Paraphilias


Studies of ancient history have recognized the cultural practice of a number of deviant sexual behaviors including bestiality and transvestitism, and prescribed harsh penalties for those who practice those behaviors. Societies throughout history have defined a distinction between normalcy and deviance, but sexual mores have not remained static over time. Today the conflict between religious conservatives and secular liberals has highlighted the issues, but that is not the only forum for disagreement. For example, while issues such as homosexuality have dominated the dispute, there are groups that would seek to legalize and normalize pedophilia. Even most “secular liberals” would agree that pedophilia is deviant behavior, harmful to children and society as a whole. Paraphilia is a term that describes a family of persistent, intense fantasies, aberrant urges, or behaviors involving sexual arousal to nonhuman objects, pain or humiliation experienced by oneself or one's partner, children or other nonconsenting individuals or unsuitable partners. Paraphilias may interfere with the capacity for reciprocal affectionate sexual activity.

The word "Paraphilia" is also used to imply non-mainstream sexual practices without necessarily implying dysfunction or deviance. Also, it may describe sexual feelings toward otherwise non-sexual objects.Some, but not all paraphilias are the result of illegal behaviors. For example, fetishistic transvestism is defined as the wearing of clothes of the opposite sex for sexual arousal. Sexual sadism, on the other hand, may be illegal or legal depending on the context. If it involves sexual violence and a non-consensual relationship, it would of course, be illegal. Pedophilia resulting in child molestation or the viewing/collection of child pornography is always a criminal behavior. Although varieties of paraphila (such as sadomacochism) are becoming more acceptable in the mainstream, the legal ramifications of these activities can sometimes be significantly damaging. The classification of paraphilias in the Diagnostic and Statistical Manual of Mental Disordersis another of society’s attempts to define the difference between normal and deviant, and even that attempt has been met with a full spectrum of opinions. For instance, zoophilia was first included in the DSM III, where it was categorized as a paraphilia, however the revised third edition removed the listing concluding that "zoophilia is virtually never a clinically significant problem by itself" (APA, 1987, p. 405), considering zoophilia under the diagnostic label of "Paraphilia Not Otherwise Specified" (302.90). The current edition of the Manual (DSM-IV, APA, 1994), treats "zoophilia" in the same manner.1

Types of Paraphilias

  • Exhibitionism: the recurrent urge or behavior to expose one's genitals to an unsuspecting person. Research supports identifying this as a predominately male disorder though females have been diagnosed as well.
  • Fetishism: the use of inanimate objects to gain sexual excitement. Typical items include feet, shoes, underwear, dresses and socks although anything can become a fetish. Freud did most of the initial work in naming this paraphilia. He attributed male fetishism mostly to childhood fears of castration. The behavioralist model stresses the potential childhood exposure to inappropriate sexual behavior which later translates into emulation. Compensation models focus on lack of exposure to normal, healthy social sexual experiences which results in less socially acceptable methods.
  • Frotteurism: the recurrent urges to slap yourself or behavior of touching or rubbing against a nonconsenting person. This often takes place in crowded public places such as subways, elevators or buses. Examples would include rubbing genitals against unsuspecting victims or grabbing breasts or buttocks. The arousal comes from the touching or rubbing and not necessarily the reaction of the victim. Studies show that it generally begins in adolescence.
  • Pedophilia: the sexual attraction to prepubescent or peripubescent children. This is thought to be the most common of paraphilias. The victims are generally 13 years of age and younger (sexually immature). Often the children are known to the person (neighbor, friend's child, relative, their own child). An "Exclusive Type" is only attracted to children while a "Nonexclusive Type" may be attracted to adults as well. Those offending may justify their behavior as mutually beneficial, educational or even provoked by the children themselves. Some people "groom" the children so as to avoid "forcing" them to engage in sexual activities. Others may resort to abducting or taking in foster children although this is not as common.
  • Sexual Masochism: the recurrent urge or behavior of wanting to be humiliated, beaten, bound, or otherwisexternal image 41B9JGZZMZL._SL500_AA240_.jpge made to suffer for sexual pleasure. One particularly unique and distressing subcategory of this behavior is Paraphilic asphyxia (see details below under "Paraphilias, Not Otherwise Specified").
  • Sexual Sadism:The feeling of sexual pleasure derived from humiliating, causing suffering, or harming another person. This other person may be a willing or unwilling participant. The sadist often desires dominance of the other party. This dominance may be in the form of non-harmful (though often humiliating) behavior such as urinating or deficating on the other party. It may also extend to deadly behavior such as raping, murdering, or mutilating. The most common practices (which are gaining more public exposure) could be restraining the other party with ropes, cages, handcuffs or chains. Spanking and whipping the partner may also be seen as forms of sexual sadism. The DSM IV requires these criteria be present:
    • Recurrent, intense sexually arousing fantasies, sexual urges, or behaviours involving acts (real, not simulated) in which the psychological or physical suffering (including humiliation) of the victim is sexually exciting for the person, have been present for at least 6 months.
    • The fantasies, sexual urges, or behaviours cause clinically significant stress or impairment in social, occupational or other important areas of function.
  • Transvestic fetishism: a sexual attraction towards the clothing of the opposite gender. (Compare to autogynephilia.)
  • Voyeurism:the recurrent urge or behavior to observe an unsuspecting person who is naked, disrobing or engaging in sexual activities, or may not be sexual in nature at all. The arousal seems to stem from the fact that The onset is often by the age of 15 and it can eventually become the sole sexual activity of the voyeur. The DSM IV requires these criteria to be present for a diagnosis:
    • Having intense sexual desires, fantasies or behaviors concerning the act of watching an unsuspecting person who is naked, disrobing or having sex for a long period of time.
    • Voyeuristic activity is the primary mode of sexual arousal and expression. The subject is increasingly incapable of sexuality without this activity.
    • Voyeuristic activity causes clinically important distress or impairs work, social or personal functioning.

Paraphilias, Not Otherwise Specified (NOS)

These are less common paraphilias which do not meet the criteria for the aforementioned paraphilias. They are given a NOS classification.
  • Coprophilia (feces) and Urolagnia (urine): The term "Coprophilia" is used to describe a predilection for fecal and related matters Urolagnia (also known as urophilia or undinism) is a sexual fetish in which participants derive sexual pleasure from urine and urination.People with urolagnia often like to urinate in public, or urinate on, or be urinated on by other people, and may drink the urine.
  • Gerontophilia (older persons)
  • Hypephilia (fabrics)
  • Hybristophilia is a paraphilia involving being sexually aroused by people who have committed crimes; in particular cruel or outrageous crimes. One definition of Hybristophilia refers ito it as: "a paraphilia of the marauding/predatory type in which sexuerotic arousal and facilitation and attainment of orgasm are responsive to and contingent on being with a partner known to have ommitted an outrage or crime, such as rape, murder, or armed robbery" Many high-profile criminals, particularly those who have committed atrocious crimes, receive fan mail in prison, presumably as a result of this phenomenon. In some cases, admirers of these criminals have gone on to marry the object of their affections in prison. An example of this is Ted Bundy who is known to have received about two hundred fan letters each day from female admirers.
  • Infantilism: Sexual arousal from being treated like an infant (example: wearing diapers or drinking from a bottle).
  • Klismaphilia: Sexual arousal through giving oneself an enema.
  • Necrophilia: Sexual arousal from viewing or having sexual contact with a corpse. Access to a cemetary or working in a funeral home is often a way to acommodate this disorder.
  • Paraphilic asphyxia, or asphyxiophilia: Restricting the supply of oxygen or blood to the body during sex leading to a heightened orgasmic experience.There are two major types of asphyxiophilia, that which is practiced consentually with a partner, and that which is done alone, known as autoerotic asphyxiophilia. The goal of this practice is increased pleasure resulting from the body producing more endorphins as it approaches the state of asphyxia. The process is extremely dangerous and has resulted in many accidental deaths.Erotic asphyxia with a partner usually involves one of two practices. The first involves the cutting off a lover's air supply during sex. This is often achieved by placing a plastic bag over the head or the use of a ligature of some sort to restrict air supply, a practice sometimes known as “scarfing.” The second is through restricting the blood supply to the brain by placing pressure on the carotid arteries in the neck. People who perform autoerotic asphyxiation alone often set-up sophisticated release mechanisms to make sure they do not suffocate to death. This practice is considered particularly dangerous, due to the added danger of not being able to rescue oneself if the release mechanism fails to function. Some reports indicate that autoerotic asphyxiation may trigger carotid sinus reflex, resulting in death. Usually, cases of paraphilic asphyxia resulting in death are a surprise to family and friends. There is no documented evidence that practicing asphyxiophilia is a form of suicidal ideation.
  • Partialism: Partialism involves preoccupation with a portion of the body (breasts, buttock, feet, nose). Negative partialism is attraction to people with missing body parts.
  • Stigmatophilia (tattoo, piercing)
  • Telephone scatologia (obscene phone calls)
  • Zoophilia or Zoosexuality (animals):The term "zoosexuality" signifes the entire spectrum of emotional or sexual attraction and/or orientation to animals. The term "bestiality" is more specific, and defines a sexual act between humans and animals. Scientific surveys estimating the frequency of zoosexual activity suggest that more than 1- 2% — and perhaps as many as 8-10% — of sexually active adults have had significant sexual experience with an animal at some point in their lives. A number of states in the U.S. have laws that prohibit sexual activity with animals.

Etiology

Ultimately, the onset of a paraphilia has to do with multiple factors including biology, psychology, and environment. This said, there remains much ambiguity in regards to knowing the origins of these abnormalities.
Androgens, which are male hormones that regulate sexual desire, may play a significant role. Another theory is that brain malfunction can play a part in abnormal sexual behavior (temporal lobe abnormalities,Langevin et al., 1988). Many people who suffer from paraphilias had adverse environmental issues as they developed. They may have been exposed to activities that encouraged their aberrant behaviors. Additionally, they may have experienced physical, sexual, or relational abuse. It is also likely that cognitive distortions play an important role in a person who has a paraphilia. Another theory is that the person may have accidentally (or intentionally) stumbled on a stimulous and paired it with the sexual excitement. For instance, masturbating while seeing women's stocking hanging up and thus coorelating sexual excitement with women's stockings (fetishism). Henceforth, the person develops a psychological dependency on the presence of female stockings to be in order to achieve sexual satisfaction.From a psychodynamic perspective, some people may have an underdeveloped ability to have adult social and sexual relationships. This may cause the person with a paraphilia to act out to feel powerful in the areas that the person is really deficient.

Treatment

The treatment of men with paraphilias and related disorders has been challenging for patients and clinicians. Historically, surgical castration was advocated as a therapy for men with paraphilias, but it was abandoned because it is considered a cruel punishment and is now illegal in most countries. Paraphilic behavior often results in guilt, shame, depression, isolation and impairment in sexual and social relationships. Possibilities of the paraphilia becoming extremely ritualized and idiosyncratic are high.

Currently, two particular problems need to be taken into account when developing a treatment plan addressing paraphilic behavior. First, treatments for paraphilias not related to sexually offending behaviors have rarely been described in scientific literature, and consequently, strategies for treatment are not based on solid empirical evidence. Second, studies have called into question the reliability of DSM diagnoses of paraphilias and evidence suggesting that these diagnoses are unreliable has been presented (Marshall, 1997, 2006; Marshall & Kennedy, 2003). As a result, non-offending paraphilias are usually considered to contain similar features with sexual offending ones and have been addressed with similar treatment strategies (Laws & O'Donohue, 1997).


Targets of Treatment
When addressing paraphilias relating to sexual offending, the client is often resistant, unmotivated, and defensive. Typically, a treatment strategy targets both offense-specific aspects which are common to all offending behavior and specific identified problems such as substance abuse and impulse control that are functionally related to the offending pattern. Several


  • Life History: The client produces a life history that covers his relevant and important experiences (both positive and negative) through childhood, adolescence, young adulthood, midlife, and older age, if each is relevant. The life history will both assist the therapist in developing a deeper understanding of the client and help him to identify persistent behavioral, cognitive and emotional difficulties that can be addressed in treatment. It also serves to initiate the collaborative process of generating each client's offense pathways. Identifying these can help to develop an effective self-management plan that is aimed at reducing risk to reoffend.
  • Self-Esteem: The examination of each client's level of self-esteem begins in the very early sessions of the program, as do treatment procedures for enhancing self-worth. This early attention to self-esteem serves to convince clients that the therapist is concerned about their welfare and that the focus of treatment will be on enhancing their lives; it also engages clients in the treatment processes. Therapists assist clients with low self-esteem to identify actions they can take within the domain of functioning where they lack confidence.
  • Acceptance of Responsibility: The goal of this phase of treatment is to increase the client's capacity to accept responsibility for his actions. The client examines factors influencing his decision to offend. These can include both external contributing factors (i.e. exposure to pornography as a child) as well as situational and behavioral factors that the client has endorsed to set up and commit the offense. Addressing cognitive distortions is a major component of treatment. For example, denial ("I didn’t do it"), blaming ("She initiated the sexual contact", and minimizing ("It only happened once") are common responses after confrontation for sexually abusive behaviors. The therapist challenges the client's cognitive distortions and beliefs about the harm he caused in a firm, supportive manner throughout the treatment process whenever the client avoids responsibility.
  • Emotions Management: Difficulty regulating emotions is a common problem among people who have offended sexually. Ineffective coping often leads to a sense of frustration. The goal is to assist clients in recognizing dysfunctional styles of coping and the costs associated with these styles. The therapist assists them in developing more effective responses. The therapist encourages the client to recognize and appropriately express their emotions.
  • Social Skills Development: The primary focus for all clients in this component is on the skills, attitudes, and self-beliefs that facilitate the formation of effective interpersonal relationships. Beyond specifically training clients to develop effective attachment styles in order to increase their future experience of satisfaction and intimacy, we also train them to deal with anger and anxiety and to become appropriately assertive. Issues such as jealousy, loneliness, living alone, and the value of mutually enjoyable activities are discussed in detail. These procedures significantly enhance intimacy skills and reduce loneliness.
  • Sexual Interests:Although some sexual offenders display deviant patterns of sexual arousal, not all do. When deviant sexual arousal is identified, a number of behavioral techniques are used to address those patterns.
    • **Aversion therapy**
    • **Covert Sensitization**: Paraphilia stimulus is paired with a negative consequence image
    • **Assisted Aversive Conditioning**
    • Desensitization procedures: Gradual exposure to the object in question and a retraining of the response.
    • Ogasmic Reconditioning: The person is instructed to continue masurbating with the paraphilic fantasy, but is instructed to change the image at the point of orgasm to some more appropriate fantasy.
    • "Stop-Switch" Techniques: Used for control of deviant fantasymasturbatory reconditioning (which includes procedures for enhancing appropriate interests, sometimes called thematic shift, and procedures for reducing deviant arousal called satiation.
  • Self-Management: Relapse prevention approaches to the treatment of sexual offending require clients to develop an extensive set of avoidance plans. These plans are meant to equip them with strategies to reduce involvement in situations and avoid internal states that would raise their risk to reoffend. However, avoidance goals are typically not sustainable over time and noted a considerable body of literature in which approach goals are preferred. Many approaches to relapse prevention place unreasonable demands on clients, all but convincing them of an inevitable relapse. Andrews and Bonta (2001) insisted that the targets of treatment be restricted to criminogenic factors, but Ward and Stewart (2003a, 2003c) have offered cogent criticism of this view. They argue that enhancing sexual offenders' overall functioning will lead them to attain the goals of a "good life" which, in turn, will reduce their need to offend. Ward and Stewart (2003b) and Ward and Marshall (2004) provided a detailed account of how a therapist can implement a good lives approach with sexual offenders. In all aspects of this approach, the therapist works collaboratively with the client. First, it is necessary to assist the client in identifying an individualized set of goals that is consistent with his interests and abilities and that would lead to the attainment of a more satisfying life. Next, the therapist helps the client identify both the skills that need to be enhanced and the attitudes that need to be modified in order to achieve these goals. Then, specific treatment implements the necessary skills and attitude training. As these stages evolve, therapist and client together re-examine and possibly modify these goals.
  • Drug Treatments: Some clients are unresponsive to behavioral procedures and require pharmacological interventions. Others are sexually preoccupied or have dangerous deviant interests (e.g., sexual sadists) also require medical treatments. Commonly used medications for these purposes include one or another of the so-called antiandrogens (or hormonalinterventions) to dampen libido, or one of the Selective serotonin reuptake inhibitor (SSRIs) to control sexual preoccupation. SSRIs such as fluoxetine (Prozac), sertraline (Zoloft), fluvoxamine (Luvox), and paroxitine (Paxil), have all been used to treat paraphilias and related disorders by reducing impulse control problems and/or sexual obsessions with some success.Tricyclic antidepressants (TCA), such as imipramine (Tofranil) and desipramine (Norpramin), are also used.Lithium, the mood-stabilizing drug also known as Eskalith is typically used for the treatment of mania in bipolar disorder. There are some reports of reduced sexual compulsive behavior and a reduction in obsessive sexual thoughts in patients, which they attribute to the drug's enhancement of serotonergic functioning.Anxiolytics are not considered a typical treatment for these type of disorders, however the efficacy of buspirone (BuSpar) has been clinically demonstrated.Psychostimulants have been used recently to augment the effects of serotonergic drugs in paraphiliacs. In theory, the prescription of a psychostimulant without pretreatment with an SSRI might further disinhibit sexual behavior, but when taken together, the psychostimulant may actually reduce impulsive tendencies. Methylphenidate (Ritalin) is an amphetamine related stimulant used primarily to manage the symptoms of attention deficit hyperactivity disorder (ADHD). Recent studies imply that methylphenidate may also act on serotonergic systems; this may be important in explaining the paradoxical calming effect of stimulants on ADHD patients. Amphetamine is also used medically as an adjunct to antidepressants in refractory cases of depression.Another drug that has proved effective is leurprolide acetate (a luteinizing hormone-releasing-hormone agonist) but until now it's been used primarily with adults. Recent studies showed the effectiveness in youth. When employing drugs for treatment of adolecents, one must be cautious of the interactions this will have with puberty. Drugs should not be used without concurrent psychotherapy and in some cases behavioral therapy



Bibliography


1Contemporary Sexuality; Dec2006, Vol. 40 Issue 12, p8-13, 6p
Autoerotic Fatalities by Hazelwood et al. (1983)
Autoerotic Asphyxiation: Forensic, Medical, and Social Aspects by Sheleg et al (Published 2006)