Paraphilia: Difference between revisions

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*[[Side effects]] of certain medications like [[antidepressants]], and [[neuroleptics]] show that the alteration of [[monoamine]] levels can adversely affect sexuality.<ref name="Kafka1997">{{cite journal|last1=Kafka|first1=Martin P.|journal=Archives of Sexual Behavior|volume=26|issue=4|year=1997|pages=343–358|issn=00040002|doi=10.1023/A:1024535201089}}</ref>  
*[[Side effects]] of certain medications like [[antidepressants]], and [[neuroleptics]] show that the alteration of [[monoamine]] levels can adversely affect sexuality.<ref name="Kafka1997">{{cite journal|last1=Kafka|first1=Martin P.|journal=Archives of Sexual Behavior|volume=26|issue=4|year=1997|pages=343–358|issn=00040002|doi=10.1023/A:1024535201089}}</ref>  
*These [[neurotransmitters]] also modulate [[impulsivity]], [[anxiety]], [[depression]],and [[antisocial]] behavior. Disturbance of these [[neurotransmitters]] may also produce these conditions in paraphilia patients. <ref name="Kafka1997">{{cite journal|last1=Kafka|first1=Martin P.|journal=Archives of Sexual Behavior|volume=26|issue=4|year=1997|pages=343–358|issn=00040002|doi=10.1023/A:1024535201089}}</ref>
*These [[neurotransmitters]] also modulate [[impulsivity]], [[anxiety]], [[depression]],and [[antisocial]] behavior. Disturbance of these [[neurotransmitters]] may also produce these conditions in paraphilia patients. <ref name="Kafka1997">{{cite journal|last1=Kafka|first1=Martin P.|journal=Archives of Sexual Behavior|volume=26|issue=4|year=1997|pages=343–358|issn=00040002|doi=10.1023/A:1024535201089}}</ref>
*The [[medications]] that act by increasing the [[serotonergic]] function have been found to suppress the paraphilic behavior. <ref name="Kafka2006">{{cite journal|last1=Kafka|first1=Martin P.|title=The Monoamine Hypothesis for the Pathophysiology of Paraphilic Disorders: An Update|journal=Annals of the New York Academy of Sciences|volume=989|issue=1|year=2006|pages=86–94|issn=00778923|doi=10.1111/j.1749-6632.2003.tb07295.x}}</ref>
*The [[medications]] that act by increasing the [[serotonergic]] function have been found to suppress the paraphilic behavior. This further supports the [[monoamine]] hypothesis. <ref name="Kafka2006">{{cite journal|last1=Kafka|first1=Martin P.|title=The Monoamine Hypothesis for the Pathophysiology of Paraphilic Disorders: An Update|journal=Annals of the New York Academy of Sciences|volume=989|issue=1|year=2006|pages=86–94|issn=00778923|doi=10.1111/j.1749-6632.2003.tb07295.x}}</ref>


===Role of Testosterone===
===Role of Testosterone===

Revision as of 16:23, 26 September 2020

Overview

Paraphilias are characterized by severe deviant sexual desire or urge resulting in actions that may cause significant impairment in functioning as well as distress (for oneself and/or others). Paraphilic behavior may occur intermittently or may persist for the entire life. To begin with, paraphilia occurs in the form of fantasy, and the paraphilic behavior manifests at a later age. Mostly the individuals with this condition do not seek treatment themselves due to the stigma associated with the condition and the pleasure they obtain from it. Paraphilias are not illegal but the resulting behaviors are. Timely treatment is important to prevent sexual offenses like pedophilia or serial rapes. Patients may have more than one type of paraphilia and therefore, it is essential to evaluate them thoroughly to facilitate optimum management.

Historical Perspective

  • The term 'Paraphilia' is Greek in origin and is derived from the words-'Para'(deviation) and 'philia'(attraction).[1]
  • From biblical times, human societies across the world, have placed restrictions over many types of sexual behaviors. The level of acceptability is based on cultural variations across the globe.
  • There is controversy in what should be called sexual deviation, mainly based on various factors like the degree of consent, age of the involved individuals, degree of distress caused, location of sexual behavior, degree of unacceptable by others, etc. [2]
  • Marquis de Sade (1740-1814) was the basis of the term Sadism. He was placed in a lunatic asylum multiple times and ultimately, he died there. His mental instability, is considered to have resulted in this pattern of sexual behavior . [2]
  • The term masochism comes from Baron Leopold von Sacher Masoch (1835-1895), who was of European origin.[2]
  • At the end of the nineteenth century, sexual deviance was started to be considered a medical condition, with the publication of Psychopathia Sexualis. It was written by a German psychiatrist, Krafft-Ebing and he elaborated the sexual murders in his publication. [2][3]

Classification

  • Earlier the non-reproductive sexual behaviors were considered pathological and criminalized. However, over years the boundaries of pathology have been confined to the absence of sexual consent. [4]
  • The inclusion of the pathological classification of paraphilias in the DSM and ICD has been criticized for a long time. It is based on the thin line of difference between something that is a normal variation or just unusual, and something that is pathological.
  • According to DSM-III, a patient could have more than one paraphilias but the extent of the multiplicity was not described until later editions.[5]
  • Till DSM-IV-TR, the diagnostic category of paraphilia was scrutinized for logic, clarity, and consistency. It was criticized for the fulfillment of a clear-cut mental illness.[6]
  • DSM-IV-TR had included paraphilias in the chapter ‘Sexual and Gender Identity Disorders’.[3]
  • There were proposals to remove paraphilias as a diagnostic category from DSM-5. Some considered the concept of paraphilic disorder as more ideological instead of scientific. [7][8]
  • Despite the ongoing controversies, in DSM-5, the paraphilias have been assigned a separate chapter and are termed Paraphilic disorders. [9]
  • According to DSM-5, a paraphilia does not require psychiatric intervention. For diagnosing paraphilic disorder, the paraphilia should cause harm to others or severe distress to oneself. [3]
  • It has been found that DSM-5 diagnostic criteria for paraphilias can increase the false-positive diagnoses by making the diagnosis without assessing the underlying motivation (may not necessarily be due to paraphilic sexual arousal pattern). As a result, attaining this diagnosis can produce many legal consequences. [10]
  • ICD-10 does not comprise a clear-cut definition of paraphilia. It refers to paraphilia as disorders of sexual preference. [11][12]

Pathophysiology

Mononamine Hypothesis

Role of Testosterone

The antisocial traits, and sexual behavior are affected by sex-steroid associated genetics. This is evident by the clear relationship between testosterone and paraphilia as well as the positive response seen in these patients with antiandrogen therapy.[15]

Differential Diagnosis

It is important to differentiate paraphilias from other disorders like-[16][3]

  • Impulse disorder not otherwise specified (NOS)
  • Bipolar affective disorder
  • Cyclothymic disorder
  • Substance-induced anxiety disorder
  • Substance intoxication (like cocaine, or alcohol)
  • Dissociative disorder
  • Delusional disorder (erotomania)
  • Gender identity disorder
  • Obsessive-compulsive disorder
  • Cognitive disorders like dementia
  • Delirium
  • Deep cerebral stimulation in Parkinson’s disease
  • Neurological disorders

Epidemiology and Demographics

  • The actual prevalence of Paraphilic disorders is difficult to estimate.[17]
  • Only few patients seek treatment and most of the data is obtained from the paraphilic cases caughtup in the legal system.[18][19]

Age

  • Although discrepancies in studies exist, on an average no specific age group has been predisposed to develop Paraphilia.
  • Mostly paraphilias begin in childhood and is manifested in adolescence or later. [20]

Gender

  • The paraphilic behavior is seen mostly in men. However, there are studies which show no prominent gender-differences.[12][17][21]

Race

  • Limited studies have been done regarding the racial predilection.
  • Most of the studies present mixed results and it can be concluded that there is no single race predisposed to develop paraphilia.[22]

Risk Factors

  • Noxious child-rearing experiences, non-sexual and sexual both[20]
  • Childhood emotional abuse[23]
  • Childhood sexual abuse[23]

Natural History, Complications, and Prognosis

  • Patients with paraphilias have high chances of relapse.[1]
  • After 15 years, pedophiles attracted to boys are likely to commit the crime again (35%) as compared to those attracted to girls (16%).[19]
  • Good prognostic factors are-[1]
    • Early treatment
    • Individuals with good ego strength and high motivation for treatment
    • Patients with normal adult sexual experiences
  • Poor Prognostic factors are-[1]
    • Coexisting mental disorders
    • Early onset of paraphilic behaviors
    • Lack of remorse for their behaviors
    • Substance misuse
    • Pedophilia with a sexually interested in boys
  • Risk of recurrence is based on-[19]
    • Static risk factors (history of sexual abuse)-Does not change during treatment
    • Dynamic risk factors (impulsivity, hypersexuality, or personality disorders)-Can be addressed during psychotherapy

Comorbidities

Various comorbid conditions exist with paraphilias like-[12][24][1]

  • Depression
  • Generalized Anxiety disorder
  • Substance abuse
  • Erotomania
  • Suicidality
  • Gender Dysphoria
  • Autism Spectrum Disorder (ASD)
  • Mental Retardation
  • Antisocial personality Disorder
  • Personality change due to General Medical Condition

Diagnosis

DSM-5 Diagnostic Criteria

  • Following conditions have been described under the chapter on Paraphilia:
  1. Exhibitionistic Disorder
  2. Fetishistic Disorder
  3. Frotteuristic Disorder
  4. Paedophilic Disorder
  5. Sexual Masochism Disorder
  6. Sexual Sadism Disorder
  7. Voyeuristic Disorder
  8. Transvestic Disorder
  9. Other specified Paraphilic Disorder
  10. Unspecified Paraphilic Disorder

Voyeuristic Disorder

  • A. Over a minimum period of six months, existence of recurrent and intense sexual arousal from observing an unsuspected person who is naked
  • B. Action has been taken on these urges with a non-consenting person, or significant distress/ socio-occupational functioning impairment is caused by these sexual urges or fantasies
  • C. The individual is at least 18 years old

Specify if:

  • In a controlled environment(the individual is living in an institution etc)
  • In full remission (individual has not acted on these urges and has not resulted in distress over the last 5 years, while in an uncontrolled environment)

Exhibitionistic Disorder

  • A. Over a minimum period of six months, the existence of recurrent and intense sexual arousal from exposure of one's genitals to an unsuspected individual
  • B. Action has been taken on these urges with a non-consenting person, or significant distress/ socio-occupational functioning impairment is caused by these sexual urges or fantasies

Specify whether:

  • Sexually aroused by exposing genitals to the prepubertal children
  • Sexually aroused by exposing genitals to the physically mature individuals
  • Sexually aroused by exposing genitals to the prepubertal children as well as physically mature individuals

Specify if:

  • In a controlled environment(the individual is living in an institution etc)
  • In full remission (individual has not acted on these urges and has not resulted in distress over the last 5 years, while in an uncontrolled environment)

Frotteuristic Disorder

  • A. Over a minimum period of six months, the existence of recurrent and intense sexual arousal from touching or rubbing against a non-consenting person, as manifested by fantasies, or behavior
  • B. Action has been taken on these urges with a non-consenting person, or significant distress/ socio-occupational functioning impairment is caused by these sexual urges or fantasies

Specify if:

  • In a controlled environment(the individual is living in an institution etc)
  • In full remission (individual has not acted on these urges and has not resulted in distress over the last 5 years, while in an uncontrolled environment)

Sexual Masochism Disorder

  • A. Over a minimum period of six months, the existence of recurrent and intense sexual arousal from being beaten, bound, humiliated, or made to suffer - manifested in the form of fantasies, urges, or behaviors
  • B. Significant distress/ socio-occupational functioning impairment is caused by these sexual urges or fantasies

Specify if: With asphyxiophilia: If the individual experiences sexual arousal due to restriction of breathing

Specify if:

  • In a controlled environment(the individual is living in an institution etc)
  • In full remission (individual has not acted on these urges and has not resulted in distress over the last 5 years, while in an uncontrolled environment)

Sexual Sadism Disorder

  • A. Over a minimum period of six months, the existence of recurrent and intense sexual arousal from the psychological or physical suffering of the person- manifested in the form of urges, fantasies, or behaviors
  • B. Significant distress/ socio-occupational functioning impairment is caused by these sexual urges or fantasies

Specify if:

  • In a controlled environment(the individual is living in an institution etc)
  • In full remission (individual has not acted on these urges and has not resulted in distress over the last 5 years, while in an uncontrolled environment)

Pedophilic Disorder

  • A. Over a minimum period of six months, the existence of recurrent and intense sexually arousing fantasies, urges, or behavior involving sexual activity with a child or many children of age 13 or younger
  • B. Significant distress/ interpersonal difficulty is caused by these sexual urges or fantasies, or the individual has acted on these sexual urges
  • C. The individual is at least 16 years old and a minimum of 5 years older than the child

Specify whether:

  • Exclusive type (attracted to children only)
  • Non-exclusive type

Specify if:

  • Sexually attracted to males only
  • Sexually attracted to females only
  • Sexually attracted to both

Specify if:

  • Limited to incest

Fetishistic Disorder

  • A. Over a minimum period of six months, the existence of recurrent and intense sexually arousing fantasies, urges, or behavior from the use of non-living objects, or a focus on non-genital body part/parts
  • B. Significant distress/ socio-occupational functioning impairment is caused by these sexual urges or fantasies, or behavior
  • C. The fetish objects are not limited to clothing or objects designed for tactile genital stimulation

Specify if:

  • Body part/parts
  • Non-living object/objects
  • Other

Specify if:

  • In a controlled environment(the individual is living in an institution etc)
  • In full remission (individual has not acted on these urges and has not resulted in distress over the last 5 years, while in an uncontrolled environment)

Transvestic Disorder

  • A. Over a minimum period of six months, the existence of recurrent and intense sexually arousing fantasies, urges, or behavior from cross-dressing
  • B. Significant distress/ socio-occupational functioning impairment is caused by these sexual urges or fantasies, or behavior

Specify if:

  • With fetishism
  • With autogynephilia - Sexual arousal by thoughts or images of self as a female

Specify if:

  • In a controlled environment(the individual is living in an institution etc)
  • In full remission (individual has not acted on these urges and has not resulted in distress over the last 5 years, while in an uncontrolled environment)

Other Specified Paraphilic Disorder

  • Significant distress/ socio-occupational functioning impairment is caused by the symptoms characteristic of a paraphilic disorder but does not completely fulfill the criteria of any of the categories in the Paraphilic Disorders

Unspecified Paraphilic Disorder

  • Used in the conditions where the clinician chooses not to mention the reason that the criteria are not fulfilled for a specific paraphilic disorder

Treatment

  • A treatment plan comprising of psychotherapy, and/or pharmacotherapy is usually needed to suppress the paraphiliac fantasies and behaviors.
  • The treatment depends on the severity of paraphiliac sexual fantasies as well as the risk of sexual violence. [25]
  • Very severe condition may lead to sexual offenses, like rape and it is necessary to manage such patients aggressively with hormonal intervention.[25]
  • The treatment regime consists of six levels with escalating degrees of medical intervention, based on the severity of the disorder.[26]

Pharmacotherapy

  • Three main classes of medications used in paraphilias are antidepressants, steroidal anti-androgens, and gonadotrophin-releasing hormone (GnRH) analogs.[19]
  • The comorbidities should be treated.
  • Treatment with antiandrogens may increase psychotic symptoms and depression risk.[3]

Antidepressants

  • These are used in paraphilias because of the following features- [19]
  1. Monoamine hypothesis
  2. Comorbidities
  3. Similarities with obsessive-compulsive spectrum disorders
  • Antidepressants commonly used are-
    • Selective Serotonin Reuptake Inhibitors(SSRI)- They act on 5-HT2 receptors and have become the standard of care. Additionally, SSRIs treat the comorbid conditions like depression, OCD or anxiety disorders.[26]
    • Tricyclic Antidepressants(TCA)

Hormones

  • Estrogen
  • Steroid antiandrogens
    • Medroxyprogesterone- It is a synthetic progesterone and acts by reducing the testosterone levels. They act by suppressing the hypothalamo-pituitary-gonadal axis, reducing the Luteinizing hormone(LH) release and further compromising the androgen production. [26][27]
    • Cyproterone acetate- It is a synthetic steroid, similar in structure to progesterone. It acts as an antiandrogen by binding to androgen receptors and reducing the cellular uptake of testosterone.[26]
    • Gonadotrophin Releasing Hormone Analogue (GnRH Analogue)- They reduce the circulating testosterone, in turn, reducing the aggression and hypersexuality.[26] [28]

Combined Pharmacotherapy and Psychotherapy

  • In subjects which are not at high risk of victimization, cognitive behavioral therapy(CBT) is the first-line treatment.
  • CBT addresses the cognitive distortions, along with empathy training, relapse prevention, sexual impulse control training, and biofeedback. [18]
  • The combination therapy has better response compared to either therapy used alone.[18]

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 Seligman, Linda; Hardenburg, Stephanie A. (2000). "Assessment and Treatment of Paraphilias". Journal of Counseling & Development. 78 (1): 107–113. doi:10.1002/j.1556-6676.2000.tb02567.x. ISSN 0748-9633.
  2. ↑ 2.0 2.1 2.2 2.3 Gordon, Harvey (2008). "The treatment of paraphilias: An historical perspective". Criminal Behaviour and Mental Health. 18 (2): 79–87. doi:10.1002/cbm.687. ISSN 0957-9664.
  3. ↑ 3.0 3.1 3.2 3.3 3.4 Garcia, Frederico D.; Thibaut, Florence (2011). "Current Concepts in the Pharmacotherapy of Paraphilias". Drugs. 71 (6): 771–790. doi:10.2165/11585490-000000000-00000. ISSN 0012-6667.
  4. ↑ Giami, Alain (2015). "Between DSM and ICD: Paraphilias and the Transformation of Sexual Norms". Archives of Sexual Behavior. 44 (5): 1127–1138. doi:10.1007/s10508-015-0549-6. ISSN 0004-0002.
  5. ↑ Bradford, John M.W.; Boulet, J.; Pawlak, A. (2017). "The Paraphilias: A Multiplicity of Deviant Behaviours*". The Canadian Journal of Psychiatry. 37 (2): 104–108. doi:10.1177/070674379203700206. ISSN 0706-7437.
  6. ↑ Moser, Charles; Kleinplatz, Peggy J. (2006). "DSM-IV-TRand the Paraphilias". Journal of Psychology & Human Sexuality. 17 (3–4): 91–109. doi:10.1300/J056v17n03_05. ISSN 0890-7064.
  7. ↑ Downing, Lisa (2015). "Heteronormativity and Repronormativity in Sexological "Perversion Theory" and the DSM-5's "Paraphilic Disorder" Diagnoses". Archives of Sexual Behavior. 44 (5): 1139–1145. doi:10.1007/s10508-015-0536-y. ISSN 0004-0002.
  8. ↑ Spitzer, Robert L. (2006). "Sexual and Gender Identity Disorders". Journal of Psychology & Human Sexuality. 17 (3–4): 111–116. doi:10.1300/J056v17n03_06. ISSN 0890-7064.
  9. ↑ Krueger RB, Kaplan MS (2012). "Paraphilic diagnoses in DSM-5". Isr J Psychiatry Relat Sci. 49 (4): 248–54. PMID 23585461.
  10. ↑ First MB (2014). "DSM-5 and paraphilic disorders". J Am Acad Psychiatry Law. 42 (2): 191–201. PMID 24986346.
  11. ↑ McManus, Michelle A.; Hargreaves, Paul; Rainbow, Lee; Alison, Laurence J. (2013). "Paraphilias: definition, diagnosis and treatment". F1000Prime Reports. 5. doi:10.12703/P5-36. ISSN 2051-7599.
  12. ↑ 12.0 12.1 12.2 Abdullahi, Halilu; Jafojo, Racheal Olayemi; Udofia, Owoidoho (2015). "Paraphilia Among Undergraduates in a Nigerian University". Sexual Addiction & Compulsivity. 22 (3): 249–257. doi:10.1080/10720162.2015.1057662. ISSN 1072-0162.
  13. ↑ 13.0 13.1 13.2 Kafka, Martin P. (1997). Archives of Sexual Behavior. 26 (4): 343–358. doi:10.1023/A:1024535201089. ISSN 0004-0002. Missing or empty |title= (help)
  14. ↑ Kafka, Martin P. (2006). "The Monoamine Hypothesis for the Pathophysiology of Paraphilic Disorders: An Update". Annals of the New York Academy of Sciences. 989 (1): 86–94. doi:10.1111/j.1749-6632.2003.tb07295.x. ISSN 0077-8923.
  15. ↑ Jordan, Kirsten; Fromberger, Peter; Stolpmann, Georg; Müller, Jürgen Leo (2011). "The Role of Testosterone in Sexuality and Paraphilia—A Neurobiological Approach. Part II: Testosterone and Paraphilia". The Journal of Sexual Medicine. 8 (11): 3008–3029. doi:10.1111/j.1743-6109.2011.02393.x. ISSN 1743-6095.
  16. ↑ Schneider, Jennifer P.; Irons, Richard (1996). "Differential diagnosis of addictive sexual disorders using the dsm-iv". Sexual Addiction & Compulsivity. 3 (1): 7–21. doi:10.1080/10720169608400096. ISSN 1072-0162.
  17. ↑ 17.0 17.1 Joyal, Christian C.; Carpentier, Julie (2016). "The Prevalence of Paraphilic Interests and Behaviors in the General Population: A Provincial Survey". The Journal of Sex Research. 54 (2): 161–171. doi:10.1080/00224499.2016.1139034. ISSN 0022-4499.
  18. ↑ 18.0 18.1 18.2 Hall, Ryan C.W.; Hall, Richard C.W. (2007). "A Profile of Pedophilia: Definition, Characteristics of Offenders, Recidivism, Treatment Outcomes, and Forensic Issues". Mayo Clinic Proceedings. 82 (4): 457–471. doi:10.4065/82.4.457. ISSN 0025-6196.
  19. ↑ 19.0 19.1 19.2 19.3 19.4 Abel, Gene G.; Osborn, Candice (1992). "The Paraphilias: The Extent and Nature of Sexually Deviant and Criminal Behavior". Psychiatric Clinics of North America. 15 (3): 675–687. doi:10.1016/S0193-953X(18)30231-4. ISSN 0193-953X.
  20. ↑ 20.0 20.1 Money, John; Pranzarone, Galdino F. (1993). "Development of Paraphilia in Childhood and Adolescence". Child and Adolescent Psychiatric Clinics of North America. 2 (3): 463–475. doi:10.1016/S1056-4993(18)30552-2. ISSN 1056-4993.
  21. ↑ Dawson, Samantha J.; Bannerman, Brittany A.; Lalumière, Martin L. (2014). "Paraphilic Interests". Sexual Abuse: A Journal of Research and Treatment. 28 (1): 20–45. doi:10.1177/1079063214525645. ISSN 1079-0632.
  22. ↑ Lee, Seung C.; Hanson, R. Karl; Calkins, Cynthia; Jeglic, Elizabeth (2019). "Paraphilia and Antisociality: Motivations for Sexual Offending May Differ for American Whites and Blacks". Sexual Abuse. 32 (3): 335–365. doi:10.1177/1079063219828779. ISSN 1079-0632.
  23. ↑ 23.0 23.1 Lee, Joseph K.P.; Jackson, Henry J.; Pattison, Pip; Ward, Tony (2002). "Developmental risk factors for sexual offending". Child Abuse & Neglect. 26 (1): 73–92. doi:10.1016/S0145-2134(01)00304-0. ISSN 0145-2134.
  24. ↑ Fisher, Alessandra D.; Castellini, Giovanni; Casale, Helen; Fanni, Egidia; Bandini, Elisa; Campone, Beatrice; Ferruccio, Naika; Maseroli, Elisa; Boddi, Valentina; Dèttore, Davide; Pizzocaro, Alessandro; Balercia, Giancarlo; Oppo, Alessandro; Ricca, Valdo; Maggi, Mario (2015). "Hypersexuality, Paraphilic Behaviors, and Gender Dysphoria in Individuals with Klinefelter's Syndrome". The Journal of Sexual Medicine. 12 (12): 2413–2424. doi:10.1111/jsm.13048. ISSN 1743-6095.
  25. ↑ 25.0 25.1 Thibaut, Florence (2015). "Paraphilias": 1–5. doi:10.1002/9781118625392.wbecp242.
  26. ↑ 26.0 26.1 26.2 26.3 26.4 Holoyda BJ, Kellaher DC (2016). "The Biological Treatment of Paraphilic Disorders: an Updated Review". Curr Psychiatry Rep. 18 (2): 19. doi:10.1007/s11920-015-0649-y. PMID 26800994.
  27. ↑ Radkani P, Joshi D, Barot T, Williams R (2018). "Robotic video-assisted thoracoscopy: minimally invasive approach for management of mediastinal tumors". J Robot Surg. 12 (1): 75–79. doi:10.1007/s11701-017-0692-2. PMID 28337576.
  28. ↑ Czerny JP, Briken P, Berner W (2002). "Antihormonal treatment of paraphilic patients in German forensic psychiatric clinics". Eur Psychiatry. 17 (2): 104–6. doi:10.1016/s0924-9338(02)00635-1. PMID 11973119.
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