The term was coined by Wilhelm Stekel in the 1920s and popularized by John Money in the 1960s. Psychologists and psychiatrists codified paraphilias as disorders in the 1980 Diagnostic and Statistical Manual of Mental Disorders (DSM). The DSM describes them as conditions which "are characterized by recurrent, intense sexual urges, fantasies, or behaviors that involve unusual objects, activities, or situations and cause clinically significant distress or impairment in social, occupational, or other important areas of functioning," according to the DSM-IV-TR, p. 535. Sexual arousal in association with objects that were designed for sexual purposes is not DSM diagnosable (DSM, p. 570). Some people diagnosed with paraphilias undergo voluntarily or involuntarily intervention to alter their behavior. Psychiatrist Glen Gabbard writes that despite efforts by Stekel and Money, "the term paraphilia remains pejorative in most circumstances."
The view of paraphilias as disorders is not universal. Charles Moser, a physician and advocate for sexual minorities, has argued that the diagnoses should be eliminated. Groups seeking greater understanding and acceptance of sexual diversity have lobbied for changes to the legal and medical status of unusual sexual interests and practices.
There is scientific and political controversy regarding the continued inclusion of sex-related diagnoses such as the paraphilias (sexual fetishes) and female hypoactive sexual desire disorder (low female sex drive) in the DSM. The APA's decision to remove homosexuality from the DSM has been cited by some researchers as evidence that the APA incorrectly referred to these states of being or orientations as mental illnesses.
It has also been argued that the design of the DSM and the expansion of the criteria represents an increasing medicalization of human nature, or "disease mongering", driven by drug company influence on psychiatry. The potential for direct conflict of interest has been raised, partly because roughly half the authors who selected and defined the DSM-IV psychiatric disorders had or previously had financial relationships with the pharmaceutical industry. The president of the organisation that designs and publishes the DSM, the American Psychiatric Association, recently acknowledged that in general American psychiatry has "allowed the biopsychosocial model to become the bio-bio-bio model" and routinely accepted "kickbacks and bribes" from pharmaceutical companies.
Moreover, there has been continuing scientific doubt concerning the construct validity and reliability of the diagnostic categories and criteria in the DSM even though they have been increasingly standardized to improve inter-rater agreement in controlled research. It has been argued that the DSM's claims to being empirically founded are overstated in general. Reliance on operational definitions demands that intuitive concepts such as depression need to be operationally defined before they become amenable to scientific investigation. Such definitions are used as a follow-up to a conceptual definition, in which the specific concept is defined as a measurable occurrence. John Stuart Mill pointed out the dangers of believing that anything that could be given a name must refer to a thing and Stephen Jay Gould and others have criticized psychologists for doing just that. A committed operationalist would respond that speculation about the thing in itself, or noumenon, should be resisted as meaningless, and would comment only on phenomena using operationally defined terms and tables of operationally defined measurements.
Similarly, some argue that the existing scheme does not take an integrated evolutionary approach to the conditions it classifies. It is claimed that it is "not guided by any theory about the structure and functioning of normal minds, and fails to make distinctions between those conditions which are "malfunctions" in the cognitive machinery and those which are evolved psychological adaptations. Some argue these distinctions have real implications for diagnosis and treatment, but there is also debate about their implications and the value judgements involved.
Albert Eulenburg (1914) noted a commonality across the paraphilias, using the terminology of his time, "All the forms of sexual perversion...have one thing in common: their roots reach down into the matrix of natural and normal sex life; there they are somehow closely connected with the feelings and expressions of our physiological erotism. They are...hyperbolic intensifications, distortions, monstrous fruits of certain partial and secondary expressions of this erotism which is considered 'normal' or at least within the limits of healthy sex feeling.
The clinical literature contains reports of many paraphilias, only some of which receive their own entries in the diagnostic taxonomies of the American Psychiatric Association or the World Health Organization. There is disagreement regarding which sexual interests should be deemed paraphilic disorders versus normal variants of sexual interest. For example, as of May 2000, per DSM-IV-TR, "Because some cases of Sexual Sadism may not involve harm to a victim (e.g., inflicting humiliation on a consenting partner), the wording for sexual sadism involves a hybrid of the DSM-III-R and DSM-IV wording (i.e., “the person has acted on these urges with a non-consenting person, or the urges, sexual fantasies, or behaviors cause marked distress or interpersonal difficulty”)".
The exact criteria for a DSM-IV-TR diagnosis of paraphilia are:
"Paraphilias are defined by DSM-IV-TR as sexual disorders characterized by "recurrent, intense sexually arousing fantasies, sexual urges or behaviors generally involving (1) nonhuman objects, (2) the suffering or humiliation of oneself or one's partner, or (3) children or other nonconsenting persons that occur over a period of 6 months" (Criterion A), which "cause clinically significant distress or impairment in social, occupational, or other important areas of functioning" (Criterion B). DSM-IV-TR describes 8 specific disorders of this type (exhibitionism, fetishism, frotteurism, pedophilia, sexual masochism, sexual sadism, voyeurism, and transvestic fetishism) along with a ninth residual category, paraphilia not otherwise specified (NOS).
Some paraphilias may interfere with the capacity for sexual activity with consenting adult partners. According to the DSM, "Paraphilias are almost never diagnosed in females," but some case studies of females with paraphilias have been published.
The DSM provides clinical criteria for these paraphilias:
Under Paraphilia NOS, the DSM mentions telephone scatalogia (obscene phone calls), necrophilia (corpses), partialism (exclusive focus on one part of the body), zoophilia (animals), coprophilia (feces), klismaphilia (enemas), urophilia (urine), emetophilia (vomit). The DSM's Paraphilia NOS is equivalent to the ICD-9's Sexual Disorder NOS.
The literature includes single-case studies of exceedingly rare and idiosyncratic paraphilias. These include an adolescent male who had a strong fetishistic interest in the exhaust pipes of cars, a young man with a similar interest in a specific type of car, and a man who had a paraphilic interest in sneezing (both his own and the sneezing of others). See also List of paraphilias.
Optional paraphilias are far more common than preferred paraphilias, which are, in turn, far more common than exclusive paraphilias.
Optional paraphilias sometimes disrupt stable relationships when discovered by an unsuspecting partner. Preferred paraphilias often disrupt otherwise stable relationships. Open communication and mutual support can minimize or prevent such disruption in both of these cases. Exclusive paraphilias often preclude normal courtship and committed romantic relationships, even when the person in question desires such a relationship. Loneliness or social isolation are common consequences. In extreme cases, preoccupation with a preferred or exclusive paraphilia completely displaces the more typical desire for loving human relationships.
Antiandrogenic drugs such as medroxyprogesterone (also known as the long-acting contraceptive Depo Provera) have been widely used as therapy in these men to reduce sex drive. However, their efficacy is limited and they have many unpleasant side effects, including breast growth, headaches, weight gain, and reduction in bone density. Even if compliance is good, only 60 to 80 percent of men benefit from this type of drug. Long-acting gonadotropin-releasing hormones, such as Triptorelin (Trelstar) which reduces the release of gonadotropin hormones, are also used. This drug is a synthetic hormone which may also lead to reduced sex drive.
Tricyclic antidepressants (TCA), such as imipramine (Tofranil) and desipramine (Norpramin), are also used.
Lithium, the mood-stabilizing drug also known as Eskalith is typically used for the treatment of mania in bipolar disorder. There are some reports of reduced sexual compulsive behavior and a reduction in obsessive sexual thoughts in patients, which they attribute to the drug's enhancement of serotonergic functioning.
Anxiolytics are not considered a typical treatment for these type of disorders, however the efficacy of buspirone (BuSpar) has been clinically demonstrated.
Psychostimulants have been used recently to augment the effects of serotonergic drugs in paraphiliacs. In theory, the prescription of a psychostimulant without pretreatment with an SSRI might further disinhibit sexual behavior, but when taken together, the psychostimulant may actually reduce impulsive tendencies. Methylphenidate (Ritalin) is an amphetamine like stimulant used primarily to manage the symptoms of attention deficit hyperactivity disorder (ADHD). Recent studies imply that methylphenidate may also act on serotonergic systems; this may be important in explaining the paradoxical calming effect of stimulants on ADHD patients. Amphetamine is also used medically as an adjunct to antidepressants in refractory cases of depression.
Some religious traditions include forms of extreme asceticism, such as whipping, which, when practiced as sexual activities, would usually be considered masochism and popularly viewed as paraphilias. When practiced for non-sexual reasons, they are usually valued by the religious groups concerned as a part of their religious observance and submission to their god.
Exhibitionism, in cases where people who have not previously agreed to watch are exposed to sexual display, is also an offense in most jurisdictions, as is voyeurism when unarranged (see indecent exposure and peeping tom).
Non-consensual sadomasochistic acts may legally constitute assault and therefore belong in the list below. Some jurisdictions criminalize some or all sadomasochistic acts, regardless of legal consent, and impose liability for any injuries caused. For these purposes, non-physical injuries are included in the definition of grievous bodily harm in English law. (See Consent (BDSM), Operation Spanner)