Paraphilias (PAs) and paraphilia-related disorders (PRDs) (nonparaphilic sexual compulsivity or sexual addiction) are sexual disorders that predominantly afflict men. Psychiatry in the United States, in particular, has neglected to pay significant clinical or research attention to these commonly overlooked but very serious conditions. Although many clinicians might think that these conditions are merely uncommon, exotic, or of questionable diagnostic validity, the lack of systematic clinical and research attention paid to these conditions is more related to severe sociocultural and moral stigmatization, clinician discomfort to assertively inquire about these conditions, and severe shame and guilt among persons with these disorders.
Frequently, these conditions are acknowledged by men and women under the duress of a clinical emergency, such as an impending marital separation or divorce, or arrest and legal charges associated with inappropriate sexual behaviors. In addition, even when PAs or PRDs have been identified, the specific psychiatric Axis I disorders associated with sexual impulsivity can still elude astute, forensically trained clinicians, thus diminishing the perceived value of psychiatric consultation and treatment.
PAs are intense, recurring expressions of socially deviant or anomalous sexual arousal that cause individual distress and/or clinically significant adverse consequences (typically related to repetitive enactment). The most common paraphilic disorders described in DSM-IV are exhibitionism, voyeurism, fetishism and transvestic fetishism, frotteurism, sexual sadism and sexual masochism, and pedophilia.
Because several PAs are associated with sexual offenses, persons with these serious disorders are not likely to discuss their sexual impulses with intimate partners, friends, or clinicians. Currently, the social consequences that are associated with being a sexual offender can include incarceration, limitations and restrictions on personal liberty (eg, lengthy probation or parole, residency restrictions, global positioning surveillance, or employment limitations), and personal endangerment and bodily harm by vigilantes.Treatment
Treatments that empirically have been shown to reduce sexual offender recidivism include medication and cognitive-behavioral therapy that is typically performed in a group-therapy paradigm.1 Typical medications prescribed for men with PAs might include antiandrogens (eg, injection and oral medroxyprogesterone(Drug information on medroxyprogesterone) acetate), gonadotropin-releasing hormone agonists (eg, leuprolide), or SSRIs.2
Based on published data, PRDs such as compulsive masturbation, pornography dependence or addiction (including print, computer, and telephone), protracted promiscuity, and severe sexual desire incompatibility are more common than PAs but have no specific diagnostic designation in current DSM nosology. Fortunately, these latter conditions are being considered for DSM-V classification, pending further research and field trials that include diagnostic questionnaires.
PRDs may be common in persons with current PAs, but they can occur as stand-alone conditions. PRDs are time-consuming, are associated with medical comorbidities, such as venereal disease and unplanned pregnancy, and place severe strain on the basic trust necessary for a functional intimate partnership.
Currently, PRDs are most commonly considered compulsive disorders or behavioral addictions. As such, 12-step, self-help groups based on the Alcohol(Drug information on alcohol)ics Anonymous model are widely recommended, as is concurrent individual psychotherapy. Unfortunately, consistent empirical validation of any specific psychotherapeutic treatment modality is lacking.3
A recent, small, placebo-controlled study suggested partial support for the prescription of citalopram(Drug information on citalopram) in men with protracted promiscuity.4 Other proserotonergic antidepressants have been reported to ameliorate both PAs and PRDs in open prospective (but not controlled) trials and retrospective reports.5-7 As is the case with psychotherapy for PRDs, a robust empirical validation of the role of pharmacotherapy is suggestive but requires additional clinical trials.Stigma
The reticence of persons seeking help from clinicians to recognize and acknowledge sexual impulsivity and clinician hesitance to inquire or raise an adequate index of suspicion with new patients is analogous to the "don't ask, don't tell" policy of the US military toward homosexuality. For example, while clinicians routinely inquire about changes (either notable increases or decreases) in sleep, psychomotor behavior, and eating during an initial clinical evaluation, most clinicians do not ask questions related to a person's sexual behavior (such as those listed in the Table).
Screening questions for sexual impulsivity disorders
|Have you ever felt your sexual behavior was compulsive, excessive, or that you were addicted to sex?|
|Has your sexual behavior ever caused you persistent personal distress, medical problems (such as sexually transmitted disease or unwanted pregnancy), and/or legal difficulties?|
|Has your sexual behavior been associated with the loss of a job or has it caused significant problems in an important romantic relationship?|
|Have you ever engaged in repetitive sexual behaviors that you felt needed to be kept a secret (including affairs)?|
|Have you ever thought of yourself as someone who was either blessed or cursed with a high sex drive?3|