Commentary

Paraphilic disorders: A better understanding

Current Psychiatry. 2019 April;18(4):22-26,28

References

1. Diagnostic and statistical manual of mental disorders, 5th ed. Washington, DC: American Psychiatric Association; 2013:423-450.
2. Berlin FS. Pedophilia: criminal mind-set or mental disorder? A conceptual review. American Journal of Forensic Psychiatry. 2001;32(2):3-25.
3. Berlin FS. A conceptual overview and commentary on gender dysphoria. J Am Acad Psychiatry Law. 2016;44(2):246-252
4. Berlin FS. Pedophilia: when is a difference a disorder: Peer commentaries on Green (2002) and Schmidt (2002). Arch Sex Behav. 2002;31:1-2.
5. Ford B, Chase C. Betty: a glad awakening. New York, NY: Doubleday; 1987.
6. Virtuous Pedophiles. https://www.virped.org/. Accessed September 28, 2018.
7. Freund K, Kuban M. The basis of the abused abuser theory of pedophilia: A further elaboration of an earlier study. Arch Sex Behav. 1994;23(5):553-563.
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. Love and love sickness: The science of sex, gender differences, and pair bonding. Baltimore, MD: Johns Hopkins University Press; 1980.
10. The Nobel Prize in Chemistry 1939. https://www.nobelprize.org/prizes/chemistry/1939/summary/. Accessed September 29, 2018.
11. Berlin FS. Commentary: The impact of surgical castration on sexual recidivism risk among civilly committed sex offenders. J Am Acad Psychiatry Law. 2005;33(1):37-41.
12. Hansen H. Treatment of dangerous sexual offenders. In: Seminar on Prison Health Services in Tampere, Finland. Helsinki, Finland: Ministry of Justice, Government Printing Centre; 1991:33-38.
13. Berlin FS. Risk/benefit ratio of androgen deprivation treatment for sex offenders. J Am Acad Psychiatry Law. 2009;37(1):59-62.
14. Berlin FS, Meinecke CF. Treatment of sex offenders with antiandrogenic medication: conceptualization, review of treatment modalities, and preliminary findings. Am J Psychiatry. 1981;138(5):601-607.
15. Neri R. Pharmacology and pharmacokinetics of flutamide. Urology. 1989;34(suppl 4):19-21; discussion 46-56.
16. Adi Y, Ashcroft D, Browne K, et al. Clinical effectiveness and cost consequences of selective serotonin receptor reuptake inhibitors in the treatment of sex offenders. Health Technol Assess. 2002;6(28):1-66.
17. Anton RF. Naltrexone for the management of alcohol dependence. N Engl J Med. 2008;359(7):715-721.
18. Berlin FS. Commentary on pedophilia diagnostic criteria in DSM-5. J Am Acad Psychiatry Law. 2011;39(2):242-244.

Can treated patients still be sexual?

If pharmacologic treatment of a paraphilic disorder results in erectile dysfunction, prescription of a medication such as sildenafil can be considered for patients who are in a consenting adult relationship, generally with the knowledge of their partner. Sildenafil can facilitate erectile capacity without increasing sexual drive. It can be helpful to explain to a patient that the purpose of pharmacologic treatment is not to prevent the enjoyment of sexual feelings within the context of a healthy, consenting, adult relationship, but instead to lower the intensity of problematic sexual urges, thereby facilitating sexual self-control. Just as lowering the appetite for food can make it easier to diet but not impossible to eat, lowering sexual appetite can facilitate successful self-control without necessarily interfering with erotic feelings experienced during sexual intimacy.

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 patient’s sexual drive can facilitate successful sexual self-regulation.

Related Resources

LeVay S. Gay, straight and the reason why: the science of sexual orientation. London, UK: Oxford University Press; 2011.
Rosler A, Witztum E. Treatment of men with paraphilia with a long-acting analogue of gonadotropin-releasing hormone. N Engl J Med. 1998;338(7):416-422.
Brown GR. Overview of paraphilic disorders (paraphilias). https://www.merckmanuals.com/professional/psychiatricdisorders/sexuality,-gender-dysphoria,-and-paraphilias/overview-of-paraphilic-disorders.

Drug Brand Names

Flutamide • Eulexin
Leuprolide injection •
Eligard, Lupron Depot
Medroxyprogesterone •
Provera
Naltrexone • Revia, Vivitrol
Progesterone • Prometrium
Sildenafil • Viagra