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Paraphilias -ˈfil-ē-ə

by George R. Brown, MD

Paraphilias are frequent, intense, sexually arousing fantasies or behaviors that involve inanimate objects, children or nonconsenting adults, or suffering or humiliation of oneself or the partner.

Sexual arousal may depend on one of the above. Once these arousal patterns are established, usually in late childhood or near puberty, they are often lifelong.

Some degree of variety in sexual activity is very common in healthy adult sexual relationships and fantasies. When people mutually agree to engage in them, noninjurious sexual behaviors of an unusual nature may be part of a loving and caring relationship. When taken to the extreme, however, such sexual behaviors are paraphilias—psychosexual disorders that seriously impair the capacity for affectionate, reciprocal sexual activity. Partners of people with a paraphilia may feel like an object or as if they are unimportant or unnecessary in the sexual relationship. Paraphilias cause significant distress and interfere with functioning. Distress may result from other people's reactions or from guilt about doing something socially unacceptable.

The most common paraphilias are transvestic fetishism, pedophilia, exhibitionism, and voyeurism. Others include sexual masochism and sadism. Most people with paraphilias are men, and many have more than one type of paraphilia. Some of them also have a severe personality disorder, such as an antisocial or narcissistic personality. Some paraphilias are against the law.

Fetishism

Fetishism is use of a physical object (the fetish) as the preferred way to produce sexual arousal.

People with fetishes may become sexually stimulated and gratified by wearing another person's undergarments, wearing rubber or leather, or holding, rubbing, or smelling objects, such as high-heeled shoes. People with this disorder may not be able to function sexually without their fetish. The fetish may replace typical sexual activity with a partner or may be integrated into sexual activity with a willing partner.

Transvestic fetishism

In transvestic fetishism (cross-dressing), men prefer to wear women’s clothing, or, far less commonly, women prefer to wear men's clothing. However, they do not wish to change their sex, as transsexuals do. Cross-dressing may not hurt a couple’s sexual relationship, although if a partner is not cooperative, transvestites may feel anxious, depressed, and guilty and ashamed about their desire.

Transvestic fetishism is considered a mental health disorder only if it causes distress, interferes with functioning, or involves daredevil behavior likely to lead to injury, loss of a job, or imprisonment. Transvestites also cross-dress for reasons other than sexual stimulation—for example, to reduce anxiety, to relax, or, in the case of male transvestites, to experiment with the feminine side of their otherwise male personalities. Some men who appear to be transvestites only in their teens and twenties develop gender identity disorder later in life and may seek to change their body through hormones and genital surgery.

Only a few transvestites seek medical care. They may be motivated by an unhappy spouse or by worry about how the cross-dressing is affecting their social life and work. Some seek medical care for other problems, such as substance abuse or depression. Treatment involves psychotherapy to help them accept themselves and control behaviors that could cause problems.

Pedophilia

Pedophilia is a preference for sexual activity with young children.

In Western societies, pedophilia is defined as sexual fantasy about or sexual relations with a prepubertal child younger than 13 by a person 16 or older. Some pedophiles are attracted only to children, often of a specific age range or developmental stage. Others are attracted to both children and adults. Pedophiles may be attracted to young boys, young girls, or both, but most pedophiles prefer children of the opposite sex. Usually, the adult is known to the child and may be a family member, stepparent, or a person with authority (such as a teacher). Looking or general touching seems more common than touching the genitals or having sexual intercourse.

Although state laws vary in the United States, the law generally considers a person older than 18 to be committing statutory rape if the victim is 16 or younger. Statutory rape cases often do not meet the definition of pedophilia, highlighting the somewhat arbitrary nature of selecting a specific age cutoff point in a medical or legal definition. In many other countries and cultures, children as young as 12 can legally marry, further complicating the definition of pedophilia and statutory rape.

Pedophilia is much more common among men than among women. Both boys and girls can be victims, although more reported cases involve girls. Pedophiles may focus only on children within their families (incest), or they may prey on children in the community. Force or coercion may be used to engage children sexually, and threats (for example, to harm the child or the child's pets) may be invoked to prevent the child from telling anyone.

Many pedophiles have or develop substance abuse or dependence and depression. They often come from dysfunctional families, and marital conflict is common.

Treatment

Pedophilia can be treated with long-term psychotherapy and drugs that alter the sex drive and reduce testosterone levels. Results vary. Outcome is best when participation is voluntary and the person receives training in social skills and treatment of other problems, such as drug abuse or depression. Treatment that is sought only after criminal apprehension and legal action may be less effective. Simple incarceration, even long-term, does not change pedophilic desires or fantasies. However, some incarcerated pedophiles who are committed to long-term, monitored treatment (usually including drugs) can refrain from pedophilic activity and be reintegrated into society.

For drug treatment, doctors in the United States usually use the drug medroxyprogesterone acetate, which is injected into a muscle. This drug (a progestin) is similar to the female hormone progesterone. Alternatives are drugs such as leuprolide and goserelin that stop the pituitary gland from signaling the testicles to produce testosterone . It is not clear how useful these drugs are in women who are pedophiles.

Exhibitionism

Exhibitionism involves exposing the genitals in order to become sexually excited or having a strong desire to be observed by other people during sexual activity.

Exhibitionists (usually males) expose their genitals, usually to unsuspecting strangers, and become sexually excited when doing so. They may be aware of their need to surprise, shock, or impress the unwilling observer. The victim is almost always a woman or a child of either sex. Actual sexual contact is almost never sought, so exhibitionists rarely commit rape. Exhibitionism usually starts when people are in their mid 20s. Most exhibitionists are married, but the marriage is often troubled.

About 30% of male sex offenders who are arrested are exhibitionists. They tend to persist in their behavior. About 20 to 50% are re-arrested.

Exposure of genitals to unsuspecting strangers for sexual excitement is rare among women. Women have other venues to expose themselves: dressing provocatively (which is increasingly accepted as normal) and appearing in various media and entertainment venues. Participation in these venues may not constitute a mental health disorder.

For some people, exhibitionism is expressed as a strong desire to have other people watch their sexual acts. Such people want to be seen by a consenting audience, rather than to surprise people. People with this form of exhibitionism may make pornographic films or become adult entertainers. They are rarely troubled by their desire and thus may not have a mental health disorder.

Treatment

Treatment usually begins after exhibitionists are arrested. It includes psychotherapy, support groups, and antidepressants called selective serotonin reuptake inhibitors (SSRIs). If these drugs are ineffective, drugs that alter the sex drive and reduce testosterone levels may be used. People must give their informed consent to the use of these drugs, and doctors periodically do blood tests to monitor the drug’s effects on liver function and serum testosterone levels.

Voyeurism

Voyeurism involves becoming sexually aroused by watching someone who is disrobing, naked, or engaged in sexual activity.

In voyeurism, it is the act of observing (peeping) that is arousing, not sexual activity with the observed person. Voyeurs do not seek sexual contact with the people being observed. When voyeurs observe unsuspecting people, they may have problems with the law.

Voyeurism usually begins during adolescence or early adulthood. Some degree of voyeurism is common, more among boys and men but increasingly among women. Society often regards mild forms of this behavior as normal when involving consenting adults. Viewing sexually explicit pictures and shows, now widely available in private on the Internet, is not considered voyeurism because it lacks the element of secret observation, which is the hallmark of voyeurism.

As a disorder, voyeurism is much more common among men. When voyeurism is a disorder, voyeurs spend a lot of time seeking out viewing opportunities. It may become the preferred method of sexual activity and consume countless hours of watching.

Treatment

When voyeurs are arrested, treatment usually begins. It includes therapy, support groups, and antidepressants called selective serotonin reuptake inhibitors (SSRIs). If these drugs are ineffective, drugs that alter the sex drive and reduce testosterone levels may be used. People must give their informed consent to the use of these drugs, and doctors periodically do blood tests to monitor the drug’s effects on liver function and serum testosterone levels.

Sexual Masochism and Sadism

Sexual masochism involves acts in which a person experiences sexual excitement from being humiliated, beaten, bound, or otherwise abused. Sexual sadism involves acts in which a person experiences sexual excitement from inflicting physical or psychologic suffering on another person.

Some amount of sadism and masochism is commonly play-acted in healthy sexual relationships, and mutually compatible partners often seek one another out. For example, the use of silk handkerchiefs for simulated bondage and mild spanking during sexual activity are common practices between consenting partners and are not considered sadomasochistic.

Most sadists interact with a consenting partner (who may have sexual masochism). In these relationships, the humiliation and beating are simply acted out, with participants knowing that it is a game and carefully avoiding actual humiliation or injury. Fantasies of total control and dominance are often important, and sadists may bind and gag their partner in elaborate ways.

In contrast, the disorder of sexual masochism or of sexual sadism takes these acts to an extreme or involves nonconsenting victims (and thus constitutes a crime). Some acts result in severe bodily or psychologic harm and even death. For example, masochistic sexual activity may involve asphyxiophilia, in which the person is partially choked or strangled (by a partner or by self-application of a noose around the neck). A temporary decrease in oxygen to the brain at the point of orgasm is sought as an enhancement to sexual release, but the practice may accidentally result in death.

Treatment of masochism and sadism is usually ineffective.

Drugs Mentioned In This Article

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  • PROVERA
  • DELATESTRYL
  • ZOLADEX
  • CRINONE
  • LUPRON