Paraphilic disorders involve intense and persistent sexual interests that are considered unusual or socially inappropriate. The document discusses several specific paraphilic disorders including voyeuristic disorder, exhibitionistic disorder, frotteuristic disorder, sexual masochism disorder, sexual sadism disorder, pedophilic disorder, fetishistic disorder, and transvestic disorder. It provides diagnostic criteria for each disorder from the DSM-5 and describes characteristics, prevalence, historical aspects, etiology, and related topics for paraphilias and these specific disorders.

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.

17. 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.

18.  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.

19. 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

20.  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.

21. 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.

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

23. 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.

24. 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.

25. 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.

26.  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 .

27.  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.

28.  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.

29. 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.

30. 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.

31.  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

32.  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.

33. 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

34.  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.

35. 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.

36. 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.

37.  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.

38. RARE PARAPHILIAS

39. 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.

40. 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.

41. 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.

42. 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.

43.  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.

44.  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.

45. 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.