PARAPHILIC DISORDERS

PRESENTER : [Link] ,
JUNIOR RESIDENT
MODERATOR : DR. [Link] CHANDRA ,
ASSISTANT PROFESSOR
DEPARTMENT OF PSYCHIATRY ,
VBMC .
SCHEME OF PRESENTATION:

• Introduction • Individual disorders in detail

• Definition • Investigations
• History • Course and prognosis
• Nosology • Differential diagnosis
• Classification • Management
• Epidemiology • Ethical and legal considerations
• Etiology • References
INTRODUCTION:

• The term paraphilia is derived from the Greek words “para” meaning next to and
“philia” meaning love.

• The term paraphilia therefore refers to a love that is perverted or “alongside the
norm.”

• In addition to the presence of a deviant sexual interest, paraphilias are

characterized by the inability to resist an impulse for the sexual act .
DEFINITION:

• DSM-5 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 term paraphilic disorder, is used to refer to 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.
HISTORY:
• Richard von Krafft-Ebing, a German psychiatrist credited with formally introducing
the study of sexology as a psychiatric phenomenon, identified paraphilias first in
his book, Psychopathia Sexualis (Sexual Psychopathy) in 1886.

• The term paraphilia was coined by psychologists in the early 1900s to refer to the
sexual variations.

• Because of a lack of understanding, it included transvestism and other nonsexual

variations as well. Previously, these were called perversions.
HISTORY contd…

• Sigmund Freud held that human sexuality advanced through stages. He theorized
that individuals would progress toward “normal” heterosexuality unless
prevented. He saw all paraphilias as infantile, that is, not mature sexual behavior.

• Wilhelm Stekel’s Patterns of Psychosexual Infantilism came from this perspective.

Homosexuality, sadism, zoophilia, and many others were included in his
examples.
HISTORY contd…
• Freud’s notion of psychosexual infantilism was replaced with different views.
These views dealt individually with the major paraphilias, such as fetishism,
masochism, and transvestism.

• In 1987, the third revised edition of DSM (DSM-III-R) used infantilism to refer to
those who had a “desire to be treated as a helpless infant and clothed in diapers”
and categorized infantilism under sexual masochism.
NOSOLOGY:
• DSM originally classified sexual deviations with psychopathic personality
disturbances.
• DSM-II: sexual deviations were classified with the personality disorders.
• DSM-III changed the nomenclature of these behaviors from sexual deviation to
paraphilia. Paraphilias were classified as psychosexual disorders, which included
gender identity disorders, psychosexual dysfunctions, and egodystonic
homosexuality.
• DSM-IV-TR reclassified transvestism from a disorder of gender identity to a
paraphilia called transvestic fetishism.
• DSM-5 redefined paraphilias, made a distinction between paraphilias and
paraphilic disorders and added course specifiers.
CLASSIFICATION: DSM-5
• The paraphilic disorders are presented in DSM-5 according to the following
classification scheme:

• anomalous activity preferences which include voyeuristic disorder, exhibitionistic

disorder, and frotteuristic disorder

• algolagnic disorders which include sexual masochism disorder and sexual sadism
disorder

• anomalous target preferences which include pedophilic disorder, fetishistic

disorder, and transvestic disorder.
 CLASSIFICATION
ICD-10: F65 ICD-11 (BLOCK L1- 6D3)
DISORDERS OF SEXUAL PREFERENCE. PARAPHILIC DISORDERS .
• F65.0: Fetishism • 6D30: Exhibitionistic disorder
• F65.1: Fetishistic transvestism • 6D31: Voyeuristic disorder
• F65.2: Exhibitionism • 6D32: Pedophilic disorder
• F65.3: Voyeurism • 6D33: Coercive sexual sadism disorder
• F65.4: Paedophilia • 6D34: Frotteuristic disorder
• F65.5: Sadomasochism • 6D35: Other paraphilic disorder involving non-
consenting individuals
• F65.6: Multiple disorders of sexual preference
• 6D36: Paraphilic disorder involving solitary
• F65.8: Other disorders of sexual preference behaviour or consenting individuals
• F65.9: Disorder of sexual preference, • 6D3Z: Paraphilic disorders, unspecified
unspecified
DIFFERENCES :

DSM - 5 ICD - 10 ICD – 11

SEXUAL DISFUNCTIONS DISORDERS OF SEXUAL CONDITIONS RELATED TO SEXUAL

PREFERENCE HEALTH

OTHER SEXUAL DISORDERS OTHER SEXUAL DISORDERS (BlockL1-6D3) PARAPHILIC

DISORDERS IN CHAPTER 17.
EPIDEMIOLOGY:

➢Gender ratio:

• Paraphilias are predominantly male sexuality disorders. Except for sadism and
masochism, the paraphilias are almost never diagnosed in females.

➢Nonparaphilic Populations:

• 61.7% - initiating young girl into sexuality.

• 33% - raping adult women.

• 11.7% - masochistic fantasies

EPIDEMIOLOGY contd…
• 5.3% - having sex with an animal.
• 3.2% - initiating a young boy into sexuality.
• 42 % - voyeurism.
• 35% - frottage.
• 8% - obscene telephone calls.
• 5% - coercive sexual activity.
• 3% - sexual contact with girls under 12 yr of age
• 2% - exhibitionism
EPIDEMIOLOGY contd…

➢Crossing over:

• Individuals with paraphilias “crossover” from one paraphilia behaviour to

another.

• paraphiliacs tend to cross over between touching and non touching of their
victims, between family and non family members, between female and male
victims, and to victims of various ages.
ETIOLOGY:
• Etiology is unknown for paraphilic disorders.

1. BIOLOGICAL THEORY:
• Subtle defects of the right amygdala and closely related structures are
implicated in the pathogenesis of pedophilia and reflect developmental
disturbances or environmental insults at critical periods.

• Neurological hypothesis of paraphilia propose that sexual deviance is

associated with frontal and/or temporal lobe damage. This damage may
translate into an individual’s inability to control sexual impulse or directly
cause paraphilic behavior as a result tissue damage.
ETIOLOGY contd…
• A monoamine hypothesis for the pathophysiology of paraphilic disorders was first
articulated in 1997 by Kafka. This was based on-
• First, the monoamine neurotransmitters, dopamine, norepinephrine, and
serotonin serve a modulatory role in human and mammalian sexual
motivation, appetite, and consummatory behavior.
• Second, the sexual effects of pharmacological agents that affect monoamine
neurotransmitter can have both significant facilitative and inhibitory effects
on sexual behavior.
• Third, paraphilic disorders appear to have Axis I comorbid associations with
nonsexual psychopathologies that are associated with monoaminergic
dysregulation.
• Last, pharmacological agents that enhance central serotonergic function in
particular have been reported to ameliorate paraphilic sexual arousal and
behavior.
ETIOLOGY contd….
• Among the paraphilic patients with positive physical findings included-
• 74 % : abnormal hormone levels
• 27 % : hard or soft neurologic signs
• 24 % : chromosomal abnormalities
• 9 % : seizures
• 9 % : dyslexia
• 4 % : abnormal electroencephalography (EEG) studies
• 4 % : major mental disorders
• 4 % : intellectual disorder.
It is not clear whether these abnormalities are causally related or incidental to the
paraphilia.
ETIOLOGY contd…..
2. PSYCHOANALYTICAL THEORY:
• Psychoanalysts generally theorize that these conditions represent a regression to
or a fixation at an earlier level of psychosexual development, resulting in a
repetitive pattern of sexual behavior that is not mature in its application and
expression.

• Another psychoanalytic theory holds that these conditions are all expressions of
hostility in which sexual fantasies or unusual sexual acts become a means of
obtaining revenge for a childhood trauma. The persistent, repetitive nature of the
paraphilia is caused by an inability to erase the underlying trauma completely.
 ETIOLOGY contd…
3. BEHAVIOURIST THEORY:

• The onset of paraphilic acts can result from persons’ modeling their behavior on the
behavior of others carrying out paraphilic acts, mimicking sexual behavior depicted in
the media, or recalling emotionally laden events from the past, such as their
molestation.
• Learning theory indicates that because the fantasizing of paraphilic interests begins at
an early age and because children are likely to hide their fantasies from others (who
might discourage them), the use and misuse of paraphilic fantasies and urges continue
uninhibited until late in life.
• Persons begin to realize that such paraphilic interests and urges are inconsistent with
societal norms.
• By that time, however, the repetitive use of such fantasies has become ingrained, and
sexual thoughts and behaviors have become associated with or conditioned to
paraphilic fantasies.
ETIOLOGY contd….
• PSYCHOSOCIAL FACTORS:

• Many paraphilias can be traced back to childhood experiences that condition or

socialize children into committing a paraphilic act.
• The first shared sexual experience can be significant in that regard.
• Molestation as a child can predispose a person to accept continued abuse as an
adult or, conversely, to become an abuser of others.
• Early experiences of abuse that are not explicitly sexual, such as spanking,
enemas, or verbal humiliation, can be sexualized by a child and can form the basis
for a paraphilia.
 1. EXHIBITIONISTIC DISORDER:
DSM-5 ICD-10
Name Exhibitionistic Disorder Exhibitionism
Duration ≥6 months
Symptoms Sexual arousal/fantasies/urges/behaviors that result expose the genitalia to strangers (usually of the
from exposing one’s genitals to unsuspecting individuals opposite sex) or to people in public places, without
inviting or intending closer contact. There is usually,
but not invariably, sexual excitement at the time of the
exposure and the act is commonly followed by
masturbation
Psychosocial Marked distress and/or psychosocial impairment
Impact
Symptom Sexually aroused by: exposing genitals to prepubertal
Specifiers children
exposing genitals to physically mature individuals
both
Severity In a controlled environment: lives in institution/other
Specifiers controlled environment
Course In full remission: no symptoms or distress for ≥5 yr
Specifiers
Paraphilic disorders (BlockL1-6D3)- ICD - 11
• 6D30 Exhibitionistic disorder :
• Characterized by a sustained, focused and intense pattern of sexual arousal—as
manifested by persistent sexual thoughts, fantasies, urges, or behaviors.

• Involves exposing one’s genitals to an unsuspecting individual in public places,

usually without inviting or intending closer contact.

• Exhibitionistic Disorder is diagnosed, when the individual must have acted on

these thoughts, fantasies or urges or be markedly distressed by them.
EXHIBITIONISTIC DISORDER contd….

• also known as “flashing” or “indecent exposure.”

• predominately in men with a peak age of onset in the 20s.

• About half of exhibitionists are married

• The course of exhibitionistic disorder is likely to vary with age. Advancing age may
be associated with decreasing exhibitionistic sexual preferences and behaviour.

• Risk factors: antisocial personality disorder, alcohol use disorder, and pedophilic
interest, childhood sexual and emotional abuse and sexual
preoccupation/hypersexuality.
EXHIBITIONISTIC DISORDER contd….

• Exhibitionism is one of the three most common sexual offenses in police records
(the other two are voyeurism and pedophilia).

• Exhibitionists have been found to have a high rate of comorbidity like depressive,
bipolar, anxiety, and substance use disorders; hypersexuality; attention-
deficit/hyperactivity disorder; other paraphilic disorders; and antisocial
personality disorder.

• DD’s: conduct disorder, anti-social personality disorder, substance use disorder.

 2. FETISHISTIC DISORDER:
DSM-5 ICD-10
Name Fetishistic Disorder F65.0 Fetishism
Duration ≥6 months
Symptoms Sexual arousal/fantasies/urges/behaviors that result Sexual arousal/gratification from nonliving objects
from objects/nongenital body parts

Psychosocial Marked distress and/or psychosocial impairment

Impact
Exclusions Transvestic disorder, Using genital stimulation devices
(not result
of)
Symptom Body Part(s), Nonliving object(s), Other
Specifiers

Severity In a controlled environment (lives in institution/other

Specifiers controlled environment)
Course In full remission: no symptoms or distress for ≥5 yr
Specifiers
FETISHISTIC DISORDER contd….
• Objects most commonly used are women’s undergarments, shoes, stockings, or
other clothing items, suffer from fetishism.

• Fetishists often collect the object of their sexual gratification.

• It is exclusively described in men and often exists with other paraphilias

• Partialism refers to fetishes specifically involving nonsexual parts of the body.

• Onset during puberty, but fetishes can develop prior to adolescence. Once
established, fetishistic disorder tends to have a continuous course that fluctuates
in intensity and frequency of urges or behavior.
FETISHISTIC DISORDER contd….

• Typical impairments associated with fetishistic disorder include sexual

dysfunction during romantic reciprocal relationships when the preferred fetish
object or body part unavailable during foreplay or coitus.

• DD’s: Transvestic disorder, Sexual masochism disorder or other paraphilic

disorders, Fetishistic behavior without fetishistic disorder.

• Fetishistic disorder may co-occur with other paraphilic disorders as well as

hypersexuality, may be associated with neurological conditions.
 3. FROTTEURISTIC DISORDER:
DSM-5 ICD-10

Name Frotteuristic Disorder Other disorders of sexual preference Frotteurism

Duration ≥6 months

Symptoms Sexual arousal/fantasies/urges/behaviors that result Sexual arousal from rubbing against people in
from touching/rubbing against a nonconsenting public spaces
individual

Psychosocial Impact Marked distress and/or psychosocial impairment

Severity Specifiers In a controlled environment (lives in institution/other

controlled environment)

Course Specifiers In full remission: no symptoms or distress for ≥5 yr

Comments This category also includes Necrophilia, in addition

to behaviors such as making obscene phone calls,
engaging in sexual activity with animals,etc.
6D34 : FROTTEURISTIC DISORDER – ICD- 11

• sexual arousal— as manifested by persistent sexual thoughts, fantasies, urges, or

behaviours— that involves touching or rubbing against a non-consenting person

in crowded public places.

• Frotteuristic Disorder to be diagnosed, the individual must have acted on these

thoughts, fantasies or urges or be markedly distressed by them.

FROTTEURISTIC DISORDER contd….

• This behavior often occurs in busy, crowded places, such as on busy streets or on
crowded buses or subways.

• predominantly described in men.

• A frotteur may fantasize that the women he is rubbing up against is mutually

aroused by the behavior.

• Advancing age may be associated with decreasing frotteuristic sexual preferences

and behavior.
FROTTEURISTIC DISORDER contd….
• Nonsexual antisocial behavior and sexual preoccupation/ hypersexuality might
be nonspecific risk factors.

• DD’s: Conduct disorder, antisocial personality disorder, Substance use disorders.

• Conditions that occur comorbidly with frotteuristic disorder include-

• hypersexuality and other paraphilic disorders, particularly exhibitionistic

disorder and voyeuristic disorder.

• Conduct disorder, antisocial personality disorder, depressive disorders, bipolar

disorders, anxiety disorders, and substance use disorders.
 4. PEDOPHILIC DISORDER:
DSM-5 ICD-10

Name Pedophilic Disorder Pedophilia

Duration ≥6 months

Symptoms Sexual arousal/fantasies/urges/behaviors that result Sexually preferring young boys and girls Often
from sexual activity with prepubescent children preferring prepubertal or early pubertal age
Individual must be 16 yr or older at time of diagnosis,
and must also be a minimum of 5 yr older than the
child of sexual interest Sexually preferring young boys
and girls Often preferring prepubertal or early
pubertal age
# Symptoms Needed Both of the above
Exclusion ≤16 yr old Adolescent in relationship with child aged
12 or 13
Psychosocial Marked distress and/or psychosocial impairment
Impact
Symptom Exclusive type (attracted only to children),
Specifiers Nonexclusive type, Sexually attracted to males,
Sexually attracted to female, Sexually attracted to both
males and females, Limited to incest
6D32: PEDOPHILIC DISORDER – ICD -11

• Sexual arousal—is manifested by persistent sexual thoughts, fantasies, urges, or

behaviours—involving pre-pubertal children.

• Disorder is diagnosed, when the individual must have acted on these thoughts,

fantasies or urges or be markedly distressed by them.

PEDOPHILIC DISORDER contd….
• Some child molesters are driven by pedophilic interests

• Pedophiles typically seek treatment as a result of legal consequences for illegal

behavior.

• the onset of attraction to children begins at the time of puberty or adolescence.

• Individuals who engage in sexual activities with pubescent teenagers under the
legal age of consent (ages 16 to 18) are known as hebophiles (attracted to
individuals at the early stages of puberty) or ephebophiles (attracted to pubertal
individuals).
PEDOPHILIC DISORDER contd….
• Typically, pedophiles engage in fondling and genital manipulation more than
intercourse, with these three exceptions:
• intercourse occurring in cases of incest.
• occurring in pedophiles with a preference for older children or adolescents.
• occurring when children are physically coerced.

• Pedophiles commonly justify and minimize the actions by stating that the child
enjoyed the experience or that the experience was of educational value.

• A larger percentage of pedophiles are homosexual or bisexual in orientation to

children.
PEDOPHILIC DISORDER contd….

• Individuals attracted to females usually prefer children between the ages of 8 and
10 years.

• Individuals attracted to males usually prefer boys between the ages of 10 and 13
years.

• Pedophiles are approximately two and a half times more likely to engage in
physical contact with a child than simply voyeuristic or exhibitionist activities.

• Risk factors include antisocial personality disorder, childhood sexual abuse,

neurodevelopmental perturbation in utero.
PEDOPHILIC DISORDER contd….

• fMRI in combination with emotional and/or sexual stimuli showed pedophilia is

likely associated with altered brain activity particularly in the frontal brain areas
and the temporal lobe.

• Reported differences between pedophiles and the general population include

lower intelligence, a slight increase in the prominence of lefthanded individuals,
impaired cognitive abilities, neuroendocrine differences, and brain abnormalities,
particularly frontocortical irregularities or differences.
PEDOPHILIC DISORDER contd….

• DD’s: Antisocial personality disorder, Alcohol and substance use disorder,

Obsessive-compulsive disorder.

• Psychiatric comorbidity of pedophilic disorder includes substance use disorders;

depressive, bipolar, and anxiety disorders; antisocial personality disorder; and
other paraphilic disorders such as frotteurism, exhibitionism, voyeurism, or
sadism.
 5. SEXUAL MASOCHISM DISORDER:
DSM-5 ICD-10

Name Sexual Masochism Disorder Sadomasochism

Duration ≥6 months

Symptoms Sexual arousal/fantasies/urges/behaviors that Preference for sexual activity to include: Bondage
result from being humiliated/hit/bound/made to Infliction of pain or humiliation (as the recipient)
suffer
Psychosocial Marked distress and/or psychosocial impairment
Impact
Symptom Specifiers With asphyxiophilia: arousal from restriction of
breathing
Severity Specifiers In a controlled environment: lives in
institution/other controlled environment
Course Specifiers In full remission: no symptoms or distress for ≥5 yr

Comments ICD combined masochism and sadism into one

diagnosis
SEXUAL MASOCHISM DISORDER contd….
• sexual masochism is a fairly benign activity

• Proponents of sexual masochism as a mental disorder theorize that an individual

may become dependent on masochistic activity or may engage in dangerous or
injurious behavior warranting a pathologic aspect of the behavior.

• In most cases masochism does not cause harm to the individual.

• Sexual masochism is one of the few paraphilias described in women but almost
never diagnosed in women.

• The three main characteristics of masochism are pain, loss of control, and
humiliation.
SEXUAL MASOCHISM DISORDER contd….
• One of the psychodynamic theories postulated about masochism is Freud’s
writings that masochism is derived from sadism:
“More precisely, the person wishes to dominate and hurt others, but this desire
gives rise to guilt, so the person defensively converts it into its opposite, namely
a desire to submit to domination by others.”

However this theory is not entirely supported by the empirical evidence.

• Advancing age is likely to have a reducing effect on sexual preference involving

sexual masochism.
SEXUAL MASOCHISM DISORDER contd….

• Masochists are at risk of accidental death while practicing asphyxiophilia or other

autoerotic procedures.

• Differential diagnoses for sexual masochism disorder (e.g., transvestic fetishism,

sexual sadism disorder, hypersexuality, alcohol and substance use disorders)
sometimes occur also as comorbid diagnoses.
 6. SEXUAL SADISM DISORDER:
DSM-5 ICD-10

Name Sexual Sadism Disorder Sadomasochism

Duration ≥6 months

Symptoms Sexual arousal/fantasies/urges/behaviors that result Preference for sexual activity to include: Bondage
from inflicting physical or psychological Infliction of pain or humiliation (as the provider)
suffering/humiliation on others

Psychosocial Marked distress and/or psychosocial impairment or

Impact engaging with nonconsenting person

Severity In a controlled environment: lives in institution/other

Specifiers controlled environment

Course Specifiers In full remission: no symptoms or distress for ≥5 yr

Comments ICD combined masochism and sadism into one

diagnosis
6D33: COERCIVE SEXUAL SADISM DISORDER –
ICD- 11

• sexual arousal—as manifested by persistent sexual thoughts, fantasies, urges or

behaviours—that involves the infliction of physical or psychological suffering on a

non-consenting person.

• Coercive Sexual Sadism Disorder is diagnosed, when the individual must have

acted on these thoughts, fantasies or urges or be markedly distressed by them.

SEXUAL SADISM DISORDER contd…

• Sadists experience sexual fantasies involving the suffering of another as well as

compulsions to practice fantasies.

• The sadist’s partner may consent to the behavior in an effort to satisfy his or her
own masochistic fantasies, or the partner may be the victim.

• Sadism has been described in both men and women.

• Similarly both sadism and masochism are sexual behaviors that are reported in
the context of normal sexuality.
SEXUAL SADISM DISORDER contd….
• Krafft-Ebing subclassified sexual sadism into several categories including:
1. Lust-murder
2. Mutilation of corpses or necrophilia
3. Injury to females (stabbing)
4. Defilement of women
[Link] kinds of assaults on women—symbolic sadism in which, for example, the
perpetrator cuts the hair of his victims rather than harming them directly
6. Ideal sadism or sadistic fantasies alone without acts
7. Sadism with other objects, for example, whipping boys
8. Sadistic acts with animals.
SEXUAL SADISM DISORDER contd….

• Other paraphilic disorders can occur as comorbid illnesses along with it.

• In some individuals sadistic fantasies and compulsions lead to rape or homicide.

• The sadistic rapist is detected by demonstrating a higher level of arousal to

description of physical, but nonsexual, assault on female victims when subject to
phallometric assessment.

• The majority of sadists report the onset of fantasies in late teen years.
SEXUAL SADISM DISORDER contd….

• Some sadists’ accounts of sexual arousal to violence is based on an association

between excitement and punishment in childhood.

• Differential diagnoses for sexual sadism disorder (antisocial personality disorder,

sexual masochism disorder, hypersexuality, substance use disorders) sometimes

occur also as comorbid diagnoses.

 7. TRANSVESTIC DISORDER:
DSM-5 ICD-10

Name Transvestic Disorder Fetishistic transvestism

Duration ≥6 months

Symptoms Sexual arousal/fantasies/urges/behaviors that result Sexual excitement from wearing opposite sex
from cross-dressing clothes Desire to remove after arousal declines

Psychosocial Marked distress and/or impairment

Impact

Symptom With fetishism (sexually aroused by specific fabrics or

Specifiers garments)
With autogynephilia (sexually aroused by imagining self
as female)

Severity In a controlled environment: lives in institution/other

Specifiers controlled environment

Course Specifiers In full remission: no symptoms or distress for ≥5 yr

TRANSVESTIC DISORDER contd….
• Cross-dressing typically begins in prepubertal children but does not appear to
have a sexual component until late adolescence or early adulthood.

• Individuals with transvestic fetishism are usually heterosexual.

• However, there is a subgroup of men with transvestic fetishism who report

gender dysphoria, which can be defined as discontent with one’s biological sex,
the desire to possess the body of the opposite sex, and the desire to be regarded
by others as a member of the opposite sex.
TRANSVESTIC DISORDER contd….
• Clinical evidence suggests that transvestic fetishism impairs the ability to form
intimate pair bonds with other persons in the sense that relationships tend to
break down because the individual with transvestic fetishism often has more
interest in the nonhuman aspects of the partner (e.g., clothing).

• DD’s: fetishistic disorder, gender dysphoria

• The most frequently co-occurring paraphilias are fetishism and masochism.

• One particularly dangerous form of masochism, autoerotic asphyxia, is associated

with transvestism in a substantial proportion of fatal cases.
 8. VOYEURISTIC DISORDER:
DSM-5 ICD-10

Name Voyeuristic Disorder Voyeurism

Duration ≥6 months

Symptoms Sexual arousal/fantasies/urges/behaviors that result Experiencing sexual pleasure from watching
from observing an unaware person as they unaware people engage in: sex other intimate
undress/have sex activities (undressing)
# Symptoms Needed

Exclusion ≤18 yr old

Psychosocial Marked distress and or impairment

Impact
Symptom -
Specifiers
Severity Specifiers In a controlled environment: lives in institution/other
controlled environment
Course Specifiers In full remission: no symptoms or distress for ≥5 yr
6D31 VOYEURISTIC DISORDER – ICD -11

• Voyeuristic disorder is characterized by a sustained, focused and intense pattern

of sexual arousal.

• Manifested by persistent sexual thoughts, fantasies, urges, or behaviours—that

involves observing an unsuspecting individual who is naked, in the process of
disrobing, or engaging in sexual activity.

• Voyeuristic Disorder is diagnosed, when the individual must have acted on these
thoughts, fantasies or urges or be markedly distressed by them.
VOYEURISTIC DISORDER contd….

• men aged 20s and 30s

• They may masturbate while observing the victims but typically seek no contact
with the victim

• The onset of voyeuristic behavior is usually before the age of 15 years.

• Voyeurs tend to have multiple paraphilias and to cross over from one paraphilia
to another.

• Voyeurism is one of the least understood behaviors of the paraphilias

9. OTHER SPECIFIED PARAPHILIC DISORDERS:

• This category applies to presentations in which symptoms characteristic of a

paraphilic disorder that cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning predominate but do not
meet the full criteria for any of the disorders in the paraphilic disorders diagnostic
class.

• This category is used in situations in which the clinician chooses to communicate

the specific reason that the presentation does not meet the criteria for any
specific paraphilic disorder.
OTHER SPECIFIED PARAPHILIC DISORDERS contd….
• Examples of presentations that can be specified using the “other specified”
designation include, but are not limited to, recurrent and intense sexual arousal
involving-
• telephone and computer scatologia (obscene phone calls and cybersex)
• necrophilia (corpses)
• zoophilia (animals)
• coprophilia (feces)
• klismaphilia (enemas)
• urophilia (urine)
• Hypoxyphilia (desire to achieve an altered state of consciousness secondary to hypoxia while
experiencing orgasm)
that has been present for at least 6 months and causes marked distress or
impairment in social, occupational, or other important areas of functioning.
• Other specified paraphilic disorder can be specified as in remission and/or as
occurring in a controlled environment.
10. UNSPECIFIED PARAPHILIC DISORDERS:
• This category applies to presentations in which symptoms characteristic of a
paraphilic disorder that cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning predominate but do not
meet the full criteria for any of the disorders in the paraphilic disorders diagnostic
class.

• This category is used in situations in which the clinician chooses not to specify the
reason that the criteria are not met for a specific paraphilic disorder, and includes
presentations in which there is insufficient information to make a more specific
diagnosis.
LABORATORY INVESTIGATIONS:
• Plethysmography is the phallometric assessment of physiological sexual arousal
by use of equipment that measures penile circumference in males.

• Objective testing (e.g., plethysmography) is one way of addressing the difficulty

of self-disclosure in paraphiliacs

• Phallometric testing helps elucidate an individual’s sexual interest without

depending on self-disclosure

• phallometric testing is helpful in determination of an individual’s response to

treatment as well as in diagnosis.
LABORATORY INVESTIGATIONS contd….
• Hormone levels-
• Free testosterone

• Estradiol

• Progesterone

• FSH

• LH

• To screen abnormal levels & monitor the pharmacological interventions.

• These hormones might be helpful in predicting re-offense.

DIAGNOSIS:
• The diagnosis of a paraphilia begins with the identification of the individual’s
sexual interest.

• One of the common examples made in the area of paraphilias is to make a

diagnosis based on an individual’s behavior rather than on the individual’s sexual
preference

• The differential diagnosis of paraphilias is simple if one understands what the

sexual motivations of the subject are.
• DD’s: Organic causes, Substance abuse, Schizophrenia, personality disorder,
mental retardation.
COURSE AND PROGNOSIS:

• Paraphilic behaviors emerge in adolescence and early adulthood.

• Although it has been shown that individuals may cross over from one paraphilia

to another, the overall course of paraphilic behavior is chronic.

• Because of the early onset and repudiated biological priming of the paraphilias,

they are often difficult to treat.

MANAGEMENT :
• Individuals with paraphilic disorders typically are in extreme crisis when they
present for treatment.
• It is imp to assist the individual to not only understand that sexual urges are
controllable but that sex acts are the persons responsibility .
• People with paraphilias live with false belief that difference between themselves
and the rest of the world is lack of will power.
• Group therapy is helpful in assisting to confront cognitive distorsions and in
demonstrating that others not only do not re-offend but are capable of
establishing healthy and fulfilling lives.
• Medications are aimed at decreasing sexual anxiety and impulsivity ( SSRI) ,
moderating sex drive ( anti- androgens ) or eliminating sex drive (GNRH ).
TREATMENT:
PHARMACOLOGICAL MANAGEMENT:
TREATMENT contd….
OTHER MEDICATIONS:

• Anti-epileptic medications (for instance, topiramate) may be beneficial in

treatment of paraphilias such fetishism, as well as other non-paraphilic sexual
addiction or compulsions.

• In an interesting case report, Rubenstein and Engel report using lithium and a
serotonin reuptake inhibitor in combination to treat a patient’s transvestic
fetishism, after failure of antidepressant therapies alone.
TREATMENT contd….

• Sympathomimetic medications have been cited as helpful for paraphilic patients

(or those with paraphilia-related behaviors) who have comorbid attention-deficit
hyperactivity disorder.

• Another study reported that naltrexone, an opiate antagonist, was helpful in a

group of adolescent sex offenders. Effectiveness was measured by reduction in
frequency of sexual fantasies and masturbatory activity.

• Federoff published a case of transvestic fetishism treated successfully with

buspirone.
TREATMENT contd….

• Treatment with dopamine blockers including chlorpromazine, benperidol, and

fluphenazine have been mentioned in the literature with mixed results.

• Varela and Black reported successful treatment of a pedophilic patient with a

combination of carbamazepine and clonazepam. The patient had significant
anxiety and dysphoria associated with his pedophilic behaviors, but otherwise
had no comorbid psychiatric diagnoses.
 TREATMENT contd…
NON PHARMACOLOGICAL MANAGEMENT:
1. COGNITIVE BEHAVIOURAL THERAPY (CBT):
• Cognitive-behavioral therapy (CBT) is considered the mainstay of treatment in
paraphilic patient populations.
• The majority of literature on CBT in paraphilias focuses on sexual offender
populations.
• The applicability of this may be questionable in the case of a paraphilic patient who
has not committed sexual offenses, and this also may be problematic in the case of
an individual who has committed a sexual offense but may not suffer from a
paraphilia.
TREATMENT contd….
• Literature on sex offenders indicates that the use of CBT modalities reduces
relapse.
• There are many aspects to cognitive therapy, some of which include identifying
and challenging cognitive distortions, and breaking through patients’ denial.
• Thought substitution, redirection, and distractions are taught as ways to replace
maladaptive thoughts and redirect thinking toward more healthy topics.
• This “cognitive restructuring” is pivotal, as patients learn to challenge and
eliminate maladaptive rationalizations, which they use to justify their harmful
behaviors.
• Advanced features of cognitive therapy include victim empathy training, which is
particularly important in patients with coercive paraphilias.
 TREATMENT contd….
• Behavioral methods specific to paraphilias where patients want to focus on
decreasing aberrant sexual urges may include-
• Satiation: changing the patient’s behavioral response to previously sexually
exciting stimuli by overuse of the stimuli until response ceases
• Covert sensitization: sensitizing the patient to the stimuli by associating
negative outcomes with the stimulus
• Fading: teaching the patient to mentally transition from aberrant stimuli to
more normative stimuli
• Aversive stimulation: making the stimuli frankly unappealing by pairing it with
an unpleasant stimulus
TREATMENT contd….

• Others include-
• behavioral rehearsal

• behavioral abstinence

• positive conditioning

• These techniques help patients enhance behavioral control along with cognitive
control, so that patients can resist urges and make cognitively active choices,
instead of automatically thinking and responding in habitual and harmful ways.
TREATMENT contd….
2. RELAPSE PREVENTION:
• Since paraphilias share some features with addictive disorders, some researchers
note the utility of relapse prevention in this patient population.
• Similar to substance abusers, paraphilic patients must learn to navigate a world in
which the subject of their preoccupation (whether people of specific ages,
particular circumstances, or inanimate objects) is all around them. Identifying
risks, learning to deal with urges, and developing a plan of action if faced with a
trigger are imperative in this patient population.
• Research literature in RP proved that does not have an effect in reducing relapse
in a large sample of treated sex offenders.
• Despite that, RP has become an adjunctive treatment.
3. Motivational Interviewing (MI), Good Lives Model (GLM), and Risk
Assessment Model:
• MI uses an empathic as well as active approach with the purpose of incentives,
the individual, a commitment for treatment.
• Good Lives Matter Model is part of the “positive psychology” movement which is
based on skills build enhancing the positive qualities and reaching life fulfilling
goals.
• The Risk Assessment Model approach identifies dynamic risk factors that could be
modifiable (versus focusing on past behavior as a predictor of re-offense which
cannot be modified).
TREATMENT contd….
4. INSIGHT-ORIENTED PSYCHOTHERAPY:
• Insight-oriented psychotherapy is a long-standing treatment approach.
• Patients have the opportunity to understand their dynamics and the events that
caused the paraphilia to develop.
• In particular, they become aware of the daily events that cause them to act on
their impulses (e.g., a real or fantasized rejection).
• Treatment helps them deal more effectively with life stresses and enhances their
capacity to relate to a life partner.
• It allows patients to regain self-esteem, which in turn allows them to approach a
partner in a more normal sexual manner.
TREATMENT contd….
5. SURGICAL TREATMENT:

• Surgical treatment for sex offenders consist of two types:

• Neurosurgery
• Castration.
• The neurosurgical procedure involves stereotaxic removal of parts of the
hypothalamus to disrupt production of male hormones and decrease sexual
arousal and impulsive behaviors.
• Surgical castration is the removal of the testes which globally reduce the available
androgens.
TREATMENT contd…
• Bradford’s algorithm classifies paraphilias from the Level 1 thru 6 according to the
severity (mild, moderate, severe, and catastrophic).
• This algorithm proposes a treatment modality according to the severity of
symptoms and impairment.
• Level 1: Cognitive behavioral therapy (CBT) and relapse prevention for the mild
cases. It is recommended regardless of the severity that all patients with paraphilias
should be treated with therapy.
• Level 2: selective serotonin receptor inhibitors (SSRI).
• Level 3: when symptoms fail to improve with SSRIs within the first 4–6 weeks.
add low dose of medroxyprogesterone (MPA) or cyproterone acetate (CPA).
• Level 4: full dose of oral antiandrogen therapy.
• Level 5: for severe and catastrophic cases in which long-acting intramuscular
hormonal treatment is advised.
• Level 6: catastrophic paraphilias in which patient failed treatment mentioned above.
requires complete androgen suppression with either a higher dose of IM hormonal
treatment and/or adding additional hormones like luteinizing hormone release
hormone (LHRH)
ETHICAL CONSIDERATIONS:
• Association for Treatment of Sexual Abusers (ATSA) code of ethics endorses
standards of professional conduct that promote competent practice, and as such,
they represent a public commitment to clients and society toward the goal of
preventing sexual violence.
• The guidelines state that the ethical care of sex offenders is achieved by
encouraging individuals to take responsibility for their behavior, that is, admission
of guilt.
• It maintains that the identification and collaborative management of risk and
safety factors are indeed in the best interests of both sex offender patients and
potential victims due to the grave consequences incurred by sexual offender
relapse.
 LEGAL CONSIDERATIONS:
PARAPHILIA IPC PUNISHMENT COGNIZABLE BAILABLE TRIAL

VOYUERISM Sec. 354C Imprisonment of 1 to 3 years + Fine for first Cognizable Bailable Any
conviction Cognizable Non- Magistrate
Imprisonment of 3 to 7 years + Fine for second or bailable Any
subsequent conviction Magistrate

UNNATURAL Sec. 377 imprisonment for life or Cognizable Non Magistrate of

OFFENCES- with imprisonment of either description for a term bailable first class
sodomy which may extend to ten years, and shall also be
Tribadism/lesbi liable to fine
anism
Bestiality
Buccal coitus
 LEGAL CONSIDERATIONS contd…

PARAPHILIA IPC PUNISHMENT COGNIZABLE BAILABLE TRIAL

NECROPHILIA Sec. 297 Imprisonment up to 1 year, fine or both Cognizable Non bailable Any magistrate
EXHIBITONISM Sec. 294 Imprisonment for 3 Months or Fine or Cognizable Bailable Any magistrate
Both

FROTTEURISM Sec. 290 fine Non cognizable Bailable Any magistrate

INDECENT ASSAULT Sec. 354 Imprisonment for 1 to 5 years + Fine Cognizable Non bailable Any magistrate
REFERENCES:
• KAPLAN & SADOCK’S COMPREHENSIVE TEXTBOOK OF PSYCHIATRY, 10TH EDITION.

• KAPLAN & SADOCK’S SYNOPSIS OF PSYCHIATRY, 12TH EDITION.

• THE ICD – 10 CLASSIFICATION OF MENTAL AND BEHAVIOURAL DISORDERS.

• DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, FIFTH EDITION.

• THE ICD – 11 CLASSIFICATION OF MENTAL AND BEHAVIOURAL DISORDERS.

• OXFORD TEXT BOOK OF PSYCHIATRY.

• PRACTICAL GUIDE TO PARAPHILIA AND PARAPHILIC DISORDER BY RICHARD BALON.

• INDIAN PENAL CODE.

Thank
you