One literal translation of paraphilia—love beyond the usual—casts a benign, if not romantic, hue over a subject that has been marked by considerable pro- fessional dissidence (1). Although this chapter will not provide a critique of the paraphilia construct, any responsible discussion of the paraphilias must acknowledge the cultural underpinnings of efforts to define normality vs. abnormality in human behavior. This theoretical debate plays out in the literature, where a range of positions are evident, from loyal adherence to traditional defi- nitions of pathological sex to advocacy for the elimination or radical revision of the paraphilia diagnostic category (2 – 4). Only a greater empirical base will resolve this controversy and provide a reasonably objective basis on which clin- icians can define the boundary between “normal” and “abnormal” sexuality.
The focus of this chapter is not to engage the debate regarding normalcy, but to provide a clear conceptualization of the paraphilias, a review of etiological theories, and an articulation of current treatments. A core assumption throughout the chapter is that the most reasoned understanding of the paraphilias is one that integrates both biological and psychological perspective.
DEFINING AND CONCEPTUALIZING THE PARAPHILIAS
Paraphilias are defined as psychosexual disorders in which significant distress or impairment in an important domain of functioning results from recurrent, intense sexual urges, fantasies, or behaviors generally involving an unusual object, activity, or situation (5). Although the DSM-IV-TR lists eight specific para- philias, paraphilia as a broad category represents a heterogeneous group of disorders and diverse behavioral expressions. The DSM-IV-TR defines three subtypes of paraphilias:
those involving nonhuman objects,
those involving the suffering or humiliation of oneself or one’s partner, those involving children or other nonconsenting persons.
The minimum time duration for a fantasy, urge, or behavior to qualify as a dis- order is 6 months. Recurrent by definition, the paraphilias are generally chronic and lifelong, although the associated fantasies, urges, and behaviors diminish over the life span in some adults. Paraphilic fantasies and urges may vary in fre- quency and intensity over time, often beginning in childhood or adolescence and intensifying in adulthood. Acute episodes may occur and, in some individuals, resolve quickly with treatment. The paraphilic fantasy or behavior may be obli- gatory, or required for arousal, or nonobligatory, where an individual experiences arousal in response to other erotic stimuli as well. It may be nonobligatory in early life but become increasingly obligatory over time or with increased engage- ment with the pattern. Individuals with one paraphilia may be prone to develop others, and multiple paraphilias in one individual appear to occur with high frequency (6,7).
The present diagnostic categorizing system, in which paraphilias are defined according to the specific deviant focus, implies that each paraphilia rep- resents a distinct disease process. Difficulties stemming from this conceptualiz- ation are apparent in the common scenario of multiple paraphilias co-occurring in one individual, where the multiple paraphilia conceptualization suggests that each paraphilic interest in the individual represents a distinct pathological phenomenon. No clear evidence exists for such an assertion and, further, it is more clinically useful to conceptualize the scenario as multiple paraphilic vari- ations reflecting a shared underlying phenomenon. Lehne and Money proposed the term “multiplex paraphilia,” noting variations of paraphilic content expressed over an individual’s life span, but all influenced by a common underlying deficit or etiological process (7,8).
There is little reliable data regarding the prevalence of the paraphilias. As indi- viduals with paraphilias rarely present in mental health or medical facilities, it is assumed that the prevalence in the general population is higher than estimates based on clinical samples. A 1983 review of psychiatric hospital records revealed a 0.08% incidence of fetishism (9). In contrast, a 10-year review of the records from the authors’ specialty clinic showed a 5.4% incidence of fetishism, highlighting the variation in patient samples depending on contextual variables.
The same review revealed an overall prevalence rate of 24% for the paraphilias and paraphilia not otherwise specified relative to sexual dysfunction, sexual pain, and gender identity disorder diagnoses. For the specific paraphilias, the following rates were revealed: transvestic fetishism 35%, paraphilia NOS 31%, sexual masochism 8%, exhibitionism 7.4%, pedophilia 6.7%, fetishism 5.4%, voyeur- ism and sexual sadism 2.7% each, and frotteurism ,1%. Again, it is important to note that patient samples are not representative of the general population and patient samples in specialty clinics are not representative of general medical or psychiatric samples.
Much of the prevalence data for the offending paraphilias have been drawn from sexual offender arrest or treatment records. Such records often do not distinguish between paraphilic and nonparaphilic offenders. As a result, the prevalence of specific paraphilias among sex offenders or in the general popu- lation is unknown and data gathered from arrest records likely under-reflect the incidence of paraphilias (10).
Gender and the Paraphilias
As far as is known, the paraphilias occur predominantly in males, with the excep- tion of sexual masochism, which is also commonly observed in females, although still with less frequency than in males. Exceptions have been reported, including single case reports of female genital exhibitionism and female fetishism (11 – 13). Two recent reports described, collectively, five cases of accidental autoerotic death in females, with evidence strongly suggesting the presence of the paraphilia asphyxiophilia, in which cerebral hypoxia is induced for the purpose of generat- ing or intensifying sexual arousal (14,15). Gosink reported that autoerotic deaths occur differentially in males and females at a ratio of more than 50:1. It is not known to what extent this figure reflects gender differences in the prevalence of other paraphilias. Another recent report described multiple paraphilias in a female, including fetishistic arousal to men in diapers as well as sexual sadism characterized by extreme preoccupation with sexual torture and a collection of detailed plans to murder young males to whom she was sexually attracted (16). Another report described a female sex offender who displayed elements of hyper- sexuality, sexual sadism, sexual masochism, and pedophilia, including violent sexual fantasies involving children (17).
Pedophilia in females is rare but has been reported. A recent review of records in the authors’ clinic revealed, among 149 individuals diagnosed with one or more paraphilias, one female was diagnosed with pedophilia, one with sexual sadism, and five with paraphilia NOS. All other subjects were male. Chow and Choy recently reported on the positive response to treatment with the SSRI sertraline in a female diagnosed with pedophilia (18). True prevalence of pedophilia is difficult to determine from sex offender records, as offenders are not commonly assessed for deviant sexual interests and many studies fail to differentiate between sexually deviant and nondeviant offenders. Therefore, the relative occurrence of pedophilia in male and female sex offenders is not known.
A 1991 review by Wakefield and Underwager revealed that, among female sex offenders who were assessed for sexual deviancy, most were determined to not have pedophilia, suggesting that factors other than sexual gratification often motivate the behavior (19). Some gender differences in clinical character- istics between males and females with pedophilia have been suggested. Most sig- nificantly, while history of sexual victimization is reported with some frequency by both males and females with pedophilia, the higher frequency in females suggests that history of sexual abuse may have greater etiological significance in the development of pedophilia in females than in males (F. Berlin, personal communication, 2003) (19).
In summary, while the literature strongly supports the assumption that the paraphilias occur predominantly in males, there are increasing reports of paraphilias in females. The occurrence of paraphilias in females may be a less rare clinical phenomenon than previously assumed.
There is considerable co-occurrence of other paraphilias in patients diagnosed with one (7,20 – 24). A recent study of men with pedophilia showed the following comorbidity patterns with additional paraphilias: voyeurism 13.3%, frotteurism 11%, exhibitionism, transvestic fetishism, and paraphilia NOS 6.7% each, and fetishism and sexual sadism 4.4% each (25).
Kafka and Prentky conducted a study of lifetime comorbid nonsexual diag-noses in males with paraphilias and paraphilia-related disorders (26). Almost 72% had a lifetime prevalence of a mood disorder, with dysthymic disorder occurring most frequently. Interestingly, there were no significant differences in comorbidity patterns between men with paraphilias and men with paraphi- lia-related disorders, with the exception of retrospectively diagnosed childhood ADHD, which was identified in 50% of the paraphilia group but in only 17% of the paraphilia-related group. Similar comorbidity patterns were found in a later study (27).
It is known that many individuals with fetishistic cross-dressing have comorbid psychiatric disorders. A sample of transvestites who sought psychiatric evaluation in a sexual behaviors clinic were found to have high rates of mood or substance abuse disorders (28). This was consistent with a previous study wherein 80% of gender dysphoric transvestites qualified for a concurrent Axis I diagnosis, generally an affective disorder (29). A recent study of comorbidity between alcoholism and specific paraphilias found that .50% of sexual sadists were alcohol dependent, with the lowest association between transvestism and alcoholism (30).
A recent study of the co-occurrence of personality disorders in sex offen- ders revealed that 72% of the sample had at least one personality disorder (31).
The most prevalent was antisocial personality disorder. All subjects had impulse control disorder and a paraphilia, but it is not clear how many of the offenders in the study had a diagnosis of pedophilia or other specific paraphilias.
In another recent study, Raymond et al. (25) found that 93% of individuals with pedophilia had at least one lifetime comorbid axis I diagnosis. Highest were comorbid mood and anxiety disorders. There was high co-occurrence of alcohol and cannabis use disorders, and 60% had comorbid personality disorders, in particular obsessive-compulsive, antisocial, avoidant, and narcissistic. Contrary to commonly held assumptions, there was a relatively low incidence—23%—of antisocial personality disorder.
THE DSM-IV-TR LISTED PARAPHILIAS
The eight specifically listed paraphilias and paraphilia NOS are summarized in
Fig. 12.1. They are discussed here in logically grouped form.
Voyeurism, Exhibitionism, and Frotteurism
Voyeurism, exhibitionism, and frotteurism have also been found to frequently co- occur. It has been proposed that they may be fundamentally related through shared underlying mechanisms (32). Voyeurism and exhibitionism involve visual processing of sexual stimuli from a distance, without direct physical contact with a partner, whereas in frotteurism physical contact is made. The voyeur “looks” in order to “receive” an alluring sexual image, the exhibitionist “shows” in order to “transmit” a sexual invitation, and the frotteur touches in order to “feel” intimate (33).
The paraphilic focus in voyeurism is sexual fantasies, urges, or behaviors invol- ving observing unsuspecting persons, usually unclothed and/or engaged in sexual activity. Federoff has described the “requirement” aspect of voyeurism and the other paraphilias as the central feature distinguishing them from nonpar- aphilic equivalents (34). It is not simply the act of watching a women naked, undressing, or engaging in sex that arouses the paraphilic voyeur; the victim’s lack of suspicion that she is being observed and the risk of being discovered are central to the voyeur’s arousal. Like the exhibitionist, the voyeur rarely makes contact with his victim. His ritual often is accompanied by masturbation during or after the voyeuristic episode.
Money has described variants of voyeurism (33). They include pictophilia, or dependence on viewing pornography for arousal, and troilism, or dependence for arousal on observing one’s partner “on hire or loan” to a third party while engaged in sexual activity. The internet provides increasing opportunities for such paraphilia variants to thrive.
A paraphilia involves, over at least a 6-month period, recurrent, intense sexually arousing fantasies, sexual urges or behaviors. The targets of the fantasies, urges or behavior reflect three subtypes of paraphilia:
1) non-living objects
2) suffering or humiliation of self or partner
3) children or other nonconsenting persons
In exhibitionism, the individual displays his genitals to an unsuspecting person. The exhibitionist ordinarily becomes aroused in response to the shocked response of a stranger or to the fantasy that the stranger becomes aroused in response to his display. A response of indifference may fuel a conpulsion to repeat the behavior until the craving is satisfied.
Exhibitionism must be distinguished from “nudist” interests, such as enjoy- ment of vacationing at nude beaches and resorts, and from prank behaviors, such as flashing and mooning. While sometimes offensive or illegal, these do not involve sexual arousal. Fedoroff has stated that exhibitionists have no interest in experiences such as nude beaches, where social norms are intolerant of overt expressions of sexual arousal (34). However, in the authors’ research, a small number of diagnosed exhibitionists have reported such overlapping inter- ests and behaviors. A exhibitionistic variant that reflects this overlap is the seeking of approval or validation, such as in the form of applause, as the exhibi- tionist perceives his victims more as an audience, as does the flasher, than as individuals upon whom he perpetrates harm.
Most exhibitionists and voyeurs are heterosexual men who seek out female victims. Some seek audiences of particular age ranges, such as children or ado- lescents. In these cases, it is critical to assess for a primary or co-occurring diag- nosis of pedophilia. Some seek only adult victims and others are indiscriminate regarding age of their audience.
Frotteurism is a paraphilic preference for rubbing one’s genitals against an unsuspecting person. This paraphilia most often occurs in crowded public places where the frotteur disguises his behavior as an accidental result of crowd or vehicle motion. The frotteur tries to escape after accomplishing contact, to avoid confrontation or arrest. He may fantasize about an intimate, exclusive relationship with his victim (35). He may also fondle his victim’s gen- itals or breasts, a variant of frotteurism known as toucherism (33). Sexual arousal in response to watching other men engage in frotteurism is described as another variant (36).
Like other sexual offenders, exhibitionists, voyeurs, and frotteurs may use cogtive distortions to rationalize, justify, and minimize the negative impact of their behaviors. The voyeur may blame the victim for leaving a window open to outside view, claiming that she wants to be seen; the exhibitionist may believe that others find his display funny rather than offensive; voyeurs and exhi- bitionists may perceive a harmlessness to their acts because no one is physically touched; the frotteur, who denies intentionality, believes that no harm is done because no one is “meant” to be touched.