Commentary PARAPHILIC DISORDERS

Paraphilic disorders: A better understanding

Patients with these disorders are a significantly misunderstood and underserved population

n my role as the Director of The Johns Hopkins Sex and Gender Clinic, I have had the opportunity to provide care Ito 3 broad categories of patients: patients with sexual dysfunctions, patients experiencing gender , and patients manifesting a paraphilic disorder. This article will not address sexual dysfunctions or , but these terms are defined in the Box1-3 (page 23) to clearly dis- tinguish them from paraphilic disorders. Persons with paraphilic disorders (predominantly males) experience recurrent atypical sexual fantasies and urges that cause clinically significant impairment or distress.1 Those atypical fantasies and urges may be directed towards unac- ceptable partners such as animals or children, or towards PHOTGRAPHEE.EU unacceptable behaviors such as public . Table 11 Fred S. Berlin, MD, PhD (page 24) lists the paraphilic disorders identified in DSM-5. Associate Professor of and Behavioral Sciences This article focuses primarily, though not exclusively, upon The Johns Hopkins University School of Medicine pedophilic disorder, and its pharmacologic treatment. Founder, The Johns Hopkins Sexual Disorders Clinic Director, The Johns Hopkins Sex and Gender Clinic However, the rationale underlying such treatment is appli- Director, National Institute for the Study, Prevention, cable across the paraphilic spectrum. Before providing such and Treatment of Sexual Trauma treatment, it is important for clinicians to have a clear con- Baltimore, Maryland ceptual understanding of paraphilic disorders.

When is a difference a disorder? Cancer and respiration are 2 different biologic phenom- enon. Cancer causes suffering and impairment, and as a consequence, we label it a disorder. We do so in the hope of learning more about it, and being able to successfully

Disclosure Current Psychiatry The author reports no financial relationships with any companies whose products are mentioned 22 April 2019 in this article, or with manufacturers of competing products. treat it. We do not classify respiration as a Box disorder because we do not consider it to , paraphilic be harmful. disorders, and gender dysphoria The spectrum of is MDedge.com/psychiatry quite broad, and psychiatry is generally not ndividuals with a sexual dysfunction (eg, concerned with private sexual thoughts Ierectile dysfunction or ) generally experience conventional sexual feelings, but and behaviors involving consenting adults they may have difficulty performing sexually.1 that do not cause suffering or impairment. Although ordinarily capable of adequate When adults choose to engage in “kinky sexual performance, persons with a paraphilic disorder experience atypical erotic cravings.2 sex” that causes neither harm nor distress, Such cravings can either be for an atypical or so be it. unacceptable category of potential partner Some individuals may be privately (eg, animals or children), or for an atypical or unacceptable type of behavior (eg, cross- aware of experiencing either an exclusive dressing or public exhibitionism). Individuals or nonexclusive to chil- with gender dysphoria frequently experience dren. Some of these individuals may not distress because their internal sense of be distressed by experiencing such attrac- feeling either male or female is not congruent with their external physical anatomy.3 The tions, and may be fully capable of resisting primary concerns of individuals experiencing Clinical Point the temptation to enact them. In such an gender dysphoria relate to feelings of gender Paraphilic disorders, instance, even though an individual may identity, as opposed to problems involving erotic arousal. be experiencing sexual attractions that are including pedophilic different from the norm, there may not disorder, do not be a sufficient basis for diagnosing pedo- develop as a result of philic disorder. However, that difference in volitional choice sexual phenomenology (ie, mental experi- treatment of a pedophilic disorder could ence) could rise to the level of a diagnos- help prevent the serious consequences of able disorder if the individual in question child molestation from occurring. expresses distress about experiencing such In contemporary society, the term pedo- attractions, and/or if his capacity to resist philia, which is a psychiatric specifier acting upon them is impaired.4 Under intended to guide research and treatment, such circumstances, treatment would has been hijacked by the nonmedical com- be warranted. munity and turned into a demeaning pejo- rative. In the collective consciousness of the public, the term is routinely Patients with paraphilic disorders and mistakenly equated with the behavior deserve treatment of child molestation. Just as all alcoholics Prior to establishment of the Betty Ford are not drunk drivers, all individuals with Clinic in 1982, individuals who were drug- pedophilic disorder are not “child molest- or alcohol-dependent were often por- ers.” Conversely, not all “child molesters” trayed in a negative light and referred to have pedophilic disorder. by derogatory pejoratives such as “bum” Individuals with other types of para- or “pothead.”5 Over time, society came philic disorders are frequently similarly to appreciate that good people, deserv- maligned and referred to as “perverts” ing of treatment, can become dependent or “deviants.” Public service announce- upon substances, and in recent years ments are frequently aired to reach out to there has been considerable support for individuals who are depressed, or drug- related research initiatives and humane or alcohol-dependent, or suffering with Discuss this article at care. However, there has not been analo- other forms of mental disorders. When www.facebook.com/ MDedgePsychiatry gous support for individuals who manifest does one hear a public service announce- paraphilic disorders, especially those with ment that encourages young people who pedophilic disorder. Instead, such individ- may be experiencing disturbing or unac- uals are often perceived as undeserving ceptable sexual feelings to seek psychiatric of care and resources. This treatment? There is a support group on the Current Psychiatry has been the case, even though successful internet called Virtuous Pedophiles.6 That Vol. 18, No. 4 23 Table 1 individuals do not decide to become sexu- Paraphilic disorders in DSM-5 ally attracted to prepubescent children. Who would decide to do that? Instead, Voyeuristic disorder unlike most of us, some individuals dis- Exhibitionistic disorder cover this about themselves; this often is a Frotteuristic disorder deeply disturbing insight. It is not an individual’s fault that he or Sexual masochism disorder Paraphilic she has a paraphilic disorder. It is, how- disorders ever, his or her responsibility to do some- Pedophilic disorder thing about it. This may require accessing Fetishistic disorder appropriate psychiatric care. Transvestic disorder Other specified paraphilic disorder Why treatment may be needed Unspecified paraphilic disorder Sex is a powerful, biologically based Source: Reference 1 appetite that recurrently craves satiation. Clinical Point God or nature has put that drive into all It is not a patient’s of us to ensure the survival of human- ity. Even when that powerful biologic fault that he or she organization is unequivocally opposed to drive becomes misdirected (for example, has a paraphilic child molestation, while supporting efforts towards children, or towards a desire to disorder, but it is his to improve the mental well-being of indi- engage in public exhibitionism), it still or her responsibility viduals who, through no fault of their own, recurrently craves satisfaction. It does not experience unwanted pedophilic feelings. require mental health expertise to appre- to access appropriate ciate what a problematic situation this psychiatric care could become. Causes and noncauses Some individuals need help in over- In attempting to elucidate etiology, coming cravings related to nonsexual researchers typically investigate nature appetites. For example, Americans spend (biology) and/or nurture (life experi- millions of dollars each year trying to diet; ences). In terms of the development of they often require some form of assistance pedophilic disorder, there is evidence that in order to succeed. Individuals who both nature and nurture can a role. crave drugs or alcohol often require men- Researchers have found that boys who are tal health interventions to abstain because sexually abused are at increased risk for they are unable to consistently resist developing pedophilic disorder, and evi- through willpower alone the powerful dence of temporal lobe disturbances has biologic urges that drive their actions. also been documented in some instances.7,8 The fundamental mental characteris- From clinical, societal, and forensic per- tic of any paraphilic disorder is the pres- spectives, it may be equally important to ence of intense, recurrent, sexual urges identify noncausal factors. Paraphilic dis- of an atypical nature. In the case of a orders, including pedophilic disorder, do pedophilic disorder, those urges involve not develop as a consequence of volitional sexual feelings about children.2 In the case choice.9 For example, none of us decide of an exhibitionistic disorder, the afflicted which category, or categories, of poten- individual experiences intense, recurrent tial partners are going to attract us sexu- sexual fantasies/urges related to expos- ally. Rather, in maturing we discover the ing his genitals in public.1 Clearly, most nature of our own sexuality. Children do men do not have to recurrently fight off not ponder their options, somehow decid- the urge to act in such a fashion. Given ing while growing up to be attracted to the the driven nature of intense erotic crav- opposite sex (), the same sex ings, individuals who experience such (), or both sexes (bisexual- cravings will frequently require access to Current Psychiatry 24 April 2019 ity). Similarly, in maturing into adulthood, competent mental health care. Table 2 Paraphilic disorders: Protocol for pharmacologic treatment

Baseline laboratory MDedge.com/psychiatry testing Primary medication Ancillary medication Monitoring Complete metabolic Leuprolide panel Route: IM Route: Oral (monthly) Complete blood Dosage: 7.5 mg Dosage: 250 mg Weight (monthly) count Frequency: every Frequency: 3 times a Laboratory testing (total/ 4 weeks day for 14 days only (yearly) free) (to begin with initial Follicle-stimulating injection of leuprolide) Luteinizing hormone Bone density scan

Clinical Point Consider a sex drive- Pharmacologic treatment of a sex drive–lowering medication should of paraphilic disorders be considered when either the clinician or lowering medication if In the future, we may develop a scientifi- the patient is concerned that a nonpharma- you or the patient feel cally based understanding of the biologic cologic approach may be inadequate. In all a nonpharmacologic factors that underlie qualitative differences instances, a patient with a paraphilic disor- approach may be in sexuality. At that point, it may become der should be informed that pharmacologic inadequate possible to intervene pharmacologically, treatment is an option. A protocol for the changing the qualitative nature of a sexual pharmacologic treatment of paraphilic disor- urge with pharmacologic interventions. ders that is based on my clinical experience This cannot yet be done. However, much is summarized in Table 2. is already known about the biology related to the quantitative (intensity) dimension Leuprolide. A depot form of leuprolide of sexuality. is the most commonly employed agent to In 1939, a Nobel Prize in Chemistry was pharmacologically lower testosterone to awarded for the identification and isolation treat a paraphilic disorder.13 When injected of the hormone testosterone, which ener- into muscle, leuprolide binds to it before gizes sexual drive.10 If an individual is hun- gradually being released into the blood- gering sexually to expose himself, to view stream. Previously, a depot medroxypro- child , or to engage in sexual gesterone (a form of progesterone) had acts with children, the intensity of such hun- been used to treat paraphilic disorders.14 gers can be significantly reduced by low- However, that had required weekly rather ering testosterone, thereby enhancing the than monthly injections, and carried an capacity for successful sexual self-control. increased risk of thrombotic emboli. A large body of scientific data has docu- Prescribing leuprolide to treat a para- mented a marked decrease in sexually moti- philic disorder falls under FDA guidelines vated behaviors when testosterone levels are regarding the use of an approved drug for significantly diminished.11 There is also evi- an “off-label” indication, and therefore is dence that recidivism rates of sexually moti- not considered investigational. For treating vated crimes can be significantly reduced a paraphilic disorder, an effective dosage when testosterone-lowering interventions of leuprolide is 7.5 mg IM every 4 weeks. are used.12 Long-term treatment is generally required, Historically, removal of the testes (surgi- analogous to the management of . cal ) had been the only effective Because the initial injection of the series can way to reliably lower testosterone. Today, cause a transient increase in testosterone Current Psychiatry this can be achieved pharmacologically. Use (prior to its sustained decline), flutamide, a Vol. 18, No. 4 25 testosterone receptor blocking agent, is ordi- Tests to order before starting narily prescribed for the first 14 days only, leuprolide following initiation of treatment with depot Long-term use of leuprolide can increase leuprolide.15 Using flutamide in this fashion the risk of osteoporosis. Therefore, a prevents the transient increase in testoster- baseline bone density scan should be one from transiently increasing sexual drive. performed before starting a patient on Flutamide should be discontinued after 14 leuprolide. Baseline levels of testosterone, Paraphilic days because long-term use can result in follicle-stimulating hormone, and lutein- disorders liver toxicity. izing hormone also should be obtained. Some clinicians have been hesitant Patients should have yearly physical to prescribe leuprolide because of nega- examinations, with accompanying labora- tive connotations associated with the term tory testing. Hematocrit levels are often “.” Unlike surgical cas- marginally low after beginning treat- tration, use of leuprolide is not a physi- ment, but not in a clinically significant cally irreversible intervention, and does not way. Patients should also undergo routine result in sterility (although there may be an monitoring for possible weight gain and Clinical Point increase of atypical sperm and a decrease the potential for associated . A depot form of in total sperm production). The dosage Treatment is predicated upon the known can sometimes be titrated without a loss testosterone-suppressing effects of leupro- leuprolide can of efficacy. lide, not upon routine monitoring of blood be used to lower In general, leuprolide’s safety protocol is levels. testosterone to treat a well within the range associated with psy- Pharmacologic treatment of a paraphilic paraphilic disorder chotropic medications.13 Low-risk adverse disorder should ordinarily occur in con- effects, such as hot flashes or cold sweats, junction with nonpharmacologic modali- may occur, especially during the period ties. One such modality would be group when hormone levels are in transition. There , similar to the type frequently are no absolute contraindications to the use used to treat other craving disorders, such of leuprolide. as drug or alcohol dependency. In recent years, I have seen increasing Other medications. Some researchers have numbers of patients presenting with a his- suggested treating paraphilic disorders with tory of accessing and viewing child por- psychotropic medications known to lower nography. Once they have become more , such as selective serotonin reuptake aware of the serious consequences of this inhibitors (SSRIs).16 However, leuprolide is behavior, most patients have been able far more reliable in consistently lowering to discontinue doing so without pharma- testosterone and lowering the frequency and cologic treatment. However, for patients intensity of sexual urges. Although psychia- in whom that behavior has seemed more trists unfamiliar with treating paraphilic dis- driven (suggestive of a variant of voyeuris- orders may feel more comfortable initiating ), prescription of leuprolide treatment with an SSRI, in my clinical expe- has been beneficial. Under such circum- rience, SSRIs have often proven inadequate stances, I have diagnosed the patient’s for this purpose. When it comes to those condition as “other specified paraphilic paraphilic disorders in which treatment fail- disorder” with elements of pedophilia ure can result in significant harm (eg, pedo- and —the associated behaviors philic disorder), in my judgment, leuprolide restricted to the voyeuristic viewing of should be the pharmacologic treatment of child pornography.18 choice. The antagonist naltrexone has been used clinically to reduce cravings, Can treated patients still be primarily cravings for alcohol or drugs.17 sexual? However, I have not seen convincing evi- If pharmacologic treatment of a paraphilic dence that it can be reliably beneficial in disorder results in , pre- Current Psychiatry 26 April 2019 treating paraphilic disorders. scription of a medication such as continued on page 28 continued from page 26 References Related Resources 1. Diagnostic and statistical manual of mental disorders, 5th ed. Washington, DC: American Psychiatric Association; • LeVay S. , straight and the reason why: the science 2013:423-450. of . London, UK: Oxford University 2. Berlin FS. Pedophilia: criminal mind-set or ? Press; 2011. A conceptual review. American Journal of Forensic • Rosler A, Witztum E. Treatment of men with Psychiatry. 2001;32(2):3-25. with a long-acting analogue of gonadotropin-releasing 3. Berlin FS. A conceptual overview and commentary on hormone. N Engl J Med. 1998;338(7):416-422. gender dysphoria. J Am Acad Psychiatry Law. 2016;44(2): 246-252 • Brown GR. Overview of paraphilic disorders (). 4. Berlin FS. Pedophilia: when is a difference a disorder: Peer Paraphilic https://www.merckmanuals.com/professional/psychiatric- commentaries on Green (2002) and Schmidt (2002). Arch Sex disorders disorders/sexuality,-gender-dysphoria,-and-paraphilias/ Behav. 2002;31:1-2. overview-of-paraphilic-disorders. 5. Ford B, Chase C. Betty: a glad awakening. New York, NY: Doubleday; 1987. Drug Brand Names 6. Virtuous Pedophiles. https://www.virped.org/. Accessed Flutamide • Eulexin Naltrexone • Revia, Vivitrol September 28, 2018. Leuprolide injection • Progesterone • Prometrium 7. Freund K, Kuban M. The basis of the abused abuser theory Eligard, Lupron Depot Sildenafil • Viagra of pedophilia: A further elaboration of an earlier study. Arch Medroxyprogesterone • Sex Behav. 1994;23(5):553-563. Provera 8. Mendes MF, Chow T, Ringman T, et al. Pedophilia and temporal lobe disturbances. J Neuropsychiatry Clin Neurosci. 2000;12(1):71-76. 9. Money J. and love sickness: The science of sex, gender Clinical Point differences, and pair bonding. Baltimore, MD: Johns Hopkins University Press; 1980. In my clinical 10. The Nobel Prize in Chemistry 1939. https://www. can be considered for patients who are nobelprize.org/prizes/chemistry/1939/summary/. experience, SSRIs are in a consenting adult relationship, gener- Accessed September 29, 2018. 11. Berlin FS. Commentary: The impact of surgical castration often inadequate for ally with the knowledge of their partner. on sexual recidivism risk among civilly committed sex treating paraphilic Sildenafil can facilitate erectile capacity offenders. J Am Acad Psychiatry Law. 2005;33(1):37-41. 12. Hansen H. Treatment of dangerous sexual offenders. In: disorders without increasing sexual drive. It can be Seminar on Prison Health Services in Tampere, Finland. helpful to explain to a patient that the pur- Helsinki, Finland: Ministry of Justice, Government Printing Centre; 1991:33-38. pose of pharmacologic treatment is not to 13. Berlin FS. Risk/benefit ratio of androgen deprivation prevent the enjoyment of sexual feelings treatment for sex offenders. J Am Acad Psychiatry Law. 2009;37(1):59-62. within the context of a healthy, consenting, 14. Berlin FS, Meinecke CF. Treatment of sex offenders with adult relationship, but instead to lower antiandrogenic medication: conceptualization, review of treatment modalities, and preliminary findings. Am J the intensity of problematic sexual urges, Psychiatry. 1981;138(5):601-607. thereby facilitating sexual self-control. 15. Neri R. and pharmacokinetics of flutamide. . 1989;34(suppl 4):19-21; discussion 46-56. Just as lowering the appetite for food can 16. Adi Y, Ashcroft D, Browne K, et al. Clinical effectiveness and make it easier to diet but not impossible to cost consequences of selective serotonin receptor reuptake inhibitors in the treatment of sex offenders. Health Technol eat, lowering sexual appetite can facilitate Assess. 2002;6(28):1-66. successful self-control without necessar- 17. Anton RF. Naltrexone for the management of alcohol dependence. N Engl J Med. 2008;359(7):715-721. ily interfering with erotic feelings experi- 18. Berlin FS. Commentary on pedophilia diagnostic criteria in enced during sexual intimacy. DSM-5. J Am Acad Psychiatry Law. 2011;39(2):242-244.

Bottom Line Paraphilic disorders are not manifestations of a character flaw, but manifestations of unchosen qualitative differences in the nature of one’s sexual cravings. Not enough is yet known about the biology of sex to be able to pharmacologically alter its qualitative nature. However, pharmacologically lowering the intensity of a Current Psychiatry 28 April 2019 patient’s sexual drive can facilitate successful sexual self-regulation.