PROF MAURICE M5 Assignment 2: LASA: Etiology and Treatment
| Paraphilic Disorders |
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| Most relevant to the forensic mental health professional is the category of paraphilic disorders. Previously, DSM-IV-TR categorized all sexual deviancy and sexual dysfunctions in the same category. However, DSM-5 presents them in two separate categories to distinguish difficulties in normal sexual activity (sexual dysfunctions) from hurtful, illegal sexual behavior (paraphilic disorders). The paraphilic disorders category includes disorders related to sexual fantasies, urges, and behaviors involving (1) nonhuman objects (fetishistic disorder and transvestic disorder), (2) the suffering or humiliation of oneself or one’s partner (sexual masochism and sexual sadism, respectively), and (3) the suffering or humiliation of children or other nonconsenting persons (pedophilia, exhibitionism, frotteurism, and voyeurism). Paraphilias involving children or nonconsenting adults constitute illegal behaviors. Perpetrators of these behaviors are frequently involved with the criminal justice system. Although not all paraphilias are illegal, the manner in which an individual chooses to respond to them might be. For example, a man who is sexually aroused by women’s feet (foot fetishistic disorder) and goes to a shoe store to fondle himself while watching women try on shoes is engaging in illegal behavior, even though the fetishism in and of itself is not illegal. An individual can also be diagnosed with a paraphilic disorder without actually engaging in the behavior, because a paraphilic diagnosis is warranted if the sexual urges or fantasies alone cause marked distress or interpersonal difficulty for the individual. Some women occasionally engage in these behaviors, but as many as 90%–95% of individuals with paraphilic disorders are male. |
| Sexual Dysfunctions |
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| Sexual dysfunctions refer to disorders that impair the performance of the sexual response cycle and are not at all considered deviant or illegal. The sexual dysfunctions category includes the following disorders:
It is important to note that many of these disorders can have physiological as well as psychological causes. Individuals suffering from sexual dysfunctions should first have a complete physical evaluation to rule out any contributing physical factors. For example, male erectile disorder can be caused by diabetes. Even when the cause of the sexual dysfunction is deemed psychological, due to the complexity of human sexual behavior, it is important to consider both the functioning of the individual's relationship with the current partner and the context of the relationship. When the erectile dysfunction is determined to be nonmedical in nature, cognitive behavioral therapy can be very effective in treating it. However, some states require specific training in the treatment of sexual dysfunctions before a mental health professional can engage in that practice. As with any professional services provided, it is necessary to know state laws regarding the profession. |
| Gender Dysphoria |
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| Gender dysphoria (known as gender identity disorder in DSM-IV-TR) is an overwhelming sense of being the wrong gender for one’s body. In such cases, a female feels like a male on the inside or a male feels like a female on the inside. These individuals want their physical bodies (their exteriors) to match how they feel on the inside, and many desire a full sex change operation. Due to the high cost of such procedures, many individuals with gender dysphoria take less expensive hormone therapy to help alter some of their physical characteristics. Gender dysphoria is not the same as homosexuality. Homosexuality is an attraction to others of the same gender and is not a discontentment with one’s own gender. In other words, homosexual individuals do not want to be a physically different gender, yet individuals with gender dysphoria do. In early editions of DSM, homosexuality was listed as a deviant sexual behavior but was removed in 1974. Gender dysphoria is listed in DSM not as a deviant disorder but in its own category due to the emotional distress of experiencing a mismatch between the gender that one is and the gender that one feels. The stage and screen performer Cher has an adult son Chaz (formerly Chastity), who has been outspoken about his gender dysphoria. With hormone medication and surgical reconstruction, he has physically transformed himself from a female into a male. However, gender dysphoria is relatively rare both among the general population and even less common among the offender population because it is unrelated to criminal behavior. Nonetheless, consider the following case example: Clarence was an African American male in his mid to late twenties who in his whole life never felt quite right in his body. *** At 6’2” as an adult, he was built like a strong athlete, but he felt different on the inside—like a female. He didn’t know it, but he had gender dysphoria. When he turned eighteen years old, he began secretly taking his mother’s hormone replacement therapy, and he enjoyed how he began to look more like a female since that was congruent with the femininity that he felt within. In spite of his large build, he began to carry himself with all the grace and gentleness of a delicate, petite ballerina. Clarence felt better than he ever had. However, in his early twenties, an unrelated set of symptoms began to occur. He started to hear things sometimes, and he began feeling untrusting of others. At times, he even thought that other people wanted to hurt him. He grew increasingly more withdrawn from his family and no longer showed up for his part-time job at a record store. At age twenty-two, he was arrested one night for creating a public disturbance in a park by yelling angrily and continuously at no one. While he was in jail, the psychiatrist determined that Clarence was experiencing the onset of schizophrenia. He was released in a few days only to return to jail a few months later on similar types of charges. Thus, he began a cycle in his life of being arrested for minor crimes, incarcerated for a short period, and released. During one of Clarence’s longer periods of incarceration, related to fighting with a police officer, he had been prescribed both hormone medication and antipsychotic medication by the jail psychiatrist, which he took regularly. Then he began meeting weekly with one of the jail therapists. He felt comfortable talking to her about his desire to be fully female and his intense fear of others hurting him when his symptoms of psychosis were strong. They formed a solid therapeutic relationship that Clarence found quite helpful and supportive. He was eventually released, and upon his return to jail six months later, he requested to meet with the same therapist right away. When his therapist came to meet with him, he requested to talk in a room rather than in his cell, which was a privilege reserved for well-behaved inmates. The therapist, who was normally quite cautious, agreed since Clarence was so cooperative and easy to work with. The only room available was the one with the emergency buzzer that did not always work properly. The therapist dismissed any need for an emergency buzzer since she knew Clarence well. She also was unconcerned when she forgot protocol and walked in to the long, rectangle-shaped room first to sit at the far end. As soon as she sat down and looked at Clarence, with the door shut behind him, she heard a difference in Clarence’s voice. It was much deeper and angrier as he pointedly asked her if she was working for the police. She froze because she realized that she was not talking to the Clarence that she formerly knew. He continued to demand an answer on whether she was working for the police. The therapist knew that this had instantly become an unsafe situation. Since the buzzer to alert corrections officers did not work, her only way out of the room with this large, angry male was to carefully, calmly, and repeatedly reassure him that she was there to help him. Clarence began to believe her and disclosed his belief (delusion) that all the police and corrections officers wanted to kill him to get his important government secrets. She realized that Clarence was more afraid than angry, and she expressed understanding of his feelings, which further helped to calm Clarence. Eventually, when Clarence was calm enough, she pointed out to him that the sooner she left the room, the sooner she could talk to her supervisor about how to best help him. He stood up to leave, and his therapist was relieved as the two of them exited the small room. She immediately went to talk with her supervisor on how she could avoid that type of situation in the future. Let’s consider what had changed about Clarence. Why had his behavior and demeanour become so different in just six months? Clarence was no longer taking either his antipsychotic medication or his hormone medication (estrogen). It is quite common for inmates to discontinue medication upon their return to the community due to a lack of access to psychiatrists, a lack of finances to pay for it, and a generally itinerant lifestyle. When Clarence returned to jail, he had been off his antipsychotic medication for six months and was floridly psychotic, which means that his delusions and hallucinations were in full bloom. Further, just as testosterone is associated with aggression, estrogen is linked with a lack of aggression. So, without his estrogen medication, all his feminine gentleness was gone. While his gender dysphoria was not the cause of his psychosis or his aggression, his estrogen medication had helped to diminish some of his resulting anger from his psychotic symptoms, specifically his delusions about the city’s police force wanting to kill him. Hence, the compound effect of Clarence being off both medications left him with active delusions and plenty of aggression for responding to them. It was a valuable lesson for the jail therapist about the need to maintain personal safety at all times and on the adverse effects of noncompliance with antipsychotic medications among individuals with schizophrenia. |
| Other Conditions of Clinical Attention |
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| This module addresses the other conditions that may be a focus of clinical attention from DSM-5. Other conditions that may be a focus of clinical attention were formerly listed in DSM-IV-TR as v-codes. These conditions apply when the individual has a clinically significant problem but does not meet criteria for a specific psychological disorder. An example would be a partner relational problem or the person could have a diagnosis, but the additional problem (v-code) may not meet the full criteria for a mental illness. Examples of other conditions that may be a focus of clinical attention are problems related to abuse or neglect, malingering, relationships problems, bereavement, and occupation. Previously, in DSM-IV-TR, conditions of this nature were listed on Axis IV, but since DSM-5 has moved to a nonaxial format, they are now just listed after any primary and secondary diagnoses. This module also addresses cross-cultural issues in the assessment and treatment of sexual disorders. You can refer to the American Psychological Association (APA) website in the Webliography to learn about cultural sensitivity for mental health professionals. You are encouraged to use this website to increase your cultural sensitivity as a forensic mental health professional. |
| Conclusion |
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| Sexual dysfunction is an undesirable physical or psychological condition that occurs in both males and females and is unrelated to criminal behavior. In contrast, the paraphilias are very much intertwined with criminal offenses. Sex offenses are some of the hardest disorders to treat due to the physical pleasure that the offender experiences at the expense of his or her victims. Sexual offenders, in particular pedophiles, are of great concern because many of them begin offending at a very young age and are able to elude detection for decades. The immense number of child victims that a pedophile might have over his or her lifetime can be staggering. Sexual offenders who prey on adults can also be quite dangerous because, often, the degree of their sexual offending as well as the level of violence associated with it often increase over time. Further, each time one of these types of offenders is not caught after exploiting the victim, he or she is emboldened to engage in additional and more severe offenses in the future. These individuals are often able to evade detection for many years because, on the surface, they appear to be just like everyone else. They do not come with warning labels, and they rarely look scary or mean. In fact, sexual offenders often use their friendly disposition or attractive appearance to groom their victims, which means gaining the trust of their victims so that they can more easily violate them. It is not uncommon for both child and adult victims of sexual offenses to hesitate to come forward about the sexual assault because they fear that they will not be believed due to the likability, attractiveness, or social prominence of the offender. |
