Paraphilias are persistent and recurrent sexual interests, urges, fantasies, or behaviors of marked intensity involving objects, activities, or even situations that are atypical in nature. Although not innately pathological, a paraphilic disorder can evolve if paraphilia invokes harm, distress, or functional impairment on the lives of the affected individual or others. A total of eight Paraphilias are listed in the DSM V and include pedophilia, exhibitionism, voyeurism, sexual sadism, sexual masochism, frotteurism, fetishism, and transvestic fetishism.
Pedophilia is any sexual activity with a prepubescent child, where the offender/patient is at least sixteen years of age, and the victim is at least five years younger. Exhibitionism is the exposure of an individual’s genitalia to unsuspecting strangers for sexual satisfaction. Voyeurism is the viewing of an unsuspecting person engaging in disrobing or sexual activity. Sexual sadism is when sexual arousal is gained from inflicting mental or physical suffering on a nonconsenting person. Sexual masochism is the derivation of sexual arousal from being the recipient of physical or mental abuse and/or humiliation. Frotteurism is the touching of or rubbing against a nonconsenting person. Fetishism is the use of nonliving objects, most commonly shoes and undergarments, for sexual pleasure. Transvestic fetishism is the derivation of sexual arousal from cross-dressing or dressing in clothes of the opposite sex.
The exact etiology of paraphilia and paraphilic disorders is unknown. However, it is thought that a combination of neurobiological, interpersonal, and cognitive processes all play a role. Literature also points towards various genetic factors contributing to the development of pedophilia and pedophilic disorder, with recent evidence displaying a positive correlation of the COMT Val158Met (rs4680) polymorphism in paraphilic child sexual offenders A recent study focusing on neurotransmission of paraphilic disorders found evidence to suggest that central dopamine plays a key role in the pathogenesis of paraphilic disorders, as well as the general disturbance of the conscious regulation of behavior. The results of this study revealed increased levels of serotonin and norepinephrine, with a decreased concentration of DOPAC (3,4-dihydroxyphenylacetic acid) in urine samples of the test population diagnosed with paraphilic disorders. A correlation was made between serotonin and norepinephrine with obsessive disturbances and an association of DOPAC with affective and dissociative disorders.
Literature is lacking with information pertaining to the epidemiology of paraphilia and paraphilic disorders. Literature is also limited from an epidemiological standpoint, with paraphilia typically studied in a general sense rather than pertaining to specific paraphilia or paraphilic disorders. Paraphilias, in general, are more common in men, with reasons unknown. A recent study conducted looked specifically at the desire for and experience of paraphilic behaviors of a sample population demographically representative of the general population. The sample size contained a total of 1,040 persons classified according to gender, age, education, ethnicity, religion, and location of residency. It was found that almost half of the study population expressed interest in one or more paraphilic categories, with approximately one-third of this population actually acting on this interest at least once. Specifically, fetishism, frotteurism, voyeurism, and masochism held a prevalence of 15.9% (value considered to be statistically unusual), with interest in both males and females. Interest levels in fetishism and masochism revealed no statistically significant difference amongst males and females. It was also found that the most common paraphilic interest amongst men is often voyeurism and fetishism.
A thorough history and physical exam should be performed prior to the conduction of a comprehensive psychiatric assessment. As paraphilia is previously known as sexual perversion or sexual deviation, along with the consideration of paraphilia to be a behavior that often leads to stigmatization and legal ramifications, it is not very common for a voluntary medical evaluation to be sought. Therefore, special attention must be made to use open-ended questions, and avoidance of opinions and/or judgment must be maintained throughout the interview or history-taking process. Furthermore, signs of abuse should be monitored for, as some paraphilias either involve personal history of sexual abuse (commonly, pedophilic disorder) or involve the subjective endurance of sexual abuse (sexual masochistic disorder).
The DSM-5 diagnostic criteria for paraphilia states explicitly that the patient must have experienced intense and recurrent sexual arousal from deviant fantasies for at least six months and must have acted on these impulses. A paraphilia becomes a pathology, or a paraphilic disorder, only when this behavior causes significant distress and impairment of functioning to the individual or if the paraphilia involves personal harm or risk of harm to others. Specifiers of “in remission” (when distress or dysfunction is no longer caused) and “in a controlled environment” exist for all paraphilias, except pedophilia. Specifiers specifically added to exhibitionistic disorder include the exposure of one’s genitals to prepubescent children, physically mature individuals, or both. Age of onset is typically before eighteen years of age. Specifiers specifically added to sexual masochistic disorder include: with asphyxiophilia or autoerotic asphyxiation. Specifiers added specifically to fetishistic disorder include body parts, non-living parts, other. Specifiers added specifically to transvestic disorder include fetishism if aroused by fabrics, materials, or garments, and autogynephilia if aroused by thoughts or images of himself as a female.
Other diagnostic tools, including laboratory values, tests, and imaging, should also be obtained in the early evaluation and diagnostic phases. These are particularly important in appropriately diagnosing such conditions, as well as ruling out other potential causes. Laboratory values include, but are not limited to, the following measures: lipid panel, thyroid function tests, fasting blood glucose, erythrocyte sedimentation rate (ESR), prolactin, testosterone, estrogen, luteinizing hormone (LH), and follicle-stimulating hormone (FSH). Imaging could include ultrasonography and angiography. Studies or tests include nocturnal penile tumescence and pap smears.
The treatment and management of paraphilias and paraphilic disorders pose extreme difficulty due to a multitude of factors. Despite the egosyntonic and egodystonic dual nature of paraphilias in general, the overall majority of patients rarely seek treatment voluntarily. Many individuals may feel indignity, culpability, or discomfiture, while others focus on the difficulty and lack of desire to halt efforts of achieving intense sexual pleasure and ultimate satisfaction. Furthermore, many may fear the legal repercussions of coming forward for treatment. Those patients in treatment or seeking treatment are most often either mandated legally or convinced by family, friends, or sexual partners.
The management of paraphilic disorders falls into two main categories, incorporating both psychological and biological constituents. The psychological approach, which includes psychotherapy, but more importantly, cognitive behavioral therapy (CBT), yields an overall positive outcome in terms of efficacy, regardless of the type of diagnosed paraphilic disorder. However, due to the patient’s reluctance to seek treatment or the legal obligation to obtain treatment, psychiatrists are often forced to exceed the call of duty to the patient with the reduction of distress, but rather focus efforts on protection against potential victimization. The predisposition of committing sexual offenses demonstrates the significance of biological treatments for paraphilic disorders for not only the suffering individual but also for the greater good of society. However, specialized management, with a comprehensive treatment plan encompassing both psychological and pharmacological components, proves to be the optimal therapeutic option overall.
The three main classifications of pharmacological agents used in the management of paraphilic disorders involve selective serotonin reuptake inhibitors (SSRIs), synthetic steroidal analogs, and antiandrogens. Despite limited support in the literature and the demand for further definitive research, treatment algorithms for varying severity of illness have been devised, offering useful and rational approaches to the treatment of paraphilic disorders. The therapeutic choice is dependent upon previous medical history and medication compliance, along with the intensity of both the sexual fantasy and the risk of sexual violence.
Literature suggests that each of the three drug categories mentioned above help to target diverse physiological pathways and subsequent psychological attributes through their unique mechanism of action. Studies have shown SSRIs to be particularly useful in the adolescent population and milder paraphilias, including exhibitionism, as well as in patients suffering from comorbidities of obsessive-compulsive disorders (OCD) or depression. SSRIs have also been used in the attempted alleviation of hypersexuality, but strong evidence of actual efficacy has yet to be established. Antiandrogens, with emphasis on gonadotropin-releasing hormone (GnRH) analogs, have shown to considerably reduce the frequency and intensity of both deviant sexual arousal and behavior. GnRH analogs are also considered to be among the most promising pharmacological management for those sex offenders at high risk of particularly violent acts, particularly serial rapists or those individuals with pedophilic disorder. Of note, informed consent is obligatory before initiating antiandrogenic therapy.
Despite the psychological and pharmacological interventions designed for the management of paraphilias and paraphilic disorders, an ultimate treatment or change has yet to be established. Existing interventions merely allow for increased voluntary control through self-management skills over sexual arousal and reduction in sexual drive, with the best-yielded prognosis only from those individuals who are actually motivated to change. Those who do participate in either therapy alone, or more ideally, the combined management of psychological and medicinal intervention, show improvement with a marked reduction in the intensity and frequency of deviant sexual arousal and resultant behaviors. However, the literature suggests that most sexual offenders are likely to re-offend.
Many complications of paraphilia and paraphilic disorders can arise. Living with these intense and abnormal desires and behaviors can be troublesome and cause much turmoil to those individuals suffering from them. When the paraphilia becomes a paraphilic disorder, individuals suffer harm, distress, and functional impairment. Furthermore, legal ramifications often ensue, leading to a life of incarceration and/or probation, forensic psychiatric hospital confinement, as well as permanent induction onto the sexual offender registry. Dependent on jurisdiction, the requirements of being on the sex offender registry include address notification, making living location public knowledge, housing limitations, as well as restrictions on being in the presence of underage persons, living in proximity to a school or daycare center, internet use, or even owning toys or other items that may suggest involvement with children.
The significant complexity of paraphilias and paraphilic disorders requires specialist-level care, with a collaborative interprofessional team. The overseeing physician should have psychological expertise pertaining specifically towards such diagnoses, as well as persistent continuance on the most currently relevant medicinal interventions. Nursing and staff should have proper training and acquired knowledge to effectively approach, cope with, and manage these individuals, with any therapeutically noteworthy signs being brought immediately to the attention of the physician. The goal of the treatment team should be to provide optimal care, thus yielding better and more effective outcomes.
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