SEXUALITY

AND
PARAPHILIA
ANATHI
SESONA
KGOMOTSO
BLESSING
LEHLOGONOLO
MIRRIAM
SCENARIO
Many psychiatric patients have various sexual deviations / Paraphilias co-
existing with psychiatric disorders which may be unusual to other people.
Society is generally critical to these individuals. As health workers, we
unfortunately have to care and deal with these individuals without judging
them. Last month in the news, Mr. Mystery, a smart, well dressed, well spoken
gentleman, was reported to have a red Fiat Uno; and befriended boys under the
age of 13.
He bought hamburgers and coke for them, then took them to his room and had
sex with them. One child reported this to his parents; and in turn to the police.
Now police are calling upon other children who may have fallen victim to Mr.
Mystery to come up to report the matter. Witnesses are needed and this
individual has been released on bail.
TASKS

Identify and clarify key concepts

Decide what you plan to do
Reflect on the scenario
Report back on your feelings
What kind of measures should be put in place to protect the victim?
What should happen to the perpetrator?
Review self work and preparation
SEXUAL PARAPHILIA

• Sexual paraphilia’s are disorders categorized by abnormal sexual desires.

Simply put, they are sexual perversions deviances. According to the
DSM, “they involve recurrent fantasies, urges or behaviours of a sexual
nature that centre around children, non-humans (animals, objects,
materials), or harming others or one's self.”
• The direct causes of sexual deviances are not known, but many experts
believe that they most likely stem from childhood experiences that lead
an individual to associate sexual pleasure with a specific event or object.
It is argued that often when a child observes or directly experiences
perverse sexual events or behaviours eventually mimics those same
practices.
The factors that have been identified to increase the
risk of one being diagnosed with such disorders
include but are not limited to:
• Sexual abuse
• Sexual anxiety
• Substance abuse
• Exhibitionism
• Hyper-sexuality
• Antisocial behaviour/
personality
There are different types of paraphilic
disorders. A few of them are:
Exhibitionism aka Flashing
• This involves one exposing their genitals to an unsuspecting individual; and actual sexual contact is rare. In
this case the, the “exposer” is believed to feel the need to surprise and shock their victims.
Frotteurism 
• In this disorder, one receives their sexual pleasure from rubbing their body and genitals sexually on non-
consenting persons.
Sadism
• Here, the individual’s sexual desires and excitement is from inflicting physical or psychological pain on their
partners. “At its most extreme, sexual sadism involves illegal activities such as rape, torture, and even
murder, in which case the death of the victim produces sexual excitement.” (Johnson, 2020)
 Masochism
• Similar to sadism, the climax is reached through psychological and or
physical torture. The difference from sadism, is that the individual’s
pleasure comes from having pain inflicted on them.
Paedophilia
• In this disorder, the individual enjoys engaging in sexual acts with pre-
pubescent children; and they have a preference of either male or
CONT… female victims and rarely both. In most cases, these individuals tend
to believe that they were seduced by their child-victims; and that
their engaging in such ways with the children was beneficial as it was
educational to their victims. Some individuals only do this to children
they are biologically related to, as in their children or nieces or
nephews; while others chose victims they are not related to.
“Because the paedophile often is the parent or step-parent of the
victim child, or has worked hard to gain the confidence of the parents,
there are often few perceived safe people and places who a child
could report their victimization to anyway.”
According to
the DSM-V, Mr.
Mystery can be
diagnosed
under
pedophilia.
 • Those who openly admit to having a paraphilic interest in prepubescent
children—or those who are 13 years old and younger—and those who
continue to deny having any sexual attraction to them both suffer from
pedophilic disorder. A diagnosis has to however be made to confirm the
condition.
• In order to manage Mr Mystery a diagnosis has to be made first.
• The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
(DSM-5) lists the prerequisites for a pedophilic disorder diagnosis. The

Management following are the criteria:

• The person has powerful fantasies or cravings related to sexual activities that

of
are sexually appealing.
• with prepubescent children, for a minimum of six months.
• These cravings have either been indulged in or have caused the person

perpetrator significant distress.

• At least 5 years older than the victim and at least 16 years of age. Notably,
this does not apply to people in their late adolescence who have ongoing
sexual relationships with children, like those who are 12 or 13 years old.
• If a person satisfies the requirements for pedophilic disorder, it should be
determined if the disorder is:
• Exclusive kind, in which the person is only drawn to children
• Nonexclusive kind, where the person is attracted to both young people and
adults.
• only includes incest
 Management of the perpetrator as an
MHCU
Nonpharmacologic Therapy

• Treatment for sexually aggressive behaviours typically incorporates multiple

modalities, including individual, group, family, social skill, behavioural, and
educational therapies.
• Key elements of treatment include taking responsibility for behaviours,
developing empathy for victims, and developing skills to prevent re-offending.
• General goals of treatment include improved control of deviant behaviours,
impulse control, and coping; enhanced conflict resolution, anger management,
and social skills; enhanced sense of empathy; understanding of cycle of
thoughts, feelings, and events leading to inappropriate behaviours; respect
within relationships; and sexual education promoting healthy sexual
behaviours (especially in the treatment of juveniles).
• Community interventions must balance the safety of children with the
destabilizing consequences of stigmatizing registry efforts. Further analysis is
necessary in determining optimum approaches for intrafamilial (incest)
offenders.
Pharmacologic Therapy

All used off-label in adults, adolescents, and children

• Goals of treatment include suppression and elimination of deviant sexual
fantasies, elimination of deviant sexual urges and behaviours, and reduction of
risk for recidivism
• Selective serotonin reuptake inhibitors (SSRIs)
• Primary choice in adolescents, since few side effects (especially on adolescent
physiological development)
• Case reports and small studies supporting use of fluoxetine, sertraline
• Antiandrogens and hormonal agents (should be used only rarely in
child/adolescent offender populations by experienced psychiatrists, in
conjunction with paediatric endocrinologist for severe behaviours)

1.Medroxyprogesterone
acetate (MPA):
Also has progestinic effect,
leading to reduction of
gonadotropin secretion
Similar effects to MPA
Reduces sex drive, sexual
fantasy, sexual activity
2.Cyproterone acetate (CPA)
Effects are dose dependent
Side effects include nausea,
vomiting, feminization,
weight gain, decreased
sperm production, diabetes
mellitus, headaches, deep
vein thrombosis, hot flashes
Antiandrogenic,
antigonadotrophic,
progestinic effects
Research indicates decrease
in posttreatment recidivism
rates for paraphilias
Induces testosterone-
reductase in the liver,
increasing metabolic
clearance of testosterone and
decreasing plasma
testosterone
Principal effect at androgen
receptors––blocks
intracellular testosterone
uptake and metabolism of
androgen
Side effects include
decreased erections,
masturbation, and sexual
intercourse; liver dysfunction;
adrenal suppression;
osteoporosis; osteopenia
 Triptorelin acetate (may
3.Luteinizing hormone- Avoid in patients with
result in initial
releasing hormone active pituitary
androgen concentration
(LHRH) agonists pathology
increase)

Goserelin acetate
4.GnRH agonists Leuprolide acetate
(GnRH analog)

Pharmacologic
Pituitary gonadotropin Not recommended in
castration effect results
suppression results children <18 yrs., only
in serum testosterone
from prolonged indicated for severe
decreases equivalent to
administration symptoms in adults
surgical castration
 The manner in which the man in discussion is being described
shows that he is a person that can be trusted in the society. He
is described as being smart and being a gentleman which may
have blinded the society into thinking he is a role model to the
young boys when he approaches them. The manner in which he
carries himself makes him respected and trusted in the
community this is why it was easy for him to lure the children .

Reflection The food was used as a way of having authority or to bribe the
boys , perpetrators use these and tell their victims to not discuss
anything that happened between them with anyone. They
of scenario sometimes promise to give them more if the to keep quiet
about the whole thing. The child who reported at home helped
himself and others that will come forth, they can be given
necessary support and the man will face the consequences of
his doing. The justice system keeps on putting victims at risk why
release someone on bail for him to go back to the streets ,they
get a chance to threaten , harm the victims or silence them . He
should have been released into a place where he will be
evaluated psychologically until evidence is collected and should
be on strict rules with the bail any contact with any of his
victims should be enough for him to fined or detained.
 • This scenario made us aware of the dangers that our children face that we
can’t necessarily protect them from. In our research, we learnt that these
predators are people who present to us as safe adults who we can trust
our young ones with, which is scary because then there is no way truly to
identify who we can and who we can’t trust. This may mean that there are
some traumas that we can’t unfortunately prevent our children from
experiencing, which makes me feel powerless and very sad.
Group’s personal • Rape victims are continually failed by the criminal justice system, the

feelings regarding perpetrators are often protected than the victims in events of sexual
offense, it then gets difficult to draw the line in managing a client who has

the scenario:
paraphilia without being bothered.
• The justice system does not protect victims enough, sending perpetrator to
the streets will affect victims and sometimes they tend to not want to carry
on with the case, they see it as useless.
• Victims are placed in a central but vulnerable position within the criminal
justice system because sexual assault frequently occurs in private, victims
are frequently the only witnesses, there are generally long delays before
disclosure, there is rarely any physical evidence, and the case frequently
revolves around credibility issues and the perpetrator gets released.
• There is ongoing need for better training, educational and awareness
campaigns to promote understanding of rape myths amongst criminal
justice professionals and the general public, to protect victims and
survivors of sexual offense.
• More should be done in terms of helping the victims regain themselves.
Sex education is very significant to avoid re-victimization.
 MEASURES TO
PROTECT THE VICTIM

• Close collaboration between law enforcement and those statutory agencies or NGOs whose
primary remit is the care and welfare of children is fundamental to ensuring a
comprehensive response for victims that is respectful of the full range of children’s rights.
This collaboration will assist with information-sharing, as well as access to specialist
alternative care and the development of an end-to-end support plan. The type of specialist
support services required could include medical support, emergency accommodation,
financial assistance, education, therapeutic care and potentially longer-term assistance in
moving to a different location. A support plan should consider and research the availability
of these services from the outset.
• The step-by-step guide to victim assistance: rescuing victim from the abusive context and
providing protection, counselling them, providing medical support and/or food and clothing,
providing legal assistance, restoration and rehabilitation into the social mainstream.
PREVENTATIVE MEASURES
• Communication: listen, believe and trust what your child tells you. Children rarely lie about
sexual abuse.
• Education: teach your child healthy values about sexuality. Sex education for early
childhood does not teach children to have free sex when they are adults, but more to the
child's cognitive debriefing about the introduction of sex and the consequences. Sex
education is intended for children to understand the condition of their body, the condition of
the body of the opposite sex, and to protect and prevent children from adult sexual violence.
• Give your child specific information about where on her body she should not be touched or
touch others. Let her know that people who touch children’s private parts need help because
they have a problem with touching. Remind your child that “secret touching” is never the
child’s fault.
• Watch for any symptoms of sexual abuse your child might demonstrate, these include
aggression, isolation, frequent crying, insomnia, pain when going to bathroom, headaches,
stomach-aches, decreased school performance, swelling of genitalia and sometimes
symptoms of STIs.
 • According to the south African mental health act of 2002, sexual
offenders who are suspected of, or found to suffer from, mental illness
have the right to be provided adequate and appropriate care,
treatment and rehabilitation services. (mental health act, 2002. P54).
• The aim is to provide the offender with the capabilities to successfully
exit the criminal justice system and reintegrate as law abiding citizens
back into their communities, however, in this case it is noted that the
perpetrator is likely to inflict harm to other children , hence it is

What should necessary for him to be taken to an appropriate health establishment

where he can be admitted as an involuntary user.

happen to the • The perpetrator may be liable for transfer to a health establishment
with maximum security services since he inflicted and is likely to inflict
harm to others in the health establishment(mental health act 17 of
perpetrator? 2002).
• Should the head of the health establishment finds that the mental
illness of the offender is such a nature that the offender concerned
could appropriately be cared for, treated and rehabilitated in prison( fit
for trial), the offender can be taken to prison and the head of prison
should be notified of the necessary steps to ensure the required levels
of care, treatment and rehabilitation services are provided to that
prisoner.
REFERENCES
• An American Addiction Centers Resource (n.d.). Introduction to Sexual Disorders.
MentalHelp.net. Accessed at https://www.mentalhelp.net/sexual-disorders/
• Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision
(DSM-5-TR). Section II: Paraphilic Disorders (pages. 697 – 700).  
• Johnson, T.C. (2020). Paraphilas. WebMD. Accessed at
https://www.webmd.com/sexual-conditions/guide/paraphilias-overview
• Blanchard, R. The DSM Diagnostic Criteria for Pedophilia. Arch Sex Behav 39,
304–316 (2010). https://doi.org/10.1007/s10508-009-9536-0
• https://www.clinicalkey.com/#!/content/book/3-s2.0-B9780323755733006910
• M Swanepoel, Legal Aspects with regard to mentally ill offenders in South Africa,
2015.
• Handayani, Trini & Kurniawati, Nia. (2017). Fostering Community Awareness in
Preventing and Handling Pedophilia. 10.2991/iconeg-16.2017.25.