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Other Sexual Disorders: The Paraphilias

Lorraine Benuto, Ph.D., edited by C. E. Zupanick, Psy.D.

The paraphilias re-introduce the controversy of what is healthy vs. disordered sexual behavior. The group of disorders called paraphilias refers to a variety of conditions in which the person views, has recurrent fantasies about, or has sexual contact with unusual stimuli. Throughout this document we have emphasized that distress, and impairment in social, occupational, or other functioning, are essential for a behavior to be considered disordered. Things become slightly more complicated when we discuss the paraphilias. Individuals with paraphilias rarely seek treatment and usually only come to therapy at the insistence of the law, or a partner. Because persons with paraphilias do not seek treatment, one might be hard-pressed to argue that the paraphilia causes the individual significant distress. Thus, when discussing paraphilias it might be useful to add a third component to our definition of disordered behavior: causing harm to others. While not all paraphilias include a component that involves harm to others (or self), several do. It is important to note that while some have argued that not all paraphilias cause distress and dysfunction to the individual, the DSM-IV-TR does specify that in order for a paraphilia to be diagnosed, the behavior must cause distress, or impairment of social, occupational, or other functioning, in order to be considered a disorder. A discussion of the paraphilias defined in the DSM-IV-TR follows, with a subsequent section on treatment options.

1. Exhibitionism
The DSM-IV-TR defines exhibitionism as including recurrent (for 6 months), intense, sexually arousing fantasies or behaviors of exposing one's genitals to an unsuspecting stranger. Exhibitionism differs from socially-sanctioned, consensual displays of nudity. Clearly, if you are a nudist at a nudist beach, or a dancer at a strip club, there is an implied expectation and consent for you to display yourself. Thus, this behavior would not be considered a paraphilia.

Exhibitionism typically begins somewhere between the age of 15-25 and tends to decline when one reaches the age of 40. This disorder is mostly seen in men and their victims are typically women (Murphy, 1997).

2. Fetishism
According to the DSM-IV-TR fetishism involves recurrent (for 6 months), intense, sexually arousing fantasies, sexual urges, or behaviors that involve sexual attraction to a nonliving object that typically provide a source of specific tactile stimulation (touch). The most common fetishistic objects are ordinary items of clothing (women's underpants, stockings, shoes, boots, dresses etc.). The individual (most always male) may fondle or wear the object during sexual encounters or masturbate with it (Getzfeld, 2006). It is important to note that being aroused by a specific object is not necessarily abnormal. For example, many individuals find certain types of clothing arousing. However, finding a nonliving object arousing becomes problematic when arousal cannot occur if the object is absent. Furthermore, in fetishism, the arousal, fantasy, urges, and desires are focused on the object. Thus an individual who has a shoe fetish may be very aroused and fantasize about shoes and may engage in sexual activity with a partner but only when/if the partner is wearing sexy shoes. The focus is completely on the shoes and not on the partner. In fact, Getzfeld (2006) states that men may actually experience erectile dysfunction if the fetishistic object is not present during sexual activity.

The DSM-IV-TR emphasizes the distinction between Fetishism and Transvestic Fetishism (to be discussed next). It also indicates if the fetish object is stimulating because it has been designed for sexual purposes (e.g., a vibrator, lingerie), then Fetishism is not diagnosed. Partialism is arguably another type of fetishism that refers to recurrent, intense, sexually arousing fantasies, sexual urges, or behaviors that involve attraction to a part of the body, such as the foot, buttocks, hair, etc. However, this attraction is no longer technically classified as a fetish because it is difficult to distinguish from general patterns of arousal. Consider for example an individual who is very aroused by long hair. It would be difficult (if not impossible) to determine whether or not the individual's attraction was just to the hair or simply part of their attraction to a physical characteristic of their partner. Fetishes usually begin in adolescence and then run a chronic course. Typically individuals with fetishes do not share their fetish with others, and may feel alone and/or ashamed. They rarely seek treatment.

3. Transvestic Fetishism
Transvestic fetishism refers to a heterosexual male with recurrent (for 6 months), intense, sexually arousing fantasies, sexual urges, or behaviors that involve cross-dressing (dressing in clothing worn by the opposite sex) which has continued for at least six months. Fetishistic cross-dressing is often accompanied by masturbation or fantasies in which the man imagines that other men are attracted to him as a woman, and yet the man sees himself as a man and is heterosexual (attracted to women). Relatively few individuals with transvestic fetishism seek professional help. They are often reluctant to give up their cross-dressing behavior and many times their partners simply learn to accept the cross-dressing behavior.

4. Frotterism
The DSM-IV-TR defines frotterism as recurrent (for 6 months), intense sexually arousing fantasies, sexual urges, or behaviors involving touching and rubbing against a non-consenting person. Individuals with frotterism often seek out their victims in crowded places, such as buses or subways. They typically identify an unsuspecting victim then rub up against the person until they reach ejaculation (as they are typically men). The act occurs quickly and the individual is prepared to run.

5. Pedophilia
Pedophilia is defined in the DSM-IV-TR as consisting of recurrent (for 6 months), intense sexually arousing fantasies, sexual urges, or behaviors involving sexual activity with a prepubescent child or children (generally under the age of 13). Because of the extreme harm to innocent victims, this is perhaps the most widely investigated paraphilia. The pattern of arousal and attraction may include male and/or female children. It is also important to note that not all persons with pedophilia act upon their fantasies and urges. The word pedophile is not the same as sex offender. The term "sex offender" is a legal term and includes many types of sexual offenses. A person with pedophilia may become a sex offender when he has acted upon his sexual attraction to children and broken the law (e.g., by directly victimizing a child, purchasing child pornography, etc.) Individuals who have pedophilia may rationalize their behavior as loving the child or teaching the child useful lessons about sexuality. They may even go as far as to say the child was acting in a sexually provocative manner (Getz, 2006).

While many pedophiles were sexually and emotionally abused as children (i.e., they were once victims) most abused children do not grow up to become pedophiles. According to the DSM-IV-TR individuals with Antisocial Personality Disorder have a disregard for the rights of others and tend to violate the rights of others. It is not difficult to see how individuals with pedophilia may have antisocial tendencies. They may not consider the psychological and physical damage they are doing to the children they prey on. Clinicians and researchers working within a biological perspective focus on finding treatment that reduces sexual urges. This is typically done by administered medication that reduces testosterone (antiandrogens or the female hormone progesterone), or by surgical removal of the testes. While these procedures may help to reduce sex drive, none of these procedures eliminate sexual arousal or the ability to have intercourse. Thus, medications alone do not adequately prevent a pedophile from becoming a sex offender.

6. Sexual Masochism & Sexual Sadism
In the DSM-IV-TR sexual masochism is defined as recurrent (for 6 months), intense sexually arousing fantasies, sexual urges, or behaviors involving the act (real, not simulated) of being humiliated, beaten, bound, or otherwise made to suffer. Sexual sadism is the converse of sexual masochism in that it involves inflicting pain rather than receiving it. In fact, the DSM-IV-TR defines sexual sadism as recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving acts (real, not simulated) in which psychological or physical suffering (including humiliation) of the victim is sexually exciting to the person. The vast majority of masochists and sadists never seek treatment. Getzfeld (2006) discuses how some individuals may be bothered by such fantasies and as a result never carry out the actual actions.

7. Voyeurism
In the DSM-IV-TR voyeurism is defined as recurrent (for 6 months), intense sexually arousing fantasies, sexual urges, or behaviors involving the act of observing an unsuspecting person who is naked, in the process of undressing, or engaging in sexual activity. Clearly, many individuals enjoying seeing their partner nude, looking at images of individuals who are naked, or in some swinging scenarios, even watching other couples have sex. Thus (while this is not specified by the DSM-IV-TR) it is important to keep in mind that an individual with voyeurism typically derives sexual pleasure from observing the nudity or sexual activity of people who are unaware they are being watched (Darcangelo, 2008). Individuals with voyeurism may not be able to establish a regular sexual relationship with the person they are watching (or perhaps with anyone for that matter). Thus, if a person with voyeurism does make it into the therapy, the focus might be on self-esteem issues or helping them to develop social skills so that they can form relationships with others.