Paraphilia

Medical quality assurance by Dr. Albrecht Nonnenmacher, MD at July 27, 2016
StartDiseasesParaphilia

As defined by the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), paraphilia is a category of mental disorders involving sexual thoughts, desires, and behavior that impair a person's well-being.

Contents

Definition & Facts

Paraphilia is any intense and recurring sexual interest in atypical objects, individuals, fetishes, situations or fantasies that causes a person impairment unrelated to the disapproval of society and/or causes another person harm without their consent. The Diagnostic and Statistical Manual of Mental Disorders attempts to draw a distinction between atypical sexual behavior and fantasies versus atypical sexuality that causes harm or impairment. The latter constitutes paraphilia; the former does not constitute a type of mental disorder.

The number and classes of paraphilia are under debate though the Diagnostic and Statistical Manual of Mental Disorders lists eight disorders:

Other paraphilias include necrophilia, obscene phone calls, and attraction to animals (zoophilia). The urge to rape another person is not classified as a paraphilia distinct from sexual sadism disorder. Paraphilia are relatively rare. Men are significantly more prone to paraphilia than women. It is more common in males than in females at a ratio of 20:1.

Symptoms & Complaints

Paraphilias involve fantasies, urges, and behaviors. Engaging in fantasies without ever acting out specific behaviors can still constitute a paraphilia. Paraphilias may manifest in physical reactions like orgasm or erection.

Many people who have paraphilias have more than one at the same time. Also, most people who suffer from one of these conditions begin to have fantasies when they are under the age of 13. A paraphilia can fall into many categories each with their own set of unique symptoms:

  • Exhibitionism - Exposing oneself to an unwilling person
  • Fetishism - This is a sexual fascination with inanimate objects or very specific body parts.
  • Pedophilia - Sexual attraction to young children
  • Frotteurism - Rubbing against another person without permission
  • Sexual masochism - Gaining satisfaction from being embarrassed, beaten, bound, or some other type of suffering.
  • Sexual sadism - Getting satisfaction from the physical or emotional suffering of another person
  • Transvestism - Wearing clothes of the opposite sex in a way that interferes with regular functioning.
  • Voyeurism - This behavior consists of watching another person when they are nude or involved in sexual activity.

Causes

There are different theories about what causes paraphilias. Some see these conditions as a sign of arrested psychosexual development or as mechanisms to reduce anxiety. Other theorists think that paraphilias come as a result of the person associating something with sexual arousal or having an unusual sexual experience reinforced with an orgasm in early life.

Some theorists see these conditions as a type of obsessive-compulsive disorder. People who are pedophiles are subject to various distortions in their thinking. They may view their behavior as appropriate or rationalize it in other ways.

It is also theorized that individuals with paraphilias may be deprived of normal social sexual contacts, so they pursue gratification through alternative methods that incidentally are less socially acceptable. Finally, physiological models stress the relationship between a person's hormones, behavior, and the central nervous system

Diagnosis & Tests

Because some actions resulting from paraphilia may cause illegal behavior, many people with paraphilia are reluctant to acknowledge their fantasies or behaviors even with their partners or doctors which greatly inhibits diagnosis. The law stipulates that if a therapist has reason to believe his or her patient may harm a child, he or she must report the patient to the authorities regardless of the confidentiality that typically applies to the relationship between a patient and his or her doctor.

Nevertheless, licensed psychologists, social workers, psychiatrists, mental health therapists, and psychiatric nurses may all contribute to the diagnostic process. They may conduct a medical interview and physical examination. Some tests may involve questionnaires and self-tests to help identify symptoms of paraphilia and determine which type of sexual disorder the individual may be suffering from.

Tests such as a phallometric testing (penile plethysmography), hepatitis tests, and HIV tests will help in diagnosis. Additionally, a physician may recommend a penile strain gauge, electroencephalography (EEG), unscheduled DNA synthesis, magnetic resonance imaging (MRI), Abel assessment for interest in paraphilia, and computed tomography (CT) scan.

Treatment & Therapy

  • Cognitive-behavioral therapy- This form of psychotherapy works by applying behavioral therapy techniques to alter sexual pathologies by changing the patient's distorted thinking. It also helps individuals to recognize the rationalizations that often underlie pathological sexual behaviors. 
  • Orgasmic reconditioning- This therapy works by reconditioning the patient to a more appropriate sexual stimulus. They are encouraged to begin masturbating with the unacceptable stimulus but climax with an appropriate one. This process is then repeated many times to reinforce the new way of thinking.
  • Social skills training- This therapy goes along with the theory that paraphilias are caused by the inability of a person to develop normal relationships with other people. The therapist may work on such skills as carrying on friendly conversation with others and relating to others in different ways.
  • Individual supportive-expressive psychotherapy (SE)- The therapist tries to break through the denial of the patient and then work on discovering the unconscious meaning behind the particular paraphilia. 
  • Pharmacologic therapy- Medication is used to suppress sexual behavior. While these medications have been of help to patients, various adverse effects have been noticed. The medications that can be used include the following: antidepressants, long-acting gonadotropin-releasing hormone agonist, antiandrogens, and phenothiazenes, mood stabilizers.
  • Psychosurgery - Surgeries of various sorts have been used to control paraphilias though are highly controversial. However, the adverse effects of these surgeries make them undesirable as a form of treatment.

If the paraphilia that a person suffers from cause so much distress that there is a danger of suicide or harm to themselves, then measures must be taken to insure that the patient is monitored and placed in a situation where they cannot harm themselves. This could mean that the person must be hospitalized for some extended period of time.

Prevention & Prophylaxis

One method for relapse prevention of paraphilias beyond the basic therapies already mentioned is to identify the situations that lead to unacceptable sexual behaviors and to avoid those situations. This method is not that effective by itself, however, because paraphilias concern not just behaviors but fantasies and urges.

Another option for the prevention of relapses is to join a twelve-step program. The specific program will be a sexual addiction/compulsion program. The twelve steps compose a process for spiritual transformation that can help prevent paraphilias. Twelve-step programs involve the recognition of a higher power and the need to rely on that higher power to help resolve life problems.