Chapter 18

This is also referred to as “voyeurism” and refers to an intense urge to spy on others in their home or during other private activities. This is a paraphilia because it gives the person sexual satisfaction from seeing others undressing, naked, or engaged in sex in their home or other private place. Rarely, the observed individual is consenting but the major purpose of sexual gratification surrounds the idea that the other person does not consent and is unaware they are being observed. A person may have voyeuristic tendencies but will not have the disorder unless there is significant distress or problems with significant areas of everyday functioning. The diagnosis is not made unless the patient gets most of their sexual satisfaction from observing unsuspecting persons and has done so for a minimum of six months. There must also be stress or impairment in their life and they must have observed a minimum of three unsuspecting targeted individuals during the six-month period. The individuals must be disrobing, naked, or engaging in sex. About half of all individuals will deny their voyeuristic tendencies. Having a legal history of being caught with voyeuristic behavior also adds to make the diagnosis. 284 Many individuals who refuse to disclose their tendencies toward voyeurism will claim that the observation was nonsexual in nature or accidental. According to the DSM-V, these individuals are probably denying also that they’re having distress and/or social impairment and can still be diagnosed with voyeuristic disorder. This is the most common illegal sexual behavior, which has temperamental and environmental risk factors. There are tendencies toward voyeurism that go along with a history of hypersexuality, childhood sexual abuse, and substance abuse. Comorbid states include just about any other paraphilia, particularly exhibitionistic disorder, although many other psychiatric conditions are comorbid with this disorder. The treatment options for voyeuristic disorder include marital therapy, group therapy, cognitive therapy, psychotherapy, and other therapy types. Psychopharmacology is used to decrease sexual hormones. The paraphilias are all related to OCD and so SSRI drugs are considered firstline therapies for the treatment of this disorder. EXHIBITIONISTIC DISORDER (302.4) The DSM-V classifies Exhibitionistic Disorder as having the inordinate need to expose one’s genitals to another person—usually to an unsuspecting stranger, resulting in sexual satisfaction for the exhibitionist. Almost all exhibitionists are males and some wish to be observed while having sex. It starts in the late teens or early adulthood and may be something that is deliberate or unconscious. Exhibitionistic disorder is different from having exhibitionistic tendencies. According to the DSM-V, the behaviors linked to Exhibitionistic Disorder happen over a sixmonth period of time, are recurrent, and result in an intense feeling of sexual satisfaction after exposing one’s genitals to a stranger. It is deliberately intended to do this behavior with a nonconsenting individual. This can occur in children and in adults; it needs to cause distress or impairment in functioning to qualify as having the disorder. 285 This is a lifelong disorder that has a high rate of recidivism, despite treatment. It is difficult to treat the patient well enough to modify and/or control their behavior. Family members need to be involved in managing the behavior by limiting internet access and restricting all substances. Regular therapy is necessary to contain the behavior and to recognize triggers for the behavior. Some individuals may spontaneously remit. Comorbidities include substance abuse and the various mood disorders. The patient may exhibit suicidal behavior upon being arrested or incarcerated. Various drugs have been tried with some success, particularly SSRIs. Antiandrogens may also be prescribed to decrease testosterone production. FROTTEURISTIC DISORDER (302.89) Frotteuristic disorder is defined as a “courtship disorder” in which the patient demonstrates sexual arousal by touching or rubbing against a nonconsenting individual. There are fantasies around touching people. They tend to touch people in public places, such as in crowds or on mass transportation vehicles. The symptoms must last at least six months to qualify as having the disorder. Distress and/or impairment of function must be present to make the diagnosis. Full remission is the non-action of urges for a minimum of five years. To make the diagnosis, the touching of a nonconsenting person must have had to occur on at least three occasions and must be distressful to the patient. If distress and impulses have occurred and the patient hasn’t yet acted on it, they could be diagnosed with frotteurism; individuals who deny their behaviors despite evidence can also be diagnosed with the disorder. The symptoms start in late adolescence and may not initially involve sexual arousal. Other sexual impulse disorders (hypersexuality, exhibitionism, and voyeurism) can be comorbid, as can antisocial personality disorder, conduct disorder, substance abuse disorders, and mood disorders. This is a very common behavior, affecting up to 30 percent of adult males, who do not meet the criteria for the actual frotteuristic disorder. Patients with paraphilias have a 10-15 percent chance of also having frotteuristic disorder. It is almost exclusively seen in males and perpetrated upon women. The prevalence of frotteuristic behavior is unknown because many 286 individuals keep their behavior subtle and are private about their fantasies. Treatment can involve giving female hormones or antiandrogens, SSRIs, and antipsychotic drugs in an attempt to reduce the sexual fantasies and to redirect the behavior. Lifelong psychiatric and psychological support is usually necessary as the individual has only a rare chance of true resolution of their fantasies. There is a high likelihood for legal consequences if the patient gets caught and convicted of a sex crime. SEXUAL MASOCHISM DISORDER (302.83) This involves a patient who has sexual arousal after receiving extreme pain, bondage, torture, or humiliation in a sexual way. They may have recurrent and persistent urges and fantasies related to being beaten or otherwise mistreated during sex. The behaviors are actually very common; however, as with all of these types of disorders, the patient must experience extreme distress or impairment of function in order to have the “disorder.” Mild masochism between consenting adults is not considered a disorder. The individual with SMD (sexual masochism disorder) has recurrent fantasies or behaviors of extreme pain, torture, or humiliation. It must be present for six months and must be distressful or impair social functioning. There is a specifier to include asphyxiophilia (arousal by asphyxiation). If the behavior involves self-inflicted harm, it must be for the purposes of being sexually aroused. Individuals often enjoy pornography related to masochism. The patient must admit to having these fantasies and urges in order to make the diagnosis. The average age at onset of the disorder is 19 years, although fantasies and urges can happen as young as 12 years of age. It can involve an individual into BDSM (bondage discipline sadism and masochism) but there needs to be distress, guilt, or shame in the behavior in order to have sexual masochism disorder. Some men with the disorder will hire a dominatrix to engage in this fantasy disorder. The dominatrix rarely has actual intercourse with the individual who needs to be humiliated in order to be aroused. 287 The actual prevalence of the disorder is unknown; however, 12 percent of women and 25 percent of men report fantasies centered around masochism. About half of consenting adults enjoy being bitten or scratched as part of sexual play. The prevalence of this behavior is higher among women who are lesbians or bisexuals. Having distress around the behavior is a requirement for the diagnosis. The biggest risk is injury to the patient, particularly in cases of autoerotic asphyxia. This is the leading cause of death due to the disorder, often occurring during masturbation. The treatment can involve antiandrogen therapy to control hypersexuality and be more receptive to psychotherapy or to reduce the chances of injury or death related to the behavior. Drug therapy does not involve a long-term solution but does help psychotherapeutic goals. Journaling of fantasies is helpful to the therapeutic process. Psychoeducation and sexual education along with social skills training can help resolve the behavior. SEXUAL SADISM DISORDER (302.84) In cases of sexual sadism disorder, the individual has an algolagnic disorder in which there is sexual arousal by inflicting physical and/or psychological suffering upon another person. There is intense sexual excitement by the fantasizing over or witnessing of physical or psychological harm to another, who may or may not be consenting. It must be present for six months to qualify as being a sexual paraphilic disorder, with the diagnosis made when there is distress, impairment of functioning, or an act upon a nonconsenting individual. Specifiers involve whether the patient is in a controlled environment (such as incarceration) or has been symptom-free for five years without distress. There is a scale called the SSSS (Severe Sexual Sadism Scale) that indicates the propensity toward the disorder. The patient can deny their fantasies and their behavior and will still meet the criteria for the disorder but the differential diagnosis involves sadism versus a nonsadistic sexual assault. Mild forms of pain between consenting adults does not qualify as sexual sadism disorder. 288 Sexual sadism disorder is comorbid with other paraphilic disorders (with no clear prevalence of any one). Most of the research data comes from incarcerated males who have perpetrated sadistic crimes so it may not be representative of most men who have the disorder. There is little information on females with the disorder. There seems to be an impairment in emotional recognition and processing (as well as increased aggression levels) in individuals who have this illness. Less than 10 percent of convicted sex offenders have sexual sadism disorder; however, the incidence is as high as 75 percent in those who have committed a sexually motivated homicide. Treatment is primarily through drug therapy, such as female hormones and anti-androgen drugs. These will reduce the sexual impulses and improve the resultant behavior. There is a high rate of recidivism among people who get sexually aroused when exposed to violent content. These types of patients need ongoing monitoring if they are not incarcerated in order to avoid acting on their sexual fantasies of harming others. PEDOPHILIC DISORDER (302.2) This is a diagnosis given to individuals who are at least sixteen years of age or older who are sexually aroused by prepubescent children. Any expression of the patient’s fantasies is a criminal offense in most parts of the world. There may be a difference between individuals who have desires that are ego-dystonic and individuals who indulge in their fantasies by possessing child pornography and who associate with other pedophiles. This is a highly treatment-resistant disorder with a great deal of recidivism (as high as 50 percent). This may not be accurate as some do not come to the attention of law enforcement, while others are incarcerated. This is an extremely damaging disorder for the victims, many of whom have lifelong sexual problems and PTSD. Some believe it is a psychological/sexual preference, while others hold a more moral approach, indicating that this represents criminal behavior. The differentiating factor is whether or not the individual acts on their fantasies. A “predatory pedophile” acts on their sexual desires. Others believe that pedophilia is a repressed sexual orientation that is amenable to treatment. 289 There are three criteria with five specifiers in the DSM-V. The three criteria include: 1) having arousing fantasies or behaviors with a prepubescent child; 2) having acted on the desires or significant distress around these desires; and 3) is at least five years older than the child and sixteen years of age. The five specifiers include the following: • Sexually attracted to children only • Sexually attracted to adults and children • Attracted to boys • Attracted to girls • Incestuous only The onset of the disorder is around puberty with a prevalence of about 3-5 percent in the adult population. There is a correlation between this disorder and antisocial personality disorder. Many will have been victims as children. The DSM-V indicates a high risk of comorbidity with mood disorders, substance use disorders, anxiety disorders, and other paraphilias. It is not amenable to psychotherapy. Chemical and physical castration do not necessarily stop the behaviors. FETISHISTIC DISORDER (302.81) This involves an individual who is sexually aroused by an object or body part AND who is distressed by their fantasies or behavior. The object or body part is not considered erotic to the average person; almost anything can be the object of the individual’s desires. The sufferer of fetishistic disorder may involve gratification in the absence of a partner. This is seen almost exclusively in men with homosexuality seen in 25 percent of those who have the disorder. There are three criteria for fetishistic disorder with four specifiers. The three criteria include the following: 290 a. Having sexual urges focused on a non-genital body part or object for six months (and has acted them out) b. Having distress or impairment of function c. The object is unrelated to transvestic disorder and is not a sexual stimulation device Specifiers include the type of object that is the focus of the fantasy, whether there are other behaviors associated with acting out of the fantasies (like smoking or other behavior), if the patient is in a controlled environment, and if the patient has been in remission for five years. The onset is around the time of puberty but can begin earlier than that. It tends to wax and wane over the patient’s lifetime and is seen in males almost exclusively. It can be co-occurring with other paraphilias and may be linked to early sexual encounters and anticipation associated with sex. It is best treated with cognitive behavioral therapy and often impacts intimacy in a relationship. In order to make the diagnosis, transvestic disorder and sexual masochism need to be ruled out as does having fetishistic behavior (but not the actual disorder). TRANSVESTIC DISORDER (302.3) This is a specific paraphilia in which the patient is sexually aroused by dressing in clothing of the opposite sex and has a great deal of distress because of it. The symptoms must be present for six months to make the diagnosis. The act of cross-dressing must bring about feelings of sexual arousal. This must be differentiated from gender dysphoria, in which the patient feels they are the opposite gender. It can involve just one item of clothing or everything from clothing to hair to makeup. It is different from fetishistic disorder because the target of the fetish in some cases of fetishism is the actual woman’s clothing object and not dressing in it. The disorder is often seen in childhood and intensifies in puberty. The level of arousal peaks in puberty and lessens over time. The longer the person has the disorder, the longer they want to portray the feminine role. This is a very rare disorder and is usually seen in heterosexual males. Comorbid disorders with transvestic disorder include autogynephilia (fantasizing and being a woman), masochism, and fetishism. A greater than average proportion of these people will die 291 from autoerotic asphyxiation, which can coexist with the disorder. It is seen in about three percent of males. The diagnosis requires distress around the cross-dressing behavior. Transvestic disorder is treated with a combination of psychotherapy to deal with the urges and fantasies, antiandrogens to control hypersexuality, and SSRIs to control the obsessions associated with wanting to cross-dress. Depression and suicidality need to be managed as these are men who want a heterosexual relationship and who often have interference with their relationships because of their behavior.