| Paraphilia | |
|---|---|
| Classification and external resources | |
| MeSH | D010262 |
Paraphilia (in Greek para παρά = beside and -philia φιλία = friendship, having the meaning of love) is a biomedical term used to describe sexual arousal to objects, situations, or individuals that are not part of normative stimulation and that may cause distress or serious problems for the paraphiliac or persons associated with him or her. A paraphilia is a condition involving sex fetishes where a person's sexual arousal and gratification depend on fantasizing about, and engaging in, sexual behavior that is atypical and extreme. [1] The term was coined by Wilhelm Stekel in the 1920s.[2] Controversial sexologist John Money later popularized the term as a nonpejorative designation for unusual sexual interests.[3][4][5][6] He described paraphilia as "a sexuoerotic embellishment of, or alternative to the official, ideological norm."[7]
Psychologists and psychiatrists codified paraphilias as disorders, as a replacement for the legal constructs of sodomy[8] and perversion.[9] American Journal of Psychiatry[10] describes paraphilia as "recurrent, intense sexually arousing fantasies, sexual urges, or behaviors generally involving:
Sexual arousal in association with objects that were designed for sexual purposes is not DSM diagnosable (DSM, p. 570).[11]
The view of paraphilias as disorders is not universal. Some groups seeking greater understanding and acceptance of sexual diversity have lobbied for changes to the legal and medical status of unusual sexual interests and practices. Charles Allen Moser, a physician and advocate for sexual minorities, has argued that the diagnoses should be eliminated from diagnostic manuals.[12] Psychiatrist Glen Gabbard writes that despite efforts by Stekel and Money, "the term paraphilia remains pejorative in most circumstances." [13]
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Paraphilial psychopathology is not the same as psychologically normative adult human sexual behaviors, sexual fantasy, and sex play. These terms have been used in interchangeable ways which can allow for cognitive and clinical diagnostic misjudgment to occur. Consensual adult activities and adult entertainment that may involve some aspects of sexual roleplay, novel, superficial, or trivial aspects of sexual fetishism, or may incorporate the use of sex toys are not necessarily paraphilic.[11]
It is not known how many different kinds of paraphilias exist; one source lists as many as 547 paraphilias.[14] Because so many paraphilias exist, one needs to classify them in an orderly and meaningful way. It has long been argued that the Diagnostic and Statistical Manual of Mental Disorders (DSM) system of classification makes unjustified categorical distinctions between disorders, and between normal and abnormal. Although the DSM-V may move away from this categorical approach in some limited areas, some argue that a fully dimensional, spectrum or complaint-oriented approach would better reflect the evidence.[15][16][17][18]
There is scientific and political controversy regarding the continued inclusion of sex-related diagnoses such as the paraphilias in the DSM.[19][20]
Homosexuality was at one time categorized as a form of paraphilia.[21] Martin Kafka writes, "Sexual disorders once considered paraphilias (e.g., homosexuality) are now regarded as variants of normal sexuality."[22] Researcher Anil Aggrawal writes that the 1952 first edition of the Diagnostic and Statistical Manual of Mental Disorders considered it "deviant sexuality" and specified "the type of the pathological behavior, such as homosexuality, transvestism, pedophilia, fetishism, and sexual sadism, including rape, sexual assault, mutilation)."[23] Originally coded as 000-x63, homosexuality was the top of the classification list (Code 302.0) until it was removed in 1973.
Albert Eulenburg (1914) noted a commonality across the paraphilias, using the terminology of his time, "All the forms of sexual perversion...have one thing in common: their roots reach down into the matrix of natural and normal sex life; there they are somehow closely connected with the feelings and expressions of our physiological erotism. They are...hyperbolic intensifications, distortions, monstrous fruits of certain partial and secondary expressions of this erotism which is considered 'normal' or at least within the limits of healthy sex feeling."[24]
The clinical literature contains reports of many paraphilias, only some of which receive their own entries in the diagnostic taxonomies of the American Psychiatric Association or the World Health Organization.[25][26] There is disagreement regarding which sexual interests should be deemed paraphilic disorders versus normal variants of sexual interest. For example, as of May 2000, per DSM-IV-TR, "Because some cases of Sexual Sadism may not involve harm to a victim (e.g., inflicting humiliation on a consenting partner), the wording for sexual sadism involves a hybrid of the DSM-III-R and DSM-IV wording (i.e., “the person has acted on these urges with a non-consenting person, or the urges, sexual fantasies, or behaviors cause marked distress or interpersonal difficulty”)".[27]
Paraphilias are defined by DSM-IV-TR as sexual disorders characterized by "recurrent, intense sexually arousing fantasies, sexual urges or behaviors generally involving (1) nonhuman objects, (2) the suffering or humiliation of oneself or one's partner, or (3) children or other nonconsenting persons that occur over a period of 6 months" (Criterion A), which "cause clinically significant distress or impairment in social, occupational, or other important areas of functioning" (Criterion B). DSM-IV-TR describes 8 specific disorders of this type (exhibitionism, fetishism, frotteurism, pedophilia, sexual masochism, sexual sadism, voyeurism, and transvestic fetishism) along with a ninth residual category, paraphilia not otherwise specified (NOS).[28] Criterion B differs for exhibitionism, frotteurism, and pedophilia to include acting on these urges, and for sadism, acting on these urges with a nonconsenting person.[11]
Some paraphilias may interfere with the capacity for sexual activity with consenting adult partners.[11] According to the DSM, "Paraphilias are almost never diagnosed in females,"[11] but some case studies of females with paraphilias have been published.[29]
The DSM provides clinical criteria for these paraphilias:
Under Paraphilia NOS, the DSM mentions telephone scatalogia (obscene phone calls), necrophilia (corpses), partialism (exclusive focus on one part of the body), zoophilia (animals), coprophilia (feces), klismaphilia (enemas), urophilia (urine), emetophilia (vomit). The DSM's Paraphilia NOS is equivalent to the ICD-9's Sexual Disorder NOS.
The literature includes single-case studies of exceedingly rare and idiosyncratic paraphilias. These include an adolescent male who had a strong fetishistic interest in the exhaust pipes of cars, a young man with a similar interest in a specific type of car, and a man who had a paraphilic interest in sneezing (both his own and the sneezing of others).[37][38] See also List of paraphilias.
Clinicians distinguish between optional, preferred and exclusive paraphilias,[11] though the terminology is not completely standardized. An "optional" paraphilia is an alternative route to sexual arousal. For example, a man with otherwise unremarkable sexual interests might sometimes seek or enhance sexual arousal by wearing women's underwear. In preferred paraphilias, a person prefers the paraphilia to conventional sexual activities, but also engages in conventional sexual activities. For example, a man might prefer to wear women's underwear during sexual activity, whenever possible. In exclusive paraphilias, a person is unable to become sexually aroused in the absence of the paraphilia.
The treatment of paraphilias and related disorders has been challenging for patients and clinicians. In the past, surgical castration was advocated as a therapy for men with pedophilia, but has been abandoned for the time being because most governments consider it a cruel punishment where the express willingness and consent of the patient is not objectively indicated. Psychotherapy, self-help groups, and pharmacotherapy (including anti-androgen hormone therapy sometimes referred to as "chemical castration") have all been used. Other drug treatments for these disorders do exist, however.[39]
Antiandrogenic drugs such as medroxyprogesterone (also known as the long-acting contraceptive Depo Provera) have been widely used as therapy in these men to reduce sex drive. However, their efficacy is limited and they have many side effects, including breast growth, headaches, weight gain, and reduction in bone density. Even if compliance is good, only 60 to 80 percent of men benefit from this type of drug. Long-acting gonadotropin-releasing hormones, such as Triptorelin (Trelstar) which reduces the release of gonadotropin hormones, are also used. This drug is a synthetic hormone which may also lead to reduced sex drive.[39]
Psychostimulants have been used recently to augment the effects of serotonergic drugs in paraphiliacs. In theory, the prescription of a psychostimulant without pretreatment with an SSRI might further disinhibit sexual behavior, but when taken together, the psychostimulant may actually reduce impulsive tendencies. Methylphenidate (Ritalin) is an amphetamine-like stimulant used primarily to manage the symptoms of attention deficit hyperactivity disorder (ADHD). Recent studies imply that methylphenidate may also act on serotonergic systems; this may be important in explaining the paradoxical calming effect of stimulants on ADHD patients. Amphetamine is also used medically as an adjunct to antidepressants in refractory cases of depression.[39]
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