Paraphilic Disorders

Paraphilia is any intense and persistent sexual interest other than sexual interest in genital stimulation or preparatory fondling with phenotypically normal, physically mature, consenting human partners. If a paraphilia causes distress or impairment to the individual or if its satisfaction entails personal harm, or risk of harm, to others, it is considered a paraphilic disorder.[1]

Paraphilias are associated with arousal in response to sexual objects or stimuli not associated with normal behavior patterns and that may interfere with the establishment of sexual relationships. In modern classification systems, the term paraphilia (or paraphilic disorder, as appropriate) is preferable to the term sexual deviation because it clarifies the essential nature of this group of behaviors (ie, arousal in response to an inappropriate stimulus).

Paraphilia is a means by which some people release sexual energy or frustration. The act commonly is followed by arousal and orgasm, usually achieved through masturbation and fantasy. Paraphilic 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.

Overall, the most well-regarded criteria for diagnosis of paraphilic disorders come from the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)[1] or the International Statistical Classification of Diseases, 10th Revision (ICD-10),[2] though the definitions of these conditions remain subject to some debate.[3, 4, 5]  DSM-5 describes 8 of the more commonly observed paraphilic disorders:

• Voyeuristic disorder

• Exhibitionistic disorder

• Frotteuristic disorder

• Sexual masochism disorder

• Sexual sadism disorder

• Pedophilic disorder

• Fetishistic disorder

• Transvestic disorder

Various other presentations exist in which symptoms typical of a paraphilic disorder are present but do not meet the full criteria for any of the diagnoses above. Such presentations include the following:

• Telephone scatologia (recurrent and intense sexual arousal involving obscene phone calls)

• Necrophilia (recurrent and intense sexual arousal involving corpses)

• Zoophilia (recurrent and intense sexual arousal involving animals)

• Coprophilia (recurrent and intense sexual arousal involving feces)

• Klismaphilia (recurrent and intense sexual arousal involving enemas)

• Urophilia (recurrent and intense sexual arousal involving urine)

When the clinician wishes to specify the reason why the criteria for a listed, specific paraphilic disorder are not met, such presentations are placed in the category “other specified paraphilic disorder.” Other specified paraphilic disorders can be specified as in remission and/or as occurring in a controlled environment. If the clinician elects not to specify the reason why the criteria for a listed, specific paraphilic disorder are not met, the category “unspecified paraphilic disorder” is employed. The latter includes presentations in which there is insufficient information to make a more specific diagnosis.

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.

Voyeuristic disorder

The DSM-5 diagnostic criteria for voyeuristic disorder are as follows[1] :

• The patient experiences recurrent and intense sexual arousal (manifested by fantasies, urges, or behaviors) involving the act of observing an unsuspecting person who is naked, in the process of disrobing, or engaging in sexual activity; symptoms must be present for at least 6 months

• The patient experiences significant distress or impairment in social, occupational, or other important areas of functioning because of the fantasies, urges, or behaviors, or the patient has acted on the sexual urges

• The individual experiencing the arousal or acting on the urges is aged at least 18 years

Further specifiers include the following:

• Whether the individual is in a controlled environment (this specifier is primarily applicable to individuals living in institutional or other settings where opportunities to engage in voyeuristic behavior are restricted)

• Whether the disorder is in full remission

Exhibitionistic disorder

The DSM-5 diagnostic criteria for exhibitionistic disorder are as follows:[1]

• The patient experiences recurrent and intense sexual arousal (manifested by fantasies, urges, or behaviors) related to exposing the genitals to a stranger; symptoms must be present for at least 6 months

• The patient experiences significant distress or impairment in social, occupational, or other important areas of functioning because of the fantasies, urges, or behaviors, or the patient has acted on the sexual urges

Further specifiers include the following:

• Whether the individual is sexually aroused by exposing genitals to prepubertal children, to physically mature individuals, or to both

• Whether the individual is in a controlled environment

• Whether the disorder is in full remission

Frotteuristic disorder

The DSM-5 diagnostic criteria for frotteuristic disorder are as follows[1] :

• The patient experiences recurrent and intense sexual arousal (manifested by fantasies, urges, or behaviors) involving touching and rubbing against a nonconsenting person; symptoms must be present for at least 6 months

• The patient experiences significant distress or impairment in social, occupational, or other important areas of functioning because of the fantasies, urges, or behaviors, or the patient has acted on the sexual urges

Further specifiers include the following:/p>

• Whether the individual is in a controlled environment

• Whether the disorder is in full remission

Sexual masochism disorder

The DSM-5 diagnostic criteria for sexual masochism disorder are as follows[1] :

• The patient experiences recurrent and intense sexual arousal (manifested by fantasies, urges, or behaviors) involving the act (real, not simulated) of being humiliated, beaten, bound, or otherwise made to suffer; symptoms must be present for at least 6 months

• The fantasies, urges, or behaviors cause significant distress or impairment in social, occupational, or other important areas of functioning

Further specifiers include the following:

• Whether the individual engages in asphyxiophilia (restriction of breathing)

• Whether the individual is in a controlled environment

• Whether the disorder is in full remission

Sexual sadism disorder

The DSM-5 diagnostic criteria for sexual sadism disorder are as follows[1] :

• The patient experiences recurrent and intense sexual arousal (manifested by fantasies, urges, or behaviors) from the psychological or physical suffering of another person; symptoms must be present for at least 6 months

• The fantasies, urges, or behaviors cause significant distress or impairment in social, occupational, or other important areas of functioning, or the patient has acted on these sexual urges with a nonconsenting person

Further specifiers include the following:

• Whether the individual is in a controlled environment

• Whether the disorder is in full remission

Pedophilic disorder

The DSM-5 diagnostic criteria for pedophilic disorder are as follows[1] :

• The patient reports recurrent and intense sexually arousing fantasies, sexual urges, or behaviors involving sexual activity with a prepubescent child or children (generally ≤13 years); symptoms must be present for at least 6 months

• The disorder causes marked distress or interpersonal difficulty, or the individual has acted on these sexual urges

• The individual is age at least 16 years and at least 5 years older than the victim; individuals in late adolescence involved in an ongoing sexual relationship with a 12- or 13-year-old are excluded

Further specifiers include the following:

• Whether the disorder is exclusive (with attraction only to children) or nonexclusive

• Whether the individual is attracted to males, females, or both (note this is based on controversial gender dichotomy)

• Whether the acts are limited to incest

Fetishistic disorder

The DSM-5 diagnostic criteria for fetishistic disorder are as follows[1] :

• The patient experiences recurrent and intense sexual arousal (manifested by fantasies, urges, or behaviors) either from the use of nonliving objects or from a highly specific focus on nongenital body parts; symptoms must be present for at least 6 months

• The patient experiences significant distress or impairment in social, occupational, or other important areas of functioning because of the fantasies, urges, or behaviors

• The fetishes are not limited to articles of female clothing used in cross-dressing (as in transvestic disorder) or devices designed for genital stimulation (eg, vibrators)

Further specifiers include the following:

• Whether the fetish involves a body part, a nonliving object, or something else

• Whether the individual is in a controlled environment

• Whether the disorder is in full remission

Transvestic disorder

The DSM-5 diagnostic criteria for transvestic disorder are as follows[1] :

• The patient experiences recurrent and intense sexual arousal (manifested by fantasies, urges, or behaviors) from cross-dressing; symptoms must be present for at least 6 months

• These fantasies, urges, or behaviors cause significant distress or impairment in social, occupational, or other important areas of functioning

Further specifiers include the following:

• Whether the individual is sexually aroused by fabrics, materials, or garments (fetishism)

• Whether the individual is sexually aroused by thoughts or images of self as female (autogynephilia)

• Whether the individual is in a controlled environment

• Whether the disorder is in full remission

Paraphilias may exist as discrete anomalies in otherwise stable personalities and thus may go unnoticed by partners, families, and friends. More commonly, however, they coexist with personality disorders, substance misuse or use disorders, anxiety disorders, or affective disorders. It remains unclear why some people act on deviant urges and others do not. Persons with personality disorders who have problems with self-esteem, anger management concerns, difficulty delaying gratification, poor empathetic ability, and faulty cognitions are particularly vulnerable.

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.

Psychoanalytical theory

According to psychoanalytical theory, several possible factors may contribute to the origin of paraphilias. Freund and his colleagues suggested that some paraphilias may be attributed to possible distortion of the courtship phases. Normal courtship behavior is what brings individuals together for the purpose of sexual relations/mating. It usually occurs during adolescence and may or may not involve sexual intercourse at this early stage of sexual development.

Courtship has historically been thought of as composed of the following 4 phases:

1. Search phase – Location of a potential partner

2. Pretactile interaction phase - Talking or flirting with a potential partner

3. Tactile interaction phase – Physical contact with a potential partner, usually consisting of touching, hugging, hand-holding, and similar actions (this could also be considered foreplay)

4. Genital union phase (ie, sexual intercourse)

Although most of the population is capable of appropriate engagement in the phases of courtship, other people are unable to adhere to these socially acceptable norms. Freund et al. indicated that certain deviant or unconventional sexual practices can be viewed as exaggerations or distortions of the 4 phases of courtship. On the basis of Freund’s research with incarcerated sex offenders, one distortion of courtship behavior may result in others. According to this particular literature, however, such distortions are associated only with the first 3 phases.

Voyeurism

In this view, voyeurism is understood as a distortion of the initial courtship phase (ie, 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 to be an outlet for sexual pleasure without the threat of sexual interaction. The risk or danger of discovery may give the voyeur a false sense of masculinity (as also tends to be the case with the exhibitionist).

Exhibitionism

Psychoanalysts consider exhibitionism a distortion of the second courtship phase (ie, pretactile interaction). In psychoanalytical theory, gender identity for a little boy is held to require psychological separation from his mother, so that he will not identify with her as a member of the same sex, as a little girl would. Exhibitionists regard their mothers as rejecting them on the basis of their different genitalia.

Through exhibitionism, the individual attempts to force women to accept him by forcing them to look at his genitals. The act of self-exposure is also a way for the exhibitionist to compensate for his introversion and lack of assertiveness. This act may give the exhibitionist a false sense of power, and the danger of discovery may further reinforce this feeling. In general, psychoanalysts theorize that an exhibitionist’s display of his penis is a way of proving his manhood to the world but also, more importantly, to an adult woman.

Narcissism, the extreme form of self-admiration, is also believed to contribute to exhibitionism. Many narcissist-exhibitionist men are married and have regular sexual contact with their spouses. However, spousal appreciation of their genitalia is not sufficient by itself to fulfill their insatiable need for admiration, and as a consequence, they constantly search for other unsuspecting victims from whom to elicit admiration. The exhibitionist is sometimes compared to an actor on stage who desires an audience but does not want to participate in the act.

Frotteurism and toucherism

Frotteurism and toucherism (toucherism is sexual arousal based on grabbing or rubbing one's hands against an unexpecting and non-consenting person; it usually involves touching breasts, buttocks, or genital areas, often while quickly walking across the victim's path, which are considered exaggerations of the third courtship phase (ie, tactile interaction). These paraphilias provide a sexual outlet without the risk of rejection. Toucherism tends to occur in conjunction with other paraphilias. Freund suggested that these disorders result from unsuccessful negotiation in the developmental stages, which results 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. Paraphilias are thus felt to be a result of accidental conditioning. If nonsexual objects are frequently and repeatedly associated with a pleasurable sexual activity, then the object becomes sexually arousing.[6]

A small study was conducted with 7 heterosexual males, all of whom were free of any fetishes. The men 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 small study conducted to determine whether women could be conditioned to become sexually aroused by a stimulus found no significant differences in physiologic sexual arousal between women in the experimental group and those in the control group. These results imply that sexual arousal is not readily amenable to classic conditioning in women. This might help explain why fetishism and other paraphilias occur almost exclusively in males.

Conditioning does not always involve positive reinforcement; negative reinforcement may also play a role. 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. Individuals with paraphilias usually experience low self-esteem, which may lead to difficulty in forming person-to-person sexual relationships.

Sociobiologic theory

In an article from 1993, Richard A Gardner proposed an approach that combined 2 theories, Dawkins’s theory of gene transmission and Darwin’s well-known theory of survival of the fittest.[7] In a sense, this could be considered a sociobiologic theory.

Dawkins’s theory

In Dawkins’s theory of gene transmission, variations in human sexual behavior, even atypical sexual behaviors (paraphilias), are seen as conducing to the survival of the species. According to this view, the different paraphilias may be responsible for enhancing society’s level of sexual excitation. This higher level of excitation, in turn, would increase the likelihood that people would engage in sex acts that would ultimately lead to procreation.

In earlier (eg, pre−20th century) societies, males more often served the role of hunters and fighters, with females having child-rearing as the primary role. Those men who were more adept at hunting and fighting (protectors and warriors) were more likely to survive and attract females as mates. Those who were weaker were less likely to attract women as desirable mates, because they were unable to provide adequate food, clothing, and shelter, and they were 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, because involvement with such women was more likely to ensure that their genes would be passed down to subsequent generations. Therefore, 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 other 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 is seen in other primates. This does not make us exempt from such mating patterns with the resultant pattern of their expression.

Darwin’s theory

Darwinian theory relates more directly to reproductive capacity. Two of the operative factors in Darwinian theory are quantity and quality. Each species produces more offspring than could possibly survive (quantity); therefore, the individuals that are more capable of adapting to their environment (quality) are more likely to survive and perpetuate the species. In general, species that are less adaptable to their surroundings are more likely to become extinct.[8]

Of the sexes, the male is physically able to produce a far greater quantity of offspring. If a man devoted his whole life to procreation, he could conceivably father or produce as many as 30,000 offspring. On the other hand, if a woman were to devote her entire fecund life to procreation, she could produce no more than 40-45 babies. Accordingly, the female is responsible for quality control.

The female will also ultimately take on the responsibility of child-rearing. Of the other necessary life activities besides fornication and propagation, child-rearing may be the most important. If protection is not provided for the young, they will not survive. Thus, to devote one’s life to the sole purpose of manufacturing babies without the potential for survival would be senseless.

The female tends to be selective in choosing a mate—ideally, one that will best provide for and protect the family. To optimize their ability to make an appropriate choice of a proper mate, women tend to be more cautious in regard to their impulsivity with respect to sexual gratification. Women with inhibited sexual arousal are 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.

Men, on the other hand, 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 the literature, males are typically quicker to arousal than the average female. After gratification from a sexual encounter, they are commonly less likely than females to be interested in maintaining a relationship or commitment.

A commonly cited estimate is that men aged 12-40 years think of sex approximately 6 times an hour. If this estimate is further broken down by age ranges, males aged 12-19 years think of sex an average of 20 times per hour or once every 3 minutes, whereas males aged 30-39 years think of sex only about 4 times per hour. This may be one reason why paraphilias usually occur in males aged 15-25 years.

Such findings suggest that most men are promiscuous, either physically or psychologically; what distinguishes among them is the degree of control that is exerted toward action or inaction in regard to the sexual urges.

Females are much more relationship-oriented, and this may contribute to their greater orgasmic capacity. Although women may require more touching, caressing, and overall romance to become aroused than men do, the resulting arousal is likely to last longer. Most women have the potential for multiple orgasms, which may further enhance the procreative capacity by enabling them to capture the sustained interest and involvement of males who otherwise tend to be slow to ejaculation.

These findings may help explain why men are more like likely to be sexually aroused by visual stimuli and women by 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. Women are more susceptible to caressing, tenderness, and the reassurance of a man’s commitment. This commitment ensures that the male is emotionally invested in the union and will remain around to supply food and protection for the female and their offspring.

United States and international statistics

Paraphilias are rarely diagnosed in clinical settings—possibly, in part, because many of the acts are illegal and reporting methods (ie, self-reporting) may be unreliable. Large commercial markets in paraphilic pornography and paraphernalia suggest that prevalence is high. 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.

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 is less certain but is generally believed to be much lower than that in males.

Frotteuristic disorder 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.

Age-, sex-, and race-related demographics

Most patients are aged 15–25 years. Paraphilic disorders rarely occur in individuals older than 50 years, and data on these disorders in older people are limited. Males are more likely to be affected than females are, and most patients are white.

Predicting treatment outcomes is difficult. Long-term treatment gains appear to require approaches that address the underlying dynamics that go beyond the simple paraphilia itself. The morbidity or mortality of a paraphilia 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. Treatment and prognosis must be based on individual assessment.

The following characteristics are generally associated with a good prognosis:

• Cooperative attitude

• Normal sex life

• Motivated outlook, with a desire to change

• Voluntary approach to treatment

The following characteristics are generally associated with a poor prognosis:

• Early onset of paraphilia

• Legal charges pending

• Unmotivated attitude

• Uncooperative attitude

• Paraphilia as the only sexual activity or outlet

• Comorbidity

• Lack of remorse over acts

Paraphilias are not homogeneous phenomena; considerable variability exists. Nevertheless, a number of issues can be constructively discussed with patients and, when appropriate, with family members. The goal should be to enhance understanding about the issues being faced and the options available to address them (eg, sex education, social skills training, coping skills training, and relapse prevention).

Family education is of particular importance in the treatment of paraphilic disorders. The family should receive education about the disorder, medications, side effects, compliance with treatment, the importance of psychotherapy, and what to do in case of an emergency. The family will need contact information regarding community support programs for the patient and the family.

The family may benefit from involvement in a support group. If the patient is married, marital counseling almost always should be part of the treatment plan. The family also needs to be aware of local laws in regard to paraphilias. If the patient is on probation, the family needs to be aware of court dates and any relevant legal matters.

For some patients with paraphilias, sex offender community notification may be required. It should be kept in mind, however, that many patients with paraphilias have no legal charges filed against them, and even health care workers are not required to report all paraphilias (though reporting is mandatory for some, such as pedophilia).

Some patients may find such mandatory reporting to be a deterrent to seeking treatment for their paraphilia; others may not. Some experts agree that reporting, though required in some situations, may act as a hindrance for some patients who are trying to obtain help for their illness. This will continue to be a matter of community concern and debate for the foreseeable future. The patient should address these concerns with the treatment team. Intensive community supervision is often important.

In paraphilic disorders where significant potential for negative consequences to others poses genuine concern (eg, pedophilic disorder, sexual sadism disorder), the need for long-term therapy and monitoring must be emphasized. Partners, family, and friends should be encouraged to understand the continuing potential for harm and their responsibility to take the necessary steps to protect themselves and others who may be at risk. Warning signs and coping strategies should be discussed and formulated.

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.

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

• Standard medical workup, including complete blood count (CBC), rapid plasma reagent (RPR), and thyroid-stimulating hormone (TSH) level or thyroid function test (TFT)

• HIV screen, if indicated

• Hepatitis panel, if indicated

• Computed tomography (CT) or magnetic resonance imaging (MRI), if intracranial pathology is suspected or if the neurologic examination findings are abnormal

• Penile strain gauge

• Abel assessment for interest in paraphilia

• Phallometric testing

• Electroencephalography (EEG), if indicated

The various paraphilic disorders affect a wide variety of people. The level of severity, distress, and impairment (up to and including criminal behavior) resulting from these disorders also are highly variable. Consequently, treatment options vary and must take into account the specific needs of each individual case.

Treatment options may include individual psychotherapy, group therapy, marital/couple therapy, and family therapy, as well as pharmacotherapy or even (rarely) surgical interventions, as indicated.

Inpatient treatment is indicated for patients who are suicidal, homicidal, or disabled to the point where they cannot take care of themselves. Suicide risk may be high if they feel exposed or confronted. If patients are charged with a crime or have been arrested, they may be incarcerated.[19]

Physicians must be aware that not every therapist treats people with paraphilias. There may be a need for consultations with other professionals, such as a neurologist (if neurologic signs are present), an attorney, or even a member of the clergy depending on the needs and wishes of a given patient.

Considerations for particular paraphilic disorders

For adults with exhibitionistic disorder (those with sociopathy excluded), group therapy has been effective in improving social skills and providing support against additional offenses. Specifically, group therapy has been effective with shy inhibited adolescents but not with compulsive instinct-ridden adolescents. Individual psychotherapy has been helpful with many exhibitionists. Unfortunately, exhibitionism has one of the highest recidivist rates of all sexual offenses.

Fetishistic disorder often begins in adolescence and usually persists. Treatment of the specific fetish rather than the primary underlying dynamic has not been very promising. Behavioral techniques show some promise, particularly when aided by adequate follow-up.

Many individuals with pedophilic disorder have had sexual fantasies about children for a long time. Consequently, change can be very difficult. The physician can try to reduce the intensity of the fantasies and help the abuser develop coping strategies. The abuser must be (but often is not) willing to acknowledge the problem and to participate in treatment. Dynamic psychotherapy, behavioral techniques, chemical approaches, and surgical interventions yield mixed results. Lifelong maintenance may be the most pragmatic and realistic approach.

Unfortunately, individuals with sexual masochism or sadism disorder rarely present for treatment until someone becomes an unwilling partner or is injured. The seriousness and intensity of these behaviors often increase over time. Prognosis varies, depending on the depth of the underlying dynamics (which are especially poor when sociopathy is involved) and the patient’s level of motivation.

Cognitive-behavioral therapy

Cognitive-behavioral therapy (CBT) involves applying behavioral therapy techniques to modify sexual deviations by altering patients’ distorted thinking patterns and making them cognizant of the irrational justifications that lead to their undesirable sexual behaviors. It may be employed in accordance with a 7-step approach, as follows:

1. Aversive conditioning with ammonia or (masturbatory) satiation

2. Confrontation of cognitive distortions (especially effective in groups)

3. Victim empathy (showing videos of victims and the consequences they experience from the patient’s act)

4. Assertiveness training (including social skills training, time management, and structuring)

5. Relapse prevention (identifying antecedents to the behavior [high-risk situations] and ways of disrupting these antecedents)

6. Surveillance systems (family associates who help monitor patient behavior)

7. Lifelong maintenance

The incorporation of relapse prevention techniques helps the patient control the undesirable behaviors by avoiding situations that may generate initial desires. The commonly employed technique of covert sensitization pairs a patient’s harmful sexual variation with an unpleasant stimulus in order to discourage repetition of the act. This approach has proved effective in many cases of pedophilia and sadism.

Orgasmic reconditioning

In orgasmic reconditioning, a patient is reconditioned to a more appropriate sexual stimulus. First, the patient is instructed to masturbate to his or her typical, less socially acceptable stimulus. Then, just before orgasm, the patient is told to concentrate on a more acceptable fantasy. This process is repeated at progressively earlier points before orgasm until, eventually, the patient begins his or her masturbation fantasies with an appropriate stimulus.

Social skills training

Because of the widespread view that paraphilic disorders develop in patients who lack the ability to develop relationships, many therapists and physicians use social skills training to treat patients with these types of disorders. They may work on such issues as developing intimacy, carrying on conversations with others, and assertive skills training. Many social skills training groups also teach basic sexual education, which is very helpful to this patient population.

Twelve-step programs

Many physicians and therapists refer patients with paraphilias to 12-step programs designed for "sexual addicts." Like Alcoholics Anonymous, these programs are designed to give control to group members, who lead most of the sessions. To increase awareness of the problem, the programs incorporate cognitive restructuring with social support. The group also focuses on the sense of a “higher power” and each individual’s reliance upon spirituality.

Group therapy

Group therapy in this setting is designed to help paraphilic individuals break through the denial they so commonly exhibit by surrounding them with other patients who share their condition. Once these individuals begin to admit that they have a sexual divergence, the therapist can begin to address individual issues (eg, past sexual abuse) that may have led to the sexual disorder.

When these individual issues have been identified, initiation of gestalt-type therapy (with the victim, if any) may be desirable to help patients get past the guilt and shame associated with their particular paraphilia. The goal of this type of therapy is to lead the patient to a “healthy remorse.” These patients require lifetime therapy to reduce the likelihood of relapse.

Individual expressive-supportive psychotherapy

Individual expressive-supportive therapy requires a psychologically minded patient who is willing to focus on the paraphilia. The therapist should not set unrealistically high goals but must break through the denial. Patient countertransference and avoidance can be particular problems with this form of therapy. If the therapy enables the patient to break through the denial, they can then work on the unconscious meaning behind the particular paraphilia.

Pharmacologic interventions may be used to suppress sexual behavior. These treatments may offer genuine help to a variety of patients with paraphilic disorders; however, numerous adverse effects have been reported. Additionally, ethical, medical, and legal questions have been raised regarding issues of informed consent, especially in hospital and prison settings.

Medications that may be considered in the treatment of paraphilic disorders include the following:

• Antidepressants, such as lithium and various selective serotonin reuptake inhibitors (SSRIs)

• Long-acting gonadotropin-releasing hormones (ie, medical castration), such as leuprolide acetate and triptorelin

• Antiandrogens (to lower sex drive), such as medroxyprogesterone acetate (10 mg q12hr, with the dosage doubled every 3 days to a maximum of 200 mg/day, then maintained for 1 month and adjusted as necessary)

• Phenothiazines, such as fluphenazine

• Mood stabilizers

SSRIs may be prescribed specifically to treat associated compulsive sexual disorders, to induce libido-lowering sexual side effects, or both. The dosages used are higher than those typically administered for depression. Usual dosage ranges for several SSRIs commonly employed in this setting are as follows:

• Sertraline - 150–200 mg/day

• Fluoxetine - 20–80 mg/day

• Fluvoxamine - 200–300 mg/day

• Citalopram - 20–80 mg/day (caution needed in doses > 40 mg/day given risk for QTc prolongation)

• Escitalopram - 10–40 mg/day (caution needed in doses > 20 mg/day given risk for QTc prolongation)

• Paroxetine - 20–60 mg/day

Psychosurgery using stereotaxic tractotomy and limbic leucotomy may be performed. This is an invasive, irreversible procedure that was used on a small number of subjects, primarily in Germany. Some success has been reported in the treatment of pedophilia, hypersexuality, and exhibitionism. Given its emotional, physical, and intellectual adverse effects, as well as the availability of suitable pharmacologic interventions, this procedure is not likely to be widely used.

Bilateral orchidectomy (surgical castration) has been used since the 19th century in Europe and America, though not in Western Europe since the 1970s. Given the adverse effects of the procedure (eg, weight disturbance, gynecomastia, hot flashes, osteoporosis and bone pain in elderly patients, depression), it also is not likely to be widely used; pharmacologic interventions provide a reversible alternative.

For optimal results, patients require medication management and psychotherapy. If the patient began medication therapy in the hospital, the same therapy should be continued afterward and adjusted as necessary. If not, appropriate medications should be selected, and their risks, benefits, adverse effects, and alternatives should be discussed with the patient. Informed consent must be obtained before pharmacotherapy is initiated.

Restrictions should be imposed on activity as necessary if patients represent a danger to themselves or to others or if they are gravely disabled.

The goals of pharmacotherapy are to reduce morbidity and prevent complications. Agents employed in the management of paraphilic disorders include antidepressants, antiandrogens, phenothiazines, anxiolytics, long-acting gonadotropin-releasing hormone (GnRH) agonists, and mood stabilizers.

Class Summary

Serotonergic antidepressants such as SSRIs may be used off-label to decrease sexual obsessions and compulsive/impulsive sexual behavior, and/or induce sexual side effects.

Fluoxetine (Prozac)

Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) used to treat impulse-control problems or underlying illness. It selectively inhibits presynaptic serotonin reuptake, with minimal or no effect on the reuptake of norepinephrine or dopamine.

Paroxetine (Paxil, Pexeva)

Paroxetine is a potent selective inhibitor of neuronal serotonin reuptake; it also has a weak effect on norepinephrine and dopamine neuronal reuptake. Paroxetine is not FDA-approved for use in children. 

Citalopram (Celexa)

Citalopram appears to have the most benign side effect profile, with fewer sexual adverse effects than other SSRIs. It is not FDA-approved for children. 

Sertraline (Zoloft)

Selective inhibitor of neuronal serotonin reuptake; it also has a weak effect on norepinephrine and dopamine neuronal reuptake.

Fluvoxamine

Fluvoxamine is a potent selective inhibitor of neuronal serotonin reuptake. It does not significantly bind to alpha-adrenergic, histamine, or cholinergic receptors and thus has fewer adverse effects than TCAs do.

Escitalopram (Lexapro)

This agent is an SSRI and an S-enantiomer of citalopram that is used for the treatment of depression. Escitalopram enhances serotonin activity because of selective reuptake inhibition at the neuronal membrane. Its mechanism of action is thought to be the potentiation of serotonergic activity in the central nervous system (CNS) through the inhibition of CNS neuronal reuptake of serotonin. 

Class Summary

Non-benzodiazepine anxiolytics may help induce impulse control (off-label).

Buspirone

Buspirone is a unique anxiolytic that differs from benzodiazepines in that it does not exert anticonvulsant or muscle-relaxing effects for generalized anxiety disorder (GAD). It is a serotonin agonist with serotonergic neurotransmission and some dopaminergic effects in the central nervous system (CNS). It has an anxiolytic effect, but may take as long as 2-3 weeks to achieve full efficacy.

Class Summary

Long-acting GnRH agonists are used to reduce release of gonadotropin hormones.

Triptorelin (Trelstar, Triptodur)

Triptorelin is a synthetic decapeptide agonist analogue of GnRH, also known as luteinizing hormone (LH)-releasing hormone (LHRH). By reducing LH, follicle-stimulating hormone (FSH), and testosterone, it may lead to reduced sex drive.

Leuprolide (Eligard, Fensolvi, Lupron)

Leuprolide is a synthetic nonapeptide analogue of GnRH. When continuously administered, it acts as a potent inhibitor of gonadotropin secretion.

Class Summary

These agents are used to treat bipolar disorder and may have off-label benefit for aggression and impulse control.

Valproic acid (Depakote)

Valproic acid is indicated for manic episodes associated with bipolar disorder. Valproic acid is the most widely used agent in its class. It is modestly effective and generally well tolerated. It is chemically unrelated to other drugs that treat seizure disorders. Although its mechanism of action is not established, its activity may be related to increased brain levels of gamma-aminobutyric acid (GABA) or enhanced GABA action. It also may potentiate postsynaptic GABA responses, affect potassium channels, or have a direct membrane-stabilizing effect. The recommended plasma concentration is 50-125 µg/mL. 

Class Summary

These agents are used to treat bipolar disorder and may have off-label benefit for aggression and impulse control.

Lithium (Lithobid)

Lithium is indicated to treat bipolar disorder. The specific mechanism of action is unknown, but the drug alters sodium transport in nerve and muscle cells and influences reuptake of serotonin, norepinephrine, or both at cell membranes.

Class Summary

Antiandrogenic agents are given to reduce androgen serum levels.

Medroxyprogesterone (Depo-Provera, Provera)

Medroxyprogesterone may reduce the secretion of LH and FSH from the pituitary by decreasing the amount of GnRH secreted by the hypothalamus. This suppression in turn suppresses sex characteristics in males and may be used to reduce sex drive.

Class Summary

Phenothiazines may act through their effects in the dopaminergic mesolimbic system. Sometimes used off-label for treatment of aggression.

Fluphenazine

Fluphenazine is a high-potency typical antipsychotic with pharmacology similar to that of haloperidol. Used to treat underlying illness or decrease aggression.