Paraphilia

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Overview

Paraphilias are characterized by severe deviant sexual desire resulting in actions that may cause significant impairment in functioning as well as distress (for oneself and/or others). Paraphilic behavior may occur intermittently. Some individuals have this condition consistently for their entire life. To begin with, paraphilia occurs in the form of fantasy and at a later age, the paraphilic behavior manifests. Mostly the individuals with this condition do not seek treatment themselves due to the stigma related to the condition and the pleasure they obtain from it. Paraphilias are not illegal but the resulting behaviors are. Timely treatment is important to prevent sexual offenses like pedophilia or serial rapes. Patients may have more than one type of paraphilia and therefore, it is essential to evaluate them thoroughly to facilitate optimum management.

Historical Perspective

  • The term Paraphilia is Greek in origin and is derived from the words- Para(deviation) and philia(attraction).[1]
  • From biblical times, human societies all across the world, have placed restrictions over many types of sexual behaviors. The level of acceptability is based on cultural variations across the globe.
  • There is controversy in what should be called sexual deviation, mainly based on various factors like the degree of consent, age of the involved individuals, degree of distress caused, location of sexual behavior, degree of unacceptable by others, etc. [2]
  • Marquis de Sade (1740-1814) gave the term sadism. He was placed in a lunatic asylum multiple times and ultimately, he died there. His mental instability, is considered to heve resulted in his pattern of sexual behavior . [2]
  • The term masochism comes from Baron Leopold von Sacher Masoch (1835-1895), who was of European origin.[2]
  • At the end of the nineteenth century, sexual deviance was started to be considered a medical condition, with the publication of Psychopathia Sexualis. It was written by a German psychiatrist, Krafft-Ebing and he elaborated the sexual murders. [2][3]

Classification

  • Earlier the non-reproductive sexual behaviors were considered pathological and criminalized. However, over years the boundaries of pathology has been defined to the absence of sexual consent. [4]
  • The inclusion of pathological classification of paraphilias in the DSM and ICD has been criticized for a long time. It is based on the thin line of difference between something that is a normal variation or just unusual, and something that is pathological.
  • According to DSM-III, a patient may have more than one paraphilias but the extent of the multiplicity was not described until later editions.[5]
  • Till DSM-IV-TR, the diagnostic category of paraphilia was scrutinized for logic, clarity, and consistency. It was criticized for the fulfillment of a clear-cut mental illness.[6]
  • DSM-IV-TR had included paraphilias in the chapter ‘Sexual and Gender Identity Disorders’.[3]
  • There were proposals to remove paraphilias as a diagnostic category from DSM-5. Some considered the concept of paraphilic disorder as more ideological instead of scientific. [7][8]
  • Despite the on-going controversies, in DSM-5, the paraphilias have been assigned a separate chapter and are termed Paraphilic disorders. [9]
  • According to DSM-5, a paraphilia does not require a psychiatric intervention. For diagnosing paraphilic disorder, the paraphilia should cause harm to others or severe distress to oneself. [3]
  • It has been found that DSM-5 diagnostic criteria for paraphilias can increase the false-positive diagnoses by making the diagnosis without assessing the underlying motivation (may not necessarily be due to paraphilic sexual arousal pattern). As a result, attaining this diagnosis can produce many legal consequences. [10]
  • ICD-10 does not comprise a clear-cut definition of paraphilia. It refers to paraphilia as disorders of sexual preference. [11][12]

Pathophysiology

Mononamine Hypothesis

  • Norepinephrine, serotonin, and dopamine are the monoamines involved in the physiology of sexual behavior.[13]
  • Side effects of certain medications like antidepressants, and neuroleptics show that the alteration of monoamine levels can adversely affect sexuality.[13]
  • These neurotransmitters also modulate the impulsivity, anxiety, depression,and antisocial behavior. Disturbance of these neurotransmitters may cause these conditions in paraphilia patients. [13]
  • The medications that act by increasing the serotonergic function have been found to suppress the paraphilic behavior. [14]

Role of Testosterone

The antisocial traits, and sexual behavior have been noticed to be affected by sex-steroid associated genetic influence. This is evident by the clear relationship between testosterone and paraphilia as well as the positive response seen in thses patients with the antiandrogen therapy.[15]

Differential Diagnosis

It is important to differentiate paraphilias from other disorders like-[16][3]

  • Impulse disorder not otherwise specified (NOS)
  • Bipolar affective disorder
  • Cyclothymic disorder
  • Substance-induced anxiety disorder
  • Substance intoxication (like cocaine, or alcohol)
  • Dissociative disorder
  • Delusional disorder (erotomania)
  • Gender identity disorder
  • Obsessive-compulsive disorder
  • Cognitive disorders like dementia
  • Delirium
  • Deep cerebral stimulation in Parkinson’s disease
  • Neurological disorders

Epidemiology and Demographics

  • The actual prevalence of Paraphilic disorders is difficult to estimate.[17]
  • Only few patients seek treatment and most of the data is obtained from the paraphilic cases caughtup in the legal system.[18][19]

Age

  • Although discrepancies in studies exist, on an average no specific age group has been predisposed to develop Paraphilia.
  • Mostly paraphilias begin in childhood and is manifested in adolescence or later. [20]

Gender

  • The paraphilic behavior is seen mostly in men. However, there are studies which show no prominent gender-differences.[12][17][21]

Race

  • Limited studies have been done regarding the racial predilection.
  • Most of the studies present mixed results and it can be concluded that there is no single race predisposed to develop paraphilia.[22]

Risk Factors

  • Noxious child-rearing experiences, non-sexual and sexual both[20]
  • Childhood emotional abuse[23]
  • Childhood sexual abuse[23]

Natural History, Complications, and Prognosis

  • Patients with paraphilias have high chances of relapse.[1]
  • After 15 years, pedophiles attracted to boys are likely to commit the crime again (35%) as compared to those attracted to girls (16%).[19]
  • Good prognostic factors are-[1]
    • Early treatment
    • Individuals with good ego strength and high motivation for treatment
    • Patients with normal adult sexual experiences
  • Poor Prognostic factors are-[1]
    • Coexisting mental disorders
    • Early onset of paraphilic behaviors
    • Lack of remorse for their behaviors
    • Substance misuse
    • Pedophilia with a sexually interested in boys
  • Risk of recurrence is based on-[19]
    • Static risk factors (history of sexual abuse)-Does not change during treatment
    • Dynamic risk factors (impulsivity, hypersexuality, or personality disorders)-Can be addressed during psychotherapy

Comorbidities

Various comorbid conditions exist with paraphilias like-[12][24][1]

  • Depression
  • Generalized Anxiety disorder
  • Substance abuse
  • Erotomania
  • Suicidality
  • Gender Dysphoria
  • Autism Spectrum Disorder (ASD)
  • Mental Retardation
  • Antisocial personality Disorder
  • Personality change due to General Medical Condition

Diagnosis

DSM-5 Diagnostic Criteria

  • Following conditions have been described under the chapter of Paraphilia:
  1. Exhibitionism
  2. Fetishism
  3. Frotteurism
  4. Paedophilia
  5. Sexual masochism
  6. Sexual sadism
  7. Voyeurism
  8. Transvestic fetishism
  9. Paraphilia not otherwise specified

=Voyeuristic Disorder

Treatment

  • A treatment plan comprising of psychotherapy, and/or pharmacotherapy is usually needed to suppress the paraphiliac fantasies and behaviors.
  • The treatment depends on the severity of paraphiliac sexual fantasies as well as the risk of sexual violence. [25]
  • Very severe condition may lead to sexual offenses, like rape and it is necessary to manage such patients aggressively with hormonal intervention.[25]

Pharmacotherapy

  • Three main classes of medications used in paraphilias are antidepressants, steroidal anti-androgens, and gonadotrophin-releasing hormone (GnRH) analogs.[19]
  • The comorbidities should be treated.
  • Treatment with antiandrogens may increase psychotic symptoms and depression risk.[3]

Antidepressants

  • These are used in paraphilias because of the following- [19]
  1. Monoamine hypothesis
  2. Comorbidities
  3. Similarities with obsessive-compulsive spectrum disorders
  • Antidepressants commonly used are-
    • Selective Serotonin Reuptake Inhibitors(SSRI)
    • Tricyclic Antidepressants(TCA)

Hormones

  • Estrogen
  • Steroid antiandrogens
    • Medroxyprogesterone
    • Cyproterone
    • Gonadotrophin Releasing Hormone Analogue (GnRH Analogue)
  1. ↑ 1.0 1.1 1.2 1.3 1.4 Seligman, Linda; Hardenburg, Stephanie A. (2000). "Assessment and Treatment of Paraphilias". Journal of Counseling & Development. 78 (1): 107–113. doi:10.1002/j.1556-6676.2000.tb02567.x. ISSN 0748-9633.
  2. ↑ 2.0 2.1 2.2 2.3 Gordon, Harvey (2008). "The treatment of paraphilias: An historical perspective". Criminal Behaviour and Mental Health. 18 (2): 79–87. doi:10.1002/cbm.687. ISSN 0957-9664.
  3. ↑ 3.0 3.1 3.2 3.3 3.4 Garcia, Frederico D.; Thibaut, Florence (2011). "Current Concepts in the Pharmacotherapy of Paraphilias". Drugs. 71 (6): 771–790. doi:10.2165/11585490-000000000-00000. ISSN 0012-6667.
  4. ↑ Giami, Alain (2015). "Between DSM and ICD: Paraphilias and the Transformation of Sexual Norms". Archives of Sexual Behavior. 44 (5): 1127–1138. doi:10.1007/s10508-015-0549-6. ISSN 0004-0002.
  5. ↑ Bradford, John M.W.; Boulet, J.; Pawlak, A. (2017). "The Paraphilias: A Multiplicity of Deviant Behaviours*". The Canadian Journal of Psychiatry. 37 (2): 104–108. doi:10.1177/070674379203700206. ISSN 0706-7437.
  6. ↑ Moser, Charles; Kleinplatz, Peggy J. (2006). "DSM-IV-TRand the Paraphilias". Journal of Psychology & Human Sexuality. 17 (3–4): 91–109. doi:10.1300/J056v17n03_05. ISSN 0890-7064.
  7. ↑ Downing, Lisa (2015). "Heteronormativity and Repronormativity in Sexological "Perversion Theory" and the DSM-5's "Paraphilic Disorder" Diagnoses". Archives of Sexual Behavior. 44 (5): 1139–1145. doi:10.1007/s10508-015-0536-y. ISSN 0004-0002.
  8. ↑ Spitzer, Robert L. (2006). "Sexual and Gender Identity Disorders". Journal of Psychology & Human Sexuality. 17 (3–4): 111–116. doi:10.1300/J056v17n03_06. ISSN 0890-7064.
  9. ↑ Krueger RB, Kaplan MS (2012). "Paraphilic diagnoses in DSM-5". Isr J Psychiatry Relat Sci. 49 (4): 248–54. PMID 23585461.
  10. ↑ First MB (2014). "DSM-5 and paraphilic disorders". J Am Acad Psychiatry Law. 42 (2): 191–201. PMID 24986346.
  11. ↑ McManus, Michelle A.; Hargreaves, Paul; Rainbow, Lee; Alison, Laurence J. (2013). "Paraphilias: definition, diagnosis and treatment". F1000Prime Reports. 5. doi:10.12703/P5-36. ISSN 2051-7599.
  12. ↑ 12.0 12.1 12.2 Abdullahi, Halilu; Jafojo, Racheal Olayemi; Udofia, Owoidoho (2015). "Paraphilia Among Undergraduates in a Nigerian University". Sexual Addiction & Compulsivity. 22 (3): 249–257. doi:10.1080/10720162.2015.1057662. ISSN 1072-0162.
  13. ↑ 13.0 13.1 13.2 Kafka, Martin P. (1997). Archives of Sexual Behavior. 26 (4): 343–358. doi:10.1023/A:1024535201089. ISSN 0004-0002. Missing or empty |title= (help)
  14. ↑ Kafka, Martin P. (2006). "The Monoamine Hypothesis for the Pathophysiology of Paraphilic Disorders: An Update". Annals of the New York Academy of Sciences. 989 (1): 86–94. doi:10.1111/j.1749-6632.2003.tb07295.x. ISSN 0077-8923.
  15. ↑ Jordan, Kirsten; Fromberger, Peter; Stolpmann, Georg; Müller, Jürgen Leo (2011). "The Role of Testosterone in Sexuality and Paraphilia—A Neurobiological Approach. Part II: Testosterone and Paraphilia". The Journal of Sexual Medicine. 8 (11): 3008–3029. doi:10.1111/j.1743-6109.2011.02393.x. ISSN 1743-6095.
  16. ↑ Schneider, Jennifer P.; Irons, Richard (1996). "Differential diagnosis of addictive sexual disorders using the dsm-iv". Sexual Addiction & Compulsivity. 3 (1): 7–21. doi:10.1080/10720169608400096. ISSN 1072-0162.
  17. ↑ 17.0 17.1 Joyal, Christian C.; Carpentier, Julie (2016). "The Prevalence of Paraphilic Interests and Behaviors in the General Population: A Provincial Survey". The Journal of Sex Research. 54 (2): 161–171. doi:10.1080/00224499.2016.1139034. ISSN 0022-4499.
  18. ↑ Hall, Ryan C.W.; Hall, Richard C.W. (2007). "A Profile of Pedophilia: Definition, Characteristics of Offenders, Recidivism, Treatment Outcomes, and Forensic Issues". Mayo Clinic Proceedings. 82 (4): 457–471. doi:10.4065/82.4.457. ISSN 0025-6196.
  19. ↑ 19.0 19.1 19.2 19.3 19.4 Abel, Gene G.; Osborn, Candice (1992). "The Paraphilias: The Extent and Nature of Sexually Deviant and Criminal Behavior". Psychiatric Clinics of North America. 15 (3): 675–687. doi:10.1016/S0193-953X(18)30231-4. ISSN 0193-953X.
  20. ↑ 20.0 20.1 Money, John; Pranzarone, Galdino F. (1993). "Development of Paraphilia in Childhood and Adolescence". Child and Adolescent Psychiatric Clinics of North America. 2 (3): 463–475. doi:10.1016/S1056-4993(18)30552-2. ISSN 1056-4993.
  21. ↑ Dawson, Samantha J.; Bannerman, Brittany A.; Lalumière, Martin L. (2014). "Paraphilic Interests". Sexual Abuse: A Journal of Research and Treatment. 28 (1): 20–45. doi:10.1177/1079063214525645. ISSN 1079-0632.
  22. ↑ Lee, Seung C.; Hanson, R. Karl; Calkins, Cynthia; Jeglic, Elizabeth (2019). "Paraphilia and Antisociality: Motivations for Sexual Offending May Differ for American Whites and Blacks". Sexual Abuse. 32 (3): 335–365. doi:10.1177/1079063219828779. ISSN 1079-0632.
  23. ↑ 23.0 23.1 Lee, Joseph K.P.; Jackson, Henry J.; Pattison, Pip; Ward, Tony (2002). "Developmental risk factors for sexual offending". Child Abuse & Neglect. 26 (1): 73–92. doi:10.1016/S0145-2134(01)00304-0. ISSN 0145-2134.
  24. ↑ Fisher, Alessandra D.; Castellini, Giovanni; Casale, Helen; Fanni, Egidia; Bandini, Elisa; Campone, Beatrice; Ferruccio, Naika; Maseroli, Elisa; Boddi, Valentina; Dèttore, Davide; Pizzocaro, Alessandro; Balercia, Giancarlo; Oppo, Alessandro; Ricca, Valdo; Maggi, Mario (2015). "Hypersexuality, Paraphilic Behaviors, and Gender Dysphoria in Individuals with Klinefelter's Syndrome". The Journal of Sexual Medicine. 12 (12): 2413–2424. doi:10.1111/jsm.13048. ISSN 1743-6095.
  25. ↑ 25.0 25.1 Thibaut, Florence (2015). "Paraphilias": 1–5. doi:10.1002/9781118625392.wbecp242.
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