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Paraphilic Disorders

  • Author: Guy E Brannon, MD; Chief Editor: David Bienenfeld, MD  more...
 
Updated: Dec 03, 2015
 

Practice Essentials

Paraphilia is any intense and persistent sexual interest other than sexual interest in genital stimulation or preparatory fondling with phenotypically normal, physically mature, consenting human partners; if a paraphilia causes distress or impairment to the individual or if its satisfaction entails personal harm (or the risk of such harm) to others, it is considered a paraphilic disorder.

Signs and symptoms

A complete history (including psychiatric and psychosexual history) should be obtained. People with paraphilic disorders may be difficult to interview because of guilt and reluctance to share information openly with the interviewer. It is essential to establish rapport with these patients to allow them to talk more freely about their disorder.

Many different paraphilias have been identified, but the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), lists the following 8 specific paraphilic disorders[1] :

  • Voyeuristic disorder
  • Exhibitionistic disorder (including type I, the inhibited flaccid exposer, and type II, the sociopathic exposer who may have a history of other conduct)
  • Frotteuristic disorder
  • Sexual masochism disorder
  • Sexual sadism disorder
  • Pedophilic disorder
  • Fetishistic disorder
  • Transvestic disorder

Other paraphilias, almost any of which could develop into a paraphilic disorder in certain circumstances, include (but are not limited to) the following:

  • Telephone scatologia
  • Necrophilia
  • Partialism
  • Zoophilia
  • Coprophilia
  • Klismaphilia
  • Urophilia
  • Autogynephilia
  • Asphyxiophilia or hypoxyphilia
  • Video voyeurism
  • Infantophilia (a newer subcategory of pedophilia)

In addition to a complete history, complete mental status, physical, and neurologic examinations must be performed to assist with the evaluation and to rule out other disease processes. Ruling out major medical or psychiatric illnesses is critical for diagnosis and management.

See Clinical Presentation for more detail.

Diagnosis

Paraphilic disorders must be distinguished from nonpathologic use of sexual fantasies, behaviors, or objects as stimuli for sexual excitement. Studies that may be considered in the assessment of a patient with a paraphilic disorder include the following:

  • Standard medical workup, including sequential multiple analysis, complete blood count, rapid plasma reagent, and thyroid-stimulating hormone level or thyroid function test
  • HIV screen
  • Hepatitis panel
  • Unscheduled DNA synthesis
  • Computed tomography (CT)
  • Magnetic resonance imaging (MRI)
  • Penile strain gauge
  • Abel assessment for interest in paraphilia
  • Phallometric testing
  • Electroencephalography (EEG)

See DDx and Workup for more detail.

Management

Treatment options vary and must take into account the specific needs of each individual case. The following options are available:

  • Psychotherapy
  • Pharmacologic therapy
  • Surgical interventions (not widely used)

Psychotherapeutic interventions include the following:

  • Cognitive-behavioral therapy
  • Orgasmic reconditioning
  • Social skills training
  • Twelve-step programs
  • Group therapy
  • Individual expressive-supportive psychotherapy

Pharmacologic interventions may be used to suppress sexual behavior. Medications that may be considered in the treatment of paraphilic disorders include the following:

  • Antidepressants (eg, selective serotonin reuptake inhibitors [SSRIs])
  • Long-acting gonadotropin-releasing hormones
  • Antiandrogens
  • Phenothiazines
  • Mood stabilizers

Numerous adverse effects of pharmacotherapy have been reported. Additionally, ethical, medical, and legal questions have been raised regarding issues of informed consent, especially in hospital and prison settings.

Surgical interventions that may be considered (though not widely used) are as follows:

  • Psychosurgery using stereotaxic tractotomy and limbic leucotomy
  • Bilateral orchidectomy (surgical castration)

See Treatment and Medication for more detail.

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Background

Paraphilia is any intense and persistent sexual interest other than sexual interest in genital stimulation or preparatory fondling with phenotypically normal, physically mature, consenting human partners; a paraphilic disorder is a paraphilia that is causing distress or impairment to the individual or that, if satisfied, entails personal harm (or the risk of such harm) to others.[1]

Paraphilias are associated with arousal in response to sexual objects or stimuli not associated with normal behavior patterns and that may interfere with the establishment of sexual relationships. In modern classification systems, the term paraphilia (or paraphilic disorder, as appropriate) is preferable to the term sexual deviation because it clarifies the essential nature of this group of behaviors (ie, arousal in response to an inappropriate stimulus).

Paraphilia is a means by which some people release sexual energy or frustration. The act commonly is followed by arousal and orgasm, usually achieved through masturbation and fantasy. Paraphilic disorders are not well recognized and often are difficult to treat, for several reasons. Often, people who have these disorders conceal them, experience guilt and shame, have financial or legal problems, and can (at times) be uncooperative with medical professionals.

Overall, the best criteria for diagnosis of paraphilic disorders come from the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)[1] or the International Statistical Classification of Diseases, 10th Revision (ICD-10),[2] though the definitions of these conditions remain subject to some debate.[3, 4, 5] DSM-5 describes 8 of the more commonly observed paraphilic disorders:

  • Voyeuristic disorder
  • Exhibitionistic disorder
  • Frotteuristic disorder
  • Sexual masochism disorder
  • Sexual sadism disorder
  • Pedophilic disorder
  • Fetishistic disorder
  • Transvestic disorder

Various other presentations exist in which symptoms typical of a paraphilic disorder are present but do not meet the full criteria for any of the diagnoses above. Such presentations include the following:

  • Telephone scatologia (obscene phone calls)
  • Necrophilia
  • Zoophilia
  • Coprophilia
  • Klismaphilia
  • Urophilia

When the clinician wishes to specify the reason why the criteria for a listed paraphilic disorder are not met, such presentations are placed in the category “other specified paraphilic disorder.” If the clinician elects not to specify the reason, the category “unspecified paraphilic disorder” is employed.

Diagnostic criteria (DSM-5)

Generally, for each of the specific paraphilic disorders listed in DSM-5, the first diagnostic criterion specifies the qualitative nature of the paraphilia (eg, an erotic focus on children or on exposing the genitals to strangers), whereas the second criterion specifies the negative consequences of the paraphilia (see below). Both criteria must be satisfied to establish a diagnosis of a paraphilic disorder. An individual who meets the first criterion but not the second is considered to have a paraphilia but not a paraphilic disorder.

Voyeuristic disorder

The DSM-5 diagnostic criteria for voyeuristic disorder are as follows[1] :

  • The patient experiences recurrent and intense sexual arousal (manifested by fantasies, urges, or behaviors) involving the act of observing an unsuspecting person who is naked, in the process of disrobing, or engaging in sexual activity; symptoms must be present for at least 6 months
  • The patient experiences significant distress or impairment in social, occupational, or other important areas of functioning because of the fantasies, urges, or behaviors, or the patient has acted on the sexual urges
  • The individual experiencing the arousal or acting on the urges is aged at least 18 years

Further specifiers include the following:

  • Whether the individual is in a controlled environment
  • Whether the disorder is in full remission

Exhibitionistic disorder

The DSM-5 diagnostic criteria for exhibitionistic disorder are as follows[1] :

  • The patient experiences recurrent and intense sexual arousal (manifested by fantasies, urges, or behaviors) related to exposing the genitals to a stranger; symptoms must be present for at least 6 months
  • The patient experiences significant distress or impairment in social, occupational, or other important areas of functioning because of the fantasies, urges, or behaviors, or the patient has acted on the sexual urges

Further specifiers include the following:

  • Whether the individual is sexually aroused by exposing genitals to prepubertal children, to physically mature individuals, or to both
  • Whether the individual is in a controlled environment
  • Whether the disorder is in full remission

Frotteuristic disorder

The DSM-5 diagnostic criteria for frotteuristic disorder are as follows[1] :

  • The patient experiences recurrent and intense sexual arousal (manifested by fantasies, urges, or behaviors) involving touching and rubbing against a nonconsenting person; symptoms must be present for at least 6 months
  • The patient experiences significant distress or impairment in social, occupational, or other important areas of functioning because of the fantasies, urges, or behaviors, or the patient has acted on the sexual urges

Further specifiers include the following:/p>

  • Whether the individual is in a controlled environment
  • Whether the disorder is in full remission

Sexual masochism disorder

The DSM-5 diagnostic criteria for sexual masochism disorder are as follows[1] :

  • The patient experiences recurrent and intense sexual arousal (manifested by fantasies, urges, or behaviors) involving the act (real, not simulated) of being humiliated, beaten, bound, or otherwise made to suffer; symptoms must be present for at least 6 months
  • The fantasies, urges, or behaviors cause significant distress or impairment in social, occupational, or other important areas of functioning

Further specifiers include the following:

  • Whether the individual engages in asphyxiophilia
  • Whether the individual is in a controlled environment
  • Whether the disorder is in full remission

Sexual sadism disorder

The DSM-5 diagnostic criteria for sexual sadism disorder are as follows[1] :

  • The patient experiences recurrent and intense sexual arousal (manifested by fantasies, urges, or behaviors) from the psychological or physical suffering of another person; symptoms must be present for at least 6 months
  • The fantasies, urges, or behaviors cause significant distress or impairment in social, occupational, or other important areas of functioning, or the patient has acted on these sexual urges with a nonconsenting person

Further specifiers include the following:

  • Whether the individual is in a controlled environment
  • Whether the disorder is in full remission

Pedophilic disorder

The DSM-5 diagnostic criteria for pedophilic disorder are as follows[1] :

  • The patient reports recurrent and intense sexually arousing fantasies, sexual urges, or behaviors involving sexual activity with a prepubescent child or children (generally ≤13 years); symptoms must be present for at least 6 months
  • The disorder causes marked distress or interpersonal difficulty, or the individual has acted on these sexual urges
  • The individual is age at least 16 years and at least 5 years older than the victim; individuals in late adolescence involved in an ongoing sexual relationship with a 12- or 13-year-old are excluded

Further specifiers include the following:

  • Whether the disorder is exclusive (with attraction only to children) or nonexclusive
  • Whether the individual is attracted to males, females, or both
  • Whether the acts are limited to incest

Fetishistic disorder

The DSM-5 diagnostic criteria for fetishistic disorder are as follows[1] :

  • The patient experiences recurrent and intense sexual arousal (manifested by fantasies, urges, or behaviors) either from the use of nonliving objects or from a highly specific focus on nongenital body parts; symptoms must be present for at least 6 months
  • The patient experiences significant distress or impairment in social, occupational, or other important areas of functioning because of the fantasies, urges, or behaviors
  • The fetishes are not limited to articles of female clothing used in cross-dressing (as in transvestic disorder) or devices designed for genital stimulation (eg, vibrators)

Further specifiers include the following:

  • Whether the fetish involves a body part, a nonliving object, or something else
  • Whether the individual is in a controlled environment
  • Whether the disorder is in full remission

Transvestic disorder

The DSM-5 diagnostic criteria for transvestic disorder are as follows[1] :

  • The patient experiences recurrent and intense sexual arousal (manifested by fantasies, urges, or behaviors) from cross-dressing; symptoms must be present for at least 6 months
  • These fantasies, urges, or behaviors cause significant distress or impairment in social, occupational, or other important areas of functioning

Further specifiers include the following:

  • Whether the individual is sexually aroused by fabrics, materials, or garments (fetishism)
  • Whether the individual is sexually aroused by thoughts or images of himself as female (autogynephilia)
  • Whether the individual is in a controlled environment
  • Whether the disorder is in full remission
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Etiology

Paraphilias may exist as discrete anomalies in otherwise stable personalities and thus may go unnoticed by partners, families, and friends. More commonly, however, they coexist with personality disorders, substance abuse, anxiety disorders, or affective disorders. It remains unclear why some people act on deviant urges and others do not. Persons with personality disorders who have problems with self-esteem, anger management concerns, difficulty delaying gratification, poor empathetic ability, and faulty cognitions are particularly vulnerable.

Many theories exist regarding the etiology of paraphilias, including psychoanalytical, behavioral, biologic, and sociobiologic theories. To date, however, none have proved conclusive; additional research is required.

Psychoanalytical theory

According to psychoanalytical theory, several possible factors may contribute to the origin of paraphilias. Freund and his colleagues suggested that some paraphilias may be attributed to possible distortion of the courtship phases. Normal courtship behavior is what brings males and females together for the purpose of mating. It usually occurs during adolescence and may or may not involve sexual intercourse at this early stage of sexual development.

Courtship is composed of the following 4 phases:

  1. Search phase – Location of a potential partner
  2. Pretactile interaction phase - Talking or flirting with a potential partner
  3. Tactile interaction phase – Physical contact with a potential partner, usually consisting of touching, hugging, hand-holding, and similar actions (this could also be considered foreplay)
  4. Genital union phase (ie, sexual intercourse)

Although most of the population is capable of appropriate engagement in the phases of courtship, other people are unable to adhere to these socially acceptable norms. Freund and his colleagues have indicated that certain deviant or unconventional sexual practices can be viewed as exaggerations of the 4 phases of courtship. On the basis of Freund’s research with incarcerated sex offenders, one distortion of courtship behavior may result in others.

Certain paraphilias are associated with distortions of courtship behaviors. According to this particular literature, however, such distortions are associated only with the first 3 phases.

Voyeurism

In this view, voyeurism is understood as a distortion of the initial courtship phase (ie, locating a potential partner). Psychoanalysts postulate that voyeurism may be attributed to a child witnessing episodes of his or her parents engaged in sexual intercourse. Individuals with maladaptive social and sexual skills find voyeurism to be an outlet for sexual pleasure without the threat of sexual interaction. The risk or danger of discovery may give the voyeur a false sense of masculinity (as also tends to be the case with the exhibitionist).

Exhibitionism

Psychoanalysts consider exhibitionism a distortion of the second courtship phase (ie, pretactile interaction). In psychoanalytical theory, gender identity for a little boy is held to require psychological separation from his mother, so that he will not identify with her as a member of the same sex, as a little girl would. Exhibitionists regard their mothers as rejecting them on the basis of their different genitalia.

Through exhibitionism, the individual attempts to force women to accept him by forcing them to look at his genitals. The act of self-exposure is also a way for the exhibitionist to compensate for his introversion and lack of assertiveness. This act may give the exhibitionist a false sense of power, and the danger of discovery may further reinforce this feeling. In general, psychoanalysts theorize that an exhibitionist’s display of his penis is a way of proving his manhood to the world but also, more importantly, to an adult woman.

Narcissism, the extreme form of self-admiration, is also believed to contribute to exhibitionism. Many narcissist-exhibitionist men are married and have regular sexual contact with their spouses. However, spousal appreciation of their genitalia is not sufficient by itself to fulfill their insatiable need for admiration, and as a consequence, they constantly search for other unsuspecting victims from whom to elicit admiration. The exhibitionist is sometimes compared to an actor on stage who desires an audience but does not want to participate in the act.

Frotteurism and toucherism

Frotteurism and toucherism are considered exaggerations of the third courtship phase (ie, tactile interaction). These paraphilias provide a sexual outlet without the risk of rejection. Toucherism tends to occur in conjunction with other paraphilias. Freund suggested that these disorders result from unsuccessful negotiation in the developmental stages, which results in sexual urges becoming blocked and expressing themselves at a later time as paraphilias.

Behavioral theory

Behavioral theory attributes the development of certain paraphilias to the process of conditioning. Actually, paraphilias are a result of accidental conditioning. If nonsexual objects are frequently and repeatedly associated with a pleasurable sexual activity, then the object becomes sexually arousing.[6]

A small study was conducted with 7 heterosexual males, all of whom were free of any fetishes. The men were repeatedly shown erotic stimuli that were paired with a slide of women’s black knee-high boots. Later, when the slide of the boots was shown alone, 5 of the 7 men experienced penile erection. This indicated that a boot fetish had been conditioned.

A similar small study conducted to determine whether women could be conditioned to become sexually aroused by a stimulus found no significant differences in physiologic sexual arousal between women in the experimental group and those in the control group. These results imply that sexual arousal is not readily amenable to classic conditioning in women. This might help explain why fetishism and other paraphilias occur almost exclusively in males.

Conditioning does not always involve positive reinforcement; negative reinforcement may also play a role. If an individual experiences unpleasant consequences with normal sexual activity, an aversion to sex may occur, resulting in the development of deviant behavior. An example of this would be a young boy who is humiliated and punished by his parents for proudly displaying his erect penis. As the boy matures, he may associate guilt and shame with normal sexual behavior.

Certain atypical sex acts, such as exhibitionism and voyeurism, that provide intense sexual arousal may lead to individual preference of that behavior. Pedophiliacs, exhibitionists, and voyeurs may be driven by risk-taking behaviors. Therefore, the constant threat of discovery may be as arousing to them as the act itself.

Conditioning is not the only contributing factor in the development of paraphilias. Individuals with paraphilias usually experience low self-esteem, which may lead to difficulty in forming person-to-person sexual relationships.

Sociobiologic theory

In an article from 1993, Richard A Gardner proposed an approach that combined 2 theories, Dawkins’s theory of gene transmission and Darwin’s well-known theory of survival of the fittest.[7] In a sense, this could be considered a sociobiologic theory.

Dawkins’s theory

In Dawkins’s theory of gene transmission, variations in human sexual behavior, even atypical sexual behaviors (paraphilias), are seen as conducing to the survival of the species. According to this view, the different paraphilias may be responsible for enhancing society’s level of sexual excitation. This higher level of excitation, in turn, would increase the likelihood that people would engage in sex acts that would ultimately lead to procreation.

In earlier (eg, pre−20th century) societies, males more often served the role of hunters and fighters, with females having child-rearing as the primary role. Those men who were more adept at hunting and fighting (protectors and warriors) were more likely to survive and attract females as mates. Those who were weaker were less likely to attract women as desirable mates, because they were unable to provide adequate food, clothing, and shelter, and they were less able to protect their potential family from enemies.

Men were also more likely to be attracted to women who were stronger in child-rearing abilities, because involvement with such women was more likely to ensure that their genes would be passed down to subsequent generations. Therefore, stronger and more aggressive men, as well as women with a stronger capacity for raising children, were more likely to acquire mates. This would ensure propagation of their genes.

Today, this genetic programming is carried in both sexes. Although other primates are more instinctually driven, humans are also affected to a certain degree. During the mating season, animals are compelled to go through the mating ritual of their species. Humans also have procreative urges, but not in a particular mating season or in a particular mating ritual, as is seen in other primates. Unfortunately, this does not make us exempt from such mating patterns with the resultant pattern of their expression.

Darwin’s theory

Darwinian theory relates more directly to reproductive capacity. Two of the operative factors in Darwinian theory are quantity and quality. Each species produces more offspring than could possibly survive (quantity); therefore, the individuals that are more capable of adapting to their environment (quality) are more likely to survive and perpetuate the species. In general, species that are less adaptable to their surroundings are more likely to become extinct.[8]

Of the sexes, the male is physically able to produce a far greater quantity of offspring. If a man devoted his whole life to procreation, he could conceivably father or produce as many as 30,000 offspring. On the other hand, if a woman were to devote her entire fecund life to procreation, she could produce no more than 40-45 babies. Accordingly, the female is responsible for quality control.

The female will also ultimately take on the responsibility of child-rearing. Of the other necessary life activities besides fornication and propagation, child-rearing may be the most important. If protection is not provided for the young, they will not survive. Thus, to devote one’s life to the sole purpose of manufacturing babies without the potential for survival would be senseless.

The female tends to be selective in choosing a mate—ideally, one that will best provide for and protect the family. To optimize their ability to make an appropriate choice a proper mate, women tend to be more cautious in regard to their impulsivity with respect to sexual gratification. Women with inhibited sexual arousal are more likely to select a proper mate and increase their likelihood of survival. Also, once aroused, a woman is more likely to attempt an ongoing relationship with her mate.

Men, on the other hand, tend to desire sex indiscriminately with large amounts of women. Again, this is a means of spreading their sperm for the purpose of procreation and passing down their genes. According to the literature, males are typically quicker to arousal than the average female. After gratification from a sexual encounter, they are commonly less likely than females to be interested in maintaining a relationship or commitment.

A commonly cited estimate is that men aged 12-40 years think of sex approximately 6 times an hour. If this estimate is further broken down by age ranges, males aged 12-19 years think of sex an average of 20 times per hour or once every 3 minutes, whereas males aged 30-39 years think of sex only about 4 times per hour. This may be one reason why paraphilias usually occur in males aged 15-25 years.

Such findings suggest that most men are promiscuous, either physically or psychologically; what distinguishes among them is the degree of control that is exerted toward action or inaction in regard to the sexual urges.

Females are much more relationship-oriented, and this may contribute to their greater orgasmic capacity. Although women may require more touching, caressing, and overall romance to become aroused than men do, the resulting arousal is likely to last longer. Most women have the potential for multiple orgasms, which may further enhance the procreative capacity by enabling them to capture the sustained interest and involvement of males who otherwise tend to be slow to ejaculation.

These findings may help explain why men are more like likely to be sexually aroused by visual stimuli and women by tactile stimuli. The hunters (roving bands of men) spot their prey (women) at a distance and are able to achieve excitement just by the sight of a possible future conquest. Women are more susceptible to caressing, tenderness, and the reassurance of a man’s commitment. This commitment ensures that the male is emotionally invested in the union and will remain around to supply food and protection for the female and their offspring.

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Epidemiology

United States and international statistics

Paraphilias are rarely diagnosed in clinical settings—possibly, in part, because many of the acts are illegal and reporting methods (ie, self-reporting) may be unreliable. Large commercial markets in paraphilic pornography and paraphernalia suggest that prevalence is high. Pedophilia, voyeurism, and exhibitionism are the most commonly observed behaviors in clinics that specialize in paraphilia treatment; sexual masochism and sadism are much less common. About 50% of patients observed in clinics for treatment of paraphilias are married.

According to DSM-5, the frequency of voyeuristic disorder is unknown, but the estimated highest possible lifetime prevalence is approximately 12% for males and 4% for females.[1] The frequency of exhibitionistic disorder is also unknown, but the highest possible prevalence in males is 2-4%; prevalence in females less certain but is generally believed to be much lower than that in males.

Frotteuristic disorder, including uninvited sexual touching of or rubbing against another individual, may occur in as many as 30% of adult males in the general population; 10-14% of adult males seen in the outpatient setting for paraphilic disorder and hypersexuality meet the diagnostic criteria.

The frequency of sexual masochism disorder is unknown. In Australia, 2.2% of males and 1.3% of females were estimated to have been involved in bondage, sadomasochism, or dominance and submission in the preceding 12 months. The frequency of sexual sadism disorder is also unknown but has been estimated to range from 2% to 30%, depending on the criteria used. Among sex offenders in the US, fewer than 10% have sexual sadism disorder; however, 37-75% of those who have committed sexually motivated homicides have this disorder.

The frequency of pedophilic disorder is unknown as well. The highest possible prevalence among males is estimated to be 3-5%; the prevalence in females is thought to be a small fraction of that in males.

International incidences of paraphilias are difficult to determine.

Age-, sex-, and race-related demographics

Most patients are aged 15-25 years. Paraphilic disorders rarely occur in individuals older than 50 years, and data on these disorders in older people are limited. Males are more likely to be affected than females are, and most patients are white.

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Prognosis

Predicting treatment outcomes is difficult. Long-term treatment gains appear to require approaches that address the underlying dynamics that go beyond the simple paraphilia itself. The morbidity or mortality of a paraphilia depends on the act practiced, the comorbidity involved, the patient’s cooperation with the therapist, and whether or not the legal system is involved.

Paraphilias can be transient, as demonstrated by experimentation during the teenage years, or can remain a life-long problem involving legal, financial, interpersonal, occupational, academic, and other problems. Death may occur in some circumstances, through acts such as autoerotic asphyxiation. Treatment and prognosis must be based on individual assessment.

The following characteristics are generally associated with a good prognosis:

  • Cooperative attitude
  • Normal sex life
  • Motivated outlook, with a desire to change
  • Voluntary approach to treatment

The following characteristics are generally associated with a poor prognosis:

  • Early onset of paraphilia
  • Legal charges pending
  • Unmotivated attitude
  • Uncooperative attitude
  • Paraphilia as the only sexual activity or outlet
  • Comorbidity
  • Lack of remorse over acts
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Patient Education

Paraphilias are not homogeneous phenomena; considerable variability exists. Nevertheless, a number of issues can be constructively discussed with patients and, when appropriate, with family members. The goal should be to enhance understanding about the issues being faced and the options available to address them (eg, sex education, social skills training, coping skills training, and relapse prevention).

Family education is of particular importance in the treatment of paraphilic disorders. The family should receive education about the disorder, medications, side effects, and medication compliance, the importance of psychotherapy, and what to do in case of an emergency. The family will need contact information regarding community support programs for the patient and the family.

The family may need to be involved in a support group (eg, church). If the patient is on medication, the family must be informed of potential problems (eg, side effects and drug interactions). If the patient is married, marital counseling must be part of the treatment plan. The family also needs to be aware of local laws in regard to paraphilias. If the patient is on probation, the family needs to be aware of court dates and any relevant legal matters.

For some patients with paraphilias, sex offender community notification may be required. It should be kept in mind, however, that many patients with paraphilias have no legal charges filed against them, and even health care workers are not required to report all paraphilias (though reporting is mandatory for some, such as pedophilia).

Some patients may find such notification to be a deterrent to their paraphilia; others may not. Some experts suggest that notification, though required, may act as a hindrance for some patients who are trying to obtain help for their illness. This will continue to be a matter of community concern and debate for the foreseeable future. The patient should address these concerns with the treatment team. Intensive community supervision is important.

In paraphilic disorders where significant potential for negative consequences to others poses genuine concern (eg, pedophilia, sexual sadomasochism), the need for long-term therapy and monitoring must be emphasized. Partners, family, and friends should be encouraged to understand the continuing potential for harm and their responsibility to take the necessary steps to protect themselves and others who may be at risk. Warning signs and coping strategies should be discussed and formulated.

The following Web sites may provide useful information and suggestions:

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Contributor Information and Disclosures
Author

Guy E Brannon, MD Associate Clinical Professor of Psychiatry, Louisiana State University Health Sciences Center; Director, Adult Psychiatry Unit, Chemical Dependency Unit, Clinical Research, Brentwood Behavior Health Company

Disclosure: Received income in an amount equal to or greater than $250 from: Sunovion; Forest.

Chief Editor

David Bienenfeld, MD Professor, Departments of Psychiatry and Geriatric Medicine, Wright State University, Boonshoft School of Medicine

David Bienenfeld, MD is a member of the following medical societies: American Medical Association, American Psychiatric Association, Association for Academic Psychiatry

Disclosure: Nothing to disclose.

Acknowledgements

Robert Levey, PhD, MPH Associate Professor, Department of Medicine, Section of Psychiatry, University of Tennessee Graduate School of Medicine

Robert Levey, PhD, MPH is a member of the following medical societies: American Public Health Association, Association for Hospital Medical Education, and Sigma Xi

Disclosure: Nothing to disclose.

Mohammed A Memon, MD Chairman and Attending Geriatric Psychiatrist, Department of Psychiatry, Spartanburg Regional Medical Center

Mohammed A Memon, MD is a member of the following medical societies: American Association for Geriatric Psychiatry, American Medical Association, and American Psychiatric Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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