A thorough history and physical exam should be performed prior to the conduction of a comprehensive psychiatric assessment. As paraphilia is previously known as sexual perversion or sexual deviation, along with the consideration of paraphilia to be a behavior that often leads to stigmatization and legal ramifications, it is not very common for a voluntary medical evaluation to be sought. Therefore, special attention must be made to use open-ended questions, and avoidance of opinions and/or judgment must be maintained throughout the interview or history-taking process. Furthermore, signs of abuse should be monitored for, as some paraphilias either involve personal history of sexual abuse (commonly, pedophilic disorder) or involve the subjective endurance of sexual abuse (sexual masochistic disorder).

The DSM-5 diagnostic criteria for paraphilia states explicitly that the patient must have experienced intense and recurrent sexual arousal from deviant fantasies for at least six months and must have acted on these impulses. A paraphilia becomes a pathology, or a paraphilic disorder, only when this behavior causes significant distress and impairment of functioning to the individual or if the paraphilia involves personal harm or risk of harm to others.[15] Specifiers of “in remission” (when distress or dysfunction is no longer caused) and “in a controlled environment” exist for all paraphilias, except pedophilia.[16][13] Specifiers specifically added to exhibitionistic disorder include the exposure of one’s genitals to prepubescent children, physically mature individuals, or both. Age of onset is typically before eighteen years of age. Specifiers specifically added to sexual masochistic disorder include: with asphyxiophilia or autoerotic asphyxiation. Specifiers added specifically to fetishistic disorder include body parts, non-living parts, other. Specifiers added specifically to transvestic disorder include fetishism if aroused by fabrics, materials, or garments, and autogynephilia if aroused by thoughts or images of himself as a female.

Other diagnostic tools, including laboratory values, tests, and imaging, should also be obtained in the early evaluation and diagnostic phases. These are particularly important in appropriately diagnosing such conditions, as well as ruling out other potential causes. Laboratory values include, but are not limited to, the following measures: lipid panel, thyroid function tests, fasting blood glucose, erythrocyte sedimentation rate (ESR), prolactin, testosterone, estrogen, luteinizing hormone (LH), and follicle-stimulating hormone (FSH). Imaging could include ultrasonography and angiography. Studies or tests include nocturnal penile tumescence and pap smears.

The treatment and management of paraphilias and paraphilic disorders pose extreme difficulty due to a multitude of factors. Despite the egosyntonic and egodystonic dual nature of paraphilias in general, the overall majority of patients rarely seek treatment voluntarily. Many individuals may feel indignity, culpability, or discomfiture, while others focus on the difficulty and lack of desire to halt efforts of achieving intense sexual pleasure and ultimate satisfaction. Furthermore, many may fear the legal repercussions of coming forward for treatment. Those patients in treatment or seeking treatment are most often either mandated legally or convinced by family, friends, or sexual partners.

The management of paraphilic disorders falls into two main categories, incorporating both psychological and biological constituents. The psychological approach, which includes psychotherapy, but more importantly, cognitive behavioral therapy (CBT), yields an overall positive outcome in terms of efficacy, regardless of the type of diagnosed paraphilic disorder.[17] However, due to the patient’s reluctance to seek treatment or the legal obligation to obtain treatment, psychiatrists are often forced to exceed the call of duty to the patient with the reduction of distress, but rather focus efforts on protection against potential victimization.[18] The predisposition of committing sexual offenses demonstrates the significance of biological treatments for paraphilic disorders for not only the suffering individual but also for the greater good of society.[19] However, specialized management, with a comprehensive treatment plan encompassing both psychological and pharmacological components, proves to be the optimal therapeutic option overall.[18]

The three main classifications of pharmacological agents used in the management of paraphilic disorders involve selective serotonin reuptake inhibitors (SSRIs), synthetic steroidal analogs, and antiandrogens. Despite limited support in the literature and the demand for further definitive research, treatment algorithms for varying severity of illness have been devised, offering useful and rational approaches to the treatment of paraphilic disorders. The therapeutic choice is dependent upon previous medical history and medication compliance, along with the intensity of both the sexual fantasy and the risk of sexual violence.[19]

Literature suggests that each of the three drug categories mentioned above help to target diverse physiological pathways and subsequent psychological attributes through their unique mechanism of action. Studies have shown SSRIs to be particularly useful in the adolescent population and milder paraphilias, including exhibitionism, as well as in patients suffering from comorbidities of obsessive-compulsive disorders (OCD) or depression. SSRIs have also been used in the attempted alleviation of hypersexuality, but strong evidence of actual efficacy has yet to be established. Antiandrogens, with emphasis on gonadotropin-releasing hormone (GnRH) analogs, have shown to considerably reduce the frequency and intensity of both deviant sexual arousal and behavior. GnRH analogs are also considered to be among the most promising pharmacological management for those sex offenders at high risk of particularly violent acts, particularly serial rapists or those individuals with pedophilic disorder. Of note, informed consent is obligatory before initiating antiandrogenic therapy.[18]

• Sexual dysfunction disorders
• Gender identity disorder
• Hypersexuality or sex addiction
• Nonparaphillic compulsive sexual disorders
• Psychological Issues (fears of intimacy, commitment, etc.)
• Other psychiatric disorders: Obsessive-compulsive disorder (OCD), depression, bipolar disorder (manic episodes), schizophrenia, personality disorder, anxiety disorders
• Other disorders: Substance intoxication, intellectual disability, dementia

Despite the psychological and pharmacological interventions designed for the management of paraphilias and paraphilic disorders, an ultimate treatment or change has yet to be established. Existing interventions merely allow for increased voluntary control through self-management skills over sexual arousal and reduction in sexual drive, with the best-yielded prognosis only from those individuals who are actually motivated to change.[2] Those who do participate in either therapy alone, or more ideally, the combined management of psychological and medicinal intervention, show improvement with a marked reduction in the intensity and frequency of deviant sexual arousal and resultant behaviors.[18] However, the literature suggests that most sexual offenders are likely to re-offend.[2]

Many complications of paraphilia and paraphilic disorders can arise. Living with these intense and abnormal desires and behaviors can be troublesome and cause much turmoil to those individuals suffering from them. When the paraphilia becomes a paraphilic disorder, individuals suffer harm, distress, and functional impairment. Furthermore, legal ramifications often ensue, leading to a life of incarceration and/or probation, forensic psychiatric hospital confinement, as well as permanent induction onto the sexual offender registry. Dependent on jurisdiction, the requirements of being on the sex offender registry include address notification, making living location public knowledge, housing limitations, as well as restrictions on being in the presence of underage persons, living in proximity to a school or daycare center, internet use, or even owning toys or other items that may suggest involvement with children.[20][21]

• Overall, the majority of patients suffering from paraphilic disorders rarely seek treatment voluntarily, as many individuals feel indignity, culpability, or discomfiture, while others focus on the difficulty and lack of desire to halt efforts of achieving intense sexual pleasure and ultimate satisfaction.
• Furthermore, the very nature of paraphilic disorders in many individuals leads to victimization and often legal repercussions. This will only further deter patients from seeking treatment. Those patients actually involved in treatment plans are most often either mandated legally or convinced by family, friends, or sexual partners.
• Despite the medications used in the management of paraphilic disorders discussed above, better preventative measures are deemed necessary to reduce victimization, as many of those with paraphilic disorders will only be under evaluation upon incarceration after the harm has been inflicted.
• Childhood sexual abuse is considered to be a leading cause of pedophilia, among other paraphilias and resultant paraphilic disorders. Maybe preventative measures should start here.
• Many psychiatrists and mental healthcare providers feel that the only cure for pedophilic disorder is incarceration. As paraphilias and paraphilic disorders are deeply engrained thoughts and irresistible behaviors of the individual, whether viewed as right or wrong, it is currently deemed as merely impossible to fix.

The significant complexity of paraphilias and paraphilic disorders requires specialist-level care, with a collaborative interprofessional team. The overseeing physician should have psychological expertise pertaining specifically towards such diagnoses, as well as persistent continuance on the most currently relevant medicinal interventions. Nursing and staff should have proper training and acquired knowledge to effectively approach, cope with, and manage these individuals, with any therapeutically noteworthy signs being brought immediately to the attention of the physician. The goal of the treatment team should be to provide optimal care, thus yielding better and more effective outcomes.