April 15, 2007
Psychiatric Times.
No. 5
Paraphilias: Clinical and Forensic Considerations
H. Martin Malin, PhD and Fabian M. Saleh, MD
Dr Malin is a professor of clinical sexology at the Institute for the Advanced Study of Human Sexuality in San Francisco. He is also a research associate at the Baltimore-based National Institute for the Study, Prevention, and Treatment of Sexual Trauma. Dr Saleh is the director and founder of the Sexual Disorders Clinic at UMass Memorial, Community Healthlink. He is also an assistant professor of psychiatry in the Law and Psychiatry Program and the Child and Adolescent Psychiatry Division at UMass Memorial Medical Center and director of research at the National Institute for the Study, Prevention, and Treatment of Sexual Trauma. The autors report no conflicts of interest concerning the subject matter of this article.
Treatment and prognosis
Optimal treatment of the paraphilias entails some combination of psychologically and biologically based treatments, although it is not uncommon for therapists of some schools to rely solely on psychological interventions. Among the psychologically based techniques used in the treatment of persons with paraphilia, as well as nonparaphilic sex offenders, are group and individual cognitive and/or behavioral therapies and relapse prevention therapy.
The neurobiology of paraphilias is not completely understood, but pharmacotherapy directed at hormones (through their action on the hypothalamic-pituitary-gonadal axis) known to impact sexual arousal is often helpful in the management of paraphilias.9 Biologically based treatment includes agents that reduce testosterone levels, such as medroxyprogesterone (or cyproterone acetate outside the United States). More recently, there has been a switch away from medroxyprogesterone and cyproterone toward luteinizing hormone-releasing hormone agonists such as leuprolide. The tendency to keep pharmacological treatments in reserve for refractory cases when the psychologically based therapies seem ineffective appears to be giving way to using pharmacotherapy as a first-line adjunct to therapy.
A discussion of treatment would be incomplete without acknowledging concerns about countertransference. In the treatment of persons with paraphilia in general, and particularly with those whose behaviors arising from paraphilic ideation are illegal, it has been commonplace to define countertransference as emotions experienced by a treatment provider that may interfere with the delivery of appropriate patient care. The treatment of a patient for paraphilia may be compromised by the feelings and negative opinions of a clinician toward the patient.
For effective treatment to occur, a treatment provider must be aware of countertransference and be capable of keeping it in check. While a patient with paraphilia may provoke a range of emotional responses ranging from boredom to amusement or anger in the treating clinician, such personal responses may be quite damaging if they spill over into the treatment process. Not all treatment providers want to work with a pedophile or a necrophile; however, those who attempt this difficult task should be scrupulously honest with themselves with respect to whether they can be competent and comfortable working with these patients.10
Forensic considerations
Simply having paraphilia is, obviously, not illegal. Acting in response to paraphilic urges, however, may be illegal and in some cases subjects the person with paraphilia to severe sanctions. The distinguishing phenomenological characteristic of paraphilias is an intense craving or urge to fantasize or engage in some form of sexual expression that most people would not find erotic. Most people simply do not experience such cravings. These urges are often difficult and, in some cases, may even be impossible to control. It is this putative lack of impulse control that underlies the insanity defense in trials alleging sexually criminal behavior. Such defenses are based on impaired mental capacity and are sometimes, although infrequently, successful.
The importance of these distinctions, particularly the phenomenology of paraphilias, cannot be overemphasized: sex offenders are not necessarily persons with paraphilia and persons with paraphilia are not all sex offenders. Forensic considerations aside, it is quite possible to be a person with paraphilia on the proverbial desert island without becoming a sex offender.
It is also crucial to recognize the differences between working in the forensic arena and more conventional treatment settings. Treatment providers who are not comfortable with the adversarial nature of forensic psychiatry and the milieu of the courtroom may be reluctant to treat patients with paraphilia who are also sex offenders.
Conclusion
While neither the causation of nor the specific modes of action of the various modalities for managing the paraphilias are well understood, evidence suggests that treatment is worthwhile, both in reducing the rate of recidivism and subsequent danger to society from sex crimes and in relieving the suffering of individuals with paraphilias and comorbid conditions. It seems well worth the efforts of psychiatrists to continue to refine both their diagnostic and treatment skills toward this end.
References:
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4. Saleh FM, Berlin FS, Malin HM, Thomas K. Treatment of the nonpedophilic and nontransvestitic paraphilias. In: Gabbard GO, ed. The Treatment of Psychiatric Disorders. 3rd ed. Washington, DC: American Psychiatric Association. In press.
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7. Berlin FS, Saleh FM, Malin HM. Comorbid psychiatric illness in sex offenders. In: Saleh FS, Grudzinsky A, Bradford J, Brodsky D, eds. Sex Offenders: Identification, Risk Assessment, Treatment, and Legal Issues. New York: Oxford University Press. In press.
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10. Malin HM. Should you work with sex offenders? The Therapist (CAMFT). 2002;November/December: 54-59.
