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Paraphilia (previously known as sexual perversion and sexual deviation) is the experience of intense sexual arousal to atypical objects, situations, fantasies, behaviors, or individuals. It has also been defined as sexual interest in anything other than a consenting human partner. There is no scientific consensus for any precise border between unusual sexual interests and paraphilic ones. There is debate over which, if any, of the paraphilias should be listed in diagnostic manuals, such as the '' Diagnostic and Statistical Manual of Mental Disorders'' (DSM) or the
International Classification of Diseases The International Classification of Diseases (ICD) is a globally used diagnostic tool for epidemiology, health management and clinical purposes. The ICD is maintained by the World Health Organization (WHO), which is the directing and coordinating ...
(ICD). The number and
taxonomy Taxonomy is the practice and science of categorization or classification. A taxonomy (or taxonomical classification) is a scheme of classification, especially a hierarchical classification, in which things are organized into groups or types. ...
of paraphilia is under debate; one source lists as many as 549 types of paraphilia. The
DSM-5 The ''Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition'' (DSM-5), is the 2013 update to the '' Diagnostic and Statistical Manual of Mental Disorders'', the taxonomic and diagnostic tool published by the American Psychiatri ...
has specific listings for eight paraphilic disorders. Several sub-classifications of the paraphilias have been proposed, and some argue that a fully dimensional, spectrum or complaint-oriented approach would better reflect the evidence.


Terminology


History

Many terms have been used to describe atypical sexual interests, and there remains debate regarding technical accuracy and perceptions of stigma.
Sexologist Sexology is the scientific study of human sexuality, including human sexual interests, behaviors, and functions. The term ''sexology'' does not generally refer to the non-scientific study of sexuality, such as social criticism. Sexologists a ...
John Money John William Money (8 July 1921 – 7 July 2006) was a New Zealand psychologist, sexologist and author known for his research into sexual identity and Sex determination and differentiation (human), biology of gender. He was one of the first ...
popularized the term ''paraphilia'' as a non-
pejorative A pejorative or slur is a word or grammatical form expressing a negative or a disrespectful connotation, a low opinion, or a lack of respect toward someone or something. It is also used to express criticism, hostility, or disregard. Sometimes, a ...
designation for unusual sexual interests. Money described paraphilia as "a sexuoerotic embellishment of, or alternative to the official, ideological norm." Psychiatrist
Glen Gabbard Glen Owens Gabbard (born 1949) is an American psychiatrist known for authoring professional teaching texts for the field. He is Clinical Professor of Psychiatry at Baylor College of Medicine in Houston, Texas, and is also training and supervising ...
writes that despite efforts by Stekel and Money, "the term ''paraphilia'' remains pejorative in most circumstances." Coinage of the term ''paraphilia'' (''paraphilie'') has been credited to
Friedrich Salomon Krauss Friedrich Salomon Krauss (7 October 1859, Požega, Kingdom of Hungary – 29 May 1938, Vienna, Austria) was a Croatian Austrian Jewish sexologist, ethnographer, folklorist, and Slavist. Education In 1877–78, Krauss attended the Universit ...
in 1903 and it was used with some regularity by
Wilhelm Stekel Wilhelm Stekel (; 18 March 1868 – 25 June 1940) was an Austrian physician and psychologist, who became one of Sigmund Freud's earliest followers, and was once described as "Freud's most distinguished pupil". According to Ernest Jones, "Stekel ...
in the 1920s. The term comes from the
Greek Greek may refer to: Greece Anything of, from, or related to Greece, a country in Southern Europe: *Greeks, an ethnic group. *Greek language, a branch of the Indo-European language family. **Proto-Greek language, the assumed last common ancestor ...
παρά (''para'') "beside" and φιλία ('' -philia'') "friendship,
love Love encompasses a range of strong and positive emotional and mental states, from the most sublime virtue or good habit, the deepest interpersonal affection, to the simplest pleasure. An example of this range of meanings is that the love o ...
". In the late 19th century, psychologists and psychiatrists started to categorize various paraphilias as they wanted a more descriptive system than the legal and religious constructs of
sodomy Sodomy () or buggery (British English) is generally anal or oral sex between people, or sexual activity between a person and a non-human animal ( bestiality), but it may also mean any non- procreative sexual activity. Originally, the term ''sod ...
and
perversion Perversion is a form of human behavior which deviates from what is considered to be orthodox or normal. Although the term ''perversion'' can refer to a variety of forms of deviation, it is most often used to describe sexual behaviors that are c ...
. Before the introduction of the term ''paraphilia'' in the DSM-III (1980), the term ''sexual deviation'' was used to refer to paraphilias in the first two editions of the manual. In 1981, an article published in ''
American Journal of Psychiatry ''The American Journal of Psychiatry'' is a monthly peer-reviewed medical journal covering all aspects of psychiatry, and is the official journal of the American Psychiatric Association. The first volume was issued in 1844, at which time it was k ...
'' described paraphilia as "recurrent, intense sexually arousing fantasies, sexual urges, or behaviors generally involving" the following: * Non-human objects * The suffering or humiliation of oneself or one's partner * Children * Non-consenting persons


Homosexuality and non-heterosexuality

Homosexuality Homosexuality is romantic attraction, sexual attraction, or sexual behavior between members of the same sex or gender. As a sexual orientation, homosexuality is "an enduring pattern of emotional, romantic, and/or sexual attractions" to pe ...
, now widely accepted as a variant of human sexuality, was at one time discussed as a sexual deviation.
Sigmund Freud Sigmund Freud ( , ; born Sigismund Schlomo Freud; 6 May 1856 – 23 September 1939) was an Austrian neurologist and the founder of psychoanalysis, a clinical method for evaluating and treating pathologies explained as originating in conflicts ...
and subsequent
psychoanalytic PsychoanalysisFrom Greek: + . is a set of theories and therapeutic techniques"What is psychoanalysis? Of course, one is supposed to answer that it is many things — a theory, a research method, a therapy, a body of knowledge. In what might ...
thinkers considered homosexuality and paraphilias to result from
psychosexual In Freudian psychology, psychosexual development is a central element of the psychoanalytic sexual drive theory. Freud believed that personality developed through a series of childhood stages in which pleasure seeking energies from the child b ...
non-normative relations to the
Oedipal complex The Oedipus complex (also spelled Œdipus complex) is an idea in psychoanalytic theory. The complex is an ostensibly universal phase in the life of a young boy in which, to try to immediately satisfy basic desires, he unconsciously wishes to have ...
. As such, the term ''sexual perversion'' or the epithet ''pervert'' have historically referred to
gay ''Gay'' is a term that primarily refers to a homosexual person or the trait of being homosexual. The term originally meant 'carefree', 'cheerful', or 'bright and showy'. While scant usage referring to male homosexuality dates to the late 1 ...
men, as well as other
non-heterosexual Non-heterosexual is a word for a sexual orientation or sexual identity that is not heterosexual. The term helps define the "concept of what is the norm and how a particular group is different from that norm". ''Non-heterosexual'' is used in fem ...
s (people who fall outside the perceived norms of sexual orientation). By the mid-20th century, mental health practitioners began formalizing "deviant sexuality" classifications into categories. Originally coded as 000-x63, homosexuality was the top of the classification list (Code 302.0) until the
American Psychiatric Association The American Psychiatric Association (APA) is the main professional organization of psychiatrists and trainee psychiatrists in the United States, and the largest psychiatric organization in the world. It has more than 37,000 members are involv ...
removed homosexuality from the DSM in 1973. Martin Kafka writes, "Sexual disorders once considered paraphilias (e.g., homosexuality) are now regarded as variants of normal sexuality." A 2012 literature study by clinical psychologist
James Cantor James M. Cantor is an American-Canadian clinical psychologist and sexologist specializing in hypersexuality and paraphilias. A former senior scientist with the Centre for Addiction and Mental Health (CAMH) in Toronto,fraternal birth order Fraternal birth order has been correlated with male sexual orientation, with a significant volume of research finding that the more older Brother, brothers a male has from the same mother, the greater the probability he will have a Homosexuality, ...
, handedness, IQ and cognitive profile, and
neuroanatomy Neuroanatomy is the study of the structure and organization of the nervous system. In contrast to animals with radial symmetry, whose nervous system consists of a distributed network of cells, animals with bilateral symmetry have segregated, defi ...
". The research then concluded that the data seemed to suggest paraphilias and homosexuality as two distinct categories, but regarded the conclusion as "quite tentative" given the current limited understanding of paraphilias.


Causes

The causes of paraphilias in people are unclear, but some research points to a possible prenatal
neurodevelopmental The development of the nervous system, or neural development (neurodevelopment), refers to the processes that generate, shape, and reshape the nervous system of animals, from the earliest stages of embryonic development to adulthood. The fie ...
correlation. A 2008 study analyzing the sexual fantasies of 200 heterosexual men by using the Wilson Sex Fantasy Questionnaire exam determined that males with a pronounced degree of fetish interest had a greater number of older brothers, a high 2D:4D
digit ratio The digit ratio is the ratio of the lengths of different digits or fingers on a hand, the study of which has been considered pseudoscience. The 2D:4D ratio is the most studied digit ratio and is calculated by dividing the length of the index f ...
(which would indicate excessive prenatal estrogen exposure), and an elevated probability of being
left-handed In human biology, handedness is an individual's preferential use of one hand, known as the dominant hand, due to it being stronger, faster or more dextrous. The other hand, comparatively often the weaker, less dextrous or simply less subject ...
, suggesting that disturbed hemispheric
brain lateralization A brain is an organ that serves as the center of the nervous system in all vertebrate and most invertebrate animals. It is located in the head, usually close to the sensory organs for senses such as vision. It is the most complex organ in a v ...
may play a role in paraphilic attractions.
Behavioral Behavior (American English) or behaviour (British English) is the range of actions and mannerisms made by individuals, organisms, systems or artificial entities in some environment. These systems can include other systems or organisms as we ...
explanations propose that paraphilias are conditioned early in life, during an experience that pairs the paraphilic stimulus with intense sexual arousal.
Susan Nolen-Hoeksema Susan Kay Nolen-Hoeksema (May 22, 1959 – January 2, 2013) was an American professor of psychology at Yale University. Her research explored how mood regulation strategies could correlate to a person's vulnerability to depression, with special ...
suggests that, once established, masturbatory fantasies about the stimulus reinforce and broaden the paraphilic arousal.


Diagnosis

There is scientific and political controversy regarding the continued inclusion of sex-related diagnoses such as the paraphilias in the DSM, due to the stigma of being classified as a mental illness. Some groups, seeking greater understanding and acceptance of
sexual diversity Gender and sexual diversity (GSD), or simply sexual diversity, refers to all the diversities of sex characteristics, sexual orientations and gender identities, without the need to specify each of the identities, behaviors, or characteristics that ...
, have lobbied for changes to the legal and medical status of unusual sexual interests and practices.
Charles Allen Moser Charles Allen Moser (born 1952) is an American physician specializing in transgender health, a clinical sexologist, sex therapist, and sex educator practicing in San Francisco, California. He is the author of numerous academic publications and b ...
, a physician and advocate for sexual minorities, has argued that the diagnoses should be eliminated from diagnostic manuals.


Typical versus atypical interests

Albert Eulenburg (1914) noted a commonality across the paraphilias, using the terminology of his time, "All the forms of sexual perversion...have one thing in common: their roots reach down into the matrix of natural and normal sex life; there they are somehow closely connected with the feelings and expressions of our physiological erotism. They are...hyperbolic intensifications, distortions, monstrous fruits of certain partial and secondary expressions of this erotism which is considered 'normal' or at least within the limits of healthy sex feeling." The clinical literature contains reports of many paraphilias, only some of which receive their own entries in the diagnostic taxonomies of the
American Psychiatric Association The American Psychiatric Association (APA) is the main professional organization of psychiatrists and trainee psychiatrists in the United States, and the largest psychiatric organization in the world. It has more than 37,000 members are involv ...
or the
World Health Organization The World Health Organization (WHO) is a specialized agency of the United Nations responsible for international public health. The WHO Constitution states its main objective as "the attainment by all peoples of the highest possible level of ...
. There is disagreement regarding which sexual interests should be deemed paraphilic disorders versus normal variants of sexual interest. For example, as of May 2000, per
DSM-IV-TR The ''Diagnostic and Statistical Manual of Mental Disorders'' (DSM; latest edition: DSM-5-TR, published in March 2022) is a publication by the American Psychiatric Association (APA) for the classification of mental disorders using a common langua ...
, "Because some cases of Sexual Sadism may not involve harm to a victim (e.g., inflicting humiliation on a consenting partner), the wording for sexual sadism involves a hybrid of the
DSM-III-R The ''Diagnostic and Statistical Manual of Mental Disorders'' (DSM; latest edition: DSM-5-TR, published in March 2022) is a publication by the American Psychiatric Association (APA) for the classification of mental disorders using a common langua ...
and
DSM-IV The ''Diagnostic and Statistical Manual of Mental Disorders'' (DSM; latest edition: DSM-5-TR, published in March 2022) is a publication by the American Psychiatric Association (APA) for the classification of mental disorders using a common langu ...
wording (i.e., "the person has acted on these urges with a non-consenting person, or the urges, sexual fantasies, or behaviors cause marked distress or interpersonal difficulty")". The DSM-IV-TR also acknowledges that the diagnosis and classification of paraphilias across cultures or religions "is complicated by the fact that what is considered deviant in one cultural setting may be more acceptable in another setting”.American Psychiatric Association. (2000). ''Diagnostic and statistical manual of mental disorders'' (4th ed., text rev.). Washington, DC: Author. Some argue that cultural relativism is important to consider when discussing paraphilias, because there is wide variance concerning what is sexually acceptable across cultures.
Consensual Consent occurs when one person voluntarily agrees to the proposal or desires of another. It is a term of common speech, with specific definitions as used in such fields as the law, medicine, research, and sexual relationships. Consent as und ...
adult activities and adult entertainment involving
sexual roleplay Sexual roleplay is roleplay that has a strong erotic element. It may involve two or more people who act out roles in order to bring to life a sexual fantasy and may be a form of foreplay and be sexually arousing. Many people regard sexual rolep ...
, novel, superficial, or trivial aspects of sexual fetishism, or incorporating the use of
sex toys A sex toy is an object or device that is primarily used to facilitate human sexual pleasure, such as a dildo, artificial vagina or vibrator. Many popular sex toys are designed to resemble human genitals, and may be vibrating or non-vibratin ...
are not necessarily paraphilic. Paraphilial psychopathology is not the same as psychologically normative adult
human sexual behavior Human sexual activity, human sexual practice or human sexual behaviour is the manner in which humans experience and express their sexuality. People engage in a variety of sexual acts, ranging from activities done alone (e.g., masturbation) t ...
s,
sexual fantasy A sexual fantasy or erotic fantasy is a mental image or pattern of thought that stirs a person's sexuality and can create or enhance sexual arousal. A sexual fantasy can be created by the person's imagination or memory, and may be triggered auto ...
, and sex play.


Intensity and specificity

Clinicians distinguish between optional, preferred and exclusive paraphilias, although the terminology is not completely standardized. An "optional" paraphilia is an alternative route to sexual arousal. In preferred paraphilias, a person prefers the paraphilia to conventional sexual activities, but also engages in conventional sexual activities. The literature includes single-case studies of very rare and idiosyncratic paraphilias. These include an adolescent male who had a strong fetishistic interest in the exhaust pipes of cars, a young man with a similar interest in a specific type of car, and a man who had a paraphilic interest in sneezing (both his own and the sneezing of others).


Diagnostic and Statistical Manual of Mental Disorders


DSM-I and DSM-II

In American psychiatry, prior to the publication of the DSM-I, paraphilias were classified as cases of "
psychopathic Psychopathy, sometimes considered synonymous with sociopathy, is characterized by persistent antisocial behavior, impaired empathy and remorse, and bold, disinhibited, and egotistical traits. Different conceptions of psychopathy have been u ...
personality with pathologic sexuality". The DSM-I (1952) included sexual deviation as a
personality disorder Personality disorders (PD) are a class of mental disorders characterized by enduring maladaptive patterns of behavior, cognition, and inner experience, exhibited across many contexts and deviating from those accepted by the individual's culture ...
of
sociopathic Psychopathy, sometimes considered synonymous with sociopathy, is characterized by persistent antisocial behavior, impaired empathy and remorse, and bold, disinhibited, and egotistical traits. Different conceptions of psychopathy have been ...
subtype. The only diagnostic guidance was that sexual deviation should have been "reserved for deviant sexuality which asnot symptomatic of more extensive syndromes, such as
schizophrenic Schizophrenia is a mental disorder characterized by continuous or relapsing episodes of psychosis. Major symptoms include hallucinations (typically hearing voices), delusions, and disorganized thinking. Other symptoms include social withdr ...
or obsessional reactions". The specifics of the disorder were to be provided by the clinician as a "supplementary term" to the sexual deviation diagnosis; there were no restrictions in the DSM-I on what this supplementary term could be. Researcher
Anil Aggrawal Anil Aggrawal is a professor of forensic medicine at the Maulana Azad Medical College, New Delhi, India. He is known chiefly for his online journal, ''Anil Aggrawal's Internet Journal of Forensic Medicine and Toxicology''. He joined Maulana Aza ...
writes that the now-obsolete DSM-I listed examples of supplementary terms for pathological behavior to include "homosexuality,
transvestism Transvestism is the practice of dressing in a manner traditionally associated with the opposite sex. In some cultures, transvestism is practiced for religious, traditional, or ceremonial reasons. The term is considered outdated in Western ...
,
pedophilia Pedophilia ( alternatively spelt paedophilia) is a psychiatric disorder in which an adult or older adolescent experiences a primary or exclusive sexual attraction to prepubescent children. Although girls typically begin the process of puberty ...
,
fetishism A fetish (derived from the French , which comes from the Portuguese , and this in turn from Latin , 'artificial' and , 'to make') is an object believed to have supernatural powers, or in particular, a human-made object that has power over ot ...
, and
sexual sadism Sexual sadism disorder is the condition of experiencing sexual arousal in response to the extreme pain, suffering or humiliation of others. Several other terms have been used to describe the condition, and the condition may overlap with other c ...
, including
rape Rape is a type of sexual assault usually involving sexual intercourse or other forms of sexual penetration carried out against a person without their consent. The act may be carried out by physical force, coercion, abuse of authority, or ...
, sexual assault, mutilation." The DSM-II (1968) continued to use the term ''sexual deviations'', but no longer ascribed them under personality disorders, but rather alongside them in a broad category titled "personality disorders and certain other nonpsychotic mental disorders". The types of sexual deviations listed in the DSM-II were: sexual orientation disturbance (homosexuality), fetishism, pedophilia, transvestitism (sic), exhibitionism,
voyeurism Voyeurism is the sexual interest in or practice of watching other people engaged in intimate behaviors, such as undressing, sexual activity, or other actions of a private nature. The term comes from the French ''voir'' which means "to see". ...
,
sadism Sadism may refer to: * Sadomasochism, the giving or receiving of pleasure from acts involving the receipt or infliction of pain or humiliation * Sadistic personality disorder, an obsolete term proposed for individuals who derive pleasure from the s ...
,
masochism Sadomasochism ( ) is the giving and receiving of pleasure from acts involving the receipt or infliction of pain or humiliation. Practitioners of sadomasochism may seek sexual pleasure from their acts. While the terms sadist and masochist refer ...
, and "other sexual deviation". No definition or examples were provided for "other sexual deviation", but the general category of sexual deviation was meant to describe the sexual preference of individuals that was "directed primarily toward objects other than people of opposite sex, toward sexual acts not usually associated with
coitus Sexual intercourse (or coitus or copulation) is a sexual activity typically involving the insertion and thrusting of the penis into the vagina for sexual pleasure or reproduction.Sexual intercourse most commonly means penile–vaginal penetr ...
, or toward coitus performed under bizarre circumstances, as in necrophilia, pedophilia, sexual sadism, and fetishism." Except for the removal of homosexuality from the DSM-III onwards, this definition provided a general standard that has guided specific definitions of paraphilias in subsequent DSM editions, up to DSM-IV-TR.Laws and O'Donohue (2008) p. 386


DSM-III through DSM-IV

The term ''paraphilia'' was introduced in the DSM-III (1980) as a subset of the new category of "psychosexual disorders." The DSM-III-R (1987) renamed the broad category to sexual disorders, renamed atypical paraphilia to paraphilia NOS (not otherwise specified), renamed transvestism as
transvestic fetishism Transvestic fetishism is a psychiatric diagnosis applied to men who are thought to have an excessive sexual or erotic interest in cross-dressing; this interest is often expressed in autoerotic behavior. It differs from cross-dressing for enter ...
, added
frotteurism Frotteurism is a paraphilic interest in rubbing, usually one's pelvic area or erect penis, against a non-consenting person for sexual pleasure. It may involve touching any part of the body, including the genital area. A person who practices fro ...
, and moved
zoophilia Zoophilia is a paraphilia involving a sexual fixation on non-human animals. Bestiality is cross-species sexual activity between humans and non-human animals. The terms are often used interchangeably, but some researchers make a distinction b ...
to the NOS category. It also provided seven nonexhaustive examples of NOS paraphilias, which besides
zoophilia Zoophilia is a paraphilia involving a sexual fixation on non-human animals. Bestiality is cross-species sexual activity between humans and non-human animals. The terms are often used interchangeably, but some researchers make a distinction b ...
included exhibitionism, necrophilia,
partialism Partialism is sexual fetish with an exclusive focus on a specific part of the body other than genitals. Partialism is categorized as a fetishistic disorder in the DSM-5 of the American Psychiatric Association only if it causes significant psyc ...
,
coprophilia Coprophilia (from Greek κόπρος, ''kópros'' 'excrement' and φιλία, ''philía'' 'liking, fondness'), also called scatophilia or scat (Greek: σκατά, ''skatá'' 'feces'), is the paraphilia involving sexual arousal and pleasure from ...
,
klismaphilia Klismaphilia (or ''klysmaphilia''), from the Greek words ("enema", from , "deluge, flood") and ("love"), is a paraphilia involving enjoyment of, and sexual arousal from, enemas. History The term ''klismaphilia'' was coined in 1973 by Dr. Jo ...
, and
urophilia Urolagnia (also urophilia, and, more colloquially, a golden shower or watersports) associates sexual excitement with the sight or thought of urine or urination, and may also refer to such behaviours or acts. It is a paraphilia. The term has o ...
. The DSM-IV (1994) retained the sexual disorders classification for paraphilias, but added an even broader category, "sexual and
gender identity disorder Gender dysphoria (GD) is the distress a person experiences due to a mismatch between their gender identitytheir personal sense of their own genderand their sex assigned at birth. The diagnostic label gender identity disorder (GID) was used unti ...
s," which includes them. The DSM-IV retained the same types of paraphilias listed in DSM-III-R, including the NOS examples, but introduced some changes to the definitions of some specific types.


DSM-IV-TR

The DSM-IV-TR describes paraphilias as "recurrent, intense sexually arousing fantasies, sexual urges or behaviors generally involving nonhuman objects, the suffering or humiliation of oneself or one's partner, or children or other nonconsenting persons that occur over a period of six months" (criterion A), which "cause clinically significant distress or impairment in social, occupational, or other important areas of functioning" (criterion B). DSM-IV-TR names eight specific paraphilic disorders ( exhibitionism,
fetishism A fetish (derived from the French , which comes from the Portuguese , and this in turn from Latin , 'artificial' and , 'to make') is an object believed to have supernatural powers, or in particular, a human-made object that has power over ot ...
,
frotteurism Frotteurism is a paraphilic interest in rubbing, usually one's pelvic area or erect penis, against a non-consenting person for sexual pleasure. It may involve touching any part of the body, including the genital area. A person who practices fro ...
,
pedophilia Pedophilia ( alternatively spelt paedophilia) is a psychiatric disorder in which an adult or older adolescent experiences a primary or exclusive sexual attraction to prepubescent children. Although girls typically begin the process of puberty ...
,
sexual masochism Sadomasochism ( ) is the giving and receiving of pleasure from acts involving the receipt or infliction of pain or humiliation. Practitioners of sadomasochism may seek sexual pleasure from their acts. While the terms sadist and masochist refer ...
,
sexual sadism Sexual sadism disorder is the condition of experiencing sexual arousal in response to the extreme pain, suffering or humiliation of others. Several other terms have been used to describe the condition, and the condition may overlap with other c ...
,
voyeurism Voyeurism is the sexual interest in or practice of watching other people engaged in intimate behaviors, such as undressing, sexual activity, or other actions of a private nature. The term comes from the French ''voir'' which means "to see". ...
, and
transvestic fetishism Transvestic fetishism is a psychiatric diagnosis applied to men who are thought to have an excessive sexual or erotic interest in cross-dressing; this interest is often expressed in autoerotic behavior. It differs from cross-dressing for enter ...
, plus a residual category, paraphilia—not otherwise specified). Criterion B differs for exhibitionism, frotteurism, and pedophilia to include acting on these urges, and for sadism, acting on these urges with a nonconsenting person.American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). pp. 569-570, 572, 574, Washington, DC: Author. Sexual arousal in association with objects that were designed for sexual purposes is not diagnosable. Some paraphilias may interfere with the capacity for sexual activity with consenting adult partners. In the current version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), a paraphilia is not diagnosable as a
psychiatric disorder A mental disorder, also referred to as a mental illness or psychiatric disorder, is a behavioral or mental pattern that causes significant distress or impairment of personal functioning. Such features may be persistent, relapsing and remitt ...
unless it causes distress to the individual or harm to others.


DSM-5

The
DSM-5 The ''Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition'' (DSM-5), is the 2013 update to the '' Diagnostic and Statistical Manual of Mental Disorders'', the taxonomic and diagnostic tool published by the American Psychiatri ...
adds a distinction between ''paraphilias'' and ''paraphilic disorders'', stating that paraphilias do not require or justify psychiatric treatment in themselves, and defining ''paraphilic disorder'' as "a paraphilia that is currently causing distress or impairment to the individual or a paraphilia whose satisfaction has entailed personal harm, or risk of harm, to others". The DSM-5 Paraphilias Subworkgroup reached a "consensus that paraphilias are not ''ipso facto'' psychiatric disorders", and proposed "that the DSM-V make a distinction between ''paraphilias'' and paraphilic ''disorders''. ..One would ''ascertain'' a paraphilia (according to the nature of the urges, fantasies, or behaviors) but ''diagnose'' a paraphilic disorder (on the basis of distress and impairment). In this conception, having a paraphilia would be a necessary but not a sufficient condition for having a paraphilic disorder." The 'Rationale' page of any paraphilia in the electronic DSM-5 draft continues: "This approach leaves intact the distinction between normative and non-normative sexual behavior, which could be important to researchers, but without automatically labeling non-normative sexual behavior as psychopathological. It also eliminates certain logical absurdities in the DSM-IV-TR. In that version, for example, a man cannot be classified as a transvestite—however much he cross-dresses and however sexually exciting that is to him—unless he is unhappy about this activity or impaired by it. This change in viewpoint would be reflected in the diagnostic criteria sets by the addition of the word 'Disorder' to all the paraphilias. Thus, Sexual Sadism would become
Sexual Sadism Disorder Sexual sadism disorder is the condition of experiencing sexual arousal in response to the extreme pain, suffering or humiliation of others. Several other terms have been used to describe the condition, and the condition may overlap with other co ...
; Sexual Masochism would become
Sexual Masochism Disorder Sexual masochism disorder (SMD) is the condition of experiencing recurring and intense sexual arousal in response to enduring moderate or extreme pain, suffering, or humiliation.American Psychiatric Association. (2013). ''Diagnostic and Statistic ...
, and so on."
Bioethics Bioethics is both a field of study and professional practice, interested in ethical issues related to health (primarily focused on the human, but also increasingly includes animal ethics), including those emerging from advances in biology, m ...
professor
Alice Dreger Alice Domurat Dreger () is an American historian, bioethicist, author, and former professor of clinical medical humanities and bioethics at the Feinberg School of Medicine, Northwestern University in Chicago, Illinois. Dreger engages in academic ...
interpreted these changes as "a subtle way of saying sexual kinks are basically okay – so okay, the sub-work group doesn't actually bother to define paraphilia. But a paraphilic disorder is defined: that's when an atypical sexual interest causes distress or impairment to the individual or harm to others." Interviewed by Dreger,
Ray Blanchard Ray Milton Blanchard ( ; born October 9, 1945) is an American-Canadian sexologist, best known for his research studies on transsexualism, pedophilia and sexual orientation. He found that men with more older brothers are more likely to be gay th ...
, the Chair of the Paraphilias Sub-Work Group, stated, "We tried to go as far as we could in depathologizing mild and harmless paraphilias, while recognizing that severe paraphilias that distress or impair people or cause them to do harm to others are validly regarded as disorders."
Charles Allen Moser Charles Allen Moser (born 1952) is an American physician specializing in transgender health, a clinical sexologist, sex therapist, and sex educator practicing in San Francisco, California. He is the author of numerous academic publications and b ...
stated that this change is not really substantive, as the DSM-IV already acknowledged a difference between paraphilias and non-pathological but unusual sexual interests, a distinction that is virtually identical to what was being proposed for DSM-5, and it is a distinction that, in practice, has often been ignored. Linguist Andrew Clinton Hinderliter argued that "including some sexual interests—but not others—in the DSM creates a fundamental asymmetry and communicates a negative value judgment against the sexual interests included," and leaves the paraphilias in a situation similar to
ego-dystonic homosexuality Ego-dystonic sexual orientation is a highly controversial mental health diagnosis that was included in the American Psychiatric Association's (APA) ''Diagnostic and Statistical Manual of Mental Disorders'' (DSM) from 1980 to 1987 (under the name ...
, which was removed from the DSM because it was no longer recognized as a mental disorder. The DSM-5 acknowledges that many dozens of paraphilias exist, but only has specific listings for eight that are forensically important and relatively common. These are voyeuristic disorder, exhibitionistic disorder, frotteuristic disorder, sexual masochism disorder, sexual sadism disorder, pedophilic disorder, fetishistic disorder, and transvestic disorder. Other paraphilias can be diagnosed under the
Other Specified Paraphilic Disorder Other specified paraphilic disorder is the term used by the fifth edition of the '' Diagnostic and Statistical Manual of Mental Disorders'' (DSM-5) to refer to any of the many other paraphilic disorders that are not explicitly named in the manual. A ...
or Unspecified Paraphilic Disorder listings, if accompanied by distress or impairment.


International Classification of Diseases


ICD-6,  ICD-7,  ICD-8

In the ICD-6 (1948) and ICD-7 (1955), a category of “sexual deviation” was listed with “other Pathological personality disorders”. In the ICD-8 (1965), “sexual deviations” were categorized as homosexuality, fetishism, pedophilia, transvestism, exhibitionism, voyeurism, sadism and masochism.


ICD-9

In the ICD-9 (1975), the category of sexual deviations and disorders was expanded to include
transsexualism Transsexual people experience a gender identity that is inconsistent with their assigned sex, and desire to permanently transition to the sex or gender with which they identify, usually seeking medical assistance (including sex reassignmen ...
, sexual dysfunctions, and psychosexual identity disorders. The list contained homosexuality, bestiality, pedophilia, transvestism, exhibitionism, transexualism, Disorders of psychosexual identity, frigidity and
impotence Erectile dysfunction (ED), also called impotence, is the type of sexual dysfunction in which the penis fails to become or stay erect during sexual activity. It is the most common sexual problem in men.Cunningham GR, Rosen RC. Overview of mal ...
, Other sexual deviations and disorders (including fetishism, masochism, and
sadism Sadism may refer to: * Sadomasochism, the giving or receiving of pleasure from acts involving the receipt or infliction of pain or humiliation * Sadistic personality disorder, an obsolete term proposed for individuals who derive pleasure from the s ...
).


ICD-10

In the ICD-10 (1990), the category "sexual deviations and disorders" was divided into several subcategories. Paraphilias were placed in subcategory of "sexual preference disorders". The list included fetishism, fetishistic transvestism, exhibitionism,
voyeurism Voyeurism is the sexual interest in or practice of watching other people engaged in intimate behaviors, such as undressing, sexual activity, or other actions of a private nature. The term comes from the French ''voir'' which means "to see". ...
, pedophilia, sadomasochism and other disorders of sexual preference (including
frotteurism Frotteurism is a paraphilic interest in rubbing, usually one's pelvic area or erect penis, against a non-consenting person for sexual pleasure. It may involve touching any part of the body, including the genital area. A person who practices fro ...
, necrophilia, and
zoophilia Zoophilia is a paraphilia involving a sexual fixation on non-human animals. Bestiality is cross-species sexual activity between humans and non-human animals. The terms are often used interchangeably, but some researchers make a distinction b ...
). Homosexuality was removed from the list, but
ego-dystonic sexual orientation Ego-dystonic sexual orientation is a highly controversial mental health diagnosis that was included in the American Psychiatric Association's (APA) ''Diagnostic and Statistical Manual of Mental Disorders'' (DSM) from 1980 to 1987 (under the name ...
was still considered a deviation which was placed in subcategory "psychological and behavioural disorders associated with sexual development and orientation".


ICD-11

In the ICD-11 (2022), "paraphilia" has been replaced with "paraphilic disorder". Any paraphilia and any other arousal pattern ''by itself'' no longer constitutes a disorder. To date, the diagnosis must meet criteria of paraphilia ''and'' one of the following: 1) a marked distress associated with arousal pattern (but not one that comes from rejection or fear of rejection); 2) the person has acted on the arousal pattern towards unwilling others or others considered as unable to give
consent Consent occurs when one person voluntarily agrees to the proposal or desires of another. It is a term of common speech, with specific definitions as used in such fields as the law, medicine, research, and sexual relationships. Consent as und ...
; 3) a serious risk of injury or death. The list of the paraphilic disorders includes: Exhibitionistic Disorder, Voyeuristic Disorder, Pedophilic Disorder, Coercive Sexual Sadism Disorder, Frotteuristic Disorder, Other Paraphilic Disorder Involving Non-Consenting Individuals, and Other Paraphilic Disorder Involving Solitary Behaviour or Consenting Individuals. As of now, disorders associated with sexual orientation have been removed from the ICD. Gender issues have been removed from the mental health category and have been placed under "Conditions related to sexual health".


Management

Most clinicians and researchers believe that paraphilic sexual interests cannot be altered, although evidence is needed to support this. Instead, the goal of therapy is normally to reduce the person's discomfort with their paraphilia and limit any criminal behavior. Both
psychotherapeutic Psychotherapy (also psychological therapy, talk therapy, or talking therapy) is the use of psychological methods, particularly when based on regular personal interaction, to help a person change behavior, increase happiness, and overcome prob ...
and pharmacological methods are available to these ends. Cognitive behavioral therapy, at times, can help people with paraphilias develop strategies to avoid acting on their interests. Patients are taught to identify and cope with factors that make acting on their interests more likely, such as stress. It is currently the only form of psychotherapy for paraphilias supported by randomized
double-blind In a blind or blinded experiment, information which may influence the participants of the experiment is withheld until after the experiment is complete. Good blinding can reduce or eliminate experimental biases that arise from a participants' expec ...
trials, as opposed to case studies and consensus of expert opinion.


Medications

Pharmacological Pharmacology is a branch of medicine, biology and pharmaceutical sciences concerned with drug or medication action, where a drug may be defined as any artificial, natural, or endogenous (from within the body) molecule which exerts a biochemica ...
treatments can help people control their sexual behaviors, but do not change the content of the paraphilia. They are typically combined with cognitive behavioral therapy for best effect.


SSRIs

Selective serotonin reuptake inhibitor Selective serotonin reuptake inhibitors (SSRIs) are a class of drugs that are typically used as antidepressants in the treatment of major depressive disorder, anxiety disorders, and other psychological conditions. SSRIs increase the extracellul ...
s (SSRIs) are used, especially with exhibitionists, non-offending pedophiles, and compulsive masturbators. They are proposed to work by reducing sexual arousal,
compulsivity Compulsive behavior is defined as performing an action persistently and repetitively. Compulsive behaviors could be an attempt to make obsessions go away. The act is usually a small, restricted and repetitive behavior, yet not disturbing in a pa ...
, and depressive symptoms. They have been well received and are considered an important pharmacological treatment of paraphilia.


Antiandrogens

Antiandrogen Antiandrogens, also known as androgen antagonists or testosterone blockers, are a class of drugs that prevent androgens like testosterone and dihydrotestosterone (DHT) from mediating their biological effects in the body. They act by blocking the ...
s are used in more severe cases. Similar to physical
castration Castration is any action, surgical, chemical, or otherwise, by which an individual loses use of the testicles: the male gonad. Surgical castration is bilateral orchiectomy (excision of both testicles), while chemical castration uses pharma ...
, they work by reducing
androgen An androgen (from Greek ''andr-'', the stem of the word meaning "man") is any natural or synthetic steroid hormone that regulates the development and maintenance of male characteristics in vertebrates by binding to androgen receptors. This in ...
levels, and have thus been described as
chemical castration Chemical castration is castration via anaphrodisiac drugs, whether to reduce libido and sexual activity, to treat cancer, or otherwise. Unlike surgical castration, where the gonads are removed through an incision in the body,
. The antiandrogen
cyproterone acetate Cyproterone acetate (CPA), sold alone under the brand name Androcur or with ethinylestradiol under the brand names Diane or Diane-35 among others, is an antiandrogen and progestin medication used in the treatment of androgen-dependent condition ...
has been shown to substantially reduce sexual fantasies and offending behaviors. Medroxyprogesterone acetate and
gonadotropin-releasing hormone agonist A gonadotropin-releasing hormone agonist (GnRH agonist) is a type of medication which affects gonadotropins and sex hormones. They are used for a variety of indications including in fertility medicine and to lower sex hormone levels in the treatm ...
s (such as
leuprorelin Leuprorelin, also known as leuprolide, is a manufactured version of a hormone used to treat prostate cancer, breast cancer, endometriosis, uterine fibroids, as part of transgender hormone therapy, for early puberty, or to perform chemical cas ...
) have also been used to lower sex drive. Due to the side effects, the World Federation of Societies of Biological Psychiatry recommends that hormonal treatments only be used when there is a serious risk of sexual violence, or when other methods have failed. Surgical
castration Castration is any action, surgical, chemical, or otherwise, by which an individual loses use of the testicles: the male gonad. Surgical castration is bilateral orchiectomy (excision of both testicles), while chemical castration uses pharma ...
has largely been abandoned because these pharmacological alternatives are similarly effective and less invasive.


Epidemiology

Research has shown that paraphilias are rarely observed in women. However, there have been some studies on females with paraphilias. Sexual masochism has been found to be the most commonly observed paraphilia in women, with approximately 1 in 20 cases of sexual masochism being female. Many acknowledge the scarcity of research on female paraphilias. The majority of paraphilia studies are conducted on people who have been convicted of
sex crimes Sex and the law deals with the regulation by law of human sexual activity. Sex laws vary from one place or jurisdiction to another, and have varied over time. Unlawful sexual acts are called sex crimes. Some laws regarding sexual activity are ...
. Since the number of male convicted sex offenders far exceeds the number of female convicted sex offenders, research on paraphilic behavior in women is consequently lacking. Some researchers argue that an underrepresentation exists concerning pedophilia in females. Due to the low number of women in studies on pedophilia, most studies are based from "exclusively male samples". This likely underrepresentation may also be attributable to a "societal tendency to dismiss the negative impact of sexual relationships between young boys and adult women". Michele Elliott has done extensive research on child sexual abuse committed by females, publishing the book ''Female Sexual Abuse of Children: The Ultimate Taboo'' in an attempt to challenge the gender-biased discourse surrounding sex crimes. John Hunsley states that physiological limitations in the study of
female sexuality Human female sexuality encompasses a broad range of behaviors and processes, including female sexual identity and Human sexual activity, sexual behavior, the physiological, psychological, social, cultural, political, and spiritual or religious ...
must also be acknowledged when considering research on paraphilias. He states that while a man's sexual arousal can be directly measured from his erection (see
penile plethysmograph Penile plethysmography (PPG) or phallometry is measurement of blood flow to the penis, typically used as a proxy for measurement of sexual arousal. The most commonly reported methods of conducting penile plethysmography involve the measurement of ...
), a woman's sexual arousal cannot be measured as clearly (see
vaginal photoplethysmograph Vaginal photoplethysmography (VPG, VPP) is a technique using light to measure the amount of blood in the walls of the vagina. The device that is used is called a vaginal photometer. Use The device is used to try to obtain an objective measure o ...
), and therefore research concerning female sexuality is rarely as conclusive as research on men.


Legal issues

In the United States, since 1990 a significant number of states have passed
sexually violent predator law Some jurisdictions may civil confinement, commit certain types of dangerous sex offenders to state-run detention facilities following the completion of their sentence (law), sentence if that person has a "mental abnormality" or personality disorde ...
s. Following a series of landmark cases in the Supreme Court of the United States, persons diagnosed with paraphilias, particularly pedophilia ('' Kansas v. Hendricks'', 1997) and exhibitionism (''
Kansas v. Crane ''Kansas v. Crane'', 534 U.S. 407 (2002), is a United States Supreme Court case in which the Court upheld the Kansas Sexually Violent Predator Act ( SVPA) as consistent with substantive due process. The Court clarified that its earlier holding in ...
'', 2002), with a history of
anti-social behavior Antisocial behavior is a behavior that is defined as the violation of the rights of others by committing crime, such as stealing and physical attack in addition to other behaviors such as lying and manipulation. It is considered to be disrupti ...
and related criminal history (that includes at a determination of at least "some lack-of-control" by the person), can be held indefinitely in
civil confinement Some jurisdictions may commit certain types of dangerous sex offenders to state-run detention facilities following the completion of their sentence if that person has a "mental abnormality" or personality disorder that makes the person likely to ...
under various state legislation generically known as sexually violent predator laws and the federal Adam Walsh Act ('' United States v. Comstock'', 2010).JESSE J. HOLLAND
Court: Sexually dangerous can be kept in prison
Associated Press The Associated Press (AP) is an American non-profit news agency headquartered in New York City. Founded in 1846, it operates as a cooperative, unincorporated association. It produces news reports that are distributed to its members, U.S. ne ...
. Retrieved 16 May 2010.


See also

*
-phil- The Greek root "-Phil-" originates from the Greek word meaning "love". For example, Philosophy (along with the Greek root "-soph-" meaning "wisdom") is the study of human customs and the significance of life. One of the most common uses of the ro ...
(list of philias) *
Courtship disorder Courtship disorder is a theoretical construct in sexology developed by Kurt Freund in which a certain set of paraphilias are seen as specific instances of anomalous courtship instincts in humans. The specific paraphilias are biastophilia (paraphilic ...
*
Dorian Gray syndrome Dorian Gray syndrome (DGS) denotes a cultural and societal phenomenon characterized by a man's extreme pride in his personal appearance and the fitness of his physique, which is accompanied by difficulties in coping with the requirements of psycho ...
*
Erotic target location error Erotic target location error (ETLE) is a hypothesized paraphilia defined by having a sexual preference or strong sexual interest in features that are somewhere other than on one's sexual partners. When one's sexual arousal is based on imagining o ...
*
Human sexuality Human sexuality is the way people experience and express themselves sexually. This involves biological, psychological, physical, erotic, emotional, social, or spiritual feelings and behaviors. Because it is a broad term, which has varied ...
*
List of paraphilias Paraphilias are sexual interests in objects, situations, or individuals that are atypical. The American Psychiatric Association, in its ''Diagnostic and Statistical Manual, Fifth Edition'' (DSM), draws a distinction between paraphilias (which ...
*
Lovemap The lovemap is a concept originated by sexologist John Money in his discussions of how people develop their sexual preferences. Money defined it as "a developmental representation or template in the mind and in the brain depicting the idealized lo ...
*
Object sexuality Object sexuality or objectophilia is a group of paraphilias characterized by sexual or romantic attraction focused on particular inanimate objects. Individuals with this attraction may have strong feelings of love and commitment to certain items ...
*
Perversion Perversion is a form of human behavior which deviates from what is considered to be orthodox or normal. Although the term ''perversion'' can refer to a variety of forms of deviation, it is most often used to describe sexual behaviors that are c ...
*
Psychosexual development In Freudian psychology, psychosexual development is a central element of the psychoanalytic sexual drive theory. Freud believed that personality developed through a series of childhood stages in which pleasure seeking energies from the child b ...
*
Sex and the law Sex and the law deals with the regulation by law of human sexual activity. Sex laws vary from one place or jurisdiction to another, and have varied over time. Unlawful sexual acts are called sex crimes. Some laws regarding sexual activity are ...
*
Sexual ethics Sexual ethics (also known as sex ethics or sexual morality) is a branch of philosophy that considers the ethics or morality or otherwise in sexual behavior. Sexual ethics seeks to understand, evaluate and critique interpersonal relationships and ...
*
Richard von Krafft-Ebing Richard Freiherr von Krafft-Ebing (full name Richard Fridolin Joseph Freiherr Krafft von Festenberg auf Frohnberg, genannt von Ebing; 14 August 1840 – 22 December 1902) was a German psychiatrist and author of the foundational work '' Psychopath ...


References


Citations


General bibliography

* D. Richard Laws, William T. O'Donohue (ed.), ''Sexual Deviance: Theory, Assessment, and Treatment'', 2nd ed., Guilford Press, 2008,


Further reading

* Kenneth Plummer, ''Sexual stigma: an interactionist account'', Routledge, 1975, * Elisabeth Roudinesco, ''Our Dark Side, a History of Perversion'', Polity Press, 2009, *
David Morgan (psychoanalyst) David Howell Morgan (BAHons Msc.Clin.Psych. FBPAS FPBPA SMBPF. Training Analyst Supervisor IPA. AMBPS. MBPC) is a psychoanalyst and consultant psychotherapist who has worked at the Portman Clinic London and Tavistock and Portman NHS Trust for 25 y ...
, ''
Married to the Eiffel Tower ''Married to the Eiffel Tower'' is The Wolfmen's second studio album. It was released digitally on 2 May 2011 and in August 2011 on Compact Disc and vinyl Vinyl may refer to: Chemistry * Polyvinyl chloride (PVC), a particular vinyl polymer ...
''
''Married to the Eiffel Tower''
a post on the blog ''Documentary Heaven''. *


External links


Proposed diagnostic criteria for sex and gender section of DSM5
{{Authority control