From diagnosis to treatment, paraphilias and paraphilic disorders present unique challenges for the general psychiatrist.
Significance for Practicing Psychiatrists
Table 1. DSM-5 specified paraphilic disorders
Table 2. Strategies for obtaining a complete sexual behavior history
Table 3. Medication treatments for paraphilic disorders
Table 4. Brief overview of WFSBP paraphilia/paraphilic disorder treatment algorithm
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.”1 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. Table 1 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.2 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.”3
Furthermore, an incomplete understanding of the breadth of a patient’s atypical sexual interests precludes effective treatment planning. Table 2 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.4
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.5 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.6 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.7
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. Table 3 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.8 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.
Table 4 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.2 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.10 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. Accessed November 4, 2019.
2. Holoyda B, Kellaher D. The biological treatment of paraphilic disorders: an updated review. Curr Psychiatry Rep. 2016;18:19.
3. Abel G, Becker JV, Cunningham-Rathner J, et al. Multiple paraphilic diagnoses among sex offenders. Bull Am Acad Psychiatry Law. 1988 16:153-168.
4. Holoyda B, Sorrentino R, Friedman SH, Allgire J.
Bestiality: an introduction for legal and mental health professionals. Behav Sci Law. 2018;36:687-697.
5. Holoyda B, Newman W. Recidivism risk assessment for adult sexual offenders. Curr Psychiatry Rep. 2016;18:17.
6. Dennis JA, Khan O, Ferriter M, et al. Psychological interventions for adults who have sexually offended or are at risk of offending. Cochrane Database Sys Rev. 2012;12:1-96.
7. Mews A, DiBella L, Purver M. Impact evaluation of the prison-based Core Sex Offender Treatment Program. Ministry of Justice Analytic Series. London: Crown; 2017.
8. Khan O, Ferriter M, Huband N, et al. Pharmacological interventions for those who have sexually offended or are at risk of offending. Cochrane Database Sys Rev. 2015;2:1-74.
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. World J Biol Psychiatry. 2010;11:604-655.
10. Berlin FS. Evaluating and reducing risk in online child pornography cases. J Am Acad Psychiatry Law. 2019;47:165-170.