During the past three decades, there has been extraordinary growth in teaching human sexuality to both medical students and postgraduate physicians (1, 2). Yet educational challenges remain. A recent survey assessed the educational needs for teaching human sexuality in both undergraduate and postgraduate medical programs. The study reported that 88% of medical schools taught a course on human sexuality focusing upon sexual dysfunctions with no mention of paraphilic disorders (3). Most psychiatric residency programs (60%) offer some training in the diagnosis and treatment of sexual dysfunctions but have limited opportunities in clinical experience with paraphilic disorders (4). This report describes a program that trains residents in evaluating and developing treatment plans for patients with paraphilic disorders in a sexual behaviors clinic.
Sexual Behaviors Consultation Unit
Third-year psychiatric residents spend half a day per week at the Sexual Behaviors Consultation Unit for 6 months. The unit was established in 1971 to evaluate and treat individuals with a broad range of sexual disorders and dysfunctions (5). The clinic is part of the ambulatory psychiatric services within the Department of Psychiatry at the Johns Hopkins Medical Institutions.
During the clinic’s existence there has been a shift from seeing patients with common sexual dysfunctions, which are now often managed by primary care physicians, urologists, or other mental health professionals, to seeing more patients with paraphilic and gender disorders. Although percentages vary from year to year, about half of the clinic patients present with paraphilic and gender disorders, and the remaining patients primarily have dysfunctions such as erectile problems or anorgasmia.
Each clinic session begins with a 1-hour seminar followed by the clinical encounter. The patients may be self-referred or referred by other physicians or governmental agencies. Patients may be accompanied by a significant other or a parent if the patient is a minor. The resident interviews the identified patient for 75 minutes. If available, the partner is also interviewed by another resident. Residents, students, and faculty often observe interviews through a one-way mirror, if the patient consents. After the formal interview, an attending faculty member discusses the case and briefly interviews the patient with the resident present. The clinic concludes with a case conference with a patient again interviewed in front of the clinic faculty and residents.
The formal didactic seminars are divided into four areas. They begin with a basic module discussing the history of psychosexual disorders as a psychiatric construct. Then the basic physiology of sexual behavior is outlined. Discussions on sexual orientation and gender identity development are included, as is information on diagnostic approaches to sexual dysfunctions and disorders. Module 2 includes male and female sexual dysfunctions. Modules 3 and 4 include gender identity disorders and paraphilic disorders. The section on paraphilias reviews diagnosis, etiologic factors, and the treatment of specific paraphilic disorders.
This curriculum has been developed with the goals of teaching psychiatric residents about paraphilic disorders including diagnoses, common comorbidities, and current approaches to diagnose and treat these disorders. Another goal is to recognize the socially constructed approach to understanding such behaviors with attention to issues of psychopathology versus normality. Objectives include offering psychiatric residents clinical experience with such patients, a didactic basis for their evaluations, and clinical supervision and case conferences about their patients with paraphilic disorders. A final objective is to introduce what evidence-based data exist regarding treatment options. Evaluations are based on the clinical faculty’s observations of clinical interviewing skills, mastery of case formulation during supervision, and participation in didactic seminars.
The Use of Perspectives in Psychiatry
The organizing principles of the rotation reside in the concurrent perspectives of psychiatry as discussed by McHugh and Slavney (6). The specific perspectives utilized within psychiatry are the disease model, the life story, the dimensional perspective, and the behavioral model (7). Perspectives of Sexuality (8), a monograph by Dr. Peter Fagan, a senior faculty member, provides an in-depth discussion of such perspectives when evaluating and understanding patients with sexual disorders. Each approach has strengths and weaknesses and is discussed as it pertains to paraphilic disorders.
The disease model is most familiar to physicians and medical students. It categorizes through signs and symptoms a coherent syndrome to allow reliability in a diagnostic label that can correlate such with pathophysiology. It is built on a comprehensive history and examination.
In the early stages of the rotation, residents are often anxiously hesitant about taking a comprehensive sexual history from a patient with paraphilic disorder. Such histories demand careful questioning about unusual sexual repertoires.
The disease model becomes complicated when dealing with paraphilic disorders. Some residents may view such behaviors as demonstrating the diversity of human sexual preferences. They may view the pathologizing of behaviors such as fetishistic preferences as overly judgmental. Postmodern constructs eschew the labels of “abnormality” denoted in the DSM iterations that define paraphilias. Social constructionism, a postmodern philosophy, views behaviors and phenomenon from a nonjudgmental perspective (10). From a socially constructed view, paraphilic behaviors that do not take advantage of or harm another person are considered to exemplify the diversity of human behavior and not be a “disease” (11).
Such discussions are useful, but residents need to be reminded that the patients they see are usually distressed. Such emotional pain may be a reaction to the paraphilia itself or, more commonly, to their significant others or society.
A practical approach is to consider whether paraphilic behavior is “normal” as defined by Offer and Sabshin (13), who note five definitions of normality (Table 1).
The DSM exemplifies the disease perspective (14). Paraphilias are classified as recurrent and intensely sexually arousing fantasies, urges, or behaviors that involve nonhuman objects, suffering, the humiliation of others, or children and nonconsenting individuals. Such phenomena must occur over a period of at least 6 months and not be caused by another disorder such as a coarse brain disorder. These two criteria may be part of additional diagnostic elements, as in pedophilia, where age is specified to be at least 16 years with the abused victim at least 5 years younger or a child. For paraphilic entities such as sexual masochism, the fantasies or behaviors of being humiliated, bound, or made to suffer in a sexually arousing manner must be accompanied by distress or impairment in personal, social, or occupational domains.
In addition to diagnosing the paraphilia, it is imperative to assess comorbid psychiatric disorders. Fagan et al. (15) found that 38% of their paraphilic patients were suffering from another comorbid axis I disorder in addition to the paraphilic complaint.
The life story approach to psychiatry is familiar to psychiatric residents. The life story is the patient’s biography, which outlines his or her developmental history from a psychological perspective (16). The patient’s unique vicissitudes should be outlined to give the clinician an understanding of the salient events of his or her life. The accuracy of such a history may be limited, but as Spence (17) has noted, narrative truths are equally as important as historical truths.
For paraphilic behaviors, a careful history of sexual development is necessary. A clinician should inquire about sexual abuse and trauma, sexual education, initial sexual events, and masturbatory behaviors and fantasies in particular. Such histories illuminate the unique aspects of each patient. Transference—repetitive patterns of reaction to important figures in one’s past, whether parents or other authoritarian figures—is an important element of clinical work (18). The life story can help the clinician understand such reactions. Nevertheless, it is essential to fully understand an individual’s life history, both to have a framework in which to understand the patient and also to understand countertransference phenomena (19).
The problem with using theoretical constructs, such as behavioral theory (24), to explain life stories is that although they may have some sensitivity, they are not particularly specific for etiologic factors in various paraphilic behaviors (23). For example, an individual with a fetish who becomes aroused by using feminine garments in an experimental manner as a teenager may reinforce such stimuli during a period of emerging sexual arousal during puberty, and this becomes a required or preferred stimuli for such arousal. Thus, the life story is an essential element in understanding paraphilic behaviors but must be viewed as one perspective with strengths, such as understanding individuals as unique, and significant limits, such as the difficulty of empirically “proving” any such hypotheses.
Dimensions are quantitative measures that use arbitrary cutoff points to demarcate normal values from abnormal values. Dimensions of personality are useful descriptions of temperaments and personal characteristics that describe an individual’s characteristic reaction to stress (25). Although residents frequently use categorical descriptions of axis II disorders, the use of various dimensions of personality better illuminate the characteristics of the patients and how they relate to provocative stressors. The Sexual Behaviors Clinic has long taught dimensional approaches to personality characteristics on the basis of the five-factor model, which quantitatively describes individuals by the five major personality dimensions of neuroticism, extroversion, openness, conscientiousness, and agreeableness (26). Individuals with paraphilic disorders are often found to have elevated neuroticism and decreased agreeableness, which makes dyadic relationships more complicated. This “psychological fingerprint” can identify personality profiles that bring characteristic responses when faced with a stressor and can be very useful in understanding a patient’s current presentation.
Behaviors are the hallmark symptom of paraphilic disorders. Although some individuals have paraphilic fantasies that are preferred, the actual action or behavior of the individual is what distresses either themselves or others. Sexual functioning may be best described as a motivated behavior such as eating or sleeping. For the individual with paraphilic disorder, the behavior is goal-oriented to seek out the preferred paraphilic object to allow enjoyable sexuality to occur. Careful behavioral analysis is necessary to best understand the actual behavior and then to develop treatment approaches to modify or interrupt such phenomena (28). This requires thorough documentation of the antecedents leading to the behavior, such as a sense of emptiness, depression, or anxiety. The actual behavior and its consequences must be understood in detail by careful history. Response prevention paradigms can then be developed.
At the end of each rotation, residents are asked about the benefits and criticisms of the experience, which often leads to changes in the rotation. In addition, regular departmental assessments of the clinic rotation are conducted. Finally, a survey was conducted to assess the utility of the clinic experience. The 120 respondents were residents of the Hopkins program who completed the rotation from 1988 to 1998. They reported that the knowledge and skills acquired were very helpful clinically in conducting a sexual interview in a nonjudgmental manner. They also felt that the experience increased their appreciation of the role of comorbid psychiatric disorders upon sexuality. Some suggested adding seminars about legal issues in paraphilias and more discussion of childhood gender disorders. These comments led to curricular additions (29).
Each case requires understanding of the various perspectives, but often one or more of these approaches will better illuminate the situation for case formulation and treatment suggestions. Some individuals with paraphilias will present with clear elements that make their diagnosis simple but will have limited ability to report their life history in detail. A significant other may often provide important corollary information. Personality dimensions are best identified through psychometric testing using the five-factor model or the Esyenck Personality Inventory (30). Behaviors require careful historical documentation. In attempting to develop a treatment plan it is necessary to initially stop certain behaviors such as coercive sexuality. Use of antiandrogen medications can lower libidinal drive to aid in such behavioral cessation (26). Only then can the physician and patient consider earlier life events, which can offer some understanding of the individual’s unique introduction to sexuality and subsequent development.
Financial challenges are ever-present in ambulatory academic programs due to the overhead inherent in a hospital setting. Nevertheless, generous departmental support and a cadre of voluntary faculty have allowed the program to continue.
An educational challenge is to allow sufficient time for trainees to treat patients in ongoing therapy. This is available for all residents who can manage such patients in a supervised setting. Due to many competing educational and clinical demands, only a few residents do this during their third year. A popular fourth-year elective is available for ongoing treatment of patients evaluated in the clinic.
As Sir William Osler noted, “He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all” (31). This embodies what is necessary for programs to develop an effective teaching module for paraphilic disorders. The essential elements include an interested and knowledgeable faculty and an adequate clinical experience.