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) but 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 far more common in men than in women. The focus of a paraphilia is usually very specific and unchanging.
Paraphilias include sexual behaviors society may view as distasteful, unusual, or abnormal. The most common 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 much 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 dead people, urine, feces, enemas, or obscene phone calls. Some of the behaviors associated with paraphilias are illegal; individuals under treatment for paraphilic disorders often encounter legal complications surrounding their behaviors.
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. Others want to be bitten or spanked, or 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 or cause harm to a non-consenting party.
It is unclear what causes paraphilic disorders to develop. Psychoanalysts 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. Or particular sexual acts (such as peeping, exhibiting, bestiality) that provide especially intense erotic pleasure can lead the 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, and is later reinforced for it. 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.
Treatment approaches for paraphilias have included traditional psychoanalysis, hypnosis, and behavior therapy techniques. More recently, 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. Increasingly, the evidence suggests that combining drug therapy with cognitive behavior therapy can be effective.
The level of an individual's sex drive is not consistently related to paraphiliac behavior. Additionally, high levels of circulating testosterone do not predispose a male to paraphilias. That said, hormones such as medroxyprogesterone acetate (Depo-Provera) and cyproterone acetate decrease the level of circulating testosterone, thus reducing sex drive and aggression. These hormones can result in reduction of frequency of erections, sexual fantasies, and initiation of sexual behaviors, including masturbation and intercourse. Hormones are typically used in tandem with behavioral and cognitive treatments. Antidepressants such as fluoxetine (Prozac) have also successfully decreased sex drive but have not effectively targeted sexual fantasies.
Research suggests that cognitive-behavioral models are effective in treating paraphiliacs. Aversive conditioning, for example, 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. Vicarious sensitization entails showing videotapes of deviant behaviors and their consequences, such as victims describing desired revenge or perhaps even watching surgical castrations.
There are also positive conditioning approaches that might 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 so that the behavior will be changed right away. For example, a person might be connected to a plethysmographic biofeedback machine that is hooked up to a light. The person is taught to keep the light within a specific range of color while the person is exposed to sexually stimulating material. Masturbation training might focus on separating the pleasure inherent in masturbation and climax from the deviant behavior.
Cognitive therapies described 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. 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.