In this series, I dig a little deeper into the meaning of psychology-related terms. This week, we’ll look at paraphilic disorders.
Paraphilias involve atypical patterns of sexual arousal. Paraphilic disorders are a more extreme version of paraphilias, involving arousal patterns that are a) intense and persistent and b) cause significant distress or functional impairment or cause harm to nonconsenting others.
Types of paraphilic disorders
There are a variety of paraphilias, but the DSM-5 identifies these specific paraphilic disorders:
- pedophilic disorder (I’ve opted not to include this particular disorder in the scope of this post)
- voyeuristic disorder
- transvestic disorder
- exhibitionist disorder
- sexual masochism disorder
- sexual sadism disorder
- fetishistic disorder
- frotteuristic disorder
Individuals may have a combination of multiple paraphilic disorders.
In the DSM-5, the naming of these disorders was revised from the previous names in the DSM-IV to more clearly separate the paraphilias from the associated disorders. The American Psychiatric Association has explicitly stated that people who engage in consenting atypical sexual behaviour should not be inappropriately diagnosed with a disorder.
Most people who have voyeuristic interests don’t have voyeuristic disorder. It rises to the level of disorder when it involves repeated and intense arousal by secretly observing unsuspecting individuals (watching porn wouldn’t count towards this) as well as either acting out of urges with nonconsenting individuals or experiencing functional impairment. As an example of functional impairment, people may spend so much time searching for viewing opportunities that it interferes with work or other areas of functioning.
To be diagnosed, the condition must be present for at least 6 months, and the individual must be at least 18 years old. It’s estimated that as many as 12% of males and 4% of females have this condition, but most don’t seek out evaluation or treatment. The disorder tends to be chronic.
Most people who cross-dress don’t have transvestic disorder. This is a disorder of sexual arousal, not a question of what clothes people choose to wear. Arousal by items of clothing themselves is considered to be a form of fetishism, while transvestic disorder is arousal from wearing the clothing or fantasizing about doing so.
The disorder involves repeated and intense sexual arousal produced by cross-dressing, as well as clinically significant distress or impairment in functioning. The condition must be present for at least 6 months for a diagnosis.
Transvestic disorder occurs almost entirely in males. In the DSM-IV, the diagnosis was limited to heterosexual males, but this restriction was removed in the DSM-5. There may be a pattern of accumulating items that one feels aroused in, experiencing guilt and shame, and then purging these items.
Again, most people who are into exhibitionism don’t have an exhibitionist disorder. To be diagnosed with the disorder, there must be clinically significant distress or functional impairment, or else people have acted out their urges with a nonconsenting person. This may involve public masturbation.
This disorder is estimated to occur in about 2-4% of males, and it’s less common in females. There may be co-occurring antisocial personality disorder or conduct disorder.
Most people with the disorder don’t engage in physically aggressive sexual behaviours. Among those who offend criminally, recidivism rates are higher than other sex offenders, at 20-50%.
Sexual masochism disorders
Sexual masochism (being aroused by being humiliated or abused) is not a disorder; however, it can rise to the level of disorder when it causes clinically significant distress or impairment in functioning.
Sexual sadism disorder
Sexual sadism involves experiencing arousal from inflicting suffering on others. To be considered a disorder, it must involve either acting out urges on a nonconsenting person or clinically significant distress or impairment in functioning. The condition must be present for at least 6 months. It’s particularly problematic if it co-occurs with antisocial personality disorder.
The onset of sadistic activities tends to occur by early adulthood, and they often increase in severity over time.
Less than 10% of rapists are diagnosed with this disorder, but it’s much more common among people who have committed sexually-motivated homicides (37-75%).
Fetishes involve intense arousal by nonliving objects or specific nongenital body parts. The disorder involves clinically significant distress or impairment in functioning, and the fetishes don’t involve genital vibrators or clothing used in cross-dressing.
Frotteuristic disorder involves at least six months of recurrent and intense arousal involving touching or rubbing against a nonconsenting person, with either acting out on those urges or clinically significant distress or functional impairment. The acts typically take place in crowded environments, and they’re most commonly performed by those between the ages of 15 and 25.
According to Medscape, as many as 30% of men may experience frotteuristic disorder. That initially struck me as very high, but given how many allegations keep coming up of sexual misconduct, maybe that is accurate.
How/why they occur
These patterns are typically established by the time an individual reaches puberty (although in exhibitionist disorder, the onset is usually during adolescence). In general, paraphilias are more common in men, although it’s not clear why this is.
Their development may be influenced by trauma that impacts normal development or exposure to highly charged sexual experiences. Childhood sexual abuse is thought to be a key contributor.
Symbolism and accidental conditioning may also play a role. Abnormalities in brain functioning may be involved in the development of these disorders, but that remains unclear.
Sexologist Kurt Freund suggested that paraphilic disorders could arise from distortion of the courtship phases of search, pretactile interaction, tactile interaction, and genital union (i.e. sex).
Unsurprisingly, there are plenty of ideas on paraphilias from the field of psychoanalysis. For example, exhibitionists are thought to view their mothers as rejecting them based on their different genitalia. For an adult man, displaying his penis would be a way to prove his manhood to adult women and force them to accept him. In the case of fetishistic disorders, the fetish is seen as serving a defensive function as an adjunct to a penis whose potency is otherwise uncertain.
Paraphilic disorders are commonly comorbid with other conditions, including personality disorders, substance use disorders, anxiety disorders, or mood disorders. People with personality disorders involving low self-esteem or problems with anger management or delayed gratification are particularly vulnerable.
The majority of people with paraphilic disorders don’t seek out treatment voluntarily. No treatments for the actual paraphilias themselves have been identified, and interventions are aimed at managing behaviours.
Psychotherapy (particularly cognitive behaviour therapy) and support groups may be helpful. In the case of fetishistic disorder, treatment tends to be more effective when the focus is on underlying dynamics rather than the fetish itself.
Orgasmic reconditioning is a behavioural approach that involves masturbation beginning with the individual’s usual fantasies, and then switching to a more acceptable fantasy just before orgasm. This is repeated with the aim to substitute fantasies progressively earlier before orgasm.
SSRI antidepressants may have some benefit in some cases of voyeuristic disorder and exhibitionist disorder. Transvestic disorder doesn’t tend to respond to medications, but SSRIs may be helpful if there’s an OCD element present. Mood stabilizers may have some benefit in terms of impulse control in paraphilic disorders.
Antiandrogen drugs, like gonadotropin-releasing hormone analogues or medroxyprogesterone acetate, may be used to reduce testosterone levels. These drugs may be able to reduce behaviours that are likely to lead to arrest.
Sexual sadism disorder is generally not responsive to treatment.
I like that the DSM-5 makes a distinction between paraphilias and paraphilic disorders. Even if they do exist on a continuum, it makes sense to me to at least try to avoid unnecessarily pathologizing people and factor in actions directed at nonconsenting individuals. Then again, perhaps using behaviour that would be considered criminal as a deciding factor diagnostically is a bit weird.
What are your thoughts on this group of disorders?
- American Psychiatric Association: Paraphilic Disorders
- Medscape: Paraphilic Disorders
- Merck Manual Professional Version:
- StatPearls: Paraphilia
The Psychology Corner has an overview of terms covered in the What Is… series, along with a collection of scientifically validated psychological tests.
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