Aparaphilia is an experience of recurring or intensesexual arousal to atypical objects, places, situations, fantasies, behaviors, or individuals.[3][4] It has also been defined as a sexual interest in anything other than a legally consenting human partner.[5][6] Paraphilias are contrasted with normophilic ("normal") sexual interests,[7][8] although the definition of what makes a sexual interest normal or atypical remains controversial.
The exact number andtaxonomy of paraphilia is under debate;Anil Aggrawal has listed as many as 549types of paraphilias.[9][10] Several sub-classifications of paraphilia have been proposed; some argue that a fully dimensional, spectrum, or complaint-oriented approach would better reflect the evident diversity ofhuman sexuality.[11][12] Although paraphilias were believed in the 20th century to be rare among the general population, recent research has indicated that paraphilic interests are relatively common.[8][13]
Coinage of the termparaphilia (paraphilie) has been credited toFriedrich Salomon Krauss in 1903 and it was used with some regularity byWilhelm Stekel in the 1920s.[14][15] The term comes from theGreek παρά (para), meaning "other" or "outside of", and φιλία (-philia), meaning "loving".[16] The word was popularized byJohn Money in the 1980s as a non-pejorative designation for unusual sexual interests. It was first included in theDSM in its 1980 edition.[16][17][18]
To date there is no broadscientific consensus for definitive boundaries between what are considered "unconventional sexual interests",kinks,fetishes, and paraphilias.[19][20] As such, these terms are often used loosely and interchangeably, especially in common parlance.
Many terms have been used to describe atypical sexual interests, and there remains debate regarding technical accuracy and perceptions of stigma.[16][17][18][21] Money described paraphilia as "a sexuoerotic embellishment of, or alternative to the official, ideological norm."[22] PsychiatristGlen Gabbard writes that despite efforts by Wilhelm Stekel and John Money, "the termparaphilia remains pejorative in most circumstances."[23]
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 ofsodomy,[24] as well asperversion.[25] In 1914,Albert Eulenburg observed a commonality across the paraphilias, using the terminology of his time writing, "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."[26]
Before the introduction of the termparaphilia in the DSM-III (1980), the termsexual deviation was used to refer to paraphilias in the first two editions of the manual.[27] In 1981, an article published inAmerican Journal of Psychiatry described paraphilia as "recurrent, intense sexually arousing fantasies, sexual urges, or behaviors generally involving" the following:[28]
Clinical literature contains reports of many paraphilias, only some of which receive their own entries in the diagnostic taxonomies of theAmerican Psychiatric Association or theWorld Health Organization.[29][30] There is disagreement regarding which sexual interests should be deemed paraphilic disorders versus normal variants of sexual interest.[31] 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".[32] Some argue thatcultural relativism is important to consider when discussing paraphilias, because there is wide variance concerning what is sexually acceptable across cultures.[33]Consensual adult activities andadult entertainment involvingsexual roleplay, novel, superficial, or trivial aspects ofsexual fetishism, or incorporating the use ofsex toys are not necessarily paraphilic.[32]
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.[34] Some groups, seeking greater understanding and acceptance ofsexual diversity, have lobbied for changes to the legal and medical status of unusual sexual interests and practices.Charles Allen Moser, a physician and advocate for sexual minorities, has argued that the diagnoses should be eliminated from diagnostic manuals.[35]Ray Blanchard stated that the current definition of paraphilia in the DSM done by concatenation (i.e. by listing a set of paraphilias) and that defining the term by exclusion (anything that is not normophilic) is preferable.[36]
Inclusion and subsequent exclusion of homosexuality
Homosexuality, now widely accepted as a variant of human sexuality, was at one time discussed as a sexual deviation.[37]Sigmund Freud and subsequentpsychoanalytic thinkers considered homosexuality and paraphilias to result frompsychosexual non-normative relations to theOedipal complex,[38][39] although not in the antecedent version of the 'Three Essays on Sexual Theory' where paraphilias are considered as stemming from an original polymorphous perversity.[40] As such, the termsexual perversion or theepithetpervert have historically referred togay men, as well as othernon-heterosexuals (people who fall outside the perceived norms of sexual orientation).[37][38][41][42]
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 theAmerican Psychiatric Association 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."[41]
A 2012 literature study by clinical psychologistJames Cantor, when comparing homosexuality with paraphilias, found that both share "the features of onset and course (both homosexuality and paraphilia being life-long), but they appear to differ on sex ratio,fraternal birth order,handedness,IQ andcognitive profile, andneuroanatomy." 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.[42]
Paraphilias typically arise in late adolescence or early adulthood. Persons with paraphilias are generallyegosyntonic and view their paraphilias as something inherent in their being, although they recognize that their sexual fantasies lie outside the norm and may attempt to conceal them.[16] Paraphilic interests are rarely exclusive[43] and some people have more than one paraphilia.[13] Some people with paraphilias may seek occupations and avocations that increase their access to objects of their sexual fantasies (e.g. voyeurs working in rental properties to "peep" on others or pedophiles working with Boy Scouts).[16]
Research has found that some paraphilias, such asvoyeurism andsadomasochism, are associated with more lifetime sexual partners, contradicting theories that paraphilias are associated withcourtship disorders and arrested social development.[43] Scientific literature includes some 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).[44][45]
The causes of paraphilias in people are unclear, but some research points to a possible prenatalneurodevelopmental 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:4Ddigit ratio (which would indicate excessive prenatal estrogen exposure), and an elevated probability of beingleft-handed, suggesting that disturbed hemisphericbrain lateralization may play a role in paraphilic attractions.[46]Behavioral explanations propose that paraphilias areconditioned early in life, during an experience that pairs the paraphilic stimulus with intense sexual arousal.[47]Susan Nolen-Hoeksema suggests that, once established,masturbatory fantasies about the stimulus reinforce and broaden the paraphilic arousal.[47]
Although paraphilic interests in the general population were believed to be rare, research has shown that fantasies and behaviors related to voyeurism, sadomasochism and coupleexhibitionism are not statistically uncommon among adults.[43] In a study conducted in a population of men, 62% of participants reported at least one paraphilic interest. In another sample of college students, voyeurism was reported in 52% of men.[13] The DSM-5 estimates that 2.2% of males and 1.3% of females in Australia engaged in bondage and discipline, sadomasochism, or dominance and submission within the past 12 months. The population prevalence of sexual masochism disorder is unknown.[48]
Paraphilias are rarely observed in women;[49][50] however, there have been some studies on females with paraphilias.[51] Men and women differ on the content of their sexual fantasies, with the former reporting greater proportions offetishism, exhibitionism and sadism, and the latter reporting greater proportions of masochism.[52] Sexual masochism has been found to be the most commonly observed paraphilia in women, with approximately 1 in 20 cases.[53][50]
Paraphilic fantasies and behaviors have been registered in multiple old and ancient sources. Voyeurism, bestiality and exhibitionism have been described in theBible. Sexual relations with animals have also been depicted incave paintings.[54] Some ancient sex manuals such as theKama Sutra (450),Koka Shastra (1150) andAnanga Ranga (1500) discuss biting, marks left after sex and love blows. Although evidence suggests that paraphilic behaviors have existed prior to theRenaissance, it is difficult to ascertain how common they were and how many people had persistent paraphilic fantasies in ancient times.[8]
"Leda and the Swan" (fromthe Greek tale) by Esther Huillard
Bestiality has been depicted multiple times in Greek mythology, although the act itself usually involved a deity in zoomorphic form, such as Zeus seducingEuropa,Leda andPersephone while disguised as a bull, a swan and a serpent, respectively. Zeus was also depicted, in the form of an eagle, abductingGanymede, an act that alludes to both bestiality and pederastry. Some fragments ofHittite law include prohibitions of and permissions to engage in specific acts of bestiality.[55]
Havelock Ellis pointed to an example of sexual masochism in the fifteenth century. The report, written byGiovanni Pico della Mirandola, described a man who could only be aroused by being beaten with a whip dipped in vinegar.[8] Wilhelm Stekel also noted thatRousseau also discussed his own masochism in hisConfessions.[56] Other similar instances of persistent paraphilic fantasies were reported between 1516 and 1643 byCoelius Sedulius,Rhodiginus, Brundel andMeibomius.[8]
Diagnostic and Statistical Manual of Mental Disorders (DSM)
In American psychiatry, prior to the publication of the DSM-I, paraphilias were classified as cases of "psychopathic personality with pathologic sexuality". The DSM-I (1952) included sexual deviation as apersonality disorder ofsociopathic subtype. The only diagnostic guidance was that sexual deviation should have been "reserved for deviant sexuality which [was] not symptomatic of more extensive syndromes, such asschizophrenic 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.[57] ResearcherAnil Aggrawal writes that the now-obsolete DSM-I listed examples of supplementary terms for pathological behavior to include "homosexuality,transvestism,pedophilia,fetishism, andsexual sadism, includingrape,sexual assault, mutilation."[58]
The DSM-II (1968) continued to use the termsexual deviations, 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,exhibitionism,voyeurism,sadism,masochism, 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 withcoitus, or toward coitus performed under bizarre circumstances, as innecrophilia, pedophilia, sexual sadism, and fetishism."[59] 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.[60]
The termparaphilia 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 astransvestic fetishism, addedfrotteurism, and movedzoophilia to the NOS category. It also provided seven nonexhaustive examples of NOS paraphilias, which besideszoophilia includedexhibitionism,necrophilia,partialism,coprophilia,klismaphilia, andurophilia.[61] The DSM-IV (1994) retained the sexual disorders classification for paraphilias, but added an even broader category, "sexual andgender identity disorders", 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.[60]
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,frotteurism,pedophilia,sexual masochism,sexual sadism,voyeurism, andtransvestic fetishism, plus a residual category,paraphilia—not otherwise specified).[62] 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.[53]Sexual arousal in association with objects that were designed for sexual purposes is not diagnosable.[53] Some paraphilias may interfere with the capacity for sexual activity with consenting adult partners.[53] In the current version of theDiagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), a paraphilia is not diagnosable as apsychiatric disorder unless it causes distress to the individual or harm to others.[4]
TheDSM-5 adds a distinction betweenparaphilias and"paraphilic disorders", stating that paraphilias do not require or justify psychiatric treatment in themselves, and definingparaphilic 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".[3] The DSM-5 Paraphilias Subworkgroup reached a "consensus that paraphilias are notipso facto psychiatric disorders", and proposed "that the DSM-V make a distinction betweenparaphilias and paraphilicdisorders. One wouldascertain a paraphilia (according to the nature of the urges, fantasies, or behaviors) butdiagnose 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 becomeSexual Sadism Disorder; Sexual Masochism would becomeSexual Masochism Disorder, and so on."[63]
Bioethics professorAlice Dreger 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, 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."[64]Charles Allen Moser 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.[65] 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 toego-dystonic homosexuality, which was removed from the DSM because it was no longer recognized as a mental disorder.[66]
TheDSM-5 has specific listings for eight paraphilic disorders.[3] These are voyeuristic disorder, exhibitionistic disorder,frotteuristic disorder, sexual masochism disorder, sexual sadism disorder, pedophilic disorder, fetishistic disorder, andtransvestic disorder.[3] Other paraphilic disorders can be diagnosed under theOther Specified Paraphilic Disorder or Unspecified Paraphilic Disorder listings, if accompanied by distress or impairment.[67]
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.[68]
In the ICD-9 (1975), the category of sexual deviations and disorders was expanded to includetranssexualism, sexual dysfunctions, and psychosexual identity disorders. The list contained homosexuality, bestiality, pedophilia, transvestism, exhibitionism, transexualism, Disorders of psychosexual identity,frigidity andimpotence, Other sexual deviations and disorders (including fetishism, masochism, andsadism).[69]
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, pedophilia,sadomasochism and other disorders of sexual preference (includingfrotteurism,necrophilia, andzoophilia). Homosexuality was removed from the list, butego-dystonic sexual orientation was still considered a deviation which was placed in subcategory "psychological and behavioural disorders associated with sexual development and orientation".[70]
In the ICD-11 (2022), "paraphilia" has been replaced with "paraphilic disorder". Any paraphilia and any other arousal patternby itself no longer constitutes a disorder. To date, the diagnosis must meet criteria of paraphiliaand 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 giveconsent; 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".[71]
Most clinicians and researchers believe that paraphilic sexual interests cannot be altered,[72] although evidence is needed to support this.[72] Instead, the goal of therapy is normally to reduce the person's discomfort with their paraphilia and limit the risk of any harmful, anti-social, or criminal behavior.[72] Bothpsychotherapeutic andpharmacological methods are available to these ends.[72]Cognitive behavioral therapy, at times, can help people with extreme paraphilic disorders develop strategies to avoid acting on their interests.[72] Patients are taught to identify and cope with factors that make acting on their interests more likely, such as stress.[72] It is currently the only form of psychotherapy for paraphilic disorders supported by randomizeddouble-blind trials, as opposed to case studies and consensus of expert opinion.[73]
Pharmacological treatments can help people control their sexual behaviors, but do not change the content of the paraphilia.[73] They are typically combined withcognitive behavioral therapy for best effect.[74]
Selective serotonin reuptake inhibitors (SSRIs) have been well received and are considered an important pharmacological treatment of severe paraphilic disorders.[75] They are proposed to work by reducing sexual arousal,compulsivity, and depressive symptoms. They have been used with exhibitionists, non-offending pedophiles, and compulsive masturbators.[74]
Antiandrogens are used in more extreme cases.[74] Similar to physicalcastration, they work by reducingandrogen levels, and have thus been described aschemical castration.[74] The antiandrogencyproterone acetate has been shown to substantially reduce sexual fantasies and offending behaviors.[74]Medroxyprogesterone acetate andgonadotropin-releasing hormone agonists (such asleuprorelin) have also been used to lower sex drive.[74] 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.[73] Surgicalcastration has largely been abandoned because these pharmacological alternatives are similarly effective and less invasive.[76]
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