The Specific Paraphilias
Exhibitionism generally involves teenagers and men display-ing their
penises so that the witness will be shocked or (in the paraphilic’s fantasy)
sexually interested. They may or may not masturbate during or immediately
following this act of victimi-zation. This diagnosis is not usually made when a
man is arrested for “public indecency” and his penile exposures are motivated
to arrange homosexual contact in a public place generally unseen by
heterosexuals. Penile display in parks is one way to make anony-mous contact.
The presence or absence of exhibitionistic imagery allows the clinician to make
the distinction between paraphilia and homosexual courting.
Pedophilia is the most widely and intensely socially repudiated of the
paraphilias. Pedophiles are men who erotically and roman-tically prefer
children or young adolescents. They are grouped into categories depending upon
their erotic preferences for boys or girls and for infant, young, or pubertal
children. Some pedo-philes have highly age- and sex-specific tastes, others are
less discriminating. Since the diagnosis of pedophilia requires that 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, the disorder should not be expected to be present in every person
who is guilty of child molestation. Some intrafamilial child abuse oc-curs over
a shorter time interval and results from combinations of deteriorated
marriages, sexual deprivation, sociopathy and substance abuse. Child
molestation, whether paraphilic or not, is a crime, however. Child molesters
show several patterns of erectile responses to visual stimulation in the
laboratory. Some have their largest arousal to children of a specific age and
oth-ers respond to both children and adults (Barbaree and Marshall, 1989).
Others respond with their greatest arousal to aggressive cues.
Men whose sexual life consist of watching homosexual or hetero-sexual
videos in sexual book stores occasionally come to psychi-atric attention after
being charged with a crime following a police raid. They may or may not qualify
for this diagnosis. The vo-yeurs who are more problematic for society are those
who watch women through windows or break into their dwellings for this purpose.
Some of these crimes result in rape or nonsexual vio-lence, but many are
motivated by pure voyeuristic intent (which is subtly aggressive).
While rape is an extreme variety of sadism, paraphilic sadism is present
only in a minority of rapists. It is defined by the rapist’s prior use of
erotic scripts that involve a partner’s fear, pain, hu-miliation and suffering.
Rapists are highly dangerous men whose antisocial behaviors are generally thought
to be unresponsive to ordinary psychiatric methods. Their violence potential
often makes psychiatric therapy outside of institutions imprudent. Noncriminal
paraphilic sadism, that is, arousal to images of harming another that has not
crossed into the behavioral realm, can be treated in outpatient settings.
Frotteurism, the need to touch and rub against nonconsenting persons,
although delineated as a criminal act, is probably better understood as the
most socially benign form of paraphilic sad-ism. Frotteurism often occurs in
socially isolated men who be-come sexually driven to act out. They often are
unaware of how frightening they can be.
Stalking is the latest erotic preoccupation to be criminalized. Forensic
psychiatry has defined various motivations for arrested stalkers, including
those who have made the transition from ro-mantic to violent preoccupation with
the victim. Stalking is par-ticularly frightening because murder occasionally
results. It is likely that stalking as a behavior is the product of further
deterio-ration of an already compromised mind, although not necessarily a
Because the individual manifestations of paraphilia depend on the
particular individual life history of the affected, over 40 para-philic
categories have been identified although only a few are listed in the DSM-IV.
Most of these are unusual means of attain-ing arousal during masturbation or
consenting partner behaviors. Each of the themes identified below demonstrate a
wide range of manifestations from the bizarre to the more “reasonable” and from
the common to the unique. They often subtly combine ele-ments of more than one
Fetishism, the pairing of arousal with wearing or holding an ar-ticle of
clothing or inanimate object such as an inflatable doll, has a range of
manifestations from infantilism in which a person dresses up in diapers to
pretend he is a baby to the far more com-mon use of a female undergarment for
arousal purposes. Fetish-ism when confined to one garment for decades is
classified as a paraphilia, but many cases involve more complex varieties of
cross-dressing and overlap with gender identity disorders, usu-ally GIDNOS.
Fetishistic transvestism is the diagnosis used when it is apparent that the
urges to use the clothing of the opposite sex is part of a larger mental
preoccupation with that sex.
Sexual masochism is diagnosed over a range of behaviors from the
sometimes fatal need to nearly asphyxiate oneself to the re-quest to be spanked
by the partner in order to be excited. Mas-ochism may be the most commonly
reported or acknowledged form of female paraphilia, although it is more common
among men. Sadists and masochists sometimes find one another and work out
arrangement to act out their fantasies and occasionally reverse roles.
Paraphilia not otherwise specified is a DSM-IV category for other
endpoints of abnormal sexual development that lead to pre-occupations with
amputated body parts, feces, urine, sexualized enemas and sex with animals.
Four general approaches are employed to treat the paraphilias. The
treatments are not mutually exclusive, rather they are often multimodal in application.
Evaluation only is often selected when the evaluator concludes that the
paraphilia is benign in terms of society, the patient will be re-sistant to the
other approaches, and does not suffer greatly in terms of social and vocational
functioning in ways that might be im-proved. Often these are isolated men with
private paraphilic sexual pleasures, such as telephone sex with a masochistic
What constitutes psychotherapy for paraphilia heavily de-pends on the
therapist training rather than strident declara-tions of treatment of choice.
Little optimism exists that any form of therapy can permanently change the
nature of a long established paraphilic erotic script, even among teenage sex
offenders. Individual psychodynamic psychotherapy can be highly useful in
diminishing paraphilic intensifications and gradually teaching the patient
better management techniques of the situations that have triggered acting out.
Well-described cognitive–behavioral interventions exist for interrupting
para-philic arousal via pairing masturbatory excitement with either aversive
imagery or aversive stimuli. Comprehensive behavio-ral treatment involves
social skills training, assertiveness train-ing and confrontation with the
rationalizations that are used to minimize awareness of the victims of sexual
crimes, and mari-tal therapy (Abel and Osborn, 1995). The self-help movement
has created 12-step programs for sexual addictions to which many individuals
now belong. Group psychotherapy is offered by trained therapists as well. When
the lives of paraphilics are illuminated in various therapies, it becomes
apparent that the emotional pain of the patients is thought to be great; the
sexual acting out is often perceived as a defense against recurrent un-pleasant
emotions from any source. These often, however, in-volve self-esteem and
In the early 1980s, depo-medroxy-progesterone (Provera) was first used
to treat those who were constantly masturbating, seek-ing out personally
dangerous sexual outlets, or committing sex crimes. The weekly 400 to 600 mg
injections often led to the men being able to work, study, or participate in
activities that were previously beyond them because of concentration or
atten-tion difficulties. In the late 1980s, the use of oral Provera, 20 to 120
mg/day led to similar results: the drug enabled these men to leave their former
state in which their sexual needs took priority over other life demands, and
they did not have depo-Provera’s side-effect profile: weight gain,
hypertension, muscle cramps and gynecomastia. Today, gonadotrophin-releasing
blockers are oc-casionally used for this. The possible side effects are similar
to oral Provera. Despite the fact that the clinical results are among the most
powerful effected by any psychopharmacologic treat-ment, many psychiatrists
cannot overcome their disinclination about giving a “female” hormone to a man
or working with pa-tients who victimize others sexually. Serotonergic agents
are now more commonly used as a first line of treatment and their
admin-istration, of course, creates fewer countertransference obstacles. While
these studies are not as methodologically sophisticated as they need to be, the
SSRIs are in widespread use for compul-sive sexual behaviors and sexual
obsessions. Their efficacy is the source of the speculation that some of the
paraphilias may be an obsessive–compulsive spectrum disorder.
Sexual advantage-taking, whether it be by a paraphilic physician with
his patients, by a pedophilic mentally retarded man in the neighborhood, or of
a grandfather who has abused several gen-erations of his offspring, can often
be stopped by making it im-possible for
these behaviors to be unknown to
most people in his life. The
doctor’s staff can be told, the neighbors can know, the family can meet to
discuss the current crisis and review who has been abused over the years and
plan to never allow grandfather alone with any child in or outside the family.
The concept of external control is taken over by the judicial system when sex
crimes are highly repugnant or heinous. The offender is removed from society
for punishment and the protection of the public. In-creasing pressure exists to
criminalize sexual advantage-taking by physicians who are even more susceptible
to losing their medi-cal licenses at least for several years.
Psychiatrists need to be realistic about the limitations of various
therapeutic ventures. Sexual acting out may readily con-tinue during therapy
beyond the awareness of the therapist. The more violent and destructive the
paraphilic behavior to others, the less the therapist should risk ambulatory
treatment. Since para-philia occurs in patients with other psychiatric
conditions, the psychiatrist needs to remain vigilant that the treatment
program is comprehensive and does not lose sight of the paraphilia just because
the depressive or compulsive symptoms are improved. Paraphilia may be improved
by medications and psychotherapy but the clinician should expect that the
intention disorder is the patient’s lasting vulnerability.