Background
Paraphilia is a rare disorder, and the best criteria for diagnosis come from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR)[1] or the International Statistical Classification of Diseases, 10th Revision (ICD-10)[2] . The disorder is characterized by a 6-month period of recurrent, intense, sexually arousing fantasies or sexual urges involving a specific act, depending on the paraphilia.
Paraphilia is a means for some people to release sexual energy or frustration. The act commonly is followed by arousal and orgasm, usually achieved by masturbation and fantasy. These disorders are not well recognized and often are difficult to treat for several reasons. Often, people who have these disorders conceal them, experience guilt and shame, have financial or legal problems, and can (at times) be uncooperative with medical professionals.
Some psychiatrists discuss whether paraphilias are a part of the impulse control disorders or if they fall within the spectrum of obsessive-compulsive disorders. The more common paraphilias include voyeurism and frotteurism, and the most rare paraphilia is zoophilia. In this age of computer technology, individuals can easily access information about paraphilias from any computer, thus fueling a disorder that already is difficult to control.
Case study
A 16-year-old white male was found peering through the window at his neighbor's wife undressing. The police were called and the patient was taking to the emergency room for further evaluation. This has been the second time in a year he was discovered looking through someone's window at other people undressing. During the evaluation, the physical examination and laboratory results were unremarkable. Additional history is that the patient has intense sexual fantasies, which leads him to watch people undress and concludes with masturbation. The patient has few friends and no afterschool activities.
The psychiatrist noted on the mental status examination a 16-year-old white male wearing a t-shirt and blue jeans with decreased eye contact, neutral facial expression, decreased motor activity, and overall was cooperative with the examination process. The patient was alert and oriented to person, place, and situation. The patient denied auditory and visual hallucinations, delusions, and suicidal/homicidal ideations. The patient's general fund of knowledge was fair and he could perform simple calculations. Impulse control was decreased and IQ was felt to be average. Overall he seemed reliable. The patient was discharged from the emergency room for outpatient therapy. The patient missed his first appointment and was subsequently lost to follow up.
Pathophysiology
Many theories exist regarding the etiology of paraphilias, including psychoanalytical, biological, and sociobiological theories; however, none are conclusive. This subject requires additional research.
Psychoanalytical Theory
According to psychoanalytical theory, several possible factors may contribute to the origin of paraphilias. Freud and his colleagues suggested that some paraphilias may be attributed to possible distortion of the courtship phases. Normal courtship behavior is what brings males and females together for the purpose of mating. It usually occurs during adolescence and may or may not involve sexual intercourse at this early stage of sexual development. Courtship is composed of 4 definitive phases.
- Location of a potential partner - The initial phase of courtship
- Pretactile interaction - Talking or flirting with a potential partner
- Tactile interaction - Usually consists of touching, hugging, hand holding, etc (This could also be considered foreplay.)
- Effecting genital union - More commonly known as sexual intercourse
According to this particular literature, distortions of the courtship behaviors are only associated with the first 3 phases.
Although most of the population is able to appropriately engage in these 4 phases of interaction, other people are unable to adhere to these socially acceptable norms. Freud and his colleagues have indicated that certain deviant or unconventional sexual practices can be viewed as exaggerations of the 4 phases of courtship. Based on Freud's research with incarcerated sex offenders, one distortion of courtship behavior may result in others.
Certain paraphilias are associated with distortions of courtship behaviors.
- Voyeurism: This is the distorted view of the initial courtship phase. Normally the initial courtship phase is known as locating a potential partner. Psychoanalysts postulate that voyeurism may be attributed to a child witnessing episodes of his or her parents engaged in sexual intercourse. Individuals with maladaptive social and sexual skills find voyeurism as an outlet for sexual pleasure void of the threat of sexual interaction. The risk or danger of discovery may likely give the voyeur a false sense of masculinity, this behavior tends to be similar for the exhibitionist as well.
- Exhibitionism:
- Psychoanalysts consider exhibitionism a distortion of the pretactile interaction of the courtship phase. Psychoanalytical theory is based on the theory that gender identity for little boys requires psychological separation from the mother, so that he will not identify with her as a member of the same sex as do little girls. Exhibitionists regard their mothers as rejecting them on the basis of their different genitalia. The act of exhibitionism forces women to accept them by forcing them to look at their genitals. The act of self-exposure is also a way for the exhibitionist to compensate for his introversion and lack of assertiveness. The act of exposing oneself may give the exhibitionist a false sense of power, and the danger of discovery may further reinforce this feeling. In general, psychoanalysts theorize that the act of an exhibitionist displaying his penis is a way of proving his manhood to the world, but more importantly to an adult woman.
- Narcissism, the extreme form of self-admiration, is also believed to contribute to exhibitionism. Many of these men are married and have regular sexual contact with their spouse. However, in the mind of the exhibitionist/narcissist, by receiving only his wife's admiration of his genitalia is not sufficient in feeding his endless secondary narcissistic supply. Therefore, this leads to his search for other unsuspecting victims to fulfill his insatiable need for admiration. The exhibitionist is sometimes compared to an actor on stage who desires an audience, but does not want to participate in the act.
- Toucherism and frotteurism: These are considered exaggerations of the tactile interaction of the courtship phase. These paraphilias provide a sexual outlet without the risk of rejection. Toucherism tends to occur in conjunction with other paraphilias.
Freud suggested that these disorders result from unsuccessful negotiating in the developmental stages resulting in sexual urges becoming blocked and expressing themselves at a later time as paraphilias.
Behavioral Theory
Behavioral theory attributes the development of certain paraphilias to the process of conditioning. Actually, paraphilias are a result of accidental conditioning. If nonsexual objects are frequently and repeatedly associated with a pleasurable sexual activity, then the object becomes sexually arousing. A small study was conducted with 7 heterosexual males, all of whom were free of any fetishes. They were repeatedly shown erotic stimuli that were paired with a slide of women’s black knee-high boots. Later, when the slide of the boots was shown alone, 5 of the 7 men experienced penile erection. This indicated that a boot fetish had been conditioned.
A similar study with a small group of women was conducted to determine if they could be conditioned to become sexually aroused by a stimulus. Results showed no significant differences found in physiological sexual arousal between the experimental and control groups. These results imply that sexual arousal is not readily classically conditioned in women. This might explain why fetishism and other paraphilias occur almost exclusively in males. In this article, these findings are supported in another school of theory.
Conditioning does not always involve positive reinforcement. Negative reinforcement may occur as well. If an individual experiences unpleasant consequences with normal sexual activity, an aversion to sex may occur, resulting in the development of deviant behavior. An example of this would be a young boy who is humiliated and punished by his parents for proudly displaying his erect penis. As the boy matures he may associate guilt and shame with normal sexual behavior.
Certain atypical sex acts, such as exhibitionism and voyeurism, that provide intense sexual arousal may lead to individual preference of that behavior. Pedophiliacs, exhibitionists, and voyeurs may be driven by risk-taking behaviors. Therefore, the constant threat of discovery may be as arousing to them as the act itself.
Conditioning is not the only contributing factor in the development of paraphilias. These individuals usually experience low self-esteem, which may lead to difficulty in forming person-to-person sexual relationships.
Sociobiological Theory
An article of particular interest in explaining possible etiologies of paraphilias is A Theory about the Variety of Human Sexual Behavior, written by Richard A Gardner . Gardner’s article combines a couple of theories. These theories are Dawkins’s theory of gene transmission and Darwin’s well-known survival of the fittest theory. In a sense, this could be considered a sociobiological theory.
Dawkin's theory
Dawkins’s theory of gene transmission is used in developing a theory regarding the variations in human sexual behavior. These variants in sexual behavior, even atypical sexual behavior (paraphilias), are seen as survival of the species. According to this view, the different paraphilias may be responsible for enhancing society’s level of sexual excitation. In turn, this would increase the likelihood of people engaging in sex acts that would ultimately lead to procreation.
First, we discuss the origin of the gender differences in mating patterns. In the courtship process, women seem to be genetically programmed to be more passive and seductive, while men are more assertive and aggressive. Before the 20th century, males served the role of hunters and fighters, while the primary role of the female was in child rearing. The men who were more adapt at hunting and fighting (protectors and warriors) were more likely to survive and attract females as mates. The weaker men were less likely to attract women as desirable mates because they were unable to adequately provide food, clothing, and shelter. This would make them less able to protect their potential family from enemies.
Men were also more likely to be attracted to women who were stronger in child rearing abilities. This would more likely ensure that their genes would be passed down to subsequent generations. Therefore, the stronger and more aggressive men, as well as women with a stronger capacity for raising children, were more likely to acquire mates. This would ensure propagation of their genes.
Today, this genetic programming is carried in both sexes. Although lower primates are more instinctually driven, humans are also affected to a certain degree. During the mating season, animals are compelled to go through the mating ritual of their species.
Humans also have procreative urges, but not in a particular mating season or in a particular mating ritual as seen in the lower primates. Unfortunately, this does not make us exempt from such mating patterns with the resultant pattern of their expression.
Darwin's theory
Darwin’s theory of survival of the fittest relates more directly to reproductive capacity. Each species produces more offspring than could possibly survive; therefore, those who are more capable of adapting to their environment are more likely to survive and perpetuate the species. In general, those species that are less adaptable to their surroundings are more likely to become extinct.
Quantity and quality are 2 of the operative factors in Darwinian Theory. As already mentioned, the quantity of offspring produced in an environment is far greater than what can actually survive. Therefore, the quality of offspring that is most adaptable to the environment will survive.
Each of the sexes is designated to provide either quantity or quality. The male is the species physically able to produce the greatest amount of offspring. Since a female producing a greater quantity of offspring than the male is biologically impossible, she is the one responsible for quality control. As discussed earlier, the woman tends to be selective in the process of choosing a mate. The mate of choice is one that will be the best in providing for and protecting the family. The female will also ultimately take on the responsibility of child rearing.
This brings us to the procreative process discerning males versus females. A biology professor at Louisiana State University in Shreveport once said, "Sperm are cheap and eggs are expensive." This pretty much sums it up. If a man devoted his whole life to the procreation process, he could possibly father or produce 30,000 offspring. On the other hand, if a woman were to devote her entire fecund life to procreation, she could only possibly produce 40-45 babies.
Although this procreative potential may exist, humans partake in other necessary life activities besides fornication and propagation. Child rearing may be the most important of these life activities. If protection is not provided for the young, the babies would be unable to survive. Therefore, to devote one’s life to the sole purpose of manufacturing babies without the potential for survival would be senseless. Also, women must try and select the mate that will remain around after impregnation and serve the role as protector and gatherer. In order to have the ability to assess a proper mate, women were more cautious in regards to their impulsivity regarding sexual gratification. Women with inhibited sexual arousal were more likely to select a proper mate and increase their likelihood of survival. Also, once aroused, a woman is more likely to attempt an ongoing relationship with her mate.
While women are programmed to be more cautious in the selection of a mate, men tend to desire sex indiscriminately with large amounts of women. Again, this is a means of spreading their sperm for the purpose of procreation and passing down their genes. According to literature, males are quicker to arousal than the average female. Following gratification from a sexual encounter, the man is less likely to be interested in maintaining a relationship or commitment.
The old saying, "Men are looking for girls, and girls are looking for husbands" suggests that men are on the prowl, hunting solely for sexual companionship from women. Shanor (1978) conducted a study that found men aged 12-40 years think of sex approximately 6 times an hour. However, we need to determine the distribution by age ranges. Males aged 12-19 years think of sex an average of 20 times per hour or once every 3 minutes. In males aged 30-39 years, this slows down to approximately 4 times per hour. This may be one reason in explaining that paraphilias usually occur in males aged 15-25 years.
According to this data, most men are promiscuous, either physically or psychologically. The distinguishing factor is the degree of control that is exerted toward action or inaction in regard to the sexual urges. Women must be aware of this fact and reject most of the "men in heat" or risk the possibility of impregnation without commitment.
Females are much more relationship oriented. This is one of the factors that contribute to women having a greater orgasmic capacity than men. While it may be necessary for a woman to acquire more touching, caressing, and overall romance to become aroused, this will ensure that her arousal will more likely last longer. Most women have the potential for multiple orgasms, which may further enhance the procreative capacity. This capacity for multiple orgasms enables the female to captivate the sustained interest and involvement of the male who otherwise tends to be slow to ejaculation. This may prove difficult because males reach the point of orgasm, which is immediately followed by the refractory period, otherwise known as "falling asleep."
The data mentioned above may explain why men are more like likely to be sexually aroused by visual stimuli, and women are more readily to respond to tactile stimuli. The hunters (roving bands of men) spot their prey (women) at a distance and are able to achieve excitement just by the sight of a possible future conquest. Their hunting nature in itself enlarges the potential for sexual partners. Unlike females, this may explain why males gawk at females. If women are watching men, they are much less obvious and exhibitionistic than men in their plight.
Women are more susceptible to caressing, tenderness, and the reassurance of a man’s commitment. This commitment ensures that he is emotionally invested in this union and will remain around to supply food and protection for her and their offspring. This may explain one of the reasons that men are more likely to be sexually aroused by visual pornography.
Epidemiology
Frequency
United States
Paraphilias are considered rare, affecting only a small percentage of the US population. Researchers have a difficult time trying to determine a specific percentage of involved individuals because many of the acts are illegal and reporting methods (ie, self-reporting) typically are unreliable.
International
International percentages of patients with paraphilias are difficult to discern because these disorders are rare.
Mortality/Morbidity
Determining the morbidity or mortality of paraphilias depends on the act practiced, the comorbidity involved, the patient's cooperation with the therapist, and whether or not the legal system is involved. Paraphilias can be transient, as demonstrated by experimentation during the teenage years, or can remain a life-long problem involving legal, financial, interpersonal, occupational, academic, and other problems. Death may occur in some circumstances, through acts such as autoerotic asphyxiation.
Race
Patients typically are white.
Sex
Patients typically are men.
Age
Most patients are aged 15-25 years; this disorder rarely occurs in individuals older than 50 years. The information on paraphilia in older individuals is limited.
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