Advances in psychiatric treatment (2014), vol. 20, 202–213 doi: 10.1192/apt.bp.113.011197 ARTICLE Paraphilias and paraphilic disorders: diagnosis, assessment and management Jessica Yakeley & Heather Wood Jessica Yakeley is a consultant to general mental health services, presenting SUMMARY psychiatrist in forensic psychiatrists with complex diagnostic, ethical and psychotherapy at the Portman We outline the difficulties in classifying paraphilias treatment challenges. Clinic, and Director of Medical as mental disorder and summarise the changes to Education and Associate Medical this diagnostic category in DSM-5. We review the Director at the Tavistock and Problems with diagnosis and classification Portman NHS Foundation Trust. The research on the epidemiology and aetiology of Portman Clinic specialises in the paraphilias, and provide guidance on assessment Medicalisation of sexuality treatment of paraphilias, criminality, and referral options for general psychiatrists Many psychiatrists do not equate paraphilic violent and antisocial behaviour. when they encounter patients who may meet behaviours or fantasies with psychopathology or Heather Wood is a consultant diagnostic criteria for a paraphilic disorder. mental illness, and engaging mental health services clinical psychologist and adult Empirical evidence for effective treatments for psychotherapist at the Portman in providing appropriate assessment, treatment paraphilias is limited, and specific treatment Clinic, Tavistock and Portman NHS and liaison with criminal justice agencies remains Foundation Trust. services are scarce, particularly for individuals Correspondence Dr Jessica presenting with legal paraphilias or those who a challenge. DSM-IV-TR attempted to clarify Yakeley, Portman Clinic, 8 Fitzjohns are committing paraphilic sexual offences but who when a paraphilia might be deemed pathological Avenue, London NW3 5NA, UK. have not been convicted. by delineating two distinct criteria that had to be Email: [email protected] fulfilled before the diagnosis could be made: that LEARNING OBJECTIVES an abnormal sexual focus be present for at least • Be able to diagnose a paraphilic disorder 6 months; and that the paraphilia must cause according to DSM-5 criteria. ‘clinically significant distress or impairment in • Understand the epidemiology, comorbidity and social, occupational, or other important areas of theories of aetiology of paraphilic disorders. functioning’ (American Psychiatric Association • Know how to assess the need for disclosure if the 2000: p. 523). However, anomalies remained: for patient presents with illegal paraphilias. example, a man who habitually dresses in women’s DeclARAtion OF inteRest clothing because it makes him feel sexually excited None. could not be classified as a fetishistic transvestite according to these criteria unless he felt distressed or impaired by the activity. The designation of paraphilias (Box 1) as a medical disorder has aroused much debate and Normality v. abnormality disagreement over the years. Many rightly object The DSM does not clearly distinguish between to the pathologising of sexual activities that some sexual deviance, sexual offending and paraphilias. consider a lifestyle choice between consenting Sexual deviance is a moral construct that refers adults. Nevertheless, people suffering considerable to sexual behaviours that contravene the mores of distress from sexual fantasies and behaviours that the particular society or culture. It is often equated they find difficult to control continue to be referred with sexual abnormality, although this may reflect the general perception of what should be normal rather than what people really do (Grubin 2008). BOX 1 DSM-5 definition of paraphilia Attempts to define sexual deviance in purely statistical terms are problematic: what is ‘[A]ny intense and persistent sexual interest other than considered sexually deviant may change over time sexual interest in genital stimulation or preparatory (e.g. homosexuality); what many cultures consider fondling with phenotypically normal, physically mature, deviant is the norm in certain subcultures (e.g. consenting human partners.’ fetishistic behaviours in pubertal boys of the (American Psychiatric Association 2013a: p. 685) Sambian tribe in Papua New Guinea (Bhugra 2010)); and quantifying sexual behaviour and 202 Paraphilias and paraphilic disorders determining an appropriate cut-off for abnormal manifestations of other disorders – for example, behaviour is difficult. The Kinsey reports on male the obsessive–compulsive spectrum, mood and female sexuality in the USA in the 1940s and disorders, attention-deficit hyperactivity disorder 1950s (Kinsey 1948, 1953) exposed the wide range and personality disorders – on the basis of common of unusual sexual practices that were found to underlying features such as poor impulse control be more common in the general public than had and emotional dysregulation. previously been acknowledged. Poor reliability and validity Relationship with criminality and sexual offending The DSM diagnostic classification of paraphilias A further important limitation to the current has been criticised for its poor reliability and diagnostic criteria for paraphilias is the confusion validity (Zander 2008), and patients often fulfil regarding their relationship with sexual offending diagnostic criteria for several different paraphilias and criminality. Not all sex offenders have concurrently. Although eight different paraphilias paraphilias and most people with paraphilias are specified in DSM-5 (Box 2), more than 100 do not commit offences (Federoff 2009). Certain unique paraphilias have been described in the paraphilias – such as paedophilia, voyeurism and literature (Federoff 2010). This exposes one of exhibitionism – are illegal if enacted, although it is the limitations of the DSM classification as a not illegal to have fantasies or urges to enact. But whole: it is based on descriptions of symptoms many other forms of sexual behaviour that would and behaviours rather than on underlying be classified as paraphilias – such as fetishism, psychopathological mechanisms or aetiology. DSM- cross-dressing and coprophilia – are not illegal, IV diagnostic criteria have also been criticised for although some may seem bizarre or evoke disgust. their vagueness (e.g. what is meant by recurrent Some have objected to the medicalisation of and intense in Criterion A) and the arbitrariness criminal offences and the potential misuse of in the stipulation that the person must experience psychiatry in diagnosing mental disorder in sexual the paraphilia for 6 months before the diagnosis offenders to legitimise long-term involuntary can be made (O’Donohue 2000). psychiatric commitment to protect the public (Frances 2011). The DSM-5 development team Compulsive sexual activity and sex addiction considered including a new disorder (paraphilic There has been much debate as to whether people coercive disorder) for people who experienced have a mental disorder if they experience recurrent recurrent and intense sexual arousal from sexual and intense sexual fantasies, urges or behaviours coercion and sought sexual stimulation from that they feel compelled to act out and that cause forcing sex on three or more non-consenting persons on separate occasions (American Psychiatric Association 2013a). The proposal was BOX 2 DSM-5 specified paraphilic disorders rejected on the grounds that it would unjustifiably • Voyeuristic disorder (spying on others engaged in transform the crime of repeated rape into a mental private activities) disorder (Zonana 2011). • Exhibitionistic disorder (exposing the genitals) Focus on behaviours • Frotteuristic disorder (touching or rubbing against a non-consenting individual) Although a necessary starting point, a sole focus • Sexual masochism disorder (undergoing humiliation, on paraphilic behaviours invites judgement rather bondage or suffering) than understanding, and risks confounding the • Sexual sadism disorder (inflicting humiliation, bondage important distinction between sexual deviance (as or suffering) defined socially and legally) and mental disorder. A more satisfactory model of paraphilias would be • Paedophilic disorder (sexual focus on children) to describe and understand the phenomenology • Fetishistic disorder (using non-living objects or having a and psychopathology of sexual fantasy and desire highly specific focus on non-genital body parts) (Grubin 2008). For example, repeated rape is a • Transvestic disorder (engaging in sexually arousing behaviour, whereas sexually sadistic fantasy is a cross-dressing) form of psychopathology that is rare even in rapists, ‘Other specified paraphilic disorder’: includes zoophilia but important to identify as it has implications for (animals), scatalogia (obscene phone calls), necrophilia management and treatment. (corpses), coprophilia (faeces), klismaphilia (enemas), Alternative models of paraphilic behaviour urophilia (urine) have been proposed in which sexually problem- (American Psychiatric Association 2013a: pp. 685, 705) atic behaviours have been conceptualised as Advances in psychiatric treatment (2014), vol. 20, 202–213 doi: 10.1192/apt.bp.113.011197 203 Yakeley & Wood distress to themselves or others, such as excessive ICD-10 masturbation, use of pornography, sex with In ICD-10 (World Health Organization 1992), the consenting adults, cybersex or visiting strip clubs. paraphilias are classified as disorders of sexual Internet sex addiction, in which