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New Treatments for Sexual and Gender Identity Disorders

Sexual and gender identity disorders. Sexual dysfunctions: problems with desire, orgasm, function and pain. Always consider medical causes. Well, maybe you have diabetes. Thioridazine, Mellaril. Remember there’s three Board important things about thioridazine or Mellaril. Trazodone. What can trazodone do, or Desyrel? Priapism. Painful erection that you can get with trazodone, which is an antidepressant. In reality, you don’t really see a lot of priapism with that. You’ll see women come in and say, "You know what? I can’t have an orgasm anymore since starting Prozac and this is ruining my relationship." Or you’ll see women come in and say, "You know, I’m not interested in sex anymore, and this is really okay because I don’t like men. Men are a pain in the butt, I’m not in a relationship and actually it makes my life easier." Similarly you will see men who will say, "Since I started Prozac it takes two hours for an orgasm, and this is terrible. It’s ruining my relationship. I don’t even want to have sex anymore." Or you’ll have men come in and say, "You know, sex used to be five minutes and now it’s 35 minutes. Sometimes you will see SSRIs used for premature ejaculation specifically.

Paraphilias. paraphilias are what used to be called the perversions. Commonly associated with males. Include exhibitionism. Guys like to expose themselves and they get sexually aroused by doing that. Fetishism. This is sort of like where a person is into boots, or leather, or rubber, or something like that. Now people will ask, and patients will ask, "Gosh my husband really likes to see me wear boots. Is that pathology?" and the answer is, not necessarily. It’s pathology when the wife comes in and says that the "Husband likes the boot more than he likes me." Or, "We can’t just have sex. We can’t just make love. It’s 2 o’clock in the morning and I’ve got to put on those damn boots, otherwise he can’t …" It’s a problem when either the spouse or the partner or the law says it’s a problem. Frotteurism: rubbing against a non-consenting partner, like on a subway or an elevator. Obviously that’s always going to be a problem because you’ve got a non-consenting partner. Pedophilia: obviously always a problem, sex with children. That’s always considered pathology. Sexual masochism, "I like to be tied up." Sexual sadism, "I like to tie my partner up" that’s pathology if it interferes with your relationship or the law. But you know, a lot of people will come in and say, "Yeah, I like to tie my wife up, I like it, she likes it." Not necessarily pathology. Voyeurism: people will come in and say, "Hey, I like to watch Baywatch. Is that pathology?" No. It’s pathology if you have binoculars and you are looking into your neighbors windows and you are now on probation because of your behavior.

Transvestic fetishism, what used to be called cross-dressing or transvestism. Paraphilia, not otherwise specified, like bestiality, sex with animals, necrophilia, sex with corpses, and telephone scatologia, making dirty phone calls. Transvestic fetishism is a person, usually a male, classically heterosexual. He likes women and likes to wear women’s clothing.

Gender identity disorder. How does that differ from transvestic fetishism? The male or female is uncomfortable with their assigned biological gender. What does that mean, assigned biological gender? Just means what you were born as. "I was born as a man and I feel like I’m trapped in a man’s body. I’m really a woman." Or vice-versa. Often in childhood. This starts early. The kid may start dressing in the opposite gender clothing and they just kind of always felt like they should have been a little boy, or they should have been a little girl. And eventually they save up their money and commonly have sex reassignment surgery, a sex change operation. Sexually these people may be attracted to men, women, both, neither. It’s very independent of homosexuality or heterosexuality. It’s not who I’m attracted to, it’s who I am. Now classic Boards question is "How do you differ this from transvestic fetishism?" The person with gender identity disorder, that guy, he’s dressing like a woman because he want to be a woman and he feels inside that he is a woman. The transvestic fetishes patient, he’s dressing that way because he feels sexy, he feels aroused when he does that.

Homosexuality has been a controversy among psychiatrists for decades, even Freud addressed it. He wrote a letter to a homosexual patient’s mother and talked about it, "You know, it’s not that bad" and stuff like that. Currently it is not considered as pathology, per se, by the American Psychiatric Association. The APA came out and said this is not pathology. There was a time in history when there used to be what was called ego-syntonic versus ego-dystonic homosexuality where gay men who were happy with themselves were ego-syntonic, gay men who were not happy with themselves were ego-dystonic.

Eating disorders. Anorexia versus bulimia. Anorexics are those really really thin women. They are about 5’8" and they weigh about 80 pounds. Bulimics are normal weight and sometimes overweight. The anorexics starve themselves, the bulimics binge and purge. They eat all these Twinkies; they eat all these donuts and then the throw it all back up. The anorexics have to weigh like less than 85% of their normal body weight, and they have to have missed three consecutive periods, if they are post-menarche. Bulimics just basically do the eating and then the purging. Now there’s all kinds of funny variations. There’s anorexics who will purge.

Two zebras: this is important, under eating disorder differential. There’s two zebras, particularly I think for neurologists. One is Klüver-Bucy. When somebody loses their temporal lobes because they had such bad seizures, the neurosurgeon had to take them both out. Or they have something like Herpes encephalitis and they lose a temporal lobe. They get this syndrome where they are hyper-oral, hyper-sexual, constantly masturbating or constantly mounting things. It’s really a tragic disorder. Loss of rage, sometimes loss of memory, very docile. And also Kleine-Levin syndrome. Classically adolescent males with hyper-somnolence and bingeing.

Adjustment disorders. An adjustment disorder is having so bad a to a situation that you are suicidal. Post-traumatic stress disorder is the opposite. Post-traumatic stress disorder is you see something that’s not normal. Unfortunately, in some neighborhoods to see a lot of violence and stuff like that. But in post-traumatic stress you see something that would rattle anybody. You are raped, or you are assaulted, or you see combat, or an accident.