Evidence-Based Reviews

Paraphilic disorders and sexual criminality

Current Psychiatry. 2022 June;21(6):20-27 | doi: 10.12788/cp.0252

References

1. Federoff JP. The paraphilias. In: Gelder MG, Andreasen NC, López-Ibor JJ Jr, Geddes JR, eds. New Oxford Textbook of Psychiatry. 2nd ed. Oxford University Press; 2012:832-842.
2. Grubin D. Medical models and interventions in sexual deviance. In: Laws R, O’Donohue WT, eds. Sexual Deviance: Theory, Assessment and Treatment. 2nd ed. Guilford Press; 2008:594-610.
3. Guidry LL, Saleh FM. Clinical considerations of paraphilic sex offenders with comorbid psychiatric conditions. Sex Addict Compulsivity. 2004;11(1-2):21-34.
4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Association; 2013.
5. Balon R. Paraphilic disorders. In: Roberts LW, Hales RE, Yudofsky SC, eds. The American Psychiatric Association Publishing Textbook of Psychiatry. 7th ed. American Psychiatric Association Publishing; 2019:749-770.
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7. First MB, Halon RL. Use of DSM paraphilia diagnosis in sexually violent predator commitment cases. J Am Acad Psychiatry Law. 2008;36(4):443-454.
8. Specht v Patterson, 386 US 605 (1967).
9. Ra EP. The civil confinement of sexual predators: a delicate balance. J Civ Rts Econ Dev. 2007;22(1):335-372.
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13. Kansas v Crane, 534 US 407 (2002).
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15. United States v Comstock, 560 US 126 (2010).
16. Adam Walsh Child Protection and Safety Act of 2006, HR 4472, 109th Cong (2006). Accessed April 25, 2022. https://www.congress.gov/bill/109th-congress/house-bill/4472
17. Tucker DE, Brakel SJ. Sexually violent predator laws. In: Rosner R, Scott C, eds. Principles and Practice of Forensic Psychiatry. 3rd ed. CRC Press; 2017:823-831.
18. Wash. Rev. Code. Ann. §71.09.020(8)
19. Bradford J, de Amorim Levin GV, Booth BD, et al. Forensic assessment of sex offenders. In: Gold LH, Frierson RL, eds. The American Psychiatric Association Publishing Textbook of Forensic Psychiatry. 3rd ed. American Psychiatric Association Publishing; 2017:382-397.
20. Mellor E, Duff S. The use of pornography and the relationship between pornography exposure and sexual offending in males: a systematic review. Aggress Violent Beh. 2019;46:116-126.
21. Failure To Register, 18 USC § 2250 (2012). Accessed April 25, 2022. https://www.govinfo.gov/app/details/USCODE-2011-title18/USCODE-2011-title18-partI-chap109B-sec2250
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24. Thibaut F, Cosyns P, Fedoroff JP, et al; WFSBP Task Force on Paraphilias. The World Federation of Societies of Biological Psychiatry (WFSBP) 2020 guidelines for the pharmacological treatment of paraphilic disorders. World J Biol Psychiatry. 2020;21(6):412-490.
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Recidivism and treatment

The recidivism rate among sexual offenders averages 13.7% at 3- to 6-year follow-up,although rates vary by type of sexual offense.²³ Individuals who committed rape have the highest rate of recidivism, while those who engaged in incest have the lowest. Three key points about sexual offender recidivism are:

it declines over time and with increased age.
sexual offenders are more like to commit a nonsexual offense than a sexual offense.
sexual offenders who have undergone treatment are 26.3% less likely to reoffend.²³

Although there is no standard of treatment, current interventions include external control, reduction of sexual drive, treatment of comorbid conditions, cognitive-behavioral therapy (CBT), and dynamic psychotherapy. External control relies on an outside entity that affects the individual’s behavior. For sexually deviant behaviors, simply making the act illegal or involving the law may inhibit many individuals from acting on a thought. Additional external control may include pharmacotherapy, which ranges from nonhormonal options such as selective serotonin reuptake inhibitors (SSRIs) to hormonal options. Therapy tends to focus on social skills training, sex education, cognitive restructuring, and identifying triggers, as well as victim empathy. The best indicators for successful treatment include an absence of comorbidities, increased age, and adult interpersonal relationships.²⁴

Treatment choice may be predicated on the severity of the paraphilia. Psychotherapy alone is recommended for individuals able to maintain functioning if it does not affect their conventional sexual activity. Common treatment for low-risk individuals is psychotherapy and an SSRI. As risk increases, so does treatment with pharmacologic agents. Beyond SSRIs, moderate offenders may be treated with an SSRI and a low-dose antiandrogen. This is escalated in high-risk violent offenders to long-acting gonadotropin-releasing hormone analogs and synthetic steroidal analogs.²⁵

An evolving class of disorders

With the evolution and accessibility of pornography, uncommon sexual practices have become more common, gaining notoriety and increased social acceptance. As a result, mental health professionals may be tasked with evaluating patients for possible paraphilic disorders. A common misconception is that individuals with sexually deviant thoughts, sexual offenders, and patients with paraphilic disorders are all the same. However, more commonly, sexual offenders do not have a paraphilic disorder. In the case of SVPs, outside of imprisonment, civil commitment remains a consideration for possible treatment. To meet the threshold of civil commitment, a sexual offender must have a “mental abnormality,” which is most commonly a paraphilic disorder. The treatment of paraphilic disorders remains a difficult task and includes a mixture of psychotherapy and medication options.

CASE CONTINUED

Mr. J begins weekly CBT to gain control of his voyeuristic fantasies without impacting his conventional sexual activity and desire. He responds well to treatment, and after 18 months, begins a typical sexual relationship with a woman. Although his voyeuristic thoughts remain, the urge to act on the thoughts decreases as Mr. J develops coping mechanisms. He does not require pharmacologic treatment.

Bottom Line

Individuals with paraphilic disorders are too often portrayed as sexual deviants or criminals. Psychiatrists must review each case with careful consideration of individual risk factors, such as the patient’s sexual history, to evaluate potential treatment options while determining if they pose a threat to the public.

Related Resources

Sorrentino R, Abramowitz J. Minor-attracted persons: a neglected population. Current Psychiatry. 2021;20(7):21-27. doi:10.12788/cp.0149
Berlin FS. Paraphilic disorders: a better understanding. Current Psychiatry. 2019;18(4):22-26,28.