Paraphilia
Encyclopedia
Paraphilia is a biomedical term used to describe sexual arousal
to objects, situations, or individuals that are not part of normative
stimulation and that may cause distress or serious problems for the paraphiliac or persons associated with him or her. A paraphilia involves sexual arousal and gratification towards sexual behavior that is atypical or extreme.
The term was coined by Wilhelm Stekel
in the 1920s. Controversial sexologist John Money
later popularized the term as a nonpejorative designation for unusual sexual interests
. He described paraphilia as "a sexuoerotic embellishment of, or alternative to the official, ideological norm."
In the late 19th century, psychologists and psychiatrists started to categorize various paraphilias as they wanted a more descriptive system than the legal and religious constructs of sodomy
and perversion
. Before the introduction of the term paraphilia in the DSM-III (1980), the term sexual deviation was used to refer to paraphilias in the first two editions of the manual. American Journal of Psychiatry
describes paraphilia as "recurrent, intense sexually arousing fantasies, sexual urges, or behaviors generally involving:
Up until 1973, sexual attraction to persons of the same sex
was included in this list.
The view of paraphilias as disorders is not universal. Some 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. Charles Allen Moser
, a physician and advocate for sexual minorities, has argued that the diagnoses should be eliminated from diagnostic manuals. Psychiatrist Glen Gabbard
writes that despite efforts by Stekel and Money, "the term paraphilia remains pejorative
in most circumstances."
In the current version of the DSM (DSM-IV-TR), a paraphilia is not diagnosable as a psychiatric disorder unless it causes distress to the individual or harm to others. The DSM-5
draft adds a terminology distinction between the two cases, stating that "paraphilias are not ipso facto
psychiatric disorders", and defining paraphilic disorder as "a paraphilia that causes distress or impairment to the individual or harm to others". This will make a clear distinction between a healthy person with a non-normative sexual behavior and a person with a psychopathological non-normative sexual behavior.
In the United States, following a series of landmark cases in the US Supreme Court, persons diagnosed with paraphilias and a history of anti-social behavior, particularly pedophilia (Kansas v. Hendricks
, 1997) and exhibitionism (Kansas v. Crane
, 2002), can be held indefinitely in civil confinement
under various state legislation generically known as Sexually violent predator laws and the federal Adam Walsh Act (United States v. Comstock
, 2010).
is not the same as psychologically
normative adult human sexual behavior
s, sexual fantasy
, and sex play. These terms have been used in interchangeable ways 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 sex toys are not necessarily paraphilic.
(DSM) system of classification makes unjustified categorical distinctions between disorders, and between normal and abnormal. Although the DSM-5 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 in the DSM.
was at one time categorized as a form of paraphilia. Sigmund Freud
and his proponents considered homosexuality and paraphilias to be forms of psychosexual infantilism. In a 1951 symposium discussing psychiatrist Benjamin Karpman
's paper "The Sexual Psychopath," psychiatrist Emil Gutheil
said, "Looking back upon my own experience with so-called psychopaths, I find one characteristic they all have in common, and that is their infantilism. Take the man who is a homosexual. In his paraphilia he regresses to the time he was bisexual, that is, to his infantile level.
By the mid-20th century, mental health practitioners began formalizing "deviant sexuality" classifications into categories. Researcher Anil Aggrawal
writes that the 1952 first edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM) specified "the type of the pathological behavior, such as homosexuality, transvestism, pedophilia, fetishism, and sexual sadism, including rape, sexual assault, mutilation)." Originally coded as 000-x63, homosexuality was the top of the classification list (Code 302.0) until the American Psychiatric Association
removed homosexuality from the DSM in 1973. Other organizations followed suit, including the American Psychological Association
in 1975, and the National Association of Social Workers
. Martin Kafka
writes, "Sexual disorders once considered paraphilias (e.g., homosexuality) are now regarded as variants of normal sexuality."
(which would indicate excessive prenatal estrogen exposure), and an elevated probability of being left-handed, suggesting that disturbed hemispheric brain lateralization
may play a role in deviant attractions..
(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”)".
of sociopathic subtype. The only diagnostic guidance was that sexual deviation should have been "reserved for deviant sexuality which [was] not symptomatic of more extensive syndromes, such as schizophrenic or obsessional reactions". The specifics of the disorder were to be provided by the clinician as a "supplementary term" to the sexual deviation diagnosis; examples of this supplementary term provided in the DSM-I included homosexuality, transvestism, pedophilia, fetishism, and sexual sadism, including rape. There were no restrictions in the DSM-I on what this supplementary term could be.
The DSM-II (1968) continued to use the term "sexual deviations", but no longer ascribed them under personality disorders, but rather them alongside them in a broad category titled "personality disorders and certain other nonpsychotic mental disorders". The types of sexual deviations listed in the DSM-II were: sexual orientation disturbance (homosexuality), fetishism, pedophilia, transvestitism (sic), exhibitionism, voyeurism, sadism, masochism, and "other sexual deviation". No definition or examples were provided for "other sexual deviation", but the general category of sexual deviation was meant to describe the sexual preference of individuals that was "directed primarily toward objects other than people of opposite sex, toward sexual acts not usually associated with coitus, or toward coitus performed under bizarre circumstances, as in necrophilia, pedophilia, sexual sadism, and fetishism." Except for the removal of homosexuality from the DSM-III onwards, this definition provided a general standard that has guided specific definitions of paraphilias in subsequent DSM editions, up to DSM-IV-TR.
, added frotteurism
, and removed zoophilia, relegating it to the NOS category. It also provided seven nonexhaustive examples of NOS paraphilias, which besides zoophilia included telephone scatologia, necrophilia, partialism
, coprophilia
, klismaphilia
, and urophilia.
The DSM-IV (1994) retained the sexual disorders classification for paraphlias, but added an even broader category, "sexual and gender identity disorder
s", which includes them. The DSM-IV retained the same types of paraphilias listed in DSM-III-R, including the NOS examples, but introduced some changes to the definitions of some specific types.
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). Criterion B differs for exhibitionism, frotteurism, and pedophilia to include acting on these urges, and for sadism, acting on these urges with a nonconsenting person.
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.
Sexual arousal
in association with objects that were designed for sexual purposes is not diagnosable in DSM-IV (DSM, p. 570).
Bioethics
professor Alice Dreger interpreted these changes as "a subtle way of saying sexual kinks are basically okay – so okay, the sub-work group doesn’t actually bother to define paraphilia. But a paraphilic disorder is defined: that’s when an atypical sexual interest causes distress or impairment to the individual or harm to others." Interviewed by Dreger, Ray Blanchard
, the Chair of the Paraphilias Sub-Work Group, explained: "We tried to go as far as we could in depathologizing mild and harmless paraphilias, while recognizing that severe paraphilias that distress or impair people or cause them to do harm to others are validly regarded as disorders."
Charles Allen Moser
pointed out that this change is not really substantive as DSM-IV already acknowledged a difference between paraphilias and non-pathological but unusual sexual interests, a distinction that is virtually identical to what is being proposed for DSM-5, and it is a distinction that, in practice, has often been ignored. Linguist A. C. Hinderliter argued that "Including some sexual interests—but not others—in the DSM creates a fundamental asymmetry and communicates a negative value judgment against the sexual interests included," and leaves the paraphilias in a situation similar to ego-dystonic homosexuality, which was removed from the DSM because it did not meet the DSM's definition of mental disorder.
Historian and philosopher of science Patrick Singy claims that the DSM-5 is about to drastically loosen the criteria for paraphilias and to make them directly dependent on cultural values. The DSM-5 will then be closer to the DSM-I and DSM-II than to their successors, which all were at least trying to separate the concept of "mental disorder" from cultural norms, and which made "harm" or "distress" a necessary condition for having a mental disorder.
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.
was advocated as a therapy for men with pedophilia, but has been abandoned for the time being because most governments consider it a cruel punishment where the express willingness and consent of the patient is not objectively indicated. Psychotherapy, self-help groups
, and pharmacotherapy
(including anti-androgen hormone therapy sometimes referred to as "chemical castration
") have all been used. Other drug treatments for these disorders do exist, however.
ic 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 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.
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 antidepressant
s in refractory cases of depression
.
Sexual arousal
Sexual arousal, or sexual excitement, is the arousal of sexual desire, during or in anticipation of sexual activity. Things that precipitate human sexual arousal are called erotic stimuli, or colloquially known as turn-ons. There are many potential stimuli, both physical or mental, which can cause...
to objects, situations, or individuals that are not part of normative
Normative
Normative has specialized contextual meanings in several academic disciplines. Generically, it means relating to an ideal standard or model. In practice, it has strong connotations of relating to a typical standard or model ....
stimulation and that may cause distress or serious problems for the paraphiliac or persons associated with him or her. A paraphilia involves sexual arousal and gratification towards sexual behavior that is atypical or extreme.
The term was coined by Wilhelm Stekel
Wilhelm Stekel
Wilhelm Stekel was an Austrian physician and psychologist, who became one of Sigmund Freud's earliest followers, and was once described as "Freud's most distinguished pupil." According to Ernest Jones, "Stekel may be accorded the honour, together with Freud, of having founded the first...
in the 1920s. Controversial sexologist John Money
John Money
John William Money was a psychologist, sexologist and author, specializing in research into sexual identity and biology of gender...
later popularized the term as a nonpejorative designation for unusual sexual interests
Kink (sexual)
In human sexuality, kinkiness and kinky are terms used to refer to a playful usage of sexual concepts in an accentuated, and unambiguously expressive form....
. He described paraphilia as "a sexuoerotic embellishment of, or alternative to the official, ideological norm."
In the late 19th century, psychologists and psychiatrists started to categorize various paraphilias as they wanted a more descriptive system than the legal and religious constructs of sodomy
Sodomy
Sodomy is an anal or other copulation-like act, especially between male persons or between a man and animal, and one who practices sodomy is a "sodomite"...
and perversion
Perversion
Perversion is a concept describing those types of human behavior that are a serious deviation from what is considered to be orthodox or normal. Although it can refer to varying forms of deviation, it is most often used to describe sexual behaviors that are seen by an individual as abnormal,...
. Before the introduction of the term paraphilia in the DSM-III (1980), the term sexual deviation was used to refer to paraphilias in the first two editions of the manual. American Journal of Psychiatry
American Journal of Psychiatry
The American Journal of Psychiatry is a monthly peer-reviewed medical journal covering all aspects of psychiatry and the official journal of the American Psychiatric Association. The first volume was issued in 1844, at which time it was known as the American Journal of Insanity...
describes paraphilia as "recurrent, intense sexually arousing fantasies, sexual urges, or behaviors generally involving:
- Non-human objects
- The suffering or humiliation of oneself or one's partner
- Children
- Non-consenting persons
Up until 1973, sexual attraction to persons of the same sex
Same-sex attraction
Same-sex attraction is a term occasionally used instead of the more common term homosexuality to refer to a person's feelings of sexual attraction toward members of the same gender identity....
was included in this list.
The view of paraphilias as disorders is not universal. Some 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. Charles Allen Moser
Charles Allen Moser
Charles Allen Moser is an American physician specializing in internal medicine and focusing on sexual medicine. Moser is based in San Francisco and focuses his research and practice on individuals in the LGBT, kink, and fetish communities...
, a physician and advocate for sexual minorities, has argued that the diagnoses should be eliminated from diagnostic manuals. Psychiatrist Glen Gabbard
Glen Gabbard
Glen Owens Gabbard is an American psychiatrist known for authoring professional teaching texts for the field. He is Clinical Professor of Psychiatry at Baylor College of Medicine in Houston, Texas and Professor of Psychiatry at SUNY Upstate Medical University in Syracuse, New York...
writes that despite efforts by Stekel and Money, "the term paraphilia remains pejorative
Pejorative
Pejoratives , including name slurs, are words or grammatical forms that connote negativity and express contempt or distaste. A term can be regarded as pejorative in some social groups but not in others, e.g., hacker is a term used for computer criminals as well as quick and clever computer experts...
in most circumstances."
In the current version of the DSM (DSM-IV-TR), a paraphilia is not diagnosable as a psychiatric disorder unless it causes distress to the individual or harm to others. The DSM-5
DSM-5
The next edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders , commonly called DSM-5 , is currently in consultation, planning and preparation...
draft adds a terminology distinction between the two cases, stating that "paraphilias are not ipso facto
Ipso facto
Ipso facto is a Latin phrase, directly translated as "by the fact itself," which means that a certain phenomenon is a direct consequence, a resultant effect, of the action in question, instead of being brought about by a subsequent action such as the verdict of a tribunal. It is a term of art used...
psychiatric disorders", and defining paraphilic disorder as "a paraphilia that causes distress or impairment to the individual or harm to others". This will make a clear distinction between a healthy person with a non-normative sexual behavior and a person with a psychopathological non-normative sexual behavior.
In the United States, following a series of landmark cases in the US Supreme Court, persons diagnosed with paraphilias and a history of anti-social behavior, particularly pedophilia (Kansas v. Hendricks
Kansas v. Hendricks
Kansas v. Hendricks is a case in which U.S. Supreme Court set forth procedures for the indefinite civil commitment of prisoners convicted of a sex offense whom the state deems dangerous due to a mental abnormality.-Fact of case:...
, 1997) and exhibitionism (Kansas v. Crane
Kansas v. Crane
Kansas v. Crane, is a United States Supreme Court case in which the Court upheld the Kansas Sexually Violent Predator Act as consistent with substantive due process. The Court clarified that its earlier holding in Kansas v...
, 2002), can be held indefinitely in civil confinement
Civil confinement
Civil confinement is a controversial procedure permitted by a law passed in New York, advocated by the former governor, Eliot Spitzer, allowing the civil commitment of sex offenders because they are deemed by a court to be a danger to themselves or to society. One political commentator on the topic...
under various state legislation generically known as Sexually violent predator laws and the federal Adam Walsh Act (United States v. Comstock
United States v. Comstock
United States v. Comstock, 560 U.S. ___ was a decision by the Supreme Court of the United States, which ruled that the federal government has authority under the Necessary and Proper Clause to require the civil commitment of individuals already in Federal custody...
, 2010).
Terminological
Paraphilial psychopathologyPsychopathology
Psychopathology is the study of mental illness, mental distress, and abnormal/maladaptive behavior. The term is most commonly used within psychiatry where pathology refers to disease processes...
is not the same as psychologically
Psychology
Psychology is the study of the mind and behavior. Its immediate goal is to understand individuals and groups by both establishing general principles and researching specific cases. For many, the ultimate goal of psychology is to benefit society...
normative adult human sexual behavior
Human sexual behavior
Human sexual activities or human sexual practices or human sexual behavior refers to the manner in which humans experience and express their sexuality. People engage in a variety of sexual acts from time to time, and for a wide variety of reasons...
s, sexual fantasy
Sexual fantasy
A sexual fantasy, also called an erotic fantasy, is a fantasy or pattern of thoughts with the effect of creating or enhancing sexual feelings; in short, it is "almost any mental imagery that is sexually arousing or erotic to [an] individual"...
, and sex play. These terms have been used in interchangeable ways which can allow for cognitive and clinical diagnostic misjudgment to occur. Consensual
Consent
Consent refers to the provision of approval or agreement, particularly and especially after thoughtful consideration.- Types of consent :*Implied consent is a controversial form of consent which is not expressly granted by a person, but rather inferred from a person's actions and the facts and...
adult activities and adult entertainment that may involve some aspects of sexual roleplay, novel, superficial, or trivial aspects of sexual fetishism
Sexual fetishism
Sexual fetishism, or erotic fetishism, is the sexual arousal a person receives from a physical object, or from a specific situation. The object or situation of interest is called the fetish, the person a fetishist who has a fetish for that object/situation. Sexual fetishism may be regarded, e.g...
, or may incorporate the use of sex toys are not necessarily paraphilic.
Classificational
It is not known how many different kinds of paraphilias exist; one source lists as many as 549 paraphilias. Because so many paraphilias exist, one needs to classify them in an orderly and meaningful way. It has long been argued that the Diagnostic and Statistical Manual of Mental DisordersDiagnostic and Statistical Manual of Mental Disorders
The Diagnostic and Statistical Manual of Mental Disorders is published by the American Psychiatric Association and provides a common language and standard criteria for the classification of mental disorders...
(DSM) system of classification makes unjustified categorical distinctions between disorders, and between normal and abnormal. Although the DSM-5 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 in the DSM.
Homosexuality
HomosexualityHomosexuality
Homosexuality is romantic or sexual attraction or behavior between members of the same sex or gender. As a sexual orientation, homosexuality refers to "an enduring pattern of or disposition to experience sexual, affectional, or romantic attractions" primarily or exclusively to people of the same...
was at one time categorized as a form of paraphilia. Sigmund Freud
Sigmund Freud
Sigmund Freud , born Sigismund Schlomo Freud , was an Austrian neurologist who founded the discipline of psychoanalysis...
and his proponents considered homosexuality and paraphilias to be forms of psychosexual infantilism. In a 1951 symposium discussing psychiatrist Benjamin Karpman
Benjamin Karpman
Benjamin "Ben" Karpman was an American psychiatrist known for his work on human sexuality. He served as Professor and Head of Psychiatry at Howard University College of Medicine from 1921 to 1941.-Life and career:...
's paper "The Sexual Psychopath," psychiatrist Emil Gutheil
Emil Gutheil
Emil Arthur Gutheil was a Polish-American psychiatrist specializing in human sexuality, music therapy, and psychoanalysis. He was a founder of the Association for the Advancement of Psychotherapy and editor of the American Journal of Psychotherapy.-Life and career:Gutheil was born in Poland and...
said, "Looking back upon my own experience with so-called psychopaths, I find one characteristic they all have in common, and that is their infantilism. Take the man who is a homosexual. In his paraphilia he regresses to the time he was bisexual, that is, to his infantile level.
By the mid-20th century, mental health practitioners began formalizing "deviant sexuality" classifications into categories. Researcher Anil Aggrawal
Anil Aggrawal
Anil Aggrawal M.D. is a professor of forensic medicine at the Maulana Azad Medical College, New Delhi, India. He is known chiefly as the Editor-in-Chief of the Internet Journal of Forensic Medicine and Toxicology.-Early life:Dr...
writes that the 1952 first edition of the Diagnostic and Statistical Manual of Mental Disorders
Diagnostic and Statistical Manual of Mental Disorders
The Diagnostic and Statistical Manual of Mental Disorders is published by the American Psychiatric Association and provides a common language and standard criteria for the classification of mental disorders...
(DSM) specified "the type of the pathological behavior, such as homosexuality, transvestism, pedophilia, fetishism, and sexual sadism, including rape, sexual assault, mutilation)." Originally coded as 000-x63, homosexuality was the top of the classification list (Code 302.0) until the American Psychiatric Association
American Psychiatric Association
The American Psychiatric Association is the main professional organization of psychiatrists and trainee psychiatrists in the United States, and the most influential worldwide. Its some 38,000 members are mainly American but some are international...
removed homosexuality from the DSM in 1973. Other organizations followed suit, including the American Psychological Association
American Psychological Association
The American Psychological Association is the largest scientific and professional organization of psychologists in the United States. It is the world's largest association of psychologists with around 154,000 members including scientists, educators, clinicians, consultants and students. The APA...
in 1975, and the National Association of Social Workers
National Association of Social Workers
The National Association of Social Workers is a professional organization of social workers in the United States. It had over 150,000 members as of January 2008 and provides guidance, research, up to date information, advocacy, and other resources for its members and for social workers in general...
. Martin Kafka
Martin Kafka
Martin Paul Kafka is an American psychiatrist best known for his work on sex offenders, paraphilias and what he calls "paraphilia-related disorders" such as sex addiction and hypersexuality.-Career:...
writes, "Sexual disorders once considered paraphilias (e.g., homosexuality) are now regarded as variants of normal sexuality."
Neurodevelopmental correlates in men
The causes of paraphilic sexual preferences in men are unclear, although a growing body of research points to a possible prenatal neurodevelopmental correlation. A 2008 study analyzing the sexual fantasies of 200 heterosexual men by using the Wilson Sex Fantasy Questionnaire exam, determined that males with a pronounced degree of fetish interest had a greater number of older brothers, a high 2D:4D digit ratioDigit ratio
The digit ratio is the ratio of the lengths of different digits or fingers typically measured from the bottom crease where the finger joins the hand to the tip of the finger. It has been suggested by some scientists that the ratio of two digits in particular, the 2nd and 4th , is affected by...
(which would indicate excessive prenatal estrogen exposure), and an elevated probability of being left-handed, suggesting that disturbed hemispheric brain lateralization
Lateralization of brain function
A longitudinal fissure separates the human brain into two distinct cerebral hemispheres, connected by the corpus callosum. The sides resemble each other and each hemisphere's structure is generally mirrored by the other side. Yet despite the strong anatomical similarities, the functions of each...
may play a role in deviant attractions..
Classifications and theories
Albert EulenburgAlbert Eulenburg
Albert Eulenburg was a German neurologist who was a native of Berlin. He studied medicine at the Universities of Berlin, Bern and Zurich, earning his doctorate 1861. Among his instructors were Johannes Peter Müller , Ludwig Traube and Albrecht von Graefe...
(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
American Psychiatric Association
The American Psychiatric Association is the main professional organization of psychiatrists and trainee psychiatrists in the United States, and the most influential worldwide. Its some 38,000 members are mainly American but some are international...
or the World Health Organization
World Health Organization
The World Health Organization is a specialized agency of the United Nations that acts as a coordinating authority on international public health. Established on 7 April 1948, with headquarters in Geneva, Switzerland, the agency inherited the mandate and resources of its predecessor, the Health...
. 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”)".
DSM-I and DSM-II
In American psychiatry, prior to the publication of the DSM-I, paraphilias were classified as cases of "psychopathic personality with pathologic sexuality". The DSM-I (1952) included sexual deviation as a personality disorderPersonality disorder
Personality disorders, formerly referred to as character disorders, are a class of personality types and behaviors. Personality disorders are noted on Axis II of the Diagnostic and Statistical Manual of Mental Disorders or DSM-IV-TR of the American Psychiatric Association.Personality disorders are...
of sociopathic subtype. The only diagnostic guidance was that sexual deviation should have been "reserved for deviant sexuality which [was] not symptomatic of more extensive syndromes, such as schizophrenic or obsessional reactions". The specifics of the disorder were to be provided by the clinician as a "supplementary term" to the sexual deviation diagnosis; examples of this supplementary term provided in the DSM-I included homosexuality, transvestism, pedophilia, fetishism, and sexual sadism, including rape. There were no restrictions in the DSM-I on what this supplementary term could be.
The DSM-II (1968) continued to use the term "sexual deviations", but no longer ascribed them under personality disorders, but rather them alongside them in a broad category titled "personality disorders and certain other nonpsychotic mental disorders". The types of sexual deviations listed in the DSM-II were: sexual orientation disturbance (homosexuality), fetishism, pedophilia, transvestitism (sic), exhibitionism, voyeurism, sadism, masochism, and "other sexual deviation". No definition or examples were provided for "other sexual deviation", but the general category of sexual deviation was meant to describe the sexual preference of individuals that was "directed primarily toward objects other than people of opposite sex, toward sexual acts not usually associated with coitus, or toward coitus performed under bizarre circumstances, as in necrophilia, pedophilia, sexual sadism, and fetishism." Except for the removal of homosexuality from the DSM-III onwards, this definition provided a general standard that has guided specific definitions of paraphilias in subsequent DSM editions, up to DSM-IV-TR.
DSM-III through DSM-IV-TR
The term "paraphilia" was introduced in the DSM-III (1980) as a subset of the new category of "psychosexual disorders". The types of paraphlias listed were: fetishism, transvestism, zoophilia, pedophilia, exhibitionism, voyeurism, sexual masochism, sexual sadism, and "atypical paraphilia". The DSM-III-R (1987) renamed the broad category to sexual disorders, renamed atypical paraphilia to paraphilia NOS (not otherwise specified), finessed transvestism as transvestic fetishismTransvestic fetishism
Transvestic fetishism is having a sexual or erotic interest in cross-dressing. It differs from cross-dressing for entertainment or other purposes that do not involve sexual arousal and is categorized as a paraphilia in the Diagnostic and Statistical Manual of the American Psychiatric Association...
, added frotteurism
Frotteurism
Frotteurism refers to a paraphilic interest in rubbing, usually one's pelvis or erect penis, against a non-consenting person for sexual gratification. It may involve touching any part of the body including the genital area. A person who practices frotteurism is known as a frotteur...
, and removed zoophilia, relegating it to the NOS category. It also provided seven nonexhaustive examples of NOS paraphilias, which besides zoophilia included telephone scatologia, necrophilia, partialism
Partialism
Partialism refers to a sexual interest with an exclusive focus of a specific part of the body. Partialism is categorized as a paraphilia in the DSM-IV-TR of the American Psychiatric Association...
, coprophilia
Coprophilia
Coprophilia , also called scatophilia or scat, is the paraphilia involving sexual pleasure from feces...
, klismaphilia
Klismaphilia
The term Klismaphilia refers to the receiving of sexual arousal from introducing liquids into the rectum and colon via the anus. This paraphilia often involves the use of enemas. The term klismaphilia was coined in 1973 by Dr...
, and urophilia.
The DSM-IV (1994) retained the sexual disorders classification for paraphlias, but added an even broader category, "sexual and gender identity disorder
Gender identity disorder
Gender identity disorder is the formal diagnosis used by psychologists and physicians to describe persons who experience significant gender dysphoria . It describes the symptoms related to transsexualism, as well as less severe manifestations of gender dysphoria...
s", which includes them. The DSM-IV retained the same types of paraphilias listed in DSM-III-R, including the NOS examples, but introduced some changes to the definitions of some specific types.
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). Criterion B differs for exhibitionism, frotteurism, and pedophilia to include acting on these urges, and for sadism, acting on these urges with a nonconsenting person.
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
Diagnostic and Statistical Manual of Mental Disorders
The Diagnostic and Statistical Manual of Mental Disorders is published by the American Psychiatric Association and provides a common language and standard criteria for the classification of mental disorders...
provides clinical criteria for these paraphilias:
- ExhibitionismExhibitionismExhibitionism refers to a desire or compulsion to expose parts of one's body – specifically the genitals or buttocks of a man or woman, or the breasts of a woman – in a public or semi-public circumstance, in crowds or groups of friends or acquaintances, or to strangers...
: the recurrent urge or behavior to expose one's genitals to an unsuspecting person, or to perform sexual acts that can be watched by others. - FetishismSexual fetishismSexual fetishism, or erotic fetishism, is the sexual arousal a person receives from a physical object, or from a specific situation. The object or situation of interest is called the fetish, the person a fetishist who has a fetish for that object/situation. Sexual fetishism may be regarded, e.g...
: the use of inanimate objects to gain sexual excitement. Partialism refers to fetishes specifically involving nonsexual parts of the body. - FrotteurismFrotteurismFrotteurism refers to a paraphilic interest in rubbing, usually one's pelvis or erect penis, against a non-consenting person for sexual gratification. It may involve touching any part of the body including the genital area. A person who practices frotteurism is known as a frotteur...
: recurrent urges of behavior of touching or rubbing against a nonconsenting person. - PedophiliaPedophiliaAs a medical diagnosis, pedophilia is defined as a psychiatric disorder in adults or late adolescents typically characterized by a primary or exclusive sexual interest in prepubescent children...
: strong sexual attraction to prepubescent children,. - Sexual MasochismSadism and masochism as medical termsIn psychiatry, the terms sadism and masochism describe a personality type characterized by the actor or actrix deriving pleasure and gratification from inflicting physical pain and humiliation ; and from suffering pain and humiliation upon the self ; such pleasure often is sexual, but not...
: the recurrent urge or behavior of wanting to be humiliated, beaten, bound, or otherwise made to suffer for sexual pleasure. - Sexual SadismSadism and masochism as medical termsIn psychiatry, the terms sadism and masochism describe a personality type characterized by the actor or actrix deriving pleasure and gratification from inflicting physical pain and humiliation ; and from suffering pain and humiliation upon the self ; such pleasure often is sexual, but not...
: the recurrent urge or behavior involving acts in which the pain or humiliation of a person is sexually exciting. - Transvestic fetishismTransvestic fetishismTransvestic fetishism is having a sexual or erotic interest in cross-dressing. It differs from cross-dressing for entertainment or other purposes that do not involve sexual arousal and is categorized as a paraphilia in the Diagnostic and Statistical Manual of the American Psychiatric Association...
: arousal from wearing "clothing associated with members of the opposite sex." - VoyeurismVoyeurismIn clinical psychology, voyeurism is the sexual interest in or practice of spying on people engaged in intimate behaviors, such as undressing, sexual activity, or other activity usually considered to be of a private nature....
: the recurrent urge or behavior to observe an unsuspecting person who is naked, disrobing, or engaging in sexual activities, or who is engaging in activities usually considered to be of a private nature.
Under Paraphilia NOS, the DSM mentions telephone scatalogia
Obscene phone call
An obscene phone call is an unsolicited telephone call where a person derives sexual pleasure by using sexual or foul language to an unknown person. Making obscene telephone calls for sexual pleasure is known as telephone scatologia and is considered a form of exhibitionism...
(obscene phone calls), necrophilia
Necrophilia
Necrophilia, also called thanatophilia or necrolagnia, is the sexual attraction to corpses,It is classified as a paraphilia by the Diagnostic and Statistical Manual of the American Psychiatric Association. The word is artificially derived from the ancient Greek words: νεκρός and φιλία...
(corpses), partialism
Partialism
Partialism refers to a sexual interest with an exclusive focus of a specific part of the body. Partialism is categorized as a paraphilia in the DSM-IV-TR of the American Psychiatric Association...
(exclusive focus on one part of the body), zoophilia
Zoophilia
Zoophilia, from the Greek ζῷον and φιλία is the practice of sex between humans and non-human animals , or a preference or fixation on such practice...
(animals), coprophilia
Coprophilia
Coprophilia , also called scatophilia or scat, is the paraphilia involving sexual pleasure from feces...
(feces), klismaphilia
Klismaphilia
The term Klismaphilia refers to the receiving of sexual arousal from introducing liquids into the rectum and colon via the anus. This paraphilia often involves the use of enemas. The term klismaphilia was coined in 1973 by Dr...
(enemas), urophilia
Urolagnia
Urolagnia is a paraphilia in which sexual excitement is associated with the sight or thought of urine or urination. The term has origins in the Greek Language .Those who enjoy urolagnia may enjoy urinating on another person or persons, or being urinated upon...
(urine), emetophilia
Emetophilia
Emetophilia is a paraphilia in which an individual is aroused by vomiting or observing others vomit. Emetophiles put emetophilia into practice by actually vomiting, especially on a partner...
(vomit). The DSM's Paraphilia NOS is equivalent to the ICD-9's Sexual Disorder NOS.
Sexual arousal
Sexual arousal
Sexual arousal, or sexual excitement, is the arousal of sexual desire, during or in anticipation of sexual activity. Things that precipitate human sexual arousal are called erotic stimuli, or colloquially known as turn-ons. There are many potential stimuli, both physical or mental, which can cause...
in association with objects that were designed for sexual purposes is not diagnosable in DSM-IV (DSM, p. 570).
DSM-5 draft
The DSM-5 Paraphilias Subworkgroup reached a "consensus that paraphilias are not ipso facto psychiatric disorders", and proposed "that the DSM-V make a distinction between paraphilias and paraphilic disorders. A paraphilia by itself would not automatically justify or require psychiatric intervention. A paraphilic disorder is a paraphilia that causes distress or impairment to the individual or harm to others. One would ascertain a paraphilia (according to the nature of the urges, fantasies, or behaviors) but diagnose a paraphilic disorder (on the basis of distress and impairment). In this conception, having a paraphilia would be a necessary but not a sufficient condition for having a paraphilic disorder." The 'Rationale' page of any paraphilia in the electronic DSM-5 draft continues: "This approach leaves intact the distinction between normative and non-normative sexual behavior, which could be important to researchers, but without automatically labeling non-normative sexual behavior as psychopathological. It also eliminates certain logical absurdities in the DSM-IV-TR. In that version, for example, a man cannot be classified as a transvestite—however much he cross-dresses and however sexually exciting that is to him—unless he is unhappy about this activity or impaired by it. This change in viewpoint would be reflected in the diagnostic criteria sets by the addition of the word “Disorder” to all the paraphilias. Thus, Sexual Sadism would become Sexual Sadism Disorder; Sexual Masochism would become Sexual Masochism Disorder, and so on."Bioethics
Bioethics
Bioethics is the study of controversial ethics brought about by advances in biology and medicine. Bioethicists are concerned with the ethical questions that arise in the relationships among life sciences, biotechnology, medicine, politics, law, and philosophy....
professor Alice Dreger interpreted these changes as "a subtle way of saying sexual kinks are basically okay – so okay, the sub-work group doesn’t actually bother to define paraphilia. But a paraphilic disorder is defined: that’s when an atypical sexual interest causes distress or impairment to the individual or harm to others." Interviewed by Dreger, Ray Blanchard
Ray Blanchard
Ray Milton Blanchard is an American-Canadian sexologist, best known for his research studies on pedophilia, gender dysphoria, and sexual orientation. He has also published research studies on phallometry and several paraphilias, including transvestism and autoerotic asphyxia.-Education and...
, the Chair of the Paraphilias Sub-Work Group, explained: "We tried to go as far as we could in depathologizing mild and harmless paraphilias, while recognizing that severe paraphilias that distress or impair people or cause them to do harm to others are validly regarded as disorders."
Charles Allen Moser
Charles Allen Moser
Charles Allen Moser is an American physician specializing in internal medicine and focusing on sexual medicine. Moser is based in San Francisco and focuses his research and practice on individuals in the LGBT, kink, and fetish communities...
pointed out that this change is not really substantive as DSM-IV already acknowledged a difference between paraphilias and non-pathological but unusual sexual interests, a distinction that is virtually identical to what is being proposed for DSM-5, and it is a distinction that, in practice, has often been ignored. Linguist A. C. Hinderliter argued that "Including some sexual interests—but not others—in the DSM creates a fundamental asymmetry and communicates a negative value judgment against the sexual interests included," and leaves the paraphilias in a situation similar to ego-dystonic homosexuality, which was removed from the DSM because it did not meet the DSM's definition of mental disorder.
Historian and philosopher of science Patrick Singy claims that the DSM-5 is about to drastically loosen the criteria for paraphilias and to make them directly dependent on cultural values. The DSM-5 will then be closer to the DSM-I and DSM-II than to their successors, which all were at least trying to separate the concept of "mental disorder" from cultural norms, and which made "harm" or "distress" a necessary condition for having a mental disorder.
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.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.
Drug treatments
The treatment of paraphilias and related disorders has been challenging for patients and clinicians. In the past, surgical castrationCastration
Castration is any action, surgical, chemical, or otherwise, by which a male loses the functions of the testicles or a female loses the functions of the ovaries.-Humans:...
was advocated as a therapy for men with pedophilia, but has been abandoned for the time being because most governments consider it a cruel punishment where the express willingness and consent of the patient is not objectively indicated. Psychotherapy, self-help groups
Support group
In a support group, members provide each other with various types of help, usually nonprofessional and nonmaterial, for a particular shared, usually burdensome, characteristic...
, and pharmacotherapy
Pharmacotherapy
Pharmacotherapy is the treatment of disease through the administration of drugs. As such, it is considered part of the larger category of therapy....
(including anti-androgen hormone therapy sometimes referred to as "chemical castration
Chemical castration
Chemical castration is the administration of medication designed to reduce libido and sexual activity, usually in the hope of preventing rapists, child molesters and other sex offenders from repeating their crimes...
") have all been used. Other drug treatments for these disorders do exist, however.
Hormonal
AntiandrogenAntiandrogen
Antiandrogens, or androgen antagonists, first discovered in the 1960s, prevent androgens from expressing their biological effects on responsive tissues. Antiandrogens alter the androgen pathway by blocking the appropriate receptors, competing for binding sites on the cell's surface, or affecting...
ic drugs such as medroxyprogesterone (also known as the long-acting contraceptive Depo Provera
Depo Provera
Depo-Provera is a branded progestogen-only contraceptive, depot medroxyprogesterone acetate long acting reversible hormonal contraceptive birth control drug that is injected every 3 months...
) have been widely used as therapy in these men to reduce sex drive. However, their efficacy is limited and they have many 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
Psychostimulants have been used recently to augment the effects of serotonergicSerotonergic
Serotonergic or serotoninergic means "related to the neurotransmitter serotonin". A synapse is serotonergic if it uses serotonin as its neurotransmitter...
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
Amphetamine
Amphetamine or amfetamine is a psychostimulant drug of the phenethylamine class which produces increased wakefulness and focus in association with decreased fatigue and appetite.Brand names of medications that contain, or metabolize into, amphetamine include Adderall, Dexedrine, Dextrostat,...
-like stimulant used primarily to manage the symptoms of attention deficit hyperactivity disorder (ADHD). Recent studies imply that methylphenidate may also act on serotonergic
Serotonergic
Serotonergic or serotoninergic means "related to the neurotransmitter serotonin". A synapse is serotonergic if it uses serotonin as its neurotransmitter...
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 antidepressant
Antidepressant
An antidepressant is a psychiatric medication used to alleviate mood disorders, such as major depression and dysthymia and anxiety disorders such as social anxiety disorder. According to Gelder, Mayou &*Geddes people with a depressive illness will experience a therapeutic effect to their mood;...
s in refractory cases of depression
Clinical depression
Major depressive disorder is a mental disorder characterized by an all-encompassing low mood accompanied by low self-esteem, and by loss of interest or pleasure in normally enjoyable activities...
.
See also
- Courtship disorderCourtship disorderCourtship disorder is a theoretical construct in sexology in which a certain set of paraphilias are seen as specific instances of anomalous courtship instincts in men. The specific paraphilias are exhibitionism, voyeurism, telephone scatologia, frotteurism, and biastophilia...
- Developmental psychologyDevelopmental psychologyDevelopmental psychology, also known as human development, is the scientific study of systematic psychological changes, emotional changes, and perception changes that occur in human beings over the course of their life span. Originally concerned with infants and children, the field has expanded to...
- Dorian Gray syndromeDorian Gray syndromeDorian Gray Syndrome denotes a cultural and societal phenomenon characterized by an excessive preoccupation with the individual's own appearance accompanied by difficulties coping with the aging process and with the requirements of maturation. Sufferers of Dorian Gray Syndrome are heavy users of...
- Human developmentHuman development (biology)Human development is the process of growing to maturity. In biological terms, this entails growth from a one-celled zygote to an adult human being.- Biological development:...
- Human sexualityHuman sexualityHuman sexuality is the awareness of gender differences, and the capacity to have erotic experiences and responses. Human sexuality can also be described as the way someone is sexually attracted to another person whether it is to opposite sexes , to the same sex , to either sexes , or not being...
- Labeling theoryLabeling theoryLabeling theory is closely related to interactionist and social construction theories. Labeling theory was developed by sociologists during the 1960's. Howard Saul Becker's book entitled Outsiders was extremely influential in the development of this theory and its rise to popularity...
- Linguistic relativityLinguistic relativityThe principle of linguistic relativity holds that the structure of a language affects the ways in which its speakers are able to conceptualize their world, i.e. their world view...
- List of paraphilias
- LovemapLovemapThe concept of a lovemap was originated by John Money to assist a discussion of why people like what they enjoy sexually and erotically. According to Money, it is "a developmental representation or template in the mind and in the brain depicting the idealized lover and the idealized program of...
- Psychosexual developmentPsychosexual developmentIn Freudian psychology, psychosexual development is a central element of the psychoanalytic sexual drive theory, that human beings, from birth, possess an instinctual libido that develops in five stages. Each stage — the oral, the anal, the phallic, the latent, and the genital — is characterized...
- Richard von Krafft-Ebing for history of classifying sexual object choice as a disease
- Sex and the lawSex and the lawIn general, laws proscribe acts which are considered either sexual abuse, or behavior that societies consider to be inappropriate and against the social norms. In addition, certain categories of activity may be considered crimes even if freely consented to...
- -phil--phil-Suffixes with the common part -phil- are used to specify some kind of attraction or affinity to something, in particular the love or obsession with something...
(list of philias)