Paraphilias and Paraphilia-Related Disorders

   
• Introduction    
• What Are Paraphilias and Paraphilia-Related Disorders?
  • Paraphilias      
  • Paraphilia-Related Disorders

     

• Clinical Characteristics Common to Paraphilias and Paraphilia-Related Disorders
     

• Are Paraphilias and Paraphilia-Related Disorders Treatment-Responsive Psychiatric Conditions?
     

• Treatment Implications of Psychological and Psychiatric Comorbidity of Paraphilias and Paraphilia-Related Disorders
     

• Biological Correlates of Male Hypersexuality
     

• Monoamines, Sexual Behavior, and Hypersexuality
     

• Psychotherapeutic Treatments for Paraphilias and Paraphilia-Related Disorders
       

  • Individual Psychotherapy      
  • Group Psychotherapies, Including Relapse Prevention Treatment      
  • Behavior Therapies

     

• Biological Treatments for Paraphilias and Paraphilia-Related Disorders
       

  • Antiandrogen Pharmacotherapy      
  • Proserotonergic Pharmacotherapy

     

• Conclusions
     

• References

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Paraphilias and Paraphilia-Related Disorders Introduction

This chapter focuses on the psychological and pharmacological treatments available for paraphilias (PAs) and paraphilia-related disorders (PRDs). Inasmuch as there are separate chapters in this text discussing pedophilia and fetishistic transvestism, those specific PAs will not be discussed here in detail. The principles and treatments described here, however, are applicable to those paraphilic disorders as well.

What Are Paraphilias and Paraphilia-Related Disorders?

Paraphilias
The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association 1994) characterizes PAs as sexual disorders with three dimensional components:

socially deviant sexual arousal
the associated sexual fantasies, urges, or activities cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
a duration of 6 or more months is required

The common paraphilias are enumerated in

Table 68-1.

Some clinical caveats should be considered in regard to the diagnosis of a paraphilia. It is noteworthy that while repetitive child molestation would usually (but not always) be categorized as pedophilia, there is no paraphilia category that describes recidivistic adult rapists. In addition, if adults in mutually consenting sexual relationships engage in paraphilia-like behavior to enhance or maintain their relationship (e.g., sexual masochism and sexual sadism) but such behaviors do not produce psychosocial dysfunction, those behaviors do not constitute a psychiatric diagnosis. Furthermore, males or females who repetitively cross-dress or utilize fetishistic objects for sexual arousal but self-report no distress or associated impairments do not meet the threshold for a diagnosis of a paraphilia. Finally, gender identity disorder of adulthood (transsexualism in DSM-III-R [American Psychiatric Association 1987]) is a diagnostic entity distinct from transvestic fetishism, although some of the clinical features of the two conditions can overlap. Adults with gender identity disorder have a core belief that their gender identity is of the opposite sex than their anatomic genitals. They are not usually sexually aroused by cross-dressing. Transvestites, on the other hand, are sexually aroused by transgender dressing and may enjoy their opposite-sex self but will not seek to change their genital anatomy.

Paraphilia-Related Disorders
Although the persistent presence of socially “deviant” sexual arousal is a primary determinant of the diagnosis of a paraphilia, the distinction between “normal” and “deviant” sexual behavior is determined by cultural and historical contexts (Marmor 1971). Inasmuch as sexual behaviors that are now considered “normal” have been considered “deviant” in the recent past, this dimensional criterion for paraphilia may lead to an overly restrictive boundary for sexual impulse disorders (Kafka 1994a).

Consider the following examples. Masturbation, currently considered a healthy expression of sexual behavior, was socially deviant (i.e., “paraphilic”) in late-19th-century and early-20th-century Western Europe and the United States (Hare 1962). Homosexuality was also considered a paraphilia until it was deleted from DSM-III in 1980 (American Psychiatric Association 1980). This deletion was the result of contemporary community-based nonpatient sample studies that failed to demonstrate distinctive differences in adult psychopathology between homosexual males and heterosexual males (Marmor 1981; Saghir and Robins 1973).

We must therefore consider that certain contemporary culturally “acceptable” sexual activities might come to be considered paraphilia-like: repetitive, impulsive/compulsive/addictive, accompanied by intrusive sexual fantasies and urges and psychosocial distress or impairment. These behaviors, previously designated as nonparaphilic sexual addictions (sexual disorders not otherwise specified [American Psychiatric Association 1987]), are currently without an acknowledged diagnostic appellation. I prefer to use the descriptive term paraphilia-related disorders, because that appellation does not presume to characterize or designate whether these nonparaphilic sexual behaviors are specifically related to impulsivity (American Psychiatric Association 1994; Barth and Kinder 1987), compulsivity (Coleman 1986, 1987, 1992; Quadland 1985), or addiction disorders (Carnes 1983, 1989, 1991; Goodman 1997). To achieve congruence with the qualities and boundaries of PAs, I have suggested an operational definition for PRDs (Kafka 1994a, 2000; Kafka and Hennon 1999) (

Table 68-2). The common paraphilia-related disorders are listed in

Table 68-3.