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Introduction

Paraphilias are psychosexual disorders characterized by recurrent, intense sexual fantasies, urges, or behaviors involving atypical or unacceptable sexual content. They are the sexual equivalents of obsessions and compulsions, focusing on aspects of human sexuality that do not have the goal of mutual sexual arousal with a partner. The term "paraphilia" comes from the Greek for love (philia) that is "aside" (para) in the sense of being altered or modified, a deviation in the object of attraction. Paraphilia has replaced the older terms of sexual perversion or deviation.

Symptoms & Signs

The paraphilias all involve "recurrent intense sexually arousing fantasies, sexual urges, or behaviors" that have been present for more than 6 months, according to DSM-IV criteria. These urges and fantasies are not the transitory or variant sexual scenarios imagined by the sexually adventurous. They do not change readily, are difficult to keep out of sexual consciousness, and have a power that at times makes it difficult to resist acting them out. Paraphilias are manifested in imagery, which may exist as a sexual fantasy or be associated with erection or orgasm in masturbation or other sexual behavior. The DSM-IV diagnostic criteria also state that the "fantasies, sexual urges, or behaviors cause significant distress or impairment." Solo masturbation for some affected individuals is hypersexual, to the extent that it occurs many times per day. Because acting out some paraphilias may involve illegal acts, many individuals with paraphilias are reluctant to acknowledge public acts or acts with a partner.

The paraphilias are named for the sexual content that is the primary focus of the sexual fantasy. There are over 40 named paraphilias (Money, 1999), although only the more common ones for which people seek psychiatric help are listed in DSM-IV. This content may be independent of sexual orientation. Although some paraphilias usually occur only in heterosexuals, for most a person may be heterosexual, homosexual, or bisexual. Some paraphilias are distinguished by a preoccupation with objects as essential for maximal sexual arousal, primarily items of clothing or materials, as in fetishism, or by wearing the clothing of the other sex, as in transvestic fetishism. Other paraphilias derive their excitement from the lack of a mutual relationship with the partner, for example, exhibitionism, voyeurism, or frotteurism (illicit sexual touching or rubbing). Sexual maso-chism and sadism focus on humiliation and suffering. In pedophilia the fantasized partners are prepubescent children. These paraphilias are discussed in detail in the following sections.

Some paraphilic fantasies are very elaborate and may involve content from several different general paraphilic themes. Thus, for example, sadistic pedophilia involves fantasies of the humiliation and suffering of prepubescent children. Paraphilias may be acted out through masturbation accompanied by the paraphilic fantasy, sometimes incorporating relevant props. Some paraphilias are acted out with partners. The paraphilic ritual provides indications of the underlying sexual fantasy, although the ritual may act out only some select portion of the fantasy. The paraphilia is diagnosed, insofar as possible, based on the elaborated fantasy, not just the behavior. Thus, a man who masturbates his exposed penis while watching unsuspecting children and having fantasies about sadistic acts with the children would be diagnosed with sadistic pedophilia (a sexual disorder not otherwise specified in DSM-IV), not with the separate diagnoses of voyeurism, exhibitionism, sadism, and pedophilia, unless these fantasies recurrently occurred independently of each other. Sometimes two or more independent paraphilias may exist in the same individual, with no overlap or shared content. Each of the independent paraphilias must have been independently and recurrently present in fantasies for at least 6 months to meet diagnostic requirements for two or more paraphilic diagnoses.