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If a paraphilia causes distress or impairment to the individual or if its satisfaction entails personal harm, or risk of harm, to others, it is considered a paraphilic disorder. A paraphilia is thus a necessary but insufficient condition for having a paraphilic disorder. A paraphilia by itself, without distress, impairment, or potential or actual harm, does not necessarily require clinical intervention. A complete history including psychiatric and psychosexual history should be obtained.
People with paraphilic disorders may be difficult to interview because of guilt and reluctance to share information openly with the interviewer. It is essential to establish rapport with these patients to allow them to talk more freely about their disorder. Other paraphilias, almost any of which could develop into a paraphilic disorder in certain circumstances, include but are not limited to the following:.
In addition to a complete history, complete mental status, physical, and neurologic examinations must be performed to assist with the evaluation and to rule out other disease processes. Ruling out other major psychiatric or other medical illnesses is critical for diagnosis and management. See Clinical Presentation for more detail. Paraphilic disorders must be distinguished from nonpathologic use of sexual fantasies, behaviors, or objects as stimuli for sexual excitement. Studies that may be considered in the assessment of a patient with a paraphilic disorder include the following:.
Standard medical workup, including sequential multiple analysis, complete blood count, rapid plasma reagent, and thyroid-stimulating hormone level or thyroid function test. See DDx and Workup for more detail. Treatment options vary and must take into the specific needs of each individual case. The following options are available:. Pharmacologic interventions may be used to suppress sexual behavior. Medications that may be considered in the treatment of paraphilic disorders include the following:.
Numerous adverse effects of pharmacotherapy have been reported. Additionally, ethical, medical, and legal questions have been raised regarding issues of informed consent, especially in hospital and prison settings. See Treatment and Medication for more detail. Paraphilia is any intense and persistent sexual interest other than sexual interest in genital stimulation or preparatory fondling with phenotypically normal, physically mature, consenting human partners.
Paraphilias are associated with arousal in response to sexual objects or stimuli not associated with normal behavior patterns and that may interfere with the establishment of sexual relationships. In modern classification systems, the term paraphilia or paraphilic disorder, as appropriate is preferable to the term sexual deviation because it clarifies the essential nature of this group of behaviors ie, arousal in response to an inappropriate stimulus. Paraphilia is a means by which some people release sexual energy or frustration. The act commonly is followed by arousal and orgasm, usually achieved through masturbation and fantasy.
Paraphilic disorders are not well recognized and often are difficult to treat, for several reasons. Often, people who have these disorders conceal them, experience guilt and shame, have financial or legal problems, and can at times be uncooperative with medical professionals. Various other presentations exist in which symptoms typical of a paraphilic disorder are present but do not meet the full criteria for any of the diagnoses above. Such presentations include the following:.
The latter includes presentations in which there is insufficient information to make a more specific diagnosis. Generally, for each of the specific paraphilic disorders listed in DSM-5 , the first diagnostic criterion specifies the qualitative nature of the paraphilia eg, an erotic focus on children or on exposing the genitals to strangers , whereas the second criterion specifies the negative consequences of the paraphilia see below.
Both criteria must be satisfied to establish a diagnosis of a paraphilic disorder. An individual who meets the first criterion but not the second is considered to have a paraphilia but not a paraphilic disorder. The DSM-5 diagnostic criteria for voyeuristic disorder are as follows [ 1 ] :. The patient experiences recurrent and intense sexual arousal manifested by fantasies, urges, or behaviors involving the act of observing an unsuspecting person who is naked, in the process of disrobing, or engaging in sexual activity; symptoms must be present for at least 6 months.
The patient experiences ificant distress or impairment in social, occupational, or other important areas of functioning because of the fantasies, urges, or behaviors, or the patient has acted on the sexual urges. Whether the individual is in a controlled environment this specifier is primarily applicable to individuals living in institutional or other settings where opportunities to engage in voyeuristic behavior are restricted. The DSM-5 diagnostic criteria for exhibitionistic disorder are as follows: [ 1 ]. The patient experiences recurrent and intense sexual arousal manifested by fantasies, urges, or behaviors related to exposing the genitals to a stranger; symptoms must be present for at least 6 months.
Whether the individual is sexually aroused by exposing genitals to prepubertal children, to physically mature individuals, or to both. The DSM-5 diagnostic criteria for frotteuristic disorder are as follows [ 1 ] :. The patient experiences recurrent and intense sexual arousal manifested by fantasies, urges, or behaviors involving touching and rubbing against a nonconsenting person; symptoms must be present for at least 6 months.
The DSM-5 diagnostic criteria for sexual masochism disorder are as follows [ 1 ] :. The patient experiences recurrent and intense sexual arousal manifested by fantasies, urges, or behaviors involving the act real, not simulated of being humiliated, beaten, bound, or otherwise made to suffer; symptoms must be present for at least 6 months.
The fantasies, urges, or behaviors cause ificant distress or impairment in social, occupational, or other important areas of functioning. The DSM-5 diagnostic criteria for sexual sadism disorder are as follows [ 1 ] :. The patient experiences recurrent and intense sexual arousal manifested by fantasies, urges, or behaviors from the psychological or physical suffering of another person; symptoms must be present for at least 6 months.
The fantasies, urges, or behaviors cause ificant distress or impairment in social, occupational, or other important areas of functioning, or the patient has acted on these sexual urges with a nonconsenting person. The DSM-5 diagnostic criteria for pedophilic disorder are as follows [ 1 ] :.
The disorder causes marked distress or interpersonal difficulty, or the individual has acted on these sexual urges. The individual is age at least 16 years and at least 5 years older than the victim; individuals in late adolescence involved in an ongoing sexual relationship with a or year-old are excluded. Whether the individual is attracted to males, females, or both note this is based on controversial gender dichotomy. The DSM-5 diagnostic criteria for fetishistic disorder are as follows [ 1 ] :.
The patient experiences recurrent and intense sexual arousal manifested by fantasies, urges, or behaviors either from the use of nonliving objects or from a highly specific focus on nongenital body parts; symptoms must be present for at least 6 months.
The patient experiences ificant distress or impairment in social, occupational, or other important areas of functioning because of the fantasies, urges, or behaviors. The fetishes are not limited to articles of female clothing used in cross-dressing as in transvestic disorder or devices deed for genital stimulation eg, vibrators. The DSM-5 diagnostic criteria for transvestic disorder are as follows [ 1 ] :. The patient experiences recurrent and intense sexual arousal manifested by fantasies, urges, or behaviors from cross-dressing; symptoms must be present for at least 6 months.
These fantasies, urges, or behaviors cause ificant distress or impairment in social, occupational, or other important areas of functioning. Whether the individual is sexually aroused by thoughts or images of self as female autogynephilia. Paraphilias may exist as discrete anomalies in otherwise stable personalities and thus may go unnoticed by partners, families, and friends. More commonly, however, they coexist with personality disorders, substance misuse or use disorders, anxiety disorders, or affective disorders.
It remains unclear why some people act on deviant urges and others do not. Persons with personality disorders who have problems with self-esteem, anger management concerns, difficulty delaying gratification, poor empathetic ability, and faulty cognitions are particularly vulnerable.
Many theories exist regarding the etiology of paraphilias, including psychoanalytical, behavioral, biologic, and sociobiologic theories. To date, however, none have proved conclusive; additional research is required. According to psychoanalytical theory, several possible factors may contribute to the origin of paraphilias. Freund and his colleagues suggested that some paraphilias may be attributed to possible distortion of the courtship phases. It usually occurs during adolescence and may or may not involve sexual intercourse at this early stage of sexual development.
Tactile interaction phase — Physical contact with a potential partner, usually consisting of touching, hugging, hand-holding, and similar actions this could also be considered foreplay. Although most of the population is capable of appropriate engagement in the phases of courtship, other people are unable to adhere to these socially acceptable norms.
Freund et al. According to this particular literature, however, such distortions are associated only with the first 3 phases. In this view, voyeurism is understood as a distortion of the initial courtship phase ie, locating a potential partner. Psychoanalysts postulate that voyeurism may be attributed to witnessing episodes of his or her parents engaged in sexual intercourse. Individuals with maladaptive social and sexual skills find voyeurism to be an outlet for sexual pleasure without the threat of sexual interaction. The risk or danger of discovery may give the voyeur a false sense of masculinity as also tends to be the case with the exhibitionist.
Psychoanalysts consider exhibitionism a distortion of the second courtship phase ie, pretactile interaction. In psychoanalytical theory, gender identity for a little boy is held to require psychological separation from his mother, so that he will not identify with her as a member of the same sex, as a little girl would. Exhibitionists regard their mothers as rejecting them on the basis of their different genitalia. Through exhibitionism, the individual attempts to force women to accept him by forcing them to look at his genitals.
The act of self-exposure is also a way for the exhibitionist to compensate for his introversion and lack of assertiveness. This act may give the exhibitionist a false sense of power, and the danger of discovery may further reinforce this feeling. Narcissism , the extreme form of self-admiration, is also believed to contribute to exhibitionism.
Many narcissist-exhibitionist men are married and have regular sexual contact with their spouses. However, spousal appreciation of their genitalia is not sufficient by itself to fulfill their insatiable need for admiration, and as a consequence, they constantly search for other unsuspecting victims from whom to elicit admiration. The exhibitionist is sometimes compared to an actor on stage who desires an audience but does not want to participate in the act.
Frotteurism and toucherism toucherism is sexual arousal based on grabbing or rubbing one's hands against an unexpecting and non-consenting person; it usually involves touching breasts, buttocks, or genital areas, often while quickly walking across the victim's path, which are considered exaggerations of the third courtship phase ie, tactile interaction.
These paraphilias provide a sexual outlet without the risk of rejection. Toucherism tends to occur in conjunction with other paraphilias. Freund suggested that these disorders result from unsuccessful negotiation in the developmental stages, which in sexual urges becoming blocked and expressing themselves at a later time as paraphilias. Behavioral theory attributes the development of certain paraphilias to the process of conditioning. Paraphilias are thus felt to be a result of accidental conditioning.
If nonsexual objects are frequently and repeatedly associated with a pleasurable sexual activity, then the object becomes sexually arousing. A small study was conducted with 7 heterosexual males, all of whom were free of any fetishes. Later, when the slide of the boots was shown alone, 5 of the 7 men experienced penile erection.
This indicated that a boot fetish had been conditioned. A similar small study conducted to determine whether women could be conditioned to become sexually aroused by a stimulus found no ificant differences in physiologic sexual arousal between women in the experimental group and those in the control group. These imply that sexual arousal is not readily amenable to classic conditioning in women. This might help explain why fetishism and other paraphilias occur almost exclusively in males. Conditioning does not always involve positive reinforcement; negative reinforcement may also play a role.
If an individual experiences unpleasant consequences with normal sexual activity, an aversion to sex may occur, resulting in the development of deviant behavior. An example of this would be a young boy who is humiliated and punished by his parents for proudly displaying his erect penis.
As the boy matures, he may associate guilt and shame with normal sexual behavior. Certain atypical sex acts, such as exhibitionism and voyeurism, that provide intense sexual arousal may lead to individual preference of that behavior. Pedophiliacs, exhibitionists, and voyeurs may be driven by risk-taking behaviors. Therefore, the constant threat of discovery may be as arousing to them as the act itself. Conditioning is not the only contributing factor in the development of paraphilias. Individuals with paraphilias usually experience low self-esteem, which may lead to difficulty in forming person-to-person sexual relationships.
This higher level of excitation, in turn, would increase the likelihood that people would engage in sex acts that would ultimately lead to procreation. Those men who were more adept at hunting and fighting protectors and warriors were more likely to survive and attract females as mates.
Those who were weaker were less likely to attract women as desirable mates, because they were unable to provide adequate food, clothing, and shelter, and they were less able to protect their potential family from enemies. Men were also more likely to be attracted to women who were stronger in child-rearing abilities, because involvement with such women was more likely to ensure that their genes would be passed down to subsequent generations.
Therefore, stronger and more aggressive men, as well as women with a stronger capacity for raising children, were more likely to acquire mates. This would ensure propagation of their genes. Today, this genetic programming is carried in both sexes. Although other primates are more instinctually driven, humans are also affected to a certain degree.
During the mating season, animals are compelled to go through the mating ritual of their species. Humans also have procreative urges, but not in a particular mating season or in a particular mating ritual, as is seen in other primates. This does not make us exempt from such mating patterns with the resultant pattern of their expression. Darwinian theory relates more directly to reproductive capacity.Complete list of paraphilias
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