Continuing Education Activity

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. This activity outlines the evaluation and management of paraphilia and paraphilic disorders. It explains the role of the interprofessional healthcare team in managing and improving care for patients with this condition.

Objectives:

• Identify the etiology of paraphilia and paraphilic disorders.
• Outline the evaluation of paraphilia and paraphilic disorders.
• Review the management options available for paraphilia and paraphilia disorders.
• Describe interprofessional team strategies for improving care coordination and communication to advance our understanding and management of paraphilic disorders and improve outcomes.

Introduction

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.[1] 

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.[2] Exhibitionism is the exposure of an individual’s genitalia to unsuspecting strangers for sexual satisfaction.[3] Voyeurism is the viewing of an unsuspecting person engaging in disrobing or sexual activity.[4] Sexual sadism is when sexual arousal is gained from inflicting mental or physical suffering on a nonconsenting person.[5] Sexual masochism is the derivation of sexual arousal from being the recipient of physical or mental abuse and/or humiliation.[6] Frotteurism is the touching of or rubbing against a nonconsenting person.[7] Fetishism is the use of nonliving objects, most commonly shoes and undergarments, for sexual pleasure.[8] Transvestic fetishism is the derivation of sexual arousal from cross-dressing or dressing in clothes of the opposite sex.[9]

Etiology

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[10], with recent evidence displaying a positive correlation of the COMT Val158Met (rs4680) polymorphism in paraphilic child sexual offenders.[11] 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 and 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. Researchers have established a correlation between serotonin and norepinephrine with obsessive disturbances and an association of DOPAC with affective and dissociative disorders.[12]

Epidemiology

Literature is lacking with information regarding 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.[13] 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. Researchers 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. The research found that the most common paraphilic interest amongst men is often voyeurism and fetishism.[14]

History and Physical

The clinician should perform a history and physical exam before conducting 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 sought. Therefore, special attention must be made to use open-ended questions, and avoidance of opinions and/or judgment is crucial throughout the interview or history-taking process. Furthermore, signs of abuse should be monitored. Some paraphilias either involve a personal history of sexual abuse (commonly pedophilic disorder) or involve the subjective endurance of sexual abuse (sexual masochistic disorder).

Evaluation

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.[15] Specifiers of “in remission” (when distress or dysfunction is no longer caused) and “in a controlled environment” exist for all paraphilias, except pedophilia.[16][13]

Specifiers specifically added to the exhibitionistic disorder include the exposure of one’s genitals to prepubescent children, physically mature individuals, or both. The age of onset is typically before eighteen years of age. Specifiers specifically added to the sexual masochistic disorder include asphyxiophilia or autoerotic asphyxiation. Specifiers added specifically to the fetishistic disorder include body parts, non-living parts, others. Specifiers added specifically to the 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.

Treatment / Management

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 to achieve 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 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.[17] 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 to reduce distress but rather focus efforts on protection against potential victimization.[18] The predisposition of committing sexual offenses demonstrates the significance of biological treatments for paraphilic disorders for the suffering individual and the greater good of society.[19] However, specialized management, with a comprehensive treatment plan encompassing both psychological and pharmacological components, proves to be the optimal therapeutic option overall.[18]

The three main classifications of pharmacological agents used in managing 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 treating paraphilic disorders. The therapeutic choice depends on previous medical history and medication compliance, along with the intensity of both the sexual fantasy and the risk of sexual violence.[19]

Literature suggests that each of the three drug categories mentioned above helps 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 and patients suffering from comorbidities of obsessive-compulsive disorders (OCD) or depression. SSRIs have also been used to alleviate hypersexuality, but strong evidence of actual efficacy has yet to be established. Antiandrogens, particularly gonadotropin-releasing hormone (GnRH) analogs, have been 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.[18]

Differential Diagnosis

• Sexual dysfunction disorders
• Gender identity disorder
• Hypersexuality or sex addiction
• Nonparaphillic compulsive sexual disorders
• Psychological Issues (fears of intimacy, commitment, etc.)
• Other psychiatric disorders: Obsessive-compulsive disorder (OCD), depression, bipolar disorder (manic episodes), schizophrenia, personality disorder, anxiety disorders
• Other disorders: Substance intoxication, intellectual disability, dementia

Prognosis

Despite the psychological and pharmacological interventions designed to manage 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.[2] Those who do participate in either therapy alone or, 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.[18] However, the literature suggests that most sexual offenders are likely to re-offend.[2]

Complications

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 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. Depending on the 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.[20][21]

Deterrence and Patient Education

• Overall, the majority of patients suffering from paraphilic disorders rarely seek treatment voluntarily, as many individuals 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, the very nature of paraphilic disorders in many individuals leads to victimization and often legal repercussions. This will only further deter patients from seeking treatment. Those patients involved in treatment plans are often either mandated legally or convinced by family, friends, or sexual partners.
• Despite the medications used in managing paraphilic disorders discussed above, better preventative measures are deemed necessary to reduce victimization. Many of those with paraphilic disorders will only be evaluated following incarceration after the harm has been inflicted.
• Childhood sexual abuse is considered a leading cause of pedophilia, among other paraphilias and resultant paraphilic disorders. Maybe preventative measures should start here.
• Many psychiatrists and mental healthcare providers feel that the only cure for a pedophilic disorder is incarceration. As paraphilias and paraphilic disorders are deeply engrained thoughts and irresistible behaviors of the individual, whether viewed as right or wrong, it is currently deemed as merely impossible to fix.

Enhancing Healthcare Team Outcomes

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 to such diagnoses and 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 physician's attention. Pharmacists can assist with dosing and drug interaction prevention. Social workers, psychologists, and behavioral therapists can assist the team in both treatment and community placement. The goal of the treatment team should be to provide optimal care, thus yielding better and more effective outcomes, and interprofessional collaboration is a significant means toward achieving this goal. [Level 5]