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 dysphoria, and patients manifesting a paraphilic disorder. This article will not address sexual dysfunctions or gender dysphoria, 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 exhibitionism. Table 11 Fred S. Berlin, MD, PhD (page 24) lists the paraphilic disorders identified in DSM-5. Associate Professor of Psychiatry 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 Sexual dysfunction, paraphilic be harmful. disorders, and gender dysphoria The spectrum of human sexuality 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 anorgasmia) 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 sexual attraction 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 pedophilia 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 mental health 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 Sexual sadism disorder 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 play 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