Paraphilic Disorders Clinical Presentation

A complete history (including psychiatric and psychosexual history) should be obtained. People with paraphilic disorders may be especially difficult to interview because they often feel guilty about their disorder and thus are reluctant to share information openly with the interviewer. It is essential to establish rapport with these patients to allow them to talk more freely about their disorder. Asking leading questions and then allowing the patient to reveal information on his or her own helps in the treatment and management of a paraphilic disorder.

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 may present to physicians 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 distress or impairment in social, occupational, or other important areas of functioning. In 1975, Rooth classified exhibitionism into the following 2 types ^[9] :

• Type I - The inhibited flaccid exposer

• Type II - The sociopathic exposer who may have a history of other misconduct

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 ^[10] and Kohut ^[11] have viewed female exhibitionism as a disorder of bodily narcissism.

Male exhibitionists, whether timid or brash, are described as typically feeling dominated by women and resenting 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/long-term partners. They go to great lengths never to look at their wives/long-term partners 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 found that 7% of exhibitionists were later convicted of contact sexual offenses, including rape. ^[12]

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 also be 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, and 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. ^[13] 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.

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

• Other 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. ^[14] 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 undescribed in females. Women may cross-dress, but there is little representation of cross-dressing females who become sexually excited by the activity 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. 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 self 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

In the American Psychiatric Association’s Diagnostic and Statistical Manual, Fifth Edition (DSM-5), ^[1] 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 if there is insufficient information for a more specific diagnosis.

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 psychiatric and other medical illnesses is critical for diagnosis and management.

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 use/misuse, and treatment recommendations must be assessed. Assessment of sexual arousal should be considered; correlations are found between self-reports and genital measurements. ^[15]

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.