The facilitator must present the

1. diagnostic criteria of the disorder based on the DSM-5-TR,

2. the causal factors or etiology
3. assessment tools that can be used
4. treatment of the disorder based on empirical evidence
5. research article related to the disorder being presented

Paraphilia

- denotes any intense and persistent sexual interest other than sexual interest in genital
stimulation or preparatory fondling with phenotypically normal, physically mature, consenting
human partners
- In some circumstances, the criteria “intense and persistent” may be difficult to apply, such as in
the assessment of persons who are very old or medically ill and who may not have “intense”
sexual interests of any kind. In such circumstances, the term paraphilia may be defined as any
sexual interest greater than or equal to nonparaphilic sexual interests.

Paraphilic Disorders

- is a paraphilia that is currently causing distress or impairment to the individual or a paraphilia

whose satisfaction has entailed personal harm, or risk of harm, to others

 A paraphilia is a necessary but not a sufficient condition for having a paraphilic disorder, and
a paraphilia by itself does not necessarily justify or require clinical intervention.

Importance

These disorders have traditionally been selected for specific listing and assignment of explicit diagnostic
criteria in DSM for two main reasons: they are relatively common, in relation to other paraphilic
disorders, and some of them entail actions for their satisfaction that, because of their noxiousness or
potential harm to others, are classed as criminal offenses.

Classification Schemes

The first group of disorders is based on anomalous activity preferences.

- courtship disorders, which resemble distorted components of human courtship behavior

(voyeuristic disorder, exhibitionistic disorder, and frotteuristic disorder)
- algolagnic disorders, which involve pain and suffering (sexual masochism disorder and sexual
sadism disorder)

The second group of disorders is based on anomalous target preferences.

- one directed at other humans (pedophilic disorder)

- two directed elsewhere (fetishistic disorder and transvestic disorder)

 In the diagnostic criteria set for each of the listed paraphilic disorders, Criterion A specifies
the qualitative nature of the paraphilia (e.g., an erotic focus on children or on exposing the
genitals to strangers), and Criterion B specifies the negative consequences of the paraphilia
 (i.e., distress, impairment, or harm to others). In keeping with the distinction between
paraphilias and paraphilic disorders, the term diagnosis should be reserved for individuals
whose paraphilic interests or behaviors meet both Criteria A and B (i.e., individuals who
have a paraphilic disorder). If an individual’s paraphilic interests or behaviors meet Criterion
A but not Criterion B for a particular paraphilia—a circumstance that might arise when a
benign paraphilia is discovered during the clinical investigation of some other condition—
then the individual may be said to have that paraphilia but not a paraphilic disorder.

Paraphilic disorders included in this manual are voyeuristic disorder (spying on others in private
activities), exhibitionistic disorder (exposing the genitals), frotteuristic disorder (touching or rubbing
against a nonconsenting person), sexual masochism disorder (undergoing humiliation, bondage, or
suffering), sexual sadism disorder (inflicting humiliation, bondage, or suffering), pedophilic disorder
(sexual focus on children), fetishistic disorder (using nonliving objects or having a highly specific focus on
nongenital body parts), and transvestic disorder (engaging in sexually arousing cross-dressing).

Voyeuristic Disorder

- spying on others in private activities

Diagnostic Criteria

A. Over a period of at least 6 months, recurrent and intense sexual arousal from observing an
unsuspecting person who is naked, in the process of disrobing, or engaging in sexual activity, as
manifested by fantasies, urges, or behaviors.

B. The individual has acted on these sexual urges with a nonconsenting person, or the sexual urges or
fantasies cause clinically significant distress or impairment in social, occupational, or other important
areas of functioning.

C. The individual experiencing the arousal and/or acting on the urges is at least 18 years of age.

Specify if:

In a controlled environment: This specifier is primarily applicable to individuals living in institutional or

other settings where opportunities to engage in voyeuristic behavior are restricted.

In full remission: The individual has not acted on the urges with a nonconsenting person, and there has
been no distress or impairment in social, occupational, or other areas of functioning, for at least 5 years
while in an uncontrolled environment.

Development and Course

- Adult men with voyeuristic disorder often first become aware of their sexual interest in secretly
watching unsuspecting persons during adolescence. However, the minimum age for a diagnosis
of voyeuristic disorder is 18 years because there is substantial difficulty in differentiating it from
age-appropriate puberty-related sexual curiosity and activity. The persistence of voyeurism over
time is unclear. With or without treatment of voyeuristic disorder, the subjective distress (e.g.,
guilt, shame, intense sexual frustration, loneliness) or impairment from the disorder may change
over time, as may a number of factors that may potentially affect the course of the disorder,
such as psychiatric morbidity, hypersexuality, and sexual impulsivity. Thus, the severity and
 course may vary over time. As with other sexual preferences, advancing age may be associated
with decreasing voyeuristic sexual preferences and behavior. Assessment Tool

Exhibitionistic Disorder

- exposing the genitals

Diagnostic Criteria

A. Over a period of at least 6 months, recurrent and intense sexual arousal from the exposure of one’s
genitals to an unsuspecting person, as manifested by fantasies, urges, or behaviors.

B. The individual has acted on these sexual urges with a nonconsenting person, or the sexual urges or
fantasies cause clinically significant distress or impairment in social, occupational, or other important
areas of functioning.

Specify whether: Sexually aroused by exposing genitals to prepubertal children Sexually aroused by
exposing genitals to physically mature individuals Sexually aroused by exposing genitals to prepubertal
children and to physically mature individuals

Specify if:

In a controlled environment: This specifier is primarily applicable to individuals living in institutional or

other settings where opportunities to expose one’s genitals are restricted.

In full remission: The individual has not acted on the urges with a nonconsenting person, and there has
been no distress or impairment in social, occupational, or other areas of functioning, for at least 5 years
while in an uncontrolled environment.

Development and Course

- Adult men with exhibitionistic disorder often report that they first became aware of sexual
interest in exposing their genitals to unsuspecting persons during adolescence, at a somewhat
later time than the typical development of normative sexual interest in women or men.
Although there is no minimum age requirement for the diagnosis of exhibitionistic disorder, it
may be difficult to differentiate exhibitionistic behaviors from age-appropriate sexual curiosity in
adolescents. Whereas exhibitionistic impulses appear to emerge in adolescence or early
adulthood, very little is known about persistence over time. With or without treatment of
exhibitionistic disorder, the subjective distress (e.g., guilt, shame, intense sexual frustration,
loneliness) or impairment from the disorder may change over time, as may a number of factors
that may potentially affect the course of the disorder, such as psychiatric morbidity,
hypersexuality, and sexual impulsivity. Thus, the severity and course may vary over time. As with
other sexual preferences, advancing age may be associated with decreasing exhibitionistic
sexual preferences and behavior.

Frotteuristic Disorder

- touching or rubbing against a nonconsenting person

Diagnostic Criteria
A. Over a period of at least 6 months, recurrent and intense sexual arousal from touching or rubbing
against a nonconsenting person, as manifested by fantasies, urges, or behaviors.

B. The individual has acted on these sexual urges with a nonconsenting person, or the sexual urges or
fantasies cause clinically significant distress or impairment in social, occupational, or other important
areas of functioning.

Specify if:

In a controlled environment: This specifier is primarily applicable to individuals living in institutional or

other settings where opportunities to touch or rub against a nonconsenting person are restricted.

In full remission: The individual has not acted on the urges with a nonconsenting person, and there has
been no distress or impairment in social, occupational, or other areas of functioning, for at least 5 years
while in an uncontrolled environment.

Development and Course

- Adult men with frotteuristic disorder often report first becoming aware of their sexual interest
in surreptitiously touching unsuspecting persons during late adolescence or emerging
adulthood. However, children and adolescents may also touch or rub against unwilling others in
the absence of a diagnosis of frotteuristic disorder. Although there is no minimum age for the
diagnosis, frotteuristic disorder can be difficult to differentiate from conduct-disordered
behavior without sexual motivation in individuals at younger ages. The persistence of
frotteurism over time is unclear. With or without treatment of frotteuristic disorder, the
subjective distress (e.g., guilt, shame, intense sexual frustration, loneliness) or impairment from
the disorder may change over time, as may a number of factors that may potentially affect the
course of the disorder, such as psychiatric morbidity, hypersexuality, and sexual impulsivity.
Thus, the severity and course may vary over time. As with other sexual preferences, advancing
age may be associated with decreasing frotteuristic sexual preferences and behavior.

Sexual Masochism Disorder

- undergoing humiliation, bondage, or suffering

Diagnostic Criteria

A. Over a period of at least 6 months, recurrent and intense sexual arousal from the act of being
humiliated, beaten, bound, or otherwise made to suffer, as manifested by fantasies, urges, or behaviors.
B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning.

Specify if:

With asphyxiophilia: If the individual engages in the practice of achieving sexual arousal related to
restriction of breathing.

Specify if:

In a controlled environment: This specifier is primarily applicable to individuals living in institutional or

other settings where opportunities to engage in masochistic sexual behaviors are restricted.
In full remission: There has been no distress or impairment in social, occupational, or other areas of
functioning for at least 5 years while in an uncontrolled environment.

Development and Course

- Individuals with paraphilias living in the community have reported a mean age at onset for
masochism of 19.3 years, although earlier ages, including puberty and childhood, have also been
reported for the onset of masochistic fantasies. Very little is known about persistence over time.
With or without treatment of sexual masochism disorder, the subjective distress (e.g., guilt,
shame, intense sexual frustration, loneliness) or impairment from the disorder may change over
time, as may a number of factors that may potentially affect the course of the disorder, such as
psychiatric morbidity, hypersexuality, and sexual impulsivity. Thus, the severity and course may
vary over time. As with other sexual preferences, advancing age may be associated with
decreasing sexual masochistic preferences and behavior.

Sexual Sadism Disorder

- inflicting humiliation, bondage, or suffering

Diagnostic Criteria

A. Over a period of at least 6 months, recurrent and intense sexual arousal from the physical or
psychological suffering of another person, as manifested by fantasies, urges, or behaviors.

B. The individual has acted on these sexual urges with a nonconsenting person, or the sexual urges or
fantasies cause clinically significant distress or impairment in social, occupational, or other important
areas of functioning.

Specify if:

In a controlled environment: This specifier is primarily applicable to individuals living in institutional or

other settings where opportunities to engage in sadistic sexual behaviors are restricted.

In full remission: The individual has not acted on the urges with a nonconsenting person, and there has
been no distress or impairment in social, occupational, or other areas of functioning, for at least 5 years
while in an uncontrolled environment.

Development and Course

- Information on the development and course of sexual sadism disorder is extremely limited.
Whereas sexually sadistic preferences per se are probably a lifelong characteristic, sexual sadism
disorder may fluctuate according to the individual’s subjective distress or his or her propensity
to harm nonconsenting others. As with other sexual preferences, advancing age may be
associated with decreasing sexually sadistic preferences and behavior. Regarding sexually
sadistic preference, many individuals who engage in BDSM behavior became aware of their
corresponding interest in their teenage years.
Etiology

1. Psychodynamic theory postulates that adverse events during specific phases of psychosexual
development can lead to paraphilias. Significant anecdotal evidence supporting this theory is
derived from case history.
2. Unknown inborn biologic factors have also been cited as possible causes of paraphilias;
however, there is clear evidence.

Nature and history of paraphilic behaviors

The assessing clinician should delineate the person’s specific paraphilic fantasies and behavior, their
onset, history and duration. Many people with paraphilic disorders give a long-standing history of
paraphilic fantasies and behaviors which often goes back to adolescence. Although it may be important
for the patient to explore possible distal factors associated with the onset of their behaviors (e.g., a
history of sexual abuse or premature exposure to pornography or parental sexuality) to provide some
understanding and meaning for their paraphilia, such explanations may also be used by the patient to
justify and minimize their damaging behaviors. It is important to establish proximal and contextual
factors related to the paraphilic acts, such as disinhibition due to drug or alcohol misuse.

Assessment

Motivation for treatment

Some patients present to general mental health services specifically for treatment of a paraphilic
disorder, whereas others are referred for another mental disorder, such as depression, and it later
emerges that they have paraphilic fantasies and behaviors.

People who have been convicted for illegal paraphilias and are mandated to undergo treatment as part
of their sentence may be less motivated to engage in treatment than patients presenting voluntarily.
Motivation may fluctuate according to internal and external factors and it is important to assess how the
person feels about their fantasies and behaviors, what their aims for treatment are and why they have
sought help (if they have) at this time. It is important for staff to facilitate engagement by the use of
motivational techniques such as empathic understanding, mutual trust and acceptance, empowering
patients to choose to engage rather than feeling that treatment is imposed on them.

Assessment of sexual intent

Although not used as routinely in the UK as in the USA and other countries, specific physiological and
neuropsychological tests may be useful in the assessment of paraphilias. Penile plethysmography (PPG)
has historically been a standard tool for the assessment and measurement of deviant sexual arousal,
exposing the individual to visual or auditory stimuli to assess their penile responsiveness. However,
more recently its usefulness has been questioned on the grounds of concerns regarding standardization,
reliability and validity (Reference MarshallMarshall 2006).
The Abel Assessment for Sexual Interest (AASI) (Reference Abel, Huffman and WarbergAbel 1998) is a
less intrusive alternative to PPG, measuring length of time a person spends looking at various images
presented to them on a computer screen.
Cognitive tests
Cognitive tests such as the Implicit Association Test (IAT) (Reference Greenwald, McGhee and
SchwartzGreenwald 1998) have been validated and are used to assess pedophilia and other paraphilias
(Reference Camilleri, Quinsey, Laws and O'Donohue Camilleri 2008). The IAT is based on the assumption
that a person who holds a favorable view of a topic (e.g. sex with a child) is more likely to respond faster
when sexual words are paired with child images compared with a person who does not hold such a view
(Reference Gray, Brown and MacCulloch Gray 2005).
Other psychometric tests, including personality measures such as the Minnesota Multiphasic Personality
Inventory-2 (MMPI-2) (Reference Butcher, Graham and Ben-Porath Butcher 2001), are useful in assessing
specific difficulties and tailoring treatment.
In addition, many psychological tests, rating scales, questionnaires and inventories have been devised
for the assessment of specific paraphilias (for a review see Reference Laws and O'DonohueLaws &
O’Donohue 2008).

Polygraph testing
Polygraphy or ‘lie detection’ is widely used in the USA and is currently being introduced in England and
Wales, following a successful pilot trial of mandatory polygraph testing of sex offenders released on
probation (Reference Gannon, Wood and PinaGannon 2012). In addition to detecting reoffending if it
occurs, polygraph testing of convicted sex offenders has been shown to provide more accurate
information about the offender’s history, improve the identification and targets of treatment, and
enhance supervision by acting as a deterrent to reoffending (Reference Grubin, Madsen and
ParsonsGrubin 2004).

Treatment

Biological approaches
Research into effective treatments for paraphilias is limited and has mostly been conducted on samples
of convicted sex offenders. Surgical castration was the most commonly used treatment for sex offenders
in a number of European countries until the 1970s and is still available in some US states, but was never
embraced in the UK (Reference GordonGordon 2008).
Anti-androgen medication in the form of cyproterone acetate, which can be administered orally or by
depot injection, is available in most countries and, unlike surgical castration, its effects are reversible on
discontinuation.

Luteinizing hormone-releasing hormone (LHRH) agonists such as triptorelin and goserelin, which are
given by depot and decrease testosterone levels, have been used in the treatment of sex offenders, with
reported low levels of recidivism (Reference Rousseau, Couture and Dupont Rousseau 1990; Reference
DickeyDickey 1992; Reference Thibaut, Cordier and KuhnThibaut 1993). Hormonal interventions may be
indicated for paraphilias characterized by intense and frequent deviant sexual desire and arousal, which
predispose the patient to severe paraphilic behavior such as pedophilia or serial rapes (Reference
Thibaut, de la Barra and Gordon Thibaut 2010).
Antilibidinal drugs may also be used to treat sex offenders with intellectual disabilities or cognitive
dysfunctions.

There is evidence for the use of selective serotonin reuptake inhibitors (SSRIs) (Reference Grubin, Laws
and O'DonohueGrubin 2008), which also reduce male libido. The SSRIs may be particularly useful in
paraphilias associated with obsessive–compulsive, impulse control or depressive disorders, or for
individuals who experience a strong compulsive element to their paraphilic sexual urges that they find
difficult to resist.
National and international guidelines for the biological treatment of paraphilias are available
(e.g. Reference Thibaut, de la Barra and Gordon Thibaut 2010), and all patients should have a thorough
medical assessment and be monitored throughout treatment.

Psychological approaches
Although medication may be indicated for some sex offenders with paraphilias, the mainstay of
treatment for paraphilias is psychological therapy, which offers the prospect of long-lasting change.
Most of the research has focused on cognitive–behavioral interventions, which have been shown to
offer a modest reduction in recidivism in sex offenders.

A meta-analysis of 69 studies of controlled outcome evaluations of sex offender treatments involving 22

181 participants reported a 37% reduction in sexual recidivism in treated groups (Reference Losel and
SchmuckerLosel 2005). Factors that predicted positive outcomes included treatment programs that
were specifically designed for sex offenders, group therapy and use of a cognitive therapy orientation.
Another review, based on a meta-analysis of 23 recidivism outcome studies, examined whether the risk–
need–responsivity (RNR) principles associated with effective treatments for general offenders also
applied to sexual offenders (Reference Hanson, Bourgon and HelmusHanson 2009). Programs that
adhered to the RNR principles showed the largest reductions in sexual and general recidivism. However,
evidence for the long-term effectiveness of cognitive–behavioral therapy (CBT) in sex offenders is less
robust (Reference Brooks-Gordon, Bilby and Wells Brooks-Gordon 2006) and the majority of studies
relate to the treatment of sex offenders in general rather than individuals with specific paraphilias.

Cognitive–behavioral therapy
Cognitive–behavioral interventions for sex offenders have included social skills training, cognitive
restructuring, development of victim empathy and imaginal desensitization. In some motivated
individuals, behavior modification techniques such as covert desensitization and minimal arousal
conditioning have been reported to reduce deviant sexual arousal and replace it with appropriate
arousal (Reference Laws and O'DonohueLaws 2008).

Relapse prevention therapy

Relapse prevention therapy programs specifically for sex offenders have been developed from CBT
principles (Reference Federoff, Marshall, McKay, Abramowitz and Taylor Federoff 2010). Therapeutic
programs focus less on victim empathy and more on evidence-based dynamic factors such as intimacy,
attachment, emotion regulation and impulsivity, as well as paying attention to the therapeutic
relationship and attitudes of the staff.

Good Lives Model

The Good Lives Model of Offender Rehabilitation (GLM) (Reference Ward and GannonWard 2006b) has
increasingly gained prominence, and studies support its utility in sexual offender rehabilitation
(Reference Willis and WardWillis 2011). The GLM is a strengths-based approach to offender
rehabilitation that aims to equip offenders with the skills necessary to attain inherently human and
normal desires in personally meaningful and socially acceptable ways.
Psychodynamic therapy
Very few empirical studies have examined the efficacy of psychodynamic or insight-oriented
psychotherapy for paraphilias. However, this lack of evidence does not mean that psychodynamic
approaches are ineffective.

Psychodynamic therapy explores the intrapsychic and interpersonal dynamics that underlie the
individual’s paraphilic behaviors and fantasies in relation to their history and current relationships,
including that with the therapist. Psychodynamic approaches may also be helpful in case assessment
and formulation, in staff supervision and in providing a framework for delivery of other treatment
modalities, such as CBT.

Service provision
Specialized services for the treatment of paraphilias are scarce in the UK, and most individuals gain
access to treatment only after they have offended. Most treatment services for people who have been
convicted of illegal paraphilias are located within the criminal justice system. These sex offender
treatment programs, mostly underpinned by cognitive–behavioral principles and delivered via group
therapy, usually focus on the reduction of risk or rates of recidivism rather than improvements in mental
health, although newer programs do try to enable the person to improve their psychosexual and social
functioning. Some forensic mental health services offer specialized sex offender treatment services, but
provision across the UK is patchy. A key challenge is to enable clinical and criminal justice agencies to
work together in a more integrated way. Although there are some examples of excellent practice
(e.g. Reference Minoudis, Shaw and Craissati Minoudis 2012), this area needs further development.
Specific treatment services within the National Health Service for patients with legal paraphilias are even
more limited. Some patients may be treated in psychosexual clinics, others within general psychology
and psychotherapy departments. A few may be referred to specialized forensic psychotherapy services
such as the Portman Clinic in London. Treatment may be in the form of individual, group or couple
therapy.

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