A mental health evaluation can identify and help diagnose paraphilias. This evaluation may be conducted by a mental health professional and may include a history of the patient’s sexual thoughts, behaviors and consequences. A physical examination may also be conducted in order to rule out any physical conditions or disorders that may be associated with the behavior.

In order to be diagnosed with a paraphilia, patients must meet the following criteria established by the American Psychiatric Association (APA):

• Recurring and intense sexual fantasies, urges or behaviors that occur for at least six months.
  
  
• Patient has acted on the urges, or has suffered significant distress or difficulties with relationships or jobs as a result of the urges.

To be diagnosed with pedophilia, the patient must be at least 16 years old and at least five years older than the child involved (who is generally 13 or younger). Sexual activity between older teens and younger teens is not usually considered pedophilia. Criminal criteria for pedophilia may differ from the diagnostic criteria.

For a diagnosis of fetishism, the focus of sexual arousal must not be an element of cross-dressing (in which case, transvestic fetishism might be diagnosed) or be used to physically stimulate the genitals (e.g., a vibrator).

Despite report of paraphilic thoughts or behavior, certain paraphilias may remain undiagnosed. Some mental health professionals may be hesitant to label as a mental disorder sexual behavior that involves consenting adults or is not believed to cause harm to others (e.g., sexual masochism, fetishism).

On rare occasions, unusual sexual activity may occur in patients with mental retardation, dementia, schizophrenia or substance abuse. It may also occur during a manic episode. In order to rule out paraphilias, the behavior needs to be identified as:

• Not the preferred or necessary method of sexual arousal
  
• Occurring only during the course of the existing condition
  
• An isolated incident (rather than chronic)
  
• Beginning in adulthood (rather than adolescence)