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Presented by Dr Pavan Kumar K

Chaired by Dr Manju Bhaskar

• Greek words “para” - next to and “philia” - love.

• “next to or along side of love”
• normal sexual behavior results in healthy, nonharming, sexual
• Sexual practices that result in unhealthy, harming sexual
contact are judged undesirable and in need of change.
• Also behaviors considered evolutionarily maladaptive and
• Inability to resist an impulse for the deviant sexual acts.

• defined as recurrent and preferred sexually arousing fantasies

or behaviors involving
• nonhuman objects,
• sadomasochistic behaviors, or
• children or other non-consenting persons.
• duration must be for at least 6 months and
• must not be due to another disorder.

• Richard von Krafft-Ebing

• a German psychiatrist - study of sexology as a psychiatric
• identified paraphilias 1st in his 1886 Psychopathia Sexualis
(Sexual Psychopathy).
• Groundwork for the development of research and treatment.
• Sigmund Freud
• human sexuality advance through stages.
• individuals progress toward “normal” heterosexuality unless
• all paraphilias as infantile, i.e, not mature sexual behavior.
Comparative Nosology
Paraphilias – a mental disorder

• DSM - a mental disorder - “associated with present distress or

disability or significantly increased risk of suffering death,
pain, disability, or important loss of freedom.”
• Neither deviant (e.g. political, religious, or sexual)
nor conflicts that are primarily b/w the individual and society
are mental disorders
• unless the deviance/conflict is a symptom of a dysfunction in
• DSM suggests that participation in paraphilic behavior is
consistent with the diagnosis of paraphilia.
• In other words paraphilic behavior is synonymous with the
presence of a paraphilia.
• DSM classified sexual deviations with psychopathic
personality disturbances - belief that sexual deviations were
unlawful and thereby those individuals engaging in them were
• DSM-II -- sexual deviations - classified with PDs.
• DSM-III changed nomenclature from sexual deviation to
• Paraphilias were classified as psychosexual disorders, which
included gender identify disorders, psychosexual
dysfunctions, and ego-dystonic homosexuality.
• DSM-IV-TR reclassified transvestism from a disorder of gender
identity to a paraphilia called transvestic fetishism.
paraphilia-related disorders

• Sexual impulsivity disorders (SIDs)

• Paraphilias
• Paraphilia-related disorders

• sexual behaviors affected are not considered “deviant” with

respect to contemporary cultural norms
• compulsive masturbation,
• protracted heterosexual (nymphomania..) or
homosexual promiscuity,
• pornography dependence ,
• telephone-sex dependence and
• severe sexual desire incompatibility

• data regarding paraphilic phenomena are limited due to the

ego-syntonic nature of these recurrent erotic interests

• Gender Ratio
• Paraphilias are predominantly male sexuality disorders.
• Except for sadism and masochism, autoerotic asphyxia the
paraphilias are almost never diagnosed in females, although
some cases have been reported.
Prevalence in Nonparaphilic Populations

• difficult to obtain
• In one study of General population

5.3 3.2 young girl in
11.7 raping adult
33 sex with an animal

young boy in
• A study of college students' sexual behavior

5 3
8 frottage

42 making obscene
telephone calls
coercive sexual
35 sexual contact with
girls under age 12
• A total of 65% reported having participated in some variant of
paraphilic behavior.
Paraphilic population

• Data gathered from more than 90 treatment programs throughout North America regarding 2,129
cases of individuals seeking assessment

paraphilic population
child molestation
11.2 voyeurism
13.3 exhibitionism
13.8 20.2

cross over

• Initially, individuals with paraphilia thought to be obsessed

with one type of paraphilic behavior.
• Recent studies suggest that individuals with paraphilias
“cross over” from one paraphilia behavior to another
• between touching (frottage, rape, and pedophilia) and
nontouching (voyeurism and exhibitionism) of their victims,
• between family and nonfamily members,
• between female and male victims, and
• to victims of various ages
• Lehne and Money (2003) proposed the term multiplex
paraphilia to describe variations of paraphilic content being
expressed in one individual.
• Bancroft (1989) proposed that paraphilias may develop in
response to individual differences in the nervous system and
• the same conditions that allow the development of one
paraphilia may invite the development of others.

• The paraphilic fantasy or behavior may be

obligatory (required for arousal) or
nonobligatory (wherein the individual experiences arousal
with other erotic stimuli as well).
• Many individuals report a nonobligatory paraphilic pattern in
early life, with the pattern becoming increasingly obligatory
over time and with increased exposure to the stimulus

• For assessment and treatment purposes, paraphilias can be

partitioned into two types:
• coercive and noncoercive.
• Noncoercive paraphilias are more likely to consist of solo
and/or consensual activities;
• these include sadism, masochism, fetishism, and transvestic
• Coercive paraphilias, for which patients may be apprehended
by legal authorities for imposition of their paraphilic drives
onto others,
• consist of nonconsensual activities such as voyeurism,
exhibitionism, frotteurism, and pedophilia.

• Unknown
• Biological theory
• structural impairment of brain regions critical for sexual
• Subtle defects of the right amygdala and closely related
structures - pathogenesis of pedophilia and might reflect
developmental disturbances or environmental insults at
critical periods
• Neurological hypothesis –
• sexual deviance is associated with frontal and/or temporal
lobe damage.
• This damage may translate into an individual's inability to
control sexual impulse or directly cause paraphilic behavior .
• Monoamine hypothesis (1997,Kafka)
• 1st - monoamine NTs, DA,NE & 5-HT - modulatory role in
human sexual motivation, appetite, and consummatory
• 2nd - sexual effects of pharmacological agents that affect
monoamine NTs can have both significant facilitative and
inhibitory effects on sexual behavior.
• 3rd - paraphilic disorders have Axis I comorbidy with nonsexual
psychopathologies associated with monoaminergic
• 4th - drugs that enhance central 5HT function reported to
ameliorate paraphilic sexual arousal and behavior.
Psychoanalytical Theory

• represent a regression to or a fixation at an earlier level of

psychosexual development, resulting in a repetitive pattern of
sexual behavior that is not mature.
• So an individual repeats or reverts to a sexual habit arising
early in life.
• Another theory holds that these are all expressions of hostility
in which sexual fantasies or unusual sexual acts become a
means of obtaining revenge for a childhood trauma.
• The persistent, repetitive nature of the paraphilia is caused by
an inability to erase the underlying trauma completely.
• Indeed, a history of childhood sexual abuse is sometimes seen
in individuals with paraphilias.
Behaviorist Theory

• paraphilia begins via a process of conditioning.

• Nonsexual objects can become sexually arousing if they are
frequently and repeatedly associated with a pleasurable
sexual activity.
• not usually a matter of conditioning alone;
• there must usually be some predisposing factor, such as
difficulty forming person-to-person sexual relationships or
poor self-esteem.
• situations or causes that might lead in a paraphiliac direction:
• parents who humiliate and punish a small boy for strutting
around with an erect penis;
• a young boy who is sexually abused;
• an individual who is dressed in a woman's clothes as a form of
parental punishment;
• fear of sexual performance or intimacy;
• inadequate counseling;
• excessive alcohol intake;
• physiological problems;
• sociocultural factors;
• psychosexual trauma.

• ICD 10 • DSM IV
• F65 Disorders of sexual preference • Paraphilias
• Includes: paraphilias • 302.4 Exhibitionism
• Excludes: problems associated with • 302.81 Fetishism
sexual orientation (F66.-) • 302.89 Frotteurism
• F65.0 Fetishism • 302.2 Pedophilia
• F65.1 Fetishistic transvestism • Specify if
• F65.2 Exhibitionism Sexually Attracted to Males/
• F65.3 Voyeurism Females / Both
• F65.4 Paedophilia • Specify if: limited to Incest
• F65.5 Sadomasochism • Speciify type: Exclusive Type/
• F65.6 Multiple disorders of sexual Nonexclusivc Type
preference • 302.83 Sexual Masochism
• F65.8 Other disorders of sexual • 302.84 Sexual Sadism
preference • 302.3 Transvestic Fetishism
• F65.9 Disorder of sexual preference, • specify if: With Gender Dysphoria
unspecified • 302.82 Voyeurism
• 302.9 Paraphilia NOS

• G1. Recurrent intense sexual urges and fantasies involving

unusual objects or activities.
• G2. Acts on the urges or is markedly distressed by them.
• G3. The preference has been present for at least six months.
F65.0 Fetishism F65.0 Fetishism 302.81 Fetishism

diagnosed only if the A. The general criteria A. Over a period of at least 6m,
fetish is the most must be met. recurrent, intense sexually
important source of B. The fetish (some non- arousing fantasies, urges, or
sexual stimulation or living object) is the behaviors involving the use of
essential for satisfactory most important source nonliving objects (e.g., female
sexual response. of sexual stimulation; undergarments)
or is essential for B. cause clinically significant
satisfactory sexual distress or impairment in social,
Fetishistic fantasies are response. occupational, or other
common, amount to a important areas of functioning.
disorder when so C. The fetish objects are not
compelling & limited to articles of female
unacceptable as to clothing used in cross-dressing
interfere with sexual (as in Transvestic Fetishism) or
intercourse and cause devices designed for tactile
the individual distress genital stimulation ( a vibrator).
F65.1 Fetishistic F65.1 Fetishistic 302.3 Transvestic Fetishism
transvestism transvestism
Includes: transvestic A. The general criteria for A. Over a period of at least
fetishism. must be met. 6m, in a heterosexual male,
B. The wearing of articles recurrent, intense sexually
The wearing of clothes or clothing of the arousing fantasies, urges, or
of the opposite sex opposite set in order to behaviors involving cross-
principally to obtain create the appearance dressing.
sexual and feeling of being a B. cause clinically significant
excitement. member of the opposite distress or impairment
sex. in social, occupational, or
C. The cross-dressing is other important areas of
closely associated with functioning.
sexual arousal. Specify if:
Once orgasm occurs and With Gender Dysphoria: if the
sexual arousal declines, person has persistent
there is a strong desire discomfort with gender
to remove the clothing. role or identity
Fetishistic transvestism

• distinguished from simple fetishism in that the fetishistic

articles of clothing are not only worn, but worn also to create
the appearance of a person of the opposite sex.
• Usually more than one article is worn and often a complete
outfit, plus wig and makeup.
Fetishistic transvestism

• distinguished from transsexual transvestism (Crossdressing)

• by its clear association with sexual arousal and the strong
desire to remove the clothing once orgasm occurs and sexual
arousal declines.
• A history of fetishistic transvestism is commonly reported as
an earlier phase by transsexuals and probably represents a
stage in the development of transsexualism in such cases.
F65.2 Exhibitionism F65.2 Exhibitionism 302.4 Exhibitionism

almost limited to A. The general criteria A. Over a period of at least

heterosexual males who must be met. 6m, recurrent, intense
expose from a safe distance B. Either a recurrent or a sexually arousing fantasies,
in some public place. persistent tendency to urges, or behaviors
For some, it is the only sexual expose one's genitalia to involving the exposure of
outlet, but others continue unsuspecting strangers one's genitals to an
the habit along with an active (usually of the opposite unsuspecting stranger.
sex life with long-standing sex), almost invariably B. cause marked distress or
relationships. associated with sexual interpersonal difficulty.
arousal and
more pressing at times of masturbation.
emotional stress or crises. C. There is no intention
or invitation to sexual
Most find difficult to control intercourse with the
and ego-alien. "witness(es)“.
If the witness appear
shocked, frightened, or
impressed, the exhibitionist's
excitement is often
F65.3 Voyeurism F65.3 Voyeurism 302.82 Voyeurism
A recurrent or persistent A. The general criteria A. Over a period of at least
tendency to look at people must be met. 6m, recurrent, intense
engaging in sexual or B. Either a recurrent or a sexually arousing fantasies,
intimate behaviour such as persistent tendency to look urges, or behaviors
undressing. at people engaging in involving the act of
sexual or intimate observing an unsuspecting
This usually leads to sexual behaviour such person who is naked, in the
excitement as undressing, associated process of disrobing, or
and masturbation and is with sexual excitement and engaging in sexual activity.
carried out without the masturbation. B. Cause marked distress or
observed people being interpersonal difficulty.
aware. C. There is no intention to
reveal one's presence.

D. There is no intention to
have a sexual involvement
with the person(s)
F65.4 Paedophilia F65.4 Paedophilia 302.2 Pedophilia
A sexual preference for A. The general criteria A. Over a period of at least 6m,
children, usually of must be met. recurrent, intense sexually arousing
prepubertal or early B. A persistent or a fantasies,
pubertal age. predominant urges, or behaviors involving sexual
preference for sexual activity with a prepubescent child
Some paedophiles are activity with a or children (generally age 13 years
attracted only to girls, prepubescent child or or younger).
others only to boys, children. B. Cause marked distress or
and others C. The person is at interpersonal difficulty.
again are interested in least 16 years old and C. The person is at least age 16
both sexes. at least five years years and at least 5 yrs older than
older than the child the child or children in Criterion A.
Rarely identified in or children in B. Specify if;
women. Sexually Attracted to Males
Sexually Attracted to Females
Sexually Attracted t o Both
Specify if: Limited to Incest
Specify type: Exclusive Type
(attracted only to children)
Nonexclusive Type
• Contacts between adults and sexually mature adolescents are
socially disapproved, especially if the participants are of the
same sex, but are not necessarily associated with paedophilia.
• An isolated incident, especially if the perpetrator is himself an
adolescent, does not establish the presence of the persistent
or predominant tendency required for the diagnosis.
• Included among paedophiles, however, are men who retain a
preference for adult sex partners but, because they are
chronically frustrated in achieving appropriate contacts,
habitually turn to children as substitutes.
• Men who sexually molest their own prepubertal children
occasionally approach other children as well, but in either
case their behaviour is indicative of paedophilia.
F65.5 Sadomasochism F65.5 Sado-masochism 302.83 Sexual Masochism
302.84 Sexual Sadism
A preference for sexual A. The general criteria Sexual Masochism
activity that involves must be met. A. Over a period of at least 6m,
bondage or the infliction of B. A preference for recurrent, intense sexually
pain or humiliation. sexual activity, either as arousing fantasies, urges, or
If the individual prefers to be recipient (masochism), behaviors involving the act
the recipient of such or as provider (sadism), (real, not simulated) of being
stimulation - masochism; if or both, which involves humiliated, beaten, bound, or
the provider-sadism. at least one of the otherwise made to suffer.
Often an individual obtains following: Sexual Sadism
sexual excitement from both (1) pain; A. Over a period of at least 6m,
sadistic & masochistic (2) humiliation; recurrent, intense sexually
activities. (3) bondage. arousing fantasies, urges, or
Mild degrees of C. The sado-masochistic behaviors involving acts (real, not
sadomasochistic stimulation activity is the most simulated) in which psychological
are common to enhance important source of or physical suffering (including
otherwise normal sexual stimulation or humiliation) of the victim is
activity. This category should necessary for sexual sexually exciting to the person.
be used only if gratification. B. The person has acted on these
sadomasochistic activity is sexual urges with a nonconsenting
the most imp source of person, or the sexual urges or
sexual gratification. fantasies cause marked distress or
interpersonal difficulty.
• Sexual sadism is sometimes difficult to distinguish from
cruelty in sexual situations or anger unrelated to eroticism.
• Where violence is necessary for erotic arousal, the diagnosis
can be clearly established.
F65.6 Multiple disorders of F65.6 Multiple disorders of DSM IV
sexual preference sexual preference
Sometimes more than one The likelihood of more No similar entity
disorder of sexual than one abnormal sexual
preference occurs in one preference occurring in
person and none has clear one individual is greater
precedence. than would be expected by
The most common
combination is fetishism, For research purposes the
transvestism, and different types of
sadomasochism. preference, and their
relative importance
to the individual, should be
F65.8 Other disorders of sexual preference
ICD 10 ICD10 DCR 302.9 Paraphilia NOS
relatively uncommon. Paraphilias that do not meet
making obscene telephone calls, rubbing up against the criteria for any
people for sexual stimulation in crowded public places of the specific categories.
(frotteurism), sexual activity with animals, use of Examples include, but are
strangulation or anoxia for intensifying sexual not limited to, telephone
excitement, and a preference for partners with some scatologia
particular anatomical abnormality such as an (obscene phone call s),
amputated limb. necro philia (corpses ),
Necrophilia should also be coded here. partialism (exclusive focus
on part of body),
Swallowing urine, smearing faeces, or piercing foreskin zoophilia (animals),
or nipples may be part of the behavioural repertoire in coprophilia (feces),
sadomasochism. kusmaphilia (enemas), and
Masturbatory rituals of various kinds are common, but urophilia (urine).
the more extreme practices, such as the insertion of
objects into the rectum or penile urethra, or partial self
strangulation, when they take the place of ordinary
sexual contacts, amounts to abnormalities
• F65.9 Disorder of sexual preference, unspecified
• Includes: sexual deviation NOS
Pathology and Laboratory Examination

• Plethysmography - phallometric assessment of physiological

sexual arousal by measuring penile circumference in males.
• The test is conducted by placing a small circular spring gauge
around the penis.
• This gauge is calibrated to measure changes in the
circumference of the penis in response to both audio and
visual stimuli depicting various sexual vignettes.
• As the individual becomes aroused with the stimuli, the
erect penis displaces the gauge and a measurement is
• In addition to diagnostic evaluations, phallometric testing
is helpful in determination of an individual's response to
Differential Diagnosis

• make a diagnosis based on an individual's behavior rather

than on the individual's sexual preference.
• For ex, the DD for a child molester may include pedophilia,
PD, MR, or substance abuse.
• In order to determine what diagnosis fits the child
molester one has to understand what motivated the
molester to have sexual contact with the child.
• If the molester describes sexual urges and fantasies to
sexual contact with a prepubescent individual, they meet
the criteria for pedophilia.
• If the molester reports h/o learning difficulties consistent
with MR & explains his molesting behavior on his desire to
“have sex with anyone,” the diagnosis is MR & possibly PD.
• nonparaphilic Axis I comorbidities in paraphilic patients.
• mood disorders,
• anxiety disorders,
• retrospectively diagnosed childhood ADHD,
• substance use disorders, and
• impulse control disorders,
• Axis II conditions, borderline intellectual functioning or MR, may
play a role in paraphilic-type behaviors, although patients
technically are not paraphilic.
• Patients may participate in such behaviors by virtue of intellectual
limitations, stimulus availability, or lack of SST or sex education
• In one study of 47 incarcerated sexual offenders, 72% had at least
one PD, and the most prevalent was ASPD.
Course and Prognosis

• Paraphilic behaviors emerge in adolescence and early

• In general paraphilic behaviors are chronic.
• Although it has been shown that individuals may cross over
from one paraphilia to another, the overall course of
paraphilic behavior is chronic.
• Because of the early onset and repudiated biological priming
of the paraphilias, they are often difficult to treat.
Treatment Background

• Empirical evidence for treatment of individuals with

paraphilias is derived from studies of sex offenders
Assessment Tools

• no reliable or valid psychometric inventories

• Derogatis Sexual Functioning Inventory and the Psychopathy
Checklist—Revised (Derogatis 2008)
Biological Treatment

• The scientific basis of biological treatment in paraphiliacs is

the reduction of sexual behaviors by decreasing testosterone
Surgical Treatment for sexual offenders

• Neurosurgery and castration.

• The neurosurgical procedure - stereotaxic removal of parts of
the hypothalamus to disrupt production of male hormones
and decrease sexual arousal and impulsive behaviors.
• significant adverse effects and considered largely ineffective.
• Surgical castration is the removal of the testes and globally
reduce available androgen.
• Sturup followed 107 castrated sex offenders and compared
them to 58 who were not castrated for 18 years.
The castrated individuals recidivated at a rate of 4.3 % and
the uncastrated individuals recidivated at a 43 % rate
Chemical castration

• antiandrogen and hormonal medications rendered surgical

castration nearly obsolete.
• The effects of surgical castration achieved through chemical
castration (i.e., the use of medications to decrease
testosterone production), without the invasiveness and
irreversibility of surgery.
• Some states in the US (Texas, California) mandate chemical or
surgical treatment of dangerous sexual offenders.
• Controversy exists as to whether surgical castration should be
offered as a treatment, as chemical castration achieves the
same results and spares the procedure.
Pharmacologic Treatment- Antiandrogens

• block production / interfere with action of male hormones.

• Cyproterone acetate (CPA) and medroxyprogesterone (MPA) -
MC antiandrogens used to reduce serum level of testosterone.
• Thus reducing libido, erections, ejaculations & spermatogenesis.
• A meta-analysis of antiandrogen studies (Grossman et al)
suggest that recidivism rates as low as 1 % for treated patients
and as high as 68 % for untreated patients.
• s/e - weight gain, hyperglycemia, hot and cold flashes, liver
dysfunction, hypertension, muscle cramps, phlebitis, G.I
complaints, and feminization.
• little known abt long-term sequelae of antiandrogen treatment.
Hormonal Agents

• Leuprolide & triptorelin - hormonal agents referred as long-

acting GnRH agonists.
• Inhibit secretion of LH & decrease plasma testosterone levels
• Produce chemical castration in that the hypothalamic–pituitary
axis is exhausted & potent inhibition of gonadotropin.
• Patients previously treated with CPA, MPA, or SSRIs reported
better effects when taking LHRH agonists.
None of the treated patients had a relapse.
• s/e - decreased bone mineral density or osteopenia, weight gain,
hyperglycemia, diabetes, hypertension, and insomnia.
• MC s/e - erectile/ejaculatory problems and gynecomastia.
• Effective, few s/e, better tolerated alternatives to antiandrogens
Selective Serotonin Reuptake Inhibitors (SSRIs)

• mechanism poorly understood

• effective in reducing paraphilic symptoms.
• Greenberg and colleagues demonstrated that sertraline ,
fluvoxamine, and fluoxetine were equally effective in
reducing paraphilic symptoms.
• Though SSRIs are effective, presently insufficient data to
conclude that SSRIs are equally efficacious as antiandrogens
or hormonal agents.
Cognitive-Behavioral Therapy

• mainstay of treatment for patients with paraphilia

(Safer Society Foundation and ATSA) in reducing recidivism
• CBT focuses on the interaction of thoughts, affects, and
• identifying and challenging cognitive distortions and breaking
through patients’ denial.
• Thought substitution, redirection, and distractions are taught
as ways to replace maladaptive thoughts and redirect thinking
toward more healthy topics.
• victim empathy training, which is particularly important for
patients with coercive paraphilias
• behavioral methods- satiation, covert sensitization, fading,
aversive stimulation
• Other methods include behavioral rehearsal, behavioral
abstinence, and positive conditioning
• Relapse Prevention
• Similar to patients who abuse substances
• Identifying risks, learning to deal with urges, and developing a
plan of action if faced with a trigger are imperative for this
patient population.
Models of Treatment
• Cognitive behavior group treatment & pharmacologic treatment.
• Recent research reveals victim empathy, remorse, responsibility
training, and relapse prevention are integral components of a
treatment program.
• A survey (Safer Society,1994) identified
• >90% of programs utilized victim empathy, anger management
&cognitive distortions;
• 75% provided social skills/assertiveness training,
• 42% prescribed SSRIs, and 19% prescribed antiandrogens.
• Research revealed the preferred therapies were individual
psychotherapy, SST & group therapy;whereas
• aversion conditioning, castration, sex drive reducing drug
therapy were the least acceptable forms of treatment.
Ethical and Legal Considerations

• unique to this population.

• As such the traditional codes of ethics employed in medical
treatment are not applicable to the treatment of sex offenders.
• A significant percentage of sex offenders receiving treatment
have been mandated by the courts to do so as part of
sentences of incarceration or release into the community.
• The concept of mandated or involuntary treatment raises the
issue of whether informed consent is possible in sex offender
• A condition of informed consent for medical treatment is that
the consent must be voluntary.
• Obviously, court-ordered sex offender treatment is not
• Individuals who reject treatment are subject to punishment
imposed by the courts.
• Individuals who have been court ordered to receive treatment
do not have a choice regarding the type of treatment or the
treatment provider.
• Sex offenders are required to complete particular programs,
irrespective of any other treatment they might be receiving, in
order to gain community release or avoid imprisonment.
• In the medical model, patients have a right to refuse various
types of treatment. The right to refuse treatment is based on
an individual's constitutional right to privacy. The court views
sex offenders as incompetent patients, and as such the court
becomes the decision maker regarding treatment.
Confidentiality and Privilege

• Confidentiality - physician's obligation to keep information

learned in a professional relationship private from others.
• Privilege - patient's right to prevent a physician from providing
testimony about personal medical information.
• Both are routinely breached in sex offender treatment.
• When individuals enter treatment, they are required to give
permission for their cases to be discussed with both clinical &
nonclinical personnel, correctional officers, members of their
family, past and potential victims, and those associated with them
and fellow offenders.
• In response to the deviations from traditional ethical codes
inherent in sex offender treatment, ethical and practice guidelines
developed by the Association for the Treatment of Sexual
Abusers (ATSA).
ATSA's code of ethics

• endorses standards of professional conduct that promote

competent practice, and as such, they represent a public
commitment to clients and society toward the goal of
preventing sexual violence.
• ethical care of sex offenders is achieved by encouraging
individuals to take responsibility for their behavior, that is,
admission of guilt.
• maintains that the identification and collaborative
management of risk and safety factors are indeed in the best
interests of both sex offender patients and potential victims
due to the grave consequences incurred by sexual offender
Legal Issues

• Clinicians should remain mindful that “paraphilic patients” are

not necessarily “sex offenders”.
• sex offender is used to refer to an individual who has been
legally convicted of a sex offense.
• When evaluating a patient as part of legal or criminal
proceedings, the clinician needs to understand
• his or her role—as a clinician treating the patient,
• as a witness in court (for either the prosecution or the
defense, as a fact or expert witness), or
• as provider of a second opinion.
• If the patient was forced into the evaluation because of legal
difficulties, this may limit his or her honesty or disclosure to
the clinician
Key points

• Paraphilias are predominant in males.

• Other aspects of demographics & epidemiology-not well defined.
• Difficulties arise in evaluation and diagnosis because patients
hesitate to get treatment (egosyntonic nature).
• Specific populations may be quite different from general
paraphilic populations.
• Findings on forensic populations may not generalize to
nonforensic patient populations.
• Also, sexually deviant or opportunistic behaviors as related to
PDs, such as ASPD, may not represent paraphilias per se.
• Treatment begins with a thorough assessment of the patient.
• The clinician determines why the patient presented at the
current time and whether the individual truly desires treatment.
• Evaluation and treatment of psychiatric comorbidities is essential.
• Comorbid issues, such as mood or anxiety disorders, may be
secondary to paraphilic behaviors or stresses (interpersonal
problems, threat of discovery).
• Cognitive-behavioral therapy is the mainstay of psychotherapy
• Other behavioral therapies, such as SST, sex education, and
vocational rehabilitation, also may be helpful for specific patients.
• Relapse prevention techniques may be relevant as well.
• Psychotropics -commonly used in this patient population.
• Selective serotonin reuptake inhibitors are most widely used.
• Antipsychotics, antiepileptics, anxiolytics, psychostimulants, and
the opiate antagonist naltrexone may prove beneficial as well.
• Hormonal agents may act by decreasing testosterone, desire,
and arousal response.
• Routine follow-up appointments and monitoring of side effects is
crucial with any medication.

• To assess, manage, and treat paraphilias is among the least

evidence-based undertakings in all of psychiatric practice today.
• Current psychiatric literature concerns the sexual offender
population, which is not necessarily synonymous with the
paraphilic population in general.
• This patient population requires future research, via intensive
investigation, formalized research, and well-reasoned
therapeutic trials, for conceptualizing the most appropriate
treatment modalities for this population in need of care.