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Shocking sex: Complexities in treating paraphilias

MDlinx Apr 18, 2024

Paraphilias refer to the persistence of intense sexually arousing urges, behaviors, or fantasies. The term does not refer to atypical sexual behavior but is something that causes a person mental distress or makes the person psychologically and physically dangerous to someone else.

Examples of paraphilias include pedophilia, sexual sadism, and exhibitionism, among others. Treatment of the disorder is personalized and includes inpatient and outpatient interventions.

Let’s take a closer look at this sexual health issue.


Diagnosing paraphilias


Paraphilias are mental health disorders, per American Psychiatric Association (APA) guidelines in the DSM-5.

Paraphilic disorders. American Psychiatric Association. 2013.

However, it’s important to make the distinction between having atypical sexual interests and being diagnosed with a paraphilic disorder. 


Specifically, for a diagnosis of a paraphilic disorder, the DSM-5 requires that the person:

  • Feels distress about their interest (and not necessarily society’s disapproval)

  • Exhibits a sexual desire that involves another person’s distress, injury, or death

  • Exhibits a desire for sexual behaviors involving unwilling persons who cannot give legal consent





The DSM-5 identifies eight paraphilias: pedophilia, exhibitionism, voyeurism, sexual sadism, sexual masochism, frotteurism, fetishism, and transvestic disorder.

A review published in the Journal of Clinical Medicine states that paraphilias often coexist with other psychiatric conditions, including mood disorders, anxiety disorders, autism, and ADHD.

Culos C, Di Grazia M, Meneguzzo P. Pharmacological interventions in paraphilic disorders: systematic review and insights. J Clin Med. 2024 Mar 7;13(6):1524.

Some people exhibit simultaneous paraphilias, including exhibitionism or voyeurism. Moreover, certain forms of hypersexuality can be linked with exhibitionistic, voyeuristic, and other paraphilic behaviors.


“Despite societal perceptions that some paraphilias, such as pedophilia, are primarily criminal acts, extensive efforts have been made to refine paraphilia definitions and develop comprehensive treatments,” write the review authors. “It is crucial to understand that paraphilias are intricate and heterogeneous disorders, displaying characteristics reminiscent of addictive, impulsive, or obsessive compulsive disorders, and often manifesting as patterns of hypersexuality.”

According to the DSM-5, a patient must have experienced intense/recurrent sexual arousal from deviant fantasies for at least 6 months, and must have acted on these impulses, to be diagnosed with a paraphilia.

Except in the case of pedophilia, those with paraphilias can be characterized as “in remission” or “in a controlled environment,” per authors writing in StatPearls.

Fisher KA, Marwaha R. Paraphilia. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. March 6, 2023. 


Many individuals with paraphilic disorders are arrested for crimes such as rape of children (or others) or exhibitionism. As the review authors emphasize, however, not all sex offenders meet the criteria for paraphilia, and paraphilia is not synonymous with being a sex offender.


Treatment difficulties



Recent treatment paradigms make a distinction between managing and treating paraphilic disorders. Managing these disorders focuses on symptom control, harm reduction, and improvements in daily function; the treatment of such disorders focuses on addressing underlying issues, moderating symptom reduction/remission, and promoting long-term well-being and recovery.

The overview of paraphilias in StatPearls discusses the treatment options available.

Treatment plans are multifaceted and include pharmaco- and psychotherapy measures. Treatment is personalized and includes inpatient and outpatient interventions.

The treatment and management of paraphilias is challenging for various reasons. Patients rarely seek treatment voluntarily and feel indignant, uncomfortable, or culpable at the prospect of such treatment.

Many individuals don’t want to halt their paraphilias due to the sexual pleasure and satisfaction they attain from them. Legal repercussions are also a worry that discourages individuals to pursue treatment.

Ultimately, most patients with paraphilic disorder are forced by the law to undergo treatment or are convinced by family, friends, or sexual partners to do so. 


Available options


Regardless of the type of paraphilia, cognitive behavioral therapy (CBT) is an effective form of psychotherapy. Nevertheless, to protect the public, psychiatrists have to take extreme measures when addressing paraphilias or paraphilic disorders, including the use of anti-androgens (eg, GnRH analogs) to decrease the frequency and intensity of deviant sexual arousal and behaviors. GnRH agonists are most useful in sex offenders at high risk of violence, including serial rapists and those with pedophilic disorder. Patients must consent to treatment with anti-androgens.


Other psychotropic treatments for paraphilias or paraphilic disorders include SSRIs and synthetic steroidal analogs. SSRIs are helpful with milder paraphilias—often experienced by adolescents—including exhibitionism, as well as for symptom control in comorbid OCD and depression.

In appraising the therapeutic methods for paraphilias, the StatPearls authors write: “Despite limited support in the literature and the demand for further definitive research, treatment algorithms for varying severity of illness have been devised, offering useful and rational approaches to treating paraphilic disorder."


The therapeutic choice depends on previous medical history and medication compliance, along with the intensity of both the sexual fantasy and the risk of sexual violence.


What this means for you

The management and treatment of paraphilic disorders is complex, given legal underpinnings and a lack of desire to seek treatment typical among those affected. Medication management and psychotherapy following referral to a psychiatrist is essential, as is maintaining open and honest communication. Unlike conditions that affect only the patient, paraphilias can endanger the lives of others in the form of sexual abuse.


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