Paraphilic Disorders

Paraphilic disorders are characterized by intense sexual interests that are manifested as unusual behaviors or fantasies other than normal genital stimulation used to reach sexual arousal. They are directed toward persons, animals, or objects and cause significant clinical distress or functional impairment for the patient. Treatment involves psychotherapy, sexual education, and medication. However, these disorders are very difficult to treat due to social stigma and the legal ramifications associated with the diagnosis.

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Overview

Definition

Paraphilic disorders are defined as intense sexual interests or urges lasting more than 6 months that cause significant clinical distress or functional impairment for the patient or harm to others. The interest may be aimed at situations, animals, or objects considered atypical.

Epidemiology

  • Only a small percentage of people suffer from paraphilic disorders. 
  • Most paraphilias occur almost exclusively in men, but sadism, masochism, and pedophilia may also occur in women. 
  • Most common ages: 15–25
  • Voyeuristic and pedophilic disorders are the most common paraphilic disorders.
  • Commonly coexist with personality disorders (cluster A, cluster B, cluster C), substance abuse, anxiety disorders, OCD, or affective disorders.

Classification

Table: Classification of paraphilic disorders
Courtship disordersFrotteuristic disorderSexual arousal by touching or rubbing against a nonconsenting person (usually in crowded areas)
Voyeuristic disorder
  • Sexual arousal from observing a person undress, in the nude, or engaging in sexual acts (often with binoculars/camera)
  • Patient must be at least 18 years of age.
Exhibitionistic disorderSexual arousal from exposure of one’s genitals in public to unsuspecting person(s)
Algolagnic disorders: Sexual arousal is secondary to pain and suffering.Sexual masochism disorderSexual arousal from the act of being humiliated, beaten, bound, or made to suffer
Sexual sadism disorderSexual arousal from the infliction of physical or psychological suffering on another person
Anomalous target preferencesFetishistic disorder
  • Sexual arousal related to non-living objects (e.g., shoes or pantyhose) or nongenital body parts
  • Objects must be something other than sex toys or sexual clothing.
Pedophilic disorder
  • Fantasies involving sexual acts with prepubertal children (13 years of age or younger)
  • DSM-5 specifies that the patient must be at least 16 years old and at least 5 years older than the child.
Transvestic disorder
  • Sexual arousal from cross-dressing
  • Not always associated with homosexuality
Other specified paraphilic disordersZoophilia Sexual arousal from or fixation on non-human animals
CoprophiliaSexual arousal from sexual acts involving feces or defecation
UrophiliaSexual arousal from sexual acts involving urine or micturition
NecrophiliaSexual arousal from cadavers
Hypoxyphilia
  • Sexual arousal from reduction of oxygen flow (hypoxia) to the brain
  • Strangulation is usually used as a means to enhance orgasmic pleasure.

Diagnosis

Diagnosis is clinical and requires thorough examination of both psychiatric and sexual history.

Examiners must:

  • Use open-ended questions. 
  • Avoid stigmatizing attitudes and judgments.

Laboratory testing may be ordered to establish baseline and to screen for other sexual dysfunction disorders:

  • Testosterone 
  • Estradiol
  • Progesterone
  • Follicle-stimulating hormone
  • Luteinizing hormone

Management

Paraphilic disorders are difficult to treat. The majority of patients receiving treatment are legally required to do so as opposed to seeking treatment voluntarily. Physicians must monitor for signs of abuse and may need to report to authorities if there are signs of child endangerment.

Psychotherapy

  • CBT: aims to disrupt abnormally learned patterns and modify patient behavior
  • Social skills training/programs: individual or group therapy that provides sexual and social education

Pharmacotherapy

  • Beneficial if a patient’s condition is associated with other psychiatric illnesses
  • Goal is to decrease sex drive but approach is controversial due to adverse effects. 
  • Antiandrogens
  • Long-acting gonadotropin-releasing hormone antagonists
  • Selective serotonin reuptake inhibitors
  • Naltrexone

External control

  • Imprisonment in case of sexual crimes 
  • Informing supervisor, peers, or other family members to eliminate opportunities for those with paraphilia to act on their urges

Differential Diagnosis

  • Personality disorders: a cluster of mental diseases that involve semi-permanent patterns of thoughts and behavior that can be harmful and obstinate. These individuals have difficulties handling everyday stresses and issues, and their behavior can lead to serious social and laboral issues. Paraphilic disorders may occur in patients with personality disorder. 
  • Bipolar disorder: a psychiatric illness characterized by periods of depression and mania/hypomania. Symptoms include impulsivity, hypersexuality, and seeking pleasure regardless of the consequences. While there are sexual interests and behaviors similar to paraphilias, those with bipolar disorder are characterized by severe mood symptoms. 
  • OCD: a condition characterized by recurring intrusive thoughts, feelings, or sensations (known as obsessions) that are time consuming and cause severe distress; relieved partially by the performance of repetitive actions (known as compulsions). Those with OCD may report possible attraction to children; however, history taking will reveal that those without pedophilia do not have thoughts of children during sexual arousal.

References

  1. First Aid for the Psychiatry Clerkship, 4th edition, chapter 16, Sexual dysfunctions and paraphilic disorders, page 176.
  2. Sadock, B. J., Sadock, V. A., & Ruiz, P. (2014). Kaplan and Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Chapter 17, Human sexuality and sexual dysfunctions, pages 593-599. Philadelphia, PA: Lippincott Williams and Wilkins.
  3. Naghedechi, L. (2018). Paraphilic disorders. DeckerMed Medicine. Retrieved April 23, 2021. doi:10.2310/im.13034

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