Overview of Paraphilias and Paraphilic Disorders

Paraphilias involve sexual arousal to atypical objects, situations, and/or targets (eg, children, corpses, animals). The atypical nature of paraphilias is not necessarily enough to qualify them as paraphilic disorders. People may, in fact, have paraphilic interests and engage in paraphilic practices without meeting the criteria for a paraphilic disorder.

The unconventional sexual arousal patterns in paraphilias are considered pathologic disorders only when both of the following apply (1):

• They are intense and persistent (lasting generally 6 months or longer).

• They cause significant distress or impairment in social, occupational, or other important areas of functioning, or they harm or have the potential to harm others (eg, children, nonconsenting adults).

People with a paraphilic disorder may have an impaired or a 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 may be 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 unusual 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).

It is controversial whether all paraphilic development results from these psychodynamic processes, and some evidence of altered brain functioning and functional anatomy is present in some paraphilias (eg, pedophilia) (2, 3).

In most cultures, paraphilias are far more common among males (4). Biologic reasons for the unequal distribution may exist but are poorly understood.

Dozens of paraphilias have been described, but most are uncommon or rare. They can be categorized as those based on disruptions in normal courtship patterns and behaviors (eg, voyeurism, exhibitionism, frotteurism); those that involve algolagnia, the derivation of sexual pleasure from experiencing or inflicting pain (eg, sadism, masochism); and those that involve anomalous target preferences (eg, pedophilia, fetishism, transvestism) (1).

According to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, Text Revision (DSM-5-TR), the paraphilias that most commonly evolve into paraphilic disorders are

• Voyeuristic disorder

• Exhibitionistic disorder

• Frotteuristic disorder

• Sexual masochism disorder

• Sexual sadism disorder

• Pedophilic disorder

• Fetishistic disorder

• Transvestic disorder

Some paraphilias (such as pedophilia, frottereurism, voyeurism, some forms of exhibitionism) may involve behaviors that are illegal and may result in imprisonment and lifelong registration as a sex offender. Some of these offenders also have significant personality disorders (eg, antisocial, narcissistic), which make treatment difficult (5).

Often, more than 1 paraphilic disorder is present.

For clinicians who treat patients with paraphilic disorders, guidelines are available regarding the use of pharmacotherapy, supported by evidence from a systematic review (6, 7).