11.2 Paraphilic Disorders

Mike found that he was disturbed about Sam’s transformation into Samantha in part because it reminded Mike of his very private pastime during his teenage years: He had secretly “borrowed” some of his older sister’s clothes from her room, dressed up in them, and admired himself in front of the mirror. He’d found this extremely erotic but also terrifying. He had worried that he’d get caught and felt that it somehow wasn’t “right.” Throughout his adulthood, Mike had struggled to overcome his urge to dress in women’s clothes, usually successfully. During most of his marriage to Laura, he’d managed to keep this urge at bay, and he’d never told her about it. However, once he heard about Sam, he felt jealous because Samantha dressed as a woman. His urge to dress in women’s clothes became stronger, which affected his relationship with Laura: He thought it best to avoid sexual relations with her until he felt more in control of himself.

Mike had felt alone in his worries and concerns until he discovered online chat rooms in which people discussed cross-dressing. Now he’s spending a lot of time “chatting” with other men who like to cross-dress; he bought some women’s clothes (which he keeps hidden) and puts them on and masturbates when Laura is out. What’s going on with Mike? To find out, we need to consider another category of sexual disorders, called paraphilic disorders.

What Are Paraphilic Disorders?

Some people have unusual sexual interests—paraphilias. Specifically, they are sexually aroused and have fantasies about objects or activities that are not normally associated with sexual interests, such as women’s shoes or spying on other people when they take off their clothes. A paraphilia (from the Greek para-, meaning “beside” or “beyond,” and philos, meaning “fondness” or “love”) is an intense and persistent sexual interest that is different than the usual fondling or genital stimulation with “normal physically mature consenting human partners” (American Psychiatric Association, 2013.

Although paraphilias may be unusual, they are not necessarily considered to be mental disorders. In contrast, according to DSM-5, paraphilic disorders are paraphilias that lead to distress, impaired functioning, or harm—or risk of harm—to the person or to others. According to DSM-5, the sexual aspect of a paraphilic disorder is characterized by unusual preferences either in (1) sexual activity (such as activities involving pain and suffering or an odd variation of what might be considered “courtship”—such as exhibitionistic behavior) or (2) the target of the activity (such as children or objects).

This way of classifying paraphilic disorders misses an important element that some of these disorders share—that they involve partners who do not consent to the activity. Other paraphilic disorders have pain and humiliation as the primary activity. Thus, in this section, we classify paraphilic disorders according to whether they involve:

• nonconsenting adults or children,
• nonhuman objects (such as women’s shoes) or body parts, or
• suffering or humiliating oneself or one’s partner; the diagnosis of a paraphilic disorder would apply only when such experiences are not part of sexual role-playing.

These fantasies, urges, or behaviors together form a predictable pattern of arousal that is consistent for the person. In addition, the diagnostic criteria for all paraphilic disorders require that the pattern of arousal (sometimes referred to as an arousal pattern) has been present for at least 6 months (American Psychiatric Association, 2013). However, the arousal pattern doesn’t necessarily affect all areas of functioning; people with a paraphilic disorder may not be impaired at work or even necessarily in their family life.

Because DSM-5 uses a categorical approach, it must draw a line to separate “-normal” from “abnormal.” For some paraphilic disorders, DSM-5 draws the line at the point where the sexual arousal pattern causes significant distress or impairs functioning. Someone who becomes aroused in response to violent pornography or in response to particular items of clothing, for instance, would not be diagnosed as having a paraphilic disorder unless this arousal pattern caused significant distress, impaired functioning, or led to harm or a risk of harm. Thus, having a paraphilia is necessary, but not sufficient, to be diagnosed as having a paraphilic disorder. For instance, someone might have exhibitionism but not exhibitionistic disorder.

The specific arousal patterns of the types of paraphilic disorders are listed in TABLE 11.4, along with their DSM-5 diagnostic criteria. Paraphilias and paraphilic disorders are almost exclusively diagnosed in men; the only paraphilic disorder observed in a significant percentage of women is sexual sadism disorder. Because the vast majority of people who have the other paraphilic disorders are men, in this section we use the masculine pronouns (e.g., him) when discussing patients with these disorders. (In the section on understanding paraphilic disorders, we will examine possible reasons for this gender difference.)

Mental health researchers believe that, based on the number of websites and online chat rooms, the prevalence of paraphilic disorders is higher than had been previously thought, but the actual prevalence is unknown. Most research on paraphilic disorders has been conducted with men whose disorders involve nonconsenting people (such as child molesters, rapists, and exhibitionists) and who have come to the attention of mental health clinicians and researchers through the criminal justice system or at the urging of family members. We examine that type of paraphilic disorder first and then consider other types of paraphilic disorders.

The common feature of the paraphilic disorders discussed in this section is that the person with the disorder has recurrent sexual fantasies, urges, or behaviors that involve nonconsenting people of any age. Specifically, if the patient has recurrent fantasies or urges that involve a nonconsenting person but does not act on them, a diagnosis of the paraphilic disorder is given only if the fantasies and urges cause significant distress or impair functioning in some area of life (such as leading to difficulties in relationships). In contrast, if the man did act on those recurrent fantasies and urges with a nonconsenting person, the diagnosis would be made, even if the patient did not experience distress or impaired functioning. For instance, someone who “flashes” others, who molests children, or who sadistically sexually assaults victims would be diagnosed with a paraphilic disorder if the duration criterion—at least 6 months—for the behavior were met.

Thus, men who engage in criminal sexual behaviors could qualify for the diagnosis of a paraphilic disorder, which creates confusion about what constitutes criminal behavior versus mental illness. However, some psychiatrists point out that paraphilic disorders should not be diagnosed solely on the basis of sexual behaviors because doing so “blurs the distinction between mental disorder and ordinary criminality” (First & Frances, 2008. In short, some people with this diagnosis might commit crimes, but not all people with this diagnosis do so.

Exhibitionistic Disorder: Physically Exposing Oneself

The paraphilic disorder exhibitionistic disorder is characterized by sexual fantasies, urges, or behaviors that involve a person’s exposing his genitals to an unsuspecting person (see TABLE 11.4). To be considered a disorder, the man must either experience distress or impaired functioning as a result of the fantasies and urges—or must have actually exposed himself to someone who was not a willing observer. People who expose themselves for money (such as nude dancers or artists’ models) are not considered exhibitionists because they do so for compensation, not for sexual arousal (McAnulty et al., 2001).

A man with exhibitionistic disorder typically gets an erection and may masturbate while exposing himself. Men with this disorder commonly report that they don’t intend to frighten or shock strangers but hope that strangers will enjoy or be aroused by seeing their genitals (Lang et al., 1987; Langevin et al., 1979). Men with exhibitionistic disorder may rehearse beforehand; they may achieve orgasm during the exhibitionistic episode or later, when they think about it. One study found that, over the course of his life, the typical man with this disorder had “flashed” 514 people (Abel et al., 1987). (However, some very active men skew the average; the median number of people flashed is 34.) Between 2 and 4% of males are thought to have this disorder (American Psychiatric Association, 2013).

Voyeuristic Disorder: Watching Others

Voyeuristic disorder is a paraphilic disorder characterized by sexual fantasies, urges, or behaviors that involves observing someone who is in the process of undressing, is nude, or is engaged in sexual activity. The person being watched has neither consented to nor is aware of being observed (see TABLE 11.4). As with exhibitionistic disorder, for voyeuristic disorder to be classified as a disorder, the person’s urges and fantasies must cause distress or impair functioning, or the person must have acted on those fantasies and urges.

A voyeur rarely has physical contact with the observed person. Moreover, voyeuristic disorder is distinguished from looking at pornography or watching nude dancing; voyeuristic disorder involves observing someone who does not know that he or she is being observed. A man with this disorder might use binoculars to “spy” on a woman, masturbating while observing her through her window as she undresses, or might plant hidden cameras and watch the video later or via an Internet feed. According to DSM-5, this disorder can only be diagnosed in people who are 18 years old or older, in order not to pathologize what is viewed as a “normal” sexual curiosity during puberty and adolescence.

Frotteuristic Disorder: Touching a Stranger

Frotteuristic disorder (from the French frotter, “to rub”) is characterized by recurrent, intense, sexually arousing fantasies, sexual urges, or behaviors that involve touching or rubbing against a nonconsenting person (see TABLE 11.4). As with exhibitionistic disorder and voyeuristic disorder, the urges and fantasies must cause distress or problems in relationships, or the man must have acted on those fantasies and urges. This diagnosis has two types: men who like to rub and men who like to touch (“touchers”). On crowded public transportation, men with frotteuristic disorder try to stand or sit next to attractive females and rub their genitals against the victims’ buttocks, thighs, or crotch, often while fantasizing that they are having consensual sex, as Charles, in Case 11.2, did. When discovered, men with frotteuristic disorder typically flee from the train or bus.

Pedophilic Disorder: Sexually Abusing Children

Child sexual abuse is a crime, but the DSM-5 diagnosis for those who fantasize about, have urges, or actually engage in sexual activity with a child (typically one who has not yet gone through puberty) is pedophilic disorder (previously called pedophilia) (see TABLE 11.4). To be diagnosed with this disorder, the person must be at least 16 years old and at least 5 years older than the child. Thus, someone is diagnosed with pedophilic disorder if he has had sexual activity with a child (and so would also be considered a child molester) or if he has related sexual fantasies or impulses that cause distress or significantly impair his relationships. Someone with pedophilic disorder may or may not sexually molest children; a child molester may or may not be diagnosed with pedophilic disorder, if his related fantasies, urges, or behaviors have occurred for less than 6 months (Camilleri & Quinsey, 2008).

People who have this disorder may engage in sexual behaviors that range from fondling to oral–genital contact to penetration. Approximately 25% of victims (who are more likely to be girls than boys; McAnulty et al., 2001) are under 6 years of age, 25% are between 6 and 10 years old, and 50% are between 11 and 13 (Erickson et al., 1988). People with pedophilic disorder often say that they believe that adult sexual contact with children has positive effects for the child. In fact, some child molesters with pedophilic disorder report that they didn’t think they were harming the children they molested but were “sharing pleasure” (Spitzer et al., 2002). Compared to rapists, people with pedophilic disorder who have molested children view themselves as less responsible for the abuse and view the child as more responsible (Stermac & Segal, 1989)—claiming that the child “seduced” them. Studies suggest that men with pedophilic disorder who are sex offenders are likely to have at least one other paraphilic disorder (Heil & Simons, 2008; Raymond et al., 1999).

Sexual sadism disorder and sexual masochism disorder are two complementary sides of a mode of sexual interaction in which actual pain, suffering, or humiliation creates or enhances sexual excitement. People who do not experience significant distress or impaired functioning because of their sadistic or masochistic sexual fantasies, urges, and behavior and whose sexual partners are consenting adults would not be diagnosed with either of these disorders. That is, consensual, non-impairing, and nondistressing BDSM (bondage and discipline, dominance and submission, sadism and masochism) fantasies, urges, or behaviors would not be considered to be a paraphilic disorder (Shindel & Moser, 2011). In what follows we examine the DSM-5 criteria for these two disorders.

Sexual Sadism Disorder: Inflicting Pain

A person who becomes sexually aroused by fantasies, urges, and behaviors that inflict physical or psychological suffering on a nonconsenting person is said to have sexual sadism disorder (see TABLE 11.4). Note that sexual sadism disorder involves acts that actually do, or actually could (in the case of urges and fantasies) cause someone else to suffer (versus simulated acts, where no real suffering occurs). There are two sets of circumstances in which someone would be diagnosed with sexual sadism disorder: (1) The recurrent sadistic fantasies or urges cause the person significant distress, as occurs when a man is horrified to discover that he is consistently aroused when fantasizing about hurting his partner; or (2) the person has repeatedly subjected a nonconsenting partner to sexually sadistic acts, as occurs with sadistic rape, which is also a criminal act.

Any type of rape is a criminal act, and sadistic rape is also a type of sexual sadism disorder defined in DSM-5. What distinguishes sadistic rape from other forms of rape is that in the former, the offender becomes sexually aroused by gratuitous violence or the victim’s suffering or humiliation (Heil & Simons, 2008). In contrast, nonsadistic rape occurs when the rapist uses force in order to get his victim to “comply” but not because such force is a critical element of his sexual arousal pattern (Yates et al., 2008).

For people diagnosed with sexual sadism disorder, the sadistic sexual fantasies often were present in childhood, and the sadistic behavior commonly began in early adulthood—as occurred with the man in Case 11.3. Sexual sadism disorder is usually chronic, and the severity of the sadistic behaviors increases over time (American Psychiatric Association, 2013).

Sexual Masochism Disorder: Receiving Pain

Whereas sexual sadism disorder involves hurting others, sexual masochism disorder is characterized by recurrent sexual arousal in response to fantasies, urges, or behaviors related to being hurt oneself—specifically, being humiliated or made to suffer in other ways (see TABLE 11.4; American Psychiatric Association, 2013). For a diagnosis of sexual masochism disorder, the sexual fantasies, urges, and behavior must cause significant distress or impair functioning.

Sexual masochism disorder is diagnosed in both men and women and is, in fact, the only paraphilic disorder that occurs at measurable rates among women (Levitt et al., 1994). One study found that about one quarter of women who engage in sexually masochistic behavior reported a history of sexual abuse during childhood, which may suggest that the abuse made them more likely to be aroused by masochistic acts (Nordling et al., 2000). However, these women did not necessarily have sexual masochism disorder because they did not report that their sexual preferences caused distress or impaired functioning.

Two paraphilic disorders—fetishistic disorder and transvestic disorder—are characterized by persistent sexual fantasies, urges, and behaviors that focus on nonhuman animals or objects, such as clothing, which lead to significant distress or impair functioning.

Fetishistic Disorder: Sexually Arousing Objects

Fetishistic disorder is the paraphilic disorder characterized by the repeated use of nonliving objects (such as women’s shoes or undergarments) or nongenital body parts (such as feet) in sexual fantasies, urges, or behaviors, which in turn leads to distress or impaired functioning (see TABLE 11.4). The object or body part—termed a fetish—may be used to achieve sexual arousal or to maintain an erection with a partner or alone. For instance, a man with a shoe fetish will become aroused by seeing or smelling women’s footwear. He may steal women’s shoes and use them to masturbate (Shiah et al., 2006). When fetishistic disorder is severe, he may be unable to have sexual relations with a partner unless the fetish is part of the sexual experience. People with fetishistic disorder generally come to the attention of mental health professionals only after being apprehended for the theft of their fetish. As usual, in the absence of distress or impaired functioning, a diagnosis of a disorder should not be made. The man in Case 11.4 gets sexually excited about women’s underwear.

Transvestic Disorder: Cross-Dressing for Sexual Arousal

Transvestic disorder is the diagnosis given to people (almost always men) who experience sexual arousal when they dress in clothes appropriate for people opposite to the person’s assigned gender, and experience distress or impaired functioning because of it (TABLE 11.4), as Mike did. (Note that this is in contrast to people with gender dysphoria, who cross-dress not for sexual arousal but to make their outward appearance more congruent with their internal experience; see TABLE 11.5.) Moreover, men with transvestic disorder use female clothing differently than those with a nontransvestic fetish that involves female apparel, such as an underwear fetish. Men with a nontransvestic fetish may wear female clothes to achieve sexual arousal, but only if the clothes were previously worn by a woman; they do not try to appear female, as did Jenny Boylan, in Case 11.1. In contrast, men with transvestic disorder prefer to wear new female clothes and try to appear as female, as Mike did.

Transvestic disorder usually begins before age 10 and may involve only one or two items of clothing, or may involve dressing entirely as the other sex, including wearing wigs and cross-gender outer clothes (such as coats). Some men who experience distress may periodically throw away their women’s clothes in the hopes that their urges and fantasies will subside.

As adults, the cross-dressing typically is not limited to the privacy of the home: Almost three quarters of men with this disorder who were surveyed reported that they had appeared in public while dressed as women. Almost two thirds are married, often with children; you may assume that they hide their fetish from their wives, but as with Mr. A. in Case 11.5, the wives often know about the cross-dressing. Most wives are ambivalent about it, and fewer than one third accept it (Docter & Prince, 1997).

Assessing Paraphilic Disorders

The paraphilic disorders are usually assessed by examining the now-familiar three types of factors: neurological (sometimes reflected by bodily responses), psychological, and social.

From a neurological perspective, sexual arousal in men can be measured by a penile plethysmograph, which is an indirect measure of neurological events. The device is placed on a man’s penis and measures penile rigidity. The man is then shown “normal” and “deviant” stimuli (such as photos of footwear or whips), and the rigidity of the penis is measured after each stimulus is presented. If the plethysmograph registers unusual amounts of arousal when the man views deviant stimuli, compared to stimuli that induce arousal in men without a paraphilia, this response suggests that he has a paraphilia or paraphilic disorder.

From a psychological perspective, self-reports of arousal are used to assess paraphilic disorders: Men describe what they find sexually arousing, either to a mental health clinician or in response to a questionnaire.

Finally, from a social perspective, assessment of paraphilic disorders may rely on reports from partners or the criminal justice system, after men are apprehended for engaging in illegal sexual activity such as secretly observing nonconsenting people as they disrobe or having inappropriate sexual relations with children (McAnulty et al., 2001).

Criticisms of the DSM-5 Paraphilic Disorders

Critics of the set of paraphilic disorders identified in DSM-5 point out that what counts as “deviant” (or, the flip-side, “normal”) has changed over time. The paraphilic disorders are, in essence, behaviors and fantasies that Western culture currently labels as deviant—and such deviance is relative to the current cultural concept of “normal” sexual behavior or fantasies (Moser & Kleinplatz, 2005). Normal sexual behavior typically has been defined by the church, the government, or the medical community (McAnulty et al., 2001; Moser, 2001). In addition, widely different types of attraction are grouped together (e.g., pedophilic disorder and fetishistic disorder), creating an overly broad category.

Understanding Paraphilic Disorders

Researchers are only just beginning to learn why paraphilic disorders emerge and persist, and not enough is known to understand how feedback loops might arise among neurological, psychological, and social factors.

Many theorists who have considered the neurological underpinnings of paraphilic disorders have noted the apparent similarities between these disorders and OCD, both of which involve obsessions and compulsions. As discussed in Chapter 7, OCD appears to result from abnormal functioning in a neural system that includes the basal ganglia (which play a central role in producing automatic, repetitive behaviors) and the frontal lobes (which normally inhibit such behaviors). In fact, researchers found that people with pedophilic disorder have very specific cognitive deficits when performing tasks that rely on this neural system (Tost et al., 2004). For example, these patients were strikingly impaired in inhibiting responses and in working memory—both of which rely heavily on the frontal lobes (Smith & Kosslyn, 2006).

In addition, evidence suggests that the neurotransmitters that are used in this neural system, such as dopamine and serotonin, do not function properly in people who have paraphilic disorders (Kafka, 2003). Indeed, SSRIs decrease the sexual fantasies and behaviors related to paraphilic disorders, which is consistent with the view that neural interactions involved in OCD are also involved in the paraphilic disorders (Bradford, 2001; Kafka & Hennen, 2000; Roesler & Witztum, 2000).

Both psychodynamic and cognitive-behavioral theories have been invoked to explain paraphilias in general and paraphilic disorders in particular, but research to date does not generally support either type of explanation (Osborne & Wise, 2005). However, behavioral theory can answer one intriguing question about paraphilias: Why are almost all people with paraphilias male? An answer may lie in principles of classical conditioning, which can contribute to paraphilias in part because of the nature of the male body: The position of the penis and testicles on the body can easily lead to their being inadvertently stimulated (Munroe & Gauvain, 2001). This is important because classical conditioning can occur if the genitals are stimulated right after or at the same time as seeing or feeling an object (Domjan et al., 2004; Köksal et al., 2004). Consider this example: A fetish for objects such as women’s shoes can develop when an unconditioned stimulus that led to sexual arousal became paired with a conditioned stimulus (women’s shoes). Thus, a boy who coincidentally saw his mother’s shoes before—intentionally or accidentally—touching his penis may come to have a conditioned response of sexual arousal to women’s shoes in the future. In fact, humans—or at least human males—may be biologically prepared to develop classically conditioned sexual arousal to some situations or objects (Osborne & Wise, 2005), which would explain why a pillow fetish is not common.

Classical conditioning may be amplified by the Zeigarnik effect (Deutsch, 1968), which makes people more likely both to recall interrupted activities than ones that they finished and to try to complete interrupted activities when later allowed to do so. Applied to paraphilias and paraphilic disorders, sexual arousal that has been associated with an object or situation may be such an interrupted activity: Sexual arousal at a young age that isn’t allowed expression becomes “interrupted”; the person is later driven to “complete” the interrupted activity (Munroe & Gauvain, 2001).

The Zeigarnik effect can also help explain why fewer males in traditional, nonindustrialized societies have paraphilias than do males in Western societies: Western societies provide many erotic stimuli—in magazines, in movies, on billboards and television—to which males can become aroused. In turn, males, particularly boys, are thus more likely to be “interrupted,” leading to a desire to complete the task (Munroe & Gauvain, 2001).

Treating Paraphilic Disorders

Only some people who have paraphilic disorders receive treatment—typically those who were caught engaging in predatory paraphilic behavior with nonconsenting people and so were brought into the criminal justice system (where they were classified as sex offenders). The goal of treatment, which may be ordered by a judge, is to decrease paraphilic impulses and behaviors by targeting neurological, psychological, and social factors; research on treatments for paraphilic disorders is not yet advanced enough to indicate how feedback loops arise as a result of treatment.

One goal of treatment for men who have engaged in predatory paraphilic behaviors with nonconsenting people is to decrease or eliminate their sex drive. Chemical castration refers to the use of medications to achieve this goal. Such medications include antiandrogen drugs such as medroxyprogesterone acetate (Depo-Provera) and cyprotereone acetate (Androcur), which decrease testosterone levels. Decreased testosterone levels lead to decreased sexual urges, fantasies, and behaviors in sex offenders (Bradford, 2000; Gijs & Gooren, 1996; Robinson & Valcour, 1995). However, these medications don’t necessarily diminish men’s paraphilic interests along with their sex drive. Moreover, within a few weeks of stopping the medication, the men again experience the urges and may engage in the predatory behaviors (Bradford, 2000; Gijs & Gooren, 1996).

In addition, as noted earlier, SSRIs may help decrease the sexual fantasies, urges, and behaviors in men whose paraphilic disorder has obsessive-compulsive elements. Thus, a treatment that targets neurological factors can affect thoughts (fantasies), which are psychological factors.

CBT may be used to treat paraphilic disorders in several ways. For one, it can decrease cognitive distortions that promote paraphilic fantasies, urges, and behaviors. For example, such distortions might include the belief that sexual actions directed toward nonconsenting people are not harmful. In addition, behavioral methods, such as extinction, may decrease sexual arousal to paraphilic stimuli while increasing arousal to normal stimuli (Akins, 2004). Treatment for sex offenders may involve both medication and CBT (Heilbrun et al., 1998); both types of interventions, when effective, ultimately reduce problematic arousal patterns, sexual fantasies and urges, and sexual behaviors toward nonconsenting people.

In addition, treatment may sometimes include relapse prevention training, which teaches men to identify and recognize high-risk situations and learn strategies to avoid them. Such training also involves learning new coping skills, such as anger management or assertiveness (Pithers, 1990). However, such treatments tend not to reduce subsequent offenses among those sex offenders who are also psychopaths—people who lack empathy, show little remorse or guilt about hurting others, and shirk responsibility for their actions (Barbaree, 2005; Langton et al., 2006).

Some treatments for sex offenders target social factors, for example, by training these men to empathize with victims in the hopes that they will be less likely to re-offend in the future (Marshall et al., 1996). However, many offenders do not complete psychosocial treatments (Hanson et al., 2004; Langevin, 2006). Furthermore, such treatments typically are not very successful (Hanson et al., 2004).