AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Paraphilia is a rare disorder, and the best criteria for diagnosis come from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR)¹ or the International Statistical Classification of Diseases, 10th Revision (ICD-10)². The disorder is characterized by a 6-month period of recurrent, intense, sexually arousing fantasies or sexual urges involving a specific act, depending on the paraphilia.

Paraphilia is a means for some people to release sexual energy or frustration. The act commonly is followed by arousal and orgasm, usually achieved by masturbation and fantasy. These disorders are not well recognized and often are difficult to treat for several reasons. Often, people who have these disorders conceal them, experience guilt and shame, have financial or legal problems, and can (at times) be uncooperative with medical professionals.

Some psychiatrists discuss whether paraphilias are a part of the impulse control disorders or if they fall within the spectrum of obsessive-compulsive disorders. The more common paraphilias include voyeurism and frotteurism, and the most rare paraphilia is zoophilia. In this age of computer technology, individuals can easily access information about paraphilias from any computer, thus fueling a disorder that already is difficult to control.

Pathophysiology

Many theories exist regarding the etiology of paraphilias, including psychoanalytical, biological, and sociobiological theories; however, none are conclusive. This subject requires additional research.

Psychoanalytical Theory

1. Location of a potential partner - The initial phase of courtship 
2. Pretactile interaction - Talking or flirting with a potential partner 
3. Tactile interaction - Usually consists of touching, hugging, hand holding, etc (This could also be considered foreplay.) 
4. Effecting genital union - More commonly known as sexual intercourse 

• Voyeurism: This is the distorted view of the initial courtship phase. Normally the initial courtship phase is known as locating a potential partner. Psychoanalysts postulate that voyeurism may be attributed to a child witnessing episodes of his or her parents engaged in sexual intercourse. Individuals with maladaptive social and sexual skills find voyeurism as an outlet for sexual pleasure void of the threat of sexual interaction. The risk or danger of discovery may likely give the voyeur a false sense of masculinity, this behavior tends to be similar for the exhibitionist as well. 
• Exhibitionism: Psychoanalysts consider exhibitionism a distortion of the pretactile interaction of the courtship phase. Psychoanalytical theory is based on the theory that gender identity for little boys requires psychological separation from the mother, so that he will not identify with her as a member of the same sex as do little girls. Exhibitionists regard their mothers as rejecting them on the basis of their different genitalia. The act of exhibitionism forces women to accept them by forcing them to look at their genitals. The act of self-exposure is also a way for the exhibitionist to compensate for his introversion and lack of assertiveness. The act of exposing oneself may give the exhibitionist a false sense of power, and the danger of discovery may further reinforce this feeling. In general, psychoanalysts theorize that the act of an exhibitionist displaying his penis is a way of proving his manhood to the world, but more importantly to an adult woman. Narcissism, the extreme form of self-admiration, is also believed to contribute to exhibitionism. Many of these men are married and have regular sexual contact with their spouse. However, in the mind of the exhibitionist/narcissist, by receiving only his wife's admiration of his genitalia is not sufficient in feeding his endless secondary narcissistic supply. Therefore, this leads to his search for other unsuspecting victims to fulfill his insatiable need for admiration. The exhibitionist is sometimes compared to an actor on stage who desires an audience, but does not want to participate in the act.
• Toucherism and frotteurism: These are considered exaggerations of the tactile interaction of the courtship phase. These paraphilias provide a sexual outlet without the risk of rejection. Toucherism tends to occur in conjunction with other paraphilias.

Behavioral Theory

Sociobiological Theory

Frequency

United States

Paraphilias are considered rare, affecting only a small percentage of the US population. Researchers have a difficult time trying to determine a specific percentage of involved individuals because many of the acts are illegal and reporting methods (ie, self-reporting) typically are unreliable.

International

International percentages of patients with paraphilias are difficult to discern because these disorders are rare.

Mortality/Morbidity

Determining the morbidity or mortality of paraphilias depends on the act practiced, the comorbidity involved, the patient's cooperation with the therapist, and whether or not the legal system is involved. Paraphilias can be transient, as demonstrated by experimentation during the teenage years, or can remain a life-long problem involving legal, financial, interpersonal, occupational, academic, and other problems. Death may occur in some circumstances, through acts such as autoerotic asphyxiation.

Race

Patients typically are white.

Sex

Patients typically are men.

Age

Most patients are aged 15-25 years; this disorder rarely occurs in individuals older than 50 years. The information on paraphilia in older individuals is limited.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

DSM-IV-TR criteria include the following:

• Exhibitionism
• • Over a period of at least 6 months, patients have recurrent, intense, sexually arousing fantasies, sexual urges, or behaviors that involve exposing their genitals to unsuspecting strangers.
  • The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  • Exhibitionism typically involves men exposing themselves to women (not a DSM-IV-TR criterion).
• Fetishism
• • Over a period of at least 6 months, patients have recurrent, intense, sexually arousing fantasies, sexual urges, or behaviors involving nonliving objects.
  • The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  • Patients do not limit the fetish objects to articles of female clothing used in cross-dressing or to devices designated for the purpose of tactile genital stimulation.
  • Patients may have a particular pathological displacement of erotic interest and satisfaction for their entire lives (not a DSM-IV-TR criterion).
• Frotteurism
• • Over a period of at least 6 months, patients have recurrent, intense, sexually arousing fantasies, sexual urges, or behaviors involving rubbing against and touching a nonconsenting person.
  • The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  • Patients typically practice this behavior in crowded places (not a DSM-IV-TR criterion).
• Pedophilia
• • Over a period of at least 6 months, patients have recurrent, intense, sexually arousing fantasies, sexual urges, or behaviors involving sexual activity with a prepubescent child or children.
  • The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  • The patient must be aged 16 years or older and at least 5 years older than the child or children involved.
• Sexual masochism
• • Over a period of at least 6 months, patients have recurrent, intense, sexually arousing fantasies, sexual urges, or behaviors involving the act of being humiliated, beaten, bound, or otherwise made to suffer.
  • The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  • This variant is named for the activities of Leopold von Sacher-Masoch (not part of the DSM-IV-TR criterion). Sacher-Masoch was born in Lemberg, Austria in 1836. As an author he is most known for his book Venus in Furs. This writing is reportedly based on true events from his life.
  • • Sacher-Masoch's novel is said to be one long masochistic fantasy in which the principle male character desires and encourages his mistress to treat him as a slave. This story appears to parallel his relationship with his wife. He used to plead with her to treat him as a slave, and his outlandish requests would progressively become more demeaning to satisfy his sexual appetite. However, she was not interested in partaking in his deviant self-deprecating fantasies. Eventually they met other partners and parted ways.
    • Leopold von Sacher-Masoch was the eldest son of a couple in the town of Galacia, where his father was the Director of Police and his mother was a little Russian lady of noble birth. As an infant, Leopold was very frail and sickly, and not expected to survive. To increase the infant's chances of survival, his parents hired a robust Russian wet nurse who was able to nurse him back to health. Leopold later spoke of the strong bond between the 2 of them. The woman shared strange and melancholy legends about her people with the boy, and he formed a love of the Russians that remained constant throughout his life. He reportedly said that not only did he gain his health from her, but also his soul.
    • As a child, Leopold was fascinated by various representations of cruelty. He was especially drawn to pictures of executions, and some of his favorite reading materials pertained to legends of martyrs. At the onset of puberty, he had a recurring dream that he was under the power of a cruel and torturous woman. The term dream is used in this context as opposed to nightmare.
    • In the town of Galacia, where Leopold was born, women were said to either rule their husbands or vice versa. At the age of 10, the boy witnessed a sadistic scene that left a permanent impression. The scene involved a female relative from his father's side of the family. This woman was referred to as Countess X. Prior to Leopold witnessing the life-altering event, he was enamored by the Countess and was impressed by her beauty and costly furs. He used to help her with various duties, services, etc. On one occasion, as he was putting on her shoes, he bent down to kiss her feet and she smiled at him and then kicked him. Instead of being hurt, he experienced a perverse sensation of pleasure.
    • Sometime after this event, he witnessed the Countess and her lover caught in the act by her husband and 2 of his friends. The Count, who was obviously stunned, paused momentarily to plot his course of revenge.  In the meantime, the Countess beat all 3 men to a bloody pulp. Leopold had been hiding in the room throughout the encounter, and was discovered by the Countess after gasping in astonishment. Upon discovery, she beat him as well. He made his way out of the room, but was still right outside the door watching should anything else occur. Moments later, the boy witnessed the Count, back in the same room where he had been humiliated earlier, begging for her forgiveness. The Countess looked at her husband and with that same calculating smile, all too familiar to Leopold, gave him a big swift kick.
• Sexual sadists
• • Over a period of at least 6 months, patients have recurrent, intense, sexually arousing fantasies, sexual urges, or behaviors involving the acts in which psychological or physical suffering of the victim is sexually exciting to the patient.
  • The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  • This variant is named for the activities of the Marquis de Sade (not part of the DSM-IV-TR criterion).
  • • The Marquis de Sade was born in Paris, France on June 2, 1740 and died on December 2, 1814 in Charenton, France. His full name was Donatein Alphonse Francois comte de Sade. The term sadism is a derivative of his name. The Marquis was an aristocrat and an author of violent pornography. The French author's erotic books, mainly written while imprisoned, include Justine, Juliette, and 120 Days of Sodom. The Marquis de Sade regarded criminal/sexually deviant acts as being natural, which was apparent in both his writings and actions. Consequently, his novels were banned into the 20th century.
    • The Marquis de Sade's life consisted of numerous acts of cruelty, which were indicative of his total disregard for human life and the law. His acts of extremely violent physical and sexual abuse resulted in numerous imprisonments and consequent escapes. He was also declared insane and admitted to an insane asylum on 2 different occasions. The Marquis was imprisoned or committed to insane asylums for at least 32 years of his life.  Most victims of Marquis were young female prostitutes, as well as both male and female employees of his chateau.
    • Donatein's mother was a distant cousin to the Prince de Conde, a junior branch of the royal Bourbon family. She served as a lady in waiting to the Princess de Conde and was a governess to her son, the young Prince de Conde. An early account of Donatein's violent nature involved an altercation between he and his young cousin over a toy. When the young Prince tried to retrieve one of his favorite toys from the grasp of his 4-year-old cousin, Donatein pummeled his cousin with increasing blows of violence. Soon after this incident, the young Marquis was sent to live with his paternal grandmother in Avignon.
    • The troubled young boy spent his formative years in Avignon surrounded by female relatives who indulged his every need and enveloped him with sensual affection. Donatein's grandmother and aunts continually doted on the child and indulged every one of his selfish demands. There was no mention of discipline in the boy's upbringing. These actions were only detrimental to the child's development; consequently, his behavior became increasingly unruly. When the Comte de Sade (Donatein's father) received report of his son's unconventional upbringing, the young Marquis was sent to live with his father's brother. The Comte hoped that his brother, Abbe de Sade, would be able to provide a masculine presence and influence that was obviously lacking in Donatein's life.
    • Abbe de Sade was a noted author, clergyman, and scholar of his time. He was also very much like his sisters in the sense that he enjoyed the sensual side of life and indulged himself with many pleasures. He was referred to as "sybarite of Saumane" meaning one inordinately attached to pleasure and luxury. Once again the young boy was in an atmosphere that encouraged sexuality and sensual indulgence as an expectation rather that an exception to the rule. During Donatein's stay at his uncle's home, the abbe housed many female companions which included a local prostitute.
    • Throughout this period of time in Europe, men and women of the cloth, indulged themselves in various sexual escapades with little remorse. There was rumor of orgies taking place in abbeys and convents, where priests, nuns, prostitutes, and nobles all engaged in debaucherous behavior. Abbe de Sade had a library filled with a genre of literature, and some were pornographic in nature. Donatein was free to read all of the literature in the library at his leisure. After becoming abreast of the ever present debauchery in Donatein's life, his father moved him to Paris where he was enrolled in a Jesuit prep school for young men of nobility.
    • Donatein was quite young to have been uprooted so many times. He was 10 years old when he was enrolled at the prep school. Although the Jesuits had a remarkable reputation as educators, they were infamous for their practices involving sodomy and corporal punishment. The Jesuits would beat, whip, or flog the young boys in front of an assembled student body to humiliate them. The humility of the beatings, oddly enough, could also be sexually arousing. This practice came to be known as sado-masochistic behavior. As an adult, the Marquis de Sade was unable to be aroused by normal sex, so it appeared that his sexuality was arrested at the infantile anal stage.   
    • After 4 years with the Jesuits, Donatein was transferred to a military academy upon this father's request. In 1755, shortly following his arrival, Donatein served in the King's light cavalry regiment as a sub leutenant. He was only 15 years old at the time. The young Marquis served in the war and was considered a brave and decisive leader. Unsatisfied with Donatein's success in the cavalry, his father had him placed with a cavalry company commanded by one of the members of the royal family. Donatein's bravery, good looks, and social charm made him a very successful soldier. His superiors were quite impressed by the Marquis; therefore, he was promoted to captain at the young age of 18. Donatein seemed able to impress everyone but his own father. His father never praised his son for his many accomplishments, yet had no difficulty pointing out his shortcomings.
    • When the Marquis de Sade returned from the war in 1763, he had his sights set on a particular lady whom he wished to marry. However, his father was opposed to the union. Instead, he arranged for the Marquis to marry her elder sister, Renee-Pelagie de Montrieul. The couple had 3 children, 2 boys and a girl. 
    • The same year the couple was married, the Marquis de Sade frequently traveled away from home for "business" reasons. While away on his travels, he rented several different maisons around Paris where orgies were held. One particularly disturbing encounter took place between the Marquis and a young prostitute. After he was alone with her, he quizzed the young prostitute about her religious convictions regarding the Roman Catholic Church. When he discovered that she was a faithful Roman Catholic, he began degrading her with inconceivable vile insults. 
      
      To the young woman's horror, he proceeded to perform sexually explicit acts on her with the aid of religious objects that were extremely blasphemous and sacrilegious in nature. When the young prostitute refused his request to beat each other with a hot whip, he pleasured himself sexually with a pair of crucifixes. Then he held her at knife point, forcing her to repeat vulgarities in the most blasphemous manner. This resulted in the Marquis de Sade's first imprisonment; however, his lewd and debaucherous behavior would result in numerous other imprisonments during his lifetime. He died in 1814 and was buried in Charenton. Later his skull was removed from the grave for phrenological examination.
    • The Marquis de Sade's life was not an ordinary one. From early on, he was rejected by his parents and moved from one place to another. The Marquis would never gain his father's approval, no matter how hard he worked. His life lacked structure, appropriate discipline, balance, and unconditional love/approval. The young Marquis was exposed to complete self-indulgent behavior lacking any form of discipline while raised by his grandmother, aunts, and uncle. Then he was exposed to extreme corporal punishment while attending prep school with the Jesuits. He was also exposed to deviant sexual behavior in both of these very different settings.  
    • In theory, one might postulate that exposure to these extreme polarities of behavior, especially during the very crucial formative years, might cause the underdeveloped psyche to integrate the 2. Therefore associating pleasure with pain, hence the deviant masochistic behavior.       
• Transvestic fetishism
• • Over a period of 6 months, heterosexual male patients have recurrent, intense, sexually arousing fantasies, sexual urges, or behaviors involving cross-dressing.
  • The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  • Typically, patients derive sexual gratification from wearing clothes usually worn by the opposite sex, and patients typically are heterosexual married males (not a DSM-IV-TR criterion).
• Voyeurism
• • Over a period of at least 6 months, patients have recurrent, intense, sexually arousing fantasies, sexual urges, or behaviors involving the act of observing an unsuspecting person who is naked, in the process of disrobing, or engaging in sexual activity.
  • The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  • Patients derive sexual gratification from seeing sex organs and sexual acts; scopophilia is a synonym for voyeurism (not a DSM-IV-TR criterion).
• Paraphilia not otherwise specified: This category is included so physicians can code paraphilias that do not meet the criteria for any of the other specific categories.
• • Scatologia involves making obscene phone calls.
  • Necrophilia involves an erotic attraction or sexual interest in corpses. This paraphilia is rare and seldom reported to the police. Patients typically work in mortuaries and funeral parlors. This also involves dangerous situations where the individual could actually acquire infections from the corpse.
  • Partialism is sexual interest exclusively focused on a particular body part.
  • Zoophilia involves sexual activity with animals (ie, both actual sexual contact and sexual fantasies, higher in psychiatric patients).
  • Coprophilia is sexual activity involving feces.
  • Klismaphilia is sexual activity involving enemas.
  • Urophilia is sexual activity involving urine.
  • Masturbation is sexual self-gratification.
• Other paraphilias
• • Autogynephilia describes a man's propensity to be sexually aroused by thoughts or images of himself as a woman (with female attributes).
  • Asphyxiophilia or hypoxyphilia is when a patient uses hypoxia to achieve sexual excitement; this can be complicated by autoerotic asphyxiation.
  • Video voyeurs derive sexual gratification from videos, usually of women doing natural acts or women involved in sexual activity.
  • Infantophilia is a new subcategory of pedophilia in which the victims are younger than 5 years.

Physical

Obtain a complete history and perform complete mental status, physical, and neurological examinations to assist with the evaluation and to rule out other disease processes. This particular patient population may be more difficult to interview because they may be more likely to have guilt associated with their disorder, therefore making them reluctant to openly share information with the interviewer. The interviewer must establish rapport with these patients and allow them to talk more freely about their disorder. By asking leading questions and then allowing the patient to reveal information on his or her own helps in the treatment and management of this disorder.

Causes

Rule out major medical or psychiatric illnesses. Look for both hard and soft neurological signs involving the striato-thalamo-cortical processing loop (theory). This theory states that a disruption of the striato-thalamo-cortical processing loop can cause abnormal filtering of information resulting in the brain's inability to block unimportant information, which is thought to cause a propensity to initiate or perpetuation paraphilias and other psychotic phenomena. It is important to point out that this is just a theory and much more research is needed to either confirm or disprove this concept as a cause of paraphilias.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Experimentation
Hormone dysregulation
Seizures
Chromosome abnormality
Social phobia
Conduct disorder
Multiple sclerosis
Conversion disorder

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Standard medical workup, including sequential multiple analysis (SMA), CBC count, rapid plasma reagent (RPR), and thyroid-stimulating hormone (TSH) or thyroid function test (TFT)
• HIV screen, if indicated
• Hepatitis panel, if indicated
• Unscheduled deoxyribonucleic acid synthesis (UDS), if indicated

Imaging Studies

• CT scan or MRI, if intracranial pathology is suspected or if the neurological examination findings are abnormal

Other Tests

• Penile strain gauge
• Abel assessment for interest in paraphilia
• Phallometric test

Procedures

• EEG, if indicated

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

• Inpatient treatment indications
• • Patients are suicidal, homicidal, or gravely disabled (Suicide risk is high if they feel exposed or confronted.)
  • Patients are dangerous to themselves, others, or cannot take care of themselves
• Psychotherapy
• • Cognitive-behavioral therapy: This type of therapy involves applying behavioral therapy techniques to modify the patient's sexual deviations by altering distorted thinking patterns and making patients cognizant of the irrational justifications that lead to their sexual variations. This therapy also incorporates relapse prevention techniques, helping the patient to control the undesirable behaviors by avoiding situations that may generate initial desires. Many times, therapists apply the technique of "covert sensitization," in which patients' harmful sexual variation is paired with an unpleasant stimulus, such as that of a person with alcoholism who is administered Antabuse, in order to deter them from repeating the act. This approach has been proven effective in cases of pedophilia and sadism.
  • Another technique employed by therapists is that of orgasmic reconditioning. In this approach, a patient is reconditioned to a more appropriate stimulus by masturbating to his or her typical, less socially acceptable stimulus. Then, just before orgasm, the patient is told to concentrate on a more acceptable fantasy. This is repeated at earlier times before orgasm until, soon, the patient begins his masturbation fantasies with an appropriate stimulus.
  • Social skills training: Because many believe that paraphilias develop in patients who lack the ability to develop relationships, many therapists and physicians use social skills training to treat patients with these types of disorders. They may work on such issues as developing intimacy, carrying on conversations with others, and assertive skills training. Many social skills training groups also teach basic sexual education, which is very helpful to this patient population.
  • Twelve-step programs: Many physicians and therapists refer patients with paraphilias to 12-step programs designed for sexual addicts. Similar to alcoholics anonymous, these programs are designed to give control to group members, who lead most of the sessions. The program incorporates cognitive restructuring with social support to increase awareness of the problem. The group also focuses on the sense of a "higher power" and each individual's reliance upon his or her spirituality.
  • Group therapy: This mode of therapy involves breaking through the denial so commonly found in people with paraphilias by surrounding them with other patients who share their illness. Once they begin to admit that they have a sexual divergence, the therapist begins to address individual issues such as past sexual abuse or other problems that may have led to the sexual disorder. When these issues have been identified, beginning Gestalt-type therapy (with the victim, if any) may be desirable to help patients get past the guilt and shame associated with their particular paraphilia. The goal of this type of therapy is to lead the patient to a "healthy remorse." These patients require lifetime therapy in order to reduce the likelihood of relapse.
  • Individual expressive-supportive psychotherapy: This type of therapy requires a psychologically minded patient willing to focus on the paraphilia. The therapist should not set high goals but needs to break through the denial. Countertransfence and avoidance of the patient can be a problem with this form of therapy. If the patients can break through the denial, then the patient can work on the unconscious meaning behind the paticular paraphila.
• Medications
• • Antidepressants
  • Long-acting gonadotropin-releasing hormones (GnRH, ie, medical castration)
  • Antiandrogens
  • Phenothiazine
  • Mood stabilizers
• Sex education and therapy
• Social skills and training

Surgical Care

Surgical castration

Consultations

• Neurologist, if neurological signs are present
• Attorney
• Pastor

Activity

Restrict activity if patients represent a danger to themselves, to others, or if they are gravely disabled.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

The goals of pharmacotherapy are to reduce morbidity and prevent complications.

Drug Category: Antidepressants

May be used to decrease aggression and treat underlying illness.

Drug Name	Lithium (Eskalith)
Description	Indicated for treating bipolar disorder. Influences reuptake of serotonin and/or norepinephrine at cell membrane.
Adult Dose	300 PO tid/qid
Pediatric Dose	<6 years: Not established 6-12 years: 15-60 mg/kg/d PO tid/qid; not to exceed usual adult dose >12 years: Administer as in adults
Contraindications	Documented hypersensitivity; severe cardiovascular disease
Interactions	Lithium increases toxicity of thiazide diuretics, haloperidol, phenothiazines, neuromuscular blockers, carbamazepine, fluoxetine, and ACE inhibitors
Pregnancy	D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions	Lithium toxicity (ie, diarrhea, vomiting, tremor, ataxia, drowsiness, muscle weakness); lithium toxicity is closely related to serum levels and can occur at therapeutic doses; serum lithium determinations are required to monitor therapy

Drug Category: Antiandrogens

Used to reduce androgen serum levels.

Drug Category: Phenothiazines

Are effective in treating emesis possibly due to their effects in the dopaminergic mesolimbic system.

Drug Category: Anxiolytics

These agents help induce impulse control.

Drug Category: Long-acting gonadotropin-releasing hormones

These agents are used to reduce release of gonadotropin hormones.

Drug Category: Mood stabilizer

These agents are used to treat bipolar disorders.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

Patients may require further inpatient care if they represent a danger to themselves, to others, or if they are gravely disabled.

Further Outpatient Care

For the best results, patients require medication management and psychotherapy.

In/Out Patient Meds

If the patient began medication therapy in the hospital, continue the same therapy and adjust as needed. If not, select medications and discuss the risks, benefits, adverse effects, and alternatives with the patient. Obtain informed consent before starting medication therapy.

Transfer

If patients are charged with a crime or have been arrested, they may be incarcerated.

Deterrence/Prevention

• Education
• Legal ramifications

Complications

• Adverse medication effects
• Noncompliance with medications and therapy
• Pedophilia on the Internet

Prognosis

• Patients with a good prognosis have the following characteristics:
• • Cooperative attitude
  • Normal sex life
  • Motivated outlook, with a desire to change
  • Voluntary approach to treatment
• Patients with a poor prognosis have the following characteristics:
• • Early onset of paraphilia
  • Legal charges pending
  • Unmotivated attitude
  • Uncooperative attitude
  • Paraphilia as the only sexual activity or outlet
  • Comorbidity
  • Lack of remorse over acts

Patient Education

• Sex education and social skills training
• Both the patient and the family should be educated regarding paraphilias. The family may need to be involved in a support group (eg, church). If the patient is on medication the family needs to be informed of potential problems such as side effects and drug interations. If the patient is married, marital counceling needs to be part of the treatment plan. The family also needs to be aware of local laws in regard to paraphilas. If the patient is on probation, the family needs to be aware of court dates, if appicable, probation, and if the patient will need to be listed on the sexual offenders listing the community.
• Community notification of a sex offender may be required for some patients with paraphilas. It is important to point out that many patients with paraphilias have no legal charges and even health care workers are not required to report all paraphilias while others require mandatory reporting such as pedophilia. Some patients may find this notification as a deterrent to the paraphila while others may not. Some experts suggest that, while required, it may hamper some patients who are tring to obtain help for there illness. This will continue to be a matter of community concern and debate for the unforseeable future. The patient should address these concerns with the treatment team.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Failure to be familiar with the laws regarding illegal acts
• Failure to maintain or break patient confidentiality (ie, reporting patients to the proper authorities)

Special Concerns

Physicians must be aware that not every therapist treats people with paraphilias.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association; 2000:566 - 576.
2. World Health Organization. The International Statistical Classification of Diseases and Health Related Problems, Tenth Revision. 2^nd ed. World Health Organization; 2004.
3. Abdo CH, Hounie A, de Tubino Scanavino M, Miguel EC. OCD and transvestism: is there a relationship?. Acta Psychiatr Scand. Jun 2001;103(6):471-3; discussion 473. [Medline].
4. Abouesh A, Clayton A. Compulsive voyeurism and exhibitionism: a clinical response to paroxetine. Arch Sex Behav. Feb 1999;28(1):23-30. [Medline].
5. Allgeier AR, Allgeier ER. Atypical sexual activity. In: Miller J, Brooks CL, Rachlin H, O'Dea M, Michaels T, Roll M. Sexual Interactions. 2^nd ed. Canada: D.C. Heath & Company; 1988:619-641/ 21.
6. Allnutt SH, Bradford JM, Greenberg DM, Curry S. Co-morbidity of alcoholism and the paraphilias. J Forensic Sci. Mar 1996;41(2):234-9. [Medline].
7. Alvarez WA, Freinhar JP. A prevalence study of bestiality (zoophilia) in psychiatric in-patients, medical in-patients, and psychiatric staff. Int J Psychosom. 1991;38(1-4):45-7. [Medline].
8. Balon R. Pharmacological treatment of paraphilias with a focus on antidepressants. J Sex Marital Ther. Oct-Dec 1998;24(4):241-54. [Medline].
9. Berger P, Berner W, Bolterauer J. Sadistic personality disorder in sex offenders: relationship to antisocial personality disorder and sexual sadism. J Personal Disord. Summer 1999;13(2):175-86. [Medline].
10. Berlin FS. Sex offender treatment and legislation. J Am Acad Psychiatry Law. 2003;31(4):510-3. [Medline].
11. Blanchard R. Nonmonotonic relation of autogynephilia and heterosexual attraction. J Abnorm Psychol. May 1992;101(2):271-6. [Medline].
12. Blanchard R. The she-male phenomenon and the concept of partial autogynephilia. J Sex Marital Ther. Spring 1993;19(1):69-76. [Medline].
13. Blanchard R, Barbaree HE. The strength of sexual arousal as a function of the age of the sex offender: comparisons among pedophiles, hebephiles, and teleiophiles. Sex Abuse. Oct 2005;17(4):441-56. [Medline].
14. Blanchard R, Klassen P, Dickey R, et al. Sensitivity and specificity of the phallometric test for pedophilia in nonadmitting sex offenders. Psychol Assess. Mar 2001;13(1):118-26. [Medline].
15. Bradford JM. The neurobiology, neuropharmacology, and pharmacological treatment of the paraphilias and compulsive sexual behaviour. Can J Psychiatry. Feb 2001;46(1):26-34. [Medline].
16. Briken P, Hill A, Berner W. Pharmacotherapy of paraphilias with long-acting agonists of luteinizing hormone-releasing hormone: a systematic review. J Clin Psychiatry. Aug 2003;64(8):890-7. [Medline].
17. Butterfield MI, Panzer PG, Forneris CA. Victimization of women and its impact on assessment and treatment in the psychiatric emergency setting. Psychiatr Clin North Am. Dec 1999;22(4):875-96. [Medline].
18. Chiang YL, Yeh SS, Hsiao CC, Ree SC. Treatment of a transvestic fetishist with cognitive-behavioral therapy and supportive psychotherapy: case report. Chang Keng I Hsueh Tsa Chih. Jun 1999;22(2):299-312. [Medline].
19. Deirmenjian JM. Pedophilia on the Internet. J Forensic Sci. Sep 2002;47(5):1090-2. [Medline].
20. Docter RF, Prince V. Transvestism: a survey of 1032 cross-dressers. Arch Sex Behav. Dec 1997;26(6):589-605. [Medline].
21. Dubasi PM, Fosseus CG. A case of necrophilia in Medunsa. Am J Forensic Med Pathol. Jun 1995;16(2):162-3. [Medline].
22. Fagan PJ, Wise TN, Schmidt CW Jr, Berlin FS. Pedophilia. JAMA. Nov 20 2002;288(19):2458-65. [Medline].
23. Fischer L, Smith G. Statistical adequacy of the Abel Assessment for Interest in Paraphilias. Sex Abuse. Jul 1999;11(3):195-205. [Medline].
24. Frohman EM, Frohman TC, Moreault AM. Acquired sexual paraphilia in patients with multiple sclerosis. Arch Neurol. Jun 2002;59(6):1006-10. [Medline].
25. Glickauf-Hughes C. Etiology of the masochistic and narcissistic personality. Am J Psychoanal. Jun 1997;57(2):141-8. [Medline].
26. Grant JE. Clinical characteristics and psychiatric comorbidity in males with exhibitionism. J Clin Psychiatry. Nov 2005;66(11):1367-71. [Medline].
27. Grasswick LJ, Bradford JM. Osteoporosis associated with the treatment of paraphilias: a clinical review of seven case reports. J Forensic Sci. Jul 2003;48(4):849-55. [Medline].
28. Greenberg DM, Bradford J, Curry S. Infantophilia--a new subcategory of pedophilia?: a preliminary study. Bull Am Acad Psychiatry Law. 1995;23(1):63-71. [Medline].
29. Greenberg DM, Bradford JM, Curry S, O'Rourke A. A comparison of treatment of paraphilias with three serotonin reuptake inhibitors: a retrospective study. Bull Am Acad Psychiatry Law. 1996;24(4):525-32. [Medline].
30. Hollander E, Rosen J. Impulsivity. J Psychopharmacol. 2000;14(2 Suppl 1):S39-44. [Medline].
31. Hoyer J, Kunst H, Schmidt A. Social phobia as a comorbid condition in sex offenders with paraphilia or impulse control disorder. J Nerv Ment Dis. Jul 2001;189(7):463-70. [Medline].
32. Hucker SJ, Stermac L. The evaluation and treatment of sexual violence, necrophilia, and asphyxiophilia. Psychiatr Clin North Am. Sep 1992;15(3):703-19. [Medline].
33. Hyde JS, DeLamater JD. Understanding Human Sexuality. 7^th ed. New York, NY: McGraw-Hill; 2000:439-41.
34. Jackowski C, Römhild W, Aebi B, Bernhard W, Krause D, Dirnhofer R. Autoerotic accident by inhalation of propane-butane gas mixture. Am J Forensic Med Pathol. Dec 2005;26(4):355-9. [Medline].
35. Kafka MP, Hennen J. A DSM-IV Axis I comorbidity study of males (n = 120) with paraphilias and paraphilia-related disorders. Sex Abuse. Oct 2002;14(4):349-66. [Medline].
36. Kaplan HI, Sadcock BJ. Kaplan and Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry. 8^th ed. Baltimore, Md: Williams & Wilkins; 1998:700-7.
37. Maxmen JS, Ward NG. Sexual and gender identity disorders. In: Essential Psychopathology and Its Treatment. 2^nd ed. New York, NY: W.W Norton & Company; 1995:324-328.
38. Nelson E, Brusman L, Holcomb J, et al. Divalproex sodium in sex offenders with bipolar disorders and comorbid paraphilias: an open retrospective study. J Affect Disord. May 2001;64(2-3):249-55. [Medline].
39. Orfanelli L, Borkowski WJ Jr. Conversion disorder in a pediatric transgender patient. J Neurosci Nurs. Apr 2006;38(2):114-6. [Medline].
40. Philpot CD. Paraphilia and aging. Clin Geriatr Med. Aug 2003;19(3):629-36, viii-ix. [Medline].
41. Rosler A, Witztum E. Pharmacotherapy of paraphilias in the next millennium. Behav Sci Law. 2000;18(1):43-56. [Medline].
42. Saleh F. A hypersexual paraphilic patient treated with leuprolide acetate: a single case report. J Sex Marital Ther. Oct-Dec 2005;31(5):433-44. [Medline].
43. Saleh FM, Niel T, Fishman MJ. Treatment of paraphilia in young adults with leuprolide acetate: a preliminary case report series. J Forensic Sci. Nov 2004;49(6):1343-8. [Medline].
44. Sauvageau A, Racette S. Autoerotic deaths in the literature from 1954 to 2004: a review. J Forensic Sci. Jan 2006;51(1):140-6. [Medline].
45. Schober JM, Kuhn PJ, Kovacs PG, Earle JH, Byrne PM, Fries RA. Leuprolide acetate suppresses pedophilic urges and arousability. Arch Sex Behav. Dec 2005;34(6):691-705. [Medline].
46. Shiah IS, Chao CY, Mao WC, Chuang YJ. Treatment of paraphilic sexual disorder: the use of topiramate in fetishism. Int Clin Psychopharmacol. Jul 2006;21(4):241-3. [Medline].
47. Shiwach RS, Prosser J. Treatment of an unusual case of masochism. J Sex Marital Ther. Oct-Dec 1998;24(4):303-7. [Medline].
48. Simon RI. Video voyeurs and the covert videotaping of unsuspecting victims: psychological and legal consequences. J Forensic Sci. Sep 1997;42(5):884-9. [Medline].
49. Singer PP, Jones GR. An unusual autoerotic fatality associated with chloroform inhalation. J Anal Toxicol. Apr 2006;30(3):216-8. [Medline].
50. Templeman TL, Stinnett RD. Patterns of sexual arousal and history in a "normal" sample of young men. Arch Sex Behav. Apr 1991;20(2):137-50. [Medline].
51. Tost H, Vollmert C, Brassen S, et al. Pedophilia: neuropsychological evidence encouraging a brain network perspective. Med Hypotheses. 2004;63(3):528-31. [Medline].
52. Travin S. Compulsive sexual behaviors. Psychiatr Clin North Am. Mar 1995;18(1):155-69. [Medline].
53. Vollenweider FX. Recent advances and concepts in the search for biological correlates of hallucinogen-induced altered states of consciosness. The Heffter Review of Psychedelic Res. 1998;1:21-32.
54. Waismann R, Fenwick PB, Wilson GD, et al. EEG responses to visual erotic stimuli in men with normal and paraphilic interests. Arch Sex Behav. Apr 2003;32(2):135-44. [Medline].
55. Wise TN, Goldberg RL. Escalation of a fetish: coprophagia in a nonpsychotic adult of normal intelligence. J Sex Marital Ther. Winter 1995;21(4):272-5. [Medline].

Article Last Updated: Feb 14, 2008