Paraphilic Disorders

Introduction to Paraphilic Disorders

• Disclaimer: Limited research is available on paraphilic disorders.
• More research is needed on both normative and paraphilic sexual activity.
• Existing research primarily focuses on incarcerated individuals, introducing social desirability bias.
• Individuals rarely seek therapy for paraphilias unless caught.
• Etiology of paraphilias remains largely unknown with many theories but few concrete answers.
• Effective treatments are lacking.
• Quote from Sexual Deviance: "We now have a fifty year history of treatments, and it is entirely reasonable to ask. What have we got to show for it? The answer, sadly, is very little."
• The lecture will primarily describe paraphilias and their symptomatology.

Understanding Paraphilia

• Para: Latin for "beyond."
• Philia: Means "love."
• Paraphilia: Love for what is beyond normal or typical.

Four Features of Paraphilias

1. Statistically Uncommon:
   • Behaviors are not typical, but exact prevalence is unknown due to limited research.
2. Involve Non-Consenting or Immature Partners:
   • Deviation from typical sexual activity involving two mature, consenting human partners.
3. Recurrent and Persistent Symptoms:
   • Symptoms must be recurrent and persistent, typically for at least six months, according to the DSM.
   • Persistent: Lasting for a long time.
   • Recurrent: Occurring often.
4. Preferred and Primary Source of Arousal:
   • The paraphilic activity or fantasy is the primary way the individual becomes sexually aroused.
   • Individuals may also engage in normative sexual activity.

• Presence of one feature alone does not warrant a diagnosis; all four must be present.

Diagnosing Paraphilic Disorders

• Having urges or fantasies does not automatically warrant a diagnosis.

Criteria for Diagnosis

A diagnosis requires the presence of one of the following, resulting from the urges, fantasies, or acts:

1. Clinically Significant Distress:
   • The person experiences distress solely from the thoughts or fantasies.
2. Impairment in Social or Occupational Functioning:
   • Social or occupational functioning is impaired due to paraphilic behavior.
3. Acting on Urges with a Non-Consenting Partner:
   • Engaging in behavior with a non-consenting partner automatically warrants a diagnosis, even if the individual does not feel distressed or impaired.

Important Considerations and Disclaimer

• Restatement: We do not know much about paraphilic disorders, and research is crucial.
• Effective treatments could prevent harm to others.

Key Points

1. Higher Prevalence in Men:
   • The prevalence rate in men is much higher than in women.
2. Treatment Difficulty:
   • Paraphilic disorders are very difficult to treat, with limited effectiveness.
   • High recidivism rates indicate the difficulty in changing this behavior.
   • Sex offender registries exist due to the difficulty in changing harmful sexual behavior.
3. Comorbidity:
   • Comorbidity is common, meaning individuals often have more than one paraphilia.

Specific Paraphilic Disorders Listed in DSM-5

• The DSM-5 lists eight specific paraphilic disorders, but other types exist.
• Unspecified paraphilias can be diagnosed using an alternative diagnosis.

Common Criteria Reminder

• Over at least six months, the individual experiences recurrent and intense sexual arousal.
• The individual does not necessarily have to act on the urges.
• Diagnosis is warranted if:
  • The individual is distressed.
  • Social and occupational functioning is impaired.
  • The individual engages in paraphilic behavior with a non-consenting partner.

Specific Disorders and Their Symptoms

1. Voyeuristic Disorder (Peeping Toms):
   • Recurrent and intense sexual arousal from observing an unsuspecting person who is naked, disrobing, or engaging in sexual activity for at least six months.
   • Must involve unsuspecting individuals; consensual observation is not voyeuristic disorder.
2. Exhibitionistic Disorder (Flashers):
   • Recurrent and intense sexual arousal from the exposure of one's genitals to an unsuspecting person for at least six months.
   • Exposure is the primary source of sexual arousal.
3. Frotteuristic Disorder:
   • Recurrent and intense sexual arousal from touching or rubbing against a non-consenting person for at least six months.
   • Often occurs in crowded environments, such as public transportation.
4. Sexual Masochism Disorder:
   • Recurrent and intense sexual arousal from being humiliated, beaten, bound, or otherwise made to suffer for at least six months.
   • More women are diagnosed with this compared to other paraphilias, though men are still overwhelmingly the majority.
   • Involves real humiliation, beatings, or bondage.
5. Sexual Sadism Disorder:
   • Recurrent and intense sexual arousal from the physical or psychological suffering of another person for at least six months.
   • Involves inflicting pain on another person for sexual arousal.
   • Differentiated from BDSM: BDSM involves consenting individuals with strict rules and signals to stop the activity.
6. Pedophilic Disorder (Pedophiles):
   • Recurrent, intense, sexually arousing fantasies, urges, or behaviors involving sexual activity with a pre-pubescent child or children (generally age 13 years or younger) for at least six months.
   • The individual must be at least 16 years old and at least five years older than the child involved.
   • A relationship between a 15-year-old and a 12-year-old does not warrant a diagnosis, though it may be illegal.
7. Fetishistic Disorder:
   • Recurrent and intense sexual arousal from the use of non-living objects or a highly specific focus on non-genital body parts for at least six months.
   • Examples: shoe fetish or foot fetish.
   • Diagnosis requires significant distress or impairment, as it does not involve non-consenting individuals.
8. Transvestic Disorder:
   • Recurrent and intense sexual arousal from cross-dressing for at least six months.
   • Overwhelmingly diagnosed in heterosexual men.
   • Differentiated from cross-dressing for gender identity or entertainment (e.g., drag queens).

Categorization of Paraphilic Disorders

Paraphilic disorders are categorized into two distinct groups:

1. Anomalous Activity Preferences

• Deviations from typical or standard sexual activities.

• Divided into two subcategories:

  • Courtship Disorders: Activities deviate from typical courtship behavior.
  • Algolagnic Disorders: Involve pain and suffering.

2. Anomalous Target Preferences

• Deviations from typical objects of desire.
• Target is not a consenting adult; can be other humans or objects.

Specific Disorders Under Each Category

• Courtship Disorders:
  • Voyeuristic Disorder
  • Exhibitionistic Disorder
  • Frotteuristic Disorder
• Algolagnic Disorders:
  • Sexual Masochism Disorder
  • Sexual Sadism Disorder
• Anomalous Target Preferences:
  • Pedophilic Disorder: Anomaly is the age range of the person involved.
  • Fetishistic Disorder: Targets are non-human objects or non-genital body parts.
  • Transvestic Disorder: Arousal from wearing clothing of the other gender, primarily heterosexual males.

Other Specified Paraphilic Disorder

• Takes into account the infinite behaviors that could be considered paraphilic.
• Used when symptoms are characteristic of a paraphilic disorder but not listed specifically in DSM-5.

Criteria for Diagnosis

• The paraphilic disorder causes clinically significant distress or impairment of social, occupational, or other important areas of functioning.
• If the behavior causes harm to another person, it is also categorized as a paraphilic disorder.

Examples

• Telephone Scatologia: Sexual arousal from making prank phone calls, often while masturbating.
• Coprophilia: Sexual arousal involving feces or the act of defecation.
• Urophilia: Sexual arousal through the act of urination (golden showers).
• Clysmophilia: Sexual arousal related to enemas.
• Zoophilia: Sexual arousal through sexual activity with animals (bestiality).
• Hypoxophilia/Asphyxophilia: Heightened sexual arousal and gratification from restricting one's own breathing.
• Mesophilia: Sexual arousal through filth, filthy objects, or surroundings.
• Necrophilia: Sexual arousal from corpses (dead bodies).
• Autogynephilia: Sexual arousal when a male fantasizes about himself as a woman, distinct from transgender identity.

Case Study: Dave, an Exhibitionist

• Eli Coleman, a sex therapist and researcher, treats patients with paraphilias.
• Dave, a young man with exhibitionism, discusses his problems.
• Dave used drugs and alcohol to cope with problems, but his sexual behaviors escalated after stopping.

Cycle of Deviant Behavior

1. Perceived insult to masculine self-image.
2. Sense of depression and defeat.
3. Urge to expose.
4. Temporary reassurance of self-esteem from sexual sensation and the victim's reaction.
5. Negative emotions compounded by feelings of shame and remorse, leading to another cycle.

Triggering Factors

• Arguments at home, rejections of some kind, or failure at work lead to feelings of depression, loneliness, and isolation.

Treatment Approach

• Understanding the origin and pattern of feelings and activities.
• Analyzing instances of exposure to identify feelings, environments, and the overall pattern.
• Examining feelings before and after the act.
• Addressing the issues of low self-esteem.

Group Therapy Benefits

• Overcomes feelings of aloneness and shame.
• Challenges denial and defense mechanisms.
• Provides support from others with similar problems.

Individual Therapy

• Deals with other issues, particularly lack of self-worth.
• Addresses dysfunctional families and potential repetition of those dynamics.
• Aims to short-circuit the cycle of abuse from generation to generation.

Dave's Progress

• Therapy and understanding are helping him to not feel alone and to recognize his problem.
• Support from others in the group helps him through bad times and to avoid engaging in those behaviors.
• He expresses a genuine desire to stop.