Sexual dysfunction and paraphilias — structured clinical viva

Father — ED and nitrates. Sildenafil has strong efficacy evidence for ED but is contraindicated with concurrent nitrates because of severe hypotension risk. Do not prescribe PDE5 inhibitors while he remains on isosorbide mononitrate. Coordinate with cardiology/GP on anti-anginal regimen suitability before any PDE5 trial; address diabetes, vascular risk, alcohol, and relationship factors. Psychogenic-only assumptions are unsafe in a diabetic midlife man.^[1]

Partner — paroxetine anorgasmia. Classic serotonergic sexual side-effect. Options: validate, consider dose timing/adjustment if panic/depression allows, switch to a relatively lower-risk antidepressant, or specialist strategies. Separate panic efficacy from sexual tolerability in shared decision-making.^[2][6]

Son — pedophilic interest disclosure. Ego-dystonic interest in prepubescent children with help-seeking is clinically serious. Pedophilic disorder requires the interest plus acted urges with children and/or marked distress/interpersonal difficulty — distress is present; offence status needs careful assessment (including online material). Interest ≠ inevitable offending (motivation–facilitation model), but risk assessment and child-protection duties dominate. “Chemical castration” online is not a DIY plan: antiandrogen/GnRH pathways are specialist, consent-based, monitored (WFSBP), and never replace reporting duties or psychological risk work if indicated. Arrange urgent psychiatric/forensic assessment; do not ignore an email disclosure.^[3][4][5]