Paraphilia

What is Paraphilia?

Paraphilias refer to an intense and recurring interest, desire, fantasy, or behavior related to sexual activities, objects, or situations that are considered unusual. A paraphilia doesn’t necessarily mean there’s a problem. However, when these interests or behaviors cause harm, distress, or difficulties in functions of daily life for the person or others, it then becomes a disorder known as paraphilic disorder.

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM V), recognizes eight types of these disorders. This includes pedophilia, exhibitionism, voyeurism, sexual sadism, sexual masochism, frotteurism, fetishism, and transvestic fetishism.

Pedophilia involves sexual actions with a child who has not yet reached puberty. In such a situation, the person involved (the offender) should be at least sixteen years old, and the child should be at least five years younger than the offender. Exhibitionism is the act of exposing one’s private parts to unsuspecting strangers for personal sexual pleasure. Voyeurism involves watching an unknowing individual undress or involve in sexual activities.

Sexual sadism refers to deriving sexual pleasure by causing mental or physical pain to someone who did not consent to that behavior. Sexual masochism is finding sexual pleasure by receiving physical or emotional abuse or humiliation. Frotteurism is the act of touching or rubbing against an unknowing person for sexual excitement.

Lastly, Fetishism and Transvestic Fetishism refers to using non-living objects, often clothes and undergarments, or cross-dressing (wearing clothes of the opposite sex) for sexual pleasure.

What Causes Paraphilia?

The exact causes of paraphilia and paraphilic disorders, which are sexual interests or behaviors that are atypical or extreme, remain unknown. Experts believe these conditions could be caused by a mix of brain-related factors, personal relationships, and thought processes. Scientific studies also suggest that certain genetic factors could play a role in the development of particular paraphilic disorders such as pedophilia.

One intriguing discovery is the link between certain genetic characteristics, specifically a gene variation known as COMT Val158Met (rs4680), and people with paraphilic disorders who have committed sexual offenses against children. Newer research is also pointing towards the role of a substance called dopamine, a chemical in the brain, in these disorders. Dopamine is important in managing behavior and is thought to be involved in the development of paraphilic disorders.

Additionally, a recent research study observed that people diagnosed with paraphilic disorders had increased levels of two specific brain chemicals, serotonin and norepinephrine, in their urine. These chemicals have been linked in the past to obsessive behaviors. These same people also had lower levels of another chemical, DOPAC (3,4-dihydroxyphenylacetic acid), which has been associated with emotional and dissociative disorders.

Risk Factors and Frequency for Paraphilia

Studies about the commonness and characteristics of paraphilia and paraphilic disorders are lacking. It is generally known that they are more common in men, but the reasons behind this are unclear. A recent study tried to look into this matter more closely. It surveyed 1,040 people from various walks of life – differing by age, gender, education, ethnicity, religion, and where they lived.

• About half of these people admitted to having interest in one or more types of paraphilia.
• Out of these, roughly one-third had acted on their interests at least once.
• Paraphilia types like fetishism, frotteurism, voyeurism, and masochism were quite common, being found in about 15.9% (a statistically unusual level) of the people. Both males and females showed interest in these.
• No significant difference was found between males and females in their interest in fetishism and masochism.
• The most common interest amongst men was in voyeurism and fetishism.

Signs and Symptoms of Paraphilia

Conducting a comprehensive psychiatric assessment requires a careful history and physical examination. The focus here is on a condition previously termed as sexual perversion or deviation, now called ‘paraphilia’. Due to the stigma attached to this behavior, people rarely seek voluntary medical evaluation for it. Hence, during the assessment, it’s crucial for medical professionals to use open-ended questions and avoid passing judgement. It’s also important to watch out for signs of abuse. In some cases of paraphilia, there might be a personal history of sexual abuse (especially in pedophilic disorder) or the individual might tolerate sexual abuse (as seen in sexual masochistic disorder).

Testing for Paraphilia

In more simplified terms, the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) defines ‘paraphilia’ as experiencing strong and frequent sexual excitement from unusual fantasies for at least six months and acting on these feelings. However, it only becomes a problem or ‘paraphilic disorder’ if it causes significant stress and affects your daily life or if it harms or poses a risk of harm to others. The terms ‘in remission’ (when the behavior no longer causes stress or problems) and ‘in a controlled environment’ can apply to all paraphilias, except pedophilia.

The DSM-5 has added specific definitions for certain kinds of paraphilia. For example, in exhibitionistic disorder, this specifically includes exposing one’s private parts to young children or adults. This behavior usually starts before the age of 18. In sexual masochistic disorder, it specifically includes deriving excitement from suffocating oneself. In fetishistic disorder, it involves getting turned on by body parts, inanimate objects, or others, while in transvestic disorder, it can be about getting aroused by fabrics, materials, clothing, or the idea of oneself as a female.

Other diagnostic tools are also important for accurately diagnosing these conditions and for ruling out other possible causes. Diagnostic tools might include blood tests to measure levels of various things like cholesterol, thyroid function, blood sugar, inflammation, and various hormones. Depending on the individual case, imaging tests like ultrasound or angiography may also be used. Other tests may include nocturnal penile tumescence (a test to evaluate erectile function during sleep) and pap smears (a test for early detection of cervical cancer).

Treatment Options for Paraphilia

Treating and managing unusual sexual interests or behaviors, known as paraphilias and paraphilic disorders, is a complex and difficult task. This is due to various reasons, including the fact that most people with these conditions don’t typically seek treatment voluntarily. Some may feel shame, guilt, or discomfort, or find it difficult to stop pursuing intense sexual pleasure. Others may worry about the legal consequences of confessing their behaviors.

The approach to treating these conditions includes both psychological and biological methods. A psychological approach, such as psychotherapy or cognitive behavioral therapy (CBT), can be very effective. However, because many patients are reluctant to seek treatment unless compelled by law or pressure from loved ones, doctors often must try to not only help the patient but also prevent potential harm to others.

For best results, treatment usually combines both psychological therapy and medication. The exact drugs used in treatment will depend on factors like the patient’s past medical history, their ability to stick to a medication plan, and the intensity of their fantasies and potential for sexual violence.

The primary types of medication used for treating paraphilias are selective serotonin reuptake inhibitors (SSRIs), synthetic steroidal analogs, and antiandrogens. SSRIs, which can be particularly useful for teens and adults with milder issues, work by balancing the levels of a brain chemical called serotonin. Antiandrogens, specifically a group of drugs called gonadotropin-releasing hormone (GnRH) analogs, have been shown to significantly reduce both unusual sexual arousal and behavior. These medications are particularly beneficial for those who are at high risk of committing particularly violent acts. However, it’s important to note that a patient must give informed consent before beginning antiandrogenic therapy.

What else can Paraphilia be?

There are several psychological, sexual, and mental health conditions that might relate to or influence a person’s sexual behavior and perception. These include:

• Sexual dysfunction disorders
• Gender identity disorder
• Hypersexuality or sex addiction
• Nonparaphillic compulsive sexual disorders
• Psychological issues such as fears of intimacy or commitment

There are also specific psychiatric disorders that could relate to sexual behavior:

• Obsessive-compulsive disorder (OCD)
• Depression
• Bipolar disorder (during manic episodes)
• Schizophrenia
• Personality disorder
• Anxiety disorders

Other disorders that could influence sexual behavior are:

• Substance intoxication
• Intellectual disability
• Dementia

What to expect with Paraphilia

At present, there is no established ultimate treatment or change for paraphilias and disorders related to them, despite the existence of psychological and pharmacological interventions. These interventions primarily help increase voluntary control over sexual arousal and decrease sexual drive. They are most effective when the individual is genuinely motivated to change.

People who engage in either therapy alone, or preferably, a combination of psychological and medical treatment tend to show improvement. This improvement is frequently marked by a significant reduction in both the intensity and frequency of abnormal sexual arousal and the related behaviors.

However, research indicates that most sexual offenders are likely to repeat their actions.

Possible Complications When Diagnosed with Paraphilia

Living with paraphilia and paraphilic disorders can result in a range of challenges. These abnormal sexual tendencies and behaviors can be difficult to manage and cause a significant amount of trouble to the affected individuals. When paraphilia progresses into a disorder, it can cause harm, distress, and impair one’s ability to function normally.

Additionally, there can be serious legal consequences, such as imprisonment, probation, confinement to a psychiatric hospital, and being registered as a sexual offender. Being on the sex offender registry involves several restrictions which vary depending on the area you live in, but generally include:

• Disclosing your address
• Living restrictions including proximity to schools or daycare centers
• Limited internet use
• Restrictions on being around minors
• Prohibition against owning items that could imply involvement with children

These stipulations make one’s living location public knowledge and limit their housing options, making life more difficult for those on the registry.

Preventing Paraphilia

For the most part, people who struggle with improper or unusual sexual desires, known as paraphilic disorders, often don’t seek help on their own. Many of these individuals feel shameful, guilty, or embarrassed about their desires. Moreover, some find it hard to stop pursuing extreme sexual pleasure. The lure of this strong sexual satisfaction makes it harder for them to seek professional help.

These types of disorders often lead to harming others, which can result in legal problems. This fear of getting into trouble with the law can discourage these individuals from seeking help. Generally, those who do get professional help are often required to do so by law, or persuaded by their family, friends, or partners.

Despite some medications being available for managing these disorders, there is a need for more preventative measures to help reduce harm to others. Often, the disorder isn’t addressed until after harm has been done, usually following a prison sentence.

Pedophilia, a form of paraphilic disorder usually originating from childhood sexual abuse, is a significant area for potential prevention. There is a widespread belief among psychiatrists and mental health care professionals that incarceration is the only solution for such cases. This is because paraphilias and related disorders involve deep-seated thoughts and compulsive behaviors, which are hard, if not impossible, to change regardless of whether they are seen as right or wrong.