Approach Considerations
The various paraphilic disorders affect a wide variety of people. The level of severity, distress, and impairment (up to and including criminal behavior) resulting from these disorders also are highly variable. Consequently, treatment options vary and must take into account the specific needs of each individual case.
Treatment options may include individual psychotherapy, group therapy, marital/couple therapy, and family therapy, as well as pharmacotherapy or even (rarely) surgical interventions, as indicated.
Inpatient treatment is indicated for patients who are suicidal, homicidal, or disabled to the point where they cannot take care of themselves. Suicide risk may be high if they feel exposed or confronted. If patients are charged with a crime or have been arrested, they may be incarcerated. [19]
Physicians must be aware that not every therapist treats people with paraphilias. There may be a need for consultations with other professionals, such as a neurologist (if neurologic signs are present), an attorney, or even a member of the clergy depending on the needs and wishes of a given patient.
Considerations for particular paraphilic disorders
For adults with exhibitionistic disorder (those with sociopathy excluded), group therapy has been effective in improving social skills and providing support against additional offenses. Specifically, group therapy has been effective with shy inhibited adolescents but not with compulsive instinct-ridden adolescents. Individual psychotherapy has been helpful with many exhibitionists. Unfortunately, exhibitionism has one of the highest recidivist rates of all sexual offenses.
Fetishistic disorder often begins in adolescence and usually persists. Treatment of the specific fetish rather than the primary underlying dynamic has not been very promising. Behavioral techniques show some promise, particularly when aided by adequate follow-up.
Many individuals with pedophilic disorder have had sexual fantasies about children for a long time. Consequently, change can be very difficult. The physician can try to reduce the intensity of the fantasies and help the abuser develop coping strategies. The abuser must be (but often is not) willing to acknowledge the problem and to participate in treatment. Dynamic psychotherapy, behavioral techniques, chemical approaches, and surgical interventions yield mixed results. Lifelong maintenance may be the most pragmatic and realistic approach.
Unfortunately, individuals with sexual masochism or sadism disorder rarely present for treatment until someone becomes an unwilling partner or is injured. The seriousness and intensity of these behaviors often increase over time. Prognosis varies, depending on the depth of the underlying dynamics (which are especially poor when sociopathy is involved) and the patient’s level of motivation.
Psychotherapeutic Interventions
Cognitive-behavioral therapy
Cognitive-behavioral therapy (CBT) involves applying behavioral therapy techniques to modify sexual deviations by altering patients’ distorted thinking patterns and making them cognizant of the irrational justifications that lead to their undesirable sexual behaviors. It may be employed in accordance with a 7-step approach, as follows:
Aversive conditioning with ammonia or (masturbatory) satiation
Confrontation of cognitive distortions (especially effective in groups)
Victim empathy (showing videos of victims and the consequences they experience from the patient’s act)
Assertiveness training (including social skills training, time management, and structuring)
Relapse prevention (identifying antecedents to the behavior [high-risk situations] and ways of disrupting these antecedents)
Surveillance systems (family associates who help monitor patient behavior)
Lifelong maintenance
The incorporation of relapse prevention techniques helps the patient control the undesirable behaviors by avoiding situations that may generate initial desires. The commonly employed technique of covert sensitization pairs a patient’s harmful sexual variation with an unpleasant stimulus in order to discourage repetition of the act. This approach has proved effective in many cases of pedophilia and sadism.
Orgasmic reconditioning
In orgasmic reconditioning, a patient is reconditioned to a more appropriate sexual stimulus. First, the patient is instructed to masturbate to his or her typical, less socially acceptable stimulus. Then, just before orgasm, the patient is told to concentrate on a more acceptable fantasy. This process is repeated at progressively earlier points before orgasm until, eventually, the patient begins his or her masturbation fantasies with an appropriate stimulus.
Social skills training
Because of the widespread view that paraphilic disorders develop in patients who lack the ability to develop relationships, many therapists and physicians use social skills training to treat patients with these types of disorders. They may work on such issues as developing intimacy, carrying on conversations with others, and assertive skills training. Many social skills training groups also teach basic sexual education, which is very helpful to this patient population.
Twelve-step programs
Many physicians and therapists refer patients with paraphilias to 12-step programs designed for "sexual addicts." Like Alcoholics Anonymous, these programs are designed to give control to group members, who lead most of the sessions. To increase awareness of the problem, the programs incorporate cognitive restructuring with social support. The group also focuses on the sense of a “higher power” and each individual’s reliance upon spirituality.
Group therapy
Group therapy in this setting is designed to help paraphilic individuals break through the denial they so commonly exhibit by surrounding them with other patients who share their condition. Once these individuals begin to admit that they have a sexual divergence, the therapist can begin to address individual issues (eg, past sexual abuse) that may have led to the sexual disorder.
When these individual issues have been identified, initiation of gestalt-type therapy (with the victim, if any) may be desirable to help patients get past the guilt and shame associated with their particular paraphilia. The goal of this type of therapy is to lead the patient to a “healthy remorse.” These patients require lifetime therapy to reduce the likelihood of relapse.
Individual expressive-supportive psychotherapy
Individual expressive-supportive therapy requires a psychologically minded patient who is willing to focus on the paraphilia. The therapist should not set unrealistically high goals but must break through the denial. Patient countertransference and avoidance can be particular problems with this form of therapy. If the therapy enables the patient to break through the denial, they can then work on the unconscious meaning behind the particular paraphilia.
Pharmacologic Therapy
Pharmacologic interventions may be used to suppress sexual behavior. These treatments may offer genuine help to a variety of patients with paraphilic disorders; however, numerous adverse effects have been reported. Additionally, ethical, medical, and legal questions have been raised regarding issues of informed consent, especially in hospital and prison settings.
Medications that may be considered in the treatment of paraphilic disorders include the following:
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Antidepressants, such as lithium and various selective serotonin reuptake inhibitors (SSRIs)
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Long-acting gonadotropin-releasing hormones (ie, medical castration), such as leuprolide acetate and triptorelin
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Antiandrogens (to lower sex drive), such as medroxyprogesterone acetate (10 mg q12hr, with the dosage doubled every 3 days to a maximum of 200 mg/day, then maintained for 1 month and adjusted as necessary)
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Phenothiazines, such as fluphenazine
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Mood stabilizers
SSRIs may be prescribed specifically to treat associated compulsive sexual disorders, to induce libido-lowering sexual side effects, or both. The dosages used are higher than those typically administered for depression. Usual dosage ranges for several SSRIs commonly employed in this setting are as follows:
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Sertraline - 150–200 mg/day
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Fluoxetine - 20–80 mg/day
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Fluvoxamine - 200–300 mg/day
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Citalopram - 20–80 mg/day (caution needed in doses > 40 mg/day given risk for QTc prolongation)
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Escitalopram - 10–40 mg/day (caution needed in doses > 20 mg/day given risk for QTc prolongation)
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Paroxetine - 20–60 mg/day
Surgical Interventions
Psychosurgery using stereotaxic tractotomy and limbic leucotomy may be performed. This is an invasive, irreversible procedure that was used on a small number of subjects, primarily in Germany. Some success has been reported in the treatment of pedophilia, hypersexuality, and exhibitionism. Given its emotional, physical, and intellectual adverse effects, as well as the availability of suitable pharmacologic interventions, this procedure is not likely to be widely used.
Bilateral orchidectomy (surgical castration) has been used since the 19th century in Europe and America, though not in Western Europe since the 1970s. Given the adverse effects of the procedure (eg, weight disturbance, gynecomastia, hot flashes, osteoporosis and bone pain in elderly patients, depression), it also is not likely to be widely used; pharmacologic interventions provide a reversible alternative.
Long-Term Monitoring
For optimal results, patients require medication management and psychotherapy. If the patient began medication therapy in the hospital, the same therapy should be continued afterward and adjusted as necessary. If not, appropriate medications should be selected, and their risks, benefits, adverse effects, and alternatives should be discussed with the patient. Informed consent must be obtained before pharmacotherapy is initiated.
Restrictions should be imposed on activity as necessary if patients represent a danger to themselves or to others or if they are gravely disabled.
