Paraphilias

  • Medical Author:
    Roxanne Dryden-Edwards, MD

    Dr. Roxanne Dryden-Edwards is an adult, child, and adolescent psychiatrist. She is a former Chair of the Committee on Developmental Disabilities for the American Psychiatric Association, Assistant Professor of Psychiatry at Johns Hopkins Hospital in Baltimore, Maryland, and Medical Director of the National Center for Children and Families in Bethesda, Maryland.

  • Medical Editor: Melissa Conrad Stöppler, MD
    Melissa Conrad Stöppler, MD

    Melissa Conrad Stöppler, MD

    Melissa Conrad Stöppler, MD, is a U.S. board-certified Anatomic Pathologist with subspecialty training in the fields of Experimental and Molecular Pathology. Dr. Stöppler's educational background includes a BA with Highest Distinction from the University of Virginia and an MD from the University of North Carolina. She completed residency training in Anatomic Pathology at Georgetown University followed by subspecialty fellowship training in molecular diagnostics and experimental pathology.

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Paraphilia facts

  • Paraphilias are emotional disorders defined as sexually arousing fantasies, urges, or behaviors that are recurrent, intense, occur over a period of at least six months, and cause significant distress or interfere with important areas of functioning.
  • Except for masochism, paraphilias are almost exclusively diagnosed in men.
  • There are a number of different types of paraphilias, each of which has a different focus of the sufferer’s sexual arousal.
  • There are thought to be biological, psychological, and social risk factors for developing paraphilias.
  • While the desired sexual stimulant for the paraphilia sufferer depends on the specific paraphilia, the characteristics of the illness are often very similar.
  • In order to establish the diagnosis of a paraphilia, mental-health professionals usually conduct or refer the person for a medical interview, physical examination, and routine laboratory tests. The professional will assess for any history of mental-health symptoms.
  • Treatment of paraphilias usually involves the combination of psychotherapy and medication. 
  • Paraphilias have been found to be quite chronic, such that a minimum of two years of treatment is recommended for even the mildest paraphilia.
  • Prevention for the development of any paraphilic behavior usually involves alleviating the psychosocial risk factors for its development.

What is a paraphilia? What are the different types of paraphilias?

The word paraphilia is derived from Greek; para means around or beside, and philia means love. Paraphilias are emotional disorders that are defined as sexually arousing fantasies, urges, or behaviors that are recurrent, intense, occur over a period of at least six months, and cause significant distress or interfere with the sufferer’s work, social function, or other important areas of functioning. This is as opposed to sexual variants, which are sexual behaviors that are not typical but are not a part of any illness.

The number of people who suffer from a paraphilia is thought to be difficult to gauge for a number of reasons. Many people with one of these disorders suffer in secret or silence out of shame, and some are engaging in sexual offending behaviors and so are invested in not reporting their paraphilia. Therefore, many of the estimates on the prevalence of paraphilia are gained from the number of people involved with the criminal-justice system due to pedophilia. Most pedophiles are men, with just 1%-6% being women.

Except for masochism, which is 20 times more common in women than men, paraphilias are almost exclusively diagnosed in men.  Many people who suffer from one paraphilia have more than one. For example, about one-third of pedophiles also have another paraphilia. More than half engage in three or four such kinds of behaviors rather than just one. Most people who develop a paraphilia begin having fantasies about it before they are 13 years old. 

There are a number of different types of paraphilias, each of which has a different focus of the sufferer’s sexual arousal:

  • Voyeurism: watching an unsuspecting/nonconsenting individual who is either nude, disrobing, or engaging in sexual activity
  • Exhibitionism: exposing one’s own genitals to an unsuspecting person
  • Frotteurisim: touching or rubbing against a nonconsenting person
  • Sexual masochism: being humiliated, beaten, bound, or otherwise suffering
  • Sexual sadism: the physical or emotional suffering of another person
  • Pedophilia: sexual activity with a child that is prepubescent (usually 13 years old or younger)
  • Fetishism: sexual fascination with nonliving objects or highly specific body parts
  • Transvestism: cross-dressing that is sexually arousing and interferes with functioning
  • Other specified paraphilia: some paraphilias do not meet full diagnostic criteria for a paraphilic disorder but may have uncontrolled sexual impulses that cause enough distress for the sufferer that they are recognized. Examples of such specific paraphilias include necrophilia (corpses), scatologia (obscene phone calls), and zoophilia (animals).

Urges to engage in coercive or otherwise aggressive sex like rape are not considered to be symptoms of a mental illness. Such sexual offending is therefore not considered to be a paraphilia.

What are causes and risk factors for paraphilia?

Biological issues that are thought to be risk factors for paraphilias include some differences in brain activity during sexual arousal, as well as general brain structure. Male pedophiles have been found to have lower IQ scores on psychological testing compared to men who are not pedophiles. Research has also determined that they tend to have a history of earning lower grades in school than their nonpedophilic counterparts regardless of intellectual abilities and learning styles.

There are a number of psychological theories about how paraphilias develop. Some view these disorders as a manifestation of arrested psychosexual development, with the paraphilic behaviors defending the person's psyche against anxiety (defense mechanisms). Others believe paraphilias are the result of the sufferer associating something with sexual arousal or by having unusual early life sexual experiences reinforced by having an orgasm. Some view these disorders as another form of obsessive compulsive disorder.

Psychologically, pedophiles who act on their urges by sexually offending tend to engage in grossly distorted thinking, in that they use their position of power and view offending as an appropriate way to meet their needs, think about children as equal sexual beings to adults, and consider their sexual needs as uncontrollable.

Another theory about paraphilia risk factors is that they are linked to stages of childhood psychological development like temperament, early relationship formation, trauma repetition, and disrupted development of sexuality, as follows:

  • Temperament: a tendency to be overly inhibited or uncontrolled with emotions and behaviors
  • Early relationship formation: a lack of stable self-awareness, trouble managing emotions, and in seeking help and comfort from others
  • Trauma repetition: People who are abused, especially if it occurs during childhood, may identify with the abuser such that they act out what was inflicted on them by victimizing others in some way. They may also act out the trauma by somehow harming themselves.
  • Disrupted development of sexuality: The patterns of what one finds sexually arousing tend to become formed by adolescence. It is thought that people who are raised in a household that is either excessively sexually permissive or inhibited are at higher risk for developing a paraphilia.

Family risk factors for paraphilia development include high conflict between parents or low supervision by parents, a lack of affection from the mother, and generally not feeling treated well by their parents. People with paraphilia tend to have trouble making and keeping friends and other relationships.

What are paraphilia symptoms and signs?

While the desired sexual stimulant for the paraphilia sufferer depends on the specific paraphilia, the characteristics of the illness are often very similar. Specifically, people with a paraphilia tend to become aroused by the stimulant to the exclusion or near exclusion of more common sources of sexual arousal, like an attractive person of similar age. The intensity of the attraction can be overwhelming enough to cause distress. The unusual or forbidden nature of a paraphilia often causes symptoms of guilt and fear of punishment.

Symptoms of paraphilia can include preoccupation to the point of obsessiveness that may intrude on the person's attempts to think about other things or engage in more conventional sexual activity with an age-appropriate partner. Paraphilia sufferers may experience depression or anxiety that is temporarily relieved by engaging in paraphilic behavior, thus leading to an addictive cycle.

How do health professionals diagnose paraphilias?

Usually providers of mental-health care help make the diagnosis of paraphilias, including licensed mental-health therapists, psychiatrists, psychologists, psychiatric nurses, and social workers. One of these professionals will likely conduct or refer the person with paraphilia for an extensive medical interview and physical examination as part of establishing the diagnosis. To ensure that the paraphilic individual does not suffer from a medical condition that could complicate the assessment or treatment of their mental-health condition, routine laboratory tests are often performed during the initial evaluation.

As part of this examination, the sufferer may be asked a series of questions from a standardized questionnaire or self-test to help assess the presence of paraphilic symptoms.  Thorough exploration for any history or presence of all mental-health symptoms will be conducted such that paraphilia can be distinguished from other types of mental disorders. People with pedophilia may also suffer from a personality disorder or mood disorder, and about 60% have an additional paraphilia, like exhibitionism, voyeurism, or sadism.

In order to qualify for the diagnosis of a paraphilia, the individual has to experience recurrent, significant sexual arousal by the object of their attraction; act on that attraction in urges, fantasies, or actions; and experience the symptoms for at least six months to the point that the individual suffers significant levels of distress or interference with his or her work, social function, or other important aspects of life.

What is the treatment for paraphilia?

The focus of research on the treatment for paraphilias is primarily focused on pedophilia, due to the terrible impact of this behavior on victims and due to the involvement of pedophilic offenders with the justice system.  Those studies have shown that treatment only tends to work if the person with pedophilia is motivated and committed to controlling his or her behavior and when treatment combines psychotherapy and medication.

Psychotherapy for pedophilia and other paraphilias tends to use cognitive behavioral therapy. The focus of psychotherapy tends to be helping the person with pedophilia recognize and combat rationalizations about his or her behavior, as well as training the pedophilia sufferer in developing empathy for the victim and in techniques to control their sexual impulses. This therapy tends to take an approach to treating sexual offenders using a relapse prevention model that is similar to treating people with a drug addiction. This approach tries to help the paraphilic person anticipate situations that increase their risk of sexually acting out and finding ways to avoid or more productively respond to those triggers. People with paraphilia may also benefit from social skills training to help them develop age-appropriate, reciprocal relationships.

Medications that suppress production of the male hormone testosterone can be used to reduce the frequency or intensity of sexual desire in pedophiles. It may take three to 10 months for testosterone suppression to reduce sexual desire. Studies of the effectiveness of selective serotonin reuptake inhibitors (SSRIs) in treating pedophilia and other paraphilias vary in their findings on their effectiveness. However, SSRIs may be a helpful addition to other treatments, because they tend to decrease sexual obsessiveness and urges associated with paraphilias and may also help with increasing the paraphile’s ability to control his or her impulses. Examples of SSRI medications include fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa), and escitalopram (Lexapro).

There is some preliminary research that stimulant medications like methylphenidate (Ritalin) can increase the effectiveness of SSRIs, and naltrexone can decrease some of the sexual obsessiveness associated with paraphilias.

What is the prognosis of paraphilia?

Paraphilias have been found to be quite chronic such that a minimum of two years of treatment is recommended for even the mildest paraphilia. While most people with a paraphilia do not sexually offend, and sexual offending is not considered a mental illness, people who commit sexual offenses sometimes also have a paraphilia.

Is it possible to prevent paraphilias?

Given that paraphilic behavior tends to be highly stigmatized and some paraphilic behaviors are illegal, tracking how successful treatment often involves rates of criminal recidivism. Therefore, prevention of future paraphilic behavior often focuses on preventing sexual offenders from having access to potential victims. Prevention for the development of any paraphilic behavior usually involves alleviating the psychosocial risk factors for its development.

Medically reviewed by Marina Katz, MD; American Board of Psychiatry & Neurology

REFERENCES:

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, D.C.: American Psychiatric Association, 2013.

Cantor, J.M., Kuban, M.E., Blak, T., Klassen, P.E., et al. "Grade failure and special education placement in sexual offenders’ educational histories." Archives of Sexual Behavior 35 (2006): 743–751.

Gordon, H., and Grubin, D. "Psychiatric aspects of the assessment and treatment of sex offenders." Advances in Psychiatric Treatment 10 (2004): 73-80.

"Pessimissm about pedophilia." Harvard Mental Health Letter. July 2010.

Kafka, M.P., and J. Hennen. "Psychostimulant augmentation during treatment with selective serotonin reuptake inhibitors in men with paraphilias and paraphilia-related disorders: a case series." Journal of Clinical Psychiatry 61.9 Sept. 2000: 664-670.

Lawson, L. "Isolation, gratification, justification: offenders' explanations of child molesting." Issues in Mental Health Nursing 24 Sept.-Nov. 2003: 695–705.

Polisois-Keating, A., and Joyal, C.C. "Functional neuroimaging of sexual arousal: a preliminary meta-analysis comparing pedophilic to non-pedophilic men." Archives of Sexual Behavior Oct. 2013.

Raymond, N.C., Grant, J.E., and Coleman, E. "Augmentation with naltrexone to treat compulsive sexual behavior: A case series." Annals of Clinical Psychiatry 22.1 (2010):56–62.

Schwartz, M.F. "Developmental psychopathological perspectives on sexually compulsive behavior." Castlewood Treatment Center Mar. 2008.

Siegel, R.M. "Paraphilics and sexual variants: Assessing and treating sexual concerns in couples." Winter Institutes for Advanced Clinical Training Mar. 2013.

Thibaut, F., De La Barra, F., Gordon, H., et al. "Guidelines for the biological treatment of paraphilias." The World Journal of Biological Psychiatry 11 (2010): 604–655

Last Editorial Review: 3/16/2016

Reviewed on 3/16/2016
References
Medically reviewed by Marina Katz, MD; American Board of Psychiatry & Neurology

REFERENCES:

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, D.C.: American Psychiatric Association, 2013.

Cantor, J.M., Kuban, M.E., Blak, T., Klassen, P.E., et al. "Grade failure and special education placement in sexual offenders’ educational histories." Archives of Sexual Behavior 35 (2006): 743–751.

Gordon, H., and Grubin, D. "Psychiatric aspects of the assessment and treatment of sex offenders." Advances in Psychiatric Treatment 10 (2004): 73-80.

"Pessimissm about pedophilia." Harvard Mental Health Letter. July 2010.

Kafka, M.P., and J. Hennen. "Psychostimulant augmentation during treatment with selective serotonin reuptake inhibitors in men with paraphilias and paraphilia-related disorders: a case series." Journal of Clinical Psychiatry 61.9 Sept. 2000: 664-670.

Lawson, L. "Isolation, gratification, justification: offenders' explanations of child molesting." Issues in Mental Health Nursing 24 Sept.-Nov. 2003: 695–705.

Polisois-Keating, A., and Joyal, C.C. "Functional neuroimaging of sexual arousal: a preliminary meta-analysis comparing pedophilic to non-pedophilic men." Archives of Sexual Behavior Oct. 2013.

Raymond, N.C., Grant, J.E., and Coleman, E. "Augmentation with naltrexone to treat compulsive sexual behavior: A case series." Annals of Clinical Psychiatry 22.1 (2010):56–62.

Schwartz, M.F. "Developmental psychopathological perspectives on sexually compulsive behavior." Castlewood Treatment Center Mar. 2008.

Siegel, R.M. "Paraphilics and sexual variants: Assessing and treating sexual concerns in couples." Winter Institutes for Advanced Clinical Training Mar. 2013.

Thibaut, F., De La Barra, F., Gordon, H., et al. "Guidelines for the biological treatment of paraphilias." The World Journal of Biological Psychiatry 11 (2010): 604–655

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