16th November 2023

Disorders of Sexual Preference and Paraphilic Disorders

There has been a lot of change in this category between ICD-10 and ICD-11 classifications, and although initially in the workings and still present in DSM-5, the categories fetishism and fetishistic transvestism are no longer included. This leaves exhibitionism, voyeurism, paedophilia, sadomasochism and frotteurism of the ICD-10 disorders of sexual preference, although again, these have been updated. Aetiological factors may be physiological, such as hormonal imbalance in utero, in adulthood and possibly underlying genetic causes. Psychological explanations also propose factors preventing normal sexual development or factors promoting deviant sexual behaviours or thoughts.

Assessment and diagnosis

Sexually deviant desires may be present as part of other psychiatric conditions. Therefore, thorough assessment and MSE is essential, particularly focussing on the psychosexual history. These patients may present of their own accord, on the request of a partner or even the court after an offence has been committed. Physical examination may be useful if there is comorbid sexual dysfunction, which will help to decide if investigations are required. The below are ways the patient achieves sexual arousal through thoughts, fantasies or behaviours. For disorder to be present, these must cause the patient discernible distress or risk of harm to themselves or others:

• Fetishistic disorder – Use of an inanimate object.
• Transvestic disorder – Dressing in the clothes of the opposite sex.
• Exhibitionistic disorder – Exposing the genitalia to an unsuspecting person or people.
• Voyeuristic disorder – Watching others have sexual relations, being without clothes or undressing.
• Paedophilic disorder – Sexual thoughts, urges or acts involving prepubescent children (<13 years).
• Coercive sexual sadism disorder – Inflicting mental or physical pain or humiliation. Previously, DSM-5’s sexual sadism disorder also alongside sexual masochism disorder, which is no longer included.
• Frotteuristic disorder – Rubbing against or otherwise touching an unsuspecting person.
• Other paraphilic disorders involving non-consenting individuals – These include necrophilia, zoophilia, klismaphilia and autoerotic asphyxia, among others.

Treatment

Treatment should not be offered unless the patient wants it and recognises that therapies will be labour intensive on their part. Aims can be altering the focus of the arousal or managing the distress associated.

Physical treatments – Historically, neurosurgery or castration have been used.

Biological treatment – There is evidence for the use of hormonal therapies (anti-androgens and progesterone) and SSRIs. Fluoxetine is mentioned in NICE guidance; however, studies are limited.

Psychological treatment – CBT and psychodynamic psychotherapy.

References

• Semple D; Smyth R. (2019). Oxford Handbook of Psychiatry, fourth edition.
• International Statistical Classification of Diseases, tenth revision (ICD-10), Version:2016, https://icd.who.int/browse10/2016/en#/F60-F69
• International Statistical Classification of Diseases, eleventh revision (ICD-11), Version 01/2023, https://icd.who.int/browse11/l-m/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f2110604642
• National Institute for Health and Care Excellence. (20215). Hypersexuality: fluoxetine [Evidence summary ESUOM46]. https://www.nice.org.uk/advice/esuom46/chapter/Key-points-from-the-evidence