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.
Voyeuristic 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.
Transvestic disorder
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.
Exhibitionist disorder
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%).
Fetishistic disorder
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
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.
Treatment
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.
Thoughts
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?
References
- 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.
Ashley L. Peterson
BScPharm BSN MPN
Ashley is a former mental health nurse and pharmacist and the author of four books.
Transvisitc disorder? What the hell century are we living in? Sorry, it’s just I thought things like this had been eradicated from the DSM.
It’s not the wearing of different gendered clothes that’s considered a disorder, but sexual arousal from wearing that clothing that’s taken to extremes, so it’s not actually as stone ages as it sounds from the diagnostic label.
A particularly extreme example is Russell Williams, who was a Canadian air force colonel who broke into women’s homes and dressed up in their lingerie, and it eventually escalated into him killing multiple women. He was multiple kinds of sexual deviant all rolled into one truly horrible package.
😳
“using behaviour that would be considered criminal as a deciding factor diagnostically is a bit weird.” Agreed
That sexologist sounds like a figure with a bizarre history. We read about his “device” to measure male arousal and got very upset. What about arousal non-concordance, which affects therapists, criminal justice workers, abuse victims, etc.? (Shudder)
Freund sounds like he was a pretty weird, and I agree, the device sounds like it could easily be used in very problematic ways.
I can see how there’s some usefulness in trying to figure out why some people have deviant arousal patterns and what can be done to manage harmful behaviours, it seems like there’s a lot of room to actually do more harm than good.
I don’t know if you’ve watched “mind hunter” series on Netflix but there was a bit of this it seems in there…where one of the killers got very aroused by women’s shoes…
I think you are brave going into all these…
I haven’t seen it, but it sure is creepy how twisted some people’s minds can be. The stuff that I was reading to research for this post was pretty clinical and detached, but I think it would be so hard to actually work with people who take this kind of thing to a criminal level.
Definitely…it was a very fascinating but done well series. I learnt a lot from watching it too. And some people’s minds are twisted so much that they can’t be un-twisted I don’t think.
I agree.
This stuff definitely ain’t in my wheelhouse. I am as vanilla as they come.
Me too.
Paraphilic made me think of paraphernalia, guess that was way off! I didn’t realise there was an overarching term for the disorders listed here, of which I know about all bar Frotteuristic. So at least six months of arousal around touching or rubbing someone without their consent. While this won’t sound “politically correct”, all I can think of is that’s what I’d call a pervert and sexual assault. I’ll have to look into that a bit more. I’d say 30% is high too for noncosenting contact like that, unless a large proportion occurs at clubs, where it’s so commonplace it’s more like an expectation expectation for going. I imagine that paraphilia, along with others, are rather under-researched areas generally speaking.
I like that you’ve made clear that having particular interests doesn’t automatically equate to a disorder diagnosis.
When you talked about orgasmic reconditioning, it made me think of “conversion” therapies to “cure” gayness so that makes me a bit uneasy. It’s hard with disorders like these as part of me wants to say each to their own as certain interests and inclinations can be part of adult life in a way that works for them. But disordered levels are more extreme and may affect others (ie through sexual assault) or make a considerably negative impact on the individuals living with them. Another thought-provoking post. xx
Haha I agree with you on the pervert and sexual assault. I find it interesting to consider at what point being fucked in the head can or should overlap with mental illness.
When I read about orgasmic reconditioning, the first thing that popped into my mind was conversion therapy. But if people are getting off on fantasies that involve harm to others, some form of behavioural reconditioning probably makes sense.
What are your thoughts on this group of disorders?
I was under a misapprehension about two of them – the voyeuristic and the exhibitionist types. I thought and perhaps this is because this is how it went with me, that they were kinda two sides of a coin.
In another part of my life I indulged in several of those behaviors on your list (never that horrid pedo one nor that last one) and I’ve always worn men’s clothing but I don’t get turned on by doing so. Men’s sizes in shirts at least are more comfortable for my physique or lack thereof. 😉
Anyway. I found it fascinating that the development of those kind of disorders is common in people who had childhood abuse situations or have personality disorders. Is there a reason that people in those two categories are more prone to what I’d call ‘kinky sex’ acts? Particularly the voyeur/exhibition ones, but the BDSM stuff too (which I indulged in for a brief period, but learned I dislike the whole idea so intensely that it started to be a turn off rather than a turn on). I can’t stand to be restrained at all now, if someone were around who I’d do that sort of thing with.
I also would have thought there would be more of a connection between voyeurism and exhibitionism. I wonder if overlap is more common in people with healthy paraphilias, but the people with more extreme disordered versions are more likely to run with it in one way or the other.
What I came across regarding the connection to childhood abuse and personality disorder was specifically in relation to risk for paraphilic disorders, so I don’t know if those things increase the tendency towards kink in general, or if they just make it more likely that kink interests will develop into more extreme disordered versions.
Goodness gracious what an eclectic mixture of this, that and the other.
I found myself going through the listed items with a morbid fascination.
I think most healthy sexual relationships and especially those that touch base with a bit of risque and kinky behaviour anyway probably practice at times a bit of each to spice things up in the bedroom.
Years ago when l worked in the adult industry l met with a lot of very different let’s say specialist services who in fact catered to these types of things.
Well done for tackling this otherwise taboo topic Ashley …
I’ve a perpetrator brother who delighted in acting out his sadism of a physical nature but perhaps “thankfully” not sexual. I believe he has conduct disorder that was never treated.
Sadism is such a horrible trait for people to have.
Definitely. Sometimes I wonder why he turned out like that but there’s nothing I can do about it.
Plenty of trauma from him to heal from to spend energy trying to psychoanalyse this weird resentment towards me and our sister. Or fret about how she or I will likely be made responsible for his care if he ends up destitute. Though maybe that’s actually preferable instead of him harming another human being **shudder**.
I’ll park that worry for the future, plenty of problems of my own.
Yeah, you’ve got way too much shit to deal with already.