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ANNALS OF CLINICAL PSYCHIATRY
RESEARCH ARTICLE
ANNALS OF CLINICAL PSYCHIATRY 2010;22(2):129-134
Paraphilias in adult psychiatric inpatients
Patrick J. Marsh, MD
Department of Psychiatry
University of South Florida
Tampa, FL, USA
Brian L. Odlaug, BA
Nick Thomarios, DO
Andrew A. Davis, BS
Stephanie N. Buchanan, BS
Craig S. Meyer, BA
Jon E. Grant, JD, MD, MPH
Department of Psychiatry
University of Minnesota
Minneapolis, MN, USA
BACKGROUND: The goal of the present study was to examine the prevalence
of paraphilias in an adult inpatient psychiatric population.
METHODS:
One hundred twelve consecutive, voluntarily admitted, adult
male psychiatric inpatients were administered the Structured Clinical
Interview for DSM-IV, Sexual Disorders Module, Male Version, to assess
the rates of DSM-IV paraphilias.
Fifteen patients (13.4%) reported symptoms consistent with at
least one lifetime DSM-IV paraphilia. The most common paraphilias were
voyeurism (n = 9 [8.0%]), exhibitionism (n = 6 [5.4%]), and sexual masochism (n = 3 [2.7%]). Patients who screened positive for a paraphilia had
significantly more psychiatric hospitalizations (P = .006) and, on a trend
level, were more likely to have attempted suicide. In addition, patients
with paraphilias were significantly more likely to report having been sexually abused than patients without a paraphilia (P = <.001). Only 2 of the 15
paraphilic patients (13.3%) carried an admission diagnosis of a paraphilia.
RESULTS:
CONCLUSIONS: Paraphilias appear to be more common in adult male psy-
chiatric inpatients than previously estimated. The study also demonstrated
that these disorders were not screened for by the treating physician and
thus may go untreated. Further, larger-scale studies are necessary in order
to further examine the rates of these disorders in the general population.
KEYWORDS: paraphilia, voyeurism, sexual masochism, exhibitionism
CORRESPONDENCE
Patrick J. Marsh, MD
University of South Florida
Department of Psychiatry
3515 East Fletcher Avenue
Tampa, FL 33613 USA
E-MAIL
[email protected]
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INTRODUCTION
According to the DSM-IV-TR, paraphilias are defined by persistent,
intense sexually arousing fantasies, urges, or behaviors generally involving (1) nonhuman subjects, (2) the suffering or humiliation of oneself or
one’s partner, or (3) children or other nonconsenting persons, that occur
over a period of at least 6 months.1 Paraphilias have been described as
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deviant from the acceptable forms of sexual arousal as
defined by society.2 The paraphilias currently include
exhibitionism, fetishism, frotteurism, pedophilia, sexual
masochism, sexual sadism, transvestic fetishism, voyeurism, and paraphilia not otherwise specified (NOS).1
Few studies have been conducted analyzing the rates of
these disorders in the general population, and research
on paraphilias in general has focused mainly on sexual
offenders.3-6
In a non–sexual offender study conducted in Sweden, 2450 people were surveyed, and researchers found
prevalence rates of voyeurism of 7.7%; exhibitionism,
3.1%; and transvestic fetishism, 2.8%.7,8 DSM-IV criteria,
however, were not used in this study, and a diagnosis
was given if the respondent reported one or more incidents of the respective behavior. Furthermore, the sexual
thoughts or behaviors were not required to occur over at
least a 6-month period or cause clinically significant distress in functioning.
Psychosocial impairment is pervasive within the
paraphilias. According to a study by Kafka and Hennen,3 individuals with paraphilias have a significantly
higher incidence of physical abuse, fewer years of completed education, a greater number of psychiatric/substance abuse hospitalizations, higher rates of disability
or unemployment, and more contact with the criminal
justice system as compared with individuals who have
nonparaphilic hypersexuality disorders (eg, compulsive
masturbation, pornography dependence).3 Increased
risk of exposure to medical risks such as sexually transmitted diseases and HIV/AIDS is also elevated in men
with paraphilias.2
Comorbid psychiatric illness appears common in
people with paraphilias. Although paraphilias are rarely
diagnosed in general clinical settings, one study found
that 23 (92%) of 25 outpatients with a diagnosis of exhibitionism met criteria for a comorbid Axis I disorder.9
Raymond and colleagues4 found high rates of lifetime
mood (67%), anxiety (64%), substance use (60%), and
impulse control (29%) disorders in a sample of 45 pedophilic male sex offenders. Overall, current and lifetime
comorbid psychiatric disorders were found in 76% and
93% of the sample, respectively.4 In a sample of 70 individuals diagnosed with DSM-IV pedophilia, researchers
found that 59% had a co-occurring psychiatric illness.5
In a sample of 120 males with paraphilias or paraphiliarelated disorders, 109 (90.9%) had some lifetime Axis I
psychiatric diagnosis.3
130
Since limited research has examined the prevalence
of paraphilias in a population of non–sexual offenders, the
clinical characteristics of this group are relatively unknown
at this time. The goal of the present study was to assess the
prevalence of paraphilias in voluntarily hospitalized, male,
adult, psychiatric inpatients using a DSM-IV-TR diagnostic evaluation. We hypothesized that paraphilias would be
relatively common and that they would have been previously unrecognized and undiagnosed. To our knowledge,
no studies have systematically examined the prevalence
of paraphilias using DSM-IV criteria in either the general
population or in a clinical sample. Although historically,
little clinical and research attention has been given to the
paraphilias, the large market for paraphilic pornography
and paraphernalia suggests that the disorders may be
present in a substantial portion of the population.10
METHODS
One hundred twelve consecutive male patients (mean
age, 45.23 ± 13.56 [range 18 to 85] years) who were voluntarily admitted to an adult psychiatric inpatient unit at one
of 2 hospitals participated in the study. Sixty-two patients
(55.4%) from the University of Minnesota Medical Center
and 50 (44.6%) patients from the Bay Pines VA Healthcare System hospital were included in the study. All study
participants were required to meet the inclusion criteria:
(1) male gender; and (2) age 18 or older. Individuals were
excluded only for inability to understand and consent to
the study or if they had been involuntarily admitted for
treatment. Involuntary admission was an exclusion criterion, as the study sought to avoid having patients consent
under duress. Women were excluded because paraphilias appear particularly rare among females.1 The Institutional Review Boards of the University of Minnesota and
the Bay Pines VA Healthcare System hospital approved
the study and the informed consent. One investigator
discussed potential risks of the study with study participants. After providing a complete description of the
study to the participants, written informed consent was
obtained. This study was carried out in accordance with
the Declaration of Helsinki. No compensation was provided for participation in the study.
Demographic information, including relationship
status, education, and employment status, were assessed
directly with the patient, whereas ethnicity, admission and lifetime diagnoses, number of past psychiat-
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ANNALS OF CLINICAL PSYCHIATRY
ric admissions, and suicide attempts
were obtained from the patient’s chart.
Patients were also asked if they had
experienced any physical or sexual
abuse in their lifetime.
TABLE 1
Prevalence of paraphilias among adult psychiatric inpatients
(N = 112)
Current
prevalence,
n (%)
95% CI
Lifetime
prevalence,
n (%)
7 (6.25%)
95% CI
4.01% to 8.69%
15 (13.4%)
7.94% to 21.44%
Voyeurism
Exhibitionism
3 (2.6%)
1.18% to 4.16%
9 (8.04%)
3.98% to 15.12%
2 (1.78%)
0.55% to 3.01%
6 (5.36%)
2.2% to 11.78%
Sexual
masochism
2 (1.78%)
0.55% to 3.01%
3 (2.68%)
0.7% to 8.21%
Fetishism
0 (0.0%)
N/A
1 (0.89%)
0.05% to 5.59%
Frotteurism
0 (0.0%)
N/A
1 (0.89%)
0.05% to 5.59%
Pedophilia
0 (0.0%)
N/A
1 (0.89%)
0.05% to 5.59%
Sexual sadism
1 (0.89%)
0.06% to 2.92%
1 (0.89%)
0.05% to 5.59%
Paraphilia
NOS
1 (0.89%)
0.06% to 2.92%
1 (0.89%)
0.05% to 5.59%
Paraphilia
Any paraphilia
Assessments
Patients were individually and privately interviewed regarding sexual
behavior. Patients were diagnosed with
current (past year) and lifetime paraphilias using the Structured Clinical
Interview for DSM-IV, Sexual Disorders
Module, Male Version. This instrument
assesses for the presence of exhibitionism, fetishism, frotteurism, pedophilia,
sexual masochism, sexual sadism,
transvestic fetishism, and voyeurism,
using language directly taken from
DSM-IV.
CI: confidence interval; NOS: not otherwise specified.
Data analysis
The percentages of patients with current and lifetime
paraphilias and 95% confidence intervals were determined. Between-group differences (those with a lifetime
paraphilia compared with those without) were tested
using the Pearson chi-square and 2-sided Fisher’s exact
test for categorical variables and 2-tailed, independentsamples t tests for continuous variables. All comparison
tests were 2-tailed. Because we performed multiple comparisons, we used an adjusted alpha level of P < .01; we
did not adjust the alpha level to reflect all statistical comparisons because the Bonferroni correction tends to be
overly conservative.
R E S U LT S
One hundred twenty-four consecutive male psychiatric patients were approached for study inclusion. Five
VA patients and 7 University patients refused participation; 112 consecutive male psychiatric inpatients were
included in the study. The mean age of the entire sample
was 45.6 (± 13.6) years (range, 18 to 85) and consisted of
93 Caucasians (83.0%), 16 African Americans (14.3%),
and 3 of other ethnic backgrounds (2.7%).
Fifteen (13.4%) patients were diagnosed with a lifetime paraphilia and 7 (6.3%) with a current paraphilia
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(TABLE 1). The most common paraphilias were voyeurism
(n = 9 [8.04%]), exhibitionism (n = 6 [5.36%]), and sexual
masochism (n = 3 [2.68%]). Of the 15 patients, 9 (60%)
met criteria for 1 paraphilia, 4 (26.7%) had 2 paraphilias,
1 (6.7%) had 3, and 1 (6.7%) had 4 paraphilias.
No significant differences were noted between
groups on demographic variables (TABLE 2). Those
patients with a lifetime paraphilia, however, had significantly more psychiatric hospitalizations (14.5 [± 25.4] vs
5.1 [± 8.2] [P = .006]), significantly higher rates of sexual
abuse (53.3% vs 15.5%; P < .001), and significant higher
rates of any abuse (73.3% vs 32%; P < .001). In addition,
patients with lifetime paraphilias had attempted suicide
more often, on a trend level, than those without paraphilias (2.9 [± 3.7] vs 1.1 [± 2.3] [P = .011]).
Rates of psychiatric comorbidity, as expected in
an inpatient sample, were high throughout the sample
(TABLE 3). Although there was a trend for the paraphilia
group to have higher rates of current anxiety disorders
(46.7% vs 20.6%; P = .028), there were no statistically
significant differences in lifetime or current diagnoses
between groups.
DISCUSSION
To our knowledge, this is the largest study examining
the prevalence of paraphilias in a voluntarily admitted,
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PARAPHILIAS IN ADULT PSYCHIATRIC INPATIENTS
TABLE 2
Demographics and clinical characteristics of adult male psychiatric inpatients
with and without paraphilias (N = 112)
Has paraphilia
(n = 15)
No paraphilia
(n = 97)
Age
Mean (± SD) [range], y
44.1 (9.6)
[23 to 56]
Education, n (%)
High school or less
More than high school
Statistic
df
P value
45.8 (14.1)
[18 to 85]
.460a
110
.646
4 (26.7)
11 (73.3)
43 (44.3)
54 (55.7)
1.457b
1
.227
Race, n (%)
Caucasian
Other
14 (93.3)
1 (6.7)
79 (81.4)
18 (18.6)
1.304b
1
.254
Marital status, n (%)
Never married
Married
Separated/divorced/widowed
8 (53.3)
1 (6.7)
6 (40.0)
39 (40.2)
24 (24.7)
34 (35.1)
2.524b
2
.283
Employment, n (%)
Unemployed
10 (66.7)
66 (68.0)
.011b
1
.916
14.5 (25.4)
[1 to 100]
5.1 (8.2)
[0 to 50]
–2.762c
n/a
.006
No. of suicide attempts
Mean (± SD) [range]
2.9 (3.7)
[0 to 14]
1.1 (2.3)
[0 to 20]
–2.557c
n/a
.011
Any sexual abuse, n (%)
8 (53.3)
15 (15.5)
11.417b
1
<.001
Any physical abuse, n (%)
7 (46.7)
22 (22.7)
3.791
1
.052
11 (73.3)
31 (32.0)
10.873b
1
<.001
Patient demographics
Clinical characteristics
No. of psychiatric hospitalizations
Mean (± SD) [range]
Any abuse, n (%)
b
t test.
χ test.
Mann-Whitney U test.
a
b 2
c
Statistical significance is designated in bold type.
non–sexual offender sample. The results indicate that
paraphilias are present in clinically significant numbers
among male psychiatric inpatients, as approximately 1
in 8 had a current paraphilia. Only 13.3%, however, carried an admission diagnosis for a paraphilia, suggesting that these disorders often go unrecognized. Since
no other controlled studies using DSM-IV criteria have
been conducted to assess the rates of these disorders,
we are unable to determine at this time how our rates
compare with other treatment-seeking samples.
High rates of both lifetime and current psychiatric
comorbidity were found across the entire sample. The fact
that rates of current mood (80%), substance use (53.3%),
and anxiety (46.7%) disorders were found in patients
with paraphilia suggests that a variety of co-occurring
disorders are extremely common in the paraphilia group.
132
These co-occurring mood and anxiety disorders—not the
paraphilia—had historically received treatment attention
in these patients. Regardless of whether a causal relationship exists between paraphilias and co-occurring
disorders in these patients, the fact that they frequently
co-occur raises important clinical issues. Because paraphilias appear fairly common in men with psychiatric
disorders, it is important to screen for these behaviors in
these patients. This study found, however, that patients
did not reveal their paraphilia symptoms without being
directly asked by their clinician, often due to embarrassment, shame, and/or fear of legal repercussion. This
finding underscores the need for clinicians to specifically
inquire about the presence of paraphilias.
Our results also have treatment implications. All of
the patients in the study were receiving treatment for a
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ANNALS OF CLINICAL PSYCHIATRY
TABLE 3
Psychiatric comorbidity in adult male psychiatric inpatients with and without paraphilias (N = 112)
Has paraphilia
(n = 15)
No paraphilia
(n = 97)
Any mood disorder, n (%)
12 (80.0)
Any anxiety disorder, n (%)
7 (46.7)
Any substance disorder, n (%)
Any psychotic disorder, n (%)
Statistica
P value
73 (75.3)
.160
.689
29 (29.9)
1.675
.196
8 (53.3)
60 (61.9)
.369
.529
4 (26.7)
19 (19.6)
.399
.528
Any mood disorder, n (%)
12 (80.0)
70 (72.2)
.407
.524
Any anxiety disorder, n (%)
7 (46.7)
20 (20.6)
4.818
.028
Any substance disorder, n (%)
8 (53.3)
56 (57.7)
.103
.749
Any psychotic disorder, n (%)
4 (26.7)
17 (17.5)
.713
.399
Lifetime
Current
χ test; df = 1.
a 2
primary mental illness other than paraphilia. Two of the
patients carried a paraphilia diagnosis and only one had
treatment planning which considered the paraphilia.
Comorbid psychiatric disease is increasingly known to
affect treatment of primary disorders.11-13 Comorbidity
often makes treatment more complicated and comprehensive, and outcome in some illness is worse in the
presence of a comorbid disorder.11 Pharmacotherapy of
one disorder may aggravate symptoms of a second disorder.13 Treating one disorder alone may not be effective
if a co-occurring disorder is exerting a causal or maintaining influence on the treated condition.14,15 Furthermore, patients with both a paraphilia and another psychiatric disorder may require more intensive treatment
services, not only because of the comorbidity but also
because they may be at higher risk for attempting suicide or requiring hospitalization. Indeed, we found that
patients with paraphilias required inpatient hospitalization more frequently and reported almost twice the rates
of suicide attempts than patients without paraphilias.
To our knowledge, however, no research has been done
on the treatment of comorbid paraphilias in psychiatric
patients. Research on effective treatments for individuals with paraphilias and co-occurring psychiatric illness
are greatly needed. Neuropharmacologic interventions
that are reported to be effective in paraphilias and warrant investigation in this population include manipulation of the monoamines serotonin and dopamine, the
neuropeptide gonadotropin-releasing hormone, and
circulating levels of the hormone testosterone.16-18
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The present study has several limitations. First, we
based paraphilia diagnoses on subject report only and
did not obtain collateral information to confirm current
rates. Because paraphilias are often denied, the rates
found in this study may in fact underestimate the actual
rate of paraphilias in psychiatric patients. Second, it is
unclear how generalizable our results are to individuals with paraphilias in the community. Nonetheless, our
sample is broader than in previous paraphilia studies, in
that we did not limit the study to registered sex offenders.
Third, we included only males in the study based on previous literature suggesting rates of paraphilias are considerably higher in men.1 Paraphilias have been reported in
women, and future studies should examine gender difference in paraphilias.19
CONCLUSION
To our knowledge, this is the first study to examine the
prevalence of paraphilias in a treatment setting. DSMIV-TR reports paraphilias are rarely diagnosed in general
clinical facilities. The results of this study indicate that
paraphilias are present in clinically significant numbers
in male psychiatric patients and are associated with high
rates of psychiatric comorbidity. Given the significantly
higher rate of previous hospitalizations in patients with
paraphilias, there may be important diagnostic and treatment implications for male patients with chronic psychiatric illness and co-occurring paraphilias. Additional
Annals of Clinical Psychiatry | Vol. 22 No. 2 | May 2010
133
PARAPHILIAS IN ADULT PSYCHIATRIC INPATIENTS
research is needed, including larger prevalence studies,
studies of clinical correlates of paraphilias, and studies
that elucidate the relationship between paraphilias and
other psychiatric disorders. The clinical profile of patients
with paraphilias and severe mental illness requiring hospitalization may require a more focused and sustained
intervention to alleviate the symptoms of these co-occurring disorders with significant public health implications. ■
This material is the result of work
supported with resources and the use of facilities at the
ACKNOWLEDGEMENTS:
Bay Pines VA Healthcare System. This research was supported in part by an NIMH Career Development Award
(K23 MH069754-01A1 JEG - K30 RR022270-03 PJM).
Mr. Odlaug and Dr. Grant receive grant/
research support from Forest Pharmaceuticals and OrthoMcNeil/Janssen. Drs. Marsh and Thomarios, Mr. Davis,
Ms. Buchanan, and Mr. Meyer report no financial relationship with any company whose products are mentioned in
this article or with manufacturers of competing products.
rticle or with manufacturers of competing products.
DISCLOSURES:
REFERENCES
1. Diagnostic and statistical manual of mental
disorders, 4th ed, text revision ed. Washington DC:
American Psychiatric Association; 2000.
2. Kafka MP, Prentky R. A comparative study of
nonparaphilic sexual addictions and paraphilias in men.
J Clin Psychiatry. 1992;53:345-350.
3. Kafka MP, Hennen J. A DSM-IV axis I comorbidity
study of males (n = 120) with paraphilias and paraphiliarelated disorders. Sex Abuse. 2002;14:349-366.
4. Raymond NC, Coleman E, Ohlerking F, et al.
Psychiatric comorbidity in pedophilic sex offenders. Am
J Psychiatry. 1999;156:786-788.
5. Carlstedt A, Innala S, Brimse A, et al. Mental
disorders and DSM-IV paedophilia in 185 subjects
convicted of sexual child abuse. Nord J Psychiatry.
2005;59:534-537.
6. Abel GG, Becker JV, Cunningham-Rathner J, et al.
Multiple paraphilic diagnoses among sex offenders.
Bull Am Acad Psychiatry Law. 1988;16:153-168.
7. Langstrom N, Zucker KJ. Transvestic fetishism in
134
the general population: prevalence and correlates. J Sex
Marital Ther. 2005;31:87-95.
8. Langstrom N, Seto MC. Exhibitionistic and
voyeuristic behavior in a Swedish national population
survey. Arch Sex Behav. 2006;35:427-435.
9. Grant JE. Clinical characteristics and psychiatric
comorbidity in males with exhibitionism. J Clin
Psychiatry. 2005;66:1367-1371.
10. Dietz PE, Evans B. Pornographic imagery and prevalence of paraphilia. Am J Psychiatry. 1982; 139:1493-1495.
11. Gum AM, Cheavens JS. Psychiatric comorbidity
and depression in older adults. Curr Psychiatry Rep.
2008;10:23-29.
12. Petry NM, Stinson FS, Grant BF. Comorbidity of
DSM-IV pathological gambling and other psychiatric
disorders: results from the national epidemiologic
survey on alcohol and related conditions. J Clin
Psychiatry. 2005;66:564-574.
13. El-Mallakh RS, Hollifield M. Comorbid anxiety
in bipolar disorder alters treatment and prognosis.
May 2010 | Vol. 22 No. 2 | Annals of Clinical Psychiatry
Psychiatr Q. 2008;79:139-150.
14. Rounsaville BJ. Clinical implications of relapse
research. NIDA Res Monogr. 1986;72:172-184.
15. Drake RE, Alterman AI, Rosenberg SR. Detection
of substance use disorders in severely mentally ill
patients. Community Ment Health J. 1993;29:175-192;
discussion 193-194.
16. Briken P, Kafka MP. Pharmacological treatments
for paraphilic patients and sexual offenders. Curr Opin
Psychiatry. 2007;20:609-613.
17. Kafka M. Psychopharmacologic treatments for
nonparaphilic compulsive sexual behaviors. CNS Spectr.
2000;5:49-59.
18. Bradford JM. The neurobiology, neuropharmacology, and pharmacological treatment of the paraphilias
and compulsive sexual behaviour. Can J Psychiatry.
2001;46:26-34.
19. Fedoroff JP, Fishell A, Fedoroff B. A case series of
women evaluated for paraphilic sexual disorders. Can J
Human Sexuality. 1999;8:127-140.