assignment controversy associated with personality and paraphilic disorders

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Paraphilic Disorders

Learning objectives.

• Describe and differentiate between paraphilias: fetishism, transvestic fetishism, exhibitionism, voyeurism, frotteurism, sexual sadism, sexual masochism, and pedophilia

As mentioned earlier, paraphilias are persistent and recurrent sexual interests, urges, fantasies, or behaviors of marked intensity involving objects, activities, or even situations that are atypical in nature. We will discuss the characteristics and etiology of the eight paraphilias listed in the DSM-5  fetishism, transvestic fetishism,  exhibitionism, voyeurism,  frotteurism,  sexual sadism, sexual masochism, and  pedophilia. Pedophilia will be discussed in a separate section because  of its close relationship to criminal behavior and will be followed  by a discussion on sex and violence. 

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 DSM-5 or ICD-11. The number and taxonomy of paraphilias is under debate; one source lists as many as 549 types of paraphilias. The DSM-5 has specific listings for eight paraphilic disorders, but several sub-classifications of the paraphilias have been proposed and some argue that a fully dimensional, spectrum, or complaint-oriented approach would better reflect the evidence.

The DSM-5 adds a distinction between paraphilias and paraphilic disorders, stating that paraphilias do not require or justify psychiatric treatment in themselves, and defining paraphilic disorder as “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.” [1]

Types of Paraphilias

Fetishism is the use of nonliving objects, most commonly shoes and undergarments, for sexual pleasure. Transvestic fetishism is the derivation of sexual arousal from cross-dressing or dressing in clothes of the opposite sex.  Exhibitionism is the exposure of an individual’s genitalia to unsuspecting strangers for sexual satisfaction.  Voyeurism is the viewing of an unsuspecting person engaging in disrobing or sexual activity. Frotteurism is the touching of or rubbing against a nonconsenting person. Sexual masochism is the derivation of sexual arousal from being the recipient of physical or mental abuse and/or humiliation. Sexual sadism is when sexual arousal is gained from inflicting mental or physical suffering on a nonconsenting person. Pedophilia is any sexual activity with or sexual fantasies about a prepubescent child, where the offender is at least sixteen years of age. 

The exact etiology of paraphilia and paraphilic disorders is unknown. However, it is thought that a combination of neurobiological, interpersonal, and cognitive processes all play a role. Literature also points towards various genetic factors contributing to the development of pedophilia and pedophilic disorder, with recent evidence displaying a positive correlation of the COMT Val158Met (rs4680) polymorphism in paraphilic child sexual offenders. A recent study focusing on neurotransmission of paraphilic disorders found evidence to suggest that central dopamine plays a key role in the pathogenesis of paraphilic disorders as well as the general disturbance of the conscious regulation of behavior. The results of this study revealed increased levels of serotonin and norepinephrine, with a decreased concentration of DOPAC (3,4-dihydroxyphenylacetic acid) in urine samples of the test population diagnosed with paraphilic disorders. A correlation was made between serotonin and norepinephrine with obsessive disturbances and an association of DOPAC with affective and dissociative disorders.

Epidemiology

Literature is lacking with information pertaining to the epidemiology of paraphilia and paraphilic disorders. Literature is also limited from an epidemiological standpoint, with paraphilia typically studied in a general sense rather than pertaining to specific paraphilia or paraphilic disorders. Paraphilias, in general, are more common in men, with reasons unknown. A recent study conducted looked specifically at the desire for and experience of paraphilic behaviors of a sample population demographically representative of the general population. The sample size contained a total of 1,040 persons classified according to gender, age, education, ethnicity, religion, and location of residency. It was found that almost half of the study population expressed interest in one or more paraphilic categories, with approximately one-third of this population actually acting on this interest at least once. Specifically, fetishism, frotteurism, voyeurism, and masochism held a prevalence of 15.9% (value considered to be statistically unusual), with interest in both males and females. Interest levels in fetishism and masochism revealed no statistically significant difference amongst males and females. It was also found that the most common paraphilic interest amongst men is often voyeurism and fetishism.

Let’s learn a little bit more about the types of paraphillic disorders.

Fetishistic Disorder

Sexual fetishism  or  erotic fetishism  is a sexual fixation on a nonliving object or nongenital body part. The object of interest is called the  fetish ; the person who has  a fetish  for that object is a  fetishist . Sexual arousal from a particular body part can be further classified as  partialism , or sexual interest with an exclusive focus on a specific part of the body other than the genitals.  Partialism is categorized as a fetishistic disorder in the DSM-5 only if it causes significant psychosocial distress for the person or has detrimental effects on important areas of their life. Fetishism is diagnosed by recurrent and intense sexual arousal from either the use of nonliving objects or a highly specific focus on non-genital body part(s), as manifested by fantasies, urges, or behaviors that occur for at least six months. It must cause significant stress or impairment and not be related to clothing used in cross-dressing (transvestic disorder) or objects used for genital stimulation, like a vibrator.

Individuals who exhibit partialism sometimes describe the anatomy of interest to them as having an equal or greater erotic attraction for them as do the genitals. Partialism occurs in heterosexual, bisexual, and homosexual individuals. The foot is considered one of the most common partialisms.

Partialisms

The following are some of the partialisms commonly found among those with fetishes:

While medical definitions restrict the term  sexual fetishism  to objects or body parts,  fetish  can, in common discourse, also refer to sexual interest in specific activities. This broader usage of  fetish  covers parts or features of the body (including obesity and body modifications), objects, situations and activities (such as  BDSM —a variety of often erotic practices or roleplaying involving bondage, discipline, dominance and submission, sadomasochism, and other related interpersonal dynamics). Paraphilias such as urophilia, necrophilia, and coprophilia have been described as fetishes.

Erotic asphyxiation  is the use of choking to increase the pleasure in sex. The fetish also includes an individualized part that involves choking oneself during the act of masturbation, which is known as auto-erotic asphyxiation. This usually involves a person being connected and strangled by a homemade device that is tight enough to give them pleasure but not tight enough to suffocate them to death. This is dangerous due to the issue of hyperactive pleasure seeking that can result in strangulation when there is no one to help if the device gets too tight and strangles the user.

Transvestic Disorder

Transvestism  is the practice of cross-dressing , which is the act of wearing items of clothing and other accoutrements commonly associated with the opposite sex within a particular society. The term  cross-dressing  refers to an action or a behavior, without attributing or implying any specific causes or motives for that behavior. Cross-dressing is not synonymous with being transgender. A transvestic disorder is characterized by intense sexual arousal from cross-dressing that has occurred for at least six months, which also causes significant distress or impairment. It should be specified if it occurs with fetishism, meaning arousal by materials related to cross-dressing, or with autogynephilia, which includes arousal by thoughts of oneself as a female.

A transvestic fetishist is a person who cross-dresses as part of a sexual fetish. According to the DSM-4, this fetishism was limited to heterosexual men; however, DSM-5 does not have this restriction, and opens it to women and men, regardless of their sexual orientation.

Transvestic fetishism,  fetishistic transvestism , and sometimes  transvestism  are also often used to describe  any  sexual behavior or arousal that is in any way triggered by the clothes of the other gender. Especially the latter is problematic because transvestism and cross-dressing are neither a sexual fetish nor do they necessarily have anything to do with sexual behavior or arousal.

Also, not every sexual behavior where clothes of the opposite gender are involved is  transvestic fetishism ; they are also often used in sexual roleplay without being a fetish. Also, many transgendered people, mostly transwomen, also cross-dress before coming out in sexual contexts to relieve their cross-gender feelings. This behavior is likewise not considered  transvestic fetishism , as it is not cross-dressing for sexual pleasure, rather it is simply their self-gender expression.

Some male transvestic fetishists collect women’s clothing, e.g., nightgowns, babydolls, slips, other types of nightwear, lingerie stockings, and pantyhose, items of a distinct feminine look and feel. They may dress in these feminine garments and take photographs of themselves while living out their secret fantasies. Many men love the feeling of wearing silk or nylon and adore the silky fabric of women’s nightwear, lingerie, and nylons.

Most transvestic fetishists are said to be heterosexual men, although there are no studies that accurately represent either their sexual orientation or gender, and most information on this is based on anecdotal evidence or informal surveys. A small number of people with transvestic fetishism, as the years pass, want to dress and live permanently as women, and desire surgical or hormonal gender-affirming services. In such cases the diagnosis should be changed to transsexualism (or gender dysphoria).

Exhibitionist Disorder

Exhibitionism  is the act of exposing in a public or semi-public context those parts of one’s body that are not normally exposed—for example, the breasts, genitals, or buttocks. The practice may arise from a desire or compulsion to expose themselves in such a manner to groups of friends or acquaintances, or to strangers for their amusement or sexual satisfaction or to shock the bystander. Exposing oneself only to an intimate partner is normally not regarded as exhibitionism. In law, the act of exhibitionism may be called indecent exposure, “exposing one’s person,” or other expressions.

When exhibitionistic sexual interest is acted on with a non-consenting person or interferes with a person’s quality of life or normal functioning, it can be diagnosed as  exhibitionistic disorder  in the DSM-5. The DSM states that the highest possible prevalence for exhibitionistic disorder in men is 2%-4%. It is thought to be much less common in women.

Exhibitionists in some cases masturbate while exposing themselves (or while fantasizing that they are exposing themselves) to another person. There is a pattern in which males exhibit themselves and there are three characteristic features of the exhibition: 1) It is performed for unknown women. 2) It takes place where sexual intercourse is impossible (e.g., a crowded shopping center). 3) It seems designed to surprise and shock the woman. The male exhibitionist usually exposes his erect penis, but it is not necessarily essential for the activity. Ejaculation may occur at the moment of exposure or develop later with masturbatory stimulation. Some exhibitionists are aware of a conscious desire to shock or upset their target while others fantasize that the target will become sexually aroused by their display.

Child versus Adult Presentation

Generally, society accepts exhibitionism in children as a natural curiosity, not a disorder; however, if the behaviors continue, a paraphilia is probable. The disorder appears to develop before the age of 18 and rarely is found in people over the age of 50.

Gender and Cultural Differences in Presentation

Most reported cases of exhibitionism involve males. Some scientists argue that women who undress in front of windows (as to invite a person to watch), or who wear low cut outfits are exhibitionists in a sense. Exhibitionism generally appears in Western society and is believed to be almost absent in such countries as Japan, Burma, and India. Additionally, in American society it can be a crime when committed by a male, but when women expose themselves, excluding total nudity, they are often seen as victims of male voyeurism.

Prevalence and incidence are not easily defined because people with this disorder usually do not seek treatment voluntarily. Exhibitionism is one of the three most common sexual offenses, the other two being voyeurism and pedophilia. It is rarely diagnosed in general mental health clinics, but most professionals believe that it is probably underdiagnosed and under-reported.  Risk factors appear to be a ntisocial history, antisocial personality disorder, a lcohol misuse, and p edophilic sexual preference.

Voyeuristic Disorder

Voyeurism is the sexual interest in or practice of spying on people engaged in intimate behaviors, such as undressing, sexual activity, or other actions usually considered to be of a private nature. The term comes from the French  voir  which means “to see.” A male voyeur is commonly labelled as “Peeping Tom” or a “Jags,” a term which originates from the Lady Godiva legend. However, that term is usually applied to a male who observes somebody secretly and, generally, not in a public space.

It is diagnosed by recurrent and intense sexual arousal stemming from observing an unsuspecting person who is naked, undressing, or engaging in sexual activity. It should cause significant distress and the person must be at least 18 years old.

Research found voyeurism to be the most common sexual law-breaking behavior in both clinical and general populations. [2] In the same study, it was found that 42% of college males who had never been convicted of a crime had watched others in sexual situations. An earlier study indicates that 54% of men have voyeuristic fantasies, and that 42% have tried voyeurism. In a national study of Sweden, it was found that 7.7% of the population (both men and women) had engaged in voyeurism at some point. [3] It is also believed that voyeurism occurs up to 150 times more frequently than police reports indicate. This same study also indicates that there are high levels of co-occurrence between voyeurism and exhibitionism, finding that 63% of voyeurs also report exhibitionist behavior.

Frotteuristic Disorder

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.  Frotteuristic disorder is a sexual dysfunction disorder characterized by sexual arousal from rubbing against or touching a non-consenting person.

The DSM-5 lists the following diagnostic criteria for frotteuristic disorder:

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

If the individual has not acted on their interest and experiences no distress or impairment, they are considered to have a frotteuristic sexual interest, but not frotteuristic disorder. Some sexologists distinguish between frotteurism (as pelvic rubbing) and toucherism (as groping with hands), but the DSM does not.

The prevalence of frotteurism is unknown. The DSM estimates that 10–14% of men seen in clinical settings for paraphilias or hypersexuality have frotteuristic disorder, indicating that the population prevalence is lower. 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.

Sexual Masochism and Sexual Sadism Disorders

Sexual masochism disorder   (SMD) is the condition of experiencing recurring and intense sexual arousal in response to enduring moderate or extreme pain, suffering, or humiliation. Conversely, s exual sadism disorder  is the condition of experiencing sexual arousal in response to the extreme pain, suffering, or humiliation of others. The words  sadism  and  sadist  are derived from Marquis de Sade. Many of Marquis de Sade’s books, including  Justine  (1791),  Juliette  (1797) and  The 120 Days of Sodom  (published posthumously in 1905), are written from a cruelly sadistic viewpoint.

BDSM  (bondage, domination, sadomasochism) is a colloquial term relating to individuals who willingly engage in consenting forms of pain or humiliation, typically for sexual purposes. The term BDSM describes the activities between consenting partners that contain sadistic and masochistic elements. Many behaviors such as erotic spanking, tickling, and love-bites that many people think of only as “rough” sex also contain elements of sado-masochism. BDSM is not currently a diagnosable condition in either the DSM or ICD system.

Sexual Masochism

The formal diagnosis of sexual masochism disorder according to the DSM-5 involves “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.” It applies only if the individual experiences clinically significant distress or impairment in social, occupational, or other important areas of functioning.

The prevalence of sexual masochism disorder in the population is unknown, but the DSM-5 suggests that 2.2% of males and 1.3% of females may be involved in BDSM, whether they have sexual masochism disorder or not. Extensive use of pornography depicting humiliation is sometimes associated with sexual masochism disorder.

Behaviors associated with sexual masochism disorder can be acted out alone (e.g., binding, self-sticking pins, self-administration of electric shock, or self-mutilation) or with a partner (e.g., physical restraint, blindfolding, paddling, spanking, whipping, beating, electric shock, cutting, pinning and piercing, and humiliation such as by being urinated or defecated upon, being forced to crawl and bark like a dog, or being subjected to verbal abuse). Behaviors sometimes include being forced to cross-dress or being treated like an infant.

Following a phenomenological study of individuals involved in sexual masochistic sessions, sexual masochism was described as an addiction-like tendency, with several features resembling that of drug addiction: craving, intoxication, tolerance, and withdrawal. It was also demonstrated how the first masochistic experience is placed on a pedestal, with subsequent use aiming at retrieving this lost sensation, much as described in the descriptive literature on addiction. The addictive pattern presented in this study suggests an association with behavioral spin as found in problem gamblers. A behavioral spin is described as a process one goes through that is characterized by a behavior growing in frequency and magnitude. As it develops, it gains its own momentum which the individual finds almost impossible to terminate even when faced with known unwanted outcomes. For the participants in sexual masochistic sessions, the behavioral spin is manifested as a continuously reinforced process leading the masochist to engage in masochistic activity, perpetuating itself, and binding the addict to his/her behavior.

Sexual Sadism Disorder

Sexual sadism disorder refers to the “recurrent and intense sexual arousal from the physical or psychological suffering of another person, as manifested by fantasies, urges, or behaviors.” The formal diagnosis of sexual sadism disorder would apply if the individual has acted on these urges with a nonconsenting person or if the urges cause significant distress to the individual.

Paraphilic coercive disorder  refers to the preference for non-consenting over consenting sexual partners. It differs from sexual sadism disorder in that although the individual with this disorder may inflict pain or threats of pain in order to gain the compliance of the victim, the infliction of pain is not the actual goal of the individual. The condition is typically described as a paraphilia and continues to undergo research, but does not appear in the current DSM or ICD. Alternate terms for the condition have included Biastophilia, Coercive Paraphilic Disorder, and Preferential Rape.

With paraphilic coercive disorder, the individual employs enough force to subdue a victim, but with sexual sadism disorder, the individual often continues to inflict harm regardless of the compliance of the victim, which sometimes escalates not only to the death of the victim, but also to the mutilation of the body. What is experienced by the sadist as sexual does not always appear obviously sexual to non-sadists: sadistic rapes do not necessarily include penile penetration of the victim. In a survey of offenses, 77% of cases included sexual bondage, 73% included anal rape, 60% included blunt force trauma, 57% included vaginal rape, and 40% included penetration of the victim by a foreign object. In 40% of cases, the offender kept a personal item of the victim as a souvenir.

On personality testing, sadistic rapists apprehended by law enforcement have shown elevated traits of impulsivity, hypersexuality, callousness, and psychopathy. Although there appears to be a continuum of severity from mild ( hyperdominance  or  BDSM ) to moderate ( paraphilic coercive disorder ) to severe ( sexual sadism disorder ), it is not clear if they are genuinely related or only appear related superficially.

Very little is known about how sexual sadism disorder develops. Most of the people diagnosed with sexual sadism disorder come to the attention of authorities by committing sexually motivated crimes. Surveys have also been conducted to include people who are interested in only mild and consensual forms of sexual pain/humiliation (BDSM).

Most of the people with full-blown sexual sadism disorder are male, whereas the sex ratio of people interested in BDSM is closer to 2:1 male-to-female.  People with sexual sadism disorder are at an elevated likelihood of having other paraphilic sexual interests.

Controversies in Diagnosing Paraphilias

As mentioned in this module, deciding what is “normal” in the area of sexuality is an issue fraught with difficulty and controversy. Critics of the DSM argue that several of the paraphilic disorders in DSM-5 pathologize nonnormative sexual behavior. These critics maintain that even breaking the law is not a sufficient basis for determining that an individual engaging in a paraphilic behavior has a psychological disorder. This criticism also applies to exhibitionistic, voyeuristic, and frotteuristic disorders, which don’t involve victims in the same sense as do the other paraphilic disorders.​

Watch this video to review the main components of each of the paraphilic disorders in the DSM-5.

You can view the transcript for “What are Paraphilic Disorders?” here (opens in new window) .

Key Takeaways: Paraphilic Disorders

BDSM   (bondage, domination, sadomasochism): a colloquial term relating to individuals who willingly engage in consenting forms of pain or humiliation, typically for sexual purposes

exhibitionism:  the exposure of an individual’s genitalia to unsuspecting strangers for sexual satisfaction

frotteurism:  the touching of or rubbing against a nonconsenting person

paraphilias:  persistent and recurrent sexual interests, urges, fantasies, or behaviors of marked intensity involving objects, activities, or even situations that are atypical in nature

paraphilic coercive disorder: the preference for non-consenting over consenting sexual partners

Partialism: sexual interest with an exclusive focus on a specific part of the body other than the genitals

pedophilia: any sexual activity with a prepubescent child, where the offender/patient is at least sixteen years of age, and the victim is at least five years younger

sexual fetishism  or  erotic fetishism:  sexual fixation on a nonliving object or nongenital body part

sexual masochism:  the derivation of sexual arousal from being the recipient of physical or mental abuse and/or humiliation

sexual sadism:  when sexual arousal is gained from inflicting mental or physical suffering on a nonconsenting person

toucherism: sexual arousal based on grabbing or rubbing one’s hands against an unexpecting (and non-consenting) person

transvestic fetishism:  the derivation of sexual arousal from cross-dressing or dressing in clothes of the opposite sex

voyeurism:  the viewing of an unsuspecting person engaging in disrobing or sexual activity

• "Paraphilic Disorders". Diagnostic and Statistical Manual of Mental Disorders (Fifth ed.) . Philadelphia, Pennsylvania: American Psychiatric Publishing. 2013. pp. 685–686. ↵
• "The DSM Diagnostic Criteria for Exhibitionism, Voyeurism, and Frotteurism" (PDF). Niklas Langstrom. Retrieved 2013-04-04. ↵
• Långström, Niklas; Seto, Michael C. (2006). "Exhibitionistic and Voyeuristic Behavior in a Swedish National Population Survey". Archives of Sexual Behavior. 35 (4): 427–35. doi:10.1007/s10508-006-9042-6. PMID 16900414 ↵

Paraphilic Disorders Copyright © by Meredith Palm is licensed under a Creative Commons Attribution 4.0 International License , except where otherwise noted.

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Controversy Associated with Personality and Paraphilic Disorders Comprehensive Nursing Paper Sample

Explain the controversy that surrounds your selected disorder.

Antisocial personality disorder (ASPD) is a mental condition that makes individuals disregard the rights of others. According to Johnson (2019), antisocial personality disorder causes individuals to experience deficient behavioral monitoring, lack remorse, and treat others harshly. The controversy with the disorder is that people violate the law and are seen as criminals. The regard from other people helps them get away with their behavior. Substance and alcohol use can make individuals escape the scrutiny of their behavior. A lack of understanding of the rights and wrongs allows the antisocial to manipulate others.(Controversy Associated with Personality and Paraphilic Disorders Comprehensive Nursing Paper Sample)

Explain your professional beliefs about this disorder, supporting your rationale with at least three scholarly references from the literature.

A professional belief is ASPD is poorly understood. Black (2022) highlights that individuals with ASPD manifest disturbance in different facets of their lives, and wrestling with the problem has made psychiatry not understand the disorder for over 200 years. Few researches have been conducted, limiting the identification of a suitable treatment. The moral compass describes the disorder, and families end up bearing the effects of the lack of available therapy. Adverse childhood experiences such as neglect and sexual and physical abuse lead to a lifetime diagnosis of antisocial personality disorder (DeLisi, Drury, and Elbert, 2019). Research can help identify the disorder’s common patterns and guarantee that individuals can get treatment. The moral insanity compass cannot be used to shape the professional beliefs of the disorder. Mulay and Cain (2020) report the widespread belief that individuals with ASPD are untreatable, contributing to contemporary controversies. Psychiatrists and other professionals must conduct more research on the disorder, which will help shape future professional beliefs.(Controversy Associated with Personality and Paraphilic Disorders Comprehensive Nursing Paper Sample)

Explain strategies for maintaining the therapeutic relationship with a patient who may present with this disorder.

It is an excellent strategy for maintaining a good relationship with a patient. The individual suffering from symptoms of ASPD can take anti-anxiety drugs and mood stabilizers. Medication may help individuals to control their behavior and prevent violating the rights of others. Any disorder has a trigger, and medication can help individuals manage their moods. The medication’s effectiveness may help individuals open up and be close to the psychiatrist and other professionals. It would be easy to develop a treatment modality suitable for the individuals and one that will help manage their disorder.(Controversy Associated with Personality and Paraphilic Disorders Comprehensive Nursing Paper Sample)

Therapy is an efficient method of collecting information from the patient and understanding their needs and wants. The individuals can undertake behavioral therapy, psychotherapy, or family therapy . By sharing information, the professionals will help individuals identify their triggers and suggest the best strategy for managing their behavior and thinking. The objective is to make the individuals realize they have a problem, and it would be prudent to use available treatment to prevent the effects of the disorder. The professional utilizes the information to assess more research, helping them pinpoint the root cause and the correct treatment. Lack of maintaining a therapeutic relationship will cause ASPD to continue to be poorly understood by professionals and individuals not accessing treatment.(Controversy Associated with Personality and Paraphilic Disorders Comprehensive Nursing Paper Sample)

Finally, explain ethical and legal considerations related to this disorder that you need to bring to your practice and why they are important.

Nonmaleficence is an ethical consideration that arises from engagement with an ASPD patient. The professionals are not supposed not to harm the patient while striving to prevent harm to others. The lack of understanding of the disorder makes it challenging for psychiatrists to diagnose the consideration and provide treatment. That predisposes the individual to harm. Investing in research would be critical to help prevent ethical issues from engaging with ASPD patients. It is a requirement that medical professionals should improve the well-being of other individuals. Many individuals misunderstand ASPD, and that increases the risks for the patient. When a concept is misunderstood, there is no precise treatment modality, and that raises legal questions. ASPD patients cannot get help because psychiatrists and other professionals fear the legal consequences. These considerations make other people bear the effects of the personality disorder in society.(Controversy Associated with Personality and Paraphilic Disorders Comprehensive Nursing Paper Sample)

Black, D. W. (2022). Special Report: Antisocial Personality Disorder — The Patient in Need Often Overlooked.  Psychiatric News ,  57 (12). (Controversy Associated with Personality and Paraphilic Disorders Comprehensive Nursing Paper Sample) https://psychnews.psychiatryonline.org/doi/10.1176/appi.pn.2022.12.12.20

DeLisi, M., Drury, A. J., & Elbert, M. J. (2019). The etiology of antisocial personality disorder: The differential roles of adverse childhood experiences and childhood psychopathology.  Comprehensive Psychiatry ,  92 , 1-6. https://www.researchgate.net/profile/Matt-Delisi/publication/332777044_The_etiology_of_antisocial_personality_disorder_The_differential_roles_of_adverse_childhood_experiences_and_childhood_psychopathology/links/5cdee5ea299bf14d95a2cff4/The-etiology-of-antisocial-personality-disorder-The-differential-roles-of-adverse-childhood-experiences-and-childhood-psychopathology.pdf(Controversy Associated with Personality and Paraphilic Disorders Comprehensive Nursing Paper Sample)

Johnson, S. A. (2019). Understanding the violent personality: antisocial personality disorder, psychopathy, & sociopathy explored.  Forensic Research & Criminology International Journal ,  7 (2), 76-88. (Controversy Associated with Personality and Paraphilic Disorders Comprehensive Nursing Paper Sample) https://www.researchgate.net/profile/Scott-Johnson-12/publication/331993478_Understanding_the_violent_personality_2019/links/5c9a3570a6fdccd4603bf2f8/Understanding-the-violent-personality-2019.pdf

Mulay, A. L., & Cain, N. M. (2020). Antisocial personality disorder.  Encyclopedia of personality and individual differences , 206-215. https://drreidmeloy.com/wp-content/uploads/2015/12/2014_AntisocialPers.pdf

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Walden University Personality & Paraphilic Disorders Nursing Essay

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Assignment: controversy associated with personality and paraphilic disorders.

Between 10% and 20% of the population experience personality disorders. They are difficult to treat as individuals with personality disorders are less likely to seek help than individuals with other mental health disorders. Treatment can be challenging as they do not see their symptoms as painful to themselves or others.

Photo Credit: Joe Houghton - www.joehoughtonphotography.ie / Moment / Getty Images

Paraphilic disorders are far more common in men than in women, and generally quite chronic, lasting at least two years. Treatment of these disorders usually involves both psychotherapeutic and pharmacologic treatments.

In this Assignment, you will explore personality and paraphilic disorders in greater detail. You will research potentially controversial elements of the diagnosis and/or treatment and explain ethical and legal considerations when working with these disorders.

• Review this week’s Learning Resources and consider the insights they provide on assessing, diagnosing, and treating personality and paraphilic disorders.
• Select a specific personality or paraphilic disorder from the DSM-5 to use for this Assignment. 
• Use peer reviewed or scholarly articles and cite as APA guidelines. Attach PDF of the scholarly articles used. 

Explanation & Answer

View attached explanation and answer. Let me know if you have any questions.Hello, 😉 I have uploaded the assignment before the initial deadline to give you time to ask for any revisions. Kindly go through the work as soon as possible. Let me know if you need any clarification.Always happy to work with you again. Feel free to invite me privately for new tasks. Goodbye. 😊 Running head: PERSONALITY AND PARAPHILIC DISORDERS Personality and Paraphilic Disorders Student's Name Institutional Affiliation 1 PERSONALITY AND PARAPHILIC DISORDERS 2 Controversy Associated With Personality and Paraphilic Disorders Paraphilic illness entails frequent and intense sexually stimulating sensations with impulses. The disorder usually results in distressing behaviors leading to suffering and humiliation of individuals with potential causes of harm. Individuals usually develop various social, psychological, and biological risks in having paraphilia. Paraphilic inclinations and illnesses got contentiously explored. The sensations could result in a de-stigmatization of sexual desires (Turner & Briken, 2018). Paraphilia has many different types of sexual stimulants. However, as detailed in the most up-to-date diagnostic manual, the DSM-5, the symptoms are remarkably similar, regardless of the type of paraphilia a person is suffering. The Controversy on Dissociative Disorders. The disagreement surrounding dissociative disorders is the difficulty in distinguishing between dissociative disorder and personality condition and the lack of consensus on the diagnoses. The dispute surrounding dissociative illnesses stems from the difficulty distinguishing between dissociative disease and personality disorder due to the resemblance in symptoms that arise between the two conditions (Loewenstein, 2018). When this miscommunication occurred in 1988, the condition resulted in the denial of medical attention to patients who later classified with psychotic symptoms, despite constituting a danger of suicide. The second point of contention entails the significance of the observed signs, leading to debate over whether it constituted a particular condition or if physicians could prescribe something they could not see with certainty. The third concern was the possibility that offenders would be absolved by the judicial system based on a fictitious diagnosis of the disease, preventing the criminal from being held liable for the acts. The Professional Beliefs on Dissociative Disorders PERSONALITY AND PARAPHILIC DISORDERS 3 A dissociative condition has no distinctive image, lab tests, natural course, or genetic trend. Dissociative disorder is characterized by dynamically and post-traumatic distress symptoms resulting from childhood sexual abuse. Another belief states that, In order to strengthen the patient's ability to bear painful emotions when the circumstance cannot get altered instantly, stress endurance must be developed (Subramanyam et al., 2020). The array of symptoms associated with dissociative disorders include; self-mutilation, drug, sexual dysfunction, irritation, perversity, Sleeplessness, mood changes, and pathological variations in relationships. Dissociative disorder is categorized as an ailment of thrilling anxiety, possibly a form of post-traumatic tension condition, due to lengthy, recurrent strain. Symptoms of dissociative disorders are Insomnia, sexual problems, aggression, suicidal ideation, self-mutilation, substance abuse, paranoia. The dissociation got assessed as the prevalence of psychiatric conditions in clinical populations from various cultural and geographical backgrounds (Krüger, 2020). Other indicators of dissociative disorders comprise somatization, mental illness, changes in mood, and pathological alterations in relationships. As a result, dissociative syndrome is classified as a disorder of high stress, probably a kind of complicated post-traumatic stress disorder that develops due to recurrent trauma over an extended period. As a result, offenders claiming to suffer from dissociative disorder should be held liable for whatever activities they take while claiming to be suffering from the disease. As a subsequent step, the sensation of dissociation can generate distress since it affects cognitive performance and is regarded as losing control (Lyssenko et al., 2018). Nevertheless, with the help of an experienced therapist, it is possible to reverse the legislation. PERSONALITY AND PARAPHILIC DISORDERS 4 Approaches for Upholding the Therapeutic Relationship A skilled therapist familiarizes the clinical manifestations, and psychodynamic components of psychotic symptoms are essential. Healthcare practitioners should be able to make an appropriate diagnosis. However, the therapist needs to avoid prescribing too soon, resulting in a lack of understanding of the traumatic experience and a misunderstanding of the clinical findings (Subramanyam et al., 2020). Before attempts to handle dissociative conditions, it is necessary to have professional education in psychotherapy. The therapist should notice potential signs of a psychotic collapse during the therapy process and act as needed. Considerations Associated with Dissociative Disorders Healthcare providers need to minimize confusion amongst clients; a practical approach clarifies the signs of multiple personality disorder and dissociative conditions. Understanding the disorder symptoms prevents incorrect diagnosis, guaranteeing that the disease gets appropriately treated. According to recommendations provided to legislative agencies, individuals purporting to have dissociative illness should get accountable by the authorization of a professional therapist (Subramanyam et al., 2020). The process helps avoid erroneous convictions and guarantees that civil liberties got adequately exercised in the courts. PERSONALITY AND PARAPHILIC DISORDERS 5 References Krüger, C. (2020). Culture, trauma and dissociation: A broadening perspective for our field. Journal of Trauma & Dissociation, 21(1), 1-13. https://doi.org/10.1080/15299732.2020.1675134 Loewenstein, R. J. (2018). Dissociation debates: everything you know is wrong. Dialogues in clinical neuroscience, 20(3), 229. doi: 10.31887/DCNS.2018.20.3/rloewenstein Lyssenko, L., Schmahl, C., Bockhacker, L., Vonderlin, R., Bohus, M., & Kleindienst, N. (2018). Dissociation in psychiatric disorders: a meta-analysis of studies using the dissociative experiences scale. American Journal of Psychiatry, 175(1), 37-46. https://doi.org/10.1176/appi.ajp.2017.17010025 Subramanyam, A. A., Somaiya, M., Shankar, S., Nasirabadi, M., Shah, H. R., Paul, I., & Ghildiyal, R. (2020). Psychological Interventions for Dissociative disorders. Indian journal of psychiatry, 62(Suppl 2), S280. DOI: 10.4103/psychiatry.IndianJPsychiatry_777_19 Turner, D., & Briken, P. (2018). Treatment of paraphilic disorders in sexual offenders or men with a risk of sexual offending with luteinizing hormone-releasing hormone agonists: an updated systematic review. The journal of sexual medicine, 15(1), 77-93. DOI:10.1016/j.jsxm.2017.11.013  Running head: PERSONALITY AND PARAPHILIC DISORDERS Personality and Paraphilic Disorders Student's Name Institutional Affiliation 1 PERSONALITY AND PARAPHILIC DISORDERS 2 Controversy Associated With Personality and Paraphilic Disorders Paraphilic illness entails frequent and intense sexually stimulating sensations with impulses. The disorder usually results in distressing behaviors leading to suffering and humiliation of individuals with potential causes of harm. Individuals usually develop various social, psychological, and biological risks in having paraphilia. Paraphilic inclinations and illnesses got contentiously explored. The sensations could result in a de-stigmatization of sexual desires (Turner & Briken, 2018). Paraphilia has many different types of sexual stimulants. However, as detailed in the most up-to-date diagnostic manual, the DSM-5, the symptoms are remarkably similar, regardless of the type of paraphilia a person is suffering. The Controversy on Dissociative Disorders. The disagreement surrounding dissociative disorders is the difficulty in distinguishing between dissociative disorder and personality condition and the lack of consensus on the diagnoses. The dispute surrounding dissociative illnesses stems from the difficulty distinguishing between dissociative disease and personality disorder due to the resemblance in symptoms that arise between the two conditions (Loewenstein, 2018). When this miscommunication occurred in 1988, the condition resulted in the denial of medical attention to patients who later classified with psychotic symptoms, despite constituting a danger of suicide. The second point of contention entails the significance of the observed signs, leading to debate over whether it constituted a particular condition or if physicians could prescribe something they could not see with certainty. The third concern was the possibility that offenders would be absolved by the judicial system based on a fictitious diagnosis of the disease, preventing the criminal from being held liable for the acts. The Professional Beliefs on Dissociative Disorders PERSONALITY AND PARAPHILIC DISORDERS 3 A dissociative condition has no distinctive image, lab tests, natural course, or genetic trend. Dissociative disorder is characterized by dynamically and post-traumatic distress symptoms resulting from childhood sexual abuse. Another belief states that, In order to strengthen the patient's ability to bear painful emotions when the circumstance cannot get altered instantly, stress endurance must be developed (Subramanyam et al., 2020). The array of symptoms associated with dissociative disorders include; self-mutilation, drug, sexual dysfunction, irritation, perversity, Sleeplessness, mood changes, and pathological variations in relationships. Dissociative disorder is categorized as an ailment of thrilling anxiety, possibly a form of post-traumatic tension condition, due to lengthy, recurrent strain. Symptoms of dissociative disorders are Insomnia, sexual problems, aggression, suicidal ideation, self-mutilation, substance abuse, paranoia. The dissociation got assessed as the prevalence of psychiatric conditions in clinical populations from various cultural and geographical backgrounds (Krüger, 2020). Other indicators of dissociative disorders comprise somatization, mental illness, changes in mood, and pathological alterations in relationships. As a result, dissociative syndrome is classified as a disorder of high stress, probably a kind of complicated post-traumatic stress disorder that develops due to recurrent trauma over an extended period. As a result, offenders claiming to suffer from dissociative disorder should be held liable for whatever activities they take while claiming to be suffering from the disease. As a subsequent step, the sensation of dissociation can generate distress since it affects cognitive performance and is regarded as losing control (Lyssenko et al., 2018). Nevertheless, with the help of an experienced therapist, it is possible to reverse the legislation. PERSONALITY AND PARAPHILIC DISORDERS 4 Approaches for Upholding the Therapeutic Relationship A skilled therapist familiarizes the clinical manifestations, and psychodynamic components of psychotic symptoms are essential. Healthcare practitioners should be able to make an appropriate diagnosis. However, the therapist needs to avoid prescribing too soon, resulting in a lack of understanding of the traumatic experience and a misunderstanding of the clinical findings (Subramanyam et al., 2020). Before attempts to handle dissociative conditions, it is necessary to have professional education in psychotherapy. The therapist should notice potential signs of a psychotic collapse during the therapy process and act as needed. Considerations Associated with Dissociative Disorders Healthcare providers need to minimize confusion amongst clients; a practical approach clarifies the signs of multiple personality disorder and dissociative conditions. Understanding the disorder symptoms prevents incorrect diagnosis, guaranteeing that the disease gets appropriately treated. According to recommendations provided to legislative agencies, individuals purporting to have dissociative illness should get accountable by the authorization of a professional therapist (Subramanyam et al., 2020). The process helps avoid erroneous convictions and guarantees that civil liberties got adequately exercised in the courts. PERSONALITY AND PARAPHILIC DISORDERS 5 References Krüger, C. (2020). Culture, trauma and dissociation: A broadening perspective for our field. Journal of Trauma & Dissociation, 21(1), 1-13. https://doi.org/10.1080/15299732.2020.1675134 Loewenstein, R. J. (2018). Dissociation debates: everything you know is wrong. Dialogues in clinical neuroscience, 20(3), 229. doi: 10.31887/DCNS.2018.20.3/rloewenstein Lyssenko, L., Schmahl, C., Bockhacker, L., Vonderlin, R., Bohus, M., & Kleindienst, N. (2018). Dissociation in psychiatric disorders: a meta-analysis of studies using the dissociative experiences scale. American Journal of Psychiatry, 175(1), 37-46. https://doi.org/10.1176/appi.ajp.2017.17010025 Subramanyam, A. A., Somaiya, M., Shankar, S., Nasirabadi, M., Shah, H. R., Paul, I., & Ghildiyal, R. (2020). Psychological Interventions for Dissociative disorders. Indian journal of psychiatry, 62(Suppl 2), S280. DOI: 10.4103/psychiatry.IndianJPsychiatry_777_19 Turner, D., & Briken, P. (2018). Treatment of paraphilic disorders in sexual offenders or men with a risk of sexual offending with luteinizing hormone-releasing hormone agonists: an updated systematic review. The journal of sexual medicine, 15(1), 77-93. DOI:10.1016/j.jsxm.2017.11.013  Outline for Personality and Paraphilic Disorders I. Introduction • Paraphilic illness entails frequent and intense sexually stimulating sensations with impulses. • The disorder usually results in distressing behaviors leading to suffering and humiliation of individuals • The sensations could result in a de-stigmatization of sexual desires • The symptoms are remarkably similar, regardless of the type of paraphilia a person is suffering. II. The Controversy on Dissociative Disorders. • The first controversy entails difficulty in distinguishing between dissociative disorder and personality condition • The act is brought by resemblance in symptoms • The second point of contention entails the significance of the observed signs, leading to debate over whether they constituted a particular condition • The third concern was the possibility that offenders would be absolved by the judicial system based on a fictitious diagnosis III. • The Professional Beliefs on Dissociative Disorders A dissociative condition has no distinctive image, lab tests, natural course, or genetic trend. • Dissociative disorder is characterized by dynamically and post-traumatic distress symptoms resulting from childhood sexual abuse. • In order to strengthen the patient's ability to bear painful emotions when the circumstance cannot get altered instantly, stress endurance must be developed • Symptoms of dissociative disorders are Insomnia, sexual problems • IV. The dissociative syndrome is classified as a disorder of high stress Approaches for Upholding the Therapeutic Relationship • Healthcare practitioners should be able to make an appropriate diagnosis. • The therapist needs to avoid prescribing too soon, resulting in a lack of understanding of the traumatic experience • It is necessary to have professional education in psychotherapy that identifies signs of a psychotic collapse V. Considerations Associated with Dissociative Disorders • Healthcare providers need to minimize confusion amongst clients • Identification of symptoms prevents incorrect diagnosis • Individuals purporting to have dissociative illness should get confirmation from the professional therapist View attached explanation and answer. Let me know if you have any questions.The sources. 1/14/22, 3:17 PM Psychological Interventions for Dissociative disorders - PubMed full text links Indian J Psychiatry. 2020 Jan;62(Suppl 2):S280-S289. doi: 10.4103/psychiatry.IndianJPsychiatry_777_19. Epub 2020 Jan 17. Psychological Interventions for Dissociative disorders Alka A Subramanyam 1 , Mansi Somaiya 1 , Sunitha Shankar 2 , Minhaj Nasirabadi 3 , Henal R Shah 1 , Imon Paul 4 , Rakesh Ghildiyal 5 Affiliations PMID: 32055070 PMCID: PMC7001344 DOI: 10.4103/psychiatry.IndianJPsychiatry_777_19 Free PMC article No abstract available Figures Figure 1 Overview of approach to treatment… Figure 2 Choice of therapy based on… Figure 4 Radical acceptance Figure 5 Approach to dissociative identity disorder Figure 3 Possible genesis of dissociation LinkOut - more resources Full Text Sources Europe PubMed Central Ovid Technologies, Inc. PubMed Central https://pubmed.ncbi.nlm.nih.gov/32055070/ 1/1  ORIGINAL RESEARCH PARAPHILIAS Treatment of Paraphilic Disorders in Sexual Offenders or Men With a Risk of Sexual Offending With Luteinizing Hormone-Releasing Hormone Agonists: An Updated Systematic Review Daniel Turner, PhD, MD,1,2 and Peer Briken, MD, FECSM1 ABSTRACT Background: Different pharmacologic agents are used in the treatment of paraphilic disorders in sexual offenders or men with a risk of sexual offending, with luteinizing hormone-releasing hormone (LHRH) agonists being the agents introduced more recently to treatment regimens. Aim: To summarize the relevant literature concerning LHRH agonist treatment of paraphilic disorders in sexual offenders and update the previously published systematic review by Briken et al (J Clin Psychiatry 2003;64:890e897). Methods: The PubMed and Google Scholar databases were searched for literature published from January 2003 through October 2017 using the following key words: LHRH agonists, GnRH agonists, antiandrogens AND paraphilia, pedophilia, sex offenders. Outcomes: Evaluation of the effectiveness and side effects of LHRH agonist treatment of paraphilic disorders in sexual offenders. Results: After screening for duplicates and applying specific selection criteria, the search yielded 24 eligible studies reporting on a sample of 256 patients. There is increasing evidence that LHRH agonists are more effective than steroidal antiandrogens in lowering paraphilic sexual thoughts and behaviors. Current research also is based on methods that might be less susceptible to faking (eg, eye-tracking, brain imaging, and viewing-time measures). Side effects occurring most frequently are fatigue, hot flashes, depressive mood, weight gain, high blood pressure, diabetes, gynecomastia, loss of erectile function, and loss of bone mineral density. Clinical Implications: Although LHRH agonists seem to be the most effective drugs in the treatment of paraphilic fantasies and behaviors, they should be reserved for patients with a paraphilic disorder and the highest risk of sexual offending because of their extensive side effects. Strengths and Limitations: This systematic review considers all types of research on LHRH agonist treatment in patients with paraphilic disorders, thereby providing a complete overview of the current state of research. However, most studies are case reports or observational studies and randomized controlled clinical trials have not been conducted or published. Conclusions: LHRH agonists are a useful treatment when combined with psychotherapy in patients with a paraphilic disorder and the highest risk of sexual offending. However, throughout treatment, close monitoring of side effects is needed and ethical concerns must always be kept in mind. Turner D, Briken P. Treatment of Paraphilic Disorders in Sexual Offenders or Men With a Risk of Sexual Offending With Luteinizing Hormone-Releasing Hormone Agonists: An Updated Systematic Review. J Sex Med 2018;15:77e93. Copyright
2017, International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved. Key Words: Gonadotropin-Releasing Hormone Agonists; Luteinizing Hormone-Releasing Hormone Agonists; Sexual Offender; Treatment; Antiandrogens; Paraphilia; Pedophilia; Paraphilic Disorder; Pedophilic Disorder Received August 13, 2017. Accepted November 20, 2017. 1 Institute for Sex Research and Forensic Psychiatry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; INTRODUCTION 2 Department of Psychiatry and Psychotherapy, University Medical Center Mainz, Mainz, Germany Copyright ª 2017, International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jsxm.2017.11.013 J Sex Med 2018;15:77e93 In the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, paraphilic interests are defined as “any intense and persistent sexual interest other than sexual interest in genital stimulation or preparatory fondling with phenotypically normal, 77 78 physiologically mature, consenting human partners.”1 To be differentiated from paraphilic interests, paraphilic disorders also must cause distress or impairments in normal daily functioning to the patient or harm to others.1 Although discussed controversially, the distinction between paraphilic interests and disorders could lead to a de-stigmatization and de-pathologization of non-normative sexual interests.2 Prevalence rates of a paraphilic disorder of approximately 50% have been found in sexual offenders, with pedophilic disorder (40%e47%) and sexual sadism disorder (6%e13%) being among the diagnoses found most frequently.3e5 A deviant sexual preference is one of the strongest predictors for sexual recidivism in adult and adolescent sexual offenders.6 Because of the crucial role testosterone plays in male sexuality, it could be a significant factor contributing to the etiology of paraphilic urges and behaviors.7 Physiologically, testosterone is produced in the Leydig cells of the testes and to a lesser extent in the adrenal cortex and brain.8 Testosterone production in the brain is de novo from cholesterol or through transformation of classic steroids such as progesterone that enter the nervous system through the blood stream.9 Its production and secretion are controlled by the hypothalamic-pituitary-gonadal axis and follow a negative feedback mechanism. Testosterone receptors have been found in different brain areas of humans and animals, such as the mammillary body, hippocampus, amygdala, orbitofrontal cortex, inferior temporal cortex, and hypothalamus. According to the 4-component model of sexual arousal proposed by Stoleru et al,10 these brain structures are involved in cognitive (eg, orbitofrontal cortex), emotional (eg, amygdala), and motivational (eg, hypothalamus) processes that take place during sexual arousal and overt sexual behaviors.7,10e17 Alterations in these brain areas could lead to changes in sexual arousal patterns, including sexual arousal to non-normative objects or sexual practices. Underscoring this suggestion, imaging studies have found structural and functional alterations in most of these brain areas in sexual offenders with a pedophilic disorder.18e20 Structural imaging studies have found decreased gray matter volumes in the orbitofrontal and dorsolateral prefrontal cortex, insula, ventral striatum, cingulate gyrus, parahippocampal gyrus, and right amygdala in pedophilic sexual offenders compared with healthy controls.18,19 Furthermore, using functional magnetic resonance imaging (fMRI), decreased activity in the left dorsolateral prefrontal cortex, right occipital and right parietal cortex, hypothalamus, and insula has been reported in pedophilic sexual offenders during the presentation of sexual stimuli.20 However, it is not clear how changes in testosterone concentrations are associated with these changes in brain activation patterns and, hence, with paraphilic behaviors or sexual offending. Giotakos et al21 found higher plasma testosterone levels in a sample of sexual offenders against adults but not in sexual offenders against children (not necessarily with a paraphilic disorder) compared with healthy controls. However, in all 3 groups, Turner and Briken the plasma testosterone level was still within the normal range. Studer et al22 reported a positive association between higher serum testosterone levels and sexual recidivism in a sample of 501 sexual offenders (also not necessarily with a paraphilic disorder). In their study, 14.5% of sexual offenders had testosterone concentrations above the normal range, although the investigators estimated that a rate of 2.5% would be expected for the general population.22 In contrast, other studies did not find an association between serum testosterone concentrations and sexual recidivism and some found even significantly higher serum testosterone levels in healthy controls compared with child sexual abusers.23,24 A recent meta-analysis concluded that serum testosterone concentrations are not altered in sexual offenders, but that sexual offenders against adults could have higher serum testosterone concentrations than child sexual abusers; however, these are usually within the normal range.25 Furthermore, many studies did not distinguish between sexual offenders with a paraphilic disorder and those without a paraphilic disorder. The investigators suggested that increased testosterone concentrations could lead to more violent and antisocial, rather than more paraphilic, behaviors and that increased antisocial behaviors in turn could facilitate committing sexual offenses in certain individuals.21,25,26 Nonetheless, previous research has suggested that suppressed serum testosterone concentrations might cause not only decreased sexual functioning but also decreased frequency of paraphilic fantasies and behaviors.27,28 In addition to testosterone, dopamine and serotonin play an important role in male sexuality. While dopamine is mainly involved in processes of sexual excitation, serotonin is associated with sexual inhibition processes.29 Dopamine receptors relevant for sexual functioning can be found in mesolimbic, nigrostriatal, and hypothalamic brain structures.29 Some case studies found an association between the onset of paraphilic fantasies and behaviors and treatment with dopamine-enhancing drugs in patients with Parkinson disease.30 However, no differences in genetic polymorphisms in dopamine receptor or dopamine transporter genes were found between sexual offenders with a paraphilic disorder and healthy controls.31 After an extensive review of the literature published until 2009, the current guidelines of the World Federation of Societies of Biological Psychiatry (WFSBP) advocated for the use of selective serotonin reuptake inhibitors (SSRIs), steroidal antiandrogens (cyproterone acetate [CPA] and medroxyprogesterone acetate [MPA]), and luteinizing hormone-releasing hormone (LHRH) agonists in the treatment of paraphilic disorders.32 Although antipsychotics lead to alterations in dopamine metabolism and some small studies have shown that antipsychotics can lead to a decrease of paraphilic fantasies and behaviors, they should be applied only if comorbid diagnoses justify their use.32 Furthermore, in patients with a comorbid depressive or obsessive-compulsive disorder, SSRIs should be preferred over other agents.32e37 In antisocial individuals, a recent Cochrane J Sex Med 2018;15:77e93 79 Paraphilic Disorders Treated With LHRH Agonists review found that only the anticonvulsants phenytoin, carbamazepine, and valproate were more effective than placebo treatment and led to a decrease in aggressive behaviors, including sexually aggressive behaviors. However, all included studies were conducted with general rather than explicitly sexual offenders.38 Concerning comorbid attention-deficit/hyperactivity disorder, there is evidence from 1 case series that psychostimulants combined with SSRIs show some efficacy in lowering paraphilic fantasies.39 In individuals with a paraphilic disorder and a comorbid bipolar disorder, there is some evidence for the effectiveness of mood stabilizers.40,41 Furthermore, a retrospective study of bipolar sexual offenders found that divalproex sodium led to a significant decrease of manic symptoms; however, no changes in paraphilic symptoms were reported. Nevertheless, divalproex sodium could be considered in sexual offenders whose offending has been associated with manic symptoms.42 Steroidal antiandrogens and LHRH agonists suppress serum testosterone concentrations through different mechanisms and thus are considered androgen-deprivation therapy (ADT). CPA binds to androgen receptors and competitively replaces testosterone and 5-a-dihydrotestosterone from androgen receptors, thereby inhibiting their effect on sexuality and other body functions. Furthermore, CPA acts as progesterone in inhibiting LHRH secretion from the hypothalamus, leading to decreased plasma testosterone levels.43 MPA also decreases LHRH secretion from the hypothalamus through a negative feedback mechanism. Moreover, MPA leads to a decrease in serum testosterone concentrations by inducing the production of the enzyme testosterone-a-reductase and by increasing the binding of testosterone to the testosterone hormone-binding globulin, thus decreasing the amount of freely available testosterone in the body.32 Different studies, including randomized controlled trials, have shown that CPA and MPA lead to a decrease of paraphilic urges, behaviors, and fantasies.44e48 However, all controlled studies were conducted more than 25 years ago. LHRH agonists are the most recent agents introduced to the treatment regimens of paraphilic disorders in sexual offenders. Initially, they were developed for the treatment of prostate cancer and are still used for this indication.49 Currently, buserelin, goserelin, leuprolide, and triptorelin are available. The 1st 3 agents have specific amino acid substitutions in positions 6 and 10 in the natural LHRH decapeptide structure, whereas triptorelin has a single amino acid substitution at position 6.49 Usually LHRH agonists are given as a depot through intramuscular (IM) or subcutaneous (SC) injections every 1 to 6 months, whereby concentrations differ between preparations (buserelin, 6.3 mg SC/2 months, 9.45 mg SC/3 months; goserelin, 3.6 mg SC/1 month, 10.8 mg SC/3 months; leuprorelin, 7.5 mg IM/1 month, 22.5 mg IM/3 month, 30 mg IM/4 months, 45 mg IM/6 months; triptorelin, 3.75 mg IM/1 month; 11.25 mg IM/3 months, 22.5 mg IM/6 months).32,50 In 2007, triptorelin (3-month IM formulation) received official approval in the European Union for the treatment of paraphilic J Sex Med 2018;15:77e93 disorders. Although not officially approved for the treatment of paraphilic disorders by the US Food and Drug Administration, in clinical practice LHRH agonists are applied in the United States and Canada.51 As hormonal agonists, these agents mimic the function of LHRH in the pituitary gland and initially lead to a rapid increase of LH and serum testosterone levels during the first 2 weeks of treatment (“flare-up effect”). Permanent stimulation subsequently causes de-sensibilization and downregulation of LHRH receptors in the pituitary gland followed by decreased testosterone synthesis. This mechanism ultimately leads to serum testosterone concentrations below castration level (usually defined as serum testosterone concentrations < 20e50 ng/dL).49 Through these mechanisms, LHRH agonists have been proved capable of lowering the frequency of paraphilic and non-paraphilic fantasies and behaviors. In a previous systematic review summarizing the relevant literature on LHRH agonists in the treatment of paraphilic disorders in sexual offenders or men with a risk of sexual offending from 1980 through 2002, Briken et al52 identified 13 studies reporting on 118 patients. They inferred that, because of the more intense suppression of serum testosterone concentrations after LHRH agonist treatment, these agents could be more effective in lowering paraphilic fantasies and behaviors than steroidal antiandrogens and SSRIs. Thus, LHRH agonists could be considered in cases in which steroidal antiandrogens and SSRIs failed or were accompanied by too many side effects. Briken et al52 concluded that more systematic studies were needed and future research should use more objective methods to assess clinical outcomes (eg, penile plethysmography [PPG]). However, it must be noted that PPG is a highly invasive technique and it is unclear how PPG outcomes can predict sexual recidivism in men with paraphilic disorders treated with LHRH agonists.53e55 Recently, Schmucker and Lösel56 and Khan et al57 attempted to meta-analyze the relevant literature on the effectiveness of pharmacologic agents in sexual offender treatment; however, they did not find any studies evaluating the use of LHRH agonists that met their inclusion criteria. Thus, a systematic review including all types of published studies is needed to provide an overview of the current state of research concerning the treatment effectiveness and side effects of LHRH agonists in sexual offenders with a paraphilic disorder. The present systematic review updates the review conducted by Briken et al.52 METHODS The PubMed and Google Scholar databases were searched for studies published from January 2003 through October 2017 using the following key words: LHRH agonists, GnRH agonists, antiandrogens AND paraphilia, pedophilia, sex offenders. This search of these 2 databases yielded 7,910 publications (Figure 1). All publications in the English or German language were included if they contained original data on the treatment effectiveness or side effects of LHRH agonist treatment in sexual offenders with a paraphilic disorder. When at least 2 articles 80 Turner and Briken Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram: overview of search strategy. Figure 1 is available in color at www.jsm.jsexmed.org. reported comparable findings on the same sample, only the more recent study was considered. RESULTS The search yielded 24 original studies (17 case reports, 5 crosssectional studies, 1 quasi-experimental study, and 1 repeatedmeasures non-randomized, masked clinical trial).43,58e80 In total, these studies reported on 256 patients who were treated with leuprorelin, goserelin, or triptorelin for different paraphilic disorders, mainly a pedophilic disorder. An unpublished study was identified through personal contact with a scientific journal.60 Information on the number of patients, their diagnoses, the applied dose of the LHRH agonist, and any side effects occurring under LHRH agonist treatment is presented in Table 1. Furthermore, the WFSBP published clinical guidelines on the pharmacologic treatment of adolescent and adult sexual offenders.32,81 Evaluation of Effectiveness and Side Effects of LHRH Agonist Treatment in Adult Sexual Offenders Leuprolide Bussmann and Finger58 reported on 5 pedophilic sexual offenders from a forensic psychiatric hospital in Berlin, Germany. 2 patients were previously treated with CPA; however, treatment had to be stopped because of side effects, especially osteoporosis. All 5 patients reported a decrease of sexual urges and deviant sexual fantasies, increased behavioral control, and increased victim empathy.58 In a case report of a male pedophilic sexual offender with comorbid cocaine and opiate dependence, alcohol abuse, and borderline intellectual functioning, Briken et al59 reported for the 1st time a relapse with a sexual offense in a patient treated with LHRH agonists. Although the patient reported he had better control over his paraphilic urges, his sexual interest in male juveniles remained unchanged and even increased during the J Sex Med 2018;15:77e93 Study N Sample and diagnoses (n) Adult sexual offenders (with paraphilic disorder) Leuprolide Ahn et al,62 2013 (Korea); prospective cross-sectional study 9 Pedophilia (3), voyeurism (1), fetishism (1), other disorder of sexual preference (4); age NR Briken et al,59 2004 (Germany); case report 1 Sexual offender diagnosed with pedophilia by psychiatrist; age ¼ 39 y Bussmann and Finger,58 2009 (Germany); case report 5 Sexual offenders currently incarcerated age: NR Pedophilia (4), not specified (1) 1 Sexual offender diagnosed with pedophilia; age ¼ 38 y Schiffer et al,64 2009 (Germany); case report Koo et al,61 2014 (Korea); prospective cross-sectional study Habermeyer et al,65 2012 (Switzerland); case report 56 Sexual offenders diagnosed with pedophilia (29), paraphilia NOS (12), exhibitionism (5), voyeurism (3), fetishism (3), impulse control disorder (3), personality disorder (3), conduct disorder (3); group A mean age ¼ 33.4 y; group B mean age ¼ 34.9 y 1 Sexual offender diagnosed with pedophilia (DSM-IV); age ¼ 43 y Treatment Side effects Leuprolide acetate NR Main results Significant decrease in sexual fantasies (Wilson Sexual Fantasies Questionnaire); no changes in rape myth acceptance and endorsement of violence scales Leuprolide acetate (11.25 mg SC/3 NR Decreased frequency of erections, mo) þ psychotherapy ejaculations, and masturbation under therapy; paraphilic fantasies remained unchanged; after 1 y, relapse and suicide attempt Leuprolide acetate (7.5 mg SC/ NR All patients reported decrease of mo) þ psychotherapy sexual urges; in 2 patients, initial increase in (hyper-)sexual impulses and sexual impulsivity Leuprolide acetate [11.25 mg/3 mo] þ NR Decrease in deviant fantasies and psychotherapy masturbation frequency; fMRI showed suppression of neural processing of sexual stimuli in subcortical brain areas Group A: abrupt rebound upsurge of Leuprolide acetate [3.75 mg/mo]; Group A: hot flashes (17), weight serum testosterone during 1st 2 group A ¼ 3-mo treatment; gain (11), testis reduction (9), mo after treatment end; group B: group B ¼ 6-mo treatment depression (8), pain at site of slow, gradual increase in serum injection (7), myalgia (4), loss of testosterone during 1st 2 mo bone mineral density (4), after treatment end; most men in decreased body hair (2); group B: groups A and B reported hot flashes (11), weight gain (3), decreased frequency and intensity testis reduction (2), depression of sexual thoughts; no differences (3), pain at site of injection (5), in frequency of side effects myalgia (2), loss of bone mineral density (2), diaphoresis (2) Leuprolide acetate [11.25 mg/3 mo] NR Decrease in frequency and intensity of sexual fantasies and sexual arousal; different brain activation pattern at fMRI while viewing images of boys and men Paraphilic Disorders Treated With LHRH Agonists J Sex Med 2018;15:77e93 Table 1. Results from outcome studies of paraphilic patients treated with LHRH agonists (continued) 81 82 Table 1. Continued Study N Sample and diagnoses (n) 66 Moulier et al, case report 2012 (France); Treatment 2 Sexual offender diagnosed with Leuprorelin [3.75 mg/mo] þ pedophilia (DSM-IV) (1); age ¼ 46 psychotherapy y; healthy control (1) Side effects Main results NR (continued) Turner and Briken J Sex Med 2018;15:77e93 Self-reported decrease in paraphilic sexual fantasies and desires; no more penile response to pictures of boys at penile plethysmography; after treatment, no more brain activation differences between patient and healthy control No consistent change in pedophilic Schober et al,63 2005 (USA); 5 Sexual offenders with pedophilia (5); Leuprolide acetate [7.5 mg at Pain at site of injection (4), hot interests as measured with Abel age ¼ 36e58 y baseline, 22.5 mg/3 mo]; placebo flashes (3), gynecomastia (1), prospective, repeatedassessment and penile after 1 y smaller penis (2), smaller testicles measures, non-randomized, plethysmography; decrease in (1) masked study masturbation frequency during LHRH treatment; increase during placebo phase Gallo et al,60 2017 (Canada); 47 Sexual offenders with paraphilic Sexual offenders treated with LHRH Leuprolide acetate þ psychotherapy NR agonists þ psychotherapy had disorder; age ¼ 28e83 y (25) [dosage NS] vs quasi-experimental significantly higher risk according psychotherapy only (22) retrospective study to the Static-99R vs psychotherapy-only group; sexual offenders receiving LHRH agonists had significantly lower rate of recidivism Triptorelin Amelung et al,69 2012 NR Fewer cognitive empathy deficits, Triptorelin (2) þ psychotherapy; 3 Self-identified help-seeking fewer cognitive distortions, less GnRH agonist (1) þ (Germany); case report pedohebephilic men; age ¼ NR; sexual preoccupation, better psychotherapy; dosage NS pedophilia or paraphilia NOS sexual self-control (hebephilia) diagnosed based on DSM-IV-TR by psychiatrist Ho et al,72 2012 (UK); case 7 Sex offenses against children (5) or Triptorelin [11.25 mg IM/3 mo] (3); Gynecomastia (2), hot flashes (1), Decrease in sexual incidents on unit; report women (2); mean age ¼ 42 y triptorelin [4.2 mg IM/mo] (4) decrease in bone mineral density lower levels of sexual arousal (1), smaller testicles (1) measured with penile plethysmography in 2 patients (others were not tested); selfreported decrease in sexual fantasies, desire, and arousal in all patients Hoogeveen and Van der 1 Sexual offender with mild mental Triptorelin; dose NR Hot flashes, perspiration attacks, Decreased sexual preoccupation; Veer,67 2008 (Netherlands); retardation, hypersexual erection and ejaculation disorders, treatment stopped because of case report behaviors, and sexual contacts loss of bone mineral density osteoporosis; after treatment was with children; age ¼ 35 y stopped, immediate return of pedophilic sexual fantasies Study N Sample and diagnoses (n) 68 Huygh et al, 2015 (Belgium); case report Mayrhofer et al,70 2016 (Germany); case report Jordan et al,73 2014 (Germany); case report Gosereline Polak and Nijman,75 2005 (Netherlands); case report Beier et al,74 2010 (Germany); case report Treatment Side effects Main results 1 Sexual offender diagnosed with pedophilia and narcissistic personality disorder (DSM-IVTR); age ¼ 48 y 3 Sexual offenders diagnosed with pedophilia (1) and paraphilia (2); age ¼ 35e48 y 1 Sexual offender diagnosed with pedophilia, antisocial personality disorder; age ¼ 47 y Triptorelin NR Triptorelin (2) [11.25 mg/3 mo]; leuprorelin (1) [3.75 mg/mo] NR Triptorelin [11.25 mg/3 mo] þ psychotherapy NR Serum LHRH and serum androgens levels stayed high even after additional CPA treatment; MRI showed a pituitary adenoma All patients developed recidivating urinary stones after osteoporosis from LHRH agonist treatment Loss of sexual functioning; no more sexually deviant fantasies in selfreport; in eye-tracking measure, shorter relative fixation time for images of girls vs before treatment; different brain activation pattern vs before treatment 4 Sexual offenders, not necessarily with paraphilic disorder; age NR Goserelin [10.8 mg/3 mo] NR Goserelin þ psychotherapy; dosage No side effects occurred 1 Self-identified help-seeking man; NR self-reported sexual offending and child pornography consumption; pedophilia diagnosed based on DSM-IV-TR; so far, no conviction for sexual offense; age ¼ 39 y Type of LHRH agonist NS Turner et al,43 2013 (Germany); 65 Sexual offenders; age > 18 y observational study Voß et al,71 2016 (Germany); prospective observational study LHRH agonist LHRH agonist 30 Pedophilia (21), fetishism (1), sadomasochism (2), multiple paraphilia (2), paraphilia NOS (2); age ¼ 36e72 y Paraphilic Disorders Treated With LHRH Agonists J Sex Med 2018;15:77e93 Table 1. Continued Decreased paraphilic sexual fantasies and desire; decrease of sexual incidents at hospital CPA treatment had no effect on pedophilic sexual urges, fantasies, and behaviors; LHRH agonist treatment led to significant decrease in pedophilic sexual urges; patient self-reported no more risk of sexual offending Weight gain (11), gynecomastia (7), >65% of patients reported lower frequency and intensity of sexual hot flashes (27), decreased body thoughts; no differences between hair (17), smaller testis volume CPA and LHRH agonist (2), loss of bone mineral density treatment; more side effects (8), pain at injection site (19) under CPA treatment NR In 15 patients medication withdrawal trial was started; in 9 of 11 patients testosterone levels normalized within 3e7 mo; 1st erections occurred several months after testosterone levels normalized; paraphilic fantasies reoccurred after ending treatment, but there were no new sexual offenses 83 (continued) 84 Table 1. Continued Study N Sample and diagnoses (n) 76 Briken et al, 2009 (Germany); retrospective observational study Adolescent and young adult sexual offenders (with paraphilic disorder) Park and Kim,77 2014 (Korea); case report Fosdick and Mohiuddin,78 2016 (USA); case report Saleh,80 2005 (USA); case report Saleh et al,79 2004 (USA); case series Treatment LHRH agonist; dosage NR 26 Sexual offenders currently incarcerated; age NR; pedophilia or sadomasochism diagnosed by psychiatrist Side effects 91.7% of sexual offenders had sexual No side effects (11), fatigue (8), violations during incarceration headache (8), sleep disorders (8), before LHRH agonist treatment hot flashes (3), depression (2), was started, with no more osteoporosis (2), weight gain (1), violations under LHRH agonist dry skin (1), pain at injection site treatment; sexual offenders (1), testes pain (1), nausea and treated with LHRH agonists were obstipation (1) considered for home leave sooner than those not being treated Leuprolide acetate [3.6 mg/mo] Weight gain 1 Patient with paraphilia, exhibitionism, frotteurism (DSMIV-TR), severe mental retardation; age ¼ 20 y 1 Autism, moderate intellectual Leuprolide acetate [25 mg IM/3 mo] Weight gain disability, inappropriate sexual behavior toward children; age ¼ 15e22 y; no paraphilic disorder diagnosis 1 Sexual offender with paraphilia NOS Leuprolide acetate [7.5 mg/mo] þ No side effects with elements of exhibitionism; psychotherapy age ¼ 19 y 6 Sexual offenders with pedophilia (5), Leuprolide acetate [7.5 mg/mo] frotteurism (3), sexual sadism (1), paraphilia NOS (1); age ¼ 19e20 y Main results No side effects (5), loss of ejaculation (1) Decrease in masturbation frequency and sexual exposures No more incidents of sexual aggression after treatment start; stopping LHRH treatment led immediately to sexually abusive behaviors toward younger brother Decreased arousal to sexual stories at penile plethysmography; lower self-reported sexual drive and masturbation frequency All patients reported decreased frequency of paraphilic sexual thoughts and better control of paraphilic fantasies; in 1 patient, no change in content of paraphilic fantasies CPA ¼ cyproterone acetate; DSM-IV ¼ Diagnostic and Statistical Manual of Mental Disorders, 4th Edition; DSM-IV-TR ¼ Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision; fMRI ¼ functional magnetic resonance imaging; GnRH ¼ gonadotropin-releasing hormone; IM ¼ intramuscular; LHRH ¼ luteinizing hormone-releasing hormone; NOS ¼ not otherwise specified; NR ¼ not reported; NS ¼ not specified; SC ¼ subcutaneous. Turner and Briken J Sex Med 2018;15:77e93 Paraphilic Disorders Treated With LHRH Agonists course of therapy. This resulted in another sexual offense against a boy after 1 year of therapy. After disclosure to the police and in therapy, the patient tried to attempt suicide but survived.59 For the 1st time, the rate of recidivism was compared between a group of sexual offenders being treated with LHRH agonists and cognitive-behavioral therapy (CBT; n ¼ 25) and a group of sexual offenders being treated with CBT only (n ¼ 22).60 All sexual offenders receiving LHRH agonists were diagnosed with a paraphilic disorder and they had a significantly higher risk measured with the Static-99R compared with the CBT-only group.60,82 All sexual offenders were treated in a community treatment program. Minimum LHRH agonist treatment duration was 12 months, and average follow-up time after release from prison was 7.1 years. Despite their higher risk, sexual offenders treated with LHRH agonists had a lower rate of recidivism than the CBT-only group, at least concerning violent recidivism. None of the sexual offenders from the LHRH agonist group and only 1 offender from the CBT-only group recidivated with a sexual offense.60 In a prospective cross-sectional study, Koo et al61 compared treatment effectiveness and kinetics of serum testosterone recovery in a sample of 56 paraphilic sexual offenders. Of the included patients, 38 were treated with LHRH agonists for 3 months, and the remaining patients were treated for 6 months. In the 2 groups, more than 70% of paraphilic sexual offenders reported a decrease of the frequency and intensity of paraphilic sexual thoughts and fantasies. No differences in the frequency of side effects were found between groups. Terminating treatment led to an immediate upsurge of serum testosterone levels in the group being treated for only 3 months. 2 months after treatment was stopped, serum testosterone levels were even higher than at the beginning of treatment. In contrast, serum testosterone concentrations increased only gradually in patients who were treated for 6 months. In month 5, after treatment was terminated, a rapid upsurge in serum testosterone concentrations was observed in these patients and testosterone concentrations were higher compared with baseline.61 In the group treated for 3 months, scores on the Wilson Sex Fantasy Questionnaire were comparable to the baseline scores 1 year after therapy was stopped, whereas scores remained lower in the group being treated for 6 months. This also accounted for the sadism subscale of the questionnaire.61 In another cross-sectional study, Ahn et al62 found significantly lower scores on the Wilson Sex Fantasy Questionnaire for 9 paraphilic sexual offenders after 3 months of LHRH agonist treatment. However, scores in the Rape Myth Acceptance Scale and the Endorsement of Violence Scale remained unchanged. Schober et al63 included 5 male pedophilic patients in a prospective, repeated-measures, nonrandomized, masked study. All patients received an LHRH agonist depot injection at baseline and repeated injections at months 1, 4, 7, and 10. After 1 year, LHRH agonist treatment was stopped and replaced with placebo treatment without informing the patients. Placebo was J Sex Med 2018;15:77e93 85 given for 12 months. Treatment effectiveness was measured using self-report, Abel Assessment, PPG, and psychological testing at baseline and at 3-month intervals throughout the entire study period. During LHRH agonist treatment, all patients reported decreased sex drive, decreased pedophilic sexual urges, and decreased masturbation frequencies. In 2 patients, pedophilic sexual urges reoccurred after 3 months and in 1 patient after 6 months on placebo. These patients were put on the LHRH agonist treatment again. The remaining 2 patients stayed on placebo for the entire 12 months. In all 5 subjects, the Abel Assessment and the PPG measure generally indicated no change in pedophilic sexual interests while being treated with LHRH agonists. However, penile responses to pedophilic stimuli were lower under LHRH agonist treatment compared with baseline or during placebo treatment.63 Different investigators have studied brain activation patterns in pedophilic sexual offenders under LHRH agonist treatment. Schiffer et al64 evaluated the brain activation pattern of a pedophilic sexual offender using fMRI in response to sexually arousing visual stimuli (images of nude girls and women) and to neutral visual stimuli (images of dressed girls and women) after being treated with an LHRH agonist for 3 years. The patient reported a 90% decrease of deviant sexual fantasies and masturbation frequency after 9 months of treatment. Viewing images of dressed girls led to significantly stronger activation in the right prefrontal cortex, left subgenual anterior cingulate, and bilateral superior temporal cortex compared with viewing pictures of nude girls. Furthermore, viewing images of undressed girls led to stronger activation in the dorsolateral prefrontal cortex, superior parietal lobule, the 2 middle occipital gyri, and superior temporal cortex in contrast to the activation pattern found while viewing undressed women. Compared with a group of un-medicated pedophilic sexual offenders from a previous study by Schiffer et al,83 weaker activation of the hypothalamus, amygdala, insula, substantia nigra, or hippocampus was found in the patient from that study while viewing undressed children. Using a similar paradigm, Habermeyer et al65 reported on a 43-year-old sexual offender who was diagnosed with a nonexclusive pedophilia (attracted to men and boys). After LHRH agonist treatment was initiated, the participant reported a decrease of sexual fantasies and sexual arousal and rated images of boys in bathing suits as significantly less sexually attractive compared with the pretreatment ratings. When comparing brain activation patterns while viewing images of boys in bathing suits before and after treatment, stronger activation of the right amygdala, right superior frontal gyrus, right precentral gyrus, and right superior temporal gyrus was found before treatment. Moulier et al66 compared the brain activation patterns of a 46year-old man diagnosed with pedophilia with those of a 47-yearold heterosexual male healthy control. The 2 participants viewed images of boys and girls and of women wearing swimsuits and images of dressed girls and women. fMRI and PPG measurement 86 were performed before and at 5 months into therapy. After 5 months of treatment, the patient reported no more pedophilic sexual fantasies and desires and penile responses to images of boys and girls in swimsuits had decreased markedly. Before treatment, the patient showed stronger activation in the left calcarine fissure, left anterior insula, caudal anterior cingulate cortex, and left cerebellar vermis while viewing images of boys compared with the control subject. At 5 months into treatment, no differences in brain activation patterns could be observed between the patient and the control subject.66 Triptorelin In a male patient with mild mental retardation who had been convicted for child sexual abuse (no paraphilic disorder diagnosis), previous treatment approaches using antipsychotics and SSRIs did not have an influence on the patient’s sexual behavior. The patient reported a marked decrease in sexual preoccupation after LHRH agonist treatment was initiated.67 Despite being treated with bisphosphonates and vitamin D, the patient’s bone mineral density steadily decreased, so that LHRH agonist treatment had to be stopped after 37 months. After ending treatment, the pedophilic sexual fantasies almost immediately returned.67 Turner and Briken concentrations normalized after ending LHRH agonist treatment; however, the duration to normalization of serum testosterone levels varied from 2 to 18 months. Body hair, physical strength, and testicular volume increased immediately after LHRH agonist therapy was ended; however, erectile functioning remained suppressed despite normal testosterone concentrations. Most patients also described an increase of paraphilic fantasies and urges after treatment was ended.71 Ho et al72 reported on 7 sexual offenders (not necessarily with a paraphilic disorder) treated with LHRH agonists at a maximum-security hospital. In all patients a decrease of sexual and violent incidents at the hospital was observed and all patients reported decreased sexual fantasies, desire, and arousal. 2 of the 7 patients underwent additional PPG recordings. These 2 patients displayed significantly lower levels of arousal.72 A research group reported on their experiences of treating selfidentifying, help-seeking pedophiles (actually not accused, convicted, or under probation because of sexual offending) from the German Dunkelfeld project from 2005 through 2010.69,84 Of the 111 men fulfilling the criteria for pedophilia or paraphilia not otherwise specified, 7 were treated with LHRH agonists at any time throughout the program. Only 3 men took the medication for more than 8 weeks. 2 patients reported fewer empathy deficits, better sexual self-control, and fewer deviant sexual fantasies. The 3rd patient did not report any changes in the frequency of pedophilic sexual fantasies.69 In a case study of a 47-year-old pedophilic sexual offender, Jordan et al73 examined the effect of LHRH agonist treatment using eye tracking and fMRI. After 3 months of treatment, the patient reported no more pedophilic sexual fantasies. Eyetracking measurements were conducted 3 weeks before LHRH agonist treatment and 4 months after treatment start, and fMRI scans were performed 2 months before and 4 months after treatment start. During eye tracking, the patient was confronted with either the image of a girl and a woman or of a boy and a man on a computer screen while eye movements were recorded. During the fMRI sessions, the same images were subliminally presented to the patient for 16.7 ms followed by a neutral mask stimulus for 483.3 ms. Before treatment, the patient had a significantly longer relative fixation time (controlled attentional processes) for images of girls than for images of women in the eye-tracking experiment. At 4 months into treatment, he showed longer fixation times for woman than for girl stimuli. Furthermore, the patient showed lower fixation latency (automatic attentional processes) for images of girls compared with images of women at least before treatment. After 4 months of treatment, this difference was no longer significant. This patient’s brain activation patterns showed stronger activation in the bilateral cerebellum, bilateral fusiform gyrus, lingual gyrus, calcarine gyrus, and left inferior temporal gyrus to subliminally presented images of girls before vs 4 months into treatment. The bilateral superior and middle occipital gyrus, superior parietal lobule, and right lingual gyrus and precuneus showed stronger activations during the 2nd vs 1st measurement.73 30 sexual offenders with a paraphilic disorder (mainly pedophilia) were treated with LHRH agonists at a forensic outpatient center in Berlin, Germany.70 3 patients developed osteoporosis and had to be treated because of calcium-oxalate monohydrate urinary stones.70 Voß et al71 described their experiences concerning treatment withdrawal trials in 15 of these 30 patients. In all cases, LHRH agonist withdrawal was supported by psychotherapy and supervised by an experienced clinician. Mean follow-up time after ending LHRH agonist treatment was 18 months (SD ¼ 9 months). In 9 patients, serum testosterone Goserelin In a case report, Beier et al74 described a 39-year-old selfidentified pedophilic patient with an exclusive pedophilic disorder of sexual attraction to boys. The patient worked as a teacher of young boys in the sexually preferred age range at a youth center. Although he had sexually abused several young boys, he had not been convicted for any sexual offense. The patient clearly suffered from his pedophilic sexual desires and chose to be treated with an LHRH agonist after treatment with CPA failed Huygh et al68 described the case of a 48-year-old pedophilic man who was convicted for multiple child sexual abuse offenses. Before treatment was started, a full blood cell count showed a serum testosterone level at the lower range. After LHRH agonist treatment was commenced, serum testosterone levels remained unusually high and LH and follicle-stimulating hormone levels also were above the norm. MR scan of the brain showed a large adenoma of the pituitary gland that had to be resected because of the risk of pituitary apoplexy under LHRH agonist treatment. After resection, testosterone decreased to castration level.68 J Sex Med 2018;15:77e93 87 Paraphilic Disorders Treated With LHRH Agonists to lead to any decrease in pedophilic sexual desire. After LHRH agonist treatment was initiated, the patient reported a significant decrease of his sexual urges and stated that the risk of sexually abusive behaviors had vanished. Polak and Nijman75 reported on 4 sexual offenders, not necessarily with a paraphilic disorder, treated with LHRH agonists. In these patients, the number of sexual and non-sexual aggressive acts decreased markedly. 1 patient was previously treated with CPA; however, treatment had to be terminated because of severe side effects. After changing medication to an LHRH agonist, serum testosterone concentrations decreased even further and the patient experienced no more side effects.75 Type of LHRH Agonist Not Specified Of all 79 sexual offenders who were placed in a forensic psychiatric hospital in Berlin, Germany from 1998 through 2005, 32.9% were treated with LHRH agonists at any time during the observed period.76 All sexual offenders treated with pharmacologic agents were diagnosed with a paraphilic disorder. In 58% of patients, side effects were observed, with fatigue, headache, sleep disorders, hot flashes, depression, and loss of bone mineral density being observed most frequently. Patients being treated with LHRH agonists or CPA were considered for home leave sooner than un-medicated patients.76 In an observational study, Turner et al43 assessed the frequency of LHRH agonist prescription for sexual offenders in German forensic psychiatric institutions. Of the 611 sexual offenders included in the study, 65 were treated with LHRH agonists. Paraphilic disorder diagnoses were not evaluated in that study. Of those being treated pharmacologically, 75.4% reported a decrease of the frequency of sexual thoughts. A loss of bone mineral density was observed only in those patients being treated with LHRH agonists and not during treatment with CPA. Side effects occurring most frequently during LHRH agonist treatment were hot flashes, pain at the site of injection, decreased body hair, and weight gain.43 Evaluation of Effectiveness and Side Effects of LHRH Agonist Treatment in Adolescent (or Young Adult) Sexual Offenders Park and Kim77 and Fosdick and Mohiuddin78 each reported on 1 patient who had an autistic disorder and mental retardation and was treated with LHRH agonists because of sexually aggressive behaviors. The patients in these 2 studies were not diagnosed with a paraphilic disorder. The patient of Park and Kim77 was described as showing a high frequency of masturbatory behavior (4e5 hours/day), repeated genital exposure, and sexually aggressive behavior against different family members beginning at 18 years of age. Treatment with valproate and olanzapine led to an initial improvement of symptoms but was accompanied by different side effects, especially weight gain. After changing the antipsychotic medication, sexual and aggressive symptoms increased again and an LHRH agonist was added. J Sex Med 2018;15:77e93 This dual treatment led to a complete decrease in masturbatory behaviors and significantly less sexually aggressive behaviors. Other than further weight gain, the patient showed no side effects. The patient described by Fosdick and Mohiuddin78 was 11 years of age when sexually aggressive behaviors toward other children started. Different pharmacologic...

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