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Paraphilias

by George R. Brown, MD

Paraphilias are recurrent, intense, sexually arousing fantasies, urges, or behaviors that are distressing or disabling and that involve inanimate objects, children or other nonconsenting adults, or suffering or humiliation of oneself or the partner.

Sexual preferences that seem unusual to another person or health care practitioner do not constitute paraphilia simply because they are unusual. The arousal patterns are considered pathologic only when the following apply:

  • They become obligatory for sexual functioning (ie, erection or orgasm cannot occur without the stimulus).

  • They involve inappropriate partners (eg, children, nonconsenting adults).

  • They cause significant distress or impairment in social, occupational, or other important areas of functioning.

People with a paraphilia may have an impaired or nonexistent capacity for affectionate, reciprocal emotional and sexual intimacy with a consenting partner. Other aspects of personal and emotional adjustment may be impaired as well.

The pattern of disturbed erotic arousal is usually fairly well developed before puberty. At least 3 processes are involved:

  • Anxiety or early emotional trauma interferes with normal psychosexual development.

  • The standard pattern of arousal is replaced by another pattern, sometimes through early exposure to highly charged sexual experiences that reinforce the person’s experience of sexual pleasure.

  • The pattern of sexual arousal often acquires symbolic and conditioning elements (eg, a fetish symbolizes the object of arousal but may have been chosen because the fetish was accidentally associated with sexual curiosity, desire, and excitement).

Whether all paraphilic development results from these psychodynamic processes is controversial, and some evidence of altered brain functioning is present in some paraphilias (eg, pedophilia).

In most cultures, paraphilias are far more common among males. Biologic reasons for the unequal distribution may exist but are poorly defined.

Many of the paraphilias are rare. The most common are pedophilia, voyeurism, transvestic fetishism, and exhibitionism. Some paraphilias (such as pedophilia) are illegal and may result in being imprisoned and being labeled and registered as a sex offender for life. Some of these offenders have significant personality disorders accompanying the paraphilia (eg, antisocial, narcissistic), which make treatment difficult. Often, more than one paraphilia is present.

Fetishism

Fetishism is use of an inanimate object (the fetish) as the preferred method of producing sexual excitement. However, in common parlance, the word is often used to describe particular sexual interests, such as sexual role-playing, preference for certain physical characteristics, and preferred sexual activities.

Common fetishes include aprons, shoes, leather or latex items, and women’s underclothing. The fetish may replace typical sexual activity with a partner or may be integrated into sexual activity with a willing partner. Minor fetishistic behavior as an adjunct to consensual sexual behavior is not considered a disorder because distress, disability, and significant dysfunction are absent. More intense, obligatory fetishistic arousal patterns may cause problems in a relationship or become all-consuming and destructive in a person’s life.

Transvestic fetishism

Heterosexual males who dress in women’s clothing typically begin such behavior in late childhood (see Gender Identity Disorder and Transsexualism). A more common term for transvestite is cross-dresser. This behavior is associated, at least initially, with sexual arousal.

Cross-dressing per se is not a disorder because this behavior does not always cause distress or impairment. Personality profiles of cross-dressing men are generally similar to age- and race-matched norms. When their partner is cooperative, these men have intercourse in partial or full feminine attire. When their partner is not cooperative, they may feel anxiety, depression, guilt, and shame associated with the desire to cross-dress.

Most transvestites do not present for treatment. Those who do are usually brought in by an unhappy spouse, referred by courts, or self-referred out of concern about experiencing negative social and employment consequences. Some transvestites present for treatment of comorbid gender dysphoria, substance abuse, or depression. Social and support groups for transvestites are usually very helpful. No drugs are reliably effective; psychotherapy is aimed at self-acceptance and modulating risky behaviors.


Exhibitionism

Exhibitionism is characterized by achievement of sexual excitement through genital exposure, usually to an unsuspecting stranger. It may also refer to a strong desire to be observed by other people during sexual activity.

Exhibitionists (usually male) may masturbate while exposing or fantasizing about exposing themselves. They may be aware of their need to surprise, shock, or impress the unwilling observer. The victim is almost always a female adult or a child of either sex. Actual sexual contact is rarely sought. Age at onset is usually the mid 20s; occasionally, the first act occurs during preadolescence or middle age. About 30% of apprehended male sex offenders are exhibitionists. They have the highest recidivism rate of all sex offenders; about 20 to 50% are re-arrested. Most exhibitionists are married, but the marriage is often troubled by poor social and sexual adjustment, including frequent sexual dysfunction. Very few females are diagnosed as exhibitionists; society sanctions some exhibitionistic behaviors in females (through media and entertainment venues).

For some people, exhibitionism is expressed as a strong desire to have other people watch their sexual acts. What appeals to such people is not the act of surprising an audience but rather of being seen by a consenting audience. People with this form of exhibitionism may make pornographic films or become adult entertainers. They are rarely troubled by this desire and thus may not have a psychiatric disorder.

Treatment

When laws are broken and sex offender status is conferred, treatment usually begins with psychotherapy, support groups, and SSRIs (see Treatment). If these drugs are ineffective, antiandrogens should be considered; full informed consent and appropriate monitoring of liver function and serum testosterone levels are required.


Voyeurism

Voyeurism is achievement of sexual arousal by observing people who are naked, disrobing, or engaging in sexual activity. When observation is of unsuspecting people, this sexual behavior often leads to problems with the law and relationships.

Desire to watch others in sexual situations is common and not in itself abnormal. Voyeurism usually begins during adolescence or early adulthood. Adolescent voyeurism is generally viewed more leniently; few teenagers are arrested. When voyeurism is pathologic, voyeurs spend considerable time seeking out viewing opportunities. Orgasm is usually achieved by masturbating during or after the voyeuristic activity. Voyeurs do not seek sexual contact with the people being observed.

In many cultures, voyeurs have ample legal opportunities to watch sexual activity.

Treatment

When laws are broken and sex offender status is conferred, treatment usually begins with therapy, support groups, and SSRIs (see Treatment). If these drugs are ineffective, antiandrogens should be considered; full informed consent and appropriate monitoring of liver function and serum testosterone levels are required.


Sexual Masochism

Sexual masochism is intentional participation in an activity that involves being humiliated, beaten, bound, or otherwise abused to experience sexual excitement.

Sadomasochistic fantasies and sexual behavior between consenting adults is very common. Masochistic activity tends to be ritualized and chronic. For most participants, the humiliation and beating are simply acted out; participants know that it is a game and carefully avoid actual humiliation or injury. However, some masochists increase the severity of their activity with time, potentially leading to serious injury or death.

Masochistic activities may be the preferred or exclusive mode of producing sexual excitement. People may act on their masochistic fantasies themselves (eg, binding themselves, piercing their skin, applying electrical shocks, burning themselves) or seek out a partner who may be a sexual sadist. Activities with a partner include bondage, blindfolding, spanking, flagellation, humiliation by means of urination or defecation on the person, forced cross-dressing, or simulated rape.

Treatment of this disorder is often ineffective.

Sexual Sadism

Sexual sadism is infliction of physical or mental suffering (eg, humiliation, terror) on the sex partner to stimulate sexual excitement and orgasm.

Most sexual sadists have insistent, persistent fantasies in which sexual excitement results from suffering inflicted on the partner, consenting or not. Mild sadism is a common sexual practice; when it becomes pathologic is a matter of degree. Sexual sadism is not rape, a complex amalgam of sex and power over the victim. Sexual sadism is diagnosed in < 10% of rapists.

Most sadistic sexual behavior occurs between consenting adults. As is the case with masochism, sadism is usually limited in scope and not harmful. In some people, the behaviors escalate to the point of harm. When practiced with nonconsenting partners, sexual sadism constitutes criminal activity and is likely to continue until the sadist is apprehended. Sexual sadism is particularly dangerous when associated with antisocial personality disorder (see Antisocial personality disorder). This combination of disorders is particularly recalcitrant to any form of psychiatric treatment.

Pedophilia

(See also Sexual abuse.)

Pedophilia is a preference for sexual activity with prepubertal children. Pedophilia often leads to imprisonment; medical management should include drugs and psychotherapy.

Sexual offenses against children constitute a significant proportion of reported criminal sexual acts. Arbitrarily, the age of a person with pedophilia is set at 16 yr, with the age difference between offender and child victim set at 5 yr. The age of the child is usually 13 yr. For older adolescents with pedophilia (ie, 17 to 18 yr old), no precise age difference is specified; clinical and legal judgment is relied on. Legal criteria may be different from psychiatric criteria.

Most pedophiles are male. Attraction may be to young boys, girls, or both. But pedophiles prefer opposite-sex to same-sex children 2:1. In most cases, the adult is known to the child and may be a family member, stepparent, or a person with authority (eg, a teacher). Looking or touching seems more prevalent than genital contact. Homosexual males typically have a less close acquaintanceship with the child. Pedophiles may be attracted only to children (exclusive) or also adults (nonexclusive).

Some pedophiles limit their sexual activities to their own children or to close relatives (incest). Predatory pedophiles, many of whom have antisocial personality disorder, may use force and threaten to physically harm the child or the child’s pets if the abuse is disclosed. The course of pedophilia is chronic, and perpetrators often have or develop substance abuse or dependence and depression. Pervasive family dysfunction, including marital conflict, is common.

Identifying a pedophile often poses an ethical crisis for health care practitioners. They can try to protect the privacy of the patient but must protect the community of children. Practitioners should know the reporting requirements in their state. If practitioners have reasonable suspicion of child sexual or physical abuse, it must be reported to authorities.

Treatment

  • Psychotherapy

  • Treatment of associated disorders

  • Drug treatment (eg, antiandrogens, SSRIs)

Long-term individual or group psychotherapy is usually necessary and may be especially helpful when it is part of multimodal treatment that includes social skills training, treatment of comorbid physical and mental disorders (eg, seizure disorders, attention deficit disorder, depression), and drug treatment. Treatment is less effective when court ordered, although many adjudicated sex offenders have benefited from treatments, such as group psychotherapy and antiandrogens.

In the US, IM medroxyprogesterone acetate is the treatment of choice; cyproterone is used in Europe. Typical doses are medroxyprogesterone 200 mg IM 2 to 3 times/wk for 2 wk, followed by 200 mg 1 to 2 times/wk for 4 wk, then 200 mg q 2 to 4 wk. Serum testosterone should be monitored and maintained in the normal female range (< 62 ng/dL). Treatment is usually long-term because deviant fantasies usually recur weeks to months after treatment is stopped. Drugs that inhibit gonadotropin release (eg, leuprolide, goserelin), given IM, have also been used. Liver function tests and serum testosterone levels should be monitored as required.

The usefulness of antiandrogens in female pedophiles is less well established.

In addition to antiandrogens, SSRIs (eg, high-dose fluoxetine 60 to 80 mg once/day or fluvoxamine 200 to 300 mg po once/day) may be useful. Drugs are most effective when used as part of a multimodal treatment program.

Some pedophiles who are committed to treatment and monitoring can refrain from pedophilic activity and be reintegrated into society.


Drugs Mentioned In This Article

  • Drug Name
    Select Trade
  • DELATESTRYL
  • No US brand name
  • PROZAC, SARAFEM
  • PROVERA
  • ZOLADEX
  • LUPRON
  • LUVOX

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