Raiyyan Tahsan

Raiyyan Tahsan
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TC(858).(20).Sexology Case No 11. Sexual aversion / avoidance

Sexual aversion / avoidance কী?

Sexual aversion/avoidance বলতে বোঝায়—যৌন সম্পর্ক, genital contact, penetration, intimacy বা sexual cue দেখলেই ভয়, ঘৃণা, panic, disgust, anxiety বা distress তৈরি হওয়া এবং তাই যৌনতা এড়িয়ে চলা। ICD-10-এ “sexual aversion” নামে ছিল; কিন্তু DSM-5/DSM-5-TR-এ এটি আলাদা diagnosis হিসেবে রাখা হয়নি, কারণ research evidence কম এবং overlap বেশি। বর্তমানে clinically এটি সাধারণত specific phobia/anxiety, PTSD, genito-pelvic pain/penetration disorder, hypoactive sexual desire dysfunction, erectile dysfunction, depression, relationship conflict—এগুলোর মধ্যে cause অনুযায়ী classify করা হয়।

Core clinical meaning: যৌনতার প্রতি শুধু interest কম নয়; বরং fear/disgust/anxiety/pain expectation-এর কারণে active avoidance থাকে।

Cause:-

causes / মূল কারণগুলো

A. Psychological causes

  1. Sexual trauma / abuse / rape history
    Trauma memory, fear response, shame, flashback, body freeze reaction sexual avoidance     তৈরি করতে পারে।
  2. PTSD / complex trauma
    Sexual touch trigger     হিসেবে কাজ করলে panic, dissociation, crying, avoidance হতে পারে। NICE PTSD guideline-এ trauma-focused psychological therapy first-line; medication option তখন, যখন therapy নিতে না চায়/পারে না বা response কম।
  3. Anxiety disorder / panic disorder / specific phobia
    Genital contact, pregnancy fear, pain fear, performance fear—    এসব থেকে avoidance হয়।
  4. Depression / low self-esteem / body image problem
    Desire     কমে যায়, intimacy এড়ানো হয়।
  5. Relationship conflict / coercion / intimate partner violence
    Partner-    এর সাথে trust না থাকলে বা forced sex থাকলে aversion তৈরি হতে পারে। Forced sex হলে এটি sexual dysfunction নয়—এটি safety/legal issue।
  6. Religious/cultural guilt, shame, misinformation
    Sex     নিয়ে excessive guilt বা ভয় থাকলে married life-এ avoidance দেখা যায়।

B. Female genital/pelvic causes

  1. Genito-pelvic pain/penetration disorder, vaginismus, dyspareunia
    Pain → fear → pelvic floor spasm → more pain → avoidance:     এই cycle খুব common। MSD Manual অনুযায়ী provoked vestibulodynia-তে pelvic floor physical therapy first-line হতে পারে।
  2. Vulvovaginal candidiasis / bacterial vaginosis / STI / UTI
    itching, discharge, burning, odor, dysuria     থাকলে sex painful হয়ে avoidance হয়; CDC VVC/BV guidelines cause-based treatment দেয়।
  3. Vaginal dryness / genitourinary syndrome of menopause / lactation dryness
    Menopause     বা breastfeeding-এ estrogen কমে dryness ও painful sex হতে পারে।
  4. Endometriosis, PID, pelvic surgery, obstetric trauma
    Deep dyspareunia     থাকলে এগুলো ভাবতে হবে।  

C. Male causes

  1. Erectile dysfunction
    বারবার erection fail হলে performance anxiety ও avoidance হয়। AUA guideline ED-এর structured evaluation ও shared decision-making treatment support করে।
  2. Premature ejaculation / painful ejaculation / prostatitis
    Embarrassment     বা pain avoidance তৈরি করতে পারে।
  3. Low testosterone / diabetes / hypertension / vascular disease
    Low libido     বা ED-এর organic cause হতে পারে।

D. Drug/substance causes

  1. SSRI/SNRI antidepressant, antipsychotic, opioid, finasteride, alcohol/drug misuse
  2. Hormonal contraception বা antiandrogen therapy
  3. Sedatives—arousal কমাতে পারে।

Symptopms:-

Sexual Aversion / Avoidance-এর লক্ষণসমূহ

১. মানসিক / সাইকোলজিক্যাল লক্ষণ

  • যৌন সম্পর্ক বা ইন্টিমেসি ভাবলেই ভয়, দুশ্চিন্তা বা আতঙ্ক অনুভব করা।
  • যৌন স্পর্শ, চুম্বন, জেনিটাল কন্ট্যাক্ট বা penetration এড়ানো।
  • পার্টনারের সাথে intimacy শুরু করলে avoidance / withdrawal / excuse।
  • Panic symptoms: হার্টবিট দ্রুত হওয়া, ঘাম, কম্পন, শ্বাসকষ্ট।
  • অতীত ট্রমা থাকলে crying, freezing, dissociation, flashback দেখা যেতে পারে।
  • যৌনতার প্রতি ঘৃণা বা অস্বস্তি।
  • যৌনতা নিয়ে লজ্জা বা অপরাধবোধ অনুভব করা।
  • সম্পর্কের সমস্যা: partner-এর সাথে conflict, tension, distrust।

২. শারীরিক / জেনিটাল লক্ষণ

  • penetration বা genital touch-এর সময় পেইন / বার্নিং / tightness অনুভব।
  • pelvic floor বা vaginal spasm (vaginismus) হতে পারে।
  • যৌন উত্তেজনা কমে যাওয়া / low arousal / low desire।
  • Female patient-এ vaginal dryness বা lubrication কম থাকা।
  • Male patient-এ erection সমস্যা বা ejaculation anxiety।
  • বারবার infection থাকলে itching, discharge, odor, dysuria।

3. Clinical diagnosis: কীভাবে diagnose করবেন

Sexual aversion/avoidance-এর single lab test নেই; diagnosis হলো history + targeted examination + cause exclusion।

History নিতে হবে

  • Onset: lifelong না acquired?
  • Situation: সব partner/সব situation নাকি নির্দিষ্ট partner/situation?
  • Trigger: kiss, touch, nudity, genital contact, penetration, semen, pregnancy fear?
  • Pain আছে কি? কোথায়—entry pain নাকি deep pain?
  • Trauma/abuse/PTSD symptoms আছে কি?
  • Depression/anxiety/OCD symptoms আছে কি?
  • Current medicines: SSRI, antipsychotic, opioid, finasteride, OCP
  • Relationship safety: coercion, violence, fear, forced sex আছে কি?
  • Medical history: diabetes, thyroid, menopause, postpartum/lactation, pelvic surgery

Screening tools

  • PHQ-9: depression
  • GAD-7: anxiety
  • PCL-5: PTSD
  • FSFI / FSDS-R: female sexual function/distress
  • DSDS: female hypoactive sexual desire screening; ISSWSH HSDD process-of-care supports structured assessment.
  • IIEF-5: male erectile dysfunction

Physical examination

  • Female: consent-based pelvic exam, vulvar inspection, discharge, vaginal pH, cotton-swab test if vestibulodynia suspected, pelvic floor tone
  • Male: genital exam, testicular size, secondary sexual character, prostate symptoms if indicated
  • Important: trauma patient হলে examination ধীরে, consent নিয়ে, chaperone সহ।

4. Specific investigations

Female patient

  • Urine pregnancy test
  • Urine R/E, culture if dysuria
  • Vaginal pH, wet mount/KOH, whiff test
  • Vaginal/cervical swab: Candida, BV, Trichomonas, GC/CT NAAT if STI risk
  • CBC, ESR/CRP if PID/systemic symptoms
  • Fasting glucose / HbA1c
  • TSH
  • Prolactin
  • FSH/LH/Estradiol if premature ovarian insufficiency/menopause suspected
  • Pelvic ultrasound if deep dyspareunia, endometriosis, fibroid, ovarian pathology suspected
  • Pap smear/HPV test if due

Male patient

  • BP, BMI, waist circumference, cardiovascular risk assessment
  • Fasting glucose / HbA1c
  • Lipid profile
  • Morning total testosterone, repeat if low
  • LH/FSH/prolactin if hypogonadism suspected
  • TSH if symptoms suggest thyroid disorder
  • Urine R/E/culture if urinary symptoms
  • Penile Doppler only selected refractory ED cases

5. Differential diagnosis

  • Hypoactive sexual desire dysfunction
  • Female sexual interest/arousal disorder
  • Genito-pelvic pain/penetration disorder
  • Vaginismus / dyspareunia / vulvodynia
  • Erectile dysfunction
  • Premature ejaculation
  • PTSD / specific phobia / panic disorder
  • Depression / OCD / body dysmorphic concern
  • Medication-induced sexual dysfunction
  • Vaginitis, STI, UTI, PID, endometriosis
  • Relationship conflict, coercion, intimate partner violence

6. Management / Treatment: guideline-based approach

First-line non-pharmacological treatment

  1. Psychoeducation
    Patient    কে বুঝাতে হবে—avoidance “ইচ্ছার অভাব” নয়; অনেক সময় fear-pain-trauma cycle।
  2. Stop pressure-based sex
    Forced exposure     করলে aversion বাড়ে। Consent-based gradual intimacy দরকার।
  3. CBT / sex therapy / systematic desensitization
    Fear hierarchy     বানিয়ে non-sexual touch → sensual touch → genital touch → penetration, ধাপে ধাপে।
  4. Sensate focus therapy
    Goal intercourse     নয়; goal safe touch, pleasure, communication.
  5. Trauma-focused therapy
    PTSD     থাকলে trauma-focused CBT বা EMDR preferred; NICE PTSD guideline medication-এর আগে psychological treatment গুরুত্ব দেয়।
  6. Pelvic floor physiotherapy + vaginal dilator training
    Vaginismus/GPPPD/vestibulodynia     থাকলে essential। MSD Manual provoked vestibulodynia-তে pelvic floor physical therapy first-line বলে।
  7. Treat pain/infection first
    Pain     থাকলে আগে pain cause treat, পরে sex therapy।

7. Pharmacological management

Note: Sexual aversion-এর জন্য একক universal medicine নেই। নিচের medicineগুলো cause-specific। Pregnancy, lactation, hepatic/renal disease, cardiac disease, bipolar disorder, suicide risk, drug interaction—সব যাচাই করে prescribe করতে হবে।

A. Anxiety/PTSD/depression dominant হলে

1. Generic name: Sertraline

  • Therapeutic category: Antidepressant / anxiolytic
  • Pharmacological class: SSRI
  • Bangladesh available brands: Andep 25/50/100 mg, Repose 25/50/100 mg, Seronex 25/50/100 mg, Sertal 25/50/100 mg, Setra 25/50/100 mg.
  • Dose: Start 25 mg once daily for 1 week, then 50 mg once daily; titrate 50–200 mg/day.
  • Duration: Response হলে সাধারণত 6–12 months after remission; PTSD/depression severity অনুযায়ী longer.
  • Keno used hoy: Anxiety, panic, PTSD, depression sexual avoidance drive করলে। VA/DoD PTSD medication guide sertraline/paroxetine-এর evidence strongest বলে।
  • Side effects: nausea, loose stool, insomnia/somnolence, headache, delayed orgasm, low libido, sweating.
  • Interactions: MAOI/linezolid/triptan → serotonin syndrome risk; NSAID/warfarin → bleeding risk; abrupt stop করলে discontinuation symptoms.

2. Generic name: Escitalopram

  • Therapeutic category: Antidepressant / anxiolytic
  • Pharmacological class: SSRI
  • Bangladesh available brands: Nexito 5/10/20 mg, Oxapro 5/10 mg, Citalam 5/10 mg, Citalex 5/10 mg, Recita 5/10 mg.
  • Dose: 5–10 mg once daily; max 20 mg/day.
  • Duration: 6–12 months after remission; reassess regularly.
  • Keno used hoy: Generalized anxiety/depression/social anxiety sexual avoidance-এর cause হলে।
  • Side effects: nausea, sleep change, sexual dysfunction, QT prolongation risk at higher dose.
  • Interactions: other serotonergic drugs, MAOI/linezolid; QT-prolonging drugs; NSAID/warfarin bleeding risk.

3. Generic name: Paroxetine

  • Therapeutic category: Antidepressant / anxiolytic
  • Pharmacological class: SSRI
  • Bangladesh available brands: Oxat 10/20 mg, Melev 20 mg, Panirid 20 mg, Parotin 10/20 mg, Paroxet 20 mg.
  • Dose: Start 10 mg daily, then 20 mg daily; range 20–50 mg/day.
  • Duration: 6–12 months after response; taper slowly.
  • Keno used hoy: PTSD/panic prominent হলে; তবে sexual side effect বেশি হতে পারে, তাই sexual dysfunction patient-এ cautious.
  • Side effects: sedation, weight gain, sexual dysfunction, withdrawal symptoms, anticholinergic effects.
  • Interactions: MAOI contraindicated; CYP2D6 inhibition—TCA, some antipsychotics, beta-blockers interaction; pregnancy planning থাকলে avoid/prefer alternative.

4. Generic name: Bupropion SR

  • Therapeutic category: Antidepressant
  • Pharmacological class: NDRI—norepinephrine dopamine reuptake inhibitor
  • Bangladesh available brands: Depnox SR 150 mg, Zybex SR 150 mg.
  • Dose: 150 mg morning; after ≥3 days 150 mg twice daily if needed.
  • Duration: Usually 6–12 months for depression; individualize.
  • Keno used hoy: Depression with low libido, SSRI-induced sexual dysfunction; anxiety-only case-এ first choice নয়।
  • Side effects: insomnia, dry mouth, tremor, anxiety worsening, hypertension, seizure risk.
  • Interactions/contraindications: seizure disorder/eating disorder contraindicated; MAOI contraindicated; CYP2D6 inhibition.

B. Female acquired generalized HSDD থাকলে, pain/trauma/coercion বাদ দিয়ে

5. Generic name: Flibanserin

  • Therapeutic category: Female sexual desire disorder medicine
  • Pharmacological class: 5-HT1A agonist + 5-HT2A antagonist, CNS modulator
  • Bangladesh available brands: Fliban 100 mg, Feelex 100 mg, Floren 100 mg, Pink Pill 100 mg, Fevigra 100 mg.
  • Dose: 100 mg at bedtime daily.
  • Duration: 8 weeks trial; no meaningful benefit হলে stop.
  • Keno used hoy: Premenopausal/acquired generalized HSDD; এটি sexual aversion due to fear/pain/trauma-এর drug নয়।
  • Side effects: dizziness, somnolence, nausea, fatigue, insomnia, dry mouth, hypotension/syncope.
  • Major interactions: alcohol close to dose, moderate/strong CYP3A4 inhibitors, hepatic impairment—contraindicated; FDA label hypotension/syncope warning দেয়।

C. Pain / vaginismus / vestibulodynia / vaginal dryness থাকলে

6. Generic name: Lidocaine hydrochloride jelly

  • Therapeutic category: Local anesthetic
  • Pharmacological class: Amide local anesthetic
  • Bangladesh available brands: Xylogel 2%, Jasocaine 2%, GP Caine 2%, Z-Lidocaine 2%.
  • Dose: Thin layer locally 5–10 minutes before dilator/pelvic floor therapy/intercourse; excess wipe off.
  • Duration: Short-term adjunct; physiotherapy/sex therapy-এর সাথে।
  • Keno used hoy: Entry pain/vestibular pain কমাতে, fear-pain cycle break করতে।
  • Side effects: local numbness, burning, irritation, allergy; excessive use করলে systemic toxicity rare.
  • Interactions: other local anesthetics/antiarrhythmics with high dose; partner numbness হতে পারে।

7. Generic name: Estriol vaginal cream

  • Therapeutic category: Local estrogen therapy
  • Pharmacological class: Estrogen
  • Bangladesh available brands: Femastin 0.1%, Gynest 0.1%, Ovestin 0.1%, SRT 0.1%.
  • Dose: Common regimen: 0.5 g intravaginally nightly 2–3 weeks, then maintenance 2 times/week; clinician adjust.
  • Duration: GSM/atrophic vaginitis থাকলে maintenance with periodic review.
  • Keno used hoy: Menopause/lactation-related vaginal dryness, burning, dyspareunia.
  • Side effects: breast tenderness, spotting, local irritation, discharge.
  • Contraindications/interactions: unexplained vaginal bleeding, estrogen-dependent cancer, active VTE history—specialist review; aromatase inhibitor users need oncology input.

D. Infection-related pain/discharge/odor থাকলে

8. Generic name: Fluconazole

  • Therapeutic category: Antifungal
  • Pharmacological class: Triazole antifungal
  • Bangladesh available brands: Flucoder 150 mg, Nispore 150 mg, Omastin 150 mg, Fluconal 150 mg, Lucza 150 mg.
  • Dose: Uncomplicated vulvovaginal candidiasis: 150 mg orally single dose; recurrent/severe case culture-guided longer regimen. CDC VVC guideline supports oral fluconazole 150 mg single dose for uncomplicated VVC.
  • Duration: Single dose usually; recurrent VVC হলে induction + weekly maintenance specialist plan.
  • Keno used hoy: Candida itching/discharge/burning/pain causing sexual avoidance.
  • Side effects: nausea, abdominal pain, headache, rash, liver enzyme elevation, QT prolongation rare.
  • Interactions: warfarin, sulfonylurea, phenytoin, some statins, QT-prolonging drugs; pregnancy especially 1st trimesterে avoid unless specialist indicates.

9. Generic name: Metronidazole

  • Therapeutic category: Antibacterial / antiprotozoal
  • Pharmacological class: Nitroimidazole
  • Bangladesh available brands: Flagyl 400 mg, G-Metronidazole 400 mg, Jetrazole 400 mg, Kemet 400 mg, Kilpro 400 mg; Flagyl IV 500 mg/100 ml also listed.
  • Dose: BV guideline regimen: metronidazole 500 mg orally twice daily for 7 days; Bangladesh 400 mg tablet common, so local prescription may use 400 mg twice daily for 7 days depending on clinician judgment. CDC BV guideline lists 500 mg BID × 7 days.
  • Duration: Usually 7 days.
  • Keno used hoy: BV/trichomoniasis-related discharge, odor, irritation, dyspareunia.
  • Side effects: metallic taste, nausea, abdominal discomfort, headache, dark urine; prolonged useে neuropathy rare.
  • Interactions: alcohol avoid during and 48–72 h after; warfarin effect increases; lithium toxicity risk.

E. Male ED / PE causing avoidance হলে

10. Generic name: Sildenafil

  • Therapeutic category: Erectile dysfunction medicine
  • Pharmacological class: PDE-5 inhibitor
  • Bangladesh available brands: Medigra 50/100 mg, Niagra 50/100 mg, X-Fil 50 mg; multiple brands listed in Bangladesh.
  • Dose: 50 mg orally about 1 hour before sex; range 25–100 mg; max once daily.
  • Duration: As needed; reassess ED cause and cardiovascular risk.
  • Keno used hoy: ED-related performance anxiety/avoidance.
  • Side effects: headache, flushing, nasal congestion, dyspepsia, dizziness, visual tinge.
  • Major interactions: nitrate/GTN/isosorbide or riociguat absolute contraindication; alpha-blocker caution; unstable angina/recent MI/stroke—cardiology input.

11. Generic name: Tadalafil

  • Therapeutic category: Erectile dysfunction / BPH medicine
  • Pharmacological class: PDE-5 inhibitor
  • Bangladesh available brands: Intimate 2.5/5/10/20 mg, Tada 5/10/20 mg, Tadalis 10 mg, Nirvana 5/10/20 mg, Tealis 5/10/20 mg.
  • Dose: 10 mg before sex; range 5–20 mg, max once daily; daily regimen 5 mg once daily.
  • Duration: As needed or daily; reassess after 4–8 weeks.
  • Keno used hoy: ED causing avoidance; tadalafil effect up to ~36 h.
  • Side effects: headache, flushing, dyspepsia, back pain, myalgia.
  • Interactions: nitrate/riociguat contraindicated; alpha-blocker caution; strong CYP3A4 inhibitors increase level.

12. Generic name: Dapoxetine

  • Therapeutic category: Premature ejaculation medicine
  • Pharmacological class: Short-acting SSRI
  • Bangladesh available brands: Dapoxen 30 mg, Daporex 30/60 mg, Dumax 30/60 mg, Maturex 30/60 mg, Ejalong 30/60 mg.
  • Dose: 30 mg 1–3 hours before sex; if inadequate and tolerated, 60 mg; max once/day.
  • Duration: On-demand; reassess after 4 weeks or 6 doses.
  • Keno used hoy: PE-related embarrassment/avoidance.
  • Side effects: nausea, dizziness, headache, diarrhea, insomnia, syncope rare.
  • Interactions: MAOI/SSRI/SNRI/TCA, linezolid, tramadol, triptan, alcohol, strong CYP3A4 inhibitors; avoid in significant heart disease.

8. Prevention

  • Sex education: pain/fear/consent সম্পর্কে accurate knowledge
  • Forced sex, pressure, blame—avoid
  • Couple communication: “stop signal”, gradual intimacy plan
  • Lubricant use if dryness
  • Recurrent infection হলে proper diagnosis before repeated OTC treatment
  • Diabetes/thyroid/prolactin/hormonal disease control
  • Depression/anxiety/PTSD early treatment
  • Pelvic floor relaxation exercise, not excessive Kegel in pelvic floor hypertonicity
  • Alcohol/drug misuse control
  • Relationship violence থাকলে safety plan first
  • Painful sex হলে “সহ্য করে sex” করা যাবে না—কারণ pain-fear cycle chronic হয়ে যায়।

Real clinical example

Case: 29-year-old married female, intercourse attempt করলে severe fear, crying, pelvic tightness, entry pain। Vaginal examে infection নেই, cotton-swab tenderness আছে, pelvic floor hypertonicity।
Likely diagnosis: Genito-pelvic pain/penetration disorder with sexual avoidance.
Plan: psychoeducation + no forced penetration + lubricant + pelvic floor physiotherapy + graded dilator + CBT/sensate focus; entry pain severe হলে short-term lidocaine jelly adjunct। SSRI/flibanserin এখানে first-line নয়, কারণ main problem pain-fear cycle।

Overview / Summary

Sexual aversion/avoidance হলো sexual cue বা genital contact-এর প্রতি fear/disgust/anxiety-driven avoidance। DSM-5-এ আলাদা disorder নয়; cause অনুযায়ী anxiety/PTSD, GPPPD, HSDD, ED, infection, hormonal বা relationship problem হিসেবে assess করতে হয়। Treatment-এর core হলো cause diagnosis + psychotherapy/sex therapy + pelvic floor therapy + infection/pain/hormone/ED treatment। Medicine শুধুমাত্র cause-specific।

Actionable Plan / Steps

  1. প্রথমে red flag দেখুন: forced sex, abuse, IPV, suicidal depression, severe pelvic pain, STI symptoms।
  2. PHQ-9, GAD-7, PCL-5, FSFI/FSDS-R বা IIEF-5 দিয়ে screen করুন।
  3. Pain/discharge/dryness থাকলে pelvic/genital exam ও infection workup করুন।
  4. HbA1c, TSH, prolactin, testosterone/FSH/LH—history অনুযায়ী দিন।
  5. First-line: psychoeducation + CBT/sex therapy + sensate focus + pelvic floor physiotherapy।
  6. Medicine দিন only cause-specific: anxiety/PTSD হলে SSRI; HSDD হলে carefully flibanserin; infection হলে antimicrobial; dryness হলে vaginal estrogen; ED হলে PDE-5 inhibitor।
  7. 4–8 weeks পর response, side effect, relationship safety, adherence review করুন।

Reference List

Textbooks

  1. Kaplan & Sadock’s Synopsis of Psychiatry, 12th ed. Chapter: Sexual Dysfunctions.  
  2. Harrison’s Principles of Internal Medicine, 21st ed. Sections on endocrine causes of sexual dysfunction, erectile dysfunction, depression/anxiety-related medical assessment.
  3. Williams Gynecology, 4th ed. Chapters on sexual dysfunction, dyspareunia, vulvar pain, menopause/GSM.
  4. Berek & Novak’s Gynecology, 16th ed. Female sexual dysfunction, vulvovaginal disorders, pelvic pain.
  5. Guyton and Hall Textbook of Medical Physiology, 14th ed. Reproductive endocrinology and sexual physiology.

Guidelines / official sources

  1. WHO ICD-11 classification: sexual aversion from ICD-10 reclassified under sexual pain-penetration or anxiety/fear-related categories.
  2. NICE NG116, Post-traumatic stress disorder, 2018.
  3. CDC STI Treatment Guidelines, 2021: vulvovaginal candidiasis and bacterial vaginosis.
  4. American Urological Association: Erectile Dysfunction Guideline, 2018.
  5. VA/DoD PTSD pharmacotherapy guide, 2023.

Peer-reviewed journals with DOI

  1. Borg C, de Jong PJ, Elgersma H. Sexual aversion and the DSM-5: an excluded disorder with unabated relevance as a trans-diagnostic symptom. Arch Sex Behav. 2014;43:1219-1223. DOI: 10.1007/s10508-014-0341-z.
  2. Reed GM, et al. Disorders related to sexuality and gender identity in the ICD-11. World Psychiatry. 2016;15:205-221. DOI: 10.1002/wps.20354.
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Md.Rafiqul Islam Lipu.Date:- 24-05-2026 Monday Time:-03-59-55 Pm

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