1.
MODERATOR: Dr. ASHUTOSH GUPTA
PRESENTATOR: Dr. RAMASHANKAR
PARAPHILIC DISORDER

2.
Paraphilia (perversion)
 Derived from the Greek words
 “para” meaning next to
 “philia” meaning love.
 The etymological definition of paraphilia is “next to or along side of love.”
 “Recurrent, intense sexually arousing fantasies, sexual urges, or behaviors
generally involving i) non-human objects, ii) the suffering or humiliation of
oneself or one’s partner, or iii) children or other non-consenting persons that
occur over a period of at least 6 months”**
 **(p.566, [DSM-IV]).

3.
 The term paraphilia denotes any intense and persistent sexual interest other
than sexual interest in genital stimulation or preparatory fondling with
phenotypically normal, physically mature, consenting human partners.*
 A paraphilic disorder is a paraphilia that is currently causing distress or
impairment to the individual or a paraphilia whose satisfaction has entailed
personal harm, or risk of harm, to others.*
 * DSM-5 pg. 685

4.
 DSM-5 CRITERIA FOR PARAPHILIC DISORDER
 Criterion A
Specifies the qualitative nature of the paraphilia (e.g., an erotic focus on
children or on exposing the genitals to strangers).
 Criterion B
Specifies the negative consequences of the paraphilia (i.e., distress,
impairment, or harm to others).

5.
Characteristics of persons with a Paraphilia
 Beside normal sexual behaviour, paraphilic disorder involve aggression,
victimization, and extreme one-sidedness.
 The behaviors exclude or harm others and disrupt the potential for bonding
between persons.
 Usually lasts for 6 months.
 Always thinking to carry out their unusual behavior.
 Overly obsessed that if the individual cannot get to their desired object, they get
stressed.
 The individual will lose sight of other goals and concentrate of the fulfilment of
their sexual desires if worse.

6.
 It causes intense personal distress or impairment in social, work and other areas
of life functioning.
 Except for Sexual Masochism & sadism almost all cases of Paraphilia Involve
MEN.
 Paraphilias commonly involve sexual arousal and orgasm, usually achieved
through masturbation and fantasy.

7.
Historical aspect
 Richard von Krafft-Ebing, a German psychiatrist credited with formally
introducing the study of sexology as a psychiatric phenomenon, identified
paraphilias first in his 1886 Psychopathia Sexualis (Sexual Psychopathy).
 The term paraphilia was coined by psychologists in the early 1900s
 Previously, these were called perversions.
 The term paraphilia first appeared in the third version of the DSM classification. In
the first version of the DSM published in 1952, sexual deviations were
conceptualized as a subclass of sociopathic personality disturbance.
 In DSM-II sexual deviations were classified with the personality disorders.

8.
Prevalence
 Prevalence rates for paraphilias are difficult to obtain due to changes in
criterion over time and between cultures*
 Ahlers et al. surveyed a sample of 1,915 German men aged 40-79 and found
62.4% reported at least one paraphilia-associated sexual arousal pattern, and
that this caused distress in only 1.7% of cases.**
 Langstrom and Seto surveyed a sample of 2,450 individuals aged 18-60 years
and found that 3.1% of participants reported at least one incident of being
sexually aroused by exposing their genitals to a stranger and 8% admitted
being sexually aroused spying on others having sex. ***
* Bhugra D, Popelyuk D, McMullen I. Paraphilias across cultures: contexts and controversies. J Sex Res. 2010;47:242–56. doi: 10.1080/00224491003699833.
** Ahlers CJ, Schaefer GA, Mundt IA, Roll S, Englert H, Willich SN, Beier KM. How unusual are the contents of paraphilias? Paraphilia-associated sexual arousal
patterns in a community-based sample of men. J Sex Med. 2011;8:1362–70. doi: 10.1111/j.1743-6109.2009.01597.x.
*** Långström N, Seto MC. Exhibitionistic and voyeuristic behavior in a Swedish national population survey. Arch Sex Behav. 2006;35:427–35. doi: 10.1007/s10508-
006-9042-6.

9.
 Briken et al. reported that in a study of sexual murderers, there were higher
levels of sexual sadism alongside other paraphilic-related interests and
disorders.*
 *Briken P, Habermann N, Kafka MP, Berner W, Hill A. The paraphilia-related disorders: an investigation of the relevance of the concept in sexual murderers. J
Forensic Sci. 2006;51:683–8. doi: 10.1111/j.1556-4029.2006.00105.x.

10.
Etiology
 The etiology of paraphilias is unknown.
 Psychoanalytical Theory
o 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.
o 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

11.
o The persistent, repetitive nature of the paraphilia is caused by an inability to
erase the underlying trauma completely.
 Behaviorist Theory
o The paraphilia begins via a process of conditioning. Nonsexual objects can
become sexually arousing if they are frequently and repeatedly associated with
a pleasurable sexual activity.

12.
 The following are situations or causes that might lead someone in a paraphiliac
direction:
 Parents who humiliate and punish a small boy for strutting around with an
erect penis;
 A young boy who is sexually abused;
 An individual who is dressed in a woman's clothes as a form of parental
punishment;
 Fear of sexual performance or intimacy;
 Excessive alcohol intake;
 Physiological problems;
 Sociocultural factors;
 Psychosexual trauma.

13.
 Biological Factors
o sexual deviance is associated with frontal and/or temporal lobe damage, Subtle
defects of the right amygdala.

14.
Paraphillic
disorder
Anomalous
activity
preferences
Courtship
disorder
Voyeuristic
Disorder
Exhibitionisti
c Disorder
Frotteuristic
Disorder
Algolangic
disorder
Sexual
Masochism
Disorder
Sexual
Sadism
Disorder
Anomalous
target
preferences
Pedophilic
Disorder
Transvestic
Fetishism
Fetishistic
Disorder

15.
 Both the ICD-10 and DSM-IV include eight specific paraphilias outlined with
additional ‘not otherwise specified (DSM-IV), unspecified (ICD-10), other
specified paraphilic disorder and unspecified paraphilic disorder (DSM-5)’
categories.

16.
Voyeuristic Disorder
 DSM-5 DIAGNOSTIC CRITERIA
 A. Over a period of at least 6 months, recurrent and intense sexual arousal
from observing an unsuspecting person who is naked, in the process of
disrobing, or engaging in sexual activity, as manifested by fantasies, urges, or
behaviors.
 B. The individual has acted on these sexual urges with a nonconsenting
person, or the sexual urges or fantasies cause clinically significant distress or
impairment in social, occupational, or other important areas of functioning.
 C. The individual experiencing the arousal and/or acting on the urges is at
least 18 years of age.

17.
 The word comes from the term VOIR, meaning “To See”
 Voyeurism, also known as scopophilia.
 The onset of voyeuristic behavior is usually before the age of 15.
 This disorder is more common in men.
 Masturbation to orgasm usually accompanies or follows the event.
 The voyeur feels frustrated and incapable of establishing a regular sexual
relationship with the person he observes.

18.
Exhibitionistic Disorder
 DIAGNOSTIC CRITERIA DSM-5
 A. Over a period of at least 6 months, recurrent and intense sexual arousal from the
exposure of one’s genitals to an unsuspecting person, as manifested by fantasies, urges,
or behaviors.
 B. The individual has acted on these sexual urges with a nonconsenting person, or the
sexual urges or fantasies cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
 Specify whether:
 Sexually aroused by exposing genitals to prepubertal children
 Sexually aroused by exposing genitals to physically mature individuals
 Sexually aroused by exposing genitals to prepubertal children and to physically
mature individuals

19.
 Exhibitionism, also known as “flashing” or “indecent exposure,”
 Occurs predominately in men
 In almost 100 percent of cases, those with exhibitionism are men exposing
themselves to women.
 Orgasm is brought about by masturbation during or after the event.
 The dynamic of men with exhibitionism is to assert their masculinity by showing
their penises and by watching the victims' reactions -fright, surprise, and disgust.

20.
Frotteuristic Disorder
 DIAGNOSTIC CRITERIA
 A. Over a period of at least 6 months, recurrent and intense sexual arousal
from touching or rubbing against a nonconsenting person, as manifested by
fantasies, urges, or behaviors.
 B. The individual has acted on these sexual urges with a nonconsenting
person, or the sexual urges or fantasies cause clinically significant distress or
impairment in social, occupational, or other important areas of functioning.

21.
 Derived from the word ‘Frotter’ meaning ‘To rub’
 Frotteurism is described only in men.

22.
Sexual Masochism Disorder
 DIAGNOSTIC CRITERIA
 A. Over a period of at least 6 months, recurrent and intense sexual arousal
from the act of being humiliated, beaten, bound, or otherwise made to suffer,
as manifested by fantasies, urges, or behaviors.
 B. The fantasies, sexual urges, or behaviors cause clinically significant
distress or impairment in social, occupational, or other important areas of
functioning.
 Specify if:
 With asphyxiophilia: If the individual engages in the practice of
achieving sexual arousal related to restriction of breathing.

23.
Sexual Masochism
 Comes from the name of an Austrian Writer Leopold Baron von Sacher-
Masoch. Who is known for his novels about men being sexually humiliated by
women. A Masochist is someone who seeks pleasure from being subjected to
pain.
 More common among men than among women
 About 30 percent of those with sexual masochism also have sadistic fantasies.
 The three main characteristics of masochism are pain, loss of control, and
humiliation.

24.
Sexual Sadism Disorder
 DIAGNOSTIC CRITERIA DSM-5
 A. Over a period of at least 6 months, recurrent and intense sexual arousal
from the physical or psychological suffering of another person, as manifested
by fantasies, urges, or behaviors.
 B. The individual has acted on these sexual urges with a nonconsenting
person, or the sexual urges or fantasies cause clinically significant distress or
impairment in social, occupational, or other important areas of functioning.

25.
 The term Sadism comes from the name of French author Marquis de Sade, who
wrote extensively about obtaining sexual enjoyment from inflicting cruelty.
 Both terms were coined by Krafft-Ebing, a german physician.
 In contrast to Sexual Masochism, which does not require a partner, sexual
sadism clearly requires a partner to enact sadistic fantasies.
 The onset of the disorder is usually before the age of 18 years, and most
persons with sexual sadism are male .
 According to psychoanalytic theory, sadism is a defence against fears of cas-
tration; persons with sexual sadism do to others what they fear will happen to
them and derive pleasure from expressing their aggressive instincts .

26.
 John money lists five contributory causes
of sexual sadism: hereditary
predisposition, hormonal malfunctioning,
pathological relationships, a history of
sexual abuse, and the presence of other
mental disorders.

27.
 Krafft-Ebing sub classified sexual sadism into several categories including:
I. Lust-murder;
II. Mutilation of corpses or necrophilia;
III. Injury to females (stabbing);
IV. Defilement of women;
V. Other kinds of assaults on women—symbolic sadism in which, for
example, the perpetrator cuts the hair of his victims rather than harming
them directly;
VI. Ideal sadism or sadistic fantasies alone without acts;
VII. Sadism with other objects, for example, whipping boys;
VIII. Sadistic acts with animals.
In some individuals sadistic fantasies and compulsions lead to rape or homicide.

28.
Sadomasochism
 A paraphilia that combines sadistic and masochistic roles in sexual interaction.
Sadism is the intentional infliction of pain on another person or the threat to do
so, for sexual excitement.
 Masochism is a condition in which a person derives sexual gratification from
being subjected to pain or to the threat of pain.

29.
Pedophilic Disorder
 DIAGNOSTIC CRITERIA DSM-5
 A. Over a period of at least 6 months, recurrent, intense sexually arousing
fantasies, sexual urges, or behaviors involving sexual activity with a prepubescent
child or children (generally age 13 years or younger).
 B. The individual has acted on these sexual urges, or the sexual urges or fantasies
cause marked distress or interpersonal difficulty.
 C. The individual is at least age 16 years and at least 5 years older than the child or
children in Criterion A.
 Note: Do not include an individual in late adolescence involved in an ongoing
sexual relationship with a 12- or 13-year-old.

30.
 Specify whether:
 Exclusive type (attracted only to children)
 Nonexclusive type
 Specify if:
 Sexually attracted to males
 Sexually attracted to females
 Sexually attracted to both
 Specify if:
 Limited to incest

31.
 Most child molestations involve genital fondling or oral sex. Vaginal or anal
penetration of children occurs in frequently, except in cases of incest.
 Fifty to 70 percent of pedophiles can be diagnosed as having another
paraphilia, such as frotteurism, exhibitionism, voyeurism, or sadism.
 Pedophiles are approximately 2.5 times more likely to engage in physical
contact with a child than simply voyeuristic or exhibitionist activities.

32.
Fetishistic Disorder
 DIAGNOSTIC CRITERIA DSM-5
 A. Over a period of at least 6 months, recurrent and intense sexual arousal
from either the use of non-living objects or a highly specific focus on
nongenital body part(s), as manifested by fantasies, urges, or behaviors.
 B. The fantasies, sexual urges, or behaviors cause clinically significant distress
or impairment in social, occupational, or other important areas of functioning.
 C. The fetish objects are not limited to articles of clothing used in cross-
dressing (as in transvestic disorder) or devices specifically designed for the
purpose of tactile genital stimulation (e.g., vibrator).
 Specify: Body part(s)/Non-living object(s)/Other

33.
 Fetishism is where a person feels a strong recurrent sexual attraction to a
nonliving object.
 Sexual activity may be directed toward the fetish itself (e.g., masturbation with
or into a shoe), or the fetish may be incorporated into sexual intercourse (e.g.,
the demand that high-heeled shoes be worn).
 Objects include shoes, gloves, underwear, stockings, swimsuits, etc.
 Almost exclusively found in men.

34.
Partialism
 Another variant of Fetishism.
 People with Partialism are solely
interested in the sexual gratification
from a specific body part, examples
are feet, neck, underarms, back,
etc.

35.
Transvestic Disorder
 DIAGNOSTIC CRITERIA DSM-5
 A. Over a period of at least 6 months, recurrent and intense sexual arousal from cross
dressing, as manifested by fantasies, urges, or behaviors.
 B. The fantasies, sexual urges, or behaviors cause clinically significant distress or
impairment in social, occupational, or other important areas of functioning.
 Specify if:
 With fetishism: If sexually aroused by fabrics, materials, or garments.
 With autogynephilia: If sexually aroused by thoughts or images of self as female.

36.
 The literal meaning of the word transvestism is to wear the clothing of the
opposite sex.
 Sometimes accompanied by masturbation.
 Typically begins in childhood or early adolescence.
 As years pass, some men with transvestism want to dress and live permanently
as women
 Rare in female.

37.
RARE PARAPHILIAS

38.
Diagnosis
 Penile pletysmography – measurement of patient’s sexual arousal(of blood
flow to the penis) in response to audio or visual imagery
 DSM-5 criteria
Course and Prognosis
 Paraphilic behaviors emerge in adolescence and early adulthood.
 In general paraphilic behaviors are chronic.
 Individuals may cross over from one paraphilia to another
 Difficult to treat.

39.
Treatment
 Paraphiliacs seldom seek treatment because of their guilt, shame, and fear of
social ostracism and legal problems
 Five types of psychiatric interventions are used to treat persons with paraphilic
disorder and paraphilic interests: external control, reduction of sexual drives,
treatment of comorbid conditions (e.g. Depression or anxiety), cognitive-
behavioral therapy, and dynamic psychotherapy.
 The efficacy of treatment in paraphiliacs is unknown.

40.
Surgical Treatment
 Surgical treatment for sex offenders consist of two types: Neurosurgery and
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.

41.
Pharmacologic Treatment
 Antiandrogens
 Testosterone is the most common androgen in man
 Cyproterone acetate and medroxyprogesterone are the two most
commonly used antiandrogen medications.
 Reduce libido, erections, ejaculations, and spermatogenesis.
 Side effects such as weight gain, hyperglycemia, hot and cold flashes, liver
dysfunction, hypertension, muscle cramps, phlebitis, gastrointestinal
complaints, and feminization.

42.
 Hormonal Agents
 Leuprolide and triptorelin are hormonal agents referred to as long-acting
GnRH agonists.
 These agents inhibit the secretion of luteinizing hormone with a resulting
decrease in plasma testosterone levels and libido.
 They produce a chemical castration in that the hypothalamic–pituitary axis
is exhausted and there is a potent inhibition of gonadotropin.

43.
 The side effects include decreased bone mineral density or osteopenia,
weight gain, hyperglycemia, diabetes, hypertension, and insomnia.
 The most commonly reported side effects are erectile/ejaculatory problems
and gynecomastia.
 Selective Serotonin Reuptake Inhibitors (SSRIs)
 Sertraline, fluvoxamine, and fluoxetine were equally effective in reducing
paraphilic symptoms.

44.
Psychological and Behavioral Treatment
 Cognitive-behavioral therapy is used to disrupt learned paraphilic patterns and
modify behavior to make it socially acceptable.
 The interventions include social skills training, sex education, cognitive
restructuring, relaxation technique, and learning what triggers the paraphilic
impulse so that such stimuli can be avoided are also taught.
 Insight-oriented psychotherapy is a long-standing treatment approach.