Сэтгэцийн хичээлийн Парафилиа

1. Paraphilias
para = abnormal; philia = attraction
SoM-431 Anudari.S, Badamsuren.B,
Nomin-Erdene.D

2. Paraphilias
• Disorders in which an individual has
recurrent, intense sexually arousing
fantasies, sexual urges, or behaviors
involving
– nonhuman objects,
– children or other nonconsenting persons, or
– the suffering or humiliation of self or partner.
• Inability to experience sexual gratification in
the absence of the desired stimulus.
• Lasting at least six months.

3. Paraphilias
• Paraphilias commonly involve sexual arousal
and orgasm, usually achieved through
masturbation and fantasy
• Usually a paraphilia is chronic and lifelong
• The paraphiliac urge, fantasy, or behavior is
always present

4. streaking

5. Paraphilias
• Rarely diagnosed in clinical settings because
people with paraphilias are secretive about
them
• In paraphilia clinics, the most common
disorders seen include pedophilia, voyeurism,
and exhibitionism. Sadomasochism is much
less common

6. Causes of paraphilias
1. Behavioral theory – child who was the
victim or observer of inappropriate
sexual behaviors learns to imitate such
behavior and gets reinforcement for it
2. Biological theory – hormonal,
behavioral, and CNS interaction –
especially the role of aggression and
male sex hormones

7. Factors that contribute to
paraphilias
1. Dysfunctional families marked by
isolation, sexual, emotional, and physical
abuse
2. Psychoactive substance use
3. Concurrent mental or personality disorders
4. Closed head injury
5. CNS tumors

8. FEATURES OF PARAPHILIAS
• Vary by paraphilia
• Generally, ingrained behaviors
• Biopsychosocial factors
• Conditioning appears to be main cause
• Difficult to treat
• Rarely present for treatment unless legally
bound
• Treatment depends on the nature of the
paraphilia

9. PARAPHILIAS
• Pedophilia and Incest
• Fetishism
• Transvestic Fetishism
• Voyeurism
• Exhibitionism
• Frotteurism
• Sexual Sadism/Masochism

10. RARE PARAPHILIAS
Telephone scatologia Making obscene calls
Necrophilia Corpses
Zoophilia Animals
Coprophilia Feces
Klismaphilia Enemas
Urophilia Urine
Autagonistophilia Sex in front of others
Somnophilia Sleeping people
Stigmatophilia Skin piercing or tattoo
Autonepiophilia Wearing diapers

11. Pedophile activity
• During the act the pedophile may –
1. Undress the child
2. Encourage the child to watch him masturbate
3. Touch or fondle the child’s genitals
4. Forcefully perform sexual acts on the child
• Pre-pubertal children are the most common
targets

12. PEDOPHILIA
 2/3 of all sexual assault victims are children &
adolescents
 Among children age 12-17, 14-year-olds are
the most common victims
 For children under 12, 4-year-olds are the
most commonly abused
 Nearly 2/3 of victims are female
 Vast majority of perpetrators are male
 About 1/3 of offenders are relatives of the
victimized children

13. THEORIES
• EARLY LIFE EXPERIENCE
 Sexually and emotionally abused as children
 Victim-to-abuser cycle
• PERSONALITY TRAITS
 Antisocial personality traits
 Anger stemming from feelings of
inadequacy, introversion, cognitive rigidity

14.  IN TREATMENT
 Lowering testosterone.
 Hypothalamotomy.
TREATMENT
BIOLOGICAL APPROACH
These may help curb sex drive, but
inappropriateness of the choice of partner must
also be addressed.

15. • BEHAVIORAL TREATMENT
 Aversive therapy
• COGNITIVE
 Relapse prevention
• GROUP THERAPY
 Supportive context to discuss desires and
conflicts
TREATMENT

16. Exhibitionism
Exhibitionism:
A paraphilia in which a person has intense sexual urges
and arousing fantasies involving the exposure of
genitals to a stranger.

17. Fetishism:
A paraphilia in which the individual is
preoccupied with an object and depends on
this object rather than sexual intimacy with
a partner for achieving sexual gratification.

18. Partialism:
A paraphilia in which the person is interested
solely in sexual gratification from a specific
body part, such as feet.
Some experts regard this as a kind of fetishism.

19. Transvestic Fetishism
Transvestic fetishism:
A paraphilia in which a man has an
uncontrollable craving to dress in women's
clothing in order to derive sexual
gratification.

20. Frotteurism:
from French frotter (“to rub”)
A paraphilia in which the individual has intense
sexual urges and sexually arousing fantasies of
rubbing against or fondling an unsuspecting
stranger.

21. Sexual Masochism
Attraction to achieving
sexual gratification by
having painful stimulation
applied to one's own body,
either alone or with a
partner.

22. Sexual Sadism
Deriving sexual gratification
from activities that harm, or
from urges to harm, another
person.
The term sadomasochist refers to
someone who derives pleasure from
both inflicting and receiving pain.

23. Some Sadomasochistic Activities
 spanking
 master-slave
 bondage
 humiliation
 restraint
 pain infliction
 whipping
 verbal abuse
 toilet-related activities
 cutting
 shocking
 asphyxiation

24. Voyeurism:
from French voir (“to see”)
A paraphilia in which the individual has a compulsion
to derive sexual gratification from observing the
nudity or sexual activity of others.

25. Diagnosis
1. Penile pletysmography – measurement
of patient’s sexual arousal(of bloodflow
to the penis) in response to visual
imagery
2. DSM-IV-TR criteria

26. Official Criteria
Paraphilias are defined in the DSM-IV-TR as:
• intense, recurring sexual fantasies, sexual urges or
behaviors that involve
• non-human objects, children or non-consenting adults,
suffering or humiliation (to self or to others)
Two additional criteria from the DSM-IV are used in the
diagnosis of a paraphilia:
• The behavior has lasted at least 6 months
• It causes clinically significant distress or impairment in
social, occupational or other important areas of life.

27. Treatment
• Paraphiliacs seldom seek treatment because
of their guilt, shame, and fear of social
ostracism and legal problems
• Depending on the specific paraphilia,
treatment may involve a combination of
psychotherapy, cognitive therapy,
behavioral therapy, pharmacotherapy, and
surgery

28. Psychostimulant augmentation during treatment with selective
serotonin reuptake inhibitors in men with paraphilias and
paraphilia-related disorders Kafka MP1, Hennen J. (2000 j Clin)
• BACKGROUND:
• We describe an open trial of psychostimulants (primarily methylphenidate sustained release
[SR]) added to selective serotonin reuptake inhibitors (SSRIs; primarily fluoxetine) during the
course of pharmacologic treatment of men with paraphilias and paraphilia-related disorders
(PRDs).
• METHOD:
• Twenty-six men with paraphilias (N = 14) or PRDs (N = 12) were assessed for life-time mood
disorders and attention-deficit/hyperactivity disorder (ADHD) as defined by DSM-IV. All men
were assessed at baseline for total sexual outlet and average time per day associated with
paraphilia/PRD sexual behaviors. The indications for the addition of a psychostimulant to a
stable dose of SSRI included the retrospective diagnosis of ADHD with persistent adult
symptoms despite pharmacotherapy with an SSRI (N = 17); residual paraphilia/PRD fantasies,
urges, and activities despite SSRI pharmacotherapy (N = 16); the persistence or presence of
residual depressive symptoms despite SSRI pharmacotherapy (N = 6); relapse or loss of SSRI
efficacy during the treatment of sexual impulsivity disorders (N = 4); and treatment of SSRI-
induced side effects (N = 4).

29. • RESULTS:
• SSRI pharmacotherapy (mean +/- SD duration = 8.8+/-11.1 months)
had statistically significant effects in diminishing paraphilia/PRD-
related total sexual outlet (p < .001) and average time/day spent in
paraphilia/PRD sexual behavior (p < .001).
• Addition of methylphenidate SR (mean dose = 40 mg/day; mean +/-
SD duration = 9.6+/-8.2 months) was associated with additional
statistically significant effects on paraphilia/PRD-related total sexual
outlet (p = .003) and average time per day (p = .04) in addition to
improvement of putative residual ADHD and depressive symptoms.
• CONCLUSION:
• Methylphenidate SR can be cautiously and effectively combined
with SSRI antidepressants to ameliorate paraphilias and paraphilia-
related disorders for the indications listed above.

30. Paraphilias in adult psychiatric
inpatients. (2012 Ann clinic)
Marsh PJ1, Odlaug BL, Thomarios N, Davis AA, Buchanan SN, Meyer CS, Grant JE.
• BACKGROUND:
• The goal of the present study was to examine the prevalence of
paraphilias in an adult inpatient psychiatric population.
• METHODS:
• One hundred twelve consecutive, voluntarily admitted, adult male
psychiatric inpatients were administered the Structured Clinical
Interview for DSM-IV, Sexual Disorders Module, Male Version, to
assess the rates of DSM-IV paraphilias.
• Conclusion: Paraphilias appear to be more common in adult male
psychiatric inpatients than previously estimated. The study also
demonstrated that these disorders were not screened for by the
treating physician and thus may go untreated. Further, larger-scale
studies are necessary in order to further examine the rates of these
disorders in the general population.

31. 87%
13%
Result
others
At least one time DSM-IV
paraphilia
Voyeurism
• N=9 (8.0%)
Exhibionism
• N=6 (5.4%)
Sexual masochism
• N=3 (2.7%)

32. J Sex Med. 2008 Mar;5(3):626-30. Epub 2007 Oct 30.
Side effects of pharmacotherapy on bone with long-acting
gonadorelin agonist triptorelin for paraphilia.
Hoogeveen J1, Van der Veer E.
• Abstract
• INTRODUCTION:
• There have been limited research studies concerning the use of libido inhibitors for
the treatment of patients with a paraphilia. Observational studies suggest that
agents that lower testosterone are an effective treatment for paraphilia.
• AIM:
• We report a case of hormonal treatment of paraphilia that was associated with
side effects.
• METHOD:
• A 35-year-old man with a paraphilia was treated with long-acting gonadorelin.
• RESULTS:
• The desired result was reduced preoccupation with sexuality, but there were
various side effects including a serious amount of bone loss.
• CONCLUSION:
• We believe that more attention should be given to the adverse effects of long-
term treatment with triptorelin. In our view the drug regime needs to be revised.

33. The End