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CURRENT
OPINION Paraphilias
Norbert Konrad, Justus Welke, and Annette Opitz-Welke
Purpose of review
The concept of paraphilia still carries an ‘unwanted burden’ of sexual norms because the pathologization
of some sexual practices as paraphilic disorders is still based on the assumption that normal sexuality
should be genitally organized with the aim of reproduction. The aim of this review is to give an impression
of the ongoing discussion about the changes introduced with the Diagnostic and Statistical Manual of
Mental Disorders, Fifth Edition (DSM-5) and the results of recent research in this area.
Recent findings
The release of DSM-5 in the spring of 2013 introduced a distinction between paraphilias and paraphilic
disorders, implying a destigmatization of consenting adults engaging in unusual sexual behaviour.
According to DSM-5 diagnostic criteria, paedophilic disorder is the only paraphilic disorder without an ‘in
remission’ and an ‘in a controlled environment’ specifier. Today, antiandrogen treatment is offered to sex
offenders in many countries as an additional treatment strategy alongside psychotherapy.
Summary
The introduction of DSM-5 offers the possibility to distinguish between paraphilia and paraphilic disorders.
The aetiology of paraphilias is still unknown. Paraphilias are much more common in men than in women,
but the reasons for this difference remain unknown. So far there is no clear consent on the best therapeutic
approach for a paraphilic disorder.
Keywords
antiandrogen treatment, paraphilia, paraphilic disorder
disorders such as Parkinson’s disease, in some cases as typical [13 ]. The authors recommend focusing less
a side-effect of treatment. on the content of fantasies than on the effect, and
Agalaryan and Rouleau [12] pointed out that coer-
So far there is no clear consent on the best therapeutic
cive sexual fantasies can be experienced without
approach for a paraphilic disorder. In forensic
samples, the best treatment responses have been individuals ever acting them out. On the contrary,
achieved by the combination of psychotherapy and Chan and Beauregard [14] revealed that a higher
chemical castration. percentage of homicidal sexual offenders showed
paraphilic interests when compared with non-
homicidal sexual offenders. The homicidal sexual
offenders also exhibited a higher percentage of mal-
population is very scarce. In some cases, exploring adaptive personality traits [14].
sadomasochistic dynamics in psychoanalytic psy- Paraphilias are much more common in men
chotherapy can aid in understanding paraphilic than in women, but the reasons for this difference
elements as a defensive reaction to disappointing remain unknown. Various factors have been dis-
ministrations of caregivers earlier in life [7]. Recent
&&
cussed. Dawson et al. [15 ] examined a nonclinical
research on the specificity of sexual arousal has sample of men and women for the prevalence of
revealed that sexual interest in masochism may paraphilic interests. Their findings suggested a cor-
not represent a narrowing in on a category of sexual relation of sex drive and paraphilic interests that
activities, but on the contrary, a broadening of provided the best explanation for the observable
sexual repertoire [8]. Assessment of paraphilias in gender difference in paraphilic interests. They also
the general mental health context may be hindered found comorbidity of different paraphilic interests
by the fact that nearly every study of assessment
&&
[15 ]. Recent results of a systematic review by Solla
instruments for paraphilias or paraphilic disorders
&
et al. [16 ] of paraphilias and paraphilic disorders
has been conducted with sexual offender popu- in Parkinson’s disease patients revealed that both
lations [9]. could emerge as a rare iatrogenic consequence in
Although sex has always played an important Parkinson’s disease treatment. Typically, any
role in human lives all over the world, modern west- paraphilias or paraphilic disorders appear during
ern cultures tend to view sexuality as recreational, treatment with dopaminomimetic medication.
whereas Asian cultures tend to treat sex as taboo and Aberrant sexual behaviour observed included exhi-
with the sole purpose of procreation. For this reason, bitionism, frotteurism, paedophilia, sexual maso-
very limited research on sexuality-related issues has chism, and transvestism. Because hypersexuality is
been conducted on Asian populations, and it is not often described as a neuropsychiatric complication
possible to extrapolate all findings from western of Parkinson’s disease, this leads to the assumption
studies to Asian populations [10]. that hypersexuality and paraphilias may be the
phenotypical expressions of different degrees of a
&
common pathophysiological process [16 ].
DIAGNOSTIC APPROACH
The release of DSM-5 in the spring of 2013 intro-
duced a distinction between paraphilias and para- PAEDOPHILIA
philic disorders, implying a destigmatization of From what we know today, paedophilia affects
consenting adults engaging in unusual sexual around 1% of the male population. Nevertheless,
behaviour [11]. The rejection of paraphilic coercive paedophilia is the paraphilia that gets virtually all
disorder from the main body of the DSM was media coverage, although human sexual interest
approved by Agalaryan and Rouleau [12], who can become fixated on a wide variety of targets
pointed out that the proposed criteria still lack [17]. After a century of broad clinical discussion
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0951-7367 Copyright ß 2015 Wolters Kluwer Health, Inc. All rights reserved. www.co-psychiatry.com 443
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