among males with paraphilias according to dsm - iv and paraphilia - related disorders , mood disorders have been found to be the most frequent comorbid axis i diagnosis , with a lifetime prevalence of 71.6% . this has important implications for treatment strategies , as antidepressant medication , mainly selective serotonin reuptake inhibitors ( ssris ) , can be effective for both disorders . the most effective treatment options for paraphilia - related disorders are considered to be cognitive - behavioral therapy ( cbt ) , antiandrogen drugs or antidepressant medication , while the combination of pharmacotherapy and psychosocial interventions are suggested . however , patients from low income groups and especially in less developed countries have less access to effective treatment . much more important than the mere treatment synergy is the fact that the paraphilia will remain untreated until the patient seeks treatment for the comorbid disorder . in countries where sexually related disorders are highly stigmatized and sometimes underlie severe repression , the comorbid disorder can allow the patient to access treatment , which can then be expanded to the treatment of the sexual disorder . a 53-year old man came to an introductory meeting at a center for psychotherapy for low income persons ( paat : psicoterapia al alcance de todos ) in cuernavaca , mexico . he described feelings of distress that had been present for about two years with an increasing tendency in the last year . the main complaint was a depressive mood , accompanied by extensive sleep disorders , problems with concentration and thinking , as well as increased anxiety . besides reducing his feelings of well - being , the symptoms had led to an overall decrease in the level of social functioning , resulting in a sharp decrease of productivity at work . the key event leading to his decision to seek help was a panic attack with intense anxiety , tachycardia and chest pain , leading to a one - night hospitalization . due to the extent of symptoms , the patient was prescribed an antidepressant ( sertraline 100 mg / d ) in combination with weekly psychotherapy sessions . it was not until the third session that the man found enough confidence in the therapeutic relationship to be able to disclose his sexual preferences . already at an early age of ten years he had found pleasure in having objects inserted in his anus . his first such experience resulted in a playful interaction with a sexually aroused dog , which had mounted him while he was kneeling . the pleasure from the sexual act of the dog resulted in the man seeking similar actions also with other dogs . as the dogs were not always sexually aroused , he started inserting other objects , such as bottles , into his anus . it was not until the age of 19 , after hearing of public restrooms where men sought sex with other men , that he first had sexual contacts with other men . these visits continued irregularly over the years , mainly due to fears of having these tendencies become known to his social surroundings . on the other hand , he regularly sought pleasure using dildos or other objects . parallel to the sexual inclination , the man had an apparently normal sexual development , with girlfriends from the age of 16 and first sexual intercourse with a woman at the age of 19 . he got married at the age of 25 to a 22-year old woman who he had fallen in love with . they had fairly regular sexual intercourse ( about weekly in the first few years , decreasing slowly over the years to about monthly ) until three years prior to the man 's onset of depressive symptoms . at this point , since he did not want to pressure his wife to have sex with him , he increased his paraphilic masturbation activity as well as his visits to restrooms to receive anal intercourse . as it became more and more difficult to keep this activity hidden from his wife , he decided to disclose some of his inclinations to her , telling her about the pleasure he derived from inserting dildos and about what he believed was a  homosexual  inclination . he was surprised to receive full support from his wife , who apparently was relieved that she did not have to play the role of a sexual object . this support led to an initial euphoria and tension relief for the man who could pursue his inclinations without worrying about his wife . however , the initial tension relief soon turned into the above mentioned depressive mood and anxiety . parallel to his mental state , he started worrying about his work : the man 's sexual activity increased gradually and started to become a factor impeding his work . he described a daily compulsive craving for sexual pleasure , resulting in sexual activity several times a day . the symptoms of anxiety that followed further decreased his productivity , leading to a sharp decrease in income and in turn additional emotional strain . the man understood his sexual inclination to be a sign that he was really a homosexual . mexico is a country where homosexuality is greatly stigmatized to the extent that the governing party ( pan ) has even tried to pass state legislation to prohibit homosexuality . therefore his belief of being a homosexual , while at the same time not having feelings of love toward a man , created further ambivalence and insecurity . in line with psychotherapeutic work with low income groups , one key aspect was to focus on his understanding of his sexuality , mainly that he was really a heterosexual , while explaining the mechanism of his concomitant paraphilic sexual inclination . along with this , it was important for him to verbalize his desire to have a renewed sexual relationship with his wife , which had been sublimed by him for now several years . coupled with the antidepressive effect of the drug , the man 's symptoms decreased gradually , while the craving for sexual pleasure also decreased . follow - up meetings at three , six and 12 months after the end of the 12-session psychotherapy showed continued , but much less intense , symptomatology of the paraphilia , but no more signs of clinical depression . treatment was sought by the patient due to the depressive disorder which had developed over the previous three years . due to a good therapeutic relationship , the patient was able to open up and convey his problems related to his sexuality . considering the limited financial resources , the combination of pharmacotherapy and a short - term psychotherapeutic intervention can be considered an adequate treatment regime , close to standards suggested in the literature . the patient 's fear of being homosexual reflects the high stigmatization of homosexuality in mexican society , which prevents an open discussion on this topic . nonetheless , in a country where homosexuality is highly stigmatized , self - disclosure of homosexuality may be protracted and could present itself through abnormal sexual activity . however , this could not be confirmed in the above case , as no homosexual inclinations remained after treatment . the case shows the importance of treating comorbid disorders in order to even be able to address sexual disorders .
the comorbidity of paraphilia - related disorders and other psychiatric disorders is high , but the paraphilia - related disorder often remains untreated until patients seek help for the comorbid disorder . a case of a patient in mexico with comorbid paraphilia and depressive disorder , who was effectively treated with antidepressive medication and psychotherapy , 
 is reported . 
 the effect of stigmatization of homosexuality on the access to care of persons with sexual disorders is discussed .