Paraphilia

[par-uh-fil-ee-uh]

Paraphilia (in Greek para παρά = besides and -philia φιλία = love) refers to traits and behaviors involving nonstandard or unusual sexual interest.

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.

General concerns

Terminological issues and precautionary information

It is important to distinguish the differences between paraphilial psychopathology and psychologically normative, adult human sexual behaviors, sexual fantasy and sex play, because these terms have historically and terminologically been used in interchangeable manners that are sometimes ambiguous and misconstrued, which can allow for cognitive and clinical diagnostic misjudgment to occur. Consensual adult activities and adult entertainment that may involve some aspects of sexual roleplay, novel, superficial or trivial aspects of sexual fetishism, or may incorporate the use of adult novelties, such as sex toys, are not automatically or by default, inherently psychopathological or paraphilial in nature. Some humans incorporate said adult consensual activity and adult novelty items, such as sex toys, in consensually phantasmal manners to encourage or enhance normative adult sexual fantasy, their overall sexual experience or as a means to promote or enhance sexual foreplay. In this particular context, acting in said consensually phantasmic manners and constructs to gratify normative human sexual fantasy is not automatically or by default indicative of paraphilial psychopathology, and quite conversely, can serve to pique, or excite, the arousal phase of the human sexual response cycle in manners that can enhance fertility and procreation. A statistically significant example of this phenomenon is the ongoing existence and rapid combined economic growth, expansion and success of the adult entertainment and adult novelty (or sex toy) industries, both of which are multi-billion dollar industries that produce and market products and videography involving said consensual adult sex play activities. The exponential lucrative economic successes and successions of these business ventures, including high volume sales and distributions of stated products, gross revenues and profits is in and of itself, evidentiary that humans sometimes incorporate said sex play fantasies and activities in consensual manners that are not psychologically harmful to themselves or to other humans, and hence, are not psychologically paraphilial in nature.

Classificational issues and precautionary information

It has long been argued that the Diagnostic and Statistical Manual of Mental Disorders (DSM) system of classification makes unjustified categorical distinctions between disorders, and between normal and abnormal. Although the DSM-V may move away from this categorical approach in some limited areas, some argue that a fully dimensional, spectrum or complaint-oriented approach would better reflect the evidence.

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.

Clinical views

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:

Exhibitionism: the recurrent urge or behavior to expose one's genitals to an unsuspecting person. (Can also be the recurrent urge or behavior to perform sexual acts in a public place, or in view of unsuspecting persons.)
Fetishism: the use of inanimate objects to gain sexual excitement. Partialism refers to fetishes specifically involving nonsexual parts of the body.
Frotteurism: the recurrent urges of behavior of touching or rubbing against a nonconsenting person.
Pedophilia: a psychological disorder in which an adult experiences a sexual preference for prepubescent children, or has engaged in child sexual abuse.
Sexual Masochism: the recurrent urge or behavior of wanting to be humiliated, beaten, bound, or otherwise made to suffer for sexual pleasure.
Sexual Sadism: the recurrent urge or behavior involving acts in which the pain or humiliation of a person is sexually exciting.
Transvestic fetishism: arousal from "clothing associated with members of the opposite sex."
Voyeurism: the recurrent urge or behavior to observe an unsuspecting person who is naked, disrobing or engaging in sexual activities, or may not be sexual in nature at all.

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.

Intensity and specificity

Clinicians distinguish between optional, preferred and exclusive paraphilias, though the terminology is not completely standardized. An "optional" paraphilia is an alternative route to sexual arousal. For example, a man with otherwise unremarkable sexual interests might sometimes seek or enhance sexual arousal by wearing women's underwear. In preferred paraphilias, a person prefers the paraphilia to conventional sexual activities, but also engages in conventional sexual activities. For example, a man might prefer to wear women's underwear during sexual activity, whenever possible. In exclusive paraphilias, a person is unable to become sexually aroused in the absence of the paraphilia.

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.

Drug treatments

The treatment of paraphilias and related disorders has been challenging for patients and clinicians. In the past, surgical castration was advocated as a therapy for men with paraphilias, but it was abandoned because it is considered a cruel punishment and is now illegal in most countries. Psychotherapy, self-help groups, and pharmacotherapy (including the controversial hormone therapy sometimes referred to as "chemical castration") have all been used but are often unsuccessful. Other drug treatments for these disorders do exist, however.

Hormone drug treatments

In humans, testosterone has a crucial role not only in the development and maintenance of male sexual characteristics but also in the control of sexuality, aggression, cognition, emotion, and personality. Testosterone is a major determinant of sexual desire, fantasies, and behavior, and it increases the frequency, duration, and magnitude of spontaneous and nocturnal erections. The deviant sexual fantasies, urges, and behavior of men with paraphilias also appear to be triggered by testosterone. Therefore, reducing testosterone secretion or inhibiting its action is believed to control these symptoms.

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.

Psychoactive drug treatments

Selective serotonin reuptake inhibitor (SSRI) class of antidepressants such as fluoxetine (Prozac), sertraline (Zoloft), fluvoxamine (Luvox), and paroxitine (Paxil), have all been used to treat paraphilias and related disorders by reducing impulse control problems and/or sexual obsessions with some success.

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.

Religious views

Various religious adherents view various paraphilias as deviations from a divine purpose for human sexuality, as understood through their religious tradition or laws. Depending in part on the nature of the paraphilia in question, judgements can differ as to whether religiously it should be considered a case of sexual sin, mental illness, or simply harmless sexual variation. Another variable is whether it is the acting out, or (less commonly) just the desirous thought alone, which is critically viewed in such cases. In any event, several paraphilias, such as bestiality or pedophilia, are viewed negatively by various religions.

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.

Legal views

As a general rule, the law in many countries often intervenes in paraphilias involving young or adolescent children below the legal age of consent and sex with animals due to duty of care issues and general public abhorrence of the practice. There is also legal intervention concerning nonconsensual deliberate displays or illicit watching of sexual activity, illegal manipulation of dead people, harassment, nuisance, fear, injury, or assault of a sexual nature. Separately, it also usually regulates or controls censorship of pornographic material.

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)