1. Introduction
Multiple paraphilia is characterized as a disorder that includes three or more paraphilias (1). It has been shown that multiple paraphilias is very prevalent in individuals previously assumed to have only one paraphilia (2). Paraphilia is defined as “any intense and persistent sexual interest other than the genital stimulation or preparatory fondling with human partners satisfying with normal mature physical and phenotype” (3). It is hard to estimate the prevalence rates of paraphilias due to changes in criterion with time and with divergent cultures (4). On the other hand, paraphilias is often kept as a secret with the patient as it is stigmatized in the society; therefore, the prevalence of paraphilia is underestimated and a non-accurate estimation is yielded. Paraphilia previously known as sexual perversion and sexual deviation, includes zoophilia, sexual sadism, exhibitionism, and pedophilia etc (3). Paraphilia often leads to misery and clinically significant damages and eventually results in important ethical and public health problems (5). As a result, the treatment of paraphilia is of prominent importance to be considered. Cognitive-behavioral therapy has been a principal way to treat sex offenders or individuals with paraphilias (6). Furthermore, there are three categories of pharmacologic agents often applying to effectively treat patients with paraphilia. Selective serotonin reuptake inhibitor (SSRI), synthetic steroid analogs, and Gonadotropin-releasing hormone (GnRH) analogs are the medications utilized in an effective treatment of the patients, yet some algorithm existed for treating different severity of the disorder (7).
2. Case Presentation
A young, slim, married man from a village in the geographic center of Iran attended our clinic. He was a low socio-economic with an elementary education and his marital conflicts had brought him to visit us.
As he mentions, due to the lack of welfare in his family, he had decided for an unwanted marriage with a girl whom he declare was ugly and not pleasing. On the other hand, in the visit his wife noted that she is so ashamed of her appearance, which in turns made her to accept marrying a man to whom she was not interested in. She was two years older than him and the subsequent first experience of intercourse with his husband after having unpleasant feeling triggered the manic episode of bipolar mood disorder in her. Now that the problems came up between this couples, our patient requested for treatment and intervention. He is completely aware of his sexual problems while, his wife was not informed about this matter.
2.1. Personal History
Since the age of 15, he has been consuming cannabis, opium, and heroin. Prior to substance abuse, at the age of five years old he had experiences of being raped by individuals older than him. In his adolescence, he had brother-sister incest frequently and witnessed his parents’ sexual intercourse repeatedly, it seems his father had sexual sadism behaviors. There is a history of intercourse with hen and cow. His mind was mostly preoccupied with sexual matters and sex with children. Although he has no criminal back ground, he mentions a high sexual interest for children, i.e. pedophilia, sexual sadism behavior (inflicting pain), frotteurism (rubbing against another person), exhibitionism (genital exposure), voyeurism (watching sexual acts), fetishism (arousal from an inanimate object), and zoophilia. He notes no interest in having sex with his wife but a passion for normophilic extra marital sex; he is extremely hyper sexual. The experiences he had in homosexuality brings him more pleasure than normal sex. Furthermore, in sexual relationships he used to attack his wife as sexual sadistic behavior.
2.2. Psychological Factor
The patient had immature approaches in coping problems in life and used to apply primitive defense mechanism to solve them. As to say, he lacked efficient life skills. He had low personal hygiene and as well as an ego-syntonic and alloplastic attitude towards his disorders. Passive aggression got eminent in psychodynamic investigation, in addition, due to his low insight he was not cooperative enough to consume drugs or receive psychotherapy.
Bipolarity and psychosis were not proposed for him.
2.3. Physical Examination
Patient was alert with normal vital sign. Blood pressure: 120/80, T: 37.5, pulse rate: 90. Neurological examination was normal. No more organic evaluation was done before. His mood was euthymic and he is not nervous. There is no history of obsession.
Drugs prescribed for the patients included: Tab Medroxy progesterone daily; tab Thyoridazine H.S; tab Sodium-valproate 200 daily; cap Fluoxetine 20 daily.
3. Discussion
Multiple paraphilia is characterized as a disorder that includes three or more paraphilias, such as pedophilia, exhibitionism, or rape (1). We reported a patient with multiple paraphilias whose paraphilia manifestation could each have occurred together in a particular period of time. The trigger for the paraphilia started from a sexual abuse in his childhood, without feeling guilty with his problems. Subsequent to his marriage, his paraphlic behaviors exacerbated and the patient’s problem developed as aggression and more drug abuse. It is important to note that the paraphilic behavior happened prior to drug abuse. His sexual relationship with his wife was not accompanied by enjoyment and he didn’t have any interest for her. As his wife was a known case of bipolar disorder I, compromise mechanism and a weak coping led her to face difficulty in managing marital conflicts. According to a sexual dissatisfaction that existed for him due to his wife’s appearance and beauty, he frequently used to displace faults to his wife. Our patients was under a variety of stressors since his childhood and he felt that he doesn’t have sexual inadequacy. Furthermore, due to the fact that he didn’t have any passion for his wife due to her ugliness, as he mentions, he started having sexual satisfaction by extra marital sex and having sex with animals through a defense mechanism of displacement.
As paraphilias are stigmatized in society, in most cases they are going to be diagnosed if only some other category of psychiatric problem led their attendance to a psychiatrist. Similarly, our patient visits a psychiatrist for marital therapy as well as control of aggression and drug abuse, not for paraphilic behaviors. On the other hand, Abel et al. concluded that paraphilic behavior is not usually reported as a complain, it may be due to the failure of experiencing unpleasant consequences as a result of their first exposure to the deviant act, which may fortify the rationalization to repeat this manner. Therefore, they concluded that the patient may feel less self-restrained about acting upon other paraphilic acts (2).
In diagnosing paraphilic disorders, we must consider that individuals with no paraphilia are allowed to have nonpathologic applications of sexual fantasies, behaviors, or stuff to boost their sexual excitement. In mental retardation, paraphilia should be differentiated from other aspects of organic and non-organic conditions; ex. dementia and exhibitionism in patients with public urination. Other similar conditions considered as a differential diagnosis of paraphilias include: Experimentation, hormone dysregulation, seizures, chromosome abnormality, social phobia, conduct disorder, multiple sclerosis, conversion disorder, frontoparietal traumatic brain injury, abnormal amygdala activation, sexsomnia, autoerotic asphyxiation, paraphilic coercive disorder, differential diagnoses, alcoholism, depression, marrow failure syndromes, obsessive-compulsive disorder, personality disorders, posttraumatic stress disorder, schizophrenia” (8).
Most psychosexual disorders are a result of an abnormal fantasy system fed by traumatic childhood and adolescent backgrounds. As paraphilia keeps on, the behaviors on victims gradually gets worse and turns into s more hazardous phenomenon. Likewise, in our case sexual deviation started with pedophilia, voyeurism, exhibitionism, and after a period of time, sexual sadism. There are noticeable research evidence at present showing that multiple paraphilias should be considered in every case of sexual offense (9). To prevent further aversive consequences of the aggregation of paraphilia, devising a treatment plan for such patients would avoid devastating conditions.
3.1. Conclusion
Our case was represented with different paraphilia, which co-existed at the same time and was targeted from his sexual abuse in the childhood. In addition, it shows that multiple paraphilia is potentiated to trigger other psychiatric disorders in the people living around them. On the other hand, substance abuse did not influence paraphilic behavior in our patient.
