconforming as children.

Comorbidity-

Children diagnosed with gender dysphoria show higher rates than other children of
depressive disorders, anxiety disorders, and impulse-control disorders. This is likely related
to the stigma faced by these children related to their gendered behaviors and identities. There
are also reports that those diagnosed with gender dysphoria are more likely than others to fall
on the autism spectrum. Some researchers posit that this may be related to intrauterine
hormone exposure.

Gender Dysphoria in Adolescents and Adults-

Adolescents and adults diagnosed with gender dysphoria must also show an incongruence
between expressed and assigned gender. In addition, they must meet at least two of six
criteria, half of which are related to their current (or in the cases of early adolescents, future)
secondary sex characteristics or desired secondary sex characteristics. Other criteria include a
strong desire to be another gender, be treated as another gender, or the belief that one has the
typical feelings and reactions of another gender. Most adults who present to mental health
practitioners with reports of gender-related concerns are aware of the concept of transgender
identity. They may be interested in therapy to explore gender issues, or may be making
contact in order to request a letter recommending hormone treatment or surgery.

DSM-5 Diagnostic criteria- Gender Dysphoria in Adolescents and Adults

A. A marked incongruence between one's experienced/expressed gender and assigned gender,

of at least 6 months' duration, as manifested by at least two of the following:

1. A marked incongruence between one's experienced/expressed gender and primary

and/or secondary sex characteristics (or in young adolescents, the anticipated
secondary sex characteristics).
2. A strong desire to be rid of one's primary and/or secondary sex characteristics because
of a marked incongruence with one's experienced/expressed gender (or in young
adolescents, a desire to prevent the development of the anticipated secondary sex
characteristics).
3. A strong desire for the primary and/or secondary sex characteristics of the other
gender.
4. A strong desire to be of the other gender (or some alternative gender different from
one's assigned gender).
 5. A strong desire to be treated as the other gender (or some alternative gender different
from one's assigned gender).
6. A strong conviction that one has the typical feelings and reactions of the other gender
(or some alternative gender different from one's assigned gender).

B. The condition is associated with clinically significant distress or impairment in social,

occupational, or other important areas of functioning.

Specify if: With a disorder of sex development (e.g., a congenital adrenogenital disorder such
as congenital adrenal hyperplasia or androgen insensitivity syndrome).

Specify if: Post transition: The individual has transitioned to full-time living in the desired
gender (with or without legalization of gender change) and has undergone (or is preparing to
have) at least one cross-sex medical procedure or treatment regimen-namely, regular cross-
sex hormone treatment or gender reassignment surgery confirming the desired gender (e.g.,
penectomy, vaginoplasty in a natal male; mastectomy or phal loplasty in a natal female).

Course and Prognosis-

Some people diagnosed with gender dysphoria as adults recall the continuous development of
transgender identity since childhood. In these cases, some have periods of hiding their gender
identity, many entering into stereotypic activities and employment in order to convince
themselves and others that they do not have gender nonconforming identities. Others do not
recall gender identity issues during childhood. Lesbian and gay communities are often havens
for gender nonconforming people, and some people identify as gay, lesbian, or bisexual
before coming out as transgender.

Comorbidity-

Adults diagnosed with gender dysphoria show higher rates than other adults of depressive
disorders, anxiety disorders, suicidality and self-harming behaviors, and substance abuse. The
lifetime rate of suicidal thoughts in transgender people is thought to be about 40 percent. The
minority stress model predicts increases in mental illness in groups that are stigmatized,
discriminated against, harassed, and abused at higher rates than others.

Other Specified Gender Dysphoria-

The category other specified gender dysphoria 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.

Unspecified Gender Dysphoria-

The category unspecified gender dysphoria can be applied when full criteria are not met and
the clinician chooses not to specify why they are not met.

ETIOLOGY-

1. Biological Factors