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Paraphilias

Paraphilias are unusual or inappropriate sexual attractions (from para meaning outside or unusual and philia meaning an attraction or interest). The category includes fetishes (obsession with inani­mate objects, such as shoes or under­clothing), exhibitionism, transvestitism, voyeurism, zoophilia (sexual activity with animals), masochism and sadism and a variety of other interests such as arousal by feces or urine.

Paraphilias always involve something forbidden. A voyeur may enjoy the forbidden activity of watching a woman undress through a peephole in a wall. The same person may not enjoy ordinary marital sex, which lacks the elements of risk and forbiddenness.

What are paraphilias? What do paraphilias "always involve"?

DSM-5, the Diagnostic and Statistical Manual version intro­duced in 2013, made several changes regarding paraphilias. As usual with any changes to DSM, they were controversial. In this case, however, the changes (along with parallel changes in ICD, the International Classification of Diseases) were welcomed by most professionals.

DSM-5 made a distinction between paraphilas and paraphiliac disorders. Paraphilias, odd sexual desires, are not necessarily classified as psychiatric disorders. They receive that classifi­cation (and become "paraphiliac disorders") only when they cause distress or when they cause danger to others such as a risk of sexual violence.

Giami (2015) described the changes as continuing a long-term cultural trend. Psychiatrists are moving away from automatically treating unusual sexual practices as diseases, disorders, or criminal activities.

Replacing this is "a model that reflects and privileges sexual well-being and responsibility." In other words, if a behavior encourages well-being and responsibility, it is not a psychiatric disorder.

Disorders are those sexual relation­ships in which there is distress or absence of consent. Specifically, DSM-5 requires that for diagnosis of a paraphiliac disorder, one of these two conditions must apply:

1) A person must "feel personal distress about their interest, not merely distress resulting from society's disapproval"...or...

2) A person must "have a sexual desire or behavior that involves another person's psychological distress, injury, or death, or a desire for sexual behaviors involving unwilling persons or persons unable to give legal consent"

Another change in DSM-5 was to remove hypersexuality (excessive preoccupation with sex) as a paraphilia. Hypersexuality is what most people call sex addiction.

References to sex addiction are common in popular literature, even if it is not classified as an addiction by DSM-5. The decision to remove hyper­sexuality as a paraphilia was based on the reasoning that a strong sexual appetite is not, in itself, a disorder. If it disrupts a person's life or causes distress, then it is.

One of the biggest changes resulting from DSM-5 was the normalization of BDSM (bondage, domination, sadism, and maso­chism). The BDSM community previously felt that their unusual sexual preferences were being criminalized or pathol­ogized (made to seem like diseases or injuries) by psychiatrists.

"Family court judges regularly removed children or restricted custody for parents if there was evidence of their BDSM activities" (Wright, 2014). There was little recourse for parents, except to turn for aid or support to the National Coalition for Sexual Freedom (NCSF), a national advocacy organization for consenting adults in the BDSM-leather-fetish, swing, and polyamory communities.

The de-pathologizing of paraphilias in DSM-5 had immediate conse­quences. Wright (2014) cited examples where custody or visitation rights were granted after the DSM-5 revisions, when a few months earlier the child would have been taken away.

The changes left DSM with three major categories of sexual dis­orders labeled as such:

  1. sexual dysfunctions (problems in sexual desire or biological changes affecting sex)
  2. paraphiliac disorders meeting the two conditions of distress or harm to others
  3. gender identity disorders character­ized by dissatis­faction with one's biological gender or desire for sex re-assignment

DSM-5 specifies 10 categories of paraphiliac disorder:

DSM-5 label Summary definition
Exhibitionistic Disorder Exposing one's genitals to unsuspecting person or performing sexual acts watched by others
Frotteuristic Disorder Touching or rubbing against a non-consenting person
Voyeuristic Disorder Urges to observe an unsuspecting person who is partly or fully unclothed
Fetishistic Disorder Use of inanimate objects to gain sexual excitement
Pedophilic Disorder Sexual preference for prepubescent children
Sexual Masochism Disorder Wanting to be humiliated, beaten, bound or otherwise made to suffer for sexual pleasure
Sexual Sadism Disorder In which pain or humiliation of a person is sexually pleasing
Transvestic Fetishism Arousal from clothing associated with members of the opposite sex
Other Specified Paraphilic Disorders A variety of less common paraphilic behaviours

The last category ("Other Specified Paraphilic Disorders") includes less common (or less distressing and harmful) attractions to various unusual objects and activities. It includes: partialism (obsession with part of the body, such as feet); zoophilia (animals); necrophilia (dead bodies); klismaphilia (enemas); coprophilia (feces); urophilia (urine); infantilism (acting infantile), and telephone scatologia (telephone calls with sexual or obscene content to an unsuspecting victim).

How common are paraphilias? Ahlers et al. (2011) surveyed 1,915 German men. 62.4% reported at least one paraphilia-associated sexual arousal pattern, but it caused distress in only 1.7% of cases.

When paraphilias must be treated, which is usually with males, the most common approach is to reduce androgen levels (and therefore sex drive). Thibaut et al. (2010) summarized 40 years of treat­ment attempts (1969-2009) and did not find good outcomes for talking therapies, CBT, or anti-androgen therapy, except for gonadotropic-releasing hormone treatment, which is effectively castration.

Among younger offenders, chemical castration may be too radical an option. Thibaut (2016) wrote that "SSRIs [anti-depressants] remain an interesting option in adolescents, in patients with depressive or OCD disorders, or in mild paraphilias such as exhibitionism."

Transvestitism

Transvestitism is called "transvestic fetishism" if it causes enough distress to be labeled a disorder in DSM-5. It is sexual arousal achieved by dressing like the opposite sex.

Transvestites are not necessarily homo­sexuals. In fact, in a survey of subscribers to the magazine Transvestia, only 10% described themselves as homosexuals.

Transvestites typically report cross-dressing before puberty (Buhrich and Beaumont, 1981). Buhrich and Beau­mont assert that cross-dressing is often accompanied by fantasies of bondage (being tied up or dominated).

What is transvestitism and how is it distinct from homosexuality?

Both men and women are capable of cross-gender dressing, but apparently only men do it for a sexual thrill. Male transvestites are not necessarily gender dysphoric. They may be perfectly happy as males, but they get a kick out of cross-dressing.

Levine and Lothstein (1981) asserted that, if transvestism is defined by sexual arousal at cross-dressing, all transvestites are men.

Why is it said that there are no lesbian transvestites?

Money (1981) agreed. He found that women who dressed as men, whether they were heterosexuals, lesbians, or female-to-male trans­sexuals, simply felt most comfort­able in male dress and were not sexually excited by cross-dressing.

Exhibitionism

Exhibitionism ("flashing") is the most common paraphilia. Nearly all people arrested for exhibitionism are male. Female exhibitionists tend to use pro­fessional outlets such as exotic dancing.

Exhibitionism accounts for a third of sex offender arrests. The typical exhibitionist begins in his 20s and exposes himself to a woman aged 16 to 30.

About half of exhibitionists report no gratification from the act itself, but they value the shocked reaction of the woman, and they use the incident as a basis for later fantasy during masturbation.

Experts advise women to pay no attention to an exhibitionist or tell him he is foolish or disturbed. That ruins the erotic quality of the event.

What is the most common paraphilia? How can exhibitionists be discouraged?

Exhibitionism does not respond well to therapy. Recidivism (backsliding or getting arrested again for the same reason) is common with exhibitionists (Allgeier and Allgeier, 1988).

Women usually find exhibitionists "annoying and weird" rather than dangerous (Rosen & Hall, 1984). However, exhibitionists often have a history of other disorders such as pedophilia (sexual attraction to children) that might not be so harmless.

Masochism and Sadism

A sexual masochist is sexually aroused by being hurt, beaten, or dominated. The term comes from the name of Leopold , who wrote novels about such people and was a masochist himself.

Sacher-Masoch was a nobleman, which fits one stereotype of masochistic individuals. Often they are men who occupy positions of high status or authority, such as "executives, politicians, judges, and bankers" (Masters, Johnson, & Kolodny, 1982).

Experts believe the act of submission to pain or domination is an "escape valve" for such people, allowing them to act in ways forbidden by their normal role in public life (Leo, 1981).

So-called S&M parlors in big cities cater to sexual sadists and masochists, providing them with whips and other equipment for acting out their fantasies. The BDSM (Bondage/Dominance/Sadism/Masochism) community has its own clubs and societies and spokespeople who testify this is the mode of sexual expression they prefer.

Faccio, Casini, and Cipolletta (2013) interviewed 343 people who wrote in online BDSM forums. They found that among these individuals, sexuality was construed as a game acted out with specific rules, and pleasure was associated with extremely intense experiences.

"Both dominant and dominated roles were found to be tightly linked to the possession and management of power between partners." Role-playing either confirmed or reversed an extreme, physicalized version of traditional male/female roles.

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References:

Ahlers, C. J., Schaefer, G. A., Mundt, I. A., Roll, S., Englert, H., Willich, S. N., & Beier, K. M. (2011) How unusual are the contents of paraphilias? Paraphilia-associated sexual arousal patterns in a community-based sample of men. Journal of Sexual Medicine, 8, 1362-1370. doi:10.1111/j.1743-6109.2009.01597.x

Allgeier, A. R. & Allgeier, E. R. (1988) Sexual Interactions. DC Heath.

Buhrich, N. & Beaumont, T. (1981) Comparison of transvestism in Australia and America. Archives of Sexual Behavior, 10, 269-279.

Faccio, E., Casini, C., & Cipolletta, S. (2013) Forbidden games: The construction of sexuality and sexual pleasure by BDSM 'players'. Culture, Health, and Sexuality, 16, issue 7. http://dx.doi.org/10.1080/13691058.2014.909531

Giami, A. (2015) Between DSM and ICD: Paraphilias and the transformation of sexual norms. Archives of Sexual Behavior, 44, 1127-1138. doi:10.1007/s10508-015-0549-6

Leo, J. (1981, September 7) "Cradle to Grave Intimacy," Time, 118, p.69.

Levine, S. B. & Lothstein, L. J (1981) Transsexualism or the gender dysphoria syndromes. Sexual and Marital Therapy, 7, 85-113.

Masters, W. H., Johnson, V. E. & Kolodny, R. C. (1982) Human Sexuality. Boston, MA: Little, Brown & Co.

Money, J. (1981) Paraphilias: Phyletic origins of erotosexual dysfunction. International Journal Of Mental Health, 10, 75-109.

Rosen, R. & Hall, E. (1984) Sexuality. New York: Random House.

Thibaut, F., La Barra, F.de., Gordon, H., Cosyns, P., & Bradford, J. M. W. (2010) The world federation of societies of biological psychiatry (WFSBP) guidelines for the biological treatment of paraphilias. World Journal of Biological Psychiatry, 11, 604-655. doi:10.3109/15622971003671628

Thibaut, F. (2016) Pharmacological treatment of sex offenders. European Psychiatry, 33, supplement, p.S43. doi:http://dx.doi.org/10.1016/j.eurpsy.2016.01.895

Wright, S. (2014) Kinky parents and child custody: The effect of the DSM-5 differentiation between the paraphilias and paraphiliac disorders. Archives of Sexual Behavior, 43, 1257-1258. doi:10.1007/s10508-013-0250-6


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