Paraphilias Clinical Presentation

  • Author: Guy E Brannon, MD; Chief Editor: David Bienenfeld, MD   more...
 
Updated: Oct 28, 2010
 

History

DSM-IV-TR criteria include the following:

  • Exhibitionism
    • Over a period of at least 6 months, patients have recurrent, intense, sexually arousing fantasies, sexual urges, or behaviors that involve exposing their genitals to unsuspecting strangers.
    • The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
    • Exhibitionism typically involves men exposing themselves to women (not a DSM-IV-TR criterion).
  • Fetishism
    • Over a period of at least 6 months, patients have recurrent, intense, sexually arousing fantasies, sexual urges, or behaviors involving nonliving objects.
    • The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
    • Patients do not limit the fetish objects to articles of female clothing used in cross-dressing or to devices designated for the purpose of tactile genital stimulation.
    • Patients may have a particular pathological displacement of erotic interest and satisfaction for their entire lives (not a DSM-IV-TR criterion).
  • Frotteurism
    • Over a period of at least 6 months, patients have recurrent, intense, sexually arousing fantasies, sexual urges, or behaviors involving rubbing against and touching a nonconsenting person.
    • The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
    • Patients typically practice this behavior in crowded places (not a DSM-IV-TR criterion).
  • Pedophilia
    • Over a period of at least 6 months, patients have recurrent, intense, sexually arousing fantasies, sexual urges, or behaviors involving sexual activity with a prepubescent child or children.
    • The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
    • The patient must be aged 16 years or older and at least 5 years older than the child or children involved.
  • Sexual masochism
    • Over a period of at least 6 months, patients have recurrent, intense, sexually arousing fantasies, sexual urges, or behaviors involving the act of being humiliated, beaten, bound, or otherwise made to suffer.
    • The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
    • This variant is named for the activities of Leopold von Sacher-Masoch (not part of the DSM-IV-TR criterion). Sacher-Masoch was born in Lemberg, Austria in 1836. As an author he is most known for his book Venus in Furs. This writing is reportedly based on true events from his life.
      • Sacher-Masoch's novel is said to be one long masochistic fantasy in which the principle male character desires and encourages his mistress to treat him as a slave. This story appears to parallel his relationship with his wife. He used to plead with her to treat him as a slave, and his outlandish requests would progressively become more demeaning to satisfy his sexual appetite. However, she was not interested in partaking in his deviant self-deprecating fantasies. Eventually they met other partners and parted ways.
      • Leopold von Sacher-Masoch was the eldest son of a couple in the town of Galacia, where his father was the Director of Police and his mother was a little Russian lady of noble birth. As an infant, Leopold was very frail and sickly, and not expected to survive. To increase the infant's chances of survival, his parents hired a robust Russian wet nurse who was able to nurse him back to health. Leopold later spoke of the strong bond between the 2 of them. The woman shared strange and melancholy legends about her people with the boy, and he formed a love of the Russians that remained constant throughout his life. He reportedly said that not only did he gain his health from her, but also his soul.
      • As a child, Leopold was fascinated by various representations of cruelty. He was especially drawn to pictures of executions, and some of his favorite reading materials pertained to legends of martyrs. At the onset of puberty, he had a recurring dream that he was under the power of a cruel and torturous woman. The term dream is used in this context as opposed to nightmare.
      • In the town of Galacia, where Leopold was born, women were said to either rule their husbands or vice versa. At the age of 10, the boy witnessed a sadistic scene that left a permanent impression. The scene involved a female relative from his father's side of the family. This woman was referred to as Countess X. Prior to Leopold witnessing the life-altering event, he was enamored by the Countess and was impressed by her beauty and costly furs. He used to help her with various duties, services, etc. On one occasion, as he was putting on her shoes, he bent down to kiss her feet and she smiled at him and then kicked him. Instead of being hurt, he experienced a perverse sensation of pleasure.
      • Sometime after this event, he witnessed the Countess and her lover caught in the act by her husband and 2 of his friends. The Count, who was obviously stunned, paused momentarily to plot his course of revenge. In the meantime, the Countess beat all 3 men to a bloody pulp. Leopold had been hiding in the room throughout the encounter, and was discovered by the Countess after gasping in astonishment. Upon discovery, she beat him as well. He made his way out of the room, but was still right outside the door watching should anything else occur. Moments later, the boy witnessed the Count, back in the same room where he had been humiliated earlier, begging for her forgiveness. The Countess looked at her husband and with that same calculating smile, all too familiar to Leopold, gave him a big swift kick.
  • Sexual sadists
    • Over a period of at least 6 months, patients have recurrent, intense, sexually arousing fantasies, sexual urges, or behaviors involving the acts in which psychological or physical suffering of the victim is sexually exciting to the patient.
    • The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
    • This variant is named for the activities of the Marquis de Sade (not part of the DSM-IV-TR criterion).
      • The Marquis de Sade was born in Paris, France on June 2, 1740 and died on December 2, 1814 in Charenton, France. His full name was Donatein Alphonse Francois comte de Sade. The term sadism is a derivative of his name. The Marquis was an aristocrat and an author of violent pornography. The French author's erotic books, mainly written while imprisoned, include Justine, Juliette, and 120 Days of Sodom. The Marquis de Sade regarded criminal/sexually deviant acts as being natural, which was apparent in both his writings and actions. Consequently, his novels were banned into the 20th century.
      • The Marquis de Sade's life consisted of numerous acts of cruelty, which were indicative of his total disregard for human life and the law. His acts of extremely violent physical and sexual abuse resulted in numerous imprisonments and consequent escapes. He was also declared insane and admitted to an insane asylum on 2 different occasions. The Marquis was imprisoned or committed to insane asylums for at least 32 years of his life. Most victims of Marquis were young female prostitutes, as well as both male and female employees of his chateau.
      • Donatein's mother was a distant cousin to the Prince de Conde, a junior branch of the royal Bourbon family. She served as a lady in waiting to the Princess de Conde and was a governess to her son, the young Prince de Conde. An early account of Donatein's violent nature involved an altercation between he and his young cousin over a toy. When the young Prince tried to retrieve one of his favorite toys from the grasp of his 4-year-old cousin, Donatein pummeled his cousin with increasing blows of violence. Soon after this incident, the young Marquis was sent to live with his paternal grandmother in Avignon.
      • The troubled young boy spent his formative years in Avignon surrounded by female relatives who indulged his every need and enveloped him with sensual affection. Donatein's grandmother and aunts continually doted on the child and indulged every one of his selfish demands. There was no mention of discipline in the boy's upbringing. These actions were only detrimental to the child's development; consequently, his behavior became increasingly unruly. When the Comte de Sade (Donatein's father) received report of his son's unconventional upbringing, the young Marquis was sent to live with his father's brother. The Comte hoped that his brother, Abbe de Sade, would be able to provide a masculine presence and influence that was obviously lacking in Donatein's life.
      • Abbe de Sade was a noted author, clergyman, and scholar of his time. He was also very much like his sisters in the sense that he enjoyed the sensual side of life and indulged himself with many pleasures. He was referred to as "sybarite of Saumane" meaning one inordinately attached to pleasure and luxury. Once again the young boy was in an atmosphere that encouraged sexuality and sensual indulgence as an expectation rather that an exception to the rule. During Donatein's stay at his uncle's home, the abbe housed many female companions which included a local prostitute.
      • Throughout this period of time in Europe, men and women of the cloth, indulged themselves in various sexual escapades with little remorse. There was rumor of orgies taking place in abbeys and convents, where priests, nuns, prostitutes, and nobles all engaged in debaucherous behavior. Abbe de Sade had a library filled with a genre of literature, and some were pornographic in nature. Donatein was free to read all of the literature in the library at his leisure. After becoming abreast of the ever present debauchery in Donatein's life, his father moved him to Paris where he was enrolled in a Jesuit prep school for young men of nobility.
      • Donatein was quite young to have been uprooted so many times. He was 10 years old when he was enrolled at the prep school. Although the Jesuits had a remarkable reputation as educators, they were infamous for their practices involving sodomy and corporal punishment. The Jesuits would beat, whip, or flog the young boys in front of an assembled student body to humiliate them. The humility of the beatings, oddly enough, could also be sexually arousing. This practice came to be known as sado-masochistic behavior. As an adult, the Marquis de Sade was unable to be aroused by normal sex, so it appeared that his sexuality was arrested at the infantile anal stage.
      • After 4 years with the Jesuits, Donatein was transferred to a military academy upon this father's request. In 1755, shortly following his arrival, Donatein served in the King's light cavalry regiment as a sub lieutenant. He was only 15 years old at the time. The young Marquis served in the war and was considered a brave and decisive leader. Unsatisfied with Donatein's success in the cavalry, his father had him placed with a cavalry company commanded by one of the members of the royal family. Donatein's bravery, good looks, and social charm made him a very successful soldier. His superiors were quite impressed by the Marquis; therefore, he was promoted to captain at the young age of 18. Donatein seemed able to impress everyone but his own father. His father never praised his son for his many accomplishments, yet had no difficulty pointing out his shortcomings.
      • When the Marquis de Sade returned from the war in 1763, he had his sights set on a particular lady whom he wished to marry. However, his father was opposed to the union. Instead, he arranged for the Marquis to marry her elder sister, Renee-Pelagie de Montrieul. The couple had 3 children, 2 boys and a girl.
      • The same year the couple was married, the Marquis de Sade frequently traveled away from home for "business" reasons. While away on his travels, he rented several different maisons around Paris where orgies were held. One particularly disturbing encounter took place between the Marquis and a young prostitute. After he was alone with her, he quizzed the young prostitute about her religious convictions regarding the Roman Catholic Church. When he discovered that she was a faithful Roman Catholic, he began degrading her with inconceivable vile insults.
      • To the young woman's horror, he proceeded to perform sexually explicit acts on her with the aid of religious objects that were extremely blasphemous and sacrilegious in nature. When the young prostitute refused his request to beat each other with a hot whip, he pleasured himself sexually with a pair of crucifixes. Then he held her at knife point, forcing her to repeat vulgarities in the most blasphemous manner. This resulted in the Marquis de Sade's first imprisonment; however, his lewd and debaucherous behavior would result in numerous other imprisonments during his lifetime. He died in 1814 and was buried in Charenton. Later his skull was removed from the grave for phrenological examination.
      • The Marquis de Sade's life was not an ordinary one. From early on, he was rejected by his parents and moved from one place to another. The Marquis would never gain his father's approval, no matter how hard he worked. His life lacked structure, appropriate discipline, balance, and unconditional love/approval. The young Marquis was exposed to complete self-indulgent behavior lacking any form of discipline while raised by his grandmother, aunts, and uncle. Then he was exposed to extreme corporal punishment while attending prep school with the Jesuits. He was also exposed to deviant sexual behavior in both of these very different settings.
      • In theory, one might postulate that exposure to these extreme polarities of behavior, especially during the very crucial formative years, might cause the underdeveloped psyche to integrate the 2. Therefore associating pleasure with pain, hence the deviant masochistic behavior.
      • Prevalence is unknown.
  • Transvestic fetishism
    • Over a period of 6 months, heterosexual male patients have recurrent, intense, sexually arousing fantasies, sexual urges, or behaviors involving cross-dressing.
    • The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
    • Typically, patients derive sexual gratification from wearing clothes usually worn by the opposite sex, and patients typically are heterosexual married males (not a DSM-IV-TR criterion).
  • Voyeurism
    • Over a period of at least 6 months, patients have recurrent, intense, sexually arousing fantasies, sexual urges, or behaviors involving the act of observing an unsuspecting person who is naked, in the process of disrobing, or engaging in sexual activity.
    • The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
    • Patients derive sexual gratification from seeing sex organs and sexual acts; scopophilia is a synonym for voyeurism (not a DSM-IV-TR criterion).
  • Paraphilia not otherwise specified: This category is included so physicians can code paraphilias that do not meet the criteria for any of the other specific categories.
    • Scatologia involves making obscene phone calls.
    • Necrophilia involves an erotic attraction or sexual interest in corpses. This paraphilia is rare and seldom reported to the police. Patients typically work in mortuaries and funeral parlors. This also involves dangerous situations where the individual could actually acquire infections from the corpse.
    • Partialism is sexual interest exclusively focused on a particular body part.
    • Zoophilia involves sexual activity with animals (ie, both actual sexual contact and sexual fantasies, higher in psychiatric patients).
    • Coprophilia is sexual activity involving feces.
    • Klismaphilia is sexual activity involving enemas.
    • Urophilia is sexual activity involving urine.
    • Masturbation is sexual self-gratification.
  • Other paraphilias
    • Autogynephilia describes a man's propensity to be sexually aroused by thoughts or images of himself as a woman (with female attributes).
    • Asphyxiophilia or hypoxyphilia is when a patient uses hypoxia to achieve sexual excitement; this can be complicated by autoerotic asphyxiation.
    • Video voyeurs derive sexual gratification from videos, usually of women doing natural acts or women involved in sexual activity.
    • Infantophilia is a new subcategory of pedophilia in which the victims are younger than 5 years.
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Physical

Obtain a complete history and perform complete mental status, physical, and neurological examinations to assist with the evaluation and to rule out other disease processes. This particular patient population may be more difficult to interview because they may be more likely to have guilt associated with their disorder, therefore making them reluctant to openly share information with the interviewer. The interviewer must establish rapport with these patients and allow them to talk more freely about their disorder. By asking leading questions and then allowing the patient to reveal information on his or her own helps in the treatment and management of this disorder.

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Causes

Rule out major medical or psychiatric illnesses. Look for both hard and soft neurological signs involving the striato-thalamo-cortical processing loop (theory). This theory states that a disruption of the striato-thalamo-cortical processing loop can cause abnormal filtering of information resulting in the brain's inability to block unimportant information, which is thought to cause a propensity to initiate or perpetuation paraphilias and other psychotic phenomena. It is important to point out that this is just a theory and much more research is needed to either confirm or disprove this concept as a cause of paraphilias.

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Contributor Information and Disclosures
Author

Guy E Brannon, MD  Associate Clinical Professor of Psychiatry, Louisiana State University Health Sciences Center; Director, Adult Psychiatry Unit, Chemical Dependency Unit, Clinical Research, Brentwood Behavior Health Company

Guy E Brannon, MD is a member of the following medical societies: American Medical Association, American Medical Writers Association, American Psychiatric Association, American Society of Addiction Medicine, Association of Clinical Research Professionals, Louisiana State Medical Society, and Southern Medical Association

Disclosure: AstraZeneca Grant/research funds Other; Janssen Grant/research funds Other; Pfizer Honoraria Speaking and teaching; Sunovion Honoraria Speaking and teaching; Eli Lilly Grant/research funds Other; Forrest Grant/research funds Other

Specialty Editor Board

Mohammed A Memon, MD  Chairman and Attending Geriatric Psychiatrist, Department of Psychiatry, Spartanburg Regional Medical Center

Mohammed A Memon, MD is a member of the following medical societies: American Association for Geriatric Psychiatry, American Medical Association, and American Psychiatric Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Harold H Harsch, MD  Program Director of Geropsychiatry, Department of Geriatrics/Gerontology, Associate Professor, Department of Psychiatry and Department of Medicine, Froedtert Hospital, Medical College of Wisconsin

Harold H Harsch, MD is a member of the following medical societies: American Psychiatric Association

Disclosure: lilly Honoraria Speaking and teaching; Forest Labs None None; Pfizer Grant/research funds Speaking and teaching; Northstar None None; Novartis Grant/research funds research; Pfizer Honoraria Speaking and teaching; Sunovion Speaking and teaching; Otsuke Grant/research funds reseach; GlaxoSmithKline Grant/research funds research; Merck Honoraria Speaking and teaching

Chief Editor

David Bienenfeld, MD  Professor of Psychiatry, Vice-Chair and Director of Residency Training, Department of Psychiatry, Wright State University, Boonshoft School of Medicine

David Bienenfeld, MD is a member of the following medical societies: American Medical Association, American Psychiatric Association, and Association for Academic Psychiatry

Disclosure: Nothing to disclose.

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