Paraphilic disorders

The Diagnostic and Statistical Manual fifth edition (DSM-5) definition of paraphilia as “any intense and persistent sexual interest other than sexual interest in genital stimulation or preparatory fondling with phenotypically normal, physically mature, consenting human partners” ¹. In some circumstances, the criteria “intense and persistent” may be difficult to apply, such as in the assessment of persons who are very old or medically ill and who may not have “intense” sexual interests of any kind. In such circumstances, the term paraphilia may be defined as any sexual interest greater than or equal to normophilic sexual interests ¹. There are also specific paraphilias that are generally better described as preferential sexual interests than as intense sexual interests.

A paraphilic disorder is a paraphilia that is currently causing distress or impairment to the individual or a paraphilia whose satisfaction has entailed personal harm, or risk of harm, to others. A paraphilia is a necessary but not a sufficient condition for having a paraphilic disorder, and a paraphilia by itself does not necessarily justify or require clinical intervention.

Paraphilic disorders included in DSM-5 are voyeuristic disorder (spying on others in private activities), exhibitionistic disorder (exposing the genitals), frotteuristic disorder (touching or rubbing against a nonconsenting individual), sexual masochism disorder (undergoing humiliation, bondage, or suffering), sexual sadism disorder (inflicting humiliation, bondage, or suffering), pedophilic disorder (sexual focus on children), fetishistic disorder (using nonliving objects or having a highly specific focus on nongenital body parts), and transvestic disorder (engaging in sexually arousing cross-dressing) ¹. It has been estimated that some 50 paraphilias have been identified and described in the literature. Pedophilia, voyeurism, and exhibitionism are the most commonly observed behaviors in clinics that specialize in paraphilia treatment; sexual masochism and sadism are much less common. About 50% of patients observed in clinics for treatment of paraphilias are married.

The World Health Organization International Classification of Diseases and Related Health Problems (ICD-10), the paraphilias are classified as disorders of sexual preference ². Six specific disorders are listed: fetishism, fetishistic transvestism, exhibitionism, voyeurism, pedophilia and sadomasochism. Three further categories denote ‘multiple disorders of sexual preference’, ‘other disorders of sexual preference’ and ‘disorder of sexual preference, unspecified’.

According to DSM-5, the frequency of voyeuristic disorder is unknown, but the estimated highest possible lifetime prevalence is approximately 12% for males and 4% for females ¹. The frequency of exhibitionistic disorder is also unknown, but the highest possible prevalence in males is 2-4%; prevalence in females less certain but is generally believed to be much lower than that in males.

Frotteuristic disorder, including uninvited sexual touching of or rubbing against another individual, may occur in as many as 30% of adult males in the general population; 10-14% of adult males seen in the outpatient setting for paraphilic disorder and hypersexuality meet the diagnostic criteria.

The frequency of sexual masochism disorder is unknown. In Australia, 2.2% of males and 1.3% of females were estimated to have been involved in bondage, sadomasochism, or dominance and submission in the preceding 12 months. The frequency of sexual sadism disorder is also unknown but has been estimated to range from 2% to 30%, depending on the criteria used. Among sex offenders in the US, fewer than 10% have sexual sadism disorder; however, 37-75% of those who have committed sexually motivated homicides have this disorder.

The frequency of pedophilic disorder is unknown as well. The highest possible prevalence among males is estimated to be 3-5%; the prevalence in females is thought to be a small fraction of that in males.

International incidences of paraphilias are difficult to determine.

It is not rare for an individual to manifest two or more paraphilias. In some cases, the paraphilic foci are closely related and the connection between the paraphilias is intuitively comprehensible (e.g., foot fetishism and shoe fetishism). In other cases, the connection between the paraphilias is not obvious, and the presence of multiple paraphilias may be coincidental or else related to some generalized vulnerability to anomalies of psychosexual development. In any event, comorbid diagnoses of separate paraphilic disorders may be warranted if more than one paraphilia is causing suffering to the individual or harm to others.

A distinctive feature of paraphilic disorders is that they are diagnosed largely in forensic settings ³. Paraphilic disorders are related to criminal activity to varying degrees, depending on the particular disorder. For example, acting on pedophilic sexual arousal results in criminal sexual activity with children, whereas fetishistic sexual arousal may result in sexual behavior between consenting adults. However, fetishism may also involve criminal activity; for example, stealing feminine articles of clothing.

Treatment options vary and must take into account the specific needs of each individual case. The following options are available:

Psychotherapy
Pharmacologic therapy
Surgical interventions (not widely used)

Psychotherapeutic interventions include the following:

Cognitive-behavioral therapy
Orgasmic reconditioning
Social skills training
Twelve-step programs
Group therapy
Individual expressive-supportive psychotherapy

Pharmacologic interventions may be used to suppress sexual behavior. Medications that may be considered in the treatment of paraphilic disorders include the following:

Antidepressants (eg, selective serotonin reuptake inhibitors [SSRIs])
Long-acting gonadotropin-releasing hormones
Antiandrogens
Phenothiazines
Mood stabilizers

Numerous adverse effects of pharmacotherapy have been reported. Additionally, ethical, medical, and legal questions have been raised regarding issues of informed consent, especially in hospital and prison settings.

Surgical interventions that may be considered (though not widely used) are as follows:

Psychosurgery using stereotaxic tractotomy and limbic leucotomy
Bilateral orchidectomy (surgical castration)

Paraphilic disorders causes

The cause of paraphilias is unclear. Many theories exist regarding the etiology of paraphilias, including psychoanalytical, behavioral, biologic, and sociobiologic theories. To date, however, none have proved conclusive; additional research is required. Early theorists postulated that paraphilias, as well as other psychiatric conditions such as feeble mindedness, were part and parcel of brain degeneracy, a significant cause of which was overtaxing the nervous system by such phenomena as masturbation, or “nocturnal pollutions.” Degeneracy went hand in glove with “hereditary taint,” which was thought to accumulate through the generations. Although mechanisms were not clearly elucidated, exposure to excessive sexual stimulation outside socially sanctioned heterosexual marriage was believed to put individuals at risk for sexual deviations. Why such deviations developed in some individuals and not others was explained by the postulate that less tainted individuals were at less risk than more degenerate individuals for sexual perversions.

Moreover, such excessive stimulation need not always be intentional. For example, one theory enjoying some degree of acceptance in early psychoanalytic circles was that infants born to hereditarily tainted mothers were predisposed to develop a fur fetish by coming into contact with their mother’s pubic hair during birth (W. B. Pomeroy, personal communication; 1982). While such explanations seem naive today, the notion that the development and maintenance of paraphilias must be a combination of genetic susceptibility and environmental trauma persists. In reality, we still know very little about the genesis of paraphilias.

The data that have been collected, however, do support at least 1 biological marker for vulnerability: men account for the vast majority of paraphilias. Among the paraphilias specifically delineated by DSM-4, paraphilias are much more infrequently diagnosed in women than in men. Except for sexual masochism, which is still about 20 times less likely to affect men than women, paraphilias are quite unlikely to be diagnosed in women.

Paraphilias, or at least conditions that look very much like paraphilias, have also been reported as the result of brain trauma, neoplasms, temporal lobe damage, or epilepsy and may manifest as hyposexuality or hypersexuality, particularly in men. Lehne8 described a case of a frontal lobe injury in a man who suddenly developed a paraphilic interest in his stepdaughter’s breasts. Treatment with conventional methods, including anticonvulsant administration, cognitive-behavioral therapy, and individual/family therapy failed to address his illness adequately but antiandrogens brought his symptoms under control.

Paraphilic disorder symptoms

Many different paraphilias have been identified, but the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), lists the following 8 specific paraphilic disorders ¹:

Voyeuristic disorder (spying on others engaged in private activities).
Exhibitionistic disorder (exposing the genitals) (including type 1, the inhibited flaccid exposer, and type 2, the sociopathic exposer who may have a history of other conduct)
Frotteuristic disorder (touching or rubbing against a non-consenting individual)
Sexual masochism disorder (undergoing humiliation, bondage or suffering)
Sexual sadism disorder (inflicting humiliation, bondage or suffering)
Pedophilic disorder (sexual focus on children)
Fetishistic disorder (using non-living objects or having a highly specific focus on non-genital body parts)
Transvestic disorder (engaging in sexually arousing cross-dressing)

Other paraphilias, almost any of which could develop into a paraphilic disorder in certain circumstances, include (but are not limited to) the following ⁴:

Scatalogia (obscene phone calls)
Necrophilia (corpses)
Partialism
Zoophilia (animals)
Coprophilia (feces)
Klismaphilia (enemas)
Urophilia (urine)
Autogynephilia
Asphyxiophilia or hypoxyphilia
Video voyeurism
Infantophilia (a newer subcategory of pedophilia)

In addition to a complete history, complete mental status, physical, and neurologic examinations must be performed to assist with the evaluation and to rule out other disease processes. Ruling out major medical or psychiatric illnesses is critical for diagnosis and management.

Voyeuristic disorder

The term voyeurism refers to the fairly common desire to view nudity and acts of coition. Differentiating innocent enjoyment of nudity from behavior that is similar but deviant in other circumstances can be difficult. When voyeuristic disorder is severe, peeping is the exclusive form of sexual activity. Onset is usually before age 15 years, and the disorder tends to be chronic. The wide extent of voyeuristic tendencies in the general population is evidenced by the common desire to indulge in exploitative activities such as live sex shows and pornography.

Exhibitionistic disorder

Exhibitionists commonly present to physicians, probably out of a sense of guilt about their behavior and alarm about their inability to control it. Sometimes the behavior is revealed as the result of a criminal offense. More serious underlying pathology is suggested when preferred scenes include defecation or small children.

The onset of exhibitionistic disorder is usually before age 18 years but may occur later. About half of adult women have witnessed indecent exposure at some point in their lives. By definition, the disorder causes significant stress or impairment in social, occupational, or other important areas of functioning. In 1975, Rooth classified exhibitionism into the following 2 types ⁵:

Type 1 – The inhibited flaccid exposer
Type 2 – The sociopathic exposer who may have a history of other conduct

After the act of self-exposure, there is generally no attempt at further sexual activity with the stranger, though the exhibitionist may feel a desire to shock the stranger or may entertain a fantasy that the observer will become sexually aroused.

Genital exhibitionism is primarily a male behavior and is rare among women. This has been explained by the differences between the sexes in the development of the castration complex and by the absence of a reassuring effect from showing a penis because of anatomic differences in women. Eber ⁶ and Kohut ⁷ have viewed female exhibitionism as a disorder of bodily narcissism.

Male exhibitionists, whether timid or brash, typically feel dominated by women and resent it. By exposing themselves, they attempt to turn the table on women, dominating rather than being dominated. Exhibitionists view this act as making women their helpless victims, rather than being helpless before them. Some researchers have suggested that exhibitionists have a fragile sense of masculinity. Threats to this fragile masculinity are countered by demonstrations of manliness.

Men with exhibitionistic disorder find it difficult to relate to women as whole people. Rather, they look on women merely as means of providing gratification and proof against castration. Many exhibitionists are very prudish with their wives. They go to great lengths never to look at their wives or to be seen by them in the nude. Intercourse tends to be rigid and conventional.

Common to all exhibitionists is some abnormality in the handling of aggression and hostility. On one hand, they must keep their anger under tight control, yet on the other, they may become tyrannical with their family because they feel safe from retaliation.

In some individuals, male genital exhibitionism is an indicator of future sexual offenses. In a 1980 longitudinal study, Bluglass ⁸ found that 7% of exhibitionists were later convicted of contact sexual offenses, including rape.

Frotteuristic disorder

In an act of frotteurism (frottage), the (usually male) offender typically rubs his genital area against the (usually female) victim’s thighs or buttocks or fondles a woman’s genitalia or breasts with his hands. While committing the act, the frotteur typically fantasizes about an exclusive, caring relationship with the victim. The frottage typically takes place in crowded places (eg, public transportation vehicles and busy sidewalks); such locations allow relatively easy escape, and the frotteur, if confronted, can claim that the touching was accidental.

Most acts are perpetrated by people aged 15-25 years; after age 25 years, frequency gradually declines. Frotteurism has been noted to be equally common among older, shy, inhibited individuals. Fantasies of frotteuristic behavior without action have been reported as a stimulant to sexual arousal.

Sexual masochism disorder

Masochistic acts commonly involve a wide range of activities, such as restraint, blindfolding, beating, electrical shock, cutting, piercing, and humiliation (eg, being urinated or defecated on, forced to bark, verbally abused, or forced to cross-dress). Some sexual masochists inflict pain through self-mutilation, and some engage in group activity or use services provided by prostitutes.

Hypoxyphilia is a dangerous form of masochism that involves sexual arousal by oxygen deprivation achieved by means of chest compression, noose, ligature, plastic bag, mask, or chemicals. Oxygen deprivation may be accomplished either alone or with a partner. Data from the United States, England, Australia, and Canada indicate that 1-2 deaths per million population as a result of this practice are reported each year.

Some sexually masochistic males also exhibit fetishism, transvestic fetishism, or sexual sadism. Masochistic sexual fantasies are likely present in childhood. Masochistic activities commonly begin by early adulthood, tend to be chronic, and generally involve repetition of the same act. Some individuals increase the severity of the act over time, and this increasing severity may lead to injury or death.

Ritualized behavior is a noted feature of masochistic scenes; the slightest deviation from the script may result in failure to achieve the desired result. This feature is also viewed as a mechanism through which the masochist maintains control.

Sexual sadism disorder

Sadistic fantasies or acts may involve activities such as dominance, restraint, blindfolding, beating, pinching, burning, electrical shock, rape, cutting, stabbing, strangulation, torture, mutilation, and killing. Sadistic sexual fantasies are likely present in childhood. Onset of sadistic activities commonly occurs by early adulthood, and the sadistic behavior tends to be chronic.

Although some individuals with sexual sadism disorder do not increase the severity of their acts over time, most do. When practiced with nonconsenting partners, the activity is likely to be repeated until the perpetrator is apprehended. When sexual sadism is severe and associated with antisocial personality disorder, victims may be seriously injured or killed.

No clear lines divide sexual sadism from sexual masochism, and the predispositions are often interchangeable. The conditions may coexist in the same individual, sometimes in association with other paraphilias. This relation is supported by the finding that those who entertain masochistic fantasies also engage in sadistic fantasies. Some psychoanalytic theorists, however, maintain that the conditions do not coexist in an individual and that the dynamics are different.

Pedophilic disorder

Female pedophiles are considered to be rare. To some extent, however, the discrepancies between the numbers of male and female offenders may be affected by sexual stereotypes. Masculinity is commonly perceived as connoting sexual qualities, femininity as connoting maternal qualities and nurturance. When a female pets a child, she may be more likely to be seen as nurturing, whereas when a male pets a child, he may be more likely to be seen as molesting.

The majority of men who had sexual contact with a woman when they were boys viewed it positively rather than negatively; consequently, many or most such episodes probably went unreported. In one study, 16% of college males and 46% of prisoners reported having had sexual contact with older females, and half of the encounters involved intercourse. The mean age of the males at the time of sexual contact was 12 years, and the females with whom they were involved were aged 20-30 years.

Many pedophiles have a personal history of unstable parent-child relationships as children, sometimes accompanied by sexual abuse. One study demonstrates early neurocognitive disturbances in the history of those with pedophilia ⁹. The majority of pedophiles have a clear sexual preference. The undifferentiated or bisexual group accounts for only 5-25% of pedophiles. Most studies indicate that 60-90% of incidents of abuse involve girls.

Great variation exists among men who use children sexually. One third to one half prefer children as sexual partners. Others are attracted to children but act on their impulses only under stress. Some (typically younger than 30 years) are sociosexually underdeveloped, lack age-appropriate experience, and have feelings of shyness and inferiority; unable to attain adult female contact, they continue prepubescent sexual patterns.

Amoral delinquent youths (ie, individuals younger than 16 years, which is the cutoff point for pedophilic disorder), lacking control when aroused, use whoever is close at hand. Patients with the situational type of pedophilia have no special preference for children; their sexual contact with children is the result of convenience or coincidence, and contact typically is brief and nonrecurrent. A residual category of offenders includes people with mental retardation, psychosis, alcoholism, senility, or dementia.

Approximately 37% of sexual assault victims reported to law enforcement agencies were juveniles (< 18 years); 34% of all victims were younger than 12 years. One in 7 victims is younger than 6 years. Forty percent of offenders who victimized children younger than 6 years were juveniles (< 18 years).

Fetishistic disorder

Common fetishistic objects include the following:

Female underwear
Rubber, plastic, or leather garments
Specific articles of clothing, such as shoes or boots
Bodily items, such as hair, odors, or feces

The prevalence of fetishistic disorder is unknown. Fetishism can often be traced from adolescence and usually persists.

In the context of psychoanalytic theory, Greenacre associated fetishism with a severe castration complex in males and a more complicated and less readily recognized set of relational reactions in females ¹⁰. For men, the fetish serves a defensive function, a reinforcing adjunct for a penis of uncertain potency. The fetish serves to increase the efficiency of the penis, which does not perform well without it.

In women, fetishism is less common, largely because of anatomic differences that allow females to conceal inadequate sexual response more readily than males can. Women can develop symptoms more comparable to male fetishism when the illusion of having a phallus has gained sufficient strength to approach delusional proportions; this occurs in rare cases where the woman’s sense of reality is severely disturbed.

Treatment of the specific condition (fetish) rather than the primary underlying disorder (eg, organic pathology or personality disorder) is generally unsuccessful. A variety of treatment approaches have been tried, such as aversive conditioning, cognitive therapy, and psychotherapy.

Transvestic disorder

Typically, individuals with transvestic disorder derive sexual gratification from wearing clothes usually worn by the opposite sex. Most people with this disorder are heterosexual married men. Fetishistic transvestism is essentially unheard of in females. Women may cross-dress, but no cross-dressing females who become sexually excited by the activity have been described in the English-language literature.

Other paraphilias and paraphilic disorders

In addition to the conditions described above, dozens of other paraphilias have been described, almost any of which could develop into a paraphilic disorder if it carries the requisite negative consequences for the individual or for others. In the American Psychiatric Association’s Diagnostic and Statistical Manual, Fifth Edition (DSM-5) ¹¹, these paraphilias may be specified within the category “other specified paraphilic disorder” when the individual does not meet the full criteria for 1 of the 8 listed paraphilic disorders and the examiner elects to provide a specific reason why not. There is also a category for “unspecified paraphilic disorder,” for use if the examiner does not provide a specific reason or of there is insufficient information for a more specific diagnosis.

Such paraphilias include (but are not limited to) the following:

Telephone scatologia – The making of obscene phone calls
Necrophilia – An erotic attraction or sexual interest in corpses (rare and seldom reported to the police); patients typically work in mortuaries and funeral parlors; there exists a danger that the individual might actually acquire infections from the corpse
Partialism – Sexual interest exclusively focused on a particular body part
Zoophilia – Sexual activity with animals (ie, both actual sexual contact and sexual fantasies)
Coprophilia – Sexual activity involving feces
Klismaphilia – Sexual activity involving enemas
Urophilia – Sexual activity involving urine
Autogynephilia – A man’s propensity to be sexually aroused by thoughts or images of himself as a woman (with female attributes)
Asphyxiophilia or hypoxyphilia – The use of hypoxia to achieve sexual excitement; this can be complicated by autoerotic asphyxiation
Video voyeurism – The derivation of sexual gratification from videos, usually of women doing natural acts or involved in sexual activity
Infantophilia – A newer subcategory of pedophilia, in which the victims are younger than 5 years

Paraphilic disorders diagnosis

Paraphilic disorders must be distinguished from non-pathologic use of sexual fantasies, behaviors, or objects as stimuli for sexual excitement.

Multiprofessional assessment may be helpful, particularly when paraphilias result in criminal behavior. Assessment should include full standardized neuropsychological testing, behavioral analysis, physiologic measurements, and risk assessment (for future offenses). Medical health (including brain health), attitude toward the offense and the victim, social stressors, substance abuse, and treatment recommendations must be assessed. Sexual arousal should be considered; correlations are found between self-reports and genital measurements ¹².

One theory suggests that both hard and soft neurologic signs involving the striato-thalamo-cortical processing loop should be sought. According to this theory, disruption of the striato-thalamo-cortical processing loop can cause abnormal filtering of information, which hinders the brain’s ability to block unimportant information, thereby potentially helping to initiate or perpetuate paraphilias and other phenomena. At present, this possibility remains theoretical; much more research will be needed to confirm or disprove it as a cause of paraphilias.

Studies that may be considered in the assessment of a patient with a paraphilic disorder include the following:

Standard medical workup, including sequential multiple analysis, complete blood count, rapid plasma reagent, and thyroid-stimulating hormone level or thyroid function test
HIV screen
Hepatitis panel
Unscheduled DNA synthesis
Computed tomography (CT)
Magnetic resonance imaging (MRI)
Penile strain gauge
Abel assessment for interest in paraphilia
Phallometric testing
Electroencephalography (EEG)

Paraphilic disorders diagnostic criteria DSM-5

Generally, for each of the specific paraphilic disorders listed in DSM-5, the first diagnostic criterion specifies the qualitative nature of the paraphilia (eg, an erotic focus on children or on exposing the genitals to strangers), whereas the second criterion specifies the negative consequences of the paraphilia (see below). Both criteria must be satisfied to establish a diagnosis of a paraphilic disorder. An individual who meets the first criterion but not the second is considered to have a paraphilia but not a paraphilic disorder.