17 Gender Identity Disorders and Paraphilias

The American Psychiatric Publishing
TEXTBOOK OF PSYCHIATRY
Fifth Edition
Edited by Robert E. Hales, M.D., M.B.A., Stuart C. Yudofsky, M.D., Glen O. Gabbard, M.D.
© 2008 American Psychiatric Publishing, Inc. All rights reserved. www.appi.org
CHAPTER 17
Gender Identity Disorders and

Paraphilias
Judith V. Becker, Ph.D.,
Bradley R. Johnson, M.D.
Slide show includes…

Topic Headings
Tables and Figures
Key Points
The American Psychiatric Publishing Textbook of Psychiatry, Fifth Edition. Edited by Hales RE, Yudofsky SC, 1
Gabbard GO. © 2008 American Psychiatric Publishing, Inc. All rights reserved. www.appi.org
CHAPTER 17 • Topic Headings
GENDER IDENTITY DISORDERS PARAPHILIAS

Gender and Sexual Differentiation Types of Paraphilias
Criteria for Diagnosing Gender Identity Disorder Exhibitionism
Gender Identity Disorder of Adulthood Fetishism
Epidemiology Frotteurism
Comorbidity Pedophilia
Etiology Sexual Masochism
Diagnosis and Evaluation Sexual Sadism
Treatment Transvestic Fetishism
Gender Identity Disorder of Childhood Voyeurism
Prevalence and Etiology Paraphilia Not Otherwise Specified
Physical Appearance Epidemiology
Course Etiology
Treatment Diagnosis
Clinical Evaluation
Phallometric Assessment
Other Assessment Tools
Therapeutic Treatment of Paraphilias
Biological and Pharmacological Treatments
of Paraphilias
Hormonal Treatments
Other Pharmacological Treatments
Paraphilias and Comorbid Psychiatric Diagnoses
Risk Assessment of Sex Offenders
CHAPTER 17 • Tables and Figures
Table 17–1. DSM-IV-TR diagnostic criteria for gender identity disorder

Table 17–2. Paraphilias
Figure 17–1. Multiple paraphiliac diagnoses.
Table 17–3. Psychosexual assessment
Table 17–4. Sexual history
Table 17–5. Some psychosexual tests and checklists
Summary Key Points
Currently, it is accepted that there are two
necessary components of gender identity
disorder: a strong and persistent cross-
gender identification (not merely a desire for
any perceived cultural advantages of being
the other sex) and a persistent discomfort
with one’s sex or sense of inappropriateness
in the gender role of that sex (Table 17–1).
TABLE 17–1. DSM-IV-TR

diagnostic criteria for gender
identity disorder
(continued)
TABLE 17–1. (continued)
The paraphilias (Table 17–2) are characterized by
experiencing, over a period of at least 6 months,
“recurrent, intense sexually arousing fantasies,
sexual urges, or behaviors” (American Psychiatric
Association 2000, p. 566) generally involving
nonhuman objects or nonconsenting partners.
TABLE 17–2. Paraphilias
Abel et al. (1988) found that most persons with paraphilias have had significant experience with as
many as 10 different types of deviant sexual behavior (Figure 17–1).
FIGURE 17–1. Multiple

paraphiliac diagnoses.
In evaluating an individual for paraphilic behavior, a careful psychiatric evaluation must be done to
exclude other possible causes of this behavior. Table 17–3 lists information that is important to collect
during a clinical psychosexual interview, which may then be confirmed with collateral sources.
TABLE 17–3. Psychosexual assessment
A detailed sexual history should be taken, noting the onset and course of paraphilic and appropriate
sexual fantasies and behavior and the present degree of control over the deviant behavior. Table
17–4 lists specific details that may be covered in the sexual history portion of the evaluation.
TABLE 17–4. Sexual history
Psychosexual tests and checklists are used at times to gain additional information (Table 17–5).
TABLE 17– 5. Some psychosexual tests and checklists
CHAPTER 17 • Key Points
 Whereas the genetic sex of an individual is determined at conception, gender

identity develops during the early years of life.
 Gender identity disorder requires a strong and persistent cross-gender
identification and a persistent discomfort with one’s sex or sense of
inappropriateness in the gender role of that sex.
 The term transsexualism was eliminated in DSM-IV and replaced by gender
identity disorder.
 Approximately 1 in 30,000 adult males and 1 in 100,000 females seek sex
reassignment surgery. After surgery, patients report few problems and marked
improvement in their sexuality.
 The paraphilias are characterized by experiencing, over a period of at least
6 months, recurrent, intense sexually arousing fantasies, sexual urges, or
behaviors, generally involving nonhuman objects or nonconsenting partners.
 The most common paraphilias are exhibitionism, fetishism, frotteurism,
pedophilia, sexual masochism, sexual sadism, transvestic fetishism, and
voyeurism.
(continued)
CHAPTER 17 • Key Points (continued)
 The numerous other sexually deviant fantasies or behaviors are given the
diagnosis of paraphilia not otherwise specified.
 A variety of behavioral therapies, hormonal treatments, and
psychopharmacological treatments have been used to manage paraphilias.

17 Gender Identity Disorders and Paraphilias

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The American Psychiatric Publishing

Gender Identity Disorders and

Slide show includes…

GENDER IDENTITY DISORDERS PARAPHILIAS

Table 17–1. DSM-IV-TR diagnostic criteria for gender identity disorder

TABLE 17–1. DSM-IV-TR

TABLE 17–2. Paraphilias

FIGURE 17–1. Multiple

TABLE 17–3. Psychosexual assessment

TABLE 17–4. Sexual history

TABLE 17– 5. Some psychosexual tests and checklists

 Whereas the genetic sex of an individual is determined at conception, gender

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