Paraphilic Disorders And Their Management

  • Jasmine Abdy Bachelor of Science - BSc, Medical Microbiology with a Year in Industry, University of Bristol

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Introduction

Paraphilic Disorders are defined by persistent and recurrent sexual interests, urges, fantasies, or behaviours that are intense and involve objects, activities or situations that are considered abnormal.1 A paraphilic disorder can develop if these fixations and interests result in harm, distress, or impairment to the individual affected.1 There are currently eight paraphilic disorders described by the DSM (the Diagnostic and Statistical Manual of Mental Disorders), which include paedophilia, exhibitionism, voyeurism, sexual sadism, sexual masochism, frotteurism, fetishism, and transvestic fetishism.1 Within this article, we will look at each of these disorders, providing an overall insight into the nature of these whilst covering the medical management available for individuals affected. 

Types of paraphilic disorders

As discussed, the DSM has defined eight paraphilic disorders. Below are details of each of these disorders. 

Exhibitionism

Exhibitionism is defined by the DSM as ‘exposing the genitals to become sexually excited or having a strong desire to be observed by other people during sexual activity'.2 Exhibitionism usually starts during adolescence, although the first act of exhibitionism can occur either during preadolescence or during middle age.2 Exhibitionism is thought to affect those assigned male at birth (AMAB) more than those assigned female at birth (AFAB), with a lifetime prevalence of 2-4%.3 Exhibitionists tend to expose their genitals to unsuspecting, non-consenting strangers, with excitement usually stemming from their need to either surprise, shock, or impress the observer.2 Sexual contact is rarely sought by exhibitionists. Approximately 30% of male offenders arrested are exhibitionists, with persistent exhibitionist behaviour resulting in approximately 20-50% of these people re-offending.2

For some people, exhibitionism is characterised by the strong desire for others to watch them engage in sexual acts.2 Such desires may lead to people pursuing a career as adult performers, performing in pornographic films and shows. It is important to note however that not all people involved in the adult industry have this desire. Furthermore, in those adult performers with exhibitionist tendencies, it is not uncommon to find that they are not distressed or impeded by such desires, and so may not have a mental disorder.2 

In those with severe exhibitionism, exhibitionist disorder can develop. This is usually diagnosed in those who become greatly distressed or less able to function when faced with the possibility of being unable to expose themselves.2 If the person has had these tendencies for six months or longer, this further assists the diagnosis.2 When assessing the fantasies, a healthcare provider will seek to assess whether the exposure is usually to pre-adolescent or post-adolescent individuals.2 Importantly, research has identified some common risk factors present among individuals with exhibitionism, which include:3 

  • Insecure attachment styles
  • Sexual abuse in childhood
  • Substance abuse
  • Sexual dysfunction

Exhibitionism has also been associated with personality disorders, namely antisocial personality disorder.2

Fetishism

Fetishism is defined by the DSM as ‘the use of an inanimate object (the fetish) as the preferred way to produce sexual arousal.’4 In those with fetishism, there may also be significant focus afforded to typically ‘non-sexual’ aspects of the body, such as the hands and feet.5 People with fetishes may become sexually aroused by several things, including:4

  • Wearing another person's undergarments
  • Wearing materials such as rubber or leather
  • Holding, rubbing, or smelling objects such as shoes

In most people with a fetish, their behaviour does not meet the criteria for a diagnosis of a mental disorder due to it not causing them significant distress.2 However, those who are significantly impacted or distressed by their fetish may be diagnosed with fetishistic disorder.4 In these individuals, they may not be able to function sexually in the absence of their fetish. It may even replace regular sexual activity, or may even be incorporated into regular sexual activity with a consenting partner. In severe cases of fetishistic disorder, the fetish may become so consuming that it may become destructive.4

Frotteurism

Frotteurism is defined by the DSM as ‘intense sexual arousal from touching or rubbing against a non-consenting person.’6 The origin of the word ‘frotteurism’ stems from the French word ‘frotter’ which means to rub or to put pressure on someone. This term has now been coined to define frotteurism, which is characterized by the rubbing of the genital area onto a non-consenting person. This typically involves contact with an unsuspecting person in busy and crowded areas such as on public transport or at public events.6  

Many people diagnosed with frotteurism appear to derive excitement from the risk of being caught in public, with most cases occurring between those AMAB and AFAB, or between those AMAB and AMAB.6 When acts of frotteurism are committed by an adult, it is considered a crime due to it constituting non-consensual sexual interaction. 

A diagnosis of frotteurism disorder will be made by a healthcare professional and will be based on the following factors:6 

  • If the person experiences persistent and recurrent sexual arousal from touching or rubbing against a non-consenting person
  • If the person has acted on these urges with a non-consenting person, or if the urges cause significant distress or impairment to important aspects of the individual’s life
  • If the condition has been present for 6 or more months

Many proposals have been made as to why these desires occur. Some suggest it could be due to historical unmet needs regarding cuddling, whereby the individual feels the need to enact these actions on non-consenting individuals.7 Others have suggested that individuals affected by frotteurism could believe themselves to harbour a caring and loving relationship with the non-consenting individual selected.7

Pedophilia

Paedophilia, or pedophilic disorder, is defined by the DSM as ‘recurring, intense sexually arousing fantasies, urges, or behaviour involving children (usually 13 years or younger).’8 Pedophilia is considered a disorder due to causing harm to others. Whether sexual involvement between two individuals is considered a ‘pedophilic disorder’ is dependent on the age of those involved. In Western society, a diagnosis of pedophilic disorder necessitates that the assailant be 16 years or older, with at least a five-year age difference compared to the child involved.8 Sexual interaction between an older adolescent (i.e., 16-17) with a younger individual (i.e., 12-13) may not always be considered a pedophilic disorder.

In the United States, the law dictates that a person older than 18 is committing statutory rape if the victim is 16 or younger.8 These cases often do not meet the requirements of a pedophilic disorder, although legal punishment almost always occurs. Pedophilic disorder is more common among AMAB than it is among AFAB.8

Paedophiles may be attracted to either one gender or both. Usually, the adult is known to the child and maybe a family member or other person of authority. In some cases, paedophiles may only be attracted to the children within their own family. Some may be attracted to children of a particular age and developmental stage, whereas some may harbour attractions towards both children and adults alike. Predatory paedophiles may employ tactics such as force or coercion to engage the child in sexual activity, often using threats to carry out their urges. In these individuals, a concurrent diagnosis of antisocial personality disorder is sometimes present. 

Numerous life factors have been identified in those with pedophilic disorder, and these include:8 

  • Substance use disorder or dependence 
  • Depression
  • Originate from dysfunctional families 
  • Marital conflicts
  • Many were sexually abused as children

Pedophilic disorder is diagnosed by a healthcare professional in the context of the following factors:8

  • Individuals have recurrent, intense, sexually arousing urges or fantasies involving children
  • Individuals feel greatly distressed or unable to function in terms of their social life, work life etc due to the urges
  • Individuals have acted upon these urges
  • They have had these urges/fantasies for 6 months or longer

Sexual masochism

Sexual masochism is defined by the DSM as ‘acts in which a person experiences sexual excitement from being humiliated, beaten, bound or otherwise abused.’9 It is important to note, however, that some aspects of sexual sadism/masochism are common to healthy sexual relationships, with mutually consenting partners often engaging in these. For example, the use of handcuffs and other materials for sexual gratification is not considered sexually sadomasochistic. 

In consenting and healthy sexual partnerships, these acts of humiliation are often undertaken with the knowledge that it is solely for sexual gratification, rather than to intentionally humiliate their partner. Participants will usually employ a ‘safe word’ - a pre-negotiated term that when used will stop the sexual activity. In some instances, however, masochists may intensify the severity of activity, reducing the threshold for use of their ‘safe word.’ In extreme situations, this can result in death or severe injury. 

Sexual masochism disorder is therefore commonly defined by the presence of the following factors:9 

  • Individuals may be significantly distressed by their behaviour or unable to function due to their behaviour
  • Acts committed by the individual may result in significant bodily or psychological harm, with death possibly occurring in the context of asphyxiaphilia
  • The individual has been living with the disorder for 6 months or longer

Asphyxiaphilia 

Asphyxiaphilia can sometimes be present amongst those with sexual masochism disorder. Individuals with this disorder will partially choke or strangle themselves through the use of their hands or a noose during masturbation.9 A partner may also do this for them. A temporary decrease in oxygen delivery to the brain during orgasm is sought as an enhancement to sexual climax, although unsafe execution of this practice can result in brain damage or death.9

Sexual sadism

Sexual sadism is defined by the DSM as ‘acts in which a person experiences sexual excitement from inflicting physical or psychological suffering on another person.’10 Similarly to sexual masochism, elements of sexual sadism are typically found within healthy sexual relationships, with the use of a ‘safe word’ frequently employed to establish respected boundaries. Fantasies of total control and dominance are common to sexual sadism, with sadists typically binding and gagging their sexual partners.10

Sexual sadism disorder, on the other hand, is defined typically by the presence of the following factors:10

  • Individuals are distressed by their behaviour or are unable to function due to their behaviour. 
  • Individuals take their sadistic actions to the extremes, sometimes causing severe psychological or bodily harm. 
  • These acts may involve partners who are non-consenting. 
  • Individuals have been affected by the condition for at least 6 months. 

When sadistic actions are enacted upon a non-consenting individual, this is considered a crime. Sexual sadism is diagnosed in less than 10% of rapists, although it is diagnosed in 37-75% of individuals who have committed sexually motivated homicides.10

Transvestic fetishism

Transvestic fetishism is defined by the DSM as ‘intense sexual arousing from cross-dressing’.11 Transvestism refers either to those AFAB wearing the clothes of those assigned AMAB or vice versa. Individuals with transvestic fetishism, do not have an inner sense of belonging to the opposite sex or their desire to change their sex, as is seen in severe gender dysphoria

Cross-dressing itself is not considered a mental disorder, occurring in both heterosexual and homosexual men. Heterosexual individuals AMAB typically exhibit evidence of transvestic fetishism in late adolescence, with this being associated with sexual arousal.11 Cross-dressers may engage in this activity for other reasons, however, such as to reduce anxiety or to engage with ‘feminine’ aspects of an otherwise ‘masculine’ personality. Later in life, those individuals AMAB that cross-dressed in adolescence may develop gender dysphoria and wish to change sex. 

Transvestic disorder is diagnosed when:11

  • Individuals have been repeatedly and intensely aroused by cross-dressing, with the arousal expressed in fantasies or urges 
  • Individuals may feel severely distressed or unable to function as well due to these urges. 
  • Individuals have been affected for 6 months or longer

Voyeurism

Voyeurism is defined by the DSM as ‘becoming sexually aroused by watching an unsuspecting person who is disrobing, naked, or engaged in sexual activity’.12 Voyeurs tend not to seek sexual activity or intercourse, rather gaining sexual gratification from watching others engage in sexual intercourse themselves. Voyeurism typically develops during late adolescence or early adulthood.12 Some degree of voyeurism is common, with it being far more prevalent amongst individuals AMAB.12 

There are some important distinctions to be made with regard to voyeurism. For example, private viewing of sexually explicit images or pornographic videos is not considered voyeuristic due to the act lacking the element of secret observation. Despite this, the increasing digitalization of society has given rise to video voyeurism, whereby non-consenting individuals are filmed disrobing or engaging in sexual activity.12 

Voyeurism is considered a disorder when voyeurs invest significant time into seeking new viewing opportunities.12 Through seeking these opportunities, they may neglect their responsibilities and tasks. 

Medication management

Whilst the evidence underpinning the efficacy of medications in the management of paraphilic disorders is poor, three standard therapies are currently advised: antiandrogens, SSRIs, and steroid analogues. The choice of which to use depends on the individual’s previous medical history, alongside the intensity of both the sexual fantasy and risk of sexual violence.1 

Medications used to treat paraphilic disorders

Antiandrogens

Anti-androgens, namely gonadotropin-releasing hormone (GnRH) agonists such as leuprorelin, have been shown to be potent in their ability to reduce the frequency and severity of the sexual urges/fantasies common to paraphilic disorders.1 Importantly, they are the most promising intervention for sex offenders at high risk of violent crimes or in those with pedophilic disorder.1 

Antiandrogens work primarily by reducing testosterone release, thereby reducing the sexual drive of individuals taking the drugs. 

Serotonin reuptake inhibitors (SSRIs)

SSRIs such as citalopram are effective in adolescent populations and in those with milder forms of paraphilic disorders, including exhibitionism and in those suffering from other mental health diagnoses such as obsessive-compulsive disorder (OCD).1 SSRIs have also been shown to reduce levels of hypersexuality.1

Synthetic steroid analogs

Cyproterone Acetate is a synthetic steroid analogue, acting similarly to that of antiandrogens.13 Studies have shown cyproterone acetate to be impactful in its treatment of paraphilic disorders, with one trial showing 80-90% of individuals given the drug reporting a reduction in sexual fantasy frequency.13 

Non-medication interventions

Alongside pharmaceutical use, there are also a number of non-medical interventions suggested for the management of paraphilic disorders. These are discussed in detail below. 

Psychotherapy

Psychotherapy is an important psychological approach used in the treatment of paraphilic disorders. Psychologists will apply scientifically proven procedures to help individuals develop healthier and more appropriate habits and coping mechanisms.14 Psychotherapy relies largely upon the use of dialogue, and they are someone who will remain objective, neutral and non-judgmental throughout the course of the sessions. Individuals will work alongside their psychologist to help identify and change the thought patterns prevalent with the paraphilic disorder. 

Behavioural therapy

The most common psychotherapy is cognitive behaviour therapy (CBT). It operates on the basis that thoughts, feelings, physical feelings and actions are all interconnected and that negative thoughts can entrap an individual in a negative cycle. CBT compartmentalizes the problems at hand, allowing individuals to target aspects of the problem rather than the whole problem at once. This can allow individuals to change their thought patterns and actions, helping them to better deal with and process the sexual fantasies and desires that may be affecting them. 

Individuals will usually meet with their therapist once a week or once every two weeks. Sessions will range between 6 and 20, with each lasting between 30 and 60 minutes. After developing appropriate methods to deal with the intrusive sexual fantasies or urges, the therapist will then encourage individuals to employ these in everyday life. 

Self-help programs

Many individuals may feel too embarrassed or ashamed of their desire to seek out expert help. These individuals must seek help in whatever way they can if they feel these desires are significantly impacting their lives or if they believe them to be at risk of causing harm. There are numerous resources available online, including the website ‘Stop it Now’ which provides helpful steps on how to process and cope with these urges. 

Summary

Paraphilic disorders are defined by intense sexual arousal stemming from objects, situations or actions that may not be typical amongst the general population. With eight disorders defined by the DSM, each is characterized by a fixation of their own. Whilst some of the disorders may be less harmful than others in terms of their impact, it is important that affected individuals seek urgent help if they feel they are at risk of causing harm to themselves or to another person, or if their urges are consuming their everyday life. Without appropriate help and intervention, acting upon these urges can often result in incarceration and punishment, with significant harm often caused to those non-consenting individuals affected. Numerous medical therapies are available for the treatment of paraphilic disorders, with drugs such as antiandrogens showing promise in their ability to curb sexual desires and drive. In treating paraphilia, psychological interventions should also not be discounted, as these are often paramount to sufficiently curbing these urges. 

References

  1. Fisher KA, Marwaha R. Paraphilia. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 [cited 2024 Jan 12]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK554425/.
  2. Exhibitionistic Disorder - Mental Health Disorders. MSD Manual Consumer Version [Internet]. [cited 2024 Jan 12]. Available from: https://www.msdmanuals.com/en-gb/home/mental-health-disorders/paraphilias-and-paraphilic-disorders/exhibitionistic-disorder.
  3. Seeman MV. Portrait of an Exhibitionist. Psychiatr Q. 2020; 91(4):1249–63.
  4. Fetishistic Disorder - Mental Health Disorders. MSD Manual Consumer Version [Internet]. [cited 2024 Jan 12]. Available from: https://www.msdmanuals.com/en-gb/home/mental-health-disorders/paraphilias-and-paraphilic-disorders/fetishistic-disorder.
  5. Kafka MP. The DSM diagnostic criteria for fetishism. Arch Sex Behav. 2010; 39(2):357–62.
  6. Frotteuristic Disorder - Mental Health Disorders. MSD Manual Consumer Version [Internet]. [cited 2024 Jan 12]. Available from: https://www.msdmanuals.com/en-gb/home/mental-health-disorders/paraphilias-and-paraphilic-disorders/frotteuristic-disorder.
  7. Bhatia K, Parekh U. Frotteurism. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 [cited 2024 Jan 12]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK563260/.
  8. Pedophilic Disorder - Mental Health Disorders. MSD Manual Consumer Version [Internet]. [cited 2024 Jan 12]. Available from: https://www.msdmanuals.com/en-gb/home/mental-health-disorders/paraphilias-and-paraphilic-disorders/pedophilic-disorder.
  9. Sexual Masochism Disorder - Mental Health Disorders. MSD Manual Consumer Version [Internet]. [cited 2024 Jan 12]. Available from: https://www.msdmanuals.com/en-gb/home/mental-health-disorders/paraphilias-and-paraphilic-disorders/sexual-masochism-disorder.
  10. Sexual Sadism Disorder - Mental Health Disorders. MSD Manual Consumer Version [Internet]. [cited 2024 Jan 12]. Available from: https://www.msdmanuals.com/en-gb/home/mental-health-disorders/paraphilias-and-paraphilic-disorders/sexual-sadism-disorder.
  11. Transvestic Disorder - Mental Health Disorders. MSD Manual Consumer Version [Internet]. [cited 2024 Jan 12]. Available from: https://www.msdmanuals.com/en-gb/home/mental-health-disorders/paraphilias-and-paraphilic-disorders/transvestic-disorder.
  12. Voyeuristic Disorder - Mental Health Disorders. MSD Manual Consumer Version [Internet]. [cited 2024 Jan 12]. Available from: https://www.msdmanuals.com/en-gb/home/mental-health-disorders/paraphilias-and-paraphilic-disorders/voyeuristic-disorder.
  13. Holoyda BJ, Kellaher DC. The Biological Treatment of Paraphilic Disorders: an Updated Review. Curr Psychiatry Rep [Internet]. 2016 [cited 2024 Jan 12]; 18(2):19. Available from: https://doi.org/10.1007/s11920-015-0649-y.
  14. Understanding psychotherapy and how it works. https://www.apa.org [Internet]. [cited 2024 Jan 12]. Available from: https://www.apa.org/topics/psychotherapy/understanding.

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