1) Paraphilias refer to recurrent and intense sexual urges, fantasies or behaviors that involve unusual objects, activities, or situations and cause distress or impairment. They have been categorized and defined in various ways across different editions of the DSM and ICD classification systems. 2) Common paraphilic disorders include voyeuristic disorder, exhibitionistic disorder, frotteurism, sexual masochism disorder, sexual sadism disorder, pedophilic disorder, fetishistic disorder, and transvestic disorder. 3) The etiology of paraphilias is complex and multifactorial, involving possible genetic, neurological, environmental, and psychosocial factors. Common comorbidities include other

1. PARAPHILIAS- DIAGNOSIS
& MANAGEMENT
Chair person: Dr. Bevin, Assistant Professor
Presenter: Dr. Neelakandan S, III year PG
Discussant: Dr. Nasreen Fathima, III year PG
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2. INTRODUCTION
• 'Paraphilia' (Greek: Para - beside, philos - love) loving, besides ordinary/apart from,
what is normally acceptable
• 'paraphilia' coined Friedrich Solomon Krauss in 1903 as ‘abnormal erotic instinct’,
• First used by William Stekel. "paranormal or dangerous instincts where sexual
gratification was not obtained from normal heterosexual intercourse”
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3. PARAPHILIAS FROM 1ST DSM TO DSM 5
FIRST DSM Sexual deviations (now paraphilias), classified under the subclass of
Sociopathic personality disturbance
DSM II Paraphilia - a personality disorder
DSM III Paraphilia was designated as a psychosexual disorder
DSM III R Paraphilia term was used
DSM IV &
DSM IV-TR
Same as DSM III
DSM IV- TR Transvestism from GID to a paraphilia
DSM V Changes in the definition,
Included Paraphilic disorders,
Paraphilia and Paraphilic disorder had separate meaning 3

4. • ICD-10 includes paraphilia under Section V (Mental and Behavioural disorders) as
F65, ‘Disorders of sexual preference’ describing Paraphilia
• ICD-11 however, describes it under Section 17- ‘Conditions related to sexual health’;
‘Paraphilic disorders’ (6D30-6D3Z)
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5. DSM-5:
• Paraphilia - “any intense and persistent sexual interest other than sexual interest in
genital stimulation or preparatory fondling with phenotypically normal, physically
mature, consenting human partner"
• Paraphilic disorder - “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”
ICD-11:
• “persistent and intense patterns of atypical sexual arousal”, manifested by sexual
thoughts, fantasies, urges, or behaviours,
• the focus of which involves others whose age or status renders them unwilling or
unable to consent and on which the person has acted or by which he or she is
markedly distressed
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8. VOYEURISTIC DISORDER
• voyeurism comes from 'voir' (French: to see)
• common term 'peeping tom’
• 1945- Otto Fenichel described the case of a 'voyeur', renting a room in a bordello to
look through a peephole at another couple having intercourse.
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9. EXHIBITIONISTIC DISORDER 302.4 (F65.2)
• Exhibitionism has existed ever since the mentions of Adam and Eve
• With the development of concepts like 'civility', acts of undressing in public were seen as
depraved and often linked to madness
• First described as a disorder by Charles Lasègue in 1877
• 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
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10. FROTTEURISTIC DISORDER 302.89 (F65.81)
• 'frottage' (French verb 'frotter’, - 'to rub’),
• Recurrent touching and rubbing against non-consenting individuals to gain sexual
pleasure.
• Clifford Allen in 1969 coined 'frotteurism’ & popularized by Richard von Kraft-
Ebing.
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11. SEXUAL MASOCHISM DISORDER
302.83 (F65.51)
• Named after Leopold von Sacher-Masoch, engaged in paraphilic behaviour
• Krafft-Ebing again, in Psychopathia Sexualis’, used in medical parlance
• 1st theory- Johann Heinrich Meibom- "flogging a man's back increases sexual
arousal by making semen flow down into his testicles“
• Specify if:
• With asphyxiophilia: If the individual engages in the practice of achieving sexual arousal
related to restriction of breathing.
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12. SEXUAL SADISM DISORDER 302.84 (F65.52)
• The term 'sadism', given by Krafft-Ebing,
• originated in fictional literature, with the 'deviant' sexual behaviour practised and
described by Marquis Donatien Alphonse Francois de Sade, a French nobleman.
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13. PEDOPHILIC DISORDER 302.2 (F65.4)
• In 1908, Swiss psychiatrist Auguste Forel described the behaviour as 'Pederosis', the
'Sexual Appetite for Children’.
• DSM I- pedophilia included,
• DSM II- placed under ‘Sexual Deviation’, but diagnostic criteria were missing
• DSM III- criteria were provided,
• DSM III R - criteria further expanded
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14. DIAGNOSTIC CRITERIA
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
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15. SPECIFIERS
• 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
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16. FETISHISTIC DISORDER 302.81 (F65.0)
• Portuguese 'feitico' meaning 'obsessive fascination’.
• Fétichisme (fetishism) brought by Alfred Binet in 1887.
• Residual attachment remains after a possibly emotionally rousing experience linked
with the fetish object in childhood.
• Donald Winnicott (1951)- an object closely associated with the growing up child
eventually becomes sexualized
• Specify:
• Body part(s)
• Nonliving object(s)
• Other
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17. TRANSVESTIC DISORDER 302.3 (F65.1)
• Transvestism, (cross-dressing) dressing that in general agreement of society is in
close consonance with the opposite gender.
• 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.
• The presence of fetishism decreases the likelihood of gender dysphoria in men with
transvestic disorder.
• The presence of autogynephilia increases the likelihood of gender dysphoria in men
with transvestic disorder
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18. OTHER SPECIFIED PARAPHILIC DISORDER
302.89 (F65.89)
• Symptoms characteristic of a paraphilic disorder that cause clinically significant
distress or impairment in social, occupational, or other important areas of
functioning predominate
• Do not meet the full criteria for any of the disorders in the paraphilic disorders
diagnostic class.
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19. EXAMPLES
• Telephone scatologia (obscene
phone calls)
• Necrophilia (corpses)
• Zoophilia (animals)
• Coprophilia (feces)
• Klismaphilia (enemas)
• Urophilia (urine)
• Partialism (one part of the body)
• Coprolalia (compulsive utterance
of obscene words)
• Biastophilia (arousal to rape)
• Erotophonophilia (arousal to
murder)
• Hypoxyphilia (hypoxia)
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20. UNSPECIFIED PARAPHILIC DISORDER
302.9 (F65.9)
• Do not meet the full criteria for any of the disorders in the paraphilic disorders
diagnostic class.
• Insufficient information to make a more specific diagnosis.
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21. ETIOLOGY - GENETIC FACTORS
• Hypothesis of genetic factors- not much explored.
• Gaffney et al(1984)- chart review study- sexual deviancy present in 18.5% of families
of paraphilics compared to 3% in control group- suggests familial transmission.
• SOCIAL/ ENVIROMENTAL FACTORS
• Childhood sexual abuse.
• Pornography- reflective of paraphilic predisposition rather than a causal factor.
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22. NEUROBIOLOGICAL FACTORS
• Acquired or congenital brain damage.
Conditions associated with development of paraphilic or hyper sexual behaviours:
• Dementia
• Brain injury
• tourette’s syndrome
• Multiple sclerosis
• Frontal lobotomy
• AIDS related dementia
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23. NEUROLOGICAL HYPOTHESIS:
• Associated with frontal and/or temporal lobe damage.
• Inability to control sexual impulse or directly cause paraphilic behavior.
MONOAMINE HYPOTHESIS(Kafka,1997):
1. Monoamine transmitters- modulatory role in sexual motivation, appetite,
consummatory behaviour.
2. Pharmacological agents affecting monoamine transmitters- facilitatory or
inhibitory effects on sexual behaviour.
3. Comorbid axis 1 non sexual psychopathology.
4. Pharmacological agent that enhance central serotonergic function- ameliorate
paraphilic sexual arousal or behevaior.
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24. PSYCHOANALYTICAL THEORY
• Failed to complete normal development process toward sexual adjustment.
• Regression or fixation to an earlier level of psychosexual development.
• Methods chosen to cope up with threat of castration/ separation from mother/
oedipal crisis.
• Improper choice of object for libido cathexis.
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25. BEHAVIOURIST THEORY
• Suggests “conditioning” in development of paraphilias.
• Non sexual objects - sexually arousing if frequently or repeatedly associated with
pleasurable activity.
• Poor self esteem or difficulty in forming person to person relationships.
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26. COMORBIDITIES ASSOCIATED WITH
PARAPHILIAS
Axis I mental illness Axis II disorders Axis III disorders Others
Affective disorders(3 to 95%)
Substance abuse disorders,
(8 to 85%)
Schizophrenia, other
psychotic disorders
(1.7 – 16%).
Dementia and other
cognitive disorders
Anxiety disorders (3 to 64%)
ADHD (36% )
Eating disorders (10% )
Borderline or
antisocial personality
disorders (33 to 52%)
Trauma to the limbic
system
Previous head trauma
(especially when head
trauma occurred
before the age of 6)
Kleine levin and klüver bucy
syndromes
Huntington ’ s disease
Patients undergoing
dopamine receptor agonist
therapy (e.g., In parkinson ’ s
disease).
A high comorbidity of
impulse control disorders in
paedophiles (30 – 55%)
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27. COURSE
• Unpredictable course
• Hard for people to give up sexual pleasure with no assurance that alternative
approaches will be as sexually gratifying
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28. RECIDIVISM RATE
Rate is low if addressed Rate is high even if addressed
Denial
Low self esteem
Addictive disorders (mostly alcoholism or drug
abuse)
Psychiatric comorbid disorders
Psychopathy and antisocial behaviour
Previous sexual offences (especially rapes) or
non-sexual offences
Sex offenders with intellectual disabilities or
sequels of head injury
An early age of onset
A past history of sexual abuse or physical
violence during childhood
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29. DIFFERENTIAL DIAGNOSIS
• Experimental act that is not recurrent or compulsive and done for its novelty.
• Some paraphilias (especially the bizarre types) are associated with other mental
disorders, such as schizophrenia.
• Brain diseases can also release perverse impulses.
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30. LEGAL ISSUES INVOLVED IN THE
MANAGEMENT
• Legal regulation focusses more on protecting the significant rights of others
• Paraphilic disorders can be subdivided by the potential for risk to others
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Higher risk of profound
physical and
psychological harm
Less likely to cause
profound harm
Unlikely to cause
profound harm
Pedophilic disorder
Sexual sadism disorder
Frotteuristic disorder
Voyeuristic disorder
Exhibitionistic disorder
Fetishistic disorder
Sexual masochism
disorder
Transvestic fetishism

31. DIAGNOSIS & EVALUATION
• Number and type of paraphilias;
• Comorbidity with axis 1 or axis 2 of the DSM classification (especially addictive
disorders or personality disorders);
• Comorbidity with somatic diseases if any;
• Cognitive evaluation if mental retardation or dementia;
• Careful medical examination,
• Blood measurements and/or plasma hormone levels if hormonal treatment is
needed.
• Baseline osteodensitometry could be necessary in case of hormonal treatment. 31

32. TREATMENT
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33. 33
GUIDELINES FOR THE BIOLOGICAL
TREATMENT OF PARAPHILIAS (WFSBP)

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35. EXTERNAL CONTROL
• Prison - usually does not contain a treatment element
• Victimization in a family or work setting- informing supervisors, peers, or other
adult family members of the problem and advising them about eliminating
opportunities for the perpetrator to act on urges.
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36. SELECTIVE SEROTONIN RE-UPTAKE
INHIBITORS (SSRI)
• Numerous reports have confirmed the apparent efficacy of SSRI and related
medications in the treatment of men with paraphilic disorders
• Two important prescribing issues are important:
• (a) There is no evidence that the efficacy of SSRIs in the treatment of paraphilic disorders
is due to suppression of sex drive.
• (b) There is no evidence that higher doses of SSRIs are more effective than low doses.
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37. COGNITIVE-BEHAVIORAL THERAPY
• CBT can disrupt learned paraphilic patterns and modify behavior to make it socially acceptable.
• The interventions include social skills training, sex education, cognitive restructuring (confronting
and destroying the rationalizations used to support the victimization of others), and development of
victim empathy.
• Patient imaginal desensitization and relaxation technique.
• What triggers the paraphilic impulse so that they can avoid these stimuli.
• In modified aversive behavior rehearsal, the therapist videotapes the perpetrators acting out their
paraphilia with a mannequin. Then the therapist or a peer group may confront the patient with
questions about feelings, thoughts, motives associated with the act and repeatedly try to correct
cognitive distortions and point out the lack of victim empathy to the patient.
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38. DYNAMIC PSYCHOTHERAPY
• Insight-oriented psychotherapy is a long-standing treatment approach.
• Mechanism:
Opportunity to understand their dynamics and the events that caused the
paraphilia to develop  they become aware of the daily events that cause them to act on
their impulses (e.g., a real or fantasized rejection).
• Uses:
 Deal more effectively with life stresses and enhances their capacity to relate to a life partner
 Allows to regain self-esteem, which in turn allows them to approach a partner in a more
normal sexual manner.
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39. SEX THERAPY
• Sex therapy is an appropriate adjunct to the treatment of patients with specific
sexual dysfunctions when they attempt nondeviant sexual activities.
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40. GOOD TREATMENT PREDICTORS
• Presence of a single paraphilia
• Normal intelligence
• Absence of substance abuse
• Absence of nonsexual antisocial personality traits
• Presence of a successful adult attachment
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41. REFERENCES
• Diagnostic and statistical manual of mental disorders fifth edition
• New oxford textbook of psychiatry second edition
• Kaplan & sadock’s synopsis of psychiatry twelfth edition
• Practical guide to paraphilia and paraphilic disorders
• The World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for the biological
treatment of paraphilias
• Disorders of sexual preference, or paraphilias: a review of the literature J J GAYFORD
• Portrayal of paraphilia in history, by shreeya basu , Y ashutosh bhardwaj , surobhi chatterjee
• Paraphilia: concepts, classifications, epidemiology, attributes and management by surobhi
chatterjee
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