Paraphilias. Sadomasochism, fetishism, transvestism and transsexuality

Transgender data collection in the electronic health record: Current concepts and issues

There are over 1 million transgender people living in the United States, and 33% report negative experiences with a healthcare provider, many of which are connected to data representation in electronic health records (EHRs). We present recommendations and common pitfalls involving sex- and gender-related data collection in EHRs. Our recommendations leverage the needs of patients, medical providers, and researchers to optimize both individual patient experiences and the efficacy and reproducibility of EHR population-based studies. We also briefly discuss adequate additions to the EHR considering name and pronoun usage. We add the disclaimer that these questions are more complex than commonly assumed. We conclude that collaborations between local transgender and gender-diverse persons and medical providers as well as open inclusion of transgender and gender-diverse individuals on terminology and standards boards is crucial to shifting the paradigm in transgender and gender-diverse health.

Transsexualism in a Klinefelter male: a case report

We report a Klinefelter male who presents requesting gender reassignment surgery. There may be a predisposition to gender dysphoria in Klinefelter's Syndrome, and in the case we describe, the perception of his symptoms as being of biological origin coupled with the unavailability of gender reassignment surgery in the Republic of Ireland has had a negative therapeutic effect.

The DSM diagnostic criteria for fetishism

The historical definitions of sexual Fetishism are reviewed. Prior to the advent of DSM-III-R (American Psychiatric Association, 1987), Fetishism was typically operationally described as persistent preferential sexual arousal in association with non-living objects, an over-inclusive focus on (typically non-sexual) body parts (e.g., feet, hands) and body secretions. In the DSM-III-R, Partialism, an "exclusive focus on part of the body," was cleaved from Fetishism and added to the Paraphilia Not Otherwise Specified category. The current literature reviewed suggests that Partialism and Fetishism are related, can be co-associated, and are non-exclusive domains of sexual behavior. The author suggests that since the advent and elaboration of the clinical significance criterion (Criterion B) for designating a psychiatric disorder in DSM-IV (American Psychiatric Association, 1994), a diagnostic distinction between Partialism and Fetishism is no longer clinically meaningful or necessary. It is recommended that the diagnostic Criterion A for Fetishism be modified to reflect the reintegration of Partialism and that a fetishistic focus on non-sexual body parts be a specifier of Fetishism.

Erotic target location errors: an underappreciated paraphilic dimension

Based on studies of heterosexual male fetishists, transvestites, and transsexuals, Blanchard (1991) proposed the existence of a hitherto unrecognized paraphilic dimension, erotic target location errors (ETLEs), involving the erroneous location of erotic targets in the environment. ETLEs can involve preferential attention to a peripheral or inessential part of an erotic target, manifesting as fetishism, or mislocation of an erotic target in one's own body, manifesting as the desire to impersonate or become a facsimile of the erotic target (e.g., transvestism or transsexualism). Despite its potential clinical and heuristic value, the concept that ETLEs define a paraphilic dimension is underappreciated. This review summarizes the studies leading to the concept of ETLEs and describes how ETLEs are believed to manifest in men whose preferred erotic targets are women, children, men, amputees, plush animals, and real animals. This review also describes ETLEs in women; discusses possible etiologies of ETLEs; considers the implications of the ETLE concept for psychoanalytic theories of transvestism and male-to-female transsexualism, as well as for the forthcoming revision of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition; suggests reasons why the concept of ETLEs has been underappreciated; and describes what might result if the concept were more widely appreciated.

Autoerotic death--characteristic features and diagnostic difficulties

Autoerotic death refers to the accidental death of individuals of either sex due to failure of devices, or unexpected effect of materials, that were being used to enhance the sexual experience. Although asphyxia from hanging has been described most frequently, a wide variety of other lethal situations have been reported. As there is great variability in the number and types of sexual aids that may be used by individuals, careful death scene examination is essential in helping to exclude suicide and more rarely homicide. The clandestine nature of this paraphilia may, however, make subsequent identification and diagnosis difficult unless the death scene features are typical. This is particularly so in the rare cases involving women. In the following paper the typical features of this disorder are reviewed with a description of less obvious cases and possible diagnostic pitfalls.

Suicide by intrarectal gunshot wound

In this report, a bizarre case of suicide is presented. The decedent, who had a history of various paraphilias, including sexual masochism and fetishism, died from a self-inflicted intrarectal gunshot wound.

Autoerotic asphyxial death--accident or suicide?

Death during autoerotic asphyxial activity is usually considered accidental due to unanticipated failure of the device that was used to induce hypoxia during sexual arousal. Two cases of hanging are reported in which apparently typical features of autoerotic asphyxial activity were present. As a result of the discovery of a suicide note in one case and the absence of certain characteristic features in the other, the deaths could not be designated accidental. Although the majority of deaths that occur during autoerotic asphyxial episodes are accidental, the possibility of suicide must always be entertained, even in cases that may initially appear typical.

Transvestism in a person with learning disabilities presenting with behavioural problems

A case of transvestism is reported in a 47-year-old man with learning disabilities. He had developed encephalitis in childhood, which had resulted in moderate learning disabilities and epilepsy, and had been living in institutions from the age of six. He did not have any chance to express his sexual desire and this frustration manifested as aggressive behaviour. Recently, he moved to a community home and his deviant sexual behaviour became apparent. Management of his problems involves organizing a behavioural programme linking his cross dressing with aggressive behaviour.

A comparison of typical death scene features in cases of fatal male and autoerotic asphyxia with a review of the literature

Autoerotic asphyxia is an increasingly recognised syndrome in which accidental death occurs during solitary sexual activity due to failure of an apparatus that was designed to produce hypoxic augmentation of the victim's sexual response. Evidence of repetitive, secretive behaviour utilizing ropes and ligatures characterizes cases involving either males or females. Here the similarity in reported cases ends with males tending to utilize a far greater range of elaborate devices and props, often designed to cause real or simulated pain with pornographic material and evidence of cross-dressing and fetishism. Females, on the other hand, have usually been found naked with only a single ligature and no unusual or bizarre equipment. To further clarify the similarities and differences between typical cases involving males and females and to assist in the diagnosis of less obvious cases, the literature is reviewed and characteristic findings in both sexes compared and contrasted.