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Fabian M. Saleh, Fred S. Berlin, H. Martin Malin, Kate J. Thomas: Chapter 44. Paraphilias and Paraphilia-Like Disorders,

in Gabbard’s Treatments of Psychiatric Disorders, 4th Edition. Edited by Glen O. Gabbard. Copyright ©2009 American

Psychiatric Publishing, Inc. DOI: 10.1176/appi.books.9781585622986.261282. Printed 5/10/2009 from

www.psychiatryonline.com

Gabbard’s Treatments of Psychiatric Disorders > Part VIII. Sexual and Gender Identity Disorders >

Chapter 44. Paraphilias and Paraphilia-Like Disorders

INTRODUCTION

In this chapter, we examine the defining characteristics of the nonpedophilic and nontransvestic

paraphilias and consider general principles relevant to their clinical management. Pedophilia is

addressed in Chapter 43 in this volume. We focus our discussion on the remaining paraphilias

delineated in DSM-IV-TR (American Psychiatric Association 2000):

Exhibitionism. Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual

urges, or behaviors involving the exposure of one’s genitals to an unsuspecting stranger (criterion A).

Fetishism. Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual

urges, or behaviors involving the use of nonliving objects (e.g., female undergarments) (criterion A)

and the fetish objects are not limited to articles of female clothing used in cross-dressing (as in

transvestic fetishism) or devices designed for the purpose of tactile genital stimulation (e.g., a vibrator)

(criterion C).

Frotteurism. Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual

urges, or behaviors involving touching and rubbing against a nonconsenting person (criterion A).

Sexual masochism. Over a period of at least 6 months, recurrent, intense sexually arousing fantasies,

sexual urges, or behaviors involving the act (real, not simulated) of being humiliated, beaten, bound, or

otherwise made to suffer (criterion A).

Sexual sadism. Over a period of at least 6 months, recurrent, intense sexually arousing fantasies,

sexual urges, or behaviors involving acts (real, nonsimulated) in which the psychological or physical

suffering (including humiliation) of the victim is sexually exciting to the person (criterion A).

Voyeurism. Over a period of at least 6 months, 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 (criterion A).

Paraphilia not otherwise specified (NOS). A category reserved for paraphilias that do not meet the

criteria for any of the specific paraphilias listed in DSM-IV-TR but that nevertheless involve recurrent,

intense sexually arousing fantasies, sexual urges, or behaviors (category A) such as obscene phone

calls (telephone scatologia), corpses (necrophilia), or feces (coprophilia), among others. For

paraphilias, the NOS category is unique among residual categories in the other psychiatric disorders by

virtue of the sheer number of paraphilias described in the contemporary literature (Money 1986).

It is also important to note that to qualify as a paraphilia, the fantasies, sexual urges, or behaviors

must cause clinically significant distress or impairment in social, occupational, or other areas of

functioning (criterion B) (e.g., are obligatory, result in sexual dysfunction, require the participation

of nonconsenting individuals, lead to legal complications, interfere with social relationships)

(American Psychiatric Association 2000).

While this chapter focuses on the paraphilias enumerated above, much of what we know about

transvestic fetishism and pedophilia applies to nontransvestic and nonpedophilic paraphilias as

well. This is because phenomenology, or the qualitative mental experience of the illness, is a

defining factor of any paraphilia, even though observable behaviors are different for each of the

paraphilias and it is these behaviors that give name to the paraphilias.

Studies of pedophilia and transvestic fetishism are among the most commonly encountered in the

literature of paraphilias. Thus, it is inevitable that we rely to some degree on studies of pedophilic

and transvestic populations in our discussion of the nonpedophilic and nontransvestic paraphilias in Print: Chapter 44. Paraphilias and Paraphilia-Like Disorders http://www.psychiatryonline.com/popup.aspx?aID=261286&print=yes…

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this chapter.

It is not always clear, particularly with the literature on pedophilia, that studies were conducted

using homogeneous samples. It is not uncommon for even well-educated professionals who hear

the term paraphile or paraphiliac to confuse it with pedophile, arguably the most pejorative label

society can currently attach to a human being. Even more egregious is that the term pedophilia is

all too seldom used appropriately as a psychiatric descriptor even among mental health

professionals who, along with many nonpsychiatric professionals in such occupations as medicine,

law, and journalism, conflate the terms pedophile, child molester, and paraphile with sex offender.

This conflation has led to well-intentioned studies of sex offenders, for example, with erroneous

results purported to be generalizable to pedophiles. It seems likely that the reliance on

heterogeneous samples in many studies of “pedophilia” stems from the fact that such studies are

often reported from disciplines other than psychiatry, where strict criteria for the illness are not

applied.

To a lesser extent, the literature on transvestic fetishism is plagued by the same lack of

homogeneous samples. Transvestic behavior, for example, may be observed in a variety of

nonparaphilic contexts. Phenomenologically, the transvestic fetishist is worlds apart from the

so-called drag queen.

In broad terms, paraphilias can be conceptualized as sexual arousal patterns involving uncommon

or unusual erotic appetites for a wide variety of behaviors with animate or inanimate “partners.”

There are some 50 named and documented paraphilias, criteria for which have been described in

the literature. The number of paraphilias, while extensive and not immutable, seems to be finite:

apparently human beings lack the biological capacity to be aroused by anything and everything.

The term paraphilia (from the Greek para- [beside] plus philos [love]) is a translation of a term

first proposed by Wilhelm Stekel in his book Sexual Aberrations, which first appeared in the English

language in about 1925. Reportedly, Stekel believed that a new term with less pejorative

connotations than the term perversion (from the Latin for “turning around”) would be helpful in

examining and ameliorating these mental illnesses. Freud used the term, but it was not in

widespread use in the psychiatric literature until the 1950s (for an interesting discussion of the

relationship between “perversion” and “paraphilia,” see

http://www.answers.com/topic/paraphilia).

According to the revised fourth edition of the Diagnostic and Statistical Manual of Mental Disorders

(DSM-IV-TR; American Psychiatric Association 2000), the defining features of a paraphilia include

at least two and sometimes three criteria. Criterion A specifies an arousal pattern, lasting at least 6

months, that is “outside” generally observed sexual patterns. Criterion B specifies that the

paraphilia causes “clinically significant distress” or “impairment” in functioning. As in the case of

nontransvestic fetishism, criterion C further limits the scope of the pathological features of the

paraphilia, distinguishing it in differential diagnosis from other disorders.

Within the context of the listed criteria, it may be observed that the pathology residing in the

paraphilias is either that the partner is socially unacceptable (e.g., corpses or animals) or that the

behavior is unacceptable (e.g., public exhibitionism) (Berlin and Malin 1991).

Although there are exceptions, paraphilias primarily afflict males. The intrusive thoughts, fantasies,

or behaviors so sexually exciting to individuals with paraphilias would be either not sexually

arousing or repugnant to most individuals. Although the average individual might be capable of

exposing publicly, he is not afflicted by recurrent, intense sexual urges to do so. Similarly, the

average person would find the idea of having sex with a corpse repugnant; the paraphilic

necrophile experiences recurrent cravings to do just that (Rosman and Resnick 1989).

In the taxonomy of DSM-IV-TR, paraphilias are distinguished from sexual dysfunctions

(characterized by disturbance in sexual desire and the psychophysiology of the sexual response

cycle), gender identity disorders (characterized by strong and persistent cross-gender identification

accompanied by persistent discomfort with one’s assigned sex), and a residual category for sexual Print: Chapter 44. Paraphilias and Paraphilia-Like Disorders http://www.psychiatryonline.com/popup.aspx?aID=261286&print=yes…

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disorder not otherwise specified (for disorders of sexual functioning not classifiable in the other,

more specific categories).

Thus, although DSM-IV-TR includes the paraphilias in a section that also includes sexual

dysfunctions and gender identity disorders, this has not historically been the case. DSM has not

always classified paraphilias specifically as sexual disorders. Beginning with the first DSM

published in 1952, so-called sexual deviation was classified under the broad rubric of “personality

disorders,” specifically “sociopathic personality disturbance.”

The “personality disorders” of the first DSM were distinguished from “psychophysiological

autonomic and visceral disorders,” which were believed to be more physiologically based than

certain other mental disorders.

Specifically, the subcategory “psychophysiological genitourinary reaction” appears to have been

the rough equivalent of the sexual dysfunctions subcategory of the “sexual and gender identity

disorders” category of today’s DSM-IV-TR.

The term paraphilia first entered the DSM in 1980 with DSM-III (American Psychiatric Association

1980), more than half a century after Stekel first proposed it. However, despite the ongoing efforts

to define paraphilia, the term continues to mean different things to different people. Unfortunately,

Stekel’s intentions notwithstanding, the term paraphilia remains pejorative in most circumstances.

Perhaps this most unfortunate situation is attributable to a lack of understanding of the

phenomenology of the paraphilias. Although DSM-IV (American Psychiatric Association 1994)

describes some phenomenological features of the paraphilias (e.g., intense urges), it places greater

emphasis on describing the observable behaviors likely to bring an individual with a paraphilia to

the attention of the clinician or public authorities.

DSM-IV-TR begins each description of a named paraphilia with a statement of its “focus.” While the

components of fantasies and urges are included in the diagnostic criteria, foci are heavily weighted

toward displayed behaviors. DSM-IV-TR notes that it is important in making a differential diagnosis

of a paraphilia to distinguish the “nonpathological use of sexual fantasies, behaviors or objects as a

stimulus for sexual excitement” from their pathological counterparts (American Psychiatric

Association 2000).

The way paraphilic disorders are conceptualized, and therefore classified, is more than an academic

exercise in taxonomy. To the layperson, for example, an exhibitionist who acts on his paraphilia

(i.e., exposes his genitals to a nonconsenting individual) is typically considered to be a sociopath

rather than an individual suffering from a medical or psychiatric disorder. His behavior is

considered to be entirely volitional and will usually elicit little sympathy. He is generally regarded

as a criminal, and treatment, if any, for such individuals almost always includes legal oversight or

direction.

Most clinicians familiar with the phenomenology of paraphilic arousal are conversant with the

necessity for fantasizing about or engaging in an unusual or rare sexual arousal pattern as a

condition precedent for making a diagnosis of paraphilia. Those who rely primarily on behavior, to

the exclusion of phenomenology, however, are apt to make errors in diagnosis and, therefore,

treatment (Malin and Saleh 2004).

For example, exposing one’s genitals, often behaviorally described as “exhibitionism,” may occur in

many settings and for many purposes, some more socially appropriate than others. Such behaviors

may range from exposing the genitals in a physical examination or other procedure for medical

reasons to engaging in a marginally socially accepted behavior such as “streaking,” “flashing,” or

“mooning.” Such behavior does not rise to the level of pathology specified by DSM, however, in that

it does not typically meet any of the diagnostic criteria.

The nosology of DSM-IV-TR continues to engender debate, with some psychiatric professionals

arguing that paraphilias might be more accurately described, among other disorders, as process

addictions, obsessive-compulsive disorders, or impulse-control disorders. Kafka (1994a) has Print: Chapter 44. Paraphilias and Paraphilia-Like Disorders http://www.psychiatryonline.com/popup.aspx?aID=261286&print=yes…

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posited the existence of paraphilia-related disorders (PRDs). Moser and Kleinplatz (2003) have

suggested that “equating peculiar sexual interests with psychopathology” is problematic and that

the “paraphilia section [of DSM-IV-TR] is so severely flawed that its removal from the DSM is

advocated” (p. 1). While we would certainly concur that being “different” sexually is not

necessarily pathological, the authors do believe that “peculiar sexual interests” that meet criteria

established in DSM-IV-TR do qualify as evidence of psychopathology.

The authors of this chapter believe that phenomenology is central in diagnosing paraphilias and

that the paraphilias are best defined by their unique erotic valence, a postulate that requires that

they stand with the sexual disorders and not as special cases of another category of disorder. In

our view, to categorize paraphilias as anything other than sexual disorders would be akin to

classifying a gender identity disorder of adulthood (sometimes called transsexualism) as a special

kind of delusional disorder or body dysmorphic disorder. It follows that social response to any

observed sexual behavior—be it medical, legal, or psychological—is better determined by

considering phenomenology as well as behavior.

Because of some similarities between paraphilic sexual behavior and inappropriate use of

psychoactive substances or compulsive behaviors, the descriptors “sexual addiction” (Carnes 1983)

and “sexual compulsion” (Coleman 1990) have recently come into common usage, although these

terms are not used in DSM-IV-TR. There is considerable debate among mental health professionals

about the operationalization of these terms. It is clear, however, that in some cases patients with

paraphilias seem “driven” to engage in them and lack the necessary ability to exercise appropriate

volitional control over them. It is important to address this aspect of paraphilias in treatment

programs (see section titled “Goals and Methods of Treatment,” later in chapter).

Clinicians still know very little about how particular thoughts, perceptions, and behaviors acquire

the capacity to act as stimuli capable of eliciting erotic arousal. Even less is known about how

specific sexual arousal patterns develop, whether they are “normal” or “pathological.” Imprinting,

classical conditioning, and genetics may play a role (Berlin 1993). Individuals with paraphilias

appear to “discover” rather than “create” the conditions under which they experience peak erotic

arousal; they are not simply individuals who “choose” to experience an altered state of mind

(Money 1985).

TYPES OF PARAPHILIAS: EXCLUSIVE VERSUS NONEXCLUSIVE;

EGO-DYSTONIC VERSUS EGO-SYNTONIC

Paraphilias are often divided into subtypes: exclusive and nonexclusive. They may also be classified

as ego-dystonic or ego-syntonic. DSM-IV-TR no longer uses this latter terminology but does point

out these features. In the exclusive form of paraphilias, only paraphilic imagery and/or behaviors

(for example, sadistic thoughts/fantasies/activities) elicit erotic arousal. In such cases, a

completed sexual response cycle is “obligatorily dependent upon” the paraphilia. Even if the

observed behavior appears to be consensual and age-appropriate intercourse without a sadistic

component, the fantasy component must obligatorily be present for the patient to reach orgasm. In

the nonexclusive form, neither the fantasy nor the behavioral component must always be present

for sexual fulfillment.

Some individuals are distressed by their paraphilic cravings, finding them to be in conflict with their

personal sense of right and wrong. In such cases, the cravings are said to be ego-dystonic. To

others, the cravings are acceptable or even desirable, in which case they are considered to be

ego-syntonic. Attempting to treat individuals with ego-syntonic paraphilias is akin to attempting to

treat a substance user who denies having a problem.

Indeed, there may be no need—at least in theory—to attempt to treat some relatively innocuous

ego-syntonic paraphilias (e.g., foot partialism) or reciprocal paraphilias (e.g., bondage/discipline,

which can be conceptualized as a variant of sadism/masochism in which one partner’s paraphilic

urges match the other partner’s paraphilic urges) that are not causing clinically significant distress

or impairment in functioning. Clinical experience, however, may cause us to temper purely

theoretical considerations with more practical considerations. The nontransvestic fetishist mayPrint: Chapter 44. Paraphilias and Paraphilia-Like Disorders http://www.psychiatryonline.com/popup.aspx?aID=261286&print=yes…

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come to our clinical attention, for example, when he begins to steal shoes or women’s underwear.

In such cases, a seemingly harmless paraphilia does indeed cause significant clinical distress or

impaired social functioning, because the individual might face serious negative social

consequences, including public humiliation, a divorce, or even time in jail.

Certain paraphilias (e.g., exhibitionism, frotteurism) are more likely than others (e.g., fetishism) to

impel an individual to commit criminal acts. However, even in fetishism, criminal behavior may

occur and bolster the case for treatment.

DIFFERENTIAL DIAGNOSIS

The eminent neurologist John Hughlings Jackson (1835–1911) was fond of reminding his peers that

the study of causes must first be preceded by the study of things caused. Much contemporary

medical literature addresses treating sexual offenders, sexually aggressive individuals, those

addicted to sex, child molesters, incest offenders, or rapists. However, none of these behaviors

constitutes a psychiatric diagnosis in and of itself (Abel et al. 1988; Greer and Stuart 1983; Quinsey

et al. 1993).

It would be clearly inappropriate for a legal or medical professional to insist on administering any

of the psychological or pharmacological treatments designed to modify behavioral patterns or

reduce arousal where no behavioral or arousal problems exist. It is just as appropriate, even

merciful, for the same professional to support any ethical therapeutic intervention where

psychopathology does exist—whether it be, for example, exposing in response to paraphilic

exhibitionism or a psychotic condition in which a patient exposes in response to command

hallucinations.

Therefore, before attempting to treat a person with a paraphilia, one must assure oneself that a

diagnosable disorder is indeed present. To review one of our previous examples, the college

student who “moons” the Saturday afternoon football crowd while intoxicated is not necessarily an

exhibitionist. The rapist with a conventional sexual arousal pattern who takes advantage of a

situation to assault a woman because he lacks a sense of conscience or moral responsibility may

not be manifesting a paraphilia. A rapist who is predisposed to act in response to recurrent,

coercive, or sadistic urges may indeed have a paraphilia. Only the latter might require or could even

benefit from paraphilia-specific treatment (Berlin 1986; Berlin and Malin 1990).

If, in addition to suffering from a paraphilia, a given individual has an Axis II personality disorder,

both conditions require psychiatric intervention. Clinically, however, it is important to remember

that paraphilias often occur independently of Axis II pathology, a fact recognized in DSM-III,

DSM-III-R (American Psychiatric Association 1987), DSM-IV, and DSM-IV-TR but not understood in

earlier editions.

RATIONALE FOR TREATMENT

Often, behaviors such as public exhibitionism, frotteurism, or rape that may be a manifestation of a

paraphilia are considered by society only from a moral perspective. Individuals who engage in such

acts are considered simply to be bad people who behave badly, engage in criminal acts, and are

fully capable of controlling their actions. If this is so, in what way does it make sense to talk about

treatment? There are, however, lessons to be learned from the nonsexual criminal behaviors of

individuals displaying psychopathology that makes them arguably unable to conform their

behaviors to social mandates. Compare, for example, the behavior of the common thief who

chooses, for a variety of reasons (e.g., antisocial traits or dire poverty), to steal and the irrational,

driven behavior of the kleptomaniac who ordinarily can’t just simply “talk himself” out of the

decision to steal. While the observable behavior, stealing, appears to society to be the same, the

underlying dynamic is considerably different.

When it comes to behavior enacted in response to a biologically based drive such as hunger or sex,

the situation is even more complex. Treatment and other measures to correct the situation may be

necessary since the exercise of willpower alone may not suffice. For example, although Americans

are spending millions of dollars each year attempting to change their eating habits, many (if notPrint: Chapter 44. Paraphilias and Paraphilia-Like Disorders http://www.psychiatryonline.com/popup.aspx?aID=261286&print=yes…

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most) fail despite significant efforts.

Carnes (1983), among others, has pointed out that some individuals have as much trouble

controlling their sexual behavior as other people have controlling their drinking. Researchers have

produced tantalizing clues concerning mechanisms in the brain that might help explain the

phenomenology of paraphilias, but much work remains to be done. Frost et al. (1986) have

implicated endogenously produced opiates in the brain during sexual arousal. It is certainly

plausible that some individuals may be more sexually driven than others because of neurochemical

anomalies. Such findings would lend credence to observations made long ago by sexologists such as

Krafft-Ebing (1965) and Ellis (1936), who first documented the highly driven nature of the

paraphilias.

The treatment of paraphilic and nonparaphilic sexual offenders is a difficult and often complex task.

Despite the challenges, however, data from a variety of studies suggest that treatment can be

effective.

Treatments usually encompass psychologically and, where appropriate, biologically based

therapies. The main consideration in the treatment of paraphilic sexual offenders is linked to sexual

recidivism by increasing an offender’s ability to exert better behavioral control through treatment.

Generally, the authors have found that in severe paraphilias, gains from psychosocial or

psychoeducational therapies are greatly enhanced by offering pharmacological interventions.

As of yet there is no cure and no complete understanding of the etiology of paraphilia. However, the

usefulness of medication for any illness does not presuppose a complete understanding of etiology

or mechanism. Indeed, it is common in medicine to treat conditions with drugs without thoroughly

understanding their mechanism of action. It is important to remember that such treatments, though

helpful, are not necessarily curative.

GOALS AND METHODS OF TREATMENT

The goals of treatment of paraphilias are twofold: 1) to reduce recidivism and, hence, to protect

society against further victimization and 2) to reduce the adverse effect of the illness on the

paraphilic individual. Both can be achieved by the appropriate application of a variety of

psychological and pharmacological therapies.

At present, treatment of paraphilias involves interventions in three areas of concern: 1) helping

patients to identify and change distorted thinking patterns, 2) addressing impairment of volitional

control over paraphilic behaviors, and 3) helping to relieve the suffering of afflicted individuals

arising from the ego-dystonic nature of their illness, the social ostracism, and other painful

consequences (e.g., punishment by the judicial system) brought about by paraphilic thoughts and

behaviors. The judicious use of psychological and pharmacological therapies can help with all three

of these goals.

PSYCHOLOGICAL TREATMENTS

Psychological treatments, whether in groups or in individual work, can aid greatly in achieving all

three goals enumerated above. Some forms of psychotherapy are better than others in achieving

specific goals. Traditional psychodynamic and psychoanalytic psychotherapy treatment modalities

have been observed to be largely ineffective in managing paraphilias, despite decades of attempts,

and will not be discussed here.

Cognitive Therapy

Cognitive therapy is an effective way to help patients understand their illness and identify and

challenge distorted thinking patterns (thinking errors) and cycles of events leading up to acting-out

behaviors. Thus, cognitive therapy is concerned with thought processes, and its approach is largely

educational.

The goal of cognitive therapy is to change maladaptive thoughts and beliefs through techniques

such as education, cognitive restructuring, and thought stopping. The technique of cognitivePrint: Chapter 44. Paraphilias and Paraphilia-Like Disorders http://www.psychiatryonline.com/popup.aspx?aID=261286&print=yes…

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restructuring teaches a patient to identify, challenge, and ultimately replace erroneous (i.e.,

distorted) beliefs with adaptive and prosocial cognitions. Thought stopping is a technique that aims

to decrease the frequency and duration of deviant sexual thoughts with competing and adaptive

thoughts.

Both individual and group modalities are helpful “delivery forms” of cognitive therapy. In individual

cognitive therapy, the patient can be taught about human sexuality and paraphilias in educational

terms and deficiencies in knowledge remediated. The group can be used to challenge thinking

errors, foster a sense of responsibility for controlling behaviors rooted in the illness, and provide

peer support for the emotional trauma and psychic pain suffered by the patient. Such therapy is

excellent preparation for other therapies designed to give the patient control strategies. Cognitive

therapy is rarely, if ever, used by itself but is typically combined with other forms of psychotherapy

to effect behavioral change and impulse control.

Behavioral Therapy

Behavioral therapy is guided by learning theory, specifically social learning theory. In contrast to

psychodynamic or cognitive therapies, behavioral therapies are primarily concerned with the

aberrant behavior itself and not its underlying cause. Behavioral therapy aims to decrease and

extinguish deviant sexual arousal through a set of techniques, such as systematic desensitization,

aversion therapy, biofeedback, minimal arousal conditioning, and covert sensitization.

(Masturbatory satiation, a form of arousal reconditioning, is no longer widely used.)

Covert sensitization, a form of aversion therapy, has been widely used in the treatment of

paraphilic patients. It is postulated that pairing of deviant sexual fantasies with the mental image

of their humiliating consequences (i.e., the aversive experience) will dissuade a patient from acting

out sexually; that is, deviant arousal or excitement is paired with a visualized thought or fantasy.

To give an example, a voyeur will be asked to imagine being taken into custody as soon as he

begins to contemplate peeping into other people’s windows.

In contrast to the aversive behavioral therapies, other conditioning methods use positive

reinforcers. For example, positive olfactory conditioning employs pleasant aromas with nondeviant

sexual stimuli.

Because behavioral therapy is rooted in social learning theory, its precepts are influenced by the

realities of other forms of learning—such as opponent-process learning, imprinting, and

state-dependent learning. The rich constructs of all the various learning theories must be

considered when developing behavioral therapy regimens. Nevertheless, the contributions of

behavioral therapy to the treatment of sex offenders—and the management of underlying

paraphilias—have sometimes been reported to be helpful. At the same time, it is unclear whether

therapies designed to alter erotic arousal patterns can produce the sort of long-term behavioral

changes needed when treating a paraphilia.

Cognitive-Behavioral Therapy

Cognitive therapy hypothesizes that paraphilias are maintained by distorted cognitions (Murphy

and Carich 2001), and behavioral therapy teaches that paraphilic behavior can be controlled

without reference to underlying cause. Taken together, cognitive and behavioral therapies

(cognitive-behavioral therapy) form the backbone of most treatment programs.

Cognitive-behavioral therapy typically encompasses more than just a combination of cognitive and

behavioral interventions (Marshall and Laws 2003).

For example, victim empathy training has traditionally been an important component of all

cognitive behavioral treatment and involves helping a patient take on the perspective of his

victim(s). Additionally, assertiveness and a variety of social skills training programs have been

deemed important components in treatment programs, although some research (Hanson and

Bussiere 1998) seems to indicate that they may have little or no impact on sexual recidivism in

treated populations. Indeed, one might make the case that social skills training in general,Print: Chapter 44. Paraphilias and Paraphilia-Like Disorders http://www.psychiatryonline.com/popup.aspx?aID=261286&print=yes…

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particularly in nonparaphilic offenders with significant coexisting Axis II pathology such as

antisocial personality disorder, serves only to give them additional skills with which to be more

successful in seducing and assaulting victims.

Relapse Prevention

A third highly important psychological therapy used in the treatment of paraphilias is relapse

prevention (Pithers and Cummings 1995). The objective of relapse prevention is to help the patient

maintain behavioral changes. In order to reduce the risk for inappropriate sexual behavior, patients

are taught to identify escalating stages in the cycles of deviancy and to develop strategies to

interfere early on in the development of the cycle when it is triggered (Laws et al. 2000).

Group Therapy

Group psychotherapy is a widely accepted treatment modality used in the treatment of paraphilic

and nonparaphilic sex offenders (Peters and Roether 1972). It incorporates relapse prevention and

cognitive-behavioral techniques, as well as empathy and social skills training. Group therapy

creates a milieu that is conducive to frank discussion in that it permits both positive and negative

reinforcement of the patient’s efforts and provides guidance regarding effective relapse prevention

strategies. Patients may benefit from vicarious learning and the experience of other group

members. It also encourages “buy in” to treatment and promotes development of a trustworthy

social support network and of healthy adult relationships. One of the primary advantages of group

therapy over individual therapy is that it allows patients to be challenged by members of the group

rather than by the therapist. This is important, given that patients may respond and be more willing

to change if challenged by one of their peers with direct experience rather than by the therapist,

who, although experienced, is presumed to have only largely theoretical knowledge. Therapists, of

course, may have a great deal of knowledge regarding which sorts of treatments can be most

effective.

BIOLOGICAL TREATMENTS

Biologically based treatments should be made available to paraphilic patients if, for example,

cravings for deviant sexual activities become overpowering or when specific symptoms are not

responsive to other treatment modalities (e.g., behavioral therapy). In the authors’ opinion, they

should be included as first-line therapies, particularly if patients display paraphilias that are likely

to get themselves or others into serious difficulty without them. One should not wait in these

instances for all else to fail. For the patient or his victim, there may be no “second chance.”

Surgery

Among the biologically based treatments, one must differentiate between orchiectomy (surgical

removal of the gonads) and pharmacotherapy. (Stereotaxic hypothalamotomy [Roeder et al. 1972]

has only historical value and will not be discussed here.) In the authors’ opinion, orchiectomy data

are particularly relevant in that they provide the basis for our understanding of the benefits of the

currently used testosterone-lowering agents. Although many studies involving testosterone

reduction have been carried out in presumably nonhomogeneous, poorly defined samples

containing both paraphilic and nonparaphilic sex offenders, whether by orchiectomy or by so-called

chemical castration, it is clear that reducing testosterone reduces sex drive globally.

That testosterone reduction results in a significant reduction of sex offenses cannot be denied. For

example, Langelüddecke (1963) reported sexual recidivism data for 1,036 castrated sex offenders.

Six hundred eighty-five patients declined orchiectomy and served as the control group (n = 685).

Recidivism rates were as high as 84% prior to orchiectomy. Recidivism rates decreased to 2.3%

following castration (24 of 1,036 reoffended, compared with 268 of 685 [39.1%] in the control

group). Observation periods ranged between 6 weeks and 20 years. Older sex offenders had lower

recidivism rates than did younger sex offenders, who ranged in age between 20 and 30 years.

Fifty-eight offenders reported a complete cessation of their sexual drive; 15 reported a gradual

decline in their sexual functioning, and 16 maintained erectile and orgasmic functioning despitePrint: Chapter 44. Paraphilias and Paraphilia-Like Disorders http://www.psychiatryonline.com/popup.aspx?aID=261286&print=yes…

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orchiectomy.

As reported by Sturup (1968), Sand et al. (1964) presented recidivism rates data on a cohort of 900

castrated sex offenders who were reexamined over a 30-year period (approximately 4,000

follow-up inquiries). Yet again, recidivism rates were remarkably low, ranging between 1.1% and

2.2%. Similarly, Cornu (1973) reported a substantial decrease in sexual recidivism rates in 121

orchiectomized sex offenders. Sexual recidivism rates declined to 4.13% after a 5-year observation

period. In contrast, 50 sex offenders refusing castration and serving as the control group had

recidivism rates as high as 52%. These and similarly designed studies show that orchiectomy

substantially decreases a sex offender’s risk for sexual recidivism, with recidivism rates ranging

between 50% and 60% for nonorchiectomized versus 1% to 3% for orchiectomized sex offenders.

Although studies involving orchiectomy have been helpful in understanding the relationship

between testosterone levels and recidivism, it must be pointed out that with the advent of a variety

of testosterone-lowering agents, orchiectomy is currently not ordinarily recommended in the

treatment of sex offenders. While society—and, in particular, some members of the legal

community—may feel that punitive orchiectomy or the threat of orchiectomy may have some

deterrent value in the control of sexual crime, it is medically unethical for this purpose.

Pharmacotherapy

Because of ethical and medical reasons, randomized double-blind, placebo-controlled studies

cannot be conducted with most symptomatic paraphilic patients who reside in the community

(Berlin 1989). Nevertheless, the number of medications used to treat paraphilias has been steadily

increasing. They can be divided into the testosterone-lowering (e.g., progesterone derivatives and

the gonadotropin-releasing hormones) and the serotonergic (e.g., serotonin-specific reuptake

inhibitors) agents. As with all pharmacological treatments, the choice of which medication to use is

primarily based on the patient’s presenting symptoms, concomitant psychiatric/neuropsychiatric

disorders, and results of the psychosexual and medical workup.

Testosterone-Lowering Agents

The first hormonal agent used in the treatment of the paraphilias was estrogen. However, because

of its side-effect profile (e.g., gynecomastia), estrogen treatment was quickly abandoned and

replaced with progesterone derivatives. Among the latter, cyproterone acetate (CPA), available in

Canada and Europe, and medroxyprogesterone acetate (MPA), available in the United States, have

been used with considerable success. In contrast to orchiectomy, both agents decrease circulating

testosterone levels through a peripheral and a central mechanism without causing irreversible

change to the hypothalamic-pituitary-gonadal (HPG) axis.

Berlin and Meinecke (1981) treated 20 patients, diagnosed with a number of paraphilias, with

intramuscular MPA for up to 5 years, using a mean dose of 310 mg/week. All subjects reported a

decrease in the frequency and intensity of their paraphilic symptoms. Approximately 50% of

patients reoffended following discontinuation of MPA treatment—further proof of the efficacy of this

medication, so long as one continues to take it. In order to reduce the likelihood for

medication-induced side effects, trials using lower doses of MPA have been conducted (Kravitz et

1. 1996).

In a double-blind, placebo crossover design study, Bradford and Pawlak (1993) prescribed either

oral CPA or placebo to 19 paraphilic men. CPA proved to be superior to placebo on almost all

outcome measures, which included physiological (penile plethysmography) and subjective

measures.

Although very effective, CPA and MPA can sometimes cause significantly serious side effects,

including fatigue, depression, hyperglycemia, weight gain, liver dysfunction, gynecomastia, and

high blood pressure (Meyer et al. 1992).

More recently, luteinizing hormone–releasing hormone (LHRH) agonists—which are primarily

employed in the treatment of prostate carcinoma—have been prescribed to treat paraphilic patientsPrint: Chapter 44. Paraphilias and Paraphilia-Like Disorders http://www.psychiatryonline.com/popup.aspx?aID=261286&print=yes…

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(Krueger and Kaplan 2001; Rousseau et al. 1990). LHRH agonists overstimulate the hypothalamus,

which in turn results in an initial increase in gonadotropin-releasing hormone secretion, followed by

a reduction to almost nil. As a result of its depleting effects, levels of circulating testosterone and

dihydrotestosterone decrease to prepubertal levels (Bradford 2000). Consequently, paraphilic

patients report a decrease in their sexual drive and sexual potency. The most common side effects

are erectile failure, hot flashes (Dickey 1992), and decreased bone mineral density (Rosler and

Witztum 1998).

Of note, because leuprolide exerts its sexual drive–reducing properties through a direct effect on

the HPG axis, the first 2–4 weeks of treatment can cause a surge in gonadotropin secretion.

However, prolonged treatment at therapeutic doses will ultimately suppress gonadotropin and thus

testosterone secretion. Because of this biphasic effect on the HPG axis, patients receiving

treatment with an LHRH agonist should temporarily be prescribed an androgen receptor blocker,

such as flutamide (Dickey 1992), which can be discontinued after approximately 2–4 weeks. The

typical oral dosage is 250 mg three times a day.

In a case report series, Saleh et al. (2004) presented data on six treatment-resistant young adult

paraphilic patients. All subjects were between 18 and 21 years of age and met DSM-IV-TR

diagnostic criteria for one or more paraphilic disorders. All subjects reported a substantial decrease

in paraphilic symptomatology following treatment with leuprolide. One subject required

augmentation with MPA. No significant side effects were reported.

In the largest study to date, Rosler and Witztum (1998) reported data on 30 paraphilic men who

were treated with triptorelin (an LHRH agonist) for up to 42 months in an open-label study. All

patients reported a decrease in deviant sexual fantasies and behaviors. Side effects were related to

hypoestrogenic states and consisted of hot flashes, erectile failure, and decreased bone mineral

density in some men.

Serotonergic Agents

In more recent years, non-testosterone-lowering medications have been used to treat paraphilic

patients. In particular, selective serotonin reuptake inhibitors (SSRIs) have been proposed for

alleviating paraphilic symptoms because of their adverse side effects on libido. Results have been

mixed, and conclusions drawn from these studies with respect to paraphilic individuals are difficult

to evaluate because of small sample sizes, open-label designs, and other confounding variables.

In a case report series, Perilstein et al. (1991) treated 3 patients presenting with paraphilia-like

phenomena with fluoxetine at dosages ranging from 20 mg/day to 40 mg twice a day. All patients

reported a decrease in deviant sexual symptoms. Anorgasmia and retarded ejaculation were the

only reported side effects. In a retrospective study, Greenberg et al. (1996) reported that

fluvoxamine (n = 16), sertraline (n = 25), and fluoxetine (n = 17) were all effective in decreasing

paraphilic symptoms. In an open-label trial, Kafka and Prentky (1992) treated 20

patients—diagnosed with a paraphilia or “nonparaphilic sexual addiction”—with fluoxetine, using a

mean dose of 39 mg/day. Although a decrease in paraphilic symptoms was reported by 4 weeks,

nondeviant sexual behavior was preserved. Of note, outcome was measured by self-report. In

another open-label trial, Kafka (1994b) treated 12 patients diagnosed with either a paraphilia or a

paraphilia-related disorder (a term created by Kafka). Subjects were given sertraline in dosages as

high as 250 mg/day. Fluoxetine was used for partial or nonresponders. Similarly to the 1992 trial,

patients reported a decrease in paraphilic symptoms following treatment with either fluoxetine or

sertraline.

The SSRIs and other antidepressants are highly variable in the degree to which they cause sexual

side effects that might be beneficial in managing paraphilias. Some antidepressants, notably

bupropion and nefazodone, are even marketed as being superior to others because they appear to

cause sexual side effects less frequently than some SSRIs.

Although theories and treatment algorithms have been promulgated recommending the use of

serotonergic agents in paraphilias (Bradford 2001), in our opinion, such agents offer no advantage Print: Chapter 44. Paraphilias and Paraphilia-Like Disorders http://www.psychiatryonline.com/popup.aspx?aID=261286&print=yes…

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over the testosterone-lowering drugs and, in some cases, are risky choices. The

testosterone-lowering agents are the gold standard for treating any paraphilic disorder in which

sex-drive reduction is a desirable component.

CONCLUDING REMARKS

Regardless of the methods used to treat paraphilias, documentation of outcome is critical. Furby et

1. (1989), in a review of outcome studies, found mixed results. Furby and colleagues argued that

treatment might not work. However, the fact that some investigators have reported negative

results with certain populations and conditions does not negate the validity of those studies in

which positive treatment outcomes have been reported.

There are a number of studies in the literature suggesting that treatment can be helpful (Berlin et

1. 1991; Grunfield and Noreik 1986; Marshall and Barbaree 1990; Tracy et al. 1983). Berlin et al.

(1991), to cite just one example, reported rates of recidivism following treatment in a primarily

paraphilic sample that were well below rates reported in the world literature for comparable

untreated cases. Hanson et al. (2002), in their meta-analytic review of data from 43 studies

examining the sex offense recidivism rate for sex offenders (combined N = 9,454), found on

average that recidivism was about 12% lower for treatment groups than for nontreatment groups.

In interpreting all of these data, one should keep in mind that the terms sex offender and paraphile

are not synonymous, even when they are used interchangeably in the literature. Ultimately,

documentation of treatment outcome and proper scientific investigation will be what is necessary

to determine which treatments are most effective and for whom.

The question of whether individuals engaging in improper paraphilic behaviors should be thought of

as having diminished criminal culpability as the result of their psychiatric diagnosis is controversial

and complex (Berlin 1994). Over a century ago, the eminent British psychiatrist Henry Maudsley

expressed concern that society often fails to even consider such a possibility. He wrote, “If the law

cannot adjust the measure of punishment to the actual degree of responsibility . . . that is no

reason why we should shut our eyes to the facts; it is still our duty to place them on the record, in

the confident assurance that a time will come when men will be more able to deal more wisely with

them” (quoted in Restak 1988, p. 11).

There have been those who have suggested that paraphilia patients (e.g., exhibitionists, voyeurs)

who act on their urges should simply be punished. Others wholly or partially disagree, arguing that

it is not possible, or even proper, to try to “punish away” psychopathology and its associated

behaviors. The treatments that have been detailed in this chapter are intended to help accomplish

the goal of providing care for these serious psychiatric disorders.

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