MFT Practice: Paraphilic Disorders

By Robin Gluck on April 28, 2021


This month’s blog focuses on a lesser known diagnostic category, which could appear on both the California MFT Clinical or AMFTRB exams; paraphilic disorders. While these disorders may not be seen frequently in clinical practice, they can show up on the exam.

The 8 types of paraphilic disorders in the DSM 5 are: 

  1. Voyeuristic: watching unsuspecting people who are naked, undressing, or engaging in sexual activities
  2. Exhibitionistic: exposing genitalia to unsuspecting people
  3. Frotteuristic: touching or rubbing non-consenting people
  4. Sexual masochism: engaging in acts meant to cause self pain or suffering
  5. Sexual sadism: engaging in acts that cause another person pain or suffering
  6. Pedophillic: attraction to prepubescent children
  7. Fetishistic: interest in non-living objects or non-genital parts
  8. Transvestic: engaging in cross-dressing

One of the most important differentials to consider with this diagnostic group is separating out paraphilias from paraphilic disorders. This distinction is new to the DSM 5, and I would say is a big step forward in depathologizing atypical sexual behaviors. 


So what is the difference between paraphilias and paraphilic disorders? 

Paraphilias are defined as atypical patterns of sexual attraction or sexual arousal in response to atypical stimuli. 

In contrast, paraphilic disorders are diagnosed when paraphilias cause personal distress or impairment to the individual’s function or cause harm to others. 

On the exam, you could see questions that test your ability to:

  1. Identify differential diagnoses
  2. Determine appropriate adjunctive services
  3. Navigate potential legal or ethical issues
  4. Develop a treatment plan
  5. Identify appropriate interventions


Let’s see how well you can navigate the topic of paraphilic disorders with a practice question. 

Practice Question on paraphilic disorders:

A therapist working in county mental health meets with a 19-year-old male who cross-dresses. The client tells the therapist that he estranged from his family. He states, "they do not understand or accept my lifestyle.”  In addition, he shares that a week ago, he was physically and verbally assaulted by a group of teenage boys. The therapist observes bruising all over his body that were caused by one of the teens hitting him with a wooden bat. He tells the therapist that he is proud of who he is and how he presents to the world. However, the lack of familial support and the recent incident have left him feeling depressed, frequently on edge, and scared to leave his apartment. How should the therapist clinically evaluate the therapeutic needs of this client?


A. Refer the client to a psychiatrist for medication evaluation to treat transvestic disorder; Explore client’s desire to reconnect with family; Assess client’s risk of future victimization

B. Refer the client for a medical evaluation; Explore client’s access to non-familial support systems; Assess for additional symptoms of acute stress disorder

C. Refer the client for a medical evaluation; Explore the level of psychological distress caused by their lifestyle choices; Explore client’s knowledge of and interest in adjunctive resources for the LGBTQ population

D. Refer the client to a psychiatrist for medication evaluation to treat transvestic disorder; Explore client’s access to non-familial support systems; Assess client’s risk of future victimization


(Scroll down for answer and rationale…)























The correct answer is B. 


We want to make sure the answer selected does not harmfully pathologize a person who cross-dresses. The client clearly states in the vignette that they are comfortable and proud of who they are, thus we can eliminate any answer that includes treatment of a paraphilic disorder (answers A and D). 


Answer C includes, Explore the level of psychological distress caused by their lifestyle choices, which can also be seen as pathologizing or blaming the client for problems outside of his control. In addition, we do not know anything about the client’s sexual orientation, only his cross-dressing. Therefore, resources for LGBTQ may or may not be appropriate. In fact, providing this resource could point to incorrect stereotyping of cross-dressing individuals. 


Answer B directly addresses everything noted in the vignette. A medical evaluation to assess for possible complications due to the bruising would be important. Exploring the presence or absence of support systems would be important since he is estranged from his family. In addition, the symptoms he describes and the timeline included point to acute stress disorder. Therefore, we would want to further assess for acute stress disorder to guide the treatment plan. 


How did you do on this month's question on paraphilic disorders? Are you ready to tackle these types of questions on your exam? Regardless of your answer to this question, TDC’s MFT California Clinical Exam prep and AMFTRB program covers all you need to know and provides you with practice questions to help you prepare. TDC’s MFT California Clinical and AMFTRB exam prep programs give you everything you need to be successful on the exam, without overwhelming you with content you don’t need. We’ve helped THOUSANDS of MFTs PASS their exams with confidence over the past decade. Our team looks forward to helping you PASS with confidence!



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