As mentioned earlier, paraphilias are persistent and recurrent sexual interests, urges, fantasies, or behaviors of marked intensity involving objects, activities, or even situations that are atypical in nature. We will discuss the characteristics and etiology of the eight paraphilias listed in the DSM-5 fetishism, transvestic fetishism, exhibitionism, voyeurism, frotteurism, sexual sadism, sexual masochism, and pedophilia. Pedophilia will be discussed in a separate section because of its close relationship to criminal behavior and will be followed by a discussion on sex and violence. 

No consensus has been found for any precise border between unusual sexual interests and paraphilic ones. There is debate over which, if any, of the paraphilias should be listed in diagnostic manuals, such as the DSM-5 or ICD-11. The number and taxonomy of paraphilias is under debate; one source lists as many as 549 types of paraphilias. The DSM-5 has specific listings for eight paraphilic disorders, but several sub-classifications of the paraphilias have been proposed and some argue that a fully dimensional, spectrum, or complaint-oriented approach would better reflect the evidence.

The DSM-5 adds a distinction between paraphilias and paraphilic disorders, stating that paraphilias do not require or justify psychiatric treatment in themselves, and defining paraphilic disorder as “a paraphilia that is currently causing distress or impairment to the individual or a paraphilia whose satisfaction has entailed personal harm, or risk of harm, to others.”^[1]

Types of Paraphilias

Fetishism is the use of nonliving objects, most commonly shoes and undergarments, for sexual pleasure. Transvestic fetishism is the derivation of sexual arousal from cross-dressing or dressing in clothes of the opposite sex. Exhibitionism is the exposure of an individual’s genitalia to unsuspecting strangers for sexual satisfaction. Voyeurism is the viewing of an unsuspecting person engaging in disrobing or sexual activity. Frotteurism is the touching of or rubbing against a nonconsenting person. Sexual masochism is the derivation of sexual arousal from being the recipient of physical or mental abuse and/or humiliation. Sexual sadism is when sexual arousal is gained from inflicting mental or physical suffering on a nonconsenting person. Pedophilia is any sexual activity with or sexual fantasies about a prepubescent child, where the offender is at least sixteen years of age. 

Etiology

The exact etiology of paraphilia and paraphilic disorders is unknown. However, it is thought that a combination of neurobiological, interpersonal, and cognitive processes all play a role. Literature also points towards various genetic factors contributing to the development of pedophilia and pedophilic disorder, with recent evidence displaying a positive correlation of the COMT Val158Met (rs4680) polymorphism in paraphilic child sexual offenders. A recent study focusing on neurotransmission of paraphilic disorders found evidence to suggest that central dopamine plays a key role in the pathogenesis of paraphilic disorders as well as the general disturbance of the conscious regulation of behavior. The results of this study revealed increased levels of serotonin and norepinephrine, with a decreased concentration of DOPAC (3,4-dihydroxyphenylacetic acid) in urine samples of the test population diagnosed with paraphilic disorders. A correlation was made between serotonin and norepinephrine with obsessive disturbances and an association of DOPAC with affective and dissociative disorders.

Epidemiology

Literature is lacking with information pertaining to the epidemiology of paraphilia and paraphilic disorders. Literature is also limited from an epidemiological standpoint, with paraphilia typically studied in a general sense rather than pertaining to specific paraphilia or paraphilic disorders. Paraphilias, in general, are more common in men, with reasons unknown. A recent study conducted looked specifically at the desire for and experience of paraphilic behaviors of a sample population demographically representative of the general population. The sample size contained a total of 1,040 persons classified according to gender, age, education, ethnicity, religion, and location of residency. It was found that almost half of the study population expressed interest in one or more paraphilic categories, with approximately one-third of this population actually acting on this interest at least once. Specifically, fetishism, frotteurism, voyeurism, and masochism held a prevalence of 15.9% (value considered to be statistically unusual), with interest in both males and females. Interest levels in fetishism and masochism revealed no statistically significant difference amongst males and females. It was also found that the most common paraphilic interest amongst men is often voyeurism and fetishism.

Let’s learn a little bit more about the types of paraphillic disorders.

Fetishistic Disorder

Sexual fetishism or erotic fetishism is a sexual fixation on a nonliving object or nongenital body part. The object of interest is called the fetish; the person who has a fetish for that object is a fetishist. Sexual arousal from a particular body part can be further classified as partialism, or sexual interest with an exclusive focus on a specific part of the body other than the genitals. Partialism is categorized as a fetishistic disorder in the DSM-5 only if it causes significant psychosocial distress for the person or has detrimental effects on important areas of their life. Fetishism is diagnosed by recurrent and intense sexual arousal from either the use of nonliving objects or a highly specific focus on non-genital body part(s), as manifested by fantasies, urges, or behaviors that occur for at least six months. It must cause significant stress or impairment and not be related to clothing used in cross-dressing (transvestic disorder) or objects used for genital stimulation, like a vibrator.

Individuals who exhibit partialism sometimes describe the anatomy of interest to them as having an equal or greater erotic attraction for them as do the genitals. Partialism occurs in heterosexual, bisexual, and homosexual individuals. The foot is considered one of the most common partialisms.

While medical definitions restrict the term sexual fetishism to objects or body parts, fetish can, in common discourse, also refer to sexual interest in specific activities. This broader usage of fetish covers parts or features of the body (including obesity and body modifications), objects, situations and activities (such as BDSM—a variety of often erotic practices or roleplaying involving bondage, discipline, dominance and submission, sadomasochism, and other related interpersonal dynamics). Paraphilias such as urophilia, necrophilia, and coprophilia have been described as fetishes.

Erotic asphyxiation is the use of choking to increase the pleasure in sex. The fetish also includes an individualized part that involves choking oneself during the act of masturbation, which is known as auto-erotic asphyxiation. This usually involves a person being connected and strangled by a homemade device that is tight enough to give them pleasure but not tight enough to suffocate them to death. This is dangerous due to the issue of hyperactive pleasure seeking that can result in strangulation when there is no one to help if the device gets too tight and strangles the user.

Transvestic Disorder

Transvestism is the practice of cross-dressing, which is the act of wearing items of clothing and other accoutrements commonly associated with the opposite sex within a particular society. The term cross-dressing refers to an action or a behavior, without attributing or implying any specific causes or motives for that behavior. Cross-dressing is not synonymous with being transgender. A transvestic disorder is characterized by intense sexual arousal from cross-dressing that has occurred for at least six months, which also causes significant distress or impairment. It should be specified if it occurs with fetishism, meaning arousal by materials related to cross-dressing, or with autogynephilia, which includes arousal by thoughts of oneself as a female.

A transvestic fetishist is a person who cross-dresses as part of a sexual fetish. According to the DSM-4, this fetishism was limited to heterosexual men; however, DSM-5 does not have this restriction, and opens it to women and men, regardless of their sexual orientation.

Transvestic fetishism, fetishistic transvestism, and sometimes transvestism are also often used to describe any sexual behavior or arousal that is in any way triggered by the clothes of the other gender. Especially the latter is problematic because transvestism and cross-dressing are neither a sexual fetish nor do they necessarily have anything to do with sexual behavior or arousal.

Also, not every sexual behavior where clothes of the opposite gender are involved is transvestic fetishism; they are also often used in sexual roleplay without being a fetish. Also, many transgendered people, mostly transwomen, also cross-dress before coming out in sexual contexts to relieve their cross-gender feelings. This behavior is likewise not considered transvestic fetishism, as it is not cross-dressing for sexual pleasure, rather it is simply their self-gender expression.

Some male transvestic fetishists collect women’s clothing, e.g., nightgowns, babydolls, slips, other types of nightwear, lingerie stockings, and pantyhose, items of a distinct feminine look and feel. They may dress in these feminine garments and take photographs of themselves while living out their secret fantasies. Many men love the feeling of wearing silk or nylon and adore the silky fabric of women’s nightwear, lingerie, and nylons.

Most transvestic fetishists are said to be heterosexual men, although there are no studies that accurately represent either their sexual orientation or gender, and most information on this is based on anecdotal evidence or informal surveys. A small number of people with transvestic fetishism, as the years pass, want to dress and live permanently as women, and desire surgical or hormonal gender-affirming services. In such cases the diagnosis should be changed to transsexualism (or gender dysphoria).

Exhibitionist Disorder

Exhibitionism is the act of exposing in a public or semi-public context those parts of one’s body that are not normally exposed—for example, the breasts, genitals, or buttocks. The practice may arise from a desire or compulsion to expose themselves in such a manner to groups of friends or acquaintances, or to strangers for their amusement or sexual satisfaction or to shock the bystander. Exposing oneself only to an intimate partner is normally not regarded as exhibitionism. In law, the act of exhibitionism may be called indecent exposure, “exposing one’s person,” or other expressions.

When exhibitionistic sexual interest is acted on with a non-consenting person or interferes with a person’s quality of life or normal functioning, it can be diagnosed as exhibitionistic disorder in the DSM-5. The DSM states that the highest possible prevalence for exhibitionistic disorder in men is 2%-4%. It is thought to be much less common in women.

Exhibitionists in some cases masturbate while exposing themselves (or while fantasizing that they are exposing themselves) to another person. There is a pattern in which males exhibit themselves and there are three characteristic features of the exhibition: 1) It is performed for unknown women. 2) It takes place where sexual intercourse is impossible (e.g., a crowded shopping center). 3) It seems designed to surprise and shock the woman. The male exhibitionist usually exposes his erect penis, but it is not necessarily essential for the activity. Ejaculation may occur at the moment of exposure or develop later with masturbatory stimulation. Some exhibitionists are aware of a conscious desire to shock or upset their target while others fantasize that the target will become sexually aroused by their display.

Child versus Adult Presentation

Generally, society accepts exhibitionism in children as a natural curiosity, not a disorder; however, if the behaviors continue, a paraphilia is probable. The disorder appears to develop before the age of 18 and rarely is found in people over the age of 50.

Gender and Cultural Differences in Presentation

Most reported cases of exhibitionism involve males. Some scientists argue that women who undress in front of windows (as to invite a person to watch), or who wear low cut outfits are exhibitionists in a sense. Exhibitionism generally appears in Western society and is believed to be almost absent in such countries as Japan, Burma, and India. Additionally, in American society it can be a crime when committed by a male, but when women expose themselves, excluding total nudity, they are often seen as victims of male voyeurism.

Epidemiology

Prevalence and incidence are not easily defined because people with this disorder usually do not seek treatment voluntarily. Exhibitionism is one of the three most common sexual offenses, the other two being voyeurism and pedophilia. It is rarely diagnosed in general mental health clinics, but most professionals believe that it is probably underdiagnosed and under-reported. Risk factors appear to be antisocial history, antisocial personality disorder, alcohol misuse, and pedophilic sexual preference.

Voyeuristic Disorder

Voyeurism is the sexual interest in or practice of spying on people engaged in intimate behaviors, such as undressing, sexual activity, or other actions usually considered to be of a private nature. The term comes from the French voir which means “to see.” A male voyeur is commonly labelled as “Peeping Tom” or a “Jags,” a term which originates from the Lady Godiva legend. However, that term is usually applied to a male who observes somebody secretly and, generally, not in a public space.

It is diagnosed by recurrent and intense sexual arousal stemming from observing an unsuspecting person who is naked, undressing, or engaging in sexual activity. It should cause significant distress and the person must be at least 18 years old.

Research found voyeurism to be the most common sexual law-breaking behavior in both clinical and general populations.^[2] In the same study, it was found that 42% of college males who had never been convicted of a crime had watched others in sexual situations. An earlier study indicates that 54% of men have voyeuristic fantasies, and that 42% have tried voyeurism. In a national study of Sweden, it was found that 7.7% of the population (both men and women) had engaged in voyeurism at some point.^[3] It is also believed that voyeurism occurs up to 150 times more frequently than police reports indicate. This same study also indicates that there are high levels of co-occurrence between voyeurism and exhibitionism, finding that 63% of voyeurs also report exhibitionist behavior.

Frotteuristic Disorder

Frotteurism is a paraphilic interest in rubbing, usually one’s pelvic area or erect penis, against a non-consenting person for sexual pleasure. It may involve touching any part of the body, including the genital area. Frotteuristic disorder is a sexual dysfunction disorder characterized by sexual arousal from rubbing against or touching a non-consenting person.

The DSM-5 lists the following diagnostic criteria for frotteuristic disorder:

• Over a period of at least six months, recurrent and intense sexual arousal from touching or rubbing against a nonconsenting person, as manifested by fantasies, urges, or behaviors.
• The individual has acted on these sexual urges with a nonconsenting person, or the sexual urges or fantasies cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

If the individual has not acted on their interest and experiences no distress or impairment, they are considered to have a frotteuristic sexual interest, but not frotteuristic disorder. Some sexologists distinguish between frotteurism (as pelvic rubbing) and toucherism (as groping with hands), but the DSM does not.

The prevalence of frotteurism is unknown. The DSM estimates that 10–14% of men seen in clinical settings for paraphilias or hypersexuality have frotteuristic disorder, indicating that the population prevalence is lower. However, frotteuristic acts, as opposed to frotteuristic disorder, may occur in up to 30% of men in the general population. The majority of frotteurs are male and the majority of victims are female, although female-on-male, female-on-female, and male-on-male frotteurs exist. This activity is often done in circumstances where the victim cannot easily respond, in a public place such as a crowded train or concert.

Usually, such nonconsensual sexual contact is viewed as a criminal offense: a form of sexual assault albeit often classified as a misdemeanor with minor legal penalties. Conviction may result in a sentence or psychiatric treatment.

Sexual Masochism and Sexual Sadism Disorders

Sexual masochism disorder (SMD) is the condition of experiencing recurring and intense sexual arousal in response to enduring moderate or extreme pain, suffering, or humiliation. Conversely, sexual sadism disorder is the condition of experiencing sexual arousal in response to the extreme pain, suffering, or humiliation of others. The words sadism and sadist are derived from Marquis de Sade. Many of Marquis de Sade’s books, including Justine (1791), Juliette (1797) and The 120 Days of Sodom (published posthumously in 1905), are written from a cruelly sadistic viewpoint.

BDSM (bondage, domination, sadomasochism) is a colloquial term relating to individuals who willingly engage in consenting forms of pain or humiliation, typically for sexual purposes. The term BDSM describes the activities between consenting partners that contain sadistic and masochistic elements. Many behaviors such as erotic spanking, tickling, and love-bites that many people think of only as “rough” sex also contain elements of sado-masochism. BDSM is not currently a diagnosable condition in either the DSM or ICD system.

Sexual Masochism

The formal diagnosis of sexual masochism disorder according to the DSM-5 involves “recurrent and intense sexual arousal from the act of being humiliated, beaten, bound, or otherwise made to suffer, as manifested by fantasies, urges, or behaviors.” It applies only if the individual experiences clinically significant distress or impairment in social, occupational, or other important areas of functioning.

The prevalence of sexual masochism disorder in the population is unknown, but the DSM-5 suggests that 2.2% of males and 1.3% of females may be involved in BDSM, whether they have sexual masochism disorder or not. Extensive use of pornography depicting humiliation is sometimes associated with sexual masochism disorder.

Behaviors associated with sexual masochism disorder can be acted out alone (e.g., binding, self-sticking pins, self-administration of electric shock, or self-mutilation) or with a partner (e.g., physical restraint, blindfolding, paddling, spanking, whipping, beating, electric shock, cutting, pinning and piercing, and humiliation such as by being urinated or defecated upon, being forced to crawl and bark like a dog, or being subjected to verbal abuse). Behaviors sometimes include being forced to cross-dress or being treated like an infant.

Following a phenomenological study of individuals involved in sexual masochistic sessions, sexual masochism was described as an addiction-like tendency, with several features resembling that of drug addiction: craving, intoxication, tolerance, and withdrawal. It was also demonstrated how the first masochistic experience is placed on a pedestal, with subsequent use aiming at retrieving this lost sensation, much as described in the descriptive literature on addiction. The addictive pattern presented in this study suggests an association with behavioral spin as found in problem gamblers. A behavioral spin is described as a process one goes through that is characterized by a behavior growing in frequency and magnitude. As it develops, it gains its own momentum which the individual finds almost impossible to terminate even when faced with known unwanted outcomes. For the participants in sexual masochistic sessions, the behavioral spin is manifested as a continuously reinforced process leading the masochist to engage in masochistic activity, perpetuating itself, and binding the addict to his/her behavior.

Sexual Sadism Disorder

Sexual sadism disorder refers to the “recurrent and intense sexual arousal from the physical or psychological suffering of another person, as manifested by fantasies, urges, or behaviors.” The formal diagnosis of sexual sadism disorder would apply if the individual has acted on these urges with a nonconsenting person or if the urges cause significant distress to the individual.

Paraphilic coercive disorder refers to the preference for non-consenting over consenting sexual partners. It differs from sexual sadism disorder in that although the individual with this disorder may inflict pain or threats of pain in order to gain the compliance of the victim, the infliction of pain is not the actual goal of the individual. The condition is typically described as a paraphilia and continues to undergo research, but does not appear in the current DSM or ICD. Alternate terms for the condition have included Biastophilia, Coercive Paraphilic Disorder, and Preferential Rape.

With paraphilic coercive disorder, the individual employs enough force to subdue a victim, but with sexual sadism disorder, the individual often continues to inflict harm regardless of the compliance of the victim, which sometimes escalates not only to the death of the victim, but also to the mutilation of the body. What is experienced by the sadist as sexual does not always appear obviously sexual to non-sadists: sadistic rapes do not necessarily include penile penetration of the victim. In a survey of offenses, 77% of cases included sexual bondage, 73% included anal rape, 60% included blunt force trauma, 57% included vaginal rape, and 40% included penetration of the victim by a foreign object. In 40% of cases, the offender kept a personal item of the victim as a souvenir.

On personality testing, sadistic rapists apprehended by law enforcement have shown elevated traits of impulsivity, hypersexuality, callousness, and psychopathy. Although there appears to be a continuum of severity from mild (hyperdominance or BDSM) to moderate (paraphilic coercive disorder) to severe (sexual sadism disorder), it is not clear if they are genuinely related or only appear related superficially.

Very little is known about how sexual sadism disorder develops. Most of the people diagnosed with sexual sadism disorder come to the attention of authorities by committing sexually motivated crimes. Surveys have also been conducted to include people who are interested in only mild and consensual forms of sexual pain/humiliation (BDSM).

Most of the people with full-blown sexual sadism disorder are male, whereas the sex ratio of people interested in BDSM is closer to 2:1 male-to-female. People with sexual sadism disorder are at an elevated likelihood of having other paraphilic sexual interests.

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