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] AACP.com 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 Annals of Clinical Psychiatry | Vol. 22 No. 2 | May 2010 129 PARAPHILIAS IN ADULT PSYCHIATRIC INPATIENTS 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- May 2010 | Vol. 22 No. 2 | Annals of Clinical Psychiatry 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 AACP.com (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, Annals of Clinical Psychiatry | Vol. 22 No. 2 | May 2010 131 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 May 2010 | Vol. 22 No. 2 | Annals of Clinical Psychiatry 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 AACP.com 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. 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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.
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