OTHER SEXUAL PROBLEMS

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Paraphyllia

Paraphilias involve sexual arousal to atypical objects, situations and/or recipients (e.g. children, corpses, animals). However, some sexual practices that appear unusual to other people or to some health care personnel do not constitute a paraphilic disorder simply because they are unusual. Individuals may have paraphilic interests without meeting the criteria for a paraphilic disorder.

Unconventional patterns of sexual arousal in paraphilias are considered pathological disorders only when both of the following characteristics apply:

• They are intense and persistent.
• Cause significant distress or impairment in social, occupational or other important areas of functioning, or harm or have the potential to harm others (e.g. children, non-consenting adults)

People with a paraphilic disorder may have an impaired ability to feel affection and to maintain reciprocal sexual emotional intimacy with their partner. There may also be impairments in other aspects of personal and emotional adjustment.

The pattern of erotic arousal is usually well developed before puberty. At least 3 procedures are involved:

• Anxiety or early emotional trauma interferes with normal psychosexual development.
• The standard pattern of arousal is replaced by another, sometimes through early exposure to a sexually charged experience that reinforces the person's experience of sexual pleasure.
• The pattern of sexual arousal often takes on symbolic and conditioning elements (e.g., a fetish symbolises the object of arousal, but may also have been chosen because it was accidentally associated with curiosity, desire and arousal).

There is controversy as to whether the development of all paraphilias is a consequence of these psychodynamic processes, and in some paraphilias signs of altered brain functioning and functional anatomy are found (e.g. in paedophilia).

In most cultures, paraphilias are significantly more prevalent among males. There may be biological reasons for this unequal distribution, but they are not well understood.

Dozens of paraphilias have been described, but most are infrequent or rare. The most common are:

• Paedophiliais characterised by sexually arousing, intense and recurrent fantasies, urges or behaviours involving children, prepubescent adolescents or underage youth.
• Voyeurismsexual arousal: is achieving sexual arousal by observing people naked, unclothed or engaged in sexual activity without the consent of the other person.
• Transvestisminvolves recurrent and intense sexual arousal from the wearing of garments of the opposite sex, which may manifest as fantasies, urges or behaviours.
• Exhibitionismsexual arousal: is characterised by achieving sexual arousal through exposure of the genitals, usually to an unsuspecting stranger. It can also be a strong desire to be observed by others during sexual activity. It involves acting without the consent of the other person.
• Sexual masochismsexual abuse: is the participation in an activity in which the subject is humiliated, beaten and tied up or otherwise abused in order to experience sexual arousal.
• Sexual sadisminflicting physical or psychological suffering (humiliation or terror) on another person to stimulate sexual arousal and orgasm.

Gender dysphoria

Gender dysphoria manifests itself in a variety of ways. But for the diagnosis of gender dysphoria, the DSM-5 criteria require the presence of:

• Marked incongruence between one's birth sex and one's felt gender identity (identification with the opposite sex) that has been present for ≥ 6 months
• Clinically significant discomfort or functional impairment resulting from this incongruence

In addition to the required characteristics, adolescents and adults must have ≥ 1 of the following:

• A strong desire not to possess their primary and/or secondary sexual traits (or in the case of adolescents, to prevent their development)
• A strong desire for the primary and/or secondary sexual characteristics that correspond to the gender they identify with
• A strong desire to belong to the opposite sex (or some other gender)
• A strong desire to be treated as of a different gender
• A strong conviction that they have feelings and reactions typical of another gender

The diagnosis of gender dysphoria in adults focuses on whether there is significant distress or impairment in social, occupational or other important areas of functioning. Gender non-conformity is not sufficient for diagnosis.