Hero

Videos

Slideshows

Articles

Podcasts

Poll

It has been said that individuals avoid discussing religion, politics, and money. In this article, we will address another taboo topic: sexual dysfunction (SD), which occurs when an individual has difficulty with 1 or more components of the 

, presenting as decreased libido, early or delayed ejaculation, orgasmic dysfunction, impaired genital sensation, erectile dysfunction, and/or insufficient lubrication in women.

SD is relatively common. In the general adult population, the estimated prevalence of SD is 20% to 30% in men and 40% to 45% in women.

 Certain risk factors may increase the risk, including psychiatric disease. For example, based on International Classification of Diseases, Tenth Revision (ICD-10) definitions, 74% of men and 82% of women with schizophrenia, reported at least 1 sexual problem.

 However, psychiatric patients experiencing SD are often hesitant to disclose concerns to health care professionals.

Medicinal treatment of psychiatric diseases is also a significant cause of SD. Antidepressants, antipsychotics, and benzodiazepines are 3 drug classes that are potent etiologies of SD (

 According to a validated survey for assessing SD (SalSex), nearly 

 treated for a psychotic disorder developed SD.

 Another study suggested that 25% to 80% of patients treated with antidepressants developed SD.

 This is a major concern, as some patients have shown poor tolerance to the sexual side effects of psychiatric medications and have considered treatment cessation as a result.

 that the sexual side effects of psychiatric medications persist even after medication discontinuation, causing patients great distress.

SD is a significant concern for patients on psychiatric medications. However, SD is often inadequately addressed.

Medication Classes and Sexual Dysfunction

 Selective serotonin reuptake inhibitors (SSRIs) are commonly utilized in the treatment of major depression, anxiety disorders, posttraumatic stress disorder, and obsessive-compulsive disorder, among others.

 The prevalence of sexual side effects is not well defined. One post-market study estimated SD prevalence in patients treated with SSRIs between 5% and 15%,

 while some studies reported up to 80% of patients experienced sexual side effects.

 Although some patients experiencing sexual side effects may see their symptoms resolve over the course of treatment, the vast majority will continue to experience side effects during SSRI treatment.

 Some patients may continue to suffer from persistent side effects despite the discontinuing medication, a condition known as post-SSRI sexual dysfunction (PSSD).

 Although there is limited clinical trial data, available studies found the highest incidence of sexual side effects in patients treated with paroxetine, followed by fluvoxamine, sertraline, and fluoxetine.

A proposed mechanism for SSRI-induced SD lies within the interaction between serotonin and 5-hydroxytryptamine receptors (5HT1A).

 SSRIs are hypothesized to cause downregulation of 5HT1A due to the persistent stimulation by serotonin and resulting epigenetic changes that have implications for regulation of sexual motivation. It is likely that other 5HT receptor subtypes are similarly affected. The effect of elevated serotonin on levels of other hormones and neurotransmitters that play an important role in sexual function, such as testosterone and dopamine, may also account for some of SSRIs’ sexual side effects. These effects appear to be dose-dependent, with higher doses increasing one’s risk of SD.

 Thus, providers must weigh the potential benefits of increasing drug doses with increasing risk of adverse effects.

 SD is a common adverse effect (present in up to 48% to 75% of patients) of both oral and depotantipsychotic medications.

 Results of a recent meta-analysis described SD prevalence in those treated with oral 

 Treatment with quetiapine (16%), ziprasidone (18%), and aripiprazole (27%) were associated with the lowest rates of SD. Olanzapine (40%), risperidone (43%), haloperidol (45%), clozapine (52%), and thioridazine (60%) were associated with higher prevalence of SD. In long-acting depot antipsychotics, first- versus second-generation antipsychotics are more strongly associated with SD.

Sexual side effects can likely be traced to the disruption of various neurogenic and hormonal factors impacted by the antipsychotics.

 Mechanisms vary based on action of specific medications. For instance, antidopaminergic medications likely impact the dopaminergic activity of the mesolimbic system, which is integral to sexual functioning. Atypical antipsychotics that target postsynaptic 5HT receptors can negatively affect arousal, orgasm, and ejaculation, as serotonin inhibits sexual desire. Medications that influence levels of luteinizing hormone, follicle-stimulating hormone, prolactin, testosterone, or other neuroendocrine changes can lead to imbalance of these factors necessary for optimal sexual functioning. This was illustrated in the meta-analysis described previously, which generally showed prolactin-raising antipsychotics (eg, haloperidol) caused greater SD compared with prolactin-sparing drugs (eg, ziprasidone).

 Also, as with SSRIs, antipsychotic-based SD appears to be dose-related.

Thus, to assess a patient’s risk of SD, providers must consider both the dosage and mechanism of a particular antipsychotic.

 Benzodiazepines have been reported to result in SD, but this effect is less evident and less reported than the classes of drugs previously discussed. The 

 of a multicenter double-blind randomized comparative study of patients treated with acute phase alprazolam for panic disorder found that the benzodiazepines did not cause SD.

 Other studies point to increased sexual arousal because of reduced anxiety in patients treated with benzodiazepines.

 in 25% to 50% of patient samples treated with alprazolam.

 It is possible that benzodiazepines may reduce anxiety-related aspects of SD while causing anorgasmia and/or other negative impacts on sexual function.

Although there is limited evidence of the mechanism behind the SD caused by benzodiazepines, contributing factors could include effects on 

 and drug-drug interactions. Benzodiazepines are allosteric modulators of the gamma-amino butyric acid (GABA)-A receptor.

 GABA, a central nervous system neurotransmitter, has been associated with decreased sexual behavior. Increased GABA activity could account for decreased sexual function. Benzodiazepines may also contribute indirectly to SD through increased concentrations of concurrently taken medications because of interactions with the cytochrome P450 system.

Mental health care professionals should take the lead in discussing SD with patients. Patients are often unable or unwilling to initiate a dialogue about sexual concerns, and SD could go unnoticed. For example, 1 study showed that 63% of patients experiencing sexual side effects from treatment but did not spontaneously report the issue.

 Importantly, 1 of 3 of those patients felt their dysfunction was significantly impacting their quality of life. An additional study revealed that 50% of patients rarely if ever discussed their SD with providers, even if it had affected adherence to treatment.

The sexual effects of psychiatric medications should be communicated at 3 distinct times: before, during, and after treatment. It is often difficult to discern retroactively if a patient’s SD is from their mental health condition or their psychiatric medications. Thus, establishing a baseline level of sexual function before treatment is extremely helpful. Then, throughout treatment, the clinician should continuously follow up with patients on their sexual function either verbally or through the usage of validated questionnaires.

If a patient is experiencing treatment-related dysfunction, it is important to ask how distressed the patient is by their SD.

 Not all patients with treatment-induced SD are greatly concerned about it.

 It may also be helpful to directly ask patients if their SD has ever caused them to cease their medications.

Finally, if patients complete treatment, it is important to follow up and inquire if their SD has resolved, as some patients experience lingering SD after discontinuation of treatment.

 It is therefore important to detect this and help patients seek appropriate therapies to treat their SD.

Irrespective of the presumed cause of SD, the initial management of patients presenting with SD symptoms must begin with a thorough history and physical exam to 

 that the SD is indeed a product of psychiatric medication use (

 The clinician should also utilize validated psychometric questionnaires, such as the International Index of Erectile Function (IIEF) or its short version, the Sexual Health Inventory for Men (SHIM) (

),at the initial and follow-up visits to assess the various sexual function domains (ie, erectile function, libido, orgasmic function, intercourse, overall satisfaction) at 

 and following initiation or modification of a specific treatment modality.

 Identifying reversible risk factors for SD, such as hypogonadism, hypertension, and obesity, and initiating appropriate treatment should be the clinician’s primary focus during the initial evaluation.

 It is only after addressing easily reversible risk factors for SD that a clinician should suspect psychotropic medications as the cause of SD, especially if the timing of SD remains unclear.

Given the lack of evidence-based treatments, management of patients with presumed psychotropic-induced SD proves to be more of an art rather than a science, and only 20% of prescribers discuss this topic with their patients.

 For the most part, management strategies include a wait and see approach, reduction in medication dosage, switching medications, adjunct medications, cognitive behavioral therapy (CBT), and behavioral modifications (see the following subsections) (

 Regardless of which management strategy a clinician employs, treatment should always follow an individualized, patient-centered approach, focusing primarily on minimizing SD without compromising the psychiatric well-being of the patient.

 Clinicians must also determine what strategies their patients have already tried to identify which treatments are more likely to be effective.

 Specifically regarding SSRI use, clinicians must educate their patients about the risks of PSSD.

 Although various management options for PSSD have been proposed, none have proven effective and there remains no definitive treatment.

A wait and see approach may prove beneficial for some patients, as side effects from medications, particularly SSRIs, can dissipate over time. One study suggested that SD remits in 6 months for approximately 80% of patients, while others report remission in only 10%.

 Another approach involves reduction in dosage, if feasible. SD related to antidepressants may be a dose-dependent adverse effect; therefore, reduction of dosage to a minimum effective dose may be beneficial. However, reduction in dosage could compromise the patient’s mental health, and depending on the particular medication, improvement in sexual function may take several months, which makes this strategy inappropriate for some patients.

 Moreover, many patients only require short-term courses of antidepressants, so in the appropriate setting, cessation of the medication altogether could be the best option.

 Although there is some evidence supporting the use of drug holidays (ie, temporarily discontinuing the drug on weekends), this may lead to withdrawal symptoms or medication nonadherence and is not recommended.

 Another strategy involves switching medications, in particular from an SSRI to a non-SSRI antidepressant. This may allow for the continuation of psychiatric treatment while potentially improving sexual function and adherence. For instance, switching to bupropion, an antidepressant with a favorable sexual side effect profile, has been used with success in patients with previous SSRI-induced SD,

 although these medications have their own unique set of side effects which, in some situations, may be even more distressing to the patient.

 Augmentation strategies consisting of adding another pharmacological or psychotherapeutic treatment to counteract the psychotropic-related SD have shown success in some patients. Addition of bupropion, tamsulosin, phosphodiesterase-5 inhibitors (eg, sildenafil), testosterone, and 5-HT2 antagonists (eg, mirtazapine) to counteract SD without SSRI cessation can be an effective 

 CBT, sex therapy, couples counseling, acupuncture, and behavioral modifications such as the use of vibrators and scheduled sexual activity (ie, in the morning before the daily SSRI dose) have demonstrated mixed benefit.

SD from psychiatric medications is relatively common. If a patient develops SD, multiple treatment strategies exist to help alleviate it. However, SD cannot be treated until it is first identified. Early, continuous, and direct conversations with patients about their sexual function is necessary—and should be anything but taboo.

is a medical student at Tulane University School of Medicine (TUSOM) pursuing urology. 

is a professor of urology and chief of the section of andrology at TUSOM. The authors note they have nothing to disclose regarding this article.

1. Lewis RW, Fugl-Meyer KS, Corona G, et al. 

Definitions/epidemiology/risk factors for sexual dysfunction

2. Harley EW, Boardman J, Craig T. Sexual problems in schizophrenia: prevalence and characteristics. A cross sectional survey. 

3. Montejo AL, Majadas S, Rico-Villademoros F, et al. 

Frequency of sexual dysfunction in patients with a psychotic disorder receiving antipsychotics

4. Bahrick AS. Post SSRI sexual dysfunction. 

5. Atmaca M. Selective serotonin reuptake inhibitor-induced sexual dysfunction: current management perspectives. 

6. Stahl SM. Mechanism of action of serotonin selective reuptake inhibitors. Serotonin receptors and pathways mediate therapeutic effects and side effects. 

7. Hirschfeld RM. Long-term side effects of SSRIs: sexual dysfunction and weight gain. 

8. Allen K, Baban A, Munjiza J, Pappa S. Management of antipsychotic-related sexual dysfunction: systematic review. 

9. Montejo AL, de Alarcón R, Prieto N, et al. 

Management strategies for antipsychotic-related sexual dysfunction: a clinical approach

10. Kaufman KR, Coluccio M, Linke M, et al. Alprazolam-induced dose-dependent anorgasmia: case analysis. 

11. Serretti A, Chiesa A. Treatment-emergent sexual dysfunction related to antidepressants: a meta-analysis. 

12. Lambert M, Conus P, Eide P, et al. Impact of present and past antipsychotic side effects on attitude toward typical antipsychotic treatment and adherence. 

Post-SSRI sexual dysfunction: a literature review

14. Rappek NAM, Sidi H, Kumar J, et al. Serotonin selective reuptake inhibitors (SSRIs) and female sexual dysfunction (FSD): hypothesis on its association and options of treatment. 

15. Safer DJ. Raising the minimum effective dose of serotonin reuptake inhibitor antidepressants: adverse drug events. 

16. Plevin D, Galletly C, Roughan P. Sexual dysfunction in men treated with depot antipsychotic drugs: a pilot study.

17. Serretti A, Chiesa A. A meta-analysis of sexual dysfunction in psychiatric patients taking antipsychotics. 

18. Park EJ, Amatya S, Kim MS, et al. Long-acting injectable formulations of antipsychotic drugs for the treatment of schizophrenia. 

19. Novick D, Haro JM, Perrin E, Suarez D, et al. Tolerability of outpatient antipsychotic treatment: 36-month results from the European Schizophrenia Outpatient Health Outcomes (SOHO) study. 

20. Bobes J, Garc A-Portilla MP, Rejas J, et al. Frequency of sexual dysfunction and other reproductive side-effects in patients with schizophrenia treated with risperidone, olanzapine, quetiapine, or haloperidol: the results of the EIRE study. 

Efficacy of alprazolam sublingual tablets in the treatment of the acute phase of panic disorders

22. Fava M, Borofsky GF. Sexual disinhibition during treatment with a benzodiazepine: a case report. 

23. Rosenberg KP, Bleiberg KL, Koscis J, Gross C. A survey of sexual side effects among severely mentally ill patients taking psychotropic medications: impact on compliance. 

24. Rizvi SJ, Yeung NW, Kennedy SH. Instruments to measure sexual dysfunction in community and psychiatric populations. 

25. Lorenz T, Rullo J, Faubion S. Antidepressant-induced female sexual dysfunction. 

26. Shindel A, Althof S, Carrier S, et al. Disorders of ejaculation: an AUA/SMSNA guideline. American Urological Association Website. Accessed Jan 28, 2021. 

https://www.auanet.org/guidelines/disorders-of-ejaculation

27. Hatzimouratidis K, Giuliano F, Moncada I, et al. Male sexual dysfunction. European Association of Urology Website. Accessed Jan 28, 2021. 

https://uroweb.org/guideline/male-sexual-dysfunction/

28. Higgins A, Nash M, Lynch AM. Antidepressant-associated sexual dysfunction: impact, effects, and treatment. 

29. Rothschild AJ. Selective serotonin reuptake inhibitor-induced sexual dysfunction: efficacy of a drug holiday. 

30. Zajecka J. Strategies for the treatment of antidepressant-related sexual dysfunction. 

The sexual side effects of psychiatric medications are troubling enough that some patients consider treatment cessation. The authors review 5 strategies for managing sexual dysfunction.

Sex, Drugs, and Psychosis: Reviewing Psychiatric Medications’ Taboo Side Effect

C. A child molester is by definition a pedophile

What does the scientific evidence tell us about treatment for pedophilia? The answer might surprise you.

Mini Quiz: Treatment for Pedophilia?

Brendan Dunlop talks about the self-harm risks and nuanced needs of bisexual individuals. For updates on the study, follow them on Twitter 

 is a clinical psychologist in training  at the University of Manchester, UK, and co-investigator on the Self-Injury in Young Bisexual People - a Longitudinal Investigation (SIBL) study. 

Bisexual individuals are at 4.5 to 6 higher risk of self harming than heterosexual individuals, according to this online study. 

Risky Business: The Higher Risk of Nonsuicidal Self Injury in Bisexual Individuals

Jaya Jaya Myra lists aphrodisiacs for the different genders, and what works for both. In some cases, the myths are true. 

 is a best-selling author, TEDx & motivational speaker, and mind-body wellness expert teaching the definitive connections between purpose and health. Her debut book, 

Vibrational Healing: Attain Balance & Wholeness. Understand Your Energetic Type

 is published in 10 languages and available worldwide. Her 2nd book, 

What foods increase libido, and which are better for men versus women? 

Turn Up the Spice: Natural Aphrodisiacs

In case you missed it, this series features reports about sexting, paraphilias, adolescent sexual health, and more. 

7 Clinical Reports About Sexual Disorders

From diagnosis to treatment, paraphilias and paraphilic disorders present unique challenges for the general psychiatrist. Individuals with paraphilic disorders typically do not present in a general outpatient setting for management of sexual thoughts and behaviors. Once an individual discloses thoughts, feelings, or behaviors concerning for a paraphilic disorder, the psychiatrist must identify the range and extent of atypical sexual interests and stratify the individual’s risk in order to determine appropriate treatment options.

If the treatment is accepted, the patient must undergo detailed informed consent due to the potential adverse effects of the medications used to address problematic sexual behaviors. It is therefore crucial that the general psychiatrist understand the basics of diagnosis and treatment for paraphilic disorders.

The publication of DSM-5 marked the first time that the authors of the manual defined a category of paraphilic disorders as distinct from paraphilias. The text defines a paraphilia as “any intense and persistent sexual interest other than sexual interest in genital stimulation or preparatory fondling with phenotypically normal, physically mature, consenting human partners.”

The Sexual and Gender Identity Disorders Work Group, responsible for the paraphilic disorders chapter, differentiated between paraphilias and paraphilic disorders “sought to draw a line between atypical human behavior and behavior that causes mental distress to a person or makes the person a serious threat to the psychological and physical well-being of other individuals.”

 A paraphilic disorder, then, is a paraphilia “that is currently causing distress or impairment to the individual or a paraphilia whose satisfaction has entailed personal harm, or risk of harm, to others.”

DSM-5 delineates criteria for eight specified paraphilic disorders. 

 lists these paraphilic disorders and the associated atypical sexual interest. In order to make a diagnosis of a paraphilic disorder, an individual must have a history of recurrent and intense sexual arousal to the atypical focus lasting at least 6 months that manifests as sexual fantasies, urges, or behaviors. This means that an individual who engages in atypical sexual behaviors, for instance while intoxicated, but lacks the requisite duration and intensity of arousal, does not have a paraphilia or paraphilic disorder.

 DSM-5 also provides diagnoses of other specified paraphilic disorder or unspecified paraphilic disorder for clinicians who see patients who present with atypical sexual interests that do not meet the criteria for one of the specified disorders.

Individuals with atypical sexual interests or problematic sexual behaviors rarely present to the general psychiatrist for evaluation and treatment. Stigma or fear of embarrassment may deter some individuals, whereas legitimate concerns regarding the legal consequences of disclosure of sexual fantasies or behaviors to a mandated reporter may prevent others. These individuals may not be aware of treatment options for problematic sexual behaviors, or their sexual thoughts and behaviors may be ego-syntonic, so they do not see a need to change. Occasionally a patient may reveal atypical sexual interests in the context of a long-term relationship with a provider, for example during psychodynamic psychotherapy.

Psychiatrists practicing psychotherapy commonly learn about patients’ sexual fantasies and behaviors, which may be typical or atypical. In such cases it may be important for the psychiatrist to determine if a patient’s sexual interest is evidence of a paraphilia, paraphilic disorder, another psychiatric disorder, or something more benign, such as sexual experimentation. It is also necessary to assess if the sexual interest causes the individual any impairment, emotional distress, or risk of harm and if it requires any intervention.

Even when patients voluntarily present for psychiatric care related to atypical sexual interests, concerns about stigma, shame, and embarrassment may prevent them from fully sharing their sexual history and the breadth and extent of the sexual behavior, which can make diagnosis and treatment problematic. Early research on paraphilic interests demonstrated that most individuals with paraphilic interests have more than one atypical sexual interest and many have more than five, a phenomenon referred to as “cross-over.”

Furthermore, an incomplete understanding of the breadth of a patient’s atypical sexual interests precludes effective treatment planning. 

 lists strategies to overcome patients’ hesitancy to describe their history of sexual behaviors. One method to improve a patient’s comfort with disclosure is to provide a detailed self-report questionnaire prior to the initial psychosexual evaluation. Patients may find it easier to complete such an assessment in the privacy of their own home, rather than in a physician’s office. The clinical interview can then focus on specific areas in which the patient has responded affirmatively to the questionnaire.

As is often the case, collateral sources of information may also be helpful. Prior relationship and/or sexual partners may be able to elaborate on a patient’s sexual behaviors. Collateral documentation sources including prior treatment records and police reports may also be useful. Police reports can document sexual offending behaviors associated with a patient’s paraphilic interest and may signal a greater need for treatment.

Specific tests are not needed to make a diagnosis of a paraphilic disorder. When there is concern for inaccurate reporting of fantasies and arousal patterns, however, psychophysiologic assessments may assist to clarify whether a paraphilic interest is present.

 Visual reaction time (VRT) and penile plethysmography (PPG) are two types of psychophysiologic assessment. They are typically available only in forensic contexts or specialized sexual disorders clinics.

VRT describes the relative amount of time that an individual observes an image. People typically spend more time looking at images that are sexually appealing to them. Computer programs can assess VRT by displaying images of male and female adults and children on a computer screen and having a patient click through the images and rate his self-reported interest in them. Increased VRT for prepubescent images may signal the presence of a pedophilic interest. PPG, on the other hand, measures the change in penile circumference or volume in response to potentially arousing auditory or visual stimuli. PPG is also used to assess for pedophilic interest, but it can also be used to identify the presence of sexual response to other stimuli, such as sadistic themes, animals, etc.

Treatment options and risk stratification

There are limited treatment options for paraphilic disorders. Although not all individuals with paraphilic disorders are sexual offenders, much of the literature used to guide treatment in patients with paraphilic disorders derives from studies of sexual offenders. Sexual offender treatment programs typically utilize various forms of psychotherapy, though there is little evidence that such approaches are helpful at reducing recidivism. A 2012 Cochrane review failed to demonstrate a reduction in sexual offense recidivism from psychological interventions in sexual offenders.

 Similarly, a recent large-scale study of a sexual offender therapy-based intervention delivered to over 15 thousand prisoners in the UK found that treated men had an increased risk of recidivism compared to untreated men.

Mild paraphilias and sub-diagnostic atypical sexual interests and fantasies may be managed with psychotherapies such as cognitive-behavioral therapy. For paraphilic disorders, however, medications should be a mainstay of treatment. 

 summarizes the different classes of medications used to treat paraphilic disorders, as well as their mechanisms of action and beneficial effects on paraphilic disorders. SSRIs frequently cause sexual dysfunction in patients treated for other conditions such as depression and anxiety. Such impairment may be desirable in patients with paraphilic disorders, so SSRIs can be used to induce dysfunction in libido, arousal, and orgasm.

Antiandrogen medications, including synthetic steroidal analogs like medroxyprogesterone acetate and gonadotropin releasing hormone analogs like leuprorelin, reduce testosterone levels by different mechanisms with the goal of decreasing sex drive and eliminating paraphilic fantasies and urges. They have the added benefit of injectable, long-acting formulations that can improve patient adherence to the treatment regimen.

Data regarding the effectiveness of these treatments are limited. Studies tend to have small sample sizes composed primarily of sexual offenders, only some of whom have paraphilic disorders. In addition, the primary endpoint for most studies is sexual offense recidivism, as opposed to subjective improvement in paraphilic symptoms and related distress. A 2015 Cochrane review of pharmacologic interventions for individuals have who sexually offended or are at risk of offending evaluated the evidence for each medication category.

 The researchers did not identify any studies that used SSRIs or gonadotropin releasing hormone (GnRH) analogs; only six studies that used synthetic steroidal analogs were found. The overall evidence was found to be poor.

In their 2010 guidelines for the biological treatment of paraphilias, the World Federation of Societies of Biological Psychiatry (WFSBP) was able to provide recommendations on the three categories of medication with only level C evidence, or “minimal research-based evidence to support the recommendation.”9 Despite the lack of evidence, the WFSBP published practical guidelines to assist clinicians in making rational treatment decisions for paraphilic disorders.9 The guidelines indicate that treatment should be more rigorous and based on the severity of or risk of harm posed by an individual’s paraphilia or paraphilic disorder.

 briefly describes the levels of treatment need and recommended treatments per the WFSBP. Escalating severity of the paraphilic disorder and risk for violence indicate the need for antiandrogen treatment, including a combination of a GnRH analog and synthetic steroidal analog for the most severe cases. The general psychiatrist should exercise caution, however, as formulating estimates of sexual violence risk is outside the realm of general psychiatric and even most forensic psychiatric practice. If a clinician encounters a patient and has concern for sexual offending due to a paraphilic disorder, consultation with or referral to a forensically trained sexual disorders specialist is warranted.

Informed consent is an essential element of any clinical encounter, but it is particularly relevant to consider when working with patients with paraphilic disorders. Although discussing SSRIs and their associated risks with patients may be second nature to practicing psychiatrists, antiandrogen medications may be less familiar.

Psychiatrists treating patients with antiandrogen agents should be aware of the various adverse effects and educate patients accordingly. Medroxyprogesterone acetate, for example, commonly causes weight gain and headache and is also associated with the development of gallstones, thromboembolism, hot flashes, insomnia, and other distressing symptoms.

 GnRH analogs tend to be better tolerated than the synthetic steroids, but can cause hot flashes, headache, and nausea.

Another relevant issue in providing informed consent to a patient with a paraphilia or paraphilic disorder is mandated reporting. Clinicians should be aware of what specific behaviors or crimes require reporting in their jurisdiction, as they can vary state by state.

 For example, some states mandate reporting of the use of child pornography, whereas others do not. The limits of confidentiality should be fully discussed with patients prior to initiation of treatment.

Paraphilic disorders are rarely encountered in general psychiatric practice and pose numerous challenges for the treating clinician. Patients may be hesitant to seek or engage in treatment for atypical sexual interests; there is limited evidence by which to guide treatment decisions and medication selection; and the use of hormone-altering agents can have severe adverse effects that require patient education and careful informed consent procedures prior to implementation.

For difficult or high-risk cases, consultation with or referral to a sexual disorders specialist is essential. Despite these concerns, both patients and society at large can benefit from the effective management of paraphilic disorders. Treatment can curb patients’ unwanted, distressing sexual urges and fantasies and reduce the risk of harmful sexual behavior. Psychiatrists should therefore be aware of this class of disorders, feel comfortable conducting a complete sexual behaviors history, and be able to discuss treatment options, even if the patient ultimately receives care elsewhere.

Dr Holoyda is Forensic Psychiatrist and Chair, Sexual Offenders Committee, American Academy of Psychiatry and the Law, Sacramento, CA. He reports no conflicts of interest concerning the subject matter of this article.

1. American Psychiatric Association. Paraphilic Disorders Fact Sheet. 

https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM-5-Paraphilic-Disorders.pdf

2. Holoyda B, Kellaher D. The biological treatment of paraphilic disorders: an updated review. 

3. Abel G, Becker JV, Cunningham-Rathner J, et al. Multiple paraphilic diagnoses among sex offenders. 

4. Holoyda B, Sorrentino R, Friedman SH, Allgire J.
	Bestiality: an introduction for legal and mental health professionals. 

5. Holoyda B, Newman W. Recidivism risk assessment for adult sexual offenders. 

6. Dennis JA, Khan O, Ferriter M, et al. Psychological interventions for adults who have sexually offended or are at risk of offending. 

7. Mews A, DiBella L, Purver M. Impact evaluation of the prison-based Core Sex Offender Treatment Program. 

8. Khan O, Ferriter M, Huband N, et al. Pharmacological interventions for those who have sexually offended or are at risk of offending. 

9. Thibaut F, De La Barra F, Gordon H, et al. The World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the biological treatment of paraphilias. 

10. Berlin FS. Evaluating and reducing risk in online child pornography cases. 

From diagnosis to treatment, paraphilias and paraphilic disorders present unique challenges for the general psychiatrist.

Paraphilias: From Diagnosis to Treatment

Over the past two decades, the internet has allowed instant access to a wide variety of content, including sexual content that portrays a variety of sexual activities such as masturbation, oral sex, vaginal and anal intercourse, and group sex. During the normal sexual developmental phase (usually between the ages of 9 and 16 years), one of the most common sexual activities is consumption of pornography, either intentional or accidental exposure. In the United Kingdom, 53% of adolescents aged 11 to 16 years have seen online pornography at least once, and the vast majority have viewed pornography before the age of 14.

 In the United States, 20% to 30% of children aged 10 to 12 years have reported some exposure to pornography.

In most cases, consumption of pornography does not promote the development of mental health disorders and reflects a normal exploration of sexuality.

 However, in 10% to 18% of all adolescents, consumption of pornography reflects compulsive sexual behavior. The disorder is characterized by extensive pornography use and masturbation, use of paid sexual services, risky sexual behaviors, and an intense preoccupation with sex. These behaviors often lead to impaired social or occupational functioning, distress, and negative affect.

How can we identify compulsive sexual behavior among adolescents? And, what are the best practices to treat compulsive sexual behavior?

Human beings are sexual and beginning in childhood are capable of sexual responses.

 Many youngsters report experiencing sexual interest, arousal, and desire before puberty around the age of 10 years, when adrenal glands mature. Adolescence marks the onset of considerable changes in sexual and reproductive maturity that coincide with significant changes in cognitive, emotional, and social functioning.

The progression of sexual events among adolescents follows a fairly consistent sequence: kissing and holding hands, breast and chest fondling, manual genital contact, touching under clothes or without clothes, touching genitals directly, oral sex, and penile-vaginal intercourse. Sometimes these are followed by less common variations, such as anal sex. Although most adolescents show a normal sexual development, some develop compulsive sexual behavior.

ICD-11 includes compulsive sexual behavior as a disorder. This impulse control disorder is characterized by a repetitive and intense preoccupation with sexual fantasies, urges, and behaviors that leads to clinically significant distress or impairment in social and occupational functioning and to other adverse consequences.

 Moreover, it compulsive sexual behavior often promotes sexual objectification of women and risky sexual behavior.

A recent study showed that consumption of pornography as part of compulsive sexual behavior predicted objectification of women over time by sexualizing women’s buttocks, breasts, belly, and body size.

 They also fond objectification of women affected adolescents’ courtship strategies (eg, girls say “no” but really mean “yes”).

 that comprised 967 adolescents aged 13 to 14 years indicate that exposure to pornography was linked with more permissive personal sexual norms (eg, sex before marriage is OK if you are in love), greater incidence of sexual harassment (eg, grabbed or pulled at a schoolmate’s clothing in a sexual way), and higher probability of oral sex and/or sexual intercourse two years later.

A series of studies explored the facets of compulsive sexual behavior among adults and adolescents.8 Four facets of compulsive sexual behavior were identified that are in keeping with the definition of compulsive sexual behavior disorder and that manifest among adults and adolescents.

1) Unwanted consequences because of sexual fantasies.

 Sexual fantasies, urges, and behaviors promote self-harm as well as harm to close others such as family members, colleagues, and peers.

 Constant uncontrolled engagement with sexual fantasies, urges, and behaviors with numerous unsuccessful efforts to significantly reduce repetitive sexual behavior.

 Negative feelings and distress accompanied by guilt and shame because of sexual fantasies, urges, and behaviors.

 Escape to sexual fantasies, pornography, and sexual behaviors because of pain, stress, and distress.

 identified two aspects of compulsive sexual behavior: individual-based and partner-based. Individual-based compulsive sexual behavior refers to inner conflicts of individuals who constantly engage in sexual fantasies, compulsive sexual thoughts, and masturbation. Partner-based compulsive sexual behavior includes interpersonal sexual conquests and repeated infidelity.

Here lies one of the key differences between adults and adolescents in the manifestation of compulsive sexual behavior. Whereas adults often exhibit both individual-based and partner-based compulsive sexual behavior, individual-based compulsive sexual behavior is much more prevalent than partner-based among adolescents because most of the experiences during adolescence do not include physical intimacy.

The range of human sexual activity is quite variable and it is difficult to differentiate normal from abnormal sexual behavior in form and frequency. Compulsive sexual behavior is not so much mere form or frequency of sexual behavior; rather, it is a pattern of sexual behavior that is initially pleasurable but becomes unfulfilling, self-destructive, and one that the individual is unable to stop. Compulsive sexual behavior refers to a loss of control over one’s sexual thoughts and behaviors that causes negative consequences in one’s life.

The ability to differentiate normal from abnormal sexual behavior among adolescents is even more challenging. For example, Adelson and colleagues argued that “in defining hypersexuality [another term for compulsive sexual behavior], it is crucial to acknowledge the challenges to establishing norms of child and adolescent sexual development and the complexity of variables that influence it.”

One of the most reliable ways to identify compulsive sexual behavior among adolescents is the self-report Individual-Based Compulsive Sexual Behavior (I-CSB) Scale.

 The I-CSB comprises 24 items that quantify the aforementioned four facets of compulsive sexual behavior.

 “I feel that my sexual fantasies hurt people around me.”

Adolescents explore their sexuality. In most cases, this exploration is normative. At times, however, compulsive sexual behavior is developed and maintained.

Sexual & Sexuality

Sex, Drugs, and Psychosis: Reviewing Psychiatric Medications’ Taboo Side Effect

Mini Quiz: Treatment for Pedophilia?

Risky Business: The Higher Risk of Nonsuicidal Self Injury in Bisexual Individuals

Turn Up the Spice: Natural Aphrodisiacs

7 Clinical Reports About Sexual Disorders

Paraphilias: From Diagnosis to Treatment

Normal Versus Abnormal Sexual Behavior in Adolescents

Special Issues in Treating Adolescents With Gender Dysphoria

Sleep Problems Can Guide Antidepressant Selection

Special Issues in LGBTQ Geriatric Psychiatry