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Chapter: Essentials of Psychiatry: Sexual Disorders

Sexual Disorders: The Paraphilias

A paraphilia is a disorder of intention, the final component of sexual identity to develop in children and adolescents.

The Paraphilias


A paraphilia is a disorder of intention, the final component of sexual identity to develop in children and adolescents. Inten-tion refers to what individuals want to do with a sexual partner and what they want the partner to do with them during sexual behavior. Normally, the images and the behaviors of intention fall within ranges of peaceable mutuality. The disorders of in-tention are recognized by unusual eroticism (images) and often socially destructive behaviors such as sex with children, rape, exhibitionism, voyeurism, masochism, obscene phone calling, or sexual touching of strangers. While 5% of the diagnoses of paraphilia are given to women, etiologic speculations refer to male sexual identity development gone awry. This raises the im-portant question about what happens to girls who have the samedevelopmental misfortunes that are speculated to create male paraphilia. Accounts of paraphilic behaviors have been in the nonmedical literatures for centuries.


Now it is apparent that paraphilias occur among individuals of all orientations and among those with conventional and uncon-ventional gender identities. A homosexual sadist is paraphilic only on the basis of sexual cruelty. A transsexual who desires to be beaten during arousal is paraphilic only on the basis of masochism.


Three General Characteristics of the Paraphilias


A Longstanding, Unusual, Highly-arousing Erotic Preoccupation


Erotic intentions that are not longstanding, unusual, and highly arousing may be problematic in some way but they are not clearly paraphilic. The sine qua non of the diagnosis of paraphilia is unu-sual, often hostile, dehumanized eroticism which has preoccupied the patient for most of his adolescent and adult life. The paraphilic fantasy is often associated with this preoccupying arousal when it occurs in daydreams and masturbation reveries or is encountered in explicit films or magazines. The specific imagery varies from one paraphilic patient to the next, but both the imagined behavior and its implied relationship to the partner are unusual in that they are preoccupied with aggression. Images of rape, obscene phone calling, exhibitionism and touching of strangers, for example, are rehearsals of victimization. In masochistic images, the aggression is directed at the self, for instance, autoerotic strangulation, slav-ery, torture, spanking. In others, the aggression is well-disguised as love of children or teenagers. In some, such as simple clothing fetishism, the aggression may be absent. Aggression is so appar-ent in most paraphilic content, however, that when none seems to exist, the clinician needs to wonder whether it is actually absent or being hidden from the doctor. Paraphilic fantasies often rely heav-ily upon the image of a partner who does not possess “person-hood”. Some imagery in fact has no pretense of a human partner at all; clothing, animals, or excretory products are the focus. Other themes such as preoccupation with feet or hair, combine both hu-man and inanimate interests. Paraphilic images are usually devoid of any pretense of caring or human attachment. The hatred, anger, fear, vengeance, or worthlessness expressed in them require no familiarity with the partner. Paraphilic images are conscious – clearly known to the individual. They should not be confused with speculations about “unconscious” aggression or sadomasochism that some assume are part of all sexual behavior (Kernberg, 1991). Clinicians should expect occasionally to see paraphilic patients whose preoccupations are not hostile to others.


An individual’s paraphilic themes often change in inten-sity or seem to change in content from time to time. The stimuli for these changes often remain unclear. It is a moot point whether changes should be considered a shift to a different disorder, a new paraphilia, or a natural evolution of the basic problem. The shifts from imagining talking “dirty” on the phone in order to scare a woman to imagining raping can be considered an inten-sification of sadism. Switches between sadism and masochism or voyeurism and exhibitionism are common. Changes from vo-yeurism to pedophilia or from pedophilia to rape, however, raise the question whether a new disorder has developed. The most socially significant shifts are from erotic imagery to sexual be-havior. In most instances, it is reasonable to consider that para-philia is a basic developmental disorder in which particular erotic and sexual manifestations are shaped by the individuality of the person’s history.


Most paraphilic adults can trace their fantasy themes to puberty and many can remember these images from earlier years. When adolescent rapists or incest offenders are evaluated, they often are able to report prepubertal aggressive erotic preoccupa-tions. Men who report periodic paraphilic imagery interspersed with more usual eroticism have had their paraphilic themes from childhood or early adolescence. To make a diagnosis of para-philia, the patient must evidence at least 6 months of the unusual erotic preoccupation. Duration is usually not in question, even among adolescents, however (Shaw, 1999).


Pressure to Act Out the Fantasy


To be paraphilic means that the erotic imagery exerts a pressure to play out the often imagined scene. In its milder forms, the pressure results merely in a preoccupation with a behavior. For instance, a man who prefers to be spoken to harshly and domi-nated by his wife during sex thinks about his masochistic images primarily around their sexual behaviors. He does not spend hours daydreaming of his erotic preferences. In its more intense forms, paraphilias create a drivenness to act out the fantasy in sexual behavior – usually in masturbation. Frequent masturbation, often more than once daily, continues long after adolescence. In the most severe situations, the need to attend to the fantasy and mas-turbate is so overpowering that life’s ordinary activities cannot efficiently occur. Masturbation and sometimes partner-seeking behavior – such as finding a woman to shock through exhibiting an erection – is experienced as driven. The patient reports either that he cannot control his behavior or he controls it with such great effort that his work, study, parenting and relationships are disrupted. This pressure to behave sexually often leads the man to believe he has a high sex drive. Some severe paraphilics describe their masturbation-to-orgasm frequencies as 10/day. Even when the patient’s estimate of his frequency of orgasm strains credu-lity less, the return of sexual drive manifestations so soon after orgasm suggests that either something is wrong with the patients’ sexual drive generator, their satiety mechanisms, or that their existential anxiety overpowers their other defense mechanisms.


Paraphilic men often report collecting and viewing por-nography, visiting sexual book stores to see explicit videos or peep shows, frequenting prostitutes for their special sexual be-haviors, downloading explicit images from the Internet, or exten-sively using telephone sex services or strip clubs. Victimization of others, the public health problem, is the least common form of sexual acting out but it is by no means rare (Abel et al., 1987). When the behavioral diagnosis of exhibitionism, pedophilia, or sadism is made, the clinician should assume that the numbers of victims far exceed the number stated in the criminal charges.


Two other conditions, compulsive sexual behavior and sexual addiction not part of the DSM-IV, are informally and syn-onymously used to refer to heterosexual and homosexual men and women who display an intense drivenness to behave sexu-ally without paraphilic imagery. The personal, interpersonal and medical consequences of paraphilic and nonparaphilic sexual compulsivity seem indistinguishable as do their usual psychiat-ric comorbidities: depression, anxiety disorders, substance abuse and attention deficit disorders (Kafka and Prentky, 1998).


Partner Sexual Dysfunction


A severe sexual dysfunction involving desire, arousal, or or-gasm with a partner, although not invariably, often is present among paraphilics (Pawlak, 1991). The wives of paraphilics tell stories with these themes: “He is not interested in sex with me”. “He never initiates.” “He doesn’t seem to enjoy our sexual life together except when . …” “He is usually not potent.” “Even when we do make love, he rarely ejaculates.” Some paraphilic men however are able to function well without paraphilic fan-tasies but others are either able primarily to function when their partners are willing to meet their special requirements for arousal or when they fantasize about their paraphilic script (Abel, 1989).



Speculations About the Underlying Problem


Paraphilia has been considered in 15 somewhat different ways, depending on era, ideology and region: 1) an impairment in the bonding function of sexuality; 2) a courtship disorder; 3) the erotic form of hatred motivated by the need for revenge for childhood trauma; 4) a fixation to childhood misunderstandings that women had penises and that men could lose theirs during sex (castration anxiety); 5) the unsuccessful repair of early life passive, helpless experiences with a terrifying, malignant, malicious preoedipal mother; 6) a strategy to stabilize a conventional masculine or feminine gender identity; 7) a strategy to deny the differences between the sexes and the generations of child and parent; 8) an outcome of childhood sexual abuse; 9) a consequence of far less than ideal parent–child relationships; 10) a soft neurological sign of a neural wiring defect; 11) a released behavior due to cerebral pathology, for example, temporal lobe dysfunction, or substance abuse; 12) the sexual face of an addiction disorder; 13) an unusual manifestation of an affective disorder; 14) an obsessive–compul-sive spectrum disorder; 15) a defective self-system requiring a patch – that is, a sexual preoccupation – to shore up the private, carefully-hidden-from-others sense of inadequate subjective masculinity.


Whatever its ultimate etiologies and nature, the paraphilias are sexual identity disorders that generally make normal erotic and sexual loving unattainable. Culture asks us to have some im-age of attachment, some ability to neutralize anger toward oth-ers, some ability to contain the anxiety over closeness, and some psychological motive simultaneously to enhance the self and the partner through sexual contact. Ordinary intentions aim for peaceable mutuality between real people; paraphilic ones aim at aggressive one-sidedness. This sexual identity disorder could be referred to as a disorder of self, specifically of that part of the self that maintains a sense of masculinity. Paraphilics often bear an enigmatic paradox between what they want to be and what they are. They often hunger for a behavior which feels uncontrollable or sick and which robs them of autonomy. This is why the behav-iors are often thought of as addictions and are often associated with other forms of substance abuse, obsessive–compulsive phe-nomena and affective symptoms. Relative to the dynamic fluc-tuations of sexual dysfunctions, intention disorders are tenacious throughout life.


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