Paraphilias are patterns in which people repeatedly have intense sexual urges or fantasies or display sexual behaviors that involve objects or situations outside the usual sexual norms. The sexual focus may, for example, involve nonhuman objects or the experience of suffering or humiliation. Many people with a paraphilia can become aroused only when a paraphilic stimulus is present, fantasized about, or acted out. Others need the stimulus only during times of stress or under other special circumstances. Some people with one kind of paraphilia have others as well (Seto, Kingston, & Bourget, 2014). The large consumer market in paraphilic pornography and growing trends such as sexting and cybersex lead clinicians to suspect that paraphilias are, in fact, quite common (Ahlers et al., 2011; Pipe, 2010) (see MindTech below).

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According to DSM-5, a diagnosis of paraphilic disorder should be applied when paraphilias cause a person significant distress or impairment or when the satisfaction of the paraphilias places the person or other people at risk of harm—either currently or in the past (APA, 2013) (see Table 13-5). People who initiate sexual contact with children, for example, warrant a diagnosis of pedophilic disorder regardless of how troubled the individuals may or may not be over their behavior. People whose paraphilic disorder involves children or nonconsenting adults often come to the attention of clinicians as a result of legal issues generated by their inappropriate actions.

Although theorists have proposed various explanations for paraphilic disorders, there is little formal evidence to support such explanations (Becker et al., 2012; Raley, 2011). Moreover, none of the many treatments applied to these disorders have received much research or proved clearly effective (Becker et al., 2012; Roche & Quayle, 2007). Psychological and sociocultural treatments have been available the longest, but today’s professionals are also using biological interventions.

Some practitioners administer drugs called antiandrogens that lower the production of testosterone, the male sex hormone, and reduce the sex drive (Assumpção et al., 2014; Korda & Sommer, 2010). Although antiandrogens may indeed reduce paraphilic patterns, several of them disrupt normal sexual feelings and behavior as well (Kirkpatrick & Clark, 2011; Thibaut et al., 2010). Thus the drugs tend to be used primarily when the paraphilic disorders are of particular danger either to the individuals themselves or to other people. Clinicians are also increasingly prescribing SSRIs, the serotonin-enhancing antidepressant medications, to treat people with paraphilic disorders, hoping that the SSRIs will reduce these compulsion-like sexual behaviors just as they help reduce other kinds of compulsions (Assumpção et al., 2014; Berner & Briken, 2010). In addition, of course, a common effect of the SSRIs is to lower sexual arousal.

A word of caution is in order before examining the various paraphilic disorders. The definitions of these disorders, like those of sexual dysfunctions, are strongly influenced by the norms of the particular society in which they occur (McManus et al., 2013). Some clinicians argue that except when other people are hurt by them, at least some paraphilic behaviors should not be considered disorders at all (De Block & Adriaens, 2013; Wright, 2010). Especially in light of the stigma associated with sexual disorders and the self-revulsion that many people feel when they believe they have such a disorder, we need to be very careful about applying these labels to others or to ourselves (McManus et al., 2013). Keep in mind that for years clinicians considered homosexuality a paraphilic disorder, and their judgment was used to justify laws and even police actions against gay people (Dickinson et al., 2012; Kirby, 2000). Only when the gay rights movement helped change society’s understanding of and attitudes toward homosexuality did clinicians officially stop considering it a disorder and remove it from the DSM—partly in 1973 and then fully in 1986. Even then, as you observed in Chapter 2, many clinicians continued for years to recommend and offer conversion, or reparative, therapy to “fix” the sexual orientation of gay people. In the meantime, the clinical field had unintentionally contributed to the persecution, anxiety, and humiliation of millions of people because of personal sexual behavior that differed from the conventional norms.

One relatively common paraphilic disorder is fetishistic disorder. Key features of this disorder are recurrent intense sexual urges, sexually arousing fantasies, or behaviors that involve the use of a nonliving object or nongenital body part, often to the exclusion of all other stimuli (APA, 2013). Usually the disorder, which is far more common in men than in women, begins in adolescence. Almost anything can be a fetish; women’s underwear, shoes, and boots are particularly common. Some people with this disorder steal in order to collect as many of the desired objects as possible. The objects may be touched, smelled, worn, or used in some other way while the person masturbates, or the person may ask a partner to wear the object when they have sex (Marshall et al., 2008). Several of these features are seen in the following case:

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Researchers have not been able to pinpoint the causes of fetishistic disorder. Psychodynamic theorists view fetishes as defense mechanisms that help people avoid the anxiety produced by normal sexual contact. Psychodynamic treatment for this problem, however, has met with little success (Öncü et al., 2009; Zurolo & Napolitano, 2008).

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Behaviorists propose that fetishes are acquired through classical conditioning (Dozier, Iwata, & Worsdell, 2011; Roche & Quayle, 2007). In a pioneering behavioral study, male participants were shown a series of slides of nude women along with slides of boots (Rachman, 1966). After many trials, the participants became aroused by the boot photos alone. If early sexual experiences similarly occur in the presence of particular objects, perhaps the stage is set for development of fetishes.

Behaviorists have sometimes treated fetishistic disorder with aversion therapy (Plaud, 2007; Krueger & Kaplan, 2002). In one study, an electric shock was administered to the arms or legs of participants with this disorder while they imagined their objects of desire (Marks & Gelder, 1967). After 2 weeks of therapy all men in the study showed at least some improvement. In another aversion technique, covert sensitization, people with fetishistic disorder are guided to imagine the pleasurable object and repeatedly to pair this image with an imagined aversive stimulus until the object of sexual pleasure is no longer desired.

Another behavioral treatment for fetishistic disorder is masturbatory satiation (Plaud, 2007; Wright & Hatcher, 2006). In this method, the client masturbates to orgasm while fantasizing about a sexually appropriate object, then switches to fantasizing in detail about fetishistic objects while masturbating again and continues the fetishistic fantasy for an hour. The procedure is meant to produce a feeling of boredom, which in turn becomes linked to the fetishistic object.

Yet another behavioral approach to fetishistic disorder, also used for other paraphilias, is orgasmic reorientation, which teaches individuals to respond to more appropriate sources of sexual stimulation (Wright & Hatcher, 2006). People are shown conventional stimuli while they are responding to unconventional objects. A person with a shoe fetish, for example, may be instructed to obtain an erection from pictures of shoes and then to begin masturbating to a picture of a nude woman. If he starts to lose the erection, he must return to the pictures of shoes until he is masturbating effectively, then change back to the picture of the nude woman. When orgasm approaches, he must direct all attention to the conventional stimulus.

A person with transvestic disorder, also known as transvestism or cross-dressing, feels recurrent and intense sexual arousal from dressing in clothes of the opposite sex—arousal expressed through fantasies, urges, or behaviors (APA, 2013). In the following passage, a 42-year-old married father describes his pattern:

Like this man, the typical person with transvestic disorder, almost always a heterosexual male, begins cross-dressing in childhood or adolescence (Marshall et al., 2008; Långström & Zucker, 2005). He is the picture of characteristic masculinity in everyday life and is usually alone when he cross-dresses. A small percentage of such men cross-dress to visit bars or social clubs. Some wear a single item of women’s clothing, such as underwear or hosiery, under their masculine clothes. Others wear makeup and dress fully as women. Some married men with transvestic disorder involve their wives in their cross-dressing. Transvestic disorder is often confused with gender dysphoria, but, as you will see, they are two separate patterns that overlap only in some individuals (Zucker et al., 2012).

The development of transvestic disorder sometimes seems to follow the behavioral principles of operant conditioning. In such cases, parents or other adults may openly encourage the child to cross-dress or even reward them for doing so. In one case, a woman was delighted to discover that her young nephew enjoyed dressing in girls’ clothes. She had always wanted a niece, and she proceeded to buy him dresses and jewelry and sometimes dressed him as a girl and took him out shopping.

A person with exhibitionistic disorder experiences recurrent and intense sexual arousal from exposing his genitals to an unsuspecting individual—arousal reflected by fantasies, urges, or behaviors (APA, 2013). Most often, the person wants to provoke shock or surprise rather than initiate sexual activity with the victim. Sometimes an exhibitionist will expose himself in a particular neighborhood at particular hours. In a survey of 2,800 men, 4.3 percent of them reported that they perform exhibitionistic behavior (Långström & Seto, 2006). Yet between one-third and half of all women report having seen or had direct contact with an exhibitionist, or so-called flasher (Marshall et al., 2008). The urge to exhibit typically becomes stronger when the person has free time or is under significant stress.

Generally, exhibitionistic disorder begins before age 18 and usually, but not always, is found among men (APA, 2013; Holtzman & Kulish, 2012). Some studies suggest that those with the disorder are typically immature in their dealings with the opposite sex and have difficulty in interpersonal relationships (Marshall et al., 2008; Murphy & Page, 2006). Around 30 percent of them are married and another 30 percent divorced or separated; their sexual relations with their wives are not usually satisfactory (Doctor & Neff, 2001). Many have doubts or fears about their masculinity, and some seem to have a strong bond to a possessive mother. As with other paraphilic disorders, treatment generally includes aversion therapy and masturbatory satiation, possibly combined with orgasmic reorientation, social skills training, or cognitive-behavioral therapy (Assumpção et al., 2014; Federoff & Marshall, 2010).

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A person with voyeuristic disorder experiences recurrent and intense sexual arousal from observing an unsuspecting individual who is naked, disrobing, or engaging in sexual activity. As with other paraphilic disorders, this arousal takes the form of fantasies, urges, or behaviors (APA, 2013). The disorder usually begins before the age of 15 and tends to persist (APA, 2013).

A person with voyeuristic disorder may masturbate during the act of observing or when thinking about it afterward but does not generally seek to have sex with the person being spied on. The vulnerability of the people being observed and the probability that they would feel humiliated if they knew they were under observation are often part of the enjoyment. In addition, the risk of being discovered adds to the excitement, as you can see in 25-year-old Sam’s description of his disorder during an interview:

Voyeurism, like exhibitionism, is often a source of sexual excitement in fantasy; it can also play a role in normal sexual interactions, but in such cases it is engaged in with the partner’s consent or understanding. The clinical disorder of voyeuristic disorder is marked by the repeated invasion of other people’s privacy. Some people with the disorder are unable to have normal sexual relations; others have a normal sex life apart from their disorder.

Many psychodynamic clinicians propose that people with voyeuristic disorder are seeking by their actions to gain power over others, possibly because they feel inadequate or are sexually or socially shy (Metzl, 2004). Behaviorists explain the disorder as a learned behavior that can be traced to a chance and secret observation of a sexually arousing scene (Lavin, 2008). If the onlookers observe such scenes on several occasions while masturbating, they may develop a voyeuristic pattern.

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A person with frotteuristic disorder experiences repeated and intense sexual arousal from touching or rubbing against a nonconsenting person. The arousal may, like with the other paraphilic disorders, take the form of fantasies, urges, or behaviors. Frottage (from French frotter, “to rub”) is usually committed in a crowded place, such as a subway or a busy sidewalk (Guterman, Martin, & Rudes, 2010). The person, almost always a male, may rub his genitals against the victim’s thighs or buttocks or fondle her genital area or breasts with his hands. Typically he fantasizes during the act that he is having a caring relationship with the victim. This paraphilia usually begins in the teenage years or earlier, often after the person observes others committing an act of frottage. After the age of about 25, people gradually decrease and often cease their acts of frottage (APA, 2000).

A person with pedophilic disorder experiences equal or greater sexual arousal from children than from physically mature people. This arousal is expressed through fantasies, urges, or behaviors (APA, 2013) (see PsychWatch below). Those with the disorder may be attracted to prepubescent children (classic type), early pubescent children (hebephilic type), or both (pedohebephilic type). Some people with pedophilic disorder are satisfied by child pornography or seemingly innocent material such as children’s underwear ads; others are driven to actually watch, touch, fondle, or engage in sexual intercourse with children (Babchishin, Hanson, & VanZuylen, 2014; Schmidt et al., 2014). Some people with the disorder are attracted only to children; others are attracted to adults as well (Schmidt, Mokros, & Banse, 2013; Roche & Quayle, 2007). Both boys and girls can be pedophilic victims, but there is evidence suggesting that two-thirds are girls (Seto, 2008; Koss & Heslet, 1992).

People with pedophilic disorder usually develop their pattern of sexual need during adolescence (Farkas, 2013). Some were themselves sexually abused as children (Nunes et al., 2013), and many were neglected, excessively punished, or deprived of genuinely close relationships during their childhood. It is not unusual for them to be married and to have sexual difficulties or other frustrations in life that lead them to seek an area in which they can be masters. Often these individuals are immature: their social and sexual skills may be underdeveloped, and thoughts of normal sexual relationships fill them with anxiety (Seto, 2008; McAnulty, 2006).

Some people with pedophilic disorder also have distorted thinking, such as, “It’s all right to have sex with children as long as they agree” (Roche & Quayle, 2007; Abel et al., 2001, 1984). It is not uncommon for pedophiles to blame the children for adult–child sexual contacts or to assert that the children benefited from the experience (Durkin & Hundersmarck, 2008; Lanning, 2001).

While many people with this disorder believe that their feelings are indeed wrong and abnormal, others consider adult sexual activity with children to be acceptable and normal. Some even have joined pedophile organizations that advocate abolishing the ageof-consent laws. The Internet has opened the channels of communication among such people, and there is now a wide range of Web sites, newsgroups, chat rooms, forums, and message boards centered on pedophilia and adult–child sex (Durkin & Hundersmarck, 2008).

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Studies have found that most men with pedophilic disorder also display at least one additional psychological disorder (Farkas, 2013; McAnulty, 2006). Some theorists have proposed that pedophilic disorder may be related to biochemical or brain structure abnormalities such as irregular patterns of activity in the amygdala or in the frontal areas of the brain, but such abnormalities have yet to receive consistent research support (Lucka & Dziemian, 2014; Wiebking & Northoff, 2013).

Most pedophilic offenders are imprisoned or forced into treatment if they are caught (Staller & Faller, 2010). After all, they are committing child sexual abuse when they take any steps toward sexual contact with a child (Farkas, 2013). There are now many residential registration and community notification laws across the United States that help law enforcement agencies and the public account for and control where convicted child sex offenders live and work (OJJDP, 2010).

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Treatments for pedophilic disorder include those already mentioned for other paraphilic disorders, such as aversion therapy, masturbatory satiation, orgasmic reorientation, cognitive-behavioral therapy, and antiandrogen drugs (Assumpção et al., 2014; Fromberger, Jordan, & Muller, 2013; Plaud, 2007). One widely applied cognitive-behavioral treatment for this disorder, relapse-prevention training, is modeled after the relapse-prevention training programs used in the treatment of substance use disorders (see pages 413–414). In this approach, clients identify the kinds of situations that typically trigger their pedophilic fantasies and actions (such as depressed mood or distorted thinking). They then learn strategies for avoiding those situations or coping with them more appropriately and effectively. Relapse-prevention training has sometimes, but not consistently, been of help in this and certain other paraphilic disorders (Federoff & Marshall, 2010; Marshall et al., 2008).

A person with sexual masochism disorder is repeatedly and intensely sexually aroused by the act of being humiliated, beaten, bound, or otherwise made to suffer (APA, 2013). Again, this arousal may take such forms as fantasies, urges, or behaviors. Many people have fantasies of being forced into sexual acts against their will, but only those who are very distressed or impaired by the fantasies receive this diagnosis. Some people with the disorder act on the masochistic urges by themselves, perhaps tying, sticking pins into, or even cutting themselves. Others have their sexual partners restrain, tie up, blindfold, spank, paddle, whip, beat, electrically shock, “pin and pierce,” or humiliate them (APA, 2013).

An industry of products and services has arisen to meet the desires of people with the paraphilia or the paraphilic disorder of sexual masochism. Here a 34-year-old woman describes her work as the operator of a sadomasochism (S/M) facility:

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In one form of sexual masochism disorder, hypoxyphilia, people strangle or smother themselves (or ask their partner to strangle them) in order to enhance their sexual pleasure. There have, in fact, been a disturbing number of clinical reports of autoerotic asphyxia, in which people, usually males and as young as 10 years old, may accidentally induce a fatal lack of oxygen by hanging, suffocating, or strangling themselves while masturbating (Hucker, 2011, 2008; Atanasijević et al., 2010). There is some debate as to whether the practice should be characterized as sexual masochism disorder, but it is at least sometimes accompanied by other acts of bondage.

Most masochistic sexual fantasies begin in childhood. However, the person does not act out the urges until later, usually by early adulthood. The pattern typically continues for many years. Some people practice more and more dangerous acts over time or during times of particular stress (Krueger, 2010; APA, 2000).

In many cases, sexual masochism disorder seems to have developed through the behavioral process of classical conditioning (Stekel, 2010; Akins, 2004). A classic case study tells of a teenage boy with a broken arm who was caressed and held close by an attractive nurse as the physician set his fracture, a procedure done in the past without anesthesia (Gebhard, 1965). The powerful combination of pain and sexual arousal the boy felt then may have been the cause of his later masochistic urges and acts.

A person with sexual sadism disorder, usually male, is repeatedly and intensely sexually aroused by the physical or psychological suffering of another individual (APA, 2013). This arousal may be expressed through fantasies, urges, or behaviors, including acts such as dominating, restraining, blindfolding, cutting, strangling, mutilating, or even killing the victim (Nitschke et al., 2013). The label is derived from the name of the famous Marquis de Sade (1740-1814), who tortured others in order to satisfy his sexual desires.

People who fantasize about sexual sadism typically imagine that they have total control over a sexual victim who is terrified by the sadistic act. Many carry out sadistic acts with a consenting partner, often a person with sexual masochism disorder. Some, however, act out their urges on nonconsenting victims (Mokros et al., 2014). A number of rapists and sexual murderers, for example, exhibit sexual sadism disorder (Knecht, 2014; Healey, Lussier, & Beauregard, 2013). In all cases, the real or fantasized victim’s suffering is the key to arousal (Seto et al., 2012).

Fantasies of sexual sadism, like those of sexual masochism, may first appear in childhood or adolescence (Stone, 2010). People who engage in sadistic acts begin to do so by early adulthood (APA, 2013). The pattern is long-term. Some people with the disorder engage in the same level of cruelty in their sadistic acts over time, but often their sadism becomes more and more severe over the years (Robertson & Knight, 2014; Mokros et al., 2011). Obviously, people with severe forms of the disorder may be highly dangerous to others.

Some behaviorists believe that classical conditioning is at work in sexual sadism disorder (Akins, 2004). While inflicting pain, perhaps unintentionally, on an animal or person, a teenager may feel intense emotions and sexual arousal. The association between inflicting pain and being aroused sexually sets the stage for a pattern of sexual sadism. Behaviorists also propose that the disorder may result from modeling, when adolescents observe others achieving sexual satisfaction by inflicting pain. The many Internet sex sites and sexual videos, magazines, and books in our society make such models readily available (Brophy, 2010; Seto, Maric, & Barbaree, 2001).

Both psychodynamic and cognitive theorists suggest that people with sexual sadism disorder inflict pain in order to achieve a sense of power or control, necessitated perhaps by underlying feelings of sexual inadequacy. The sense of power in turn increases their sexual arousal (Stekel, 2010; Rathbone, 2001). Alternatively, certain biological studies have found signs of possible brain and hormonal abnormalities in people with sexual sadism (Harenski et al., 2012; Jacobs, 2011; Bradford et al., 2008). None of these explanations, however, has been thoroughly investigated.

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The disorder has been treated by aversion therapy. The public’s view of and distaste for this procedure have been influenced by the novel and 1971 movie A Clockwork Orange, which depicts simultaneous presentations of violent images and drug-induced stomach spasms to a sadistic young man until he is conditioned to feel nausea at the sight of such images. It is not clear that aversion therapy is helpful in cases of sexual sadism disorder. However, relapse-prevention training, used in some criminal cases, may be of value (Federoff & Marshall, 2010; Bradford et al., 2008).