The paraphilias are a set of sexual disorders that share a pattern of recurrent, intensely arousing fantasies, sexual urges, or behaviors involving either nonhuman objects, suffering and/or humiliation either of one’s self or one’s partner, or nonconsenting persons. The pattern must occur over a period of at least six months, and it must cause clinically signiﬁcant distress or impairment in functioning. The person with a paraphilia is typically aware that the symptoms are negatively affecting his or her life, but feels unable to control them. In some cases, the fantasies or objects are always necessary for erotic arousal, whereas for others, the paraphiliac fantasies and behaviors may only occur episodically, such as in times of great stress. With the exception of sexual masochism, which occurs in twenty men for every woman who has it, the paraphilias are almost never diagnosed in women.
The DSM-IV identiﬁes nine distinct categories of paraphilia, including the broad category Paraphilia Not Otherwise Speciﬁed, which brings together several rare types. They are deﬁned as follows:
- Exhibitionism—This is the classic “ﬂasher” syndrome; its primary symptom is the exposure of the genitals to strangers. Sometimes masturbation in the full view of strangers is involved as well.
- Fetishism—As the name suggests, the focus of sexual arousal is a fetish, or an inanimate object. The most frequently encountered fetishes are various women’s undergarments, shoes, or other apparel. The person with fetishism frequently becomes sexually aroused by touching or smelling the fetish object, or may ask a sexual partner to do so during a sexual encounter.
The fetish is usually required for sexual arousal, and its absence may cause erectile dysfunction.
- Frotteurism—Frotteurism involves rubbing against or touching a nonconsenting person, usually in a crowded public place. The crowded location is preferred because the individual with frotteurism is aware that his or her acts, called frottage in the DSM-IV, are illegal and can more easily escape detection and arrest in this way.
- Pedophilia—Pedophilia involves sexual activity with a prepubescent child, usually deﬁned as someone thirteen years old or younger, by a person who is age sixteen or older and at least ﬁve years older than the child (although no age difference is speciﬁed for late-adolescent pedophiles). There are two broad types of pedophile. The exclusive type is attracted only to children, whereas the nonexclusive type is sometimes attracted to adults as well. Some prefer females and some males; those attracted to females generally prefer eightto ten-year-olds, and those attracted to males tend to prefer slightly older children. The pedophile usually does not see his or her behavior as wrong. Instead he or she rationalizes the activity in terms of its “educational value” for the child, or provision of pleasure to the child, or claims that the child behaved in a sexually provocative way. Most pedophiles limit their activities to children they know, including their own children, stepchildren, relatives, and neighbors. The sexual abduction by a stranger that parents have come to fear so much, due partly to extensive media coverage of a few isolated cases, is actually extremely rare. Pedophilia is usually chronic, and it is especially so in those who prefer male children: their recidivism rate is roughly twice what it is for those who prefer females.
- Sexual Masochism—In masochism, the source of arousal is humiliation and suffering. Some individuals are disturbed by their masochistic urges and act on them while alone, sticking themselves with pins, cutting themselves, or self-administering electrical shocks, while others seek help from a sexual partner. Common masochistic acts include physical restraint and bondage, paddling, spanking, beating, electrical shocks, piercing, cutting, and humiliation, including such things as being subjected to verbal abuse, as well as being urinated or defecated upon. An unusually dangerous form of sexual masochism is hypoxyphilia, in which the person is sexually aroused by oxygen deprivation, often achieved by the use of a noose or other tight ligature around the neck. The occasional accidental death is inevitable, with several such deaths documented in the United States each year. Like other paraphilias, sexual masochism is chronic, and many individuals simply ﬁnd a particular masochistic act they like and stick with it in relative safety for many years. Some, however, increase the severity of the acts over time, especially in periods of stress, and may eventually suffer injury or death as a result.
- Sexual Sadism—Sexual masochism’s opposite number, sexual sadism focuses on deriving sexual arousal from the psychological or physical suffering of a victim, frequently an individual with sexual masochism. Some individuals with this disorder, however, prefer the suffering of unconsenting victims, and as the paraphilia is chronic, they are likely to repeat the activity until they are apprehended. The sadistic fantasies have usually been present since childhood. Although not true in all cases, the severity of the sadistic acts tends to increase over time. In severe cases, especially when sadism is associated as it sometimes is with antisocial personality disorder, serious injury or death of the victim may result.
- Transvestic Fetishism—The source of sexual arousal here is cross-dressing. While dressed in women’s clothing, the man with transvestic fetishism masturbates while fantasizing that he is both the male and female partner in the sex act. This disorder occurs exclusively in heterosexual males (in part, perhaps, because Western norms include the wearing of traditionally male clothing by women, but not the reverse), and it is different from the cross-dressing that occurs in Gender Identity Disorder. The degree of cross- dressing varies dramatically, with some men dressing entirely as females and wearing makeup, while others will wear a solitary item of women’s clothing under their regular attire. Although it is not usually a feature, gender dysphoria (dissatisfaction and discomfort with one’s gender identity) may also occur, and is listed in the DSM-IV as transvestic fetishism with gender dysphoria.
- Voyeurism—Voyeurism is the technical term for what is commonly known as being a “peeping tom.” In voyeurism, the individual becomes sexually aroused by watching unsuspecting individuals, usually strangers, as they undress or as they engage in sexual activity. A fantasy involving sexual activity with the observed person is fairly common, but no actual sexual activity with the observed person is usually sought. Like all paraphilias, it is chronic, and it usually begins before age ﬁfteen.
- Paraphilia Not Otherwise Speciﬁed—This category encompasses other paraphilias, usually quite rare, that do not meet the criteria for any of the other categories. A selected sampling, along with what the person is aroused by, follows:
- Necrophilia—dead bodies
- Zoophilia—animals (this one is often incorrectly called bestiality)
- Partialism—a single body part/area
- Telephone scatologia—obscene phone calls
Individuals with paraphilias will often select a hobby or a job that brings them into closer contact with the arousing stimulus. A fetishist may work in a lingerie shop or a shoe store, for example, or a pedophile might get a job in a school setting. As with all psychological disorders, paraphilias must cause distress and impair functioning to be diagnosed. A man who ﬁnds women’s shoes arousing, but does not require their presence to become aroused, may be a bit unusual, but he does not have a disorder.
- American Psychiatric Association. DSM-IV-TR: Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text revision. Washington, DC: American Psychiatric Association, 2000.