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Paraphilias as defined by DSM-IV, are sexual impulse disorders characterized by intensely arousing, recurrent sexual fantasies, urges and behaviors (of at least six months' duration) that are considered deviant with respect to cultural norms and that produce clinically significant distress or impairment in social, occupational or other important areas of psychosocial functioning. The common paraphilias described include exhibitionism (exposure of genitals to a stranger), pedophilia (sexual activity with a prepubescent child, generally 13 years of age or younger), voyeurism (observing others' sexual activities), fetishism (use of inert objects, such as female undergarments), transvestic fetishism (cross-dressing), sexual sadism (inflicting suffering or humiliation), sexual masochism (being humiliated, beaten, bound or made to suffer) and frotteurism (touching, rubbing against a nonconsenting person).
Although several of these disorders can be associated with aggression or harm, others are neither inherently violent nor aggressive (e.g., fetishism, transvestic fetishism).
Paraphilias are predominantly male sexuality disorders with an estimated sex differences ratio of 20:1 in sexual masochism. (The other paraphilias are almost never diagnosed in females, although some cases have been reported-Ed.)
There is a second group of sexual impulse disorders not currently classified as paraphilias because the particular sexual behaviors affected are not considered "deviant" with respect to contemporary cultural norms. I have proposed to designate these disorders as paraphilia-related disorders (Kafka 1994a) based on the following clinical data:
- The boundary for social as well as sexual deviance is largely determined by cultural and historical context. As such, sexual disorders once considered paraphilias (e.g., homosexuality) are now regarded as variants of normal sexuality; so too, sexual behaviors currently considered normal (e.g., masturbation) were once culturally proscribed.
- Paraphilia-related disorders have been diagnosed in male paraphiliacs (Longo and Groth; Langevin and others), and men selected for studies of paraphilia-related disorders are reported to have paraphilias as well (Carnes).
- Paraphilia-related disorders can produce a pattern of sexual frequency and intensity with concomitant psychosocial impairment that does not readily distinguish them from nonviolent paraphilic disorders (Carnes, Kafka and Prentky 1992a).
- Analogous with paraphilias, the presence of a single paraphilia-related disorder increases the likelihood of occurrence of a multiplicity of these behaviors in an affected person.
- Paraphilias and paraphilia-related disorders can both be ameliorated by antiandrogens and serotonergic antidepressants, especially serotonin reuptake inhibitors. Disorders of sexual impulsivity can be pleomorphic and may include sexual arousal to behaviors that are socially "deviant" as well as "normal." In fact, inasmuch as paraphilia-related disorders may be common in paraphiliacs and also occur without the companion of the latter, paraphilia-related disorders may be the more prevalent form of sexual impulsivity. In addition, although the estimated sex difference ratio for paraphilia-related disorders is unknown, protracted promiscuity (e.g., "nymphomania") and compulsive masturbation are not uncommon behaviors described by women.
Although this article is written to highlight pharmacotherapy, most males with sexual impulsivity disorders treated with pharmacotherapy should have a concurrent psychological treatment including such modalities as a specialized sex offender program, group therapy, a 12-step "sexual addiction/compulsion" recovery program or a therapist familiar with this complex's disorders.
While there is no single unifying theory to adequately explain the pathogenesis of sexual impulse disorders, there are currently two distinct classes of psychopharmacological agents, antiandrogens and serotonergic antidepressants, that are prescribed during the treatment of paraphilias and paraphilia-related disorders.
The antiandrogens cyproterone acetate (CPA) and medroxyprogesterone acetate (MPA [Amen, Depo-Provera) are the most commonly prescribed agents for the control of repetitive deviant sexual behaviors and have been prescribed for paraphilia-related disorders as well. Although neither drug has been specifically approved by the Food and Drug Administration for the treatment of paraphilic disorders, both agents are used in Canada and Europe and medroxyprogesterone is available in the United States. Both agents, available as oral or parenteral preparations, have been shown in multiple studies to reduce recidivism rates in male sexual aggressors (for review, Bradford 1995a), the group most commonly prescribed these drugs.
Common side effects of antiandrogens include weight gain, fatigue, hypertension, headaches, hyperglycemia, leg cramps and diminished spermatogenesis. In addition, there may be an increased risk of thromboembolism in men (and women) with risk factors associated with clotting disorders and rare feminization effects such as breast swelling and changes in hair distribution during prolonged treatment.
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