A paraphilia is a condition in which a person's sexual arousal and gratification depend on fantasizing about and engaging in sexual behavior that is atypical and extreme. A paraphilia is considered a disorder when it causes distress or threatens to harm someone else.
A paraphilia can revolve around a particular object (children, animals, underwear) or a particular behavior (inflicting pain, exposing oneself); it is distinguished by a preoccupation with the object or behavior to the point of being dependent on that object or behavior for sexual gratification. Most paraphilias are more common in men than in women. The focus of a paraphilia is usually very specific and unchanging.
Since many well-functioning people have sexual interests that fall outside of traditional sexual conduct, a diagnosis of a paraphilic disorder is only given if there is accompanying personal distress or impairment in social, occupational, or other important areas of functioning, or if the behavior causes harm to a non-consenting party.
Diagnosable paraphilias include: pedophilia, exhibitionism, voyeurism, frotteurism, fetishism, sexual masochism, sexual sadism, and transvestic disorder.
Although many paraphilias seem foreign or extreme, they are easier to understand if one thinks of them in terms of behaviors that, in less extreme versions, are quite common. For instance, having a partner "talk dirty" can be arousing for some people, but when talking dirty is the only way that sexual arousal or satisfaction can occur, it would be considered a paraphilia.
Some individuals want to be bitten or spanked, enjoy watching their partner perform certain acts, or become aroused by viewing a nude person or watching sexually explicit videos. But these sexual interests—if carried out by consenting adults—do not, in themselves, indicate a paraphilia. In order for a paraphilia to be diagnosed, the interest must be magnified to the point of psychological dependence, and must cause the individual significant distress to the point where it negatively interferes with their lives or relationships.
The most common paraphilias are pedophilia (sexual focus on children), exhibitionism (exposure of genitals to strangers), voyeurism (observing private activities of unaware victims), and frotteurism (touching or rubbing against a nonconsenting person). Fetishism (use of inanimate objects), sexual masochism (being humiliated or forced to suffer), sexual sadism (inflicting humiliation or suffering), and transvestic disorder (sexually arousing cross-dressing) are less common. There is also a category of paraphilias—known as Other Specified Paraphilic Disorders—which encompasses behaviors not covered by the already named diagnoses, such as those involving corpses, urine, feces, enemas, or obscene phone calls.
Men are much more likely to have a paraphilia than women. Some paraphilias, such as exhibitionistic disorder, frotteuristic disorder, pedophilic disorder, and fetishistic disorder, have little evidence of women engaging in them at a diagnostic level. One paraphilia that does appear in women in significant numbers (relative to other paraphilias) is sexual masochism.
In more than 90 percent of cases (and 99 percent in Europe), paraphilic sex offenders are males.
Paraphilic disorders are not common, but individual behaviors, which would not constitute a paraphilic disorder on their own, and fantasies about paraphilias are fairly common. While collecting data on people’s private sex lives is inherently difficult to reliably conduct, one survey of nearly 2,000 middle-aged German men found that 62.4 percent of them reported at least one paraphilia-associated sexual arousal pattern (Ahers, et. al.). A meta-analysis of research on BDSM (Bondage/Discipline, Dominance/Submission, and Sadism/Masochism) found that between 40 and 70 percent of people have had a BDSM-related sexual fantasy, and that between 5 and 20 percent of people have engaged in BDSM activity.
It is unclear what causes paraphilic disorders to develop.
Some psychologists theorize that an individual with a paraphilia is repeating or reverting to a sexual habit that arose early in life.
Behaviorists suggest that paraphilias begin through a process of conditioning: Nonsexual objects can become sexually arousing if they are repeatedly associated with pleasurable sexual activity. Particular sexual acts (such as peeping or exhibitionism) that provide especially intense erotic pleasure can lead a person to prefer that behavior. In some cases, there seems to be a predisposing factor, such as difficulty forming person-to-person relationships.
Behavioral learning models suggest that a child who is the victim or observer of inappropriate sexual behaviors may learn to imitate that behavior.
Compensation models suggest that these individuals are deprived of normal social sexual contacts and thus seek gratification through less socially acceptable means.
Physiological models focus on the relationship between hormones, behavior, and the central nervous system, with a particular interest in the role of aggression and male sexual hormones. Evidence from some studies indicates that certain abnormalities in the frontal and temporal lobes of the brain correlate with pedophilic urges. One hypothesis on foot fetishes comes from the fact that the region in the brain that processes sensory information from the feet is adjacent to the area that processes sensory information from the genitals.
Some research indicates that engaging in sadistic sexual behaviors may be driven by a desire for feelings of power and dominance, in addition to simply sexual pleasure.
Treatment approaches for paraphilic disorders have included traditional psychotherapy, behavior therapy techniques, and pharmacological medications. The standard for treating paraphilic disorders is a combination of behavioral therapy and medication.
A class of drugs called antiandrogens that drastically lower testosterone levels temporarily have been used in conjunction with these forms of treatment. The drug lowers sex drive in males and can reduce the frequency of mental imagery of sexually arousing scenes. This allows for concentration on counseling without a strong distraction from the paraphiliac urges.
Hormones, particularly gonadotrophin-releasing hormone (GnRH) analogues, can reduce sex drive and aggression. These hormones can result in substantially less interest in sex altogether, with fewer erections, sexual fantasies, and initiation of sexual behaviors, including masturbation and intercourse. Antidepressants have also successfully decreased sex drive but have not effectively targeted sexual fantasies.
Cognitive therapies include restructuring cognitive distortions and empathy training. Restructuring cognitive distortions involves correcting erroneous beliefs by the patient, which may lead to errors in behavior such as seeing a victim and constructing erroneous logic that the victim deserves to be party to the deviant act. Vicarious sensitization entails showing videotapes of deviant behaviors and their consequences, such as victims describing desired revenge. Empathy training involves helping the offender take on the perspective of the victim and better identify with them, in order to understand the harm that has been done.
Results may vary. A meta-analysis of the efficacy of cognitive behavioral therapy for sex offenders with paraphilic disorders indicates only a modest reduction in recidivism among sexual offenders.
Treatments for paraphilias can be very successful, but primarily treat symptoms. Paraphilic interests, though they can wax and wane in intensity throughout a person’s life, are believed to be enduring.
Aversive conditioning involves using negative stimuli to reduce or eliminate a behavior. Covert sensitization entails the patient relaxing, visualizing scenes of deviant behavior followed by a negative event, such as getting his penis stuck in the zipper of his pants. Assisted aversive conditioning is similar to covert sensitization except the negative event is made real, most likely in the form of a foul odor pumped in the air by the therapist. The goal is for the patient to associate the deviant behavior with the foul odor and take measures to avoid the odor by avoiding said behavior.
Positive conditioning approaches center on social skills training and alternate behaviors the patient might take that are more appropriate. Reconditioning techniques center on providing immediate feedback to the patient. Masturbation training might focus on separating the pleasure inherent in masturbation and climax from the deviant behavior.
Antidepressants, particularly selective serotonin reuptake inhibitors (SSRIs) have been shown to have clinical efficacy in treating paraphilic disorder, particularly with mild paraphilias, such as exhibitionism, and most often with juveniles. One study found a 50 percent remission of paraphilic symptoms using the SSRI sertraline (Zoloft). Though research is limited, SSRIs have shown little efficacy for more dangerous paraphilias, such as pedophilia.
Antiandrogen treatments are often successful in treating the symptoms of severe paraphilic disorders. Some research has shown these treatments result in an 80 to 90 percent reduction of sexual behavior and the remission of sexual fantasies over the course of one to three months. A follow-up study found the recidivism of sexual offenses dropped to 6 percent in those treated with antiandrogens, compared with an 85 percent recidivism rate prior to treatment (Thibaut, 2010). However, antiandrogen treatments can have severe side effects, including pulmonary embolism, depression, high blood pressure, bone mineral loss, weight gain, and others.
A specific antiandrogen hormone, Gonadotrophin-releasing hormone (GnRH) treatment may be the most effective treatment for sex offenders at high risk of sexual violence, such as pedophiles. These treatments rapidly and significantly reduce a person’s sex drive, and have been compared to medical castration. GnRH hormones desensitize gonadotropin-releasing hormone receptors, resulting in a reduction of testosterone in the testes. In one study of sexual offenders given this treatment, no sexual behavior was observed and with one exception, no participants committed sexual offenses. A more recent study found that after ten weeks of use in a double-blind trial, 58 percent of men with pedophilic disorder denied sexual attraction to minors, whereas only 12 percent in the placebo group made such a denial (Landgren, et al., 2020). GnRH treatments also have side effects, including transient pain, nausea, weight gain, bone mineral loss, decreased testicular volume, muscular tenderness, and others.
As with all treatments, both therapeutic and pharmacological, study of these medications is extremely limited, with small sample sizes and imperfect trials, so the efficacy is ultimately unknown.