Paraphilic disorders are conditions where there’s a recurrent, intense urge or sexually arousing fantasy that’s distressing or disabling because it involves inanimate objects, children or nonconsenting adults, or suffering or humiliation of oneself or another person.
Psychological factors are thought to play a major role, especially events in childhood that led the individual to associate sexual pleasure with a specific event or object.
Often, a child who is the victim or observer of inappropriate sexual behaviors – including online, learns to later imitate the behavior.
Other causes include childhood sexual abuse, substance abuse, hypersexuality, exhibitionism, and a history of antisocial behavior and sexual anxiety.
Paraphilia refers to a persistent sexual interest in things other than sex or foreplay with physically mature, consenting human partners.
However, for a paraphilia to turn into a paraphilic disorder, there are some additional criteria.
First, in paraphilic disorders the symptoms last for at least 6 months.
Second, the sexual urges must manifest as either fantasies, urges that cannot be controlled, or sexual behaviors like masturbation.
Third, the individual must have acted on these unusual sexual urges with a nonconsenting person, or they must cause anxiety, obsessions, guilt, or shame; or impairment in important areas of functioning – including sex.
According to DSM-V, there are ten disorders included in this category: voyeuristic disorder, exhibitionistic disorder, frotteuristic disorder, sexual masochism disorder, sexual sadism disorder, pedophilic disorder, fetishistic disorder, transvestic disorder, and other specified and unspecified paraphilic disorder.
The other specified and unspecified paraphilic disorder diagnoses can be applied to the various other paraphilias that cause distress or impairment.
In voyeuristic disorder the individual is at least 18 years old and experiences sexual arousal from observing an unsuspecting person who is naked, getting naked, or having sex.
In exhibitionistic disorder, the individual feels sexual arousal from exposing their genitals to an unsuspecting person.
The clinician also has to specify if the individual is sexually aroused by exposing genitals to prepubertal children, to physically mature individuals, or both.
This can help identify a co-occurring pedophilic disorder.
Third, in frotteuristic disorder, there’s recurrent and intense sexual arousal from touching or rubbing against a nonconsenting person.
Fourth, in sexual masochism disorder, there is sexual arousal from the act of being humiliated, beaten, bound, or otherwise made to suffer.
Fifth, in sexual sadism disorder the individual is sexually aroused by the physical or psychological suffering of another person.
Sixth, in pedophilic disorder, people have sexually arousing fantasies and sexual urges that involve a prepubescent child, generally age 13 years or younger.
Moreover, the individual is at least age 16 years old and at least 5 years older than the child.
Seventh, fetishistic disorder involves sexual arousal from the use of inanimate objects or have a highly specific focus on a nongenital body part like feet.
Also, the fetish objects are not limited to articles of clothing used in cross-dressing as in transvestic disorder or devices specifically designed for tactile genital stimulation.
Eighth, transvestic disorder is when individuals experience sexual arousal from cross-dressing.
The diagnosis of transvestic disorder does not apply to all individuals who dress as the opposite sex, even those who do so habitually.
It applies to individuals whose cross-dressing or thoughts of cross-dressing are accompanied by sexual excitement and are emotionally distressed by this behavior or feel it impairs their social or interpersonal functioning.
And lastly, the other specified and the unspecified paraphilic disorder categories apply to presentations characteristic of a paraphilic disorder that causes distress or impairment but does not meet the full criteria for any other.
The other specified paraphilic disorder category is used when the clinician chooses to communicate the specific reason that the presentation does not meet the criteria, whereas the unspecified paraphilic disorder category is when the clinician chooses not to specify it.
Regarding treatment, there are psychological approaches, medication, and lifestyle changes that can all help.
Psychological approaches are considered first-line treatment and can include traditional psychoanalysis, hypnosis, and behavior therapy techniques.
Therapies include aversive conditioning which involves using negative stimuli to reduce or eliminate a behavior, covert sensitization which revolves around visualizing scenes of deviant behavior followed by a negative event such as getting the genitals stuck in the zipper of the pants, or assisted aversive conditioning where the negative event is made real, usually in the form of a foul odor.
There are also positive conditioning approaches, which usually focus on social skills training and alternate behaviors the individual might take that are more appropriate.
Cognitive therapies include restructuring cognitive distortions and empathy training.
Restructuring cognitive distortions involves correcting deviant beliefs the individual might have like thinking strangers are asking to be touched inappropriately on the bus.
Empathy training involves helping the offender take on the perspective of the victim and understand the harm that their actions can cause.
Medications typically have a limited role in these conditions, and when they are used, they work best when combined with cognitive behavioral therapy.
Antiandrogens such as medroxyprogesterone acetate and cyproterone acetate decrease the level of circulating testosterone, and thus reduce the sex drive and levels of aggression.
These hormones result in the reduction of the frequency of erections, sexual fantasies, and initiation of sexual behaviors, including masturbation and sex.
Due to the side effects, they’re typically only used when there’s a serious risk of sexual violence, or when other methods have failed.
Antidepressants such as paroxetine can decrease sex drive but don’t effectively target sexual fantasies.
As an example, paroxetine can be used at an initial dose of 20 milligrams per day, which can be increased in increments of 10 to 20 milligrams per day, up to a daily dose of 50 milligrams.
These medications cause reduced libido in women and men, anorgasmia in women, and erectile dysfunction in men.
And lastly, common lifestyle changes include getting educated on the nature of the paraphilia, on the societal perceptions of the sexual behavior, and on how the victims experience the paraphilic behaviors.
Support from family and partners is also vital, especially when it comes to learning empathy skills. Additionally, addressing low self-esteem can lead to better treatment adherence and shorten the treatment period.
Summary
In all paraphilic disorders, symptoms must last for at least 6 months, the sexual urges must manifest as either fantasies, urges, or sexual behaviors, and the individual must have acted on these unusual sexual urges with a nonconsenting person, or, alternatively, these urges must cause either distress or impairment.
In voyeuristic disorder the individual is at least 18 and experiences sexual arousal from observing an unsuspecting person who is naked, getting naked, or having sex.
In exhibitionistic disorder, the sexual arousal stems from exposing their genitals to an unsuspecting person.
In frotteuristic disorder, there’s sexual arousal from touching or rubbing against a nonconsenting person.
In sexual masochism disorder, the sexual arousal is generated by being made to suffer or humiliated.
Sexual sadism disorder is when the individual is sexually aroused by physical or psychological suffering of another person.
Next, pedophilic disorder is when people have sexually arousing fantasies, sexual urges, or do things that involve sexual activity with a prepubescent child or children.
Fetishistic disorder presents sexual arousal from either the use of nonliving objects or a highly specific focus on a nongenital body part like feet.
And transvestic disorder is when individuals experience sexual arousal from cross-dressing but feel distress from that behavior.
Treatment-wise, psychological approaches are considered first-line treatment and that includes traditional psychoanalysis, hypnosis, and behavior therapy techniques.
The most used techniques are aversive conditioning, covert sensitization, restructuring cognitive distortions, and empathy training.
Pharmacological treatments include antiandrogens and antidepressants such as paroxetine.
And lastly, common lifestyle changes include getting educated on the nature of the paraphilia, on the societal perceptions of particular sexual behavior, and on how the victims experience the paraphilic behaviors.
Blog| Mehdi Gorbani 