Seventeen-year-old male, youngest of four siblings, staying with parents and three elder sisters, was brought by mother for behavioural disturbances and anger outbursts.
Since 3 years, he stole sisters' undergarments and used them for masturbation. This was recurrent and persistent despite warning by parents. He had started using these clothes out of curiosity, but later got arousal and gratification only on using the inner garments for genital stimulation. He sometimes dressed up in the inner garments during masturbation but it was not necessary for arousal. Other paraphilic behaviours like attempts to rub his genitals against the sister while she was asleep, watching females taking bath, exhibitionistic behaviour were also present. Gender identity was male and had sexual fantasies towards females. He denied fantasizing himself as a female during these episodes nor desire to become female.
Anger and aggressive behaviour over family members when confronted for such behaviour was present.
Patient's scholastic performance was poor since childhood and further deteriorated since 7th grade. Since 1 year, there were complaints from school that patient misbehaved with girls and tried to touch them inappropriately.
Physical examination was unremarkable. Secondary sexual characteristics were well-developed. Intelligence quotient (IQ) assessment revealed mild mental retardation (IQ-57). Ultrasonography (USG) abdomen ruled out any adrenal pathology.
Patient was diagnosed as mild MR with paraphilia and started on sodium valporate at 20 mg/kg in view of behavioural disturbances. Psychoeducation about appropriate sexual behaviour was done. At 12 weeks, family reported mild improvement in anger and no further episodes of paraphilic behaviour.