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Jaya Jaya Myra lists aphrodisiacs for the different genders, and what works for both. In some cases, the myths are true. 

 is a best-selling author, TEDx & motivational speaker, and mind-body wellness expert teaching the definitive connections between purpose and health. Her debut book, 

Vibrational Healing: Attain Balance & Wholeness. Understand Your Energetic Type

 is published in 10 languages and available worldwide. Her 2nd book, 

What foods increase libido, and which are better for men versus women? 

Turn Up the Spice: Natural Aphrodisiacs

In case you missed it, this series features reports about sexting, paraphilias, adolescent sexual health, and more. 

7 Clinical Reports About Sexual Disorders

From diagnosis to treatment, paraphilias and paraphilic disorders present unique challenges for the general psychiatrist. Individuals with paraphilic disorders typically do not present in a general outpatient setting for management of sexual thoughts and behaviors. Once an individual discloses thoughts, feelings, or behaviors concerning for a paraphilic disorder, the psychiatrist must identify the range and extent of atypical sexual interests and stratify the individual’s risk in order to determine appropriate treatment options.

If the treatment is accepted, the patient must undergo detailed informed consent due to the potential adverse effects of the medications used to address problematic sexual behaviors. It is therefore crucial that the general psychiatrist understand the basics of diagnosis and treatment for paraphilic disorders.

The publication of DSM-5 marked the first time that the authors of the manual defined a category of paraphilic disorders as distinct from paraphilias. The text defines a paraphilia as “any intense and persistent sexual interest other than sexual interest in genital stimulation or preparatory fondling with phenotypically normal, physically mature, consenting human partners.”

The Sexual and Gender Identity Disorders Work Group, responsible for the paraphilic disorders chapter, differentiated between paraphilias and paraphilic disorders “sought to draw a line between atypical human behavior and behavior that causes mental distress to a person or makes the person a serious threat to the psychological and physical well-being of other individuals.”

 A paraphilic disorder, then, is a paraphilia “that is currently causing distress or impairment to the individual or a paraphilia whose satisfaction has entailed personal harm, or risk of harm, to others.”

DSM-5 delineates criteria for eight specified paraphilic disorders. 

 lists these paraphilic disorders and the associated atypical sexual interest. In order to make a diagnosis of a paraphilic disorder, an individual must have a history of recurrent and intense sexual arousal to the atypical focus lasting at least 6 months that manifests as sexual fantasies, urges, or behaviors. This means that an individual who engages in atypical sexual behaviors, for instance while intoxicated, but lacks the requisite duration and intensity of arousal, does not have a paraphilia or paraphilic disorder.

 DSM-5 also provides diagnoses of other specified paraphilic disorder or unspecified paraphilic disorder for clinicians who see patients who present with atypical sexual interests that do not meet the criteria for one of the specified disorders.

Individuals with atypical sexual interests or problematic sexual behaviors rarely present to the general psychiatrist for evaluation and treatment. Stigma or fear of embarrassment may deter some individuals, whereas legitimate concerns regarding the legal consequences of disclosure of sexual fantasies or behaviors to a mandated reporter may prevent others. These individuals may not be aware of treatment options for problematic sexual behaviors, or their sexual thoughts and behaviors may be ego-syntonic, so they do not see a need to change. Occasionally a patient may reveal atypical sexual interests in the context of a long-term relationship with a provider, for example during psychodynamic psychotherapy.

Psychiatrists practicing psychotherapy commonly learn about patients’ sexual fantasies and behaviors, which may be typical or atypical. In such cases it may be important for the psychiatrist to determine if a patient’s sexual interest is evidence of a paraphilia, paraphilic disorder, another psychiatric disorder, or something more benign, such as sexual experimentation. It is also necessary to assess if the sexual interest causes the individual any impairment, emotional distress, or risk of harm and if it requires any intervention.

Even when patients voluntarily present for psychiatric care related to atypical sexual interests, concerns about stigma, shame, and embarrassment may prevent them from fully sharing their sexual history and the breadth and extent of the sexual behavior, which can make diagnosis and treatment problematic. Early research on paraphilic interests demonstrated that most individuals with paraphilic interests have more than one atypical sexual interest and many have more than five, a phenomenon referred to as “cross-over.”

Furthermore, an incomplete understanding of the breadth of a patient’s atypical sexual interests precludes effective treatment planning. 

 lists strategies to overcome patients’ hesitancy to describe their history of sexual behaviors. One method to improve a patient’s comfort with disclosure is to provide a detailed self-report questionnaire prior to the initial psychosexual evaluation. Patients may find it easier to complete such an assessment in the privacy of their own home, rather than in a physician’s office. The clinical interview can then focus on specific areas in which the patient has responded affirmatively to the questionnaire.

As is often the case, collateral sources of information may also be helpful. Prior relationship and/or sexual partners may be able to elaborate on a patient’s sexual behaviors. Collateral documentation sources including prior treatment records and police reports may also be useful. Police reports can document sexual offending behaviors associated with a patient’s paraphilic interest and may signal a greater need for treatment.

Specific tests are not needed to make a diagnosis of a paraphilic disorder. When there is concern for inaccurate reporting of fantasies and arousal patterns, however, psychophysiologic assessments may assist to clarify whether a paraphilic interest is present.

 Visual reaction time (VRT) and penile plethysmography (PPG) are two types of psychophysiologic assessment. They are typically available only in forensic contexts or specialized sexual disorders clinics.

VRT describes the relative amount of time that an individual observes an image. People typically spend more time looking at images that are sexually appealing to them. Computer programs can assess VRT by displaying images of male and female adults and children on a computer screen and having a patient click through the images and rate his self-reported interest in them. Increased VRT for prepubescent images may signal the presence of a pedophilic interest. PPG, on the other hand, measures the change in penile circumference or volume in response to potentially arousing auditory or visual stimuli. PPG is also used to assess for pedophilic interest, but it can also be used to identify the presence of sexual response to other stimuli, such as sadistic themes, animals, etc.

Treatment options and risk stratification

There are limited treatment options for paraphilic disorders. Although not all individuals with paraphilic disorders are sexual offenders, much of the literature used to guide treatment in patients with paraphilic disorders derives from studies of sexual offenders. Sexual offender treatment programs typically utilize various forms of psychotherapy, though there is little evidence that such approaches are helpful at reducing recidivism. A 2012 Cochrane review failed to demonstrate a reduction in sexual offense recidivism from psychological interventions in sexual offenders.

 Similarly, a recent large-scale study of a sexual offender therapy-based intervention delivered to over 15 thousand prisoners in the UK found that treated men had an increased risk of recidivism compared to untreated men.

Mild paraphilias and sub-diagnostic atypical sexual interests and fantasies may be managed with psychotherapies such as cognitive-behavioral therapy. For paraphilic disorders, however, medications should be a mainstay of treatment. 

 summarizes the different classes of medications used to treat paraphilic disorders, as well as their mechanisms of action and beneficial effects on paraphilic disorders. SSRIs frequently cause sexual dysfunction in patients treated for other conditions such as depression and anxiety. Such impairment may be desirable in patients with paraphilic disorders, so SSRIs can be used to induce dysfunction in libido, arousal, and orgasm.

Antiandrogen medications, including synthetic steroidal analogs like medroxyprogesterone acetate and gonadotropin releasing hormone analogs like leuprorelin, reduce testosterone levels by different mechanisms with the goal of decreasing sex drive and eliminating paraphilic fantasies and urges. They have the added benefit of injectable, long-acting formulations that can improve patient adherence to the treatment regimen.

Data regarding the effectiveness of these treatments are limited. Studies tend to have small sample sizes composed primarily of sexual offenders, only some of whom have paraphilic disorders. In addition, the primary endpoint for most studies is sexual offense recidivism, as opposed to subjective improvement in paraphilic symptoms and related distress. A 2015 Cochrane review of pharmacologic interventions for individuals have who sexually offended or are at risk of offending evaluated the evidence for each medication category.

 The researchers did not identify any studies that used SSRIs or gonadotropin releasing hormone (GnRH) analogs; only six studies that used synthetic steroidal analogs were found. The overall evidence was found to be poor.

In their 2010 guidelines for the biological treatment of paraphilias, the World Federation of Societies of Biological Psychiatry (WFSBP) was able to provide recommendations on the three categories of medication with only level C evidence, or “minimal research-based evidence to support the recommendation.”9 Despite the lack of evidence, the WFSBP published practical guidelines to assist clinicians in making rational treatment decisions for paraphilic disorders.9 The guidelines indicate that treatment should be more rigorous and based on the severity of or risk of harm posed by an individual’s paraphilia or paraphilic disorder.

 briefly describes the levels of treatment need and recommended treatments per the WFSBP. Escalating severity of the paraphilic disorder and risk for violence indicate the need for antiandrogen treatment, including a combination of a GnRH analog and synthetic steroidal analog for the most severe cases. The general psychiatrist should exercise caution, however, as formulating estimates of sexual violence risk is outside the realm of general psychiatric and even most forensic psychiatric practice. If a clinician encounters a patient and has concern for sexual offending due to a paraphilic disorder, consultation with or referral to a forensically trained sexual disorders specialist is warranted.

Informed consent is an essential element of any clinical encounter, but it is particularly relevant to consider when working with patients with paraphilic disorders. Although discussing SSRIs and their associated risks with patients may be second nature to practicing psychiatrists, antiandrogen medications may be less familiar.

Psychiatrists treating patients with antiandrogen agents should be aware of the various adverse effects and educate patients accordingly. Medroxyprogesterone acetate, for example, commonly causes weight gain and headache and is also associated with the development of gallstones, thromboembolism, hot flashes, insomnia, and other distressing symptoms.

 GnRH analogs tend to be better tolerated than the synthetic steroids, but can cause hot flashes, headache, and nausea.

Another relevant issue in providing informed consent to a patient with a paraphilia or paraphilic disorder is mandated reporting. Clinicians should be aware of what specific behaviors or crimes require reporting in their jurisdiction, as they can vary state by state.

 For example, some states mandate reporting of the use of child pornography, whereas others do not. The limits of confidentiality should be fully discussed with patients prior to initiation of treatment.

Paraphilic disorders are rarely encountered in general psychiatric practice and pose numerous challenges for the treating clinician. Patients may be hesitant to seek or engage in treatment for atypical sexual interests; there is limited evidence by which to guide treatment decisions and medication selection; and the use of hormone-altering agents can have severe adverse effects that require patient education and careful informed consent procedures prior to implementation.

For difficult or high-risk cases, consultation with or referral to a sexual disorders specialist is essential. Despite these concerns, both patients and society at large can benefit from the effective management of paraphilic disorders. Treatment can curb patients’ unwanted, distressing sexual urges and fantasies and reduce the risk of harmful sexual behavior. Psychiatrists should therefore be aware of this class of disorders, feel comfortable conducting a complete sexual behaviors history, and be able to discuss treatment options, even if the patient ultimately receives care elsewhere.

Dr Holoyda is Forensic Psychiatrist and Chair, Sexual Offenders Committee, American Academy of Psychiatry and the Law, Sacramento, CA. He reports no conflicts of interest concerning the subject matter of this article.

1. American Psychiatric Association. Paraphilic Disorders Fact Sheet. 

https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM-5-Paraphilic-Disorders.pdf

2. Holoyda B, Kellaher D. The biological treatment of paraphilic disorders: an updated review. 

3. Abel G, Becker JV, Cunningham-Rathner J, et al. Multiple paraphilic diagnoses among sex offenders. 

4. Holoyda B, Sorrentino R, Friedman SH, Allgire J.
	Bestiality: an introduction for legal and mental health professionals. 

5. Holoyda B, Newman W. Recidivism risk assessment for adult sexual offenders. 

6. Dennis JA, Khan O, Ferriter M, et al. Psychological interventions for adults who have sexually offended or are at risk of offending. 

7. Mews A, DiBella L, Purver M. Impact evaluation of the prison-based Core Sex Offender Treatment Program. 

8. Khan O, Ferriter M, Huband N, et al. Pharmacological interventions for those who have sexually offended or are at risk of offending. 

9. Thibaut F, De La Barra F, Gordon H, et al. The World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the biological treatment of paraphilias. 

10. Berlin FS. Evaluating and reducing risk in online child pornography cases. 

From diagnosis to treatment, paraphilias and paraphilic disorders present unique challenges for the general psychiatrist.

Paraphilias: From Diagnosis to Treatment

Over the past two decades, the internet has allowed instant access to a wide variety of content, including sexual content that portrays a variety of sexual activities such as masturbation, oral sex, vaginal and anal intercourse, and group sex. During the normal sexual developmental phase (usually between the ages of 9 and 16 years), one of the most common sexual activities is consumption of pornography, either intentional or accidental exposure. In the United Kingdom, 53% of adolescents aged 11 to 16 years have seen online pornography at least once, and the vast majority have viewed pornography before the age of 14.

 In the United States, 20% to 30% of children aged 10 to 12 years have reported some exposure to pornography.

In most cases, consumption of pornography does not promote the development of mental health disorders and reflects a normal exploration of sexuality.

 However, in 10% to 18% of all adolescents, consumption of pornography reflects compulsive sexual behavior. The disorder is characterized by extensive pornography use and masturbation, use of paid sexual services, risky sexual behaviors, and an intense preoccupation with sex. These behaviors often lead to impaired social or occupational functioning, distress, and negative affect.

How can we identify compulsive sexual behavior among adolescents? And, what are the best practices to treat compulsive sexual behavior?

Human beings are sexual and beginning in childhood are capable of sexual responses.

 Many youngsters report experiencing sexual interest, arousal, and desire before puberty around the age of 10 years, when adrenal glands mature. Adolescence marks the onset of considerable changes in sexual and reproductive maturity that coincide with significant changes in cognitive, emotional, and social functioning.

The progression of sexual events among adolescents follows a fairly consistent sequence: kissing and holding hands, breast and chest fondling, manual genital contact, touching under clothes or without clothes, touching genitals directly, oral sex, and penile-vaginal intercourse. Sometimes these are followed by less common variations, such as anal sex. Although most adolescents show a normal sexual development, some develop compulsive sexual behavior.

ICD-11 includes compulsive sexual behavior as a disorder. This impulse control disorder is characterized by a repetitive and intense preoccupation with sexual fantasies, urges, and behaviors that leads to clinically significant distress or impairment in social and occupational functioning and to other adverse consequences.

 Moreover, it compulsive sexual behavior often promotes sexual objectification of women and risky sexual behavior.

A recent study showed that consumption of pornography as part of compulsive sexual behavior predicted objectification of women over time by sexualizing women’s buttocks, breasts, belly, and body size.

 They also fond objectification of women affected adolescents’ courtship strategies (eg, girls say “no” but really mean “yes”).

 that comprised 967 adolescents aged 13 to 14 years indicate that exposure to pornography was linked with more permissive personal sexual norms (eg, sex before marriage is OK if you are in love), greater incidence of sexual harassment (eg, grabbed or pulled at a schoolmate’s clothing in a sexual way), and higher probability of oral sex and/or sexual intercourse two years later.

A series of studies explored the facets of compulsive sexual behavior among adults and adolescents.8 Four facets of compulsive sexual behavior were identified that are in keeping with the definition of compulsive sexual behavior disorder and that manifest among adults and adolescents.

1) Unwanted consequences because of sexual fantasies.

 Sexual fantasies, urges, and behaviors promote self-harm as well as harm to close others such as family members, colleagues, and peers.

 Constant uncontrolled engagement with sexual fantasies, urges, and behaviors with numerous unsuccessful efforts to significantly reduce repetitive sexual behavior.

 Negative feelings and distress accompanied by guilt and shame because of sexual fantasies, urges, and behaviors.

 Escape to sexual fantasies, pornography, and sexual behaviors because of pain, stress, and distress.

 identified two aspects of compulsive sexual behavior: individual-based and partner-based. Individual-based compulsive sexual behavior refers to inner conflicts of individuals who constantly engage in sexual fantasies, compulsive sexual thoughts, and masturbation. Partner-based compulsive sexual behavior includes interpersonal sexual conquests and repeated infidelity.

Here lies one of the key differences between adults and adolescents in the manifestation of compulsive sexual behavior. Whereas adults often exhibit both individual-based and partner-based compulsive sexual behavior, individual-based compulsive sexual behavior is much more prevalent than partner-based among adolescents because most of the experiences during adolescence do not include physical intimacy.

The range of human sexual activity is quite variable and it is difficult to differentiate normal from abnormal sexual behavior in form and frequency. Compulsive sexual behavior is not so much mere form or frequency of sexual behavior; rather, it is a pattern of sexual behavior that is initially pleasurable but becomes unfulfilling, self-destructive, and one that the individual is unable to stop. Compulsive sexual behavior refers to a loss of control over one’s sexual thoughts and behaviors that causes negative consequences in one’s life.

The ability to differentiate normal from abnormal sexual behavior among adolescents is even more challenging. For example, Adelson and colleagues argued that “in defining hypersexuality [another term for compulsive sexual behavior], it is crucial to acknowledge the challenges to establishing norms of child and adolescent sexual development and the complexity of variables that influence it.”

One of the most reliable ways to identify compulsive sexual behavior among adolescents is the self-report Individual-Based Compulsive Sexual Behavior (I-CSB) Scale.

 The I-CSB comprises 24 items that quantify the aforementioned four facets of compulsive sexual behavior.

 “I feel that my sexual fantasies hurt people around me.”

 “Although I promised myself that I would stop thinking about sexual desires, I find myself doing it again and again.”

 “I feel bad after being exposed to sexual content on the internet.”

 “When I’m stressed or restless, exposure to sexual content on the internet relaxes me.”

The I-CSB has a clinical cut-off that helps identify compulsive sexual behavior with a high degree of certainty.

Excessive and uncontrolled use of pornography is one reason for seeking professional help among both youths and adults.

 Despite the high prevalence of compulsive sexual behavior, research shows that a majority of clinicians have received little to no training in the treatment of compulsive sexual behavior. In addition, many do not feel competent or comfortable treating this disorder.

 This lack of training and education may promote misperceptions about the difficulties associated with problematic sexual behavior among clinicians, how to recognize these issues, and/or what factors to target in treatment. When seeking to refer a patient for compulsive sexual behavior, psychiatrists should look for a therapist who specializes in treating sexual disorders.

To date, there are no placebo-controlled studies on any treatment modality for compulsive sexual behavior. Most recommendations are based on case studies and/or on studies using small samples without control groups; the studies mainly comprise adults. The most promising modalities are cognitive behavioral therapy (CBT), cognitive analytic therapy (CAT), and mindfulness.

The aim of CBT is to identify underlying dysfunctional thoughts and utilizing cognitive tasks and behavioral interventions allow patients to avoid the triggers for compulsive sexual behavior. (See Birchard

 for a detailed review.) It begins by a formulation of therapeutic goals to create a blueprint for the intervention, to prevent therapeutic drift, and to keep the work on target. Diagrammatic explanations of the history and function of a problematic sexual behavior are used to bring order into what would otherwise be chaos and uncertainty. During this phase, factors that cause the patient to turn to their harmful behavior are recognized. Next, using various cognitive techniques these factors are targeted to break the link between them and the harmful behavior. For example, therapist may use the Socratic questioning method to elicit new understandings for the patient, helping them to think about the problem in a new way.

CAT is a relational and collaborative three-phase, time-limited psychotherapy that integrates cognitive and analytic principles.

 The first phase is assessment, which leads to a narrative reformulation of the patient’s difficulties. The next phase is enhancing the recognition of the problematic states and procedures. This recognition is gained via production of a sequential diagrammatic reformulation accompanied by self-monitoring between sessions to enhance self-awareness of the problematic patterns. The third and final phase is revision, which focuses on change and culminating in an exchange of farewell letters between therapist and patient. CBT and CAT share commonalities; the main difference is the cognitive versus the narrative construction of the problematic behavior (eg, history of relations with parents).

Mindfulness-based therapy focuses attention to thoughts, emotions, and bodily sensations in the present in a nonjudgmental manner. It is often taught through a variety of meditation techniques. Mindfulness may be a meaningful component of successful therapy among patients seeking help for compulsive sexual behavior by improving affect regulation, stress coping, and increasing tolerance for desires to act on maladaptive sexual urges and impulses.

 The main focus of mindfulness-based therapies is the reduction of shame-related cognitions; by doing so, it allows for decreased sexual dysfunction and increased enjoyment from sexual exploration.

Adolescents explore their sexuality. In most cases, this exploration is normative and has no negative consequences. At times, however, compulsive sexual behavior is developed and maintained. In these cases, it needs to be treated or it will affect functioning and relationships in adulthood.

Although several modalities of therapies have been examined, avoiding compulsive sexual behavior is even more important than treating it. Research highlights one key factor that relates to avoiding compulsive sexual behavior-open communication about sexuality between parents and children.

 Communication reduces shame, promotes sexual exploration in a supportive environment, and enables the development of healthy romantic relationships. Healthy sexuality promotes a health society.

 is Founder and Head of the Israeli Center for Healthy Sexuality, and Assistant Professor, Beit-Beri College, Kfar Saba, Israel. He reports no conflicts of interest concerning the subject matter of this article.

1. Livingstone S, Haddon L, GÃ¶rzig A, Ãlafsson K. EU Kids Online II: Final Report; 2011.

2. Romito P, Beltramini L. Watching pornography: gender differences, violence and victimization. 

3. Efrati, Y. Problematic and non-problematic pornography use and compulsive sexual behaviors among understudied populations: children and adolescents. Curr Addic Rep. (In press).

4. O’sullivan L, Thompson A. Sexuality in adolescence. In Tolman DL, Deborah L, Diamond LM, et al, Eds, 

, Vol 1. Washington, DC: American Psychological Association; 2014: 433-486.

5. Gola M, Potenza MN. The proof of the pudding is in the tasting: data are needed to test models and hypotheses related to compulsive sexual behaviors. 

6. Ward LM, Vandenbosch L, Eggermont, S. The impact of men’s magazines on adolescent boys’ objectification and courtship beliefs. 

7. Brown JD, L’Engle KL. X-rated: sexual attitudes and behaviors associated with US early adolescents’ exposure to sexually explicit media. Comm Res. 2009;36;129-151.

8. Efrati Y, Mikulincer M. Individual-based Compulsive Sexual Behavior scale: its development and importance in examining compulsive sexual behavior. 

9. Delmonico DL, Griffin EJ. Cybersex addiction and compulsivity. 

Internet Addiction: A Handbook and Guide to Evaluation and Treatment

. New Jersey: John Wiley and Sons, Inc; 2011; 113-134.

10. Adelson S, Bell R, Graff A, et al. Toward a definition of “hypersexuality” in children and adolescents. 

11. Mitchell KJ, Wells M. Problematic internet experiences: primary or secondary presenting problems in persons seeking mental health care. 

12. Reissing ED, Giulio GD. Practicing clinical psychologists’ provision of sexual health care services. Prof Psychol. 2010;41;57.

13. Birchard T. CBT for Compulsive Sexual Behaviour: A Guide for Professionals. New York: Routledge; 2015.

14. Kellett S, Simmonds-Buckley M, Totterdell P. Testing the effectiveness of cognitive analytic therapy for hypersexuality disorder: an intensive time series evaluation. 

15. Reid RC, Bramen JE, Anderson A, Cohen MS. Mindfulness, emotional dysregulation, impulsivity, and stress proneness among hypersexual patients. 

16. Efrati Y, Gola M. Adolescents’ compulsive sexual behavior: the role of parental competence, parents’ psychopathology, and quality of parent-child communication about sex. 

Adolescents explore their sexuality. In most cases, this exploration is normative. At times, however, compulsive sexual behavior is developed and maintained.

Normal Versus Abnormal Sexual Behavior in Adolescents

In recent years, transgender and gender incongruent adolescents have been the focus of media attention, public debate (eg, around the use of preferred pronouns and bathroom use), and, last but not least, best clinical practice. While the term transgender is mostly being used as an umbrella term for all forms of gender diversity, gender dysphoria is the diagnostic term as described in DSM-5.

Adolescents with gender dysphoria experience a marked incongruence between their experienced gender identity and their gender assigned at birth (based on their sexual anatomy) accompanied by distress. Gender identity refers to one’s sense of self as female or male. Increasingly, youth identify with a gender that differs from the traditional dichotomous classification of females and males: non-binary, gender fluid, gender queer etc (For an overview of terminology, see Sidebar). Parallel to the growing public attention, there has been a marked increase in the establishment of specialty gender services around the world and a sharp increase in the number of referred adolescents. Whether this is due to a true increase or increased awareness is not yet established.

The prevalence of a DSM-5 gender dysphoria diagnosis has never been studied in systematic population-based studies in adolescents and only estimates based on referrals to adult gender identity services are available. A meta-analysis found this prevalence to be 4.6 per 100,000.

 Estimates based on adolescent population samples (eg, high schoolers) provide much higher prevalence rates of self-identification as transgender or gender-incongruent of 3.6% for birth-assigned females and 1.7% for birth-assigned males.

 Another recent observation is the overrepresentation of assigned-females compared with assigned males at birth, which was reversed in earlier years.

Transgender adolescents and their families can present in many different ways. Some adolescents seek help for further gender identity exploration, while others have an already established desire for physical sex characteristics of the experienced gender. Additionally, while some transgender adolescents have shown gender non-conformity since early childhood, other adolescents might experience gender dysphoria during or after the onset of pubertal physical changes.

Some adolescents may have kept their gender incongruence to themselves for a long time. They did not speak out because they feared non-acceptance and rejection. They may have become depressed, socially isolated, and anxious. Other adolescents have been open about their feelings from an early age and may have socially transitioned to their experienced gender role supported by family and peers.

Various studies show that transgender adolescents are at a higher risk for mental health problems compared with cisgender peers and thus can present to clinicians with mental health difficulties. Stigma presumably plays an important role in this distress. In 2003, Meyer published his 

, which posits that minorities are often confronted with rejection and discrimination.

 Subsequently, this can lead to fear and negative feelings towards their minority group and themselves.

A study of transgender adolescents showed that poor peer relations were the most important predictor of mental health difficulties.

 Despite decreased stigmatization and growing tolerance, transgender adolescents are still relatively often victims of (cyber) bullying, harassment, and violence. A survey among transgender and gender diverse students from Minnesota showed that approximately 25% to 52% experienced different types of victimization is the past month.2 These negative experiences contribute to the fact that depression and anxiety occur about five times more often in transgender adolescents.

Another major health concern is the seemingly high number of suicidal ideation in transgender adolescents. A study among American high school students found that the prevalence of suicidal ideation in gender diverse students was nearly twice as high compared with cisgender youth and that both depressive symptoms and school-based victimization were associated with this ideation.

Although the above numbers are reason for concern, there are also opportunities to change the current situation. Gender diverse adolescents growing up in a supportive and tolerant environment who trust that medical affirming treatment is provided when necessary show less co-occurring mental health difficulties.

 Projects at schools that encourage acceptance and help transgender adolescents to be open about their gender identity are important as they improve adolescent well-being.

Apart from emotional problems, there is a line of research that shows a remarkable, yet unexplained overrepresentation of autism spectrum disorder diagnoses and autism characteristics in transgender adolescents compared with cisgender adolescents with up to 15% reaching clinically relevant autism characteristics levels.

 Although it has not be established why this might be the case, transgender adolescents with autism can also profit from gender affirming medical treatment.

Abigail is a 14-year-old assigned female at birth who at age 11 received a diagnosis of autism spectrum disorder. Abigail loved to play an online game building a virtual character with other people. In this game, Abigail created the male character “Amon.” Over time, Abigail started playing the game for longer periods, often for several hours a day and became socially isolated. When her parents asked about what was going on, Abigail responded that she felt she was a boy. Since the parents thought it was important to examine this further, they went to Abigail’s child and adolescent psychiatrist. After discussing gender with Abigail, the psychiatrist decided to refer her to a gender clinic.

At the clinic, Abigail had several sessions with a psychologist. During the sessions they discussed Abigail’s childhood fixations. The psychologist tried to differentiate whether Abigail’s desire to be a boy was a fixation. Abigail showed insight in these fixations and experienced them as likeable things to do, creating happiness. On the other hand, her gender dysphoric feelings were unlikeable and made Abigail sad instead of happy. After the sessions, treatment with puberty blockers was started to release the distress Abigail experienced around body changes. After social transition and the start of puberty blockers, Abigail took the name Amon and flourished: he had more contact with other adolescents, undertook more activities, and his schoolwork improved.

Support should be tailored to the adolescent. Some adolescents need individual explorative psychotherapy, others need treatment for depression or other co-occurring psychiatric conditions. Most adolescents and their families will profit from some sort of support on how to inform friends and relatives, how to present at school, and how to deal with possible stigma. In addition, transgender adolescents who are accepted and supported show better well-being.

 Assessment of adolescents with co-occurring autism (characteristics) might be more complex to understand and additional support might be needed when considering medical affirming treatment.

Medically intervening in a healthy body is a far-reaching option that has proven its usefulness in transgender adults, but has only been studied in a few adolescents.

 According to what has been named the “Dutch model,” which includes the intervention of puberty suppression without permanent effects, gender affirming care is offered in a step-wise model.

 Before medical interventions are provided, a comprehensive assessment exploring the nature of the adolescent’s gender identity is performed in a supportive and respectful way. The adolescent is assessed whether a diagnosis of gender dysphoria (according to the DSM-5) or gender incongruence (according to the ICD-11) can be given. Co-existing mental health difficulties like depression, anxiety, risk of self-harm, and suicide as well as autism characteristics that have an impact on diagnosis or treatment should be assessed and a referral for psychotherapy given if it is indicated.

Family and school functioning are also assessed and family or other caretaker support (in case an adolescent lives in out of home care) and advocacy in schools to ensure a safe and affirming environment may be necessary. Finally, it is essential to inform the adolescent and the family of the pros and cons of medical interventions with lifelong consequences, including consequences for fertility and sexuality, and assess the adolescent’s decision-making capacity for informed consent.

After the assessment, medical treatment options for adolescents can be divided in fully reversible puberty blockers, partially reversible affirming hormone treatment (estrogens or androgens) and fully irreversible surgeries (eg, mastectomy, vaginoplasty). Current guidelines differ with regard to age limits for these different treatment options; some use age 11 to 12 for puberty blockers, age 14 to 16 for hormones and age 16 to 18 for mastectomy and age 18 for genital surgeries. It has been argued that psychological maturity might be a better indicator than age, but how to assess this is not yet established.

Medical treatment is usually provided in subsequent steps from fully reversible to fully irreversible. The fully reversible blockers provide the adolescent with rest before any decision with more permanent effects is made. Ongoing counseling and support is offered. Gender affirming hormones may have partially irreversible effects (low voice, breast growth), but still provide time before completely irreversible gender affirming surgeries are performed. Some transboys prefer a different order and want to have chest surgery before hormonal treatment and some non-binary identifying adolescents prefer either surgery or hormones only. The multifaceted quality of these interventions call for involvement of a multidisciplinary care team, in which mental health professionals collaborate with (pediatric) endocrinologists, surgeons, and fertility specialists.

Transgender care for adolescents is surrounded by controversies, challenges, and uncertainties. At present, the aforementioned increase in prevalence, the shift in sex ratio, and the presentations of non-binary gender identities are yet to be understood. Long-term outcome studies of early medical interventions still come from a limited number of clinics and include only binary identifying transgender adolescents with prepubertal onset gender incongruence.

Whether puberty blocking at a young age is effective and safe for non-binary and post-puberty onset transgender adolescents is unknown. Long-term physical consequences of puberty blocking on bone density, fertility, duration, and surgical options are uncertain. Various ethical dilemmas exist around the capacity for informed consent of adolescents, parents’ role in treatment, and whether the right for best care for transgender children should include the right for medical transitioning.

Some clinicians may be hesitant in their work with transgender adolescents. Transgender adolescents and their families experience barriers to care and specialized providers might not always be available. However, the work with transgender adolescents can be rewarding. Transgender youth can profit enormously by the psychological, emotional, and social support that mental health professionals can give by showing their compassion and understanding.

Dr Miesen is Junior Researcher Adolescent Amsterdam Cohort of Gender Dysphoria (A-ACOG) and Psychiatry Consultant, Center of Expertise on Gender Dyspgoria (CEDG); and Dr Arnoldussen is Junior Researcher, A-ACOG and Psychiatry Consultant, CEDG. Dr de Vries is Principal Investigator, A-ACOG, and Lead, Department of Child and Adolescent Psychiatry, CEDG.The authors are all affiliated with Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Child and Adolescent Psychiatry. The authors report no conflicts of interest concerning the subject matter of this article.

1. Arcelus J, Bouman WP, Van Den Noortgate W, et al. Systematic review and meta-analysis of prevalence studies in transsexualism. 

2. Eisenberg ME, Gower AL, McMorris BJ, et al. Risk and protective factors in the lives of transgender/gender nonconforming adolescents. 

3. Aitken M, Steensma TD, Blanchard R, et al. Evidence for an altered sex ratio in clinic-referred adolescents with gender dysphoria. 

4. Meyer IH. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. 

5. de Vries AL, Steensma TD, Cohen-Kettenis PT, et al. Poor peer relations predict parent- and self-reported behavioral and emotional problems of adolescents with gender dysphoria: a cross-national, cross-clinic comparative analysis. 

6. Becerra-Culqui TA, Liu Y, Nash R, et al. Mental health of transgender and gender

nonconforming youth compared with their peers. 

7. Perez-Brumer A, Day JK, Russell ST, Hatzenbuehler ML. Prevalence and correlates of suicidal ideation among transgender youth in California: findings from a representative, population-based sample of High School students. 

8. de Vries AL, Doreleijers TA, Steensma TD, Cohen-Kettenis PT. Psychiatric comorbidity in gender dysphoric adolescents. 

9. van der Miesen AI, Hurley H, de Vries AL. Gender dysphoria and autism spectrum disorder: a narrative review. 

10. Ryan C, Russell ST, Huebner D, et al. Family acceptance in adolescence and the health of LGBT young adults. 

11. de Vries AL, McGuire JK, Steensma TD, et al. Young adult psychological outcome after puberty suppression and gender reassignment. 

12. Shumer DE, Spack NP. Paediatrics: transgender medicine-long-term outcomes from the Dutch model. 

Transgender adolescents and their families experience barriers to care and specialized providers might not always be available. However, the work with transgender adolescents can be rewarding.

Special Issues in Treating Adolescents With Gender Dysphoria

There’s a paradox with antidepressants. Even as they improve mood they can worsen sleep, and poor sleep is both a symptom and a cause of depression. It’s a common problem, but one that can be avoided by selecting the right antidepressant. At the 

American Psychiatric Association’s Annual Meeting

, Nikhil Rao, MD, identified antidepressants that work well with specific sleep disorders, including insomnia, restless legs syndrome (RLS), and obstructive sleep apnea.

A sedating antidepressant makes sense for patients with insomnia and depression, but just as important is how that antidepressant affects sleep quality. Mirtazapine and trazodone are two antidepressants that help patients fall asleep and improve their sleep architecture. However, mirtazapine’s sedative effects are greater in the lower dose range (15 mg and below), which may not treat depression. Trazodone also has limitations. Its sedative effects tend to wear off over time, and it comes with risks including daytime fatigue, reduced recovery rates in depression (a paradoxical phenomenon seen in adolescents),

 and dry mouthâwhich itself may interfere with sleep.

Some atypical antipsychotics have sedative effects, particularly quetiapine (Seroquel). Quetiapine carries too many risks to recommend it for primary insomnia, but it is appropriate for antidepressant augmentation (150 to 300 mg qhs). Quetiapine is not just sedating. It also improves the deep, restorative phase of sleep.

The SSRIs can cause insomnia and worsen sleep quality, but 

 is surprisingly more favorable for sleep. Although it is activating in the daytime, bupropion causes no more insomnia than the SSRIs and has neutral or positive effects on sleep architecture. Most of the tricyclics have similar problems as the SSRIs. Two exceptions are amitriptyline and doxepin. These sedating tricyclics can help with sleep initiation, but they do not improve sleep architecture.

One hypnotic that Dr Rao warned against is diphenhydramine, the sedative ingredient in many over-the-counter sleep aids from Benadryl to Tylenol PM. The problem is that diphenhydramine worsens cognition in the short term and raises the risk of dementia with chronic use.

 Its anticholinergic and histaminergic mechanism is the likely culprit here. Hydroxyzine (Vistaril) has similar effects and probably carries similar risks. Dr Rao pointed out another limitation of diphenhydramine: its sedative effects tend to wear off after 3 weeks.

Antidepressants in restless legs syndrome

RLS is common in two conditions that often co-occur with depression: ADHD and PTSD. Although serotonergic antidepressants can cause RLS, bupropion appears to treat it, according to a 

 Another medication to watch for in patients with RLS is mirtazapine. Although it is often used for insomnia, in 

 the risk of RLS is greater with mirtazapine than with other antidepressants.

Finally, there is an FDA-approved treatment for RLS that can treat depression as well: pramipexole. In 

 in both bipolar and unipolar depression, this dopaminergic agonist worked as monotherapy and as augmentation. The dose for depression (1 to 2 mg qhs) is higher than the typical RLS dose (0.125 to 1 mg qhs).

Antidepressants in obstructive sleep apnea

Obstructive sleep apnea is the only sleep disorder in which SSRIs may have an advantage. Most apneas occur during REM sleep, and SSRIs suppress this phase of sleep. SSRIs may also improve sleep apnea through direct effects on smooth muscle in the upper airway. These theoretical advantages translated into clinical benefits in a handful of studies.

 The same cannot be said for mirtazapine. That antidepressant was once thought to improve sleep apnea, through smooth muscle effects, but the theory did not hold up in practice.

 The risk of weight gain associated with mirtazapine also makes it less desirable in this population.

Sleep apnea is more common in overweight, middle-aged men with thick necks, but another type of patient is breaking this stereotype. Newer 

 have identified alarming rates of obstructive sleep apnea (40% to 75%) in PTSD.

 These patients tend to be young and thin, so how can they have sleep apnea? The exact cause is unknown but may be related to the effects of PTSD on autonomic hyperarousal and pharyngeal smooth muscle.

Although insomnia is common in patients with obstructive sleep apnea, hypnoticsâparticularly benzodiazepinesâcan suppress breathing and worsen hypoxia in these cases. Dr Rao recommends clonidine for insomnia in apneic patients. Besides its sedative effects, clonidine decreases the apnea-hypoxia index, a key outcome measure in obstructive sleep apnea.

 Clonidine reduces nightmares in PTSD and also improves a nocturnal impairment often seen in depression: sleep fragmentation.

No single antidepressant is best for sleep, but each has properties that can help or harm depending on the patient’s sleep disorder. Selecting the right one can improve daytime functioning and lead to a fuller recovery.

 is the Director of the Mood Treatment Center, Editor in Chief of

and Instructor in Clinical Psychiatry at the Wake Forest University School of Medicine. He has served as a subinvestigator on phase-III clinical trials and his research interests include diagnosis of mood disorders, novel pharmacologic agents, and natural and environmental approaches to mental health.

Even as antidepressants improve mood, they can worsen sleep-and poor sleep is both a symptom and a cause of depression.

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