Paraphilias – Causes, Signs and Symptoms

Paraphilias

Also called: Abnormal Sexual Behaviors, Perverse Sexual Behaviors, Deviant Sexual Behaviors, Deviant Sexual Arousal

Summary

Paraphilias are abnormal sexual urges, fantasies or behaviors that are recurrent and intense. They usually first occur in adolescence and last a lifetime. They may occur at any time or just recur periodically, especially during periods of stress. Sexual arousal for people with paraphilias most often involves unwilling participants (including children), inanimate objects, animals, or suffering and humiliation.

The focus of sexual arousal differs, depending on the type of paraphilia. The most commonly diagnosed paraphilias are those that involve criminal behavior and may only be diagnosed after the patient has been apprehended. These include pedophilia (sexual attraction to children), sexual exhibitionism (exposing or “flashing” one’s own genitals for sexual gratification), voyeurism (viewing the nudity or sexual activity of unsuspecting people, or “peeping”) and frotteurism (rubbing one’s genitals against strangers).

Many other types of paraphilias exist. Sources of sexual excitement can include articles of clothing, pain, specific body parts (e.g., feet), urine, feces, enemas and animals. Patients with a paraphilia often have more than one type.

It is difficult to identify signs of paraphilias or to know how common they are. Many people with paraphilias do not seek help for their behavior and they engage in the behavior in private. Consensual sexual activity among adults may encompass a wide range of behavior and may not be considered paraphilia. Paraphilias are believed to be more common than currently reported.

Nearly all patients with paraphilias are male and half of all people in treatment for a paraphilia are married, according to the American Psychiatric Association (APA). Although the cause of paraphilias is unknown, people with childhood sexual abuse or early exposure to deviant sexual behavior may have a greater risk of developing paraphilias.

The first step in identifying a paraphilia is a mental health evaluation. A person needs to meet specific criteria established by the APA for diagnosis of a paraphilia.

Some patients with paraphilias also have personality, mood, anxiety or eating disorders. In addition, they may be subject to consequences of paraphilias, including arrest, physical injury, sexually transmitted diseases, interpersonal difficulties, depression and sexual dysfunction. Mental health therapy and medications may be used to treat paraphilias. However, treatment  may be difficult since it requires compliance from people who are usually unwilling to seek help for their behavior. Recurrence of the behavior may occur, even after treatment.

About paraphilias

Certain sexual thoughts or behaviors that are considered abnormal, unusual or distasteful may indicate a complex mental disorder called paraphilia. Paraphilia literally means “abnormal or unnatural attraction.”

Paraphilias are a type of sexual disorder. They involve recurring and intense sexual fantasies, urges or behavior. Fantasies or thoughts often turn into sexual acts. For many patients with paraphilias, sexual excitement is achieved through the use of involuntary partners (including children), inanimate objects or animals, or pain and humiliation.

Many people may experience occasional sexual thoughts or behaviors that deviate from what is generally considered normal. These isolated instances are usually limited to fantasy during masturbation or occur during sexual activity with a willing partner. It is not considered a paraphilia when these thoughts or behaviors involve no illegal behavior, do not cause distress or impede development of healthy interpersonal relationships and are not required to achieve sexual gratification.

There are many different types of paraphilias, which may be distinguished from one another based on the focus of sexual desire or arousal. Patients with paraphilias often have more than one type.

Most sexual fantasies and behaviors, including those associated with paraphilias, begin during adolescence. They often continue throughout a person’s lifetime. Patients may engage in paraphilic activities with a consenting partner, use the service of prostitutes or impose their behavior upon unwilling others. 

People with paraphilias may engage in work or hobbies that bring them into contact with the focus of their paraphilia. For example, a man with a shoe fetish may choose to work in a store that sells women’s shoes, or a pedophile may spend his spare time engaging in activities that involve children. People with paraphilias may also rely on Internet images, films or other representations of the object of their arousal to achieve sexual gratification.

Almost all patients diagnosed with a paraphilia are male. Approximately 50 percent of patients in treatment for paraphilias are married, according to the American Psychiatric Association.

The exact number of people with some type of paraphilia is unknown. Although rarely diagnosed, paraphilias are believed to be more common than reported. This may be due to:

  • Secrecy surrounding sexual behavior. It can be difficult to obtain information about sexual thoughts and activities since sexual behavior is usually considered a private, personal act. People are often not willing to share information about their sexual practices with others. Feelings of embarrassment or shame may cause a person to be unwilling to admit to certain sexual thoughts or behaviors. In addition, patients with paraphilias may believe their thoughts or behaviors cause no harm and they are rarely willing to seek help for their sexual thoughts or behavior.

  • Reluctance to classify consensual sexual behavior as a disorder. Some mental health professionals may be unwilling to diagnose as a mental disorder those types of paraphilias that occur between consenting adults or are believed to cause no harm. Thus, even if these types of paraphilias are reported to a mental health professional or physician, they may go undiagnosed and unreported.

  • Availability of paraphilic products and services. Many products and services are available (sometimes illegally) that appear to cater to various paraphilias. These include child pornography and sadistic or masochistic devices. This availability indicates that the prevalence of these disorders may be higher than currently reported.   

All paraphilias may eventually involve significant consequences. Those that involve children or unwilling participants are criminal acts. These consequences include:

  • Arrest. Paraphilias that involve illegal behavior can lead to arrest. Being caught or accused of engaging in these behaviors is often the only way many paraphilias are discovered. Many people who are arrested for sex offenses commit acts such as pedophilia, sexual exhibitionism and voyeurism.

  • Physical injury. People who engage in sexual masochism may suffer from physical wounds that can range from minor cuts and bruises to life-threatening injuries.

  • Interpersonal difficulties. People with paraphilias often have difficulty maintaining healthy personal and sexual relationships. This may be due to the negative reaction of others to the paraphilia. It may also occur when the paraphilia becomes the center of a person’s life – to the exclusion of family, friends or loved ones.

  • Feelings of shame or guilt. People with paraphilias may experience feelings of intense shame or guilt over their thoughts or behavior. They may have trouble reconciling their actions with what others consider amoral, indecent or socially unacceptable.

  • Depression. Patients with paraphilias may experience depression as a result of their feelings concerning their abnormal sexual thoughts or behavior. Feelings of depression may, in turn, cause an increase in the frequency and intensity of the patient’s paraphilia.

  • Sexual dysfunction. Problems with sexual functioning or level of sexual desire (e.g., impotence, frigidity) sometimes occur in patients with a paraphilia.

  • Sexually transmitted diseases. People with paraphilias who engage in frequent, unprotected sex may contract and/or transmit sexually transmitted diseases.

Though not a consequence of paraphilias, other mental disorders sometimes occur in patients with paraphilias. For example, the emotions, thoughts and behavior patterns of people with paraphilias may sometimes meet criteria to be classified as a personality disorder.  Paraphilias are different than sexual disorders that involve dysfunction or gender identity. Sexual dysfunction occurs when there is a decrease or disturbance of sexual desire or function (e.g., frigidity, impotence). Gender identity disorders include transsexualism, in which a person wishes to become the opposite sex (e.g., a male wanting to be a female), which may include the use medication or surgery to accomplish the gender switch.

Types and differences of paraphilias

There are a wide variety of paraphilias, distinguished from one another by the focus of sexual desire or arousal. Patients with paraphilias often have more than one type. Paraphilias often involve one of the following:

  • Involuntary partners, including children
  • Inanimate objects or animals
  • Suffering and humiliation

Some paraphilias may be seen in clinical settings more than other paraphilias because they involve illegal behavior and the possibility of arrest. Patients with paraphilias may only come to the attention of mental health professionals once they have been arrested. The most commonly diagnosed paraphilias are:

  • Pedophilia. Sexual arousal associated with children who have not yet reached puberty (generally 13 years old and younger). People with pedophilia often report being attracted to children of a particular age group. They may focus on children within their own family or on strangers. Pedophilia may involve girls, boys or both. Some people with pedophilia may be attracted adults and children, whereas others are only attracted to children. Sexual activity may include undressing or looking at the nude child, masturbation in the presence of the child, fondling, oral sex or sexual penetration. Like all paraphilias, pedophilia usually begins in adolescence, although it may sometimes begin for the first time in mid-life. Sexual involvement with minors is a crime, although the age a person can consent to activity varies in different jurisdictions.
  • Sexual exhibitionism. Also known as “flashing,” achieving  sexual excitement by exposing one’s own genitals to others without their consent. This may include masturbation during exposure (or fantasizing about exposure), but generally does not include any attempt at sexual activity with another person.
  • Voyeurism. Also known as “peeping,” sexual  pleasure derived from witnessing the naked bodies or sexual activity of others without their consent. Masturbation may occur while watching others, but rarely is contact ever made with the observed person.
  • Frotteurism. Touching or rubbing one’s genitals against unsuspecting or unwilling person(s) in order to achieve sexual gratification. This usually occurs in crowded places, such as buses, subways and busy sidewalks. It may include the fondling of a stranger’s body with the hands.  

Additional paraphilias include:

  • Fetishism. Sexual desire associated with inanimate objects, such as women’s undergarments or shoes. Frequently, people with fetishism will masturbate while handling the desired item or will request a partner wear the item during sexual activity. The desired item is usually required for sexual satisfaction – its absence may trigger sexual dysfunction (e.g., impotence).  Fetishism does not refer to objects specifically designed for genital stimulation.
  • Sexual masochism. Sexual arousal associated with being humiliated or made to suffer. It may occur in fantasy, by oneself or with a partner. Methods may include being bound, beaten or subjected to verbal abuse and humiliation. When cross-dressing occurs as an element of this type of paraphilia, it is the humiliation of being forced to cross-dress that provides sexual stimulation. Hypoxyphilia, or autoerotic asphyxia, is a type of sexual masochism where sexual arousal is achieved by oxygen deprivation (e.g., via noose, plastic bag, chemicals). Mistakes can be made during this process and accidental death sometimes occurs.
  • Sexual sadism. Gaining sexual gratification from inflicting pain and suffering on others. This may include psychological as well as physical harm. Sexual sadism can occur in fantasy, with a willing other (e.g., a person with sexual masochism) or may be imposed on an unwilling person. The tactics used to inflict pain or humiliation may vary greatly (and include killing), but in all cases it is the suffering of the other that is sexually arousing. Sadism is a crime when it involves nonconsenting participants, and is likely to be repeated until the person with sexual sadism is apprehended.
  • Transvestic fetishism. The practice by heterosexual males of dressing in female clothing for sexual stimulation. It may involve a single item of clothing, but often progresses to complete cross-dressing. The act of cross-dressing provides sexual stimulation, not the clothing itself (as in fetishism). If cross-dressing occurs as part of an overall desire to become a member of the opposite sex, the behavior is associated with a gender identity disorder called transsexualism, not transvestic fetishism.

The above-listed paraphilias may be more common than currently reported. Even if reported, some mental health professionals may be hesitant to characterize as a mental disorder sexual behavior that involves willing adults or behavior that they perceive as not harmful to others. Thus, the above types of paraphilias (with the possible exception of sexual sadism) may be underdiagnosed.

Paraphilias encountered less frequently in clinical settings include, but are not limited to:

  • Telephone scatalogia. Sexual arousal obtained by making obscene phone calls to unwilling people. In order to be considered a paraphilia, the sexually explicit language must be imposed on unwilling parties. 
     
  • Zoophilia. Sexual arousal associated with animals. It may involve sexual activity or intercourse.

Risk factors and causes of paraphilias

The cause of paraphilias is poorly understood. Most sexual fantasies and behaviors, including those associated with paraphilias, begin during adolescence. What triggers a focus on inappropriate objects of sexual desire is not clear.

Problems maintaining healthy interpersonal and sexual relationships may reinforce paraphilic thoughts or behavior. Periods of stress, the existence of an accompanying mental disorder (e.g., depression), and opportunity may all increase the frequency of a particular paraphilia. 

Several factors appear to increase the likelihood of paraphilias. These include:

  • Gender. Almost all patients diagnosed with a paraphilia are male. Although most paraphilias may occur in either gender (except transvestic fetishism), they are almost exclusively diagnosed in men. However, it is believed  that female pedophilia may be a much more common disorder than previously thought. Sexual masochism is one paraphilia in particular that includes a measurable percentage of women – an estimated one female for every 20 males, according to the American Psychiatric Association(APA).
  • Age. Younger people may be at greater risk of certain paraphilias than older adults. Sexual thoughts and behaviors (including paraphilias) generally appear during the teen years. Also, sexual fantasies and behavior tend to diminish with age.
  • Childhood sexual abuse. In some studies, patients with paraphilias had significantly higher rates of childhood sexual abuse than patients without paraphilias.
  • Early exposure to deviant sexual behavior. Through imitation and conditioned learning, people exposed to abnormal sexual behaviors (including paraphilias) during their childhood may be more likely to develop paraphilias.

Signs and symptoms of paraphilias

Symptoms of paraphilias include recurrent and intense sexual fantasies, urges or behaviors involving inappropriate objects of sexual desire. This may include unwilling participants, children, inanimate objects, animals or humiliation and suffering. The focus of sexual excitement may differ, depending on the type of paraphilia involved.

These thoughts or behaviors may occur periodically (e.g., during periods of stress) or at any time. They generally last a lifetime, although sexual fantasies and behavior tend to diminish with advanced age.

Many people with paraphilias experience distorted thoughts regarding their behavior. For example, they may believe nonconsenting strangers desire their attention or action (e.g., in cases of sexual exhibitionism or frotteurism) or that the behavior is for the good of the victim (e.g., pedophilia). They also commonly fantasize about sexual relations with others (e.g., voyeurism).  Because sexual fantasies and urges occur internally, they cannot be easily identified by others. Also, sexual activity is usually conducted in private, so it is often not possible for outside parties to identify the signs of a paraphilia. Sometimes the first sign of a paraphilia (such as pedophilia) occurs when a person is accused of or caught engaging in the behavior.

Diagnosis methods for paraphilias

A mental health evaluation can identify and help diagnose paraphilias. This evaluation may be conducted by a mental health professional and may include a history of the patient’s sexual thoughts, behaviors and consequences. A physical examination may also be conducted in order to rule out any physical conditions or disorders that may be associated with the behavior.

In order to be diagnosed with a paraphilia, patients must meet the following criteria established by the American Psychiatric Association(APA):

  • Recurring and intense sexual fantasies, urges or behaviors that occur for at least six months.

  • Patient has acted on the urges, or has suffered significant distress or difficulties with relationships or jobs as a result of the urges.

To be diagnosed with pedophilia, the patient must be at least 16 years old and at least five years older than the child involved (who is generally 13 or younger). Sexual activity between older teens and younger teens is not usually considered pedophilia. Criminal criteria for pedophilia may differ from the diagnostic criteria.

For a diagnosis of fetishism, the focus of sexual arousal must not be an element of cross-dressing (in which case, transvestic fetishism might be diagnosed) or be used to physically stimulate the genitals (e.g., a vibrator).

Despite report of paraphilic thoughts or behavior, certain paraphilias may remain undiagnosed. Some mental health professionals may be hesitant to label as a mental disorder sexual behavior that involves consenting adults or is not believed to cause harm to others (e.g., sexual masochism, fetishism).

On rare occasions, unusual sexual activity may occur in patients with mental retardation, dementia, schizophrenia or substance abuse. It may also occur during a manic episode. In order to rule out paraphilias, the behavior needs to be identified as:

  • Not the preferred or necessary method of sexual arousal
  • Occurring only during the course of the existing condition
  • An isolated incident (rather than chronic)
  • Beginning in adulthood (rather than adolescence)

Penile plethysmography(PPG) is a test sometimes used to identify paraphilias. It measures changes in blood flow within the penis in response to visual or audio stimuli. For patients with paraphilias, this test is used to measure sexual arousal in response to inappropriate or abnormal cues. However, the reliability and validity of this test has been questioned, since patient reaction may be based on mental images not related to the stimuli presented in the test. This test is most likely to be used when legal issues (e.g., those surrounding pedophilia) are involved.

Treatment options for paraphilias

The purpose of treating people with paraphilias is to control or eliminate the inappropriate sexual thoughts or behavior. However, the effectiveness of treatment is questionable. Paraphilias tend to be chronic and recur throughout a person’s life, especially during times of stress. For example, as many as 25 percent of people convicted of pedophilia resume the behavior within a few years of release from prison, according to the American Psychiatric Association(APA). People with pedophilia who victimize boys are twice as likely to repeat their behavior as people who victimize girls. 

Treatment is generally long-term. Success is complicated by the fact it requires the patient’s compliance and many patients with paraphilias receive treatment only because it is mandated by the court system.

Mental health therapy may be used to treat paraphilias. It can be accomplished one-on-one with a mental health professional or in a group setting with a professional facilitator. Common types of mental health therapy used to treat paraphilias include:

  • Cognitive behavior therapy(CBT). Helps patients recognize the relationship between their thoughts and actions, and replace distorted thoughts with realistic ones. This type of therapy may help patients with paraphilias recognize and control the inappropriate thoughts preceding their sexual arousal.

  • Interpersonal Psychotherapy. Communication with a mental health professional about thoughts, feelings and behaviors. This type of therapy may help people with paraphilias identify underlying motives or issues that may be associated with their sexual attraction to inappropriate objects, people or activities.

  • Group therapy. Some people with paraphilias may benefit from groups that discuss sexual addictions. Some of these are self-help groups based on the 12-step model first used by Alcoholics Anonymous.

  • Behavior therapy. Focuses on changing negative behavior. Using various learning techniques, patients with paraphilias may be able to reduce or stop their abnormal sexual behavior. For example, aversive conditioning trains a patient to associate negative consequences (e.g., smelling a repulsive odor) with their behavior.  

Medication may also be used to treat paraphilias. These include:

  • Antiandrogens. Drugs that inhibit the action of androgens (substances that produce male hormones, such as testosterone and androsterone, responsible for sexual drive and attraction). Antiandrogens are used in patients with paraphilias to suppress their sexual urges.

  • Antidepressants. Drugs that relieve depression and anxiety by affecting neurotransmitters in the brain. Antidepressants may be used to reduce the anxiety and depression that can occur in patients with paraphilias. Decreased sexual urges, a common side effect of certain antidepressants (selective serotonin reuptake inhibitors), may offer additional benefit to patients with paraphilias.
  • Other medications may be considered if other mental health disorders are also present. These include antipsychotics, anti-anxiety medications or mood stabilizers.

Questions for your doctor regarding paraphilias

Preparing questions in advance can help patients to have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions related to paraphilias:

  1. Are my sexual urges, fantasies or behaviors abnormal? Why?
  2. Am I likely to be diagnosed with a paraphilia? Which one? Do I have more than one type of paraphilia?
  3. Can I be cured of my paraphilia?
  4. Can I learn to control my sexual thoughts or behaviors? How?
  5. What type of treatment would you recommend for me?
  6. What medications are appropriate for me, and what are their side effects?
  7. Are there specific prescription or over-the-counter medications I should avoid while taking these medications?
  8. What type of mental health counseling might be effective for me?
  9. Is there a specific mental health professional you would recommend?
  10. If my paraphilia involves illegal activity, can I receive treatment without being reported to the police?
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