PARAPHILIC DISORDERS PG 1460

Paraphilias ( sexual deviations; perversions) are disorders of sexual preference in which

sexual arousal occurs persistently and significantly in response to objects which are not a
part of normal sexual arousal (e.g. nonhuman objects; suffering or humiliation of
self and/or sexual partner; children or nonconsenting person).

Voyeuristic Disorder

Diagnostic Criteria
A. Over a period of at least 6 months, recurrent and intense sexual arousal from
observing an unsuspecting person who is naked, in the process of disrobing, or
engaging in sexual activity, as manifested by fantasies, urges, or behaviors.
B. The individual has acted on these sexual urges with a nonconsenting person, or
the sexual urges or fantasies cause clinically significant distress or impairment in
social, occupational, or other important areas of functioning.
C. The individual experiencing the arousal and/or acting on the urges is at least 18
years of age.

Voyeurism
•
also known as scopophilia. A recurrent or persistent tendency to look at people engaging in
sexual or intimate behavior such as undressing. This usually leads to sexual excitement and
masturbation and is carried out without the observed people being aware.,
•
The first voyeuristic act usually occurs during childhood, and the paraphilia is most common
in men. When persons with voyeurism are apprehended, the charge is usually loitering.

Voyeuristic acts, however, are the most common of potentially law-breaking sexual behaviors.

Adult men with voyeuristic disorder often first become aware of their sexual interest in secretly
watching unsuspecting persons during adolescence. However, the minimum age for a diagnosis of
voyeuristic disorder is 18 years because there is substantial difficulty in differentiating it from age-
appropriate puberty-related sexual curiosity and activity.

Exhibitionistic Disorder

Diagnostic Criteria
A. Over a period of at least 6 months, recurrent and intense sexual arousal from the
exposure of one’s genitals to an unsuspecting person, as manifested by fantasies,
urges, or behaviors.
B. The individual has acted on these sexual urges with a nonconsenting person, or
the sexual urges or fantasies cause clinically significant distress or impairment in
social,
occupational, or other important areas of functioning.

Exhibitionism
• A recurrent or persistent tendency to expose the genitalia to strangers (usually of the
opposite sex) or people in public places, without inviting or intending closer contact. There is
usually, but not invariably, sexual excitement at the time of the exposure, and the act is
commonly followed by masturbation. This tendency may be manifest only at times of
emotional stress or crises, interspersed with long periods without such overt behavior.
• Most exhibitionists do not have exhibitionist disorder.

• Exhibitionism is almost entirely limited to heterosexual males who are exposed to females,
adults, or adolescents, usually confronting them from a safe distance in some public place. For some,
exhibitionism is their only sexual outlet, but others continue the habit simultaneously with an active
sex life within long-standing relationships, although their urges may become more pressing at times
of conflict in those relationships. Most exhibitionists find their urges difficult to control and ego-
alien. If the witness appears shocked, frightened, or impressed, the exhibitionist's excitement is
often heightened.

• Wives of men with exhibitionism often substitute for the mothers to whom the men were
excessively attached during childhood, or conversely, by whom they were rejected. In other
related paraphilias, the central themes involve derivatives of looking or showing.

Frotteuristic Disorder

Diagnostic Criteria
A. Over a period of at least 6 months, recurrent and intense sexual arousal from
touching or rubbing against a nonconsenting person, as manifested by fantasies,
urges, or behaviors.
B. The individual has acted on these sexual urges with a nonconsenting person, or
the sexual urges or fantasies cause clinically significant distress or impairment in
social,
occupational, or other important areas of functioning.

Sexual Masochism Disorder

Diagnostic Criteria
A. Over a period of at least 6 months, recurrent and intense sexual arousal from the
act of being humiliated, beaten, bound, or otherwise made to suffer, as manifested
by
fantasies, urges, or behaviors.
B. The fantasies, sexual urges, or behaviors cause clinically significant distress or
impairment in social, occupational, or other important areas of functioning.

Sexual Sadism Disorder

Diagnostic Criteria
A. Over a period of at least 6 months, recurrent and intense sexual arousal from the
physical or psychological suffering of another person, as manifested by fantasies,
urges, or behaviors.
B. The individual has acted on these sexual urges with a nonconsenting person, or
the sexual urges or fantasies cause clinically significant distress or impairment in
social,
occupational, or other important areas of functioning.

Pedophilic Disorder

Diagnostic Criteria

A. Over a period of at least 6 months, recurrent, intense sexually arousing fantasies,

sexual urges, or behaviors involving sexual activity with a prepubescent child or
children
(generally age 13 years or younger).
B. The individual has acted on these sexual urges, or the sexual urges or fantasies
cause marked distress or interpersonal difficulty.
C. The individual is at least age 16 years and at least 5 years older than the child or
children in Criterion A.

Fetishistic Disorder
Diagnostic Criteria
A. Over a period of at least 6 months, recurrent and intense sexual arousal from
either the use of nonliving objects or a highly specific focus on nongenital body
part(s), as
manifested by fantasies, urges, or behaviors.
B. The fantasies, sexual urges, or behaviors cause clinically significant distress or
impairment in social, occupational, or other important areas of functioning.
C. The fetish objects are not limited to articles of clothing used in cross-dressing (as
in transvestic disorder) or devices specifically designed for the purpose of tactile
genital stimulation (e.g., vibrator).

Transvestic Disorder
Diagnostic Criteria
A. Over a period of at least 6 months, recurrent and intense
sexual arousal from cross-dressing, as manifested by
fantasies, urges, or behaviors.
B. The fantasies, sexual urges, or behaviors cause clinically
significant distress or impairment in social, occupational, or
other important areas of functioning.

Fetishistic transvestism
This disorder occurs exclusively in heterosexual males. The person actually or in
fantasy wears clothes of the opposite sex (cross-dres sing) for sexual arousal.
This disorder should be differentiated from dual-role transvestism and tran
sexualism.
This disorder may be associated with fantasies of other males approaching the
person who is in a female dress. Masturbation or rarely coitus is associated with
cross-dressing to achieve orgasm. To be called a disorder, this should be a
persistent and significant
mode of sexual arousal in the person.

Zoophilia (Bestiality)
Zoophilia as a persistent and significant involvement in sexual activity with animals is
rare. Occasional or situational zoophilia is much more common.

Other Paraphilias
These include sexual arousal with urine (urophilia);
faeces (coprophilia); enemas ( klismaphilia); corpses (necrophilia), among many
others.

TREATMENT
Five types of psychiatric interventions are used to treat persons with paraphilic
disorder and paraphilic interests: external control, reduction of sexual drives,
treatment of comorbid conditions (e.g., depression or anxiety), cognitive-behavioral
therapy, and dynamic psychotherapy.

• Prison is an external control mechanism for sexual crimes that usually

does not contain a treatment element. When victimization occurs in a family or
work setting, the external control comes from informing supervisors, peers, or other
adult family members of the problem and advising them about eliminating
opportunities for the perpetrator to act on urges.

Drug therapy, including antipsychotic or antidepressant medication, is

indicated for the treatment of schizophrenia or depressive disorders if the
paraphilia is associated with these disorders. Antiandrogens, such as
cyproterone acetate in Europe and medroxyprogesterone acetate (Depo-Provera) in
the United States, may reduce the drive to behave sexually by decreasing
serum testosterone levels to subnormal concentrations. Benperidol was
earlier believed to be particularly useful but the claim has not been substantiated,
and the drug is not available in the market.

• Serotonergic agents, such as fluoxetine (Prozac), have been used with

limited success in some patients with paraphilia.
• Cognitive-behavioral therapy is used to disrupt learned paraphilic
patterns and modify behavior to make it socially acceptable. The interventions
include social skills raining, sex education, cognitive restructuring
(confronting and destroying the rationalizations used to support victimization
of others), and development of victim empathy.

imaginal desensitization, relaxation technique, and learning what triggers the

paraphilic impulse so that such stimuli can be avoided are also taught.

Aversion therapy is the treatment of choice in severe, distressing paraphilia,with the

patient’s consent.In modified aversive behavior rehearsal, perpetrators are
videotaped acting out their paraphilia with a mannequin. Then the patient with
paraphilic disorder is confronted by a therapist and a group of other offenders who
ask questions about feelings, thoughts, and motives associated with the act
and repeatedly try to correct cognitive distortions and point out lack of victim
empathy to the patient.

• Insight-oriented psychotherapy is a long-standing treatment approach.

Patients have the opportunity to understand their dynamics and the events
that caused the paraphilia to develop. In particular, they become aware of the
daily events that cause them to act on their impulses (e.g., a real or fantasized
rejection). Treatment helps them deal more effectively with life stresses and
enhances their capacity to relate to a life partner. In addition, psychotherapy allows
patients to regain self-esteem, which in turn allows them to approach a partner in a
more normal sexual manner. Sex therapy is an appropriate adjunct to the treatment
of patients with specific sexual dysfunctions when they attempt non-deviant sexual
activities.

• Psychoanalysis and psychoanalytic psychotherapy: This is of particular

help if the patient is psychologically minded and has good ego strength for therapy.

ETIOLOGY OF PARAPHILIC DISORDERS

Psychosocial Factors:

1. Psychoanalytic Model:
o Failure to complete normal developmental process towards
sexual adjustment.
o Modified by new psychoanalytic approaches.
o Paraphilia as coping mechanism for anxiety related to castration
threat by father and separation from mother.
 o Behavior provides outlet for sexual and aggressive drives.
2. Oedipal Crisis and Improper Identification:
o Failure to resolve oedipal crisis leads to improper identification
with opposite-sex parent.
o Transsexualism, transvestic fetishism, exhibitionism, voyeurism
explained through this lens.
3. Anxiety Reduction and Defense Mechanisms:
o Paraphilic behaviors as attempts to calm anxiety (e.g.,
exhibitionism, voyeurism).
o Fetishism as displacement of libidinal impulses.
o Need for dominance and control in pedophilia and sexual
sadism.
o Masochism as overcoming fear of injury or directing aggression
towards self.
4. Early Experiences and Conditioning:
o Molestation or abuse as child predisposes towards paraphilic
behavior.
o Non-sexual abuse experiences (e.g., spanking, verbal
humiliation) can become sexualized.
o Modeling behavior on others, mimicking media depictions,
recalling past events.

Biological Factors:

1. Abnormal Organic Findings:

o Studies identify abnormalities in hormone levels, neurological
signs, chromosomal abnormalities, etc.
o Question of causal relationship to paraphilic interests.
2. Psychophysiological Tests:
o Measures penile volumetric size in response to stimuli.
o Limited diagnostic validity due to potential suppression of
responses.

DIFFERENTIAL DIAGNOSIS

Exhibitionism., voyureism( depending on disorder)

Individuals with exhibitionism experience recurrent, intense sexual arousal from the
act of exposing their genitals to an unsuspecting person. Unless the individual acts
on these urges with an unsuspecting person (e.g., exposing his genitals to
riders on a train) or unless there is accompanying clinically significant
distress or impairment in social, occupational, or other important areas of
functioning, a diagnosis of exhibitionistic disorder is not warranted.

Manic episode, major neurocognitive disorder, intellectual developmental

disorder, personality change due to another medical condition, substance
intoxication, and Schizophrenia

Individuals with a major neurocognitive disorder, intellectual developmental disorder,

personality change due to another medical condition, or schizophrenia, or who are in
a manic episode or experiencing substance intoxication, may become sexually
disinhibited(the inability to control an inappropriate or unwanted behavior, or the
production of socially inappropriate actions or comments) or have impaired judgment
or impulse control and engage in exhibitionistic behavior. Unless that behavior
occurs at times other than in the context of one of these disorders, a diagnosis
of exhibitionistic disorder should not be made.

Conduct disorder and antisocial personality disorder.

Conduct disorder in adolescents and antisocial personality disorder would be

characterized by additional norm-breaking and antisocial behaviors, and the
specific sexual interest in exposing the genitals will usually be lacking.

RISK AND PROGNOSTIC FACTOR

Good prognostic indicators include the presence of only one paraphilia, normal
intelligence, the absence of substance abuse, the absence of nonsexual antisocial
personality traits, and the presence of a successful adult attachment. Paraphilic disorders,
however, remain significant treatment challenges even under these circumstances.
COMORBIDITY
include depressive, bipolar, anxiety, and substance use disorders; hypersexuality; attention-
deficit/hyperactivity disorder; other paraphilic disorders; and antisocial personality disorder.

PREVALENCE
More common in males in comparison to females.
Exhibitionistic: Highly unusual in females

about 50% of men and 30% of women regularly engage in or are aroused by
one or more paraphilias