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The Best of Pill Pushing - The paraphilias - What are they? How are they treated? - (10/27/2019)

By Dr. Ron Gasbarro

Society at the time. The year was 1789. George Washington was unanimously elected the first President of the United States, by the Electoral College. North Carolina became the 12th state to join the Union. Thomas Jefferson returned from Europe, bringing the first macaroni machine to the United States. A national Thanksgiving Day (November 26) was observed in the United States as recommended by President Washington and approved by Congress. American writer James Fenimore Cooper (The Last of the Mohicans) was born. Ethan Allen, the American major general of the Revolutionary War and Vermont statesman, died.  

Marquis de Sade was an 18th-century French libertine author. His manuscript, The 120 Days of Sodom, was written that year while he was incarcerated in the Bastille, a state prison. When, at the beginning of the French Revolution, the Bastille was stormed and looted on July 14, 1789, he believed his work was destroyed and never to be published. Sade later wrote that he "wept tears of blood" over its loss. It was finally found within a wall at the Bastille and published by German psychiatrist in 1904 and considered Marquis de Sade’s most famous, if not infamous and salacious work.

Marquis de Sade – the poster boy for the paraphilias.
The word sadist is derived from de Sade’s name. His written works were deemed both pornographic and erotic. The writer was imprisoned many times for publishing sexually explicit books and stories. The 120 Days of Sodom tells the story of four wealthy male libertines who resolve to experience the ultimate sexual gratification in orgies [Sade, 2010]. To do this, they seal themselves away for four months in an inaccessible castle in the heart of the Black Forest, with a harem of 36 victims, mostly male and female teenagers, and engage four female brothel keepers to tell the stories of their lives and adventures. The women's narratives form an inspiration for the sexual abuse and torture of the victims, which gradually mounts in intensity and ends in their slaughter. A comedy, this was not!

Sadism is just one of the paraphilias. A paraphilia – previously known as sexual perversion and sexual deviation – is the experience of intense sexual arousal to atypical objects, situations, fantasies, behaviors, or individuals [American Psychiatric Association, 2013]. Such an attraction may be labeled sexual fetishism. No consensus has been found for any precise border between unusual sexual interests and paraphilic ones. There is debate over which, if any, of the paraphilias should be listed in diagnostic manuals, such as the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) or the International Classification of Diseases (ICD). The number and taxonomy of paraphilia are under debate; one source lists as many as 549 types of paraphilias. The DSM-5 has specific listings for 8 paraphilic disorders [American Psychiatric Association, 2013], as follows:  
Exhibitionism: Exposing one’s own genitals to an unsuspecting person
Fetishism: Sexual fascination with non-living objects or highly specific body parts
Frotteurism: Touching or rubbing against a non-consenting person
Pedophilia: Sexual activity with a child that is prepubescent (usually 13 years old or younger)
Sexual masochism: Being humiliated, beaten, bound, or otherwise suffering
Sexual sadism: The physical or emotional suffering of another person
Transvestism: Cross-dressing that is sexually arousing and interferes with functioning
Voyeurism: Watching an unsuspecting/non-consenting individual who is either nude, disrobing, or engaging in sexual activity

Some paraphilias do not meet full diagnostic criteria for a paraphilic disorder but may have uncontrolled sexual impulses that cause enough distress for the sufferer that they are recognized. Examples of such specific paraphilias include necrophilia (corpses), scatologia (obscene phone calls), and zoophilia (animals).

The good, the bad, and the ugly

Addiction or conviction?
Whether a paraphilia is a crime is debatable. One can get his or her jollies by dressing up as Katy Perry (if he wants) or Winston Churchill (if she wants) in the confines of their bedrooms. If you want to tie up and flog someone in your basement dungeon, the person better be of age and consent to the activity. Walking down the street in flip-flops – and nothing else – is not a problem until someone sees you and calls the police. Yet, nudist camps exist for that activity. But the definition of an exhibitionist is someone who wants an unsuspecting person to catch him strolling bareass. The seasoned guy who runs the concession stand at the nudist camp would not even blink an eye. 

Pedophilia, surprisingly, is not a crime, but rather a disorder. Pedophilia is not a criminal offense because there are no laws regulating sexual attraction. It is also impossible to tell who is a pedophile and who is not until they act on that attraction. A pedophile can be attracted to young children all they want, so long as they do not ACT on that attraction, and that includes deliberately downloading child pornography. 

Margo Kaplan is an assistant professor of law at Rutgers School of Law in Camden, NJ. She wrote in The New York Times that 1% of the male population finds themselves attracted to prepubescent children [Kaplan, 2014]. These people are living with pedophilia, a sexual attraction to young children that often constitutes a mental illness. Unfortunately, our laws are failing them and, consequently, ignoring opportunities to prevent child abuse.

The DSM-5 defines pedophilia as an intense and recurrent sexual interest in children, and as a disorder if it causes a person “marked distress or interpersonal difficulty” or if the person acts on his interests [DSM-5, 2013]. Yet, states Kaplan, our laws ignore pedophilia until after the commission of a sexual offense, emphasizing punishment, not prevention. Part of this failure stems from the misconception that pedophilia is the same as child molestation. One can live with pedophilia and not act on it. Internet sites like Virtuous Pedophiles provide support for pedophiles who do not molest children and believe that sex with children is wrong. It is not that these individuals are “inactive” or “non-practicing” pedophiles, but rather that pedophilia is a status and not an act. 

A pedophile should be held responsible for his conduct — but not for the underlying attraction to young children. Arguing for the rights of scorned and misunderstood groups is never popular, particularly when they are associated with real harm. But the fact that pedophilia is so despised is precisely why our responses to it, in criminal justice and mental health, have been so inconsistent and counterproductive. Acknowledging that pedophiles have a mental disorder, and removing the obstacles to their coming forward and seeking help, is not only the right thing to do, but it would also advance efforts to protect children from harm.

Don’t touch in the subway, darling

Frotteurism is a paraphilic interest in rubbing, usually one's pelvic area or erect penis, against a non-consenting person for sexual pleasure. It may involve touching any part of the body, including the genital area. A person who practices frotteuristic acts is known as a frotteur. The prevalence of frotteurism is unknown. The DSM-5 estimates that 10%–14% of men seen in clinical settings for paraphilias or hypersexuality have a frotteuristic disorder, indicating that the population prevalence is lower [DSM-5, 2013]. However, frotteuristic acts, as opposed to frotteuristic disorder, may occur in up to 30% of men in the general population. The majority of frotteurs are male and the majority of victims are female, although female on male, female on female, and male on male frotteurs exist. This activity is often done in circumstances where the victim cannot easily respond, in a public place such as a crowded train or concert.

Usually, such nonconsensual sexual contact is viewed as a criminal offense: a form of sexual assault albeit often classified as a misdemeanor with minor legal penalties. Conviction may result in a sentence or psychiatric treatment. The actor may also receive a black eye from the victim or from the victim’s irate boyfriend. 

Treatment of paraphilias
In paraphilic patients, pharmacological interventions should be part of a more comprehensive treatment plan including psychotherapy and, in most cases, behavior therapy [Henson, 2005]. Treatment for paraphilia should reduce or eliminate paraphilic fantasies and behaviors and decrease the level of distress of paraphilic subjects, permitting them to live a normal sexual life, it should not have significant adverse reactions and, most notably, it should avert the risk of acting out and victimization in cases of, for example, pedophilia or exhibitionism [Thibaut, 2012]. The optimal treatment for paraphilias continues to elude clinicians. Current treatments decrease sexual arousal level and behavior but are non-specific in their mechanisms of action. Surgical castration was first used in 1892 in Switzerland. By the 1940s, some attempts had been made to treat paraphilias using estrogens, but due to feminizing adverse reactions, they were replaced in the 1960s by medications that reduce testosterone levels, such as cyproterone acetate (CPA) and medroxyprogesterone acetate (MPA) [Turner, 2013]. These agents are a frequently used in addition to psychotherapy in sex offenders. Due to the lack of controlled clinical trials involving paraphiliacs and multiple side effects, benefits and risks should always be thoroughly assessed.

Combined pharmacologic and psychotherapeutic treatment is associated with better efficacy [Thibaut, 2012]. The gold standard treatment of severe paraphilias in adult males is anti-androgen treatment coupled with cognitive behavioral therapy (CBT). Selective serotonin reuptake inhibitors have been used in mild types of paraphilia and in cases of sexual compulsions and juvenile paraphilias [Assumpção, 2014]. Anti-androgen treatments appear to be effective in severe paraphilic subjects committing sexual offenses [Thibault, 2012]. In particular, gonadotropin-releasing hormone analogs (e.g., leuprorelin, triptorelin) have shown high efficacy working in a similar way to physical castration but being reversible at any time. Gonadotropin-releasing hormone (GnRH) is a hormone produced in the hypothalamus and transported to the pituitary gland through the bloodstream. GnRH controls the secretion of follicle stimulating hormone (FSH) and luteinizing hormone (LH) from the anterior pituitary. Secretion of GnRH is controlled by neural input from other parts of the brain via negative feedback by the sex steroids.

Paraphilia may be secondary to major axis I mental disorders (e.g., schizophrenia or manic episodes), in these cases, antipsychotic treatment and/or mood stabilizers are used as first-line treatment [Thibalt, 2012]. In cases of comorbid depressive or anxiety disorders, antidepressant treatment may be used as the first-line treatment or in combination with anti-androgen treatment if necessary.

Duration of treatment
Paraphilia is a chronic disorder. According to the majority of investigators, a minimum duration of treatment of 3 to 5 years is necessary for severe paraphilia with a high risk of sexual violence. Hormonal treatment must not be stopped abruptly. In case of mild paraphilia, a treatment of at least 2 years might be used, after which the patient must be carefully followed up following treatment discontinuation. Treatment must be resumed in the case of recurrence of paraphilic sexual fantasies. 

Ron Gasbarro, PharmD, is a registered pharmacist, medical writer, and principal at Rx-Press.com. Read more at www.rx-press.com 


American Psychiatric Association. Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing; 2013.

Assumpção AA, Garcia FD, Garcia HD, Bradford JM, Thibaut F. Pharmacologic treatment of paraphilias. Psychiatr Clin North Am. 2014;37:173-81.

Hanson RK, Morton-Bourgon KE. The characteristics of persistent sexual offenders: A meta-analysis of recidivism studies. J Consult Clin Psychol. 2005,73: 1154-1163.

Kaplan M. Pedophilia: A Disorder, Not a Crime. New York: New York Times; October 4, 2014.

Sade. The 120 Days of Sodom. James Havoc, ed. Northport AL: Sun Vision Press, 2012.

Thibaut F. Pharmacological treatment of paraphilias. Isr J Psychiatry Relat Sci. 2012;297-305. 

Turner D, Basdekis-Jozsa R, Briken P. Prescription of testosterone-lowering medications for sex offender treatment in German forensic-psychiatric institutions. J Sex Med. 2013;10:570-8. 



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