Paraphilias (socially prohibited sexual practices)

Reliable data on the rates of the several recognized paraphilias are unavailable because individuals with a paraphilia are understandably secretive about their practices. For the same reason, they seldom seek help from clinicians; instead, they may be referred, often against their will, through legal action. 

Most forms of paraphilia have received a great deal of media attention, and therefore are familiar to most people. Because of this familiarity and the rarity with which people with paraphilias seek and receive treatment, we will keep the coverage of paraphilias very brief, without separate sections for its subcategories.

All the paraphilias involve an attraction to a non-sanctioned source of sexual satisfaction; the source may be a behavior of the individual, as in exhibitionism or sadism, or a forbidden object of attraction, as in pedophilia or fetishism. 

As with other mental disorders, diagnosis of any paraphilia requires a minimum duration of the difficulty (6 months in the case of the paraphilias) and clinically significant distress or impairment. In the case of the paraphilias, impairment is more frequent than distress, for many people with paraphilias see no need to be cured, and most of them do not come to the attention of authorities until long after the paraphilic practices begin. 

Almost all paraphiliacs are males, according to DSM-IV, with the exception of Sexual Masochists, where the ratio of males to females is still 20 to 1. Maxmen and Ward¹ reverse the ratio, saying it is 20 females to 1 male. Neither reports a source for the ratio, and we have been unable to find a good epidemiological study; one study of a small number of Sexual Masochists included nearly equal numbers of men and women.  

The treatment of paraphiliacs includes pairing aversive stimuli like bad smells or shock with fantasies or photographs of the arousing stimuli or circumstances, and interventions calculated to provide alternatives to the forbidden behaviors. Most people with paraphilias are deficient in the social skills needed to obtain sexual satisfaction through intercourse with adults, so another part of the treatment is training in social skills or in alternative activities that can be substituted for the paraphilia. 

The first type of paraphilia in DSM-IV is Exhibitionism, which involves exposing one's genitals to a stranger. The exposure is accompanied by intense sexual excitement and often by masturbation. The disorder usually starts before age 18 and may diminish with age.

The second type is Fetishism, deriving sexual excitement from inanimate objects; favorites are women's garments like underwear and bras, which are frequently used for arousal during masturbation.

The third type is Frotteurism, which involves touching or rubbing against a non-consenting person. It occurs mostly in males between 15 and 25 years old; they typically fantasize a caring relationship between themselves and their victims, but also take care to practice their paraphilia in a situation from which they can readily escape, in order to avoid arrest.

The fourth type is pedophilia, which involves a relationship with a prepubescent child, ranging from fantasies through behaviors from touching to intercourse. To be diagnosed, the person must be at least 16 years old and at least 5 years older than the child; late adolescents in a relationship with a 12- or 13-year-old are also excluded. Pedophiles have varying preferences for the age and gender of their victims. Many probably never come to the attention of authorities; relatively few engage in violent behavior with their victims, but victims have been murdered on occasion, probably usually to prevent detection of the paraphilia. More typical are "seductive" behaviors like providing money, gifts, or drugs, particularly alcohol, to victims. Pedophiles who prefer males are more prone to recidivism after incarceration or treatment than those who prefer females.

The fifth type of paraphilia is  Sexual Masochism, which involves engaging in intensely sexually arousing fantasies or behaviors that involve pain and suffering. This includes, at least, being beaten, bound, humiliated, cut, or suffocated. The latter is particularly dangerous because oxygen deprivation is hard to control and sometimes fatal. Sexual Masochism tends to be chronic and sometimes increase in severity so that it can eventually lead to death or serious injury.  

The sixth type of paraphilia is Sexual Sadism, in which the person derives sexual pleasure from the suffering of others. Sometimes the "other" is an unwilling victim, sometimes a consenting partner (who could be a Sexual Masochist). The Sadist's fantasies typically include having complete power over the victim, and may include a fantasy that the victim is terrified. Spanking, burning, whipping, and shocking the victim can be added to the list of punitive acts listed under Sexual Masochism in the preceding paragraph. Sexual Sadists who progressively increase the intensity of their acts and who also have Antisocial Personality Disorder may injure or kill their victims. 

Transvestic Fetishistm, the seventh type, involves individuals who are intensely sexually aroused by dressing in women's clothing. They frequently masturbate while cross-dressed, fantasizing themselves in both the male and the female role. If they are dissatisfied with being male, they are also noted as having "gender dysphoria."

The eighth type of DSM-IV paraphilia is Voyeurism. Voyeurs derive their intense sexual arousal from watching people who are naked or getting naked or, perhaps even better, engaging in sexual activity. 

The ninth paraphilia is the "Not Otherwise Specified" class. There are many possibilities for this category; among them are necrophilia, zoophilia (sex with animals), obscene phone calls, and fascination with feces, urine, or enemas. 

In conclusion, we reiterate than none of the above diagnoses are justified unless the symptoms have endured for 6 months, and unless they cause clinically significant distress or impairment. 

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