Paraphilias

KEY FEATURES

• Atypical objects or orientations are associated with sexual excitement

• Stimuli can vary from common objects such as a woman's shoe, a child, animals, instruments of torture, or aggressive acts

• The pattern of sexual stimulation is usually one that has early psychological roots

• Disorders are differentiated by the object or activity used to achieve arousal

• When paraphilias are associated with distress, impairment, or risk of harm, they become paraphilic disorders

• Some paraphilias or paraphilic disorders include

  • Exhibitionism

  • Transvestism

  • Voyeurism

  • Pedophilia

  • Incest

  • Sexual sadism

  • Sexual masochism

CLINICAL FINDINGS

• Exhibitionism

  • Impulsive behavior of exposing genitalia to strangers in order to achieve sexual excitation

  • Childhood sexual behavior carried into adult life

• Transvestism

  • Recurrent cross-dressing for the purpose of sexual excitement

  • Can be part of masturbation foreplay

• Voyeurism

  • Attaining sexual arousal by watching sexual activities or disrobing of an unknowing person

• Pedophilia

  • Use of a child of either sex to achieve sexual arousal and often gratification

  • Contact is frequently oral but can include intercourse of any type

• Incest

  • Sexual relationship with a person—usually a child—in the immediate family

  • Similar to pedophilia (intrafamilial pedophilia)

• Sexual sadism

  • Attainment of sexual arousal by inflicting pain upon the sexual object

  • Much sexual activity has aggressive component (eg, biting, scratching)

• Sexual masochism

  • Erotic pleasure achieved by being humiliated, enslaved, or physically bonded and restrained

  • May be life-threatening; neck binding or partial asphyxiation is a common part of the ritual

DIAGNOSIS

• Clinical history, often including court-ordered evaluations

TREATMENT

• Psychological therapy

  • Focus is on barriers to normal arousal response

• Behavioral therapy

  • Modeling, role-playing, and conditioning procedures

• Social therapy

  • Self-help groups can facilitate the patient's adjustment to society

  • Family members can be helped to accept the situation and alleviate their guilt about the role they think they had in creating the problem

• Medications

  • Medroxyprogesterone acetate can suppress libidinal drive in men; onset of action is usually within 3 weeks

  • Selective serotonin reuptake inhibitors (SSRIs) (eg, fluoxetine) at doses used for depression may reduce some compulsive sexual behaviors

  • Luteinizing hormone-releasing hormone agonists may prevent relapse in some patients