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Chapter: Essentials of Psychiatry: Sexual Disorders

Sexual Disorders: 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.

The Specific Paraphilias


Criminal Sex Offending Behaviors




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).


Sexual Sadism


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 paraphilic one.


Noncriminal Forms of Paraphilia


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 paraphilia.




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


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 Specifi ed


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


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 scenario.




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 primitive anxiety.




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.


External Controls


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.



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