Disorders of sexual preference: clinical guidelines

List of Abbreviations

ALT - alanine aminotransferase

AST - aspartate aminotransferase

GnRH - gonadotropin-releasing hormone

CBT - cognitive behavioral therapy

ICD-10 — International Classification of Diseases (10th Revision)

ICD-11 - International Classification of Diseases (11th Revision)

RPS - Russian Society of Psychiatrists

SPD - sexual preference disorders

SSRI - selective serotonin reuptake inhibitor

LoE – level of evidence

LER — level of evidence and recommendation

Terms and Definitions

Clinical interview - the primary research method, which allows for collecting a subjective anamnesis and identifying clinical facts that determine the mental state and the state of the sexual sphere.

Aggressive-sadistic disorders - a group of sexual preference disorders characterized by the presence of aggressive or sadistic manifestations in the pattern of abnormal sexual arousal.

Sexual preference disorders (synonyms: paraphilias, paraphilic disorders) - a number of clinically significant conditions characterized by persistent and intense atypical patterns of sexual arousal, including erotic thoughts, fantasies, urges, or behaviors.

Cognitive behavioral therapy - a form of psychotherapy aimed at recognizing and processing erroneous or maladaptive thought patterns in order to subsequently change pathological behavior.

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

In ICD-10, sexual preference disorders are understood as the presence of periodically occurring intense sexual desires and fantasies involving unusual objects or activities; the individual acts on these urges or experiences significant distress because of them. Moreover, this sexual preference is observed for a minimum of 6 months [1].

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

Currently, there is no consensus on the mechanisms underlying the development of SPDs, as evidenced by the existence of several dozen theoretical concepts claiming to explain the etiopathogenesis of such disorders. It is hypothesized that SPDs arise based on a systemic interaction of genetic, neurological, hormonal, social, and situational factors [2].

Genetic influences can account for no more than 14.6% of the variance in the development of SPDs [3]; however, to date, studies of various gene polymorphisms have not shown any specificity for individuals with paraphilias, and future work has yet to delineate the influence of genetic factors from early environmental exposures [2].

There is evidence of morphological brain changes in paraphilias affecting the frontal and temporal lobes, amygdala, non-motor basal ganglia, hypothalamus, and septal nuclei [4]. Static magnetic resonance imaging revealed a reduced volume of white matter fibers connecting gray matter areas involved in responding to sexual stimulation, suggesting impaired connectivity between neural centers in pedophilic urges [5]. The results of hypothalamic studies indicate a smaller volume in the group of subjects who committed sexual acts with children independently of the presence of an abnormal sexual urge in the form of pedophilia [6]. Magnetoencephalographic study of visual mismatch negativity showed that in the group of subjects with pedophilia, in response to stimuli depicting children, there is an increase in neural activity in the frontal and temporal regions [7]. Neurocognitive impairments in pedophilia, as well as the increased incidence of left-handedness in patients with SPDs, are associated with gray matter volume in the temporoparietal junction and the left dorsolateral prefrontal cortex [8]. Thus, current data indicate the significance of the frontal and temporal brain regions for SPDs, which are likely related to behavioral control rather than the formation of aberrant sexual urges. A study by C. Kargel et al. showed that differences in resting-state neural connectivity are also associated with abnormal sexual behavior in general, rather than pedophilic urges per se [9].

According to available data, neurotransmitter influences are also associated with the control of sexual behavior, but not with the formation of the SPD itself [10].

There is no clear evidence of elevated baseline testosterone levels or increased antiandrogen receptor activity in SPDs, and the efficacy of antiandrogen medications is solely related to a general reduction in sexual arousal [11]. At the same time, it has been shown that luteinizing hormone secretion is altered in SPDs, supporting the presence of hypothalamic-pituitary-gonadal dysfunction in paraphilias [2]. There is evidence that the development of paraphilias is associated with prenatal androgenization [12].

Among the psychological factors associated with SPDs are early victimization (including sexual abuse), emotional congruence with children (matching the emotional needs of an adult and a child), social adaptation difficulties leading to an inability to build healthy sexual relationships, cognitive distortions, and self-regulation impairments [13]. A history of sexual abuse is often linked to the development of SPDs; however, only a small fraction of children who experience sexual abuse subsequently develop pedophilia [14]; nevertheless, the percentage of such individuals is still higher than in the general population. Psychological factors in the development of SPDs are associated with inadequate internalization of the male gender role and the psychosexual maladaptation of such individuals, manifested by the fact that the individual, not feeling sufficiently masculine, turns to weaker and more accessible objects in pedophilia—children—while in sadism, conversely, exhibits hyper-role behavioral patterns [15].

1.3 Epidemiology of the Disease or Condition

Data on the prevalence of sexual preference disorders (paraphilic disorders) in the population vary widely across different studies. Such estimates should be treated with great caution, as the discriminant criteria underlying these studies often have nothing in common with the diagnostic criteria for paraphilias.

According to studies conducted on large population samples that are the most representative, the percentage of individuals with pronounced abnormal sexual urges and a desire to act on them, for various forms of paraphilias, by conservative estimates, is: for exhibitionism, 2–5.9% (men) and 0.9–3.4% (women); for pedophilia, 1–1.1% (men) and 0.1–0.2% (women); for sadism, 2.2–9.5% (men) and 2.1–5.1% (women); for fetishistic transvestism, 1.5–7.2% (men) and 0.5–5.5% (women) [16, 17].

The prevalence percentage of certain forms of paraphilias, even according to population-based studies, varies within very wide ranges (tens of percent), which is likely due to insufficiently strictly formulated questions for respondents. In this case, one should focus on the minimum estimates: for voyeurism, 8.3% (men) and 2.2% (women); for frotteurism, 8.9% (men) and 2.9% (women); for fetishism, 9.9% (men) and 3% (women) [16]. Prevalence estimates for paraphilic disorders indicated in the American Psychiatric Association's nomenclature of mental disorders [18] are generally consistent with these data.

1.4 Features of Coding the Disease or Condition

In accordance with ICD-10, SPDs belong to Chapter V, which describes mental and behavioral disorders, specifically the subsection on adult personality and behavioral disorders [19].

Sexual preference disorders (F65):

F65.0 - Fetishism

F65.1 - Fetishistic transvestism

F65.2 - Exhibitionism

F65.3 - Voyeurism

F65.4 - Pedophilia

F65.5 - Sadomasochism

F65.6 - Multiple disorders of sexual preference

F65.8 - Other disorders of sexual preference

F65.9 - Disorder of sexual preference, unspecified

In ICD-11 [20], paraphilias are classified under a separate category of paraphilic disorders. The diagnosis of a paraphilic disorder implies the presence of atypical patterns of sexual arousal involving individuals who are unwilling or unable to consent to such activity, or involving a significant risk of injury or death. To establish the diagnosis, the individual must either act on the abnormal pattern or experience significant distress due to its presence.

Changes compared to ICD-10 affect two aspects. The new definition of paraphilic disorders brings the consent criterion to the forefront, as a result of which ICD-11 abolishes fetishism and fetishistic transvestism. Additionally, in the new version of the classification, the duration of the abnormal pattern does not necessarily have to exceed six months and can be assessed by the clinician at their discretion, meaning the diagnosis can be made earlier. Otherwise, the changes introduced in ICD-11 are largely nominal in nature.

The category of paraphilic disorders in ICD-11 includes:

6D30 - Exhibitionistic disorder

6D31 - Voyeuristic disorder

6D32 - Pedophilic disorder

6D33 - Coercive sexual sadism disorder

6D34 - Frotteuristic disorder (not separately classified in ICD-10)

6D35 - Other paraphilic disorder involving non-consenting individuals

6D36 - Paraphilic disorder involving consenting individuals or no other persons (it is assumed that this category will code disorders that qualify as pathology specifically due to a significant risk of injury or death)

6D3Z - Paraphilic disorders, unspecified.

Instead of the diagnosis of multiple disorders of sexual preference in ICD-11, the presence of several abnormal preferences is managed by establishing comorbid diagnoses.

1.5 Classification of the disease or condition

The classification of paraphilic disorders implemented in ICD-10 identifies the clinical forms of paraphilias most commonly encountered in practice. The ICD-10 version intended for use in general clinical, educational, and social services does not provide general criteria for paraphilic disorders, describing each disorder in the classification separately and reflecting the specifics of particular forms of abnormal sexual behavior.

The version of ICD-10 intended for research purposes provides general diagnostic criteria mandatory for each form of paraphilic disorder [1]:

G1. The individual exhibits recurrent, intense sexual urges and fantasies involving unusual objects or activities.

G2. The individual either acts on these urges or experiences significant distress because of them.

G3. This preference has been present for at least 6 months.

1.6 Clinical presentation of the disease or condition

According to ICD-10, fetishism is characterized by the use of a non-living object as a stimulus for sexual arousal and sexual satisfaction, with many fetishes being additions to the human body (articles of clothing or footwear). Other fetishes may be characterized by specific materials such as rubber, plastic, or leather. The importance of fetishes to the individual may vary; in some cases, they serve to enhance sexual arousal achieved through normative means. The diagnosis of fetishism is made only if the fetish is the most significant source of sexual stimulation or is essential for a satisfactory sexual response. Fetishistic fantasies are common, but they cannot be considered a disorder unless they lead to ritualistic actions that are so compelling and unacceptable that they interfere with sexual intercourse and cause distress to the individual [19].

Fetishistic transvestism involves wearing clothes of the opposite sex for the purpose of achieving sexual arousal. Cross-dressing aims to transform one's own appearance by imparting traits characteristic of the opposite sex. Usually, more than one item of clothing is worn, often a full outfit supplemented by a wig and makeup. During episodes of cross-dressing, a sensation of belonging to the other sex is achieved. Fetishistic transvestism has a clear link to sexual arousal, and a strong desire to remove the clothing typically arises after orgasm and subsequent sexual relaxation [19].

Exhibitionism is characterized by a recurrent or persistent tendency to expose one's genitals to strangers in public places without offering or intending direct contact. Usually, though not always, sexual arousal occurs during the display of genitals, often accompanied by masturbation [19].

Voyeurism is characterized by a recurrent or persistent tendency to observe people engaging in sexual or other intimate activities. This usually leads to sexual arousal and masturbation, carried out secretly from the observed person, without the desire to reveal one's presence or establish contact with the person being watched [19].

Pedophilia is a sexual preference for children, typically of prepubescent age. Heterosexual pedophilia involves a preference for children of the opposite sex. Homosexual pedophilia involves a preference for children of the same sex, and bisexual pedophilia involves children of both sexes. The diagnosis of pedophilia can also be made regarding men who sexually abuse their own prepubescent children. Diagnosing pedophilia in adolescence should be done with caution, and mandatory criteria for establishing the diagnosis include the subject being at least 16 years of age and having a 5-year age difference with the object used. On the other hand, contacts between adults and sexually mature adolescents, although socially condemned and in some cases criminalized, do not necessarily indicate pedophilia [19].

Sadomasochism involves a preference for sexual activity that entails the infliction of pain, humiliation, or bondage. In masochism, the individual prefers to be subjected to such stimulation, while in sadism, they prefer to be its source. A person may derive sexual satisfaction from both sadistic and masochistic activities. Mild manifestations of sadomasochistic stimulation are commonly used to enhance arousal in normal sexual activity. The diagnosis of sadomasochism is possible only when sadomasochistic activity is the primary source of sexual stimulation or is necessary for sexual satisfaction [19].

Multiple disorders of sexual preference feature more than one disorder of sexual preference without a clear predominance of any single one. The most frequent combination is fetishism, transvestism, and sadomasochism [19].

There are also numerous other types of disorders of sexual preference and sexual activity. These include obscene phone calls (scatologia), touching and rubbing against people in crowded public places for sexual stimulation (frotteurism), sexual acts with animals (zoophilia), the urge to commit rape (raptophilia), compression of blood vessels or asphyxiation to enhance sexual arousal (asphyxiophilia), a preference for partners with certain anatomical defects (apotemnophilia), sexual acts with corpses (necrophilia), and others [19].

The clinical picture of paraphilic disorders is determined by their psychopathological distinctiveness, encompassing several variants: obsessive, compulsive, and impulsive [21]. The obsessive variant generally reflects the ideational level of paraphilic disorders. A distinctive feature of this form is the prolonged existence of abnormal sexual urges without their realization. Abnormal desires take over the individual's thoughts. At the same time, the formed urge comes into conflict with both socio-restrictive norms and the person's own moral and ethical attitudes. Deviant urges typically arise involuntarily, are intrusive and irresistible. Their appearance is accompanied by pronounced autonomic reactions, depressed mood, anxiety, increased irritability, exhaustion, and sleep disturbances. Due to the awareness of the unnatural nature of the troubling desires and the presence of critical insight toward them, the individual resorts to coping behavior.

In the compulsive variant, the individual is in most cases clearly aware of the deviant nature of their sexual behavior. The drive typically arises autonomously, deriving from and depending exclusively on internal stimuli. Despite the understanding that their experiences are unnatural, memories of such acts in the past carry a hedonistic undertone, which triggers an internal conflict. The drive in this variant arises involuntarily, often against the background of asthenic states and dysphoria. Its appearance is accompanied by affective disturbances involving fear, anxiety, emotional lability, sleep and appetite disturbances. The resulting desire rapidly takes on the character of a dominant idea, possesses pronounced motivational force, hinders the execution of habitual actions, occupies all thoughts for a prolonged period, and leads to a conflict of motives, accompanied by increasing tension, irritability, and heightened anxiety. Suppressing the emerging drive contributes to increased emotional tension and restlessness, intensifying the impulses toward deviant sexual activity. As a result, the desire becomes uncontrollable by the individual and pushes them to execute the abnormal pattern. The abnormal sexual behavior occurs against the background of a narrowed state of consciousness with a distorted perception of the environment. The realization of the drive is accompanied by a subjective sense of relief, which is soon replaced by an awareness of the inadequacy of the committed act. In some cases, amnesia is noted, which is partial in nature with fragmented memories of the deed. The perception of the essence of the committed act leads to a depressed mood with ideas of self-blame and self-degradation, accompanied by feelings of shame, remorse, lethargy, and prostration.

In the impulsive variant, there is an absence of awareness regarding the impulses for deviant sexual activity against the backdrop of accumulating asthenizing factors. Immediately prior to the realization of the drive, a sharp change in the mental state is observed, accompanied by a sense of hopelessness, detachment, and indifference to the surroundings. One's own actions and deeds are perceived as independent of one's own will, which is accompanied by signs of altered consciousness with blurred perception of the environment and disorientation. Under these conditions, the sexual drive arises suddenly; its realization is not preceded by internal processing and a conflict of motives, and it directly translates into action without regard for the situation and circumstances. Following the deviant act, a sense of relief is observed alongside a state of prostration, lethargy, and relaxation. A certain period of clouded consciousness is noted, during which difficulties in communication, bewilderment, purposelessness, and inconsistency of actions are revealed, as well as partial or complete amnesia of the event.

Obsessive and impulsive variants of SDP represent the extreme poles of psychopathological states and are therefore relatively rare. Intermediate variants in various modifications of compulsivity occur significantly more often [21].

The individual's attitude toward SDP can be egosyntonic and egodystonic. With an egodystonic attitude, there is critical awareness of the SDP, which enables the individual to combat it. An egosyntonic attitude is characterized by the fusion of the personality with the abnormal drive, an inability to critically evaluate it, and a lack of control over it [21].

An important direction in describing the clinical picture of SDP is the development of clear and scientifically grounded criteria to differentiate variants of normative behavior from psychopathological manifestations. It is noted that to establish a diagnosis of SDP, the clinician must take into account at least five dimensions to assess the individual's compliance with the diagnostic criteria of the disorder [22]. Arousal dimension implies that abnormal sexual urges in some cases may manifest only occasionally and constitute a minor part of a very wide range of the individual's sexual behavior, while in other cases the individual is exclusively fixed on a paraphilic pattern, and abnormal experiences persist continuously without the possibility of achieving sexual satisfaction through alternative methods. Activity dimension implies that the frequency of implementing the abnormal pattern can vary from merely periodically occurring fantasies without any intention of carrying them out in real life, to regular planning and execution with no intention of stopping. Consent dimension implies that the degree of the partner's conscious involvement in the sexual interaction sought by the individual can be either complete and explicit (for example, in role-playing games), or may require absolute control over the partner, without which achieving sexual satisfaction becomes impossible. Distress dimension implies that the individual may either be burdened by the abnormal urges they experience or consider them completely normal, maintaining an uncritical attitude toward them. And finally, health harm dimension, caused as a result of implementing the abnormal sexual pattern, can vary from extremely cautious consensual behavior that respects the value of the partner's physical well-being, to deriving pleasure precisely from inflicting substantial harm on another person, up to taking their life.

The clinical picture of SDP largely depends on the presence of comorbid mental pathology. Thus, individuals with SDP frequently exhibit signs of concurrent personality disorders or other mental disorders, including affective disorders, substance use disorders, schizophrenia, dementia, and other cognitive impairments [23].

Comorbid mental pathology exerts a pathoplastic influence on SDP. Within the framework of schizophrenia-spectrum disorders, with escalating negative personality changes and a progredient course of organic mental disorders accompanied by the addition of affective and psychopath-like disturbances, as well as paroxysmal states, there is an aggravation of the clinical manifestations of paraphilic urges with more frequent autochthonous onset, the addition of new forms of paraphilias and affective disorders prior to the realization of abnormal fantasies in the form of non-psychotic dysphoria, and an increased psychopathological complexity of the paraphilic behavior itself with the emergence of impulsivity and dissociative disorders (depersonalization and derealization) [24].

Personality disorders exert a lesser influence on the dynamics of SDP, except for the fact that they are associated with a more rapid emergence of new forms of paraphilias and an increased frequency of paraphilic enactments, in contrast to cases where SDP is comorbid with organic mental disorders or schizophrenia [24].

Abnormal sexual behavior is not always associated with the presence of SDP, but may be due to sexual disinhibition observed within the framework of organic personality disorder, escalating negative personality changes in schizophrenia, cognitive impairments in dementia, or psychoactive substance intoxication [2, 25]. In such cases, it is necessary to conduct a differential diagnosis between SDP and inadequate sexual behavior that merely serves as a symptom of another mental disorder. Evidence supporting the diagnostic hypothesis of SDP includes the presence of persistent and long-standing paraphilic fantasies or behaviors in the individual.

2. Diagnostics, medical indications and contraindications for diagnostic methods

Criteria for establishing the diagnosis/condition: A diagnosis of SDP can be made if the subject has long-standing, periodically recurring, intense sexual urges or fantasies involving unusual objects or activities, provided that these urges or fantasies are acted upon in behavior or cause significant distress.

2.1 Complaints and Anamnesis

Comments: during the collection of complaints and anamnesis, the following should be performed [26]:

A) ascertain data regarding a family history of mental disorders among the patient's immediate circle.

B) identify the characteristics of upbringing in the parental family, taking into account the characterological traits of the parents; special attention should be paid to the subject's subjective characterization of the parents, as individuals with psychosexual disorders often have a distorted attitude toward parental images.

B) evaluate psychosexual development in the prepubertal age (nature of play activities, features of contact with peers, presence of experience with sexual advances and sexual games, presence of pathogenic impacts); identifying the features of self-awareness development during this period is of great importance for the diagnosis of psychosexual disorders (PSD), since psychosexual developmental disorders frequently reveal underdevelopment of the "Ego"; attention should be paid to various neuropathic manifestations: fears, stuttering, nocturnal enuresis; identifying autistic manifestations (preference for playing alone, monotony, stereotypy, ritualization, and symbolism of play) is of significance; the presence of overt sexual activity or memories of emotionally charged scenes of a sexual content under the age of 7 may indicate advanced somatosexual development.

C) evaluate psychosexual development at puberty (formation of platonic, erotic, and sexual libido, age of onset of sexual desire, age of onset of erotic fantasies and analysis of their content, assessment of masturbatory activity — age of onset, features of masturbatory activity and erotic fantasizing during it); in sexology, it is generally accepted as ontogenetically normative to follow the sequential stages of the formation of platonic, erotic, and sexual libido, with the erotic stage being more frequently reduced in men and the sexual stage in women; in PSD, sexual libido in its usual sense (the drive for orgasm) is often replaced by the pursuit of a special state referred to as "psychological satisfaction"; the attitude towards the opposite sex in psychosexual sphere disorders ranges from pronounced misogyny to an envy of women that is inexplicable to the patient himself, and an ambivalent attitude is frequently encountered.

D) evaluate the sexual sphere in young and mature adulthood (dynamics of sexual life — personal and external characteristics of partners, duration of relationships and reasons for their termination, gender-role interaction in the couple, features of intimate life — its regularity, preferred forms of sexual activity, presence of functional (erectile and ejaculatory) sexual disorders); contrary to popular belief, individuals with PSD marry just as frequently as healthy individuals, and a patient often enters into marriage without realizing his inclinations or in the hope of getting rid of them; the short duration of relationships, their frequency, and difficulties in the couple's sexual life should also raise suspicion regarding the patient's sexual problems.

Comments: the psychopathological examination must be concluded by systematizing the identified phenomena, their psychopathological qualification, nosological diagnosis, and selection of therapy. During the examination, it is necessary to assess the age of onset and mechanisms of disorder formation, the content of abnormal sexual fantasies, their periodicity and psychopathological formulation, the presence of coping strategies for abnormal experiences, their impact on heterosexual adaptation, the features of abnormal sexual behavior and its psychopathological formulation, as well as the impact of comorbid mental pathology and past exogenous and psychogenous harms on the dynamics of PSD. It should be taken into account that the age of appearance of explicitly paraphilic fantasies and the age at which fantasizing acquires pathological traits may not coincide; a dynamic characterization of abnormal sexual drive is required with a detailed description of the subject's experiences during fantasizing, before, during, and after the implementation of deviant acts for the purpose of clinically qualifying the nature of the abnormal drive (obsessive, compulsive, or impulsive). If the patient is undergoing treatment for PSD, its efficacy must also be evaluated.

When psychopathologically qualifying the identified phenomena, the fact that various clinical variants may exist for each PSD should also be taken into account [27].

Additional information on the specifics of conducting a clinical interview in the diagnosis of PSD is presented in reference material A3.2.

Based on the results of the psychopathological examination, the physician may formulate a clear and substantiated diagnostic conclusion relying on existing diagnostic criteria for PSD. In such cases, there is no need for additional investigations. However, if the clinical picture is unclear to the physician (which may occur due to contradictory or insufficient examination data, or only partial compliance with diagnostic criteria), making a diagnosis or expressing an opinion on the absence of a diagnosis without performing any additional investigation method is incorrect. If the institution lacks the capability to perform additional investigation methods, then in case of an unclear clinical picture, one must refrain from making a diagnosis, and the subject should be referred for evaluation to an institution where additional information can be obtained to make a more sound medical decision.

2.2 Physical Examination

Physical examination is not used for the diagnosis of PSD.

2.3 Laboratory Diagnostics

Laboratory diagnostic tests are not used for the diagnosis of PSD. The need for laboratory tests arises when addressing issues of prescribing drug therapy and its correction.

• When antiandrogens or gonadotropin-releasing hormone (GnRH) agonists are prescribed to patients suffering from PSD, before starting therapy and during its course, it is recommended to perform a series of laboratory tests aimed at preventing the development of complications associated with the use of medicinal products [26, 28, 29]:

  - general general-clinical blood chemistry analysis (determination of blood alanine aminotransferase (ALT) activity, determination of blood aspartate aminotransferase (AST) activity, study of total blood protein level, study of blood albumin level, study of blood creatinine level, study of total blood bilirubin level) before starting therapy and thereafter once a month for 3 months, then once every 3 months;

  - general (clinical) blood count before starting therapy and thereafter once every 6 months;

  - study of the levels of total calcium, inorganic phosphorus, prolactin, and glucose (fasting) in the blood before starting therapy and thereafter once every 6 months;

  - X-ray densitometry before starting therapy and thereafter once a year.

LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)

• If there are abnormalities in the results of the performed laboratory diagnostic tests aimed at preventing the development of complications associated with the use of medicinal products, before starting/continuing the intake of antiandrogens or GnRH agonists, patients with PSD are recommended a consultation with an endocrinologist (initial appointment (examination, consultation) of an endocrinologist) for the purpose of adjusting the therapy tactics [2, 29].

LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)

• When antiandrogens or GnRH agonists are prescribed to patients suffering from PSD, in order to monitor the efficacy of the ongoing therapy before the start of treatment and, as needed, thereafter, it is recommended to study the levels of total and free testosterone in the blood, and the levels of follicle-stimulating and luteinizing hormones in blood serum [2, 29].

LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)

2.4 Instrumental Diagnostics

The clinical method is the primary method for qualifying PSD. However, during an involuntary examination, patients often respond in a socially desirable manner and conceal their psychopathological experiences. In this regard, in international practice, auxiliary psychophysiological methods such as penile plethysmography, viewing time of erotic stimulus material, and the polygraph are frequently used for the diagnosis of PSD [30]. Currently, in the Russian Federation, instrumental examinations are not widely used for the diagnosis of PSD due to the lack of a transparent description of the algorithms for their implementation and subsequent data processing in the scientific literature, which calls into question the reproducibility of results and the validity of the methods used.

2.5 Other Procedures

• If the clinical picture is unclear, for the purpose of diagnosing PSD, as well as to monitor dynamics during therapy, patients are recommended to undergo a pathopsychological experimental-psychological (psychodiagnostic) study of the psychosexual sphere [15, 26, 31, 32, 33], including the following set of methods:

  - "Masculinity and Femininity" methodology. Modified version of the BSRI (Bem Sex-Role Inventory) [34]. Modification by T.L. Bessonova [35] and N.V. Dvoryanchikov [36] (Appendix G1),

  - "Color Relations Test" methodology, based on the idea of the color-associative experiment developed by A.M. Etkind [37] (Appendix G2),

  - The "Coding" method is a modified version of Z. Starowicz's "Projective Checklist" technique [38], modified by N.V. Dvoryanchikov [36] (Appendix G3).

GCP CLE 4Grade of Recommendation C (Level of Evidence 4)

Comment: The decision on the necessity of the examination is made by the attending psychiatrist or sexologist. The examination involves conducting all three designated methods and interpreting the results based on the totality of the obtained data. The results provide the physician with additional information regarding the patient's psychosexual sphere and can be used to confirm or rule out a diagnosis only when taking into account the results of the psychopathological examination. With the specified levels of certainty and confidence, these methods allow for assessing the probability of the presence of pedophilia and sadism only in the patient. When interpreting the results, the fact that the psychological profiles of the psychosexual sphere for PARS were developed exclusively on male subjects undergoing forensic psychiatric evaluation should be taken into account; therefore, when working with other patient groups, the research results must be interpreted with caution. The algorithm for writing the conclusion based on the examination results is given in the appendix (Appendix B3).

Psychological signs of pedophilia and sadism that have been confirmed in several studies and summarized in the latest comparative study [15] are presented in reference material A3.3.

• In cases of an unclear clinical picture for the diagnosis of pedophilia and the assessment of public danger, it is recommended to administer psychometric methods (one or two) aimed at assessing cognitive distortions regarding sexual relations between adults and children [30, 39, 40, 41, 42, 43, 44] (these methods can be applied by a physician during the psychopathological examination or by a medical psychologist as part of a clinical and psychological psychodiagnostic examination):

  ‐ Dichotomous Cognitive Distortions Scale (DCDS) [39] (Appendix G4).

  ‐ Russian-language version of the "Molest scale" [39, 40] (Appendix G5).

GCP CLE 4Grade of Recommendation C (Level of Evidence 4)

Comments: Cognitive distortions are attitudes and beliefs that promote the emergence and maintenance of abnormal sexual behavior. Sometimes they can also be identified during a clinical interview. The answers and comments provided by the patient while completing these methods represent significant clinical information both for assessing the probability of pedophilia and for assessing the probability of committing sexual offenses [39, 44]. When interpreting the results obtained, it is necessary to rely on the score distributions in different groups presented in the studies [39, 40].

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

The goals of PARS treatment are:

• reducing abnormal sexual interest and its behavioral manifestations;

• controlling abnormal fantasies and behavior;

• enhancing normative sexual interest and developing normative models of sexual behavior;

• improving social interaction skills and stress-coping strategies, enhancing quality of life;

• reducing the risk of committing sexual offenses;

• maintaining the ability to successfully function in society.

The PARS treatment algorithm is a multi-tiered system, and the choice of a specific tier depends on the severity of the sexual disorder. Treatment for all patients with PARS should be carried out taking into account the clinical characteristics of the disorder and the specifics of paraphilic behavior. In mild PARS, the subject has only paraphilic fantasies without the intention to act on them, maintains critical insight into their abnormal urge, and therefore treatment may be limited to psychotherapy. In moderate PARS, paraphilic fantasies and distant forms of activity (e.g., exhibitionism and voyeurism) or the intention to act on the abnormal pattern are observed, along with an egosyntonic or rather ego-dystonic attitude toward the abnormal urge when it has an obsessive, obsessive-compulsive, or compulsive character. In such cases, selective serotonin reuptake inhibitors (SSRIs) are used in addition to psychotherapy. In severe PARS, in addition to paraphilic fantasies, contact forms of paraphilic activity occur with preserved critical insight and an ego-dystonic attitude toward the urge, which has an obsessive-compulsive or compulsive character. In this case, anti-androgen therapy is administered alongside psychotherapy, combined with SSRIs if necessary. Very severe PARS is characterized by aggressive-sadistic fantasies or behavior (regardless of the attitude toward the urge and its character) or other paraphilic drives with an egosyntonic attitude toward the urge or an impulsive character of its manifestation. In such cases, the use of GnRH analogues is advisable alongside psychotherapy, and SSRIs may be prescribed if necessary [2, 26].

The optimal approach to PARS treatment includes pharmacological and psychological care. Pharmacological treatment for PARS is currently not administered in isolation from psychotherapeutic interventions [2]. Restriction of freedom and isolation of individuals with PARS, as well as the use of specific medications, do not alter the paraphilic interest; they only hinder its realization or allow for better control over abnormal sexual behavior.

3.1 Psychological interventions and psychotherapy

Psychotherapeutic interventions for PARS aim to modify abnormal sexual interest, develop coping strategies for abnormal urges, and improve social adaptation skills. There is some debate regarding the long-term efficacy of psychotherapeutic interventions. Researchers generally note a lack of large randomized controlled (including placebo-controlled) trials [45].

• It is recommended that all patients with PARS undergo various forms of cognitive behavioral therapy (CBT) in order to modify sexual interest, develop coping strategies for abnormal urges, and improve social adaptation skills [2, 46-51].

GCR BLOCE 2Grade of Recommendation B (Level of Evidence 2)

Comment: The efficacy of CBT has been confirmed for relatively short follow-up periods after treatment cessation; however, in the long term after therapy cessation, the risk of PARS relapse may increase again, which is why such patients undergo long-term therapy (starting from 2 years for mild disorders, and from 5 years for more severe forms of PARS) [2]. The main CBT approaches in PARS treatment and the ethical aspect of therapeutic interventions when working with such patients are presented in reference material A3.4.

3.2 Pharmacotherapy

In patients with PARS who act on their paraphilic fantasies, pharmacological treatment is frequently used in addition to psychotherapy. Indications for psychopharmacological agents are determined by the psychopathological presentation of PARS, the severity of the disorder, and the presence of comorbid psychiatric pathology. A comprehensive approach is justified. Using psychotherapy alone or pharmacotherapy alone yields a lower therapeutic effect compared to a combined approach [64]. The duration of pharmacological treatment for PARS should be determined by the clinical response and should be at least 3 years [2].

When deciding to prescribe pharmacological therapy to individuals with PARS, the patient's objective living conditions must be taken into account. In situations where the patient is isolated from potential objects of abnormal attraction and the commission of socially dangerous acts is excluded (e.g., while serving a sentence or undergoing prolonged inpatient treatment for another mental disorder), the approach to prescribing medical therapy should be especially judicious. Pharmacotherapy for PARS under such conditions is indicated for patients who subjectively tolerate the symptoms of the disorder with great difficulty. If the patient does not experience pronounced distress and the risk of committing a socially dangerous act is absent due to their circumstances, it is advisable to refrain from prescribing pharmacological agents. This caution is due to two factors: the high frequency and severity of side effects associated with drugs used in PARS treatment, and the need to assess the dynamics of the abnormal urge as one of the key diagnostic and prognostic markers (medical suppression of sexual drive will hinder monitoring the patient's condition).

The following pharmacological groups are used in PARS therapy: anti-androgens and GnRH analogues (administered parenterally when necessary), and SSRI antidepressants.

Antidepressants

• If a patient with a sexual preference disorder (SPD) presents with obsessive abnormal sexual fantasies, impulsivity, hypersexuality, anxiety, or depression, the use of SSRIs is recommended to alleviate psychopathological symptoms [29, 65-77]: #fluoxetine** (40-60 mg/day) or #sertraline** (50-200 mg/day) [2, 78, 79, 80].

GCP CLE 4Grade of Recommendation C (Level of Evidence 4)

• Patients suffering from SPD are not recommended to use #paroxetine** due to a higher likelihood of developing erectile dysfunction, which impairs compliance [81].

GCP CLE 4Grade of Recommendation C (Level of Evidence 4)

Comments: SSRIs can be used to reduce depressive symptoms observed in the first months of treatment with antiandrogens or GnRH analogues [2]. SPDs typically begin in adolescence and at that stage are limited to paraphilic fantasies associated with masturbation. Prescribing SSRIs at this stage is acceptable and may help prevent abnormal sexual behavioral activity [67].

Antiandrogens and GnRH analogues

• For patients with paraphilic coercive disorder (PCD) enacting paraphilic fantasies in a contact form, to reduce the intensity of abnormal urges, it is recommended to use #cyproterone** (50-200 mg/day orally or 200-400 mg intramuscularly once a week, and then every 2-4 weeks) or #medroxyprogesterone** (50-400 mg/day orally or 400 mg intramuscularly weekly, and then monthly) [2, 78, 82, 83, 84]. In severe cases of the disorder, #triptorelin** (3.75 mg/month intramuscularly) or #leuprorelin** (3.75 mg/month intramuscularly) are recommended [2].

LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)

Comments: SPD or abnormal sexual behavior is often not listed among the indications for drugs from the classes of antiandrogens and GnRH analogues. In such cases, the drug may be prescribed for treatment only by decision of a medical commission. The presence of the patient's voluntary informed consent is mandatory for treatment with antiandrogens or GnRH analogues.

Antiandrogens and GnRH analogues may be prescribed for intense and frequent paraphilic urges with a high risk of implementation, egosyntonic attitude, and impulsivity of paraphilic acts, especially of an aggressive-sadistic nature (in case of low compliance, parenteral formulation). However, antiandrogens may exacerbate existing psychotic symptoms [2, 30, 85, 86].

The dosage of these drugs is selected individually: from the minimum until an effect is achieved (disappearance of paraphilic fantasies and activity). Onset of effect: for antiandrogens – in 3–12 weeks, for GnRH analogues – in 1–3 months. The minimum duration of treatment with #medroxyprogesterone** and #cyproterone** is 2 years; with GnRH analogues – 3 years.

In most cases (in 60–90%), relapse is noted after the discontinuation of antiandrogens and GnRH analogues, which is why some patients require lifelong administration of these medications [2, 78, 83–102].

For condition monitoring, see Section 2.3 Laboratory Diagnostic Tests.

In case of thromboembolism or hepatic dysfunction, treatment with #cyproterone** or #medroxyprogesterone** is replaced by GnRH analogues. In case of relapse of paraphilic fantasies or behavior, treatment is resumed.

• To prevent an increase in paraphilic drive when using GnRH analogues during the first weeks of therapy, all patients are additionally recommended to use antiandrogens (#cyproterone** in accordance with the dosages indicated above) [2].

LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)

Comment: abrupt withdrawal of GnRH analogues must be avoided. Cyproterone can be used to prevent the risk of relapse associated with the restoration of testosterone levels in case of GnRH analogue withdrawal [2].

• Upon the development of severe osteoporosis in patients with SPD receiving antiandrogens or GnRH analogues, in order to prevent fractures and minimize complications associated with decreased bone mineral density, it is recommended to prescribe calcium preparations, vitamin D and its analogues, and/or bisphosphonates [2].

LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)

3.3 Other Treatment

In addition to pharmacological and psychotherapeutic methods, surgical castration (orchiectomy) is used in some countries to treat SPD [2]. The use of surgical methods, as causing irreversible consequences, is prohibited in compulsory treatment of mental disorders in Russia pursuant to Clause 5, Article 11 of the Law of the Russian Federation dated July 2, 1992, No. 3185-1 "On Psychiatric Care and Guarantees of Citizens' Rights in Its Provision". Orchiectomy with the patient's voluntary consent in the Russian Federation is performed in the treatment of other diseases (for example, testicular malignancies, prostate cancer, severe scrotal diseases) and severe scrotal trauma with testicular pulverization [103]. Cases of orchiectomy used for the treatment of SPD in the Russian Federation have not been documented.

4. Medical Rehabilitation and Sanatorium-Resort Treatment

Rehabilitation and integration into society of individuals with SPD, especially in cases of compulsory treatment of those who previously committed sexual offenses, is hindered by negative attitudes towards such individuals and the need to maintain a balance between social integration and public safety [104]. In many countries, restrictive measures regarding their place of residence and employment are applied to individuals with SPD who have committed offenses, and public notification systems regarding their whereabouts are used [105]. It has been shown that strict restrictive measures increase the social isolation of individuals with SPD and may contribute to an increased risk of repeated implementation of abnormal sexual urges [106]. Conversely, a favorable therapeutic climate and the focus of therapeutic interventions on integration rather than isolation contribute to the improvement of dynamic risk factors [107]. Therapeutic care in the community rather than in prison has been shown to be more effective [108].

• All patients with SPD are recommended to participate in social support groups and, if a partner is present, undergo family therapy in order to develop emotional regulation skills, social skills for interacting with an adult heterosexual partner, and coping strategies for paraphilic drive [109, 110].

Level of Evidence CGrade of Recommendation 2Level of Evidence C (Grade of Recommendation 2)

5. Prevention and Dispensary Observation

Primary prevention of SPD consists of organizing care for individuals with abnormal sexual drive who voluntarily seek help from healthcare specialists [50, 51]. According to Order of the Russian Ministry of Health dated October 14, 2022, No. 668n "On Approval of the Procedure for Providing Medical Care for Mental Disorders and Behavioral Disorders", individuals with SPD, since this disorder falls under the category of mental disorders and behavioral disorders, have the opportunity to seek medical care in the established manner.

• For patients with pronounced and severe SPD (see Appendix B2), for the secondary prevention of relapse, long-term individual or group psychotherapy and periodic preventive appointments (examinations, consultations) with a psychiatrist are recommended to monitor the effectiveness of the ongoing treatment [2].

LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)

Comments: in severe cases of SPD, treatment can last for many years. In some cases, lifelong administration of antiandrogens or GnRH analogues is recommended, due to the reappearance of paraphilic fantasies after treatment cessation.

• If the symptoms of SPD include experiences regarding violent, non-voluntary sexual contacts, it is recommended to consider establishing dispensary observation for the person with a mental disorder in accordance with the Procedure for Dispensary Observation No. 453n, approved by the Russian Ministry of Health on June 30, 2022, in order to assess the patient's adherence to treatment and the effectiveness of previously prescribed treatment, increase the patient's motivation for treatment, make necessary adjustments to the ongoing treatment, and timely detect clinical manifestations in the patient that predispose to committing socially dangerous acts [2, 111].

LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)

Comments: establishing active dispensary observation (group D-5) is recommended for individuals with SPD who have been ordered by a court to undergo compulsory outpatient observation and treatment by a psychiatrist. The decision to establish dispensary observation should be made taking into account the patient's public danger. Regarding the assessment of public danger, see also Section 2.5 Other Diagnostic Tests.

Comments: in addition to the mentioned diagnostic examinations carried out as needed, when prescribing antiandrogens or GnRH analogues to patients, it is necessary to perform a number of laboratory tests aimed at preventing the development of complications associated with the use of medicinal products, with the frequency specified in section 2.3. Laboratory diagnostic examinations [26, 28, 29].

Procedure for monitoring the application of compulsory medical measures prescribed to persons with pedophilia in accordance with Order of the Ministry of Justice of Russia No. 142, Ministry of Health of Russia No. 355n dated June 17, 2025, "On approval of the Procedure for monitoring the application of compulsory medical measures prescribed in accordance with part two.1 of Article 102 of the Criminal Code of the Russian Federation to persons who have committed a crime over the age of eighteen against the sexual integrity of a minor under the age of fourteen, and suffering from a sexual preference disorder (pedophilia) that does not exclude sanity." The said control measures are necessitated by the need to prevent socially dangerous behavior of patients suffering from mental disorders.

When prescribing dispensary observation to a patient with a paraphilic disorder who has voluntarily sought help and has preserved critical faculties, one should take into account the high risk of falling under increased police attention, which can deplete the subject's mental resources that could otherwise ensure treatment adherence and contribute to a favorable course of the disorder, prospects for recovery, and a reduction in the likelihood of socially dangerous behavior.

Secondary prevention consists of long-term pharmacotherapy and psychotherapy with the development of coping strategies for paraphilic drive, normative sexual interest, and patterns of sexual behavior.

6. Organization of Medical Care

Medical care for individuals exhibiting abnormal sexual interest is rarely provided without the intervention of the forensic and investigative system [110]; however, existing organizational regulations on the organization of medical care (Law of the RF No. 3185-1 dated July 2, 1992; Order of the Ministry of Health of Russia No. 668n dated October 14, 2022) also apply to patients with paraphilic disorders.

With regard to persons suffering from pedophilia and who have committed crimes against the sexual integrity of minors, in accordance with the current legislation of the Russian Federation, a special procedure for compulsory treatment has been established, the purpose of which is the prevention of repeated offenses. The execution of compulsory treatment during the serving of a sentence is entrusted to the medical service of the Federal Penitentiary Service of the Ministry of Justice of the Russian Federation.

The execution of outpatient compulsory observation and treatment by a psychiatrist, prescribed as a compulsory medical measure after serving a sentence (in accordance with Part 2.1 of Article 102 of the Criminal Code of the Russian Federation), is entrusted to healthcare institutions providing psychiatric care on an outpatient basis (see section 5. Prevention and dispensary observation).

Indications for hospitalization in a medical organization

Non-psychotic behavioral disorders that may be observed in individuals with paraphilic disorders without concomitant psychiatric pathology are not an indication for inpatient treatment, since the entire possible scope of medical care for such patients can be provided on an outpatient basis. For isolated paraphilic disorders, there are no clinical and organizational indications for round-the-clock inpatient observation and treatment; such a disorder in itself is not a basis for a patient's stay in a hospital, and the need for isolation is not a medical indication and is not among the tasks of inpatient psychiatric treatment. However, patients with paraphilic disorders may exhibit the full range of mental disorders, for the majority of which the paraphilic disorder is secondary. The basis for inpatient treatment may be the presence of appropriate indications for hospitalization due to a mental disorder comorbid with the paraphilic disorder.

Indications for patient discharge from a medical organization

Discharge of a patient from the hospital can be carried out if the presence in a patient with a paraphilic disorder of a comorbid mental disorder that previously served as the basis for hospitalization reaches a state of remission or compensation at which further stay in the hospital is not required. The presence of a paraphilic disorder without acute psychopathological manifestations of the concomitant disorder is not a basis for continued stay of the patient in a psychiatric hospital.

7. Additional Information

Factors contributing to the realization of paraphilic fantasies in paraphilic disorders include the presence of comorbid personality disorders and affective disorders, the use of psychoactive substances (alcohol and drugs), living alone, refusal of paraphilic disorder therapy, emotional congruence with children (in pedophilia), hostility towards women, social rejection, insufficiently developed stress-coping skills, access to potential victims, impaired social support, preoccupation with sexual topics, and past criminal behavior [55].

Criteria for Evaluating the Quality of Medical Care

Criteria for assessing the quality of primary health care

References

Appendix A1. Working Group Composition

1. Vasiliev N.G. - Researcher at the Laboratory of Forensic Sexology, V.P. Serbsky National Medical Research Center for Psychiatry and Narcology of the Russian Ministry of Health, member of the Russian Society of Psychiatrists.

2. Demidova L.Yu. - PhD in Psychology, Head of the Laboratory of Forensic Sexology, V.P. Serbsky National Medical Research Center for Psychiatry and Narcology of the Russian Ministry of Health, member of the Russian Society of Psychiatrists.

3. Kamenskov M.Yu. - MD, forensic psychiatric expert, sexologist at Psychiatric Clinical Hospital No. 1 of the Moscow Healthcare Department, member of the Russian Society of Psychiatrists.

4. Tkachenko A.A. - MD, Professor, Head of the Department of Forensic Psychiatric Examination in Criminal Proceedings, V.P. Serbsky National Medical Research Center for Psychiatry and Narcology of the Russian Ministry of Health, Board member of the Moscow Branch of the Russian Society of Psychiatrists.

There is no conflict of interest.

Appendix A2. Methodology for Developing Clinical Guidelines

Target audience for these clinical guidelines:

1. Psychiatrists

2. Sexologists

3. Psychotherapists

4. Medical psychologists

Methods used to collect evidence: the most fundamental domestic and foreign works on the problem of sexual preference disorders, official materials of the World Health Organization, and the working group for the development of the SPD category were used in drafting the clinical guidelines. The search for the most up-to-date literature sources was carried out using the Semantic Scholar platform, which aggregates scientific publications from multiple databases.

Expert review: the clinical guidelines were posted for broad discussion on the websites of the Russian Society of Psychiatrists and the Russian Ministry of Health. The guidelines were analyzed by the working group members, expert comments and feedback were taken into account, and the risk of errors was minimized.

Table 1. Scale for assessing levels of evidence (LE) for diagnostic methods (diagnostic interventions)

Table 2. Scale for assessing the levels of evidence (LE) for prevention, treatment, and medical rehabilitation methods, including those based on natural therapeutic factors (preventive, therapeutic, and rehabilitation interventions)

Table 3. Scale for evaluating the levels of убедительности рекомендаций (LoR) for prevention, diagnostic, treatment, and medical rehabilitation methods, including those based on natural therapeutic factors (preventive, therapeutic, and rehabilitative interventions)

Procedure for updating clinical guidelines

The mechanism for updating clinical guidelines provides for their systematic revision - at least once every three years, as well as upon the emergence of new evidence-based medicine data regarding the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.

Appendix A3. Reference Materials

A3.1 Legal documents

1. Federal Law of the Russian Federation No. 323-FZ dated November 21, 2011, "On the Fundamentals of Healthcare Protection in the Russian Federation";

2. Federal Law of the Russian Federation No. 3185-1 dated July 2, 1992, "On Psychiatric Care and Guarantees of Citizens' Rights in Its Provision";

3. Order of the Russian Ministry of Health No. 668n dated October 14, 2022, "On Approval of the Procedure for Providing Medical Care for Mental Disorders and Behavioral Disorders";

4. Order of the Russian Ministry of Health No. 453n dated June 30, 2022, "On Approval of the Procedure for Dispensary Observation of a Person Suffering from a Chronic and Prolonged Mental Disorder with Severe, Persistent, or Frequently Relapsing Pathological Manifestations";

5. Order of the Russian Ministry of Health and the Ministry of Internal Affairs of the Russian Federation No. 56n/39 dated February 6, 2025, "On Approval of the Procedure for Interaction Between Medical Organizations and Internal Affairs Bodies for the Purpose of Monitoring Persons Suffering from Chronic and Prolonged Mental Disorders with Severe, Persistent, or Frequently Relapsing Pathological Manifestations Who Are Under Dispensary Observation Due to Their Propensity to Commit Socially Dangerous Acts, Including the List of Transferred Information, Cases and Procedures for Informing, and the List of Measures Carried Out by Medical Organizations and Internal Affairs Bodies Upon Receipt of Relevant Information";

6. Order of the Ministry of Justice of the Russian Federation and the Ministry of Health of the Russian Federation No. 142/355n dated June 17, 2025, "On Approval of the Procedure for Monitoring the Application of Compulsory Medical Measures Prescribed in Accordance with Part 2.1 of Article 102 of the Criminal Code of the Russian Federation to Persons Who Committed a Crime Over the Age of Eighteen Against the Sexual Inviolability of a Minor Under the Age of Fourteen and Who Suffer from a Sexual Preference Disorder (Pedophilia) That Does Not Exclude Sanity";

7. Criminal Code of the Russian Federation;

8. Penal Code of the Russian Federation.

A3.2 Additional information on the specifics of conducting a clinical interview in the diagnosis of SPD

When initiating a clinical interview, the patient's attitude toward the conversation should be taken into account. There is often wariness toward the psychiatrist and sexologist, and frequently an unwillingness to undergo examination. The conversation should be conducted by the physician in a trusting atmosphere, maximally excluding factors that could create a sense of being rushed. The clinical conversation with the patient should be conducted from a neutral (non-judgmental) standpoint. If unable to detach from subjective experiences, the physician must avoid demonstrating their own personal stance and refrain from evaluative, commentary, or admonitory statements. Questions that stimulate the interviewee to tell their own story, which should be delicately guided in the direction necessary to achieve the goals of the examination, are preferred.

Questions should be as simple and understandable to the patient as possible, corresponding to their level of speech development, taking into account age and education, as well as the language barrier (in cases where the patient and the therapist are native speakers of different languages). In cases where the examinee uses words and expressions that accurately describe their experiences, these should be quoted as direct speech.

During a non-voluntary examination, the subject may not only be uninterested in providing accurate information to the physician, but may also attempt to conceal objective information about their sexual development. In this regard, the sequence of collecting the medical history is of particular importance: while in most cases the standard scheme corresponding to ontological development is suitable, it is useful to ask about the same fact directly and indirectly after some time, when the details of the previous answer have been forgotten.

A3.3 Psychological signs of pedophilia and sadism

Psychological signs of pedophilia

‐ Strong incongruence with the male image;

‐ Absence of the drive to conform to the male gender role (or a formal drive), reflected in gender-role behavior;

‐ Emotional attitude toward gender-role stereotypes (male and female images) differs from positive;

‐ Attitude toward the sexual sphere is associated with pronounced anxiety;

‐ Preference for a weak and passive object in sexual relations;

‐ Greater emotional attractiveness of the child image compared to the female one;

‐ Distorted perception of gender-role stereotypes.

Psychological signs of sadism

‐ Depersonalized perception of images;

‐ Transformed "Self" image;

‐ Semantic identification with the image of a woman or an undifferentiated type of "Self" image;

‐ Significant discrepancy between the actual and ideal self-image;

‐ Signs of hyper-role behavior;

‐ Apparent emotional inversion.

A3.4 Main CBT approaches in the treatment of sexual preference disorders (SPDs), ethical aspect of therapeutic interventions

CBT programs also aim to modify distorted thinking patterns (cognitive distortions) and social attitudes, develop empathy, improve social functioning, and address other factors associated with the presence and enactment of anomalous sexual urges. There are several varieties of CBT for working with patients with paraphilic interests, but they are all very similar in content.

The ethical aspect of therapeutic work with patients suffering from SPDs is significant, as such a disorder may be associated with unlawful behavioral activity. According to Part 3, Section 4, Article 13 of the Federal Law "On the Basics of Protecting the Health of Citizens in the Russian Federation" (dated November 21, 2011, No. 323-FZ, as amended on April 1, 2026), "the provision of information constituting medical confidentiality without the consent of the citizen or their legal representative is permitted upon request by inquiry and investigative bodies, or a court in connection with an investigation or judicial proceedings, upon request by prosecutor's offices..., upon request by the penal enforcement system in connection with the execution of a criminal sentence and supervision over the application of compulsory medical measures prescribed in accordance with Part 2.1 of Article 102 of the Criminal Code of the Russian Federation...". Before starting therapeutic work, the physician is obliged to discuss this important point with the patient, which implies the possibility of disclosing information reported by the patient if it contains elements of a crime.

Administering treatment on a compulsory basis does not preclude establishing compliance with the patient. Compulsory treatment is ordered by a court within the framework of a specific criminal case, based on an established diagnosis and an assessment of potential risk, rather than the patient's desire (or lack thereof) to undergo treatment. Therefore, each specific case must be considered individually. In many cases, patients retain insight into their anomalous urge, and compliance with such patients is achievable. Efforts to build motivation for treatment as an essential element of therapy are not abandoned either. The challenge of conducting psychotherapy on a "compulsory" basis arises only with respect to the most complex category of patients—those with a syntonic attitude toward their anomalous urge. Work with such patients can be addressed through the engagement of legal mechanisms (in Russia, there is an opportunity to motivate patients who lack insight into their disorder through the legal component, since evasion of compulsory treatment can lead to re-incarceration). The patient is explained the rational benefits of undergoing treatment. For patients who lack insight into their anomalous behavior, forms of therapy are used that aim to build motivation for treatment or focus on enhancing social adaptation and controlling the anomalous urge, rather than eliminating it.

Most therapeutic approaches are based on the risk-need-responsivity (RNR) principles, according to which, for maximum effectiveness, the intensity of therapy should be proportional to the individual's risk level, and treatment targets must be directly related to dynamic risk factors while taking the patient's own capabilities into account. This model is widely supported globally, with minor criticisms raised only regarding the first component of the model, since medical care should be equally accessible to patients with different risk levels.

Among the confirmed dynamic risk factors that therapy should target are: sexual preoccupation; deviant sexual interest; attitudes supporting non-consensual sexual behavior; emotional congruence with children; lack of emotional intimacy; self-regulation impairments; poor coping skills; resistance to rules and supervision; hostility toward women; and lack of empathy.

In working with individuals with anomalous sexual behavior, behavioral therapy techniques based on learning mechanisms are frequently utilized. Thus, when an anomalous pattern is reinforced specifically as a result of learning, the use of orgasmic reconditioning, aversion therapy, or other behavioral techniques may prove useful. However, techniques based on learning mechanisms prove insufficiently effective when used outside of cognitive therapy. Placing exclusive emphasis on the behavioral component in therapy is unjustified, because learning sexual behavior has a critical period after which new learning has only a minor effect; for some patients, sexual activity preceding orgasmic experiences (which is mainly used in the behavioral part of therapy as reinforcement) is more important than the orgasm itself, which in and of itself may even act as an aversive stimulus because it is associated with feelings of guilt and shame.

Furthermore, changing sexual interest to a normative one does not guarantee the emergence of pro-social sexual behavior. If a patient has had no prior experience of satisfying normative sexual relationships, they will still need skills, attitudes, and sufficient self-assurance after the behavioral portion of the program to enable them to establish consensual relationships with age-appropriate partners. For treatment to be effective, work aimed at addressing the individual's deficits in their ability to satisfy their needs through pro-social means must be added to the modification of sexual interest.

To address the deficits of individuals with anomalous sexual behavior, two main approaches within CBT are utilized, which—in their original or somewhat modified form—are most frequently used for treating patients with SPDs.

The relapse prevention approach is an adaptation of the addiction treatment approach applied to anomalous sexual behavior and includes features of rational emotive therapy, social learning theory, and social skills training. The primary goal of therapy is to enhance the individual's ability to recognize and adequately respond to potential risk situations. Within this framework, four main targets for work are identified: identifying situations where the risk of committing offenses is elevated; identifying erroneous behavior (e.g., in pedophilia: masturbating while fantasizing about children, spending time alone with a child); developing strategies to avoid high-risk situations; and developing coping strategies for high-risk situations that could not be avoided. This model was at the peak of its popularity for a long time, and most existing CBT protocols for anomalous sexual behavior are based on it. The main criticism of this approach is that it is problem-avoidant rather than problem-solving, and the model itself targets only those patients who are sufficiently motivated to abstain from enacting the anomalous sexual pattern.

As a result, new approaches began to emerge, the most well-known of which is the Good Lives Model (GLM) for working with sexual offenders. This model is based on self-regulation theory, and its central premise is that unlawful behavior actually serves certain functions in an individual's life to achieve primary human goods (such as work and occupational success, autonomy and independence, inner peace, relationships and friendship, striving to belong to a group, spending leisure time productively, etc.). Therapy works on teaching the individual to achieve these same goals through pro-social means.

Appendix B. Physician Action Algorithms

The management of a patient with an SPD, diagnosis, selection of therapeutic tactics, and treatment methods are carried out individually in each case, depending on the psychopathological presentation of the SPD and the presence of comorbid psychiatric pathology. Diagnostics are performed in accordance with the criteria of the current classification, and treatment efficacy is evaluated throughout the course of therapy.

Appendix B1. Diagnostic algorithm

Appendix B2. Treatment algorithm

Appendix B3. Algorithm for Writing an Experimental Psychological Assessment Report

Appendix C. Patient Information

• Abnormal sexual attraction is much more common in the population than is commonly believed.

• The presence of abnormal sexual urges does not always lead to the commission of sexual offenses; however, for certain forms of paraphilia involving other persons, the risk of unlawful behavior is increased.

• Seeking medical help in a timely manner is an important measure for preventing unlawful behavior and also increases the chances of a favorable course of the disorder and recovery from it. Consulting a specialist is the first step toward adequate treatment and the reduction of social risks.

• Diagnosis of sexual preference disorders is carried out by a psychiatrist or sexologist and in some cases involves additional examinations.

• There is no scientific evidence indicating that sexual preference disorders are incurable.

• Therapy depends on the characteristics of the disorder and requires regular interaction with the physician. The patient must learn to monitor changes in their condition and manifestations of the disorder in order to consult a specialist in a timely manner for treatment adjustment.

• Treatment involves psychotherapeutic methods and in many, but not all, cases requires medication.

The goals of therapy for sexual preference disorders are:

• reduction of abnormal sexual attraction and its behavioral manifestations;

• control of abnormal fantasies and behavior;

• enhancement of normative sexual attraction and formation of normative patterns of sexual behavior;

• improvement of social interaction skills and stress-coping strategies, and enhancement of quality of life;

• reduction of the risk of committing sexual offenses;

• maintenance of the ability to live successfully in society.

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

Appendix G1. "Masculinity and Femininity" scale

Russian Title: «Masculinity and Femininity» Questionnaire.

Original Title: The technique is a modified version of the BSRI (Bem Sex-Role Inventory) (Bem, 1974), modified by T.L. Bessonova (Bessonova, 1993) and N.V. Dvoryanchikov (Dvoryanchikov, 1998).

Source: Dvoryanchikov N.V., Nosov S.S., Salamova D.K. Polovoye samosoznaniye i metody yego diagnostiki. Moscow: Flinta, 2011. 216 p.

Type (underline):

- rating scale

- index

- questionnaire

- other (specify)

Purpose: The technique is designed to assess the structures of sexual identity in terms of perceptions of masculinity and femininity.

Content (Template): The subject is asked to rate the severity of 21 traits across eight self-images on a 4-point scale:

- self ("Actually, I am..."),

- man ("A man should be..."),

- woman ("A woman should be..."),

- self from men's perspective ("Men think that I am..."),

- self from women's perspective ("Women think that I am..."),

- ideal self ("I would like to be..."),

- real sexual partner ("My real sexual partner is..."),

- ideal sexual partner ("I would like my sexual partner to be...").

If necessary (for example, if the patient has multiple significant partners), additional images may be added for assessment by printing another form or using an alternative marker (e.g., a cross instead of a checkmark) for answers.

The traits offered for evaluation include 7 masculine traits (bold, brash, agile, tough, courageous, intrusive, resolute), 7 feminine traits (meek, neat, weak, amiable, affectionate, timid, gentle), and 8 gender-neutral traits (remaining qualities).

The questionnaire is administered by the examiner during the interview with the patient to reduce social desirability bias and eliminate the possibility of copying answers given previously for other images.

Instructions. Now I am going to read you some simple human qualities. Your task is to state how often you actually (IMAGE NAME) are (TRAIT NAME): always, usually, sometimes, or never?

After evaluating the "Actually, I am..." image on each of the suggested qualities, all other images are evaluated in a similar manner with a slight modification of the instructions.

Key (Interpretation). For each image, the score for the expression of masculine traits (opposite masculine qualities) and feminine traits (opposite feminine qualities) is calculated using the following algorithm: the number of "never" answers is multiplied by 1, "sometimes" by 2, "usually" by 3, "always" by 4, and the resulting numbers are summed.

The evaluation is based not on the numerical expression of masculine/feminine traits per se, but on the spatial arrangement of the images within the masculinity and femininity coordinates. The numerical values of masculine and feminine traits for each image are treated as X coordinates (masculinity score) and Y coordinates (femininity score). The lower value of both axes in the coordinate space corresponds to the minimum possible 7 points, and the upper value to the maximum possible 28 points.

The expression of gender-role traits in each image and the relative positioning of the images are evaluated.

The questionnaire forms are provided below.

Appendix G2. "Color Relations Test" method

Russian Title: «Color Relations Test».

Original Title: None. The technique is based on the color-association experiment developed by Soviet psychologist A.M. Etkind (Etkind, 1980).

Source: Dvoryanchikov N.V., Nosov S.S., Salamova D.K. Polovoye samosoznaniye i metody yego diagnostiki. Moscow: Flinta, 2011. 216 p.

Type (underline):

- assessment scale

- score

- questionnaire

- other (specify) Projective test

Purpose. The technique is designed to identify emotional attitudes toward various gender-role images and semantic connections between them.

Content (Template). The subject is presented with several dozen concepts, for which they must select appropriate colors from a modified eight-color Luscher test (colors of different shades are permitted, but strictly within the classical color scheme: 1 - blue, 2 - green, 3 - red, 4 - yellow, 5 - violet, 6 - brown, 7 - black, 0 - gray).

The main concepts presented include:

- various gender-role images (self, ideal self, man, woman, young man, young woman, adolescent boy, adolescent girl, boy, girl, child),

- stimuli related to sexuality (sex, ideal sexual partner, sexual desire, sexual satisfaction, orgasm),

- a set of emotionally charged words (anxiety, danger, joy, grief, pleasure, benevolence, and many others).

If necessary, additional stimuli may be added to the methodology for evaluation (free cells on the form can be used for this). This option should be used when it is necessary to assess rare forms of paraphilia associated with attraction to specific objects or forms of activity. In such cases, stimuli corresponding to the presumed attraction should be offered to the patient for association.

Instructions. Before you are colored cards. Now I will name various words and phrases for you; there will be many of them. Your task is to choose a color for the word or phrase I name that you feel fits it best. Colors can be repeated; you can name several colors for a single word or phrase if you feel together they better convey the content of the stimulus. Let's try. Which of the suggested colors fits the word "friends" best (STIMULUS NAME)?

All words from the form are named sequentially. The numbers of the colors chosen by the patient for each stimulus are recorded on the form (recording the names is permissible, but more time-consuming).

Key (Interpretation). Words and phrases assigned the same color are listed together and considered interrelated. Intersections between stimuli are interpreted. An intersection is defined as the simultaneous presence of stimuli within the same color. The specific color chosen for a stimulus is not interpreted, because in the individual experience of each patient, a certain color may acquire a subjective semantic meaning that differs from the generally accepted one. What matters is not the color, but the intersection of associations, when different stimuli are related to the same color, which indicates their semantic similarity.

The methodology form is provided below.

Appendix G3. "Coding" test

Russian Title: «Coding» Technique.

Original Title: The technique is a modified version of Z. Starowicz's «Projective Checklist» technique (Starowicz, 1991). Modified by N.V. Dvoryanchikov (Dvoryanchikov, 1998).

Source: Dvoryanchikov N.V., Nosov S.S., Salamova D.K. Polovoye samosoznaniye i metody yego diagnostiki. Moscow: Flinta, 2011. 216 p.

Type (underline):

- assessment scale

- score

- questionnaire

- other (specify) Semi-projective test

Purpose. The technique is designed to identify the characteristics of gender-role image perception (their differentiation, emotional attitude toward them, and semantic intersections between them).

Content (Template). The patient is asked to compare basic gender-role images (self, man, woman, child) with images from various categories (tree, animal, inanimate object, musical instrument, herbaceous plant, geometric figure, fairy-tale character, circus performer persona), substantiating their choice.

If necessary, additional images can be added to the methodology for evaluation by using another form. In the case of a detailed, substantive description of the proposed analogies, one can limit the presentation to the first four associations (tree, animal, inanimate object, musical instrument) for each of the gender-role images. Asking the patient to draw analogies with all the proposed images is necessary only if they give sparse, uncommunicative descriptions.

Instructions. Now I am going to ask you to compare a man, a child, a woman, and yourself with various images. Let's try it with a specific example. Please tell me, what kind of tree (IMAGE FOR ANALOGY IS NAMED) can be compared to a man (GENDER-ROLE IMAGE IS NAMED), and why?

All analogies are filled out sequentially, first for the man, then for the child, the woman, and for the patient themselves.

Key (Interpretation). Interpretation of the obtained results involves describing the differentiation and content characteristics of the images. The obtained results are used to assess the individual's identification, the formation of their concepts of gender-role stereotypes, the differentiation of images by sex and age characteristics, and to assess the emotional attitude toward images and depersonification.

The methodology form is provided below.

Appendix G4. Dichotomous Cognitive Distortion Scale (DCDS)

Original name: Dichotomous Cognitive Distortions Scale (DCDS).

Source: Author – Demidova L.Yu. (V.P. Serbsky National Medical Research Centre for Psychiatry and Narcology of the Russian Ministry of Health). Validation publication: Demidova L.Yu., Korchagin V.V., Vasilyev N.G. "Psychometric testing of methods for assessing cognitive distortions regarding sexual relations with children" // Psychology and Law, 2024, Vol. 14, No. 1, pp. 18–32. DOI: 10.17759/psylaw.2024140102

Purpose. The methodology is designed to assess the severity of cognitive distortions regarding sexual relations between adults and children.

Instructions. You are presented with pairs of opposite statements concerning sexual relations between adults and children. Read each pair carefully and choose the statement from the two with which you agree to a greater extent. Circle the number that corresponds to the degree of your agreement (the larger the number and the closer it is to a particular statement, the more confident your agreement is). If you do not lean toward either of the two statements, mark "0". Answer as you truly believe; try not to think about what answers others expect from you.

Key (Interpretation). Each subject's response can be assigned from 1 to 7 points, which are awarded according to the following scheme: responses "3", "2", and "1" on the side of the left statement are scored 7, 6, and 5 points, respectively. Response "0" is scored 4 points. Responses "1", "2", and "3" on the side of the right statement are scored 3, 2, and 1 point, respectively.

For example, for the first statement, the points for the answers will be distributed as follows:

The total score is calculated as the sum of all points scored by the subject during the testing process. Since the methodology includes 23 statements, the minimum score a subject can get is 23, and the maximum is 161 (i.e., 23*7).

Appendix G5. Russian-language version of the "Molest scale"

Original name: Molest scale.

Source: English-language version source: Bumby K.M. Assessing the cognitive distortions of child molesters and rapists: Development and validation of the MOLEST and RAPE scales. Sexual Abuse: Journal of Research and Treatment, 1996: 8(1): 37–54. DOI: 10.1177/107906329600800105. Translator – Demidova L.Yu. (V.P. Serbsky National Medical Research Centre for Psychiatry and Narcology of the Russian Ministry of Health). Validation publication on a Russian-speaking sample: Demidova L.Yu., Korchagin V.V., Vasilyev N.G. "Psychometric testing of methods for assessing cognitive distortions regarding sexual relations with children" // Psychology and Law, 2024, Vol. 14, No. 1, pp. 18–32. DOI: 10.17759/psylaw.2024140102

Purpose. The methodology is designed to assess the severity of cognitive distortions regarding sexual relations between adults and children.

Instructions. You are presented with statements concerning sexual relations between adults and children. Please read each statement carefully and circle the number that corresponds to your opinion on the respective statement. Answer as you truly believe; try not to think about what answers others expect from you.

Key (Interpretation). Each subject's response can be assigned from 1 to 4 points depending on the degree of agreement with the statement: "strongly disagree" is scored 1 point, "disagree" – 2 points, "agree" – 3 points, "strongly agree" – 4 points. The total score is calculated as the sum of all points scored by the subject during the testing process. Since the methodology includes 38 statements, the minimum score a subject can get is 38, and the maximum is 152 (i.e., 38*4).