Paraphilias are sexual disorders with recurrent intense urges and fantasies that do not follow normative arousal patterns and can diminish capacity for sexual intimacy.6 Manifestations include exhibitionism, fetishism, frotteurism, pedophilia, masochism/sadism, voyeurism, and transvestic fetishism.
Dividing transsexualism and pure transvestism paraphilia into discrete categories is simplistic, as transvestites can develop secondary components of transsexualism. Hoenig and Kenna7 assert that transsexualism—though not an anomalous erotic preference—is almost always preceded by transvestism or accompanied by cross-gender fetishism.
Nonparaphilic sexual addiction—included in DSM-IV-TR as sexual disorder not otherwise specified—describes culturally acceptable sexual interests and behaviors that are frequent or intense enough to reduce capacity for sexual intimacy. Such behaviors include compulsive masturbation, repetitive promiscuity, and dependence on anonymous sexual encounters.
An addiction model conceptualizes paraphilia as a form of pleasure seeking that has become habitual and self-destructive. Treatment involves directing patients to 12-step groups patterned after Alcoholics Anonymous.
Other models place paraphilias and related disorders within the OCD spectrum.8-13 Persons with OCD often are obsessed with sexual content and might grapple with religious and moral concerns about sexual issues. They typically consider their symptoms intrusive or senseless. Selective serotonin reuptake inhibitors—the standard medication for OCD—might alleviate paraphilia, but results are mixed.14
Mr. C’s symptoms. Mr. C shows features of GID and transvestism. His strong, persistent cross-gender identification and sense of inappropriateness with being a man indicate GID. His recurrent sexual urges and fantasies and impaired capacity for sexual intimacy suggest a paraphilia or transvestism.
The significance of Mr. C’s comorbid bipolar disorder and OCD is unclear. Both appeared controlled, but the potential for mania-induced hypersexuality cannot be ignored.
Diagnosing gender dysphoria
A thorough medical, psychiatric, and sexual history can reveal sexual identity symptoms’ source.
Consider a medical cause. Your medical workup may include a genital exam to check for irregularities such as hermaphrodism that can compound questions of sexual identity, and karyotyping to probe chromosomal anomalies, such as mosaicism or chimerism.
Consider schizophrenia or bipolar disorder, as mania or psychosis can cause aberrant sexual behavior. In gender-dysphoric patients with either disorder, treating the psychiatric comorbidity might alleviate the dysphoria. Watch for fluctuations in gender dysphoria intensity when you treat other psychopathologies.
Take a thorough sexual history. Being matter-of-fact while discussing unusual sexual acts will help the patient “open up” about his sexual problems. Ask him if he:
- showed gender-atypical behavior as a child, which can predict transsexualism or homosexuality has engaged in heterosexual, homosexual, or abnormal sexual acts; ask about frequency and preference
- is married or has a girlfriend. If so, are they getting along? How often do they have sex?
- cross-dresses. Does his partner cross-dress as well and, if so, do they cross-dress for sexual gratification or to identify with the opposite gender? Has this response changed over time? Where and how often do they cross-dress?
- is achieving sexual gratification. If so, how?
- has sexual fantasies involving breast-feeding, giving birth, or forced feminization through gender-changing surgeries or other means
- “tucks” his penis, urinates sitting down, or mimics other stereotypical feminine behavior.
The answers will uncover a motivation behind these behaviors, which is key to diagnosis. Sexual gratification as a motive suggests paraphilia, whereas a desire to live as a woman points to transsexualism. Because of the myriad presentations, multiple patient visits are necessary for a specific diagnosis.
Diagnosis: ‘i enjoy womanhood, but…’
I diagnose gender dysphoria, but because Mr. C’s mood is euthymic, I cannot discern how his mood instability might affect his dysphoria. His sexual fantasies are mood-congruent and evoke no shame.
Mr. C then states that he adamantly opposes living outwardly as a woman, and fears that an overt sex change would destroy his marriage and other relationships. Even so, he desires hormone therapy and surgical breast implants so he can more closely mimic physical womanhood and make masturbation more pleasurable. He says he would flatten his breasts with gauze while in public so he can continue to look like a man.
Though comfortable with his sexual fantasies, Mr. C laments that presenting himself as an “alpha male” drains his psychic energy.
The author’s observations
Mr. C meets criteria for GID and transvestism. Some transvestites also meet criteria for autogynephilia and report erotic arousal upon seeing oneself as a woman. Character pathology, specifically sexual fantasies associated with schizoid personality, might also contribute to unusual gender presentation. Sexologists also propose fluidity in gender identification across populations and over a person’s life span.
Autogynephilia—by which a man becomes sexually aroused by imagining or seeing himself as a woman15—usually is associated with transvestism. Autogynephiles often have sexual fantasies of possessing female anatomical structures, engaging in feminine behaviors, or performing female bodily functions such as lactation, menstruation, or childbirth.