Diagnostic Features
The essential features of a Paraphilia are recurrent, intense sexually arousing fantasies, sexual urges, or behaviors generally involving 1) nonhuman objects, 2) the suffering or humiliation of oneself or one’s partner, or 3) children or other nonconsenting persons that occur over a period of at least 6 months (Criterion A). For some individuals, paraphilic fantasies or stimuli are obligatory for erotic arousal and are always included in sexual activity. In other cases, the paraphilic preferences occur only episodically (e.g., perhaps during periods of stress), whereas at other times the person is able to function sexually without paraphilic fantasies or stimuli. For Pedophilia, Voyeurism, Exhibitionism, and Frotteurism, the diagnosis is made if the person has acted on these urges or the urges or sexual fantasies cause marked distress or interpersonal difficulty. For Sexual Sadism, the diagnosis is made if the person has acted on these urges with a nonconsenting person or the urges, sexual fantasies, or behaviors cause marked distress or interpersonal difficulty. For the remaining Paraphilias, the diagnosis is made if the behavior, sexual urges, or fantasies cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion B).
Paraphilic imagery may be acted out with a nonconsenting partner in a way that may be injurious to the partner (as in Sexual Sadism or Pedophilia). The individual may be subject to arrest and incarceration. Sexual offenses against children constitute a significant proportion of all reported criminal sex acts, and individuals with Exhibitionism, Pedophilia, and Voyeurism make up the majority of apprehended sex offenders. In some situations, acting out the paraphilic imagery may lead to self-injury (as in Sexual Masochism). Social and sexual relationships may suffer if others find the unusual sexual behavior shameful or repugnant or if the individual’s sexual partner refuses to cooperate in the unusual sexual preferences. In some instances, the unusual behavior (e.g., exhibitionistic acts or the collection of fetish objects) may become the major sexual activity in the individual’s life. These individuals are rarely self-referred and usually come to the attention of mental health professionals only when their behavior has brought them into conflict with sexual partners or society.
The Paraphilias described here are conditions that have been specifically identified by previous classifications. They include Exhibitionism (exposure of genitals), Fetishism (use of nonliving objects), Frotteurism (touching and rubbing against a nonconsenting person), Pedophilia (focus on prepubescent children), Sexual Masochism (receiving humiliation or suffering), Sexual Sadism (inflicting humiliation or suffering), Transvestic Fetishism (cross-dressing), and Voyeurism (observing sexual activity). A residual category, Paraphilia Not Otherwise Specified, includes other Paraphilias that are less frequently encountered. Not uncommonly, individuals have more than one Paraphilia.
Recording Procedures
The individual Paraphilias are differentiated based on the characteristic paraphilic focus. However, if the individual’s sexual preferences meet criteria for more than one Paraphilia, all should be diagnosed. The diagnostic code and terms are as follows: 302.4 Exhibitionism, 302.81 Fetishism, 302.89 Frotteurism, 302.2 Pedophilia, 302.83 Sexual Masochism, 302.84 Sexual Sadism, 302.3 Transvestic Fetishism, 302.82 Voyeurism, and 302.9 Paraphilia Not Otherwise Specified.
Associated Features and Disorders
Associated descriptive features and mental disorders. The preferred stimulus, even within a particular Paraphilia, may be highly specific. Individuals who do not have a consenting partner with whom their fantasies can be acted out may purchase the services of prostitutes or may act out their fantasies with unwilling victims. Individuals with a Paraphilia may select an occupation or develop a hobby or volunteer work that brings them into contact with the desired stimulus (e.g., selling women’s shoes or lingerie [Fetishism], working with children [Pedophilia], or driving an ambulance [Sexual Sadism]). They may selectively view, read, purchase, or collect photographs, films, and textual depictions that focus on their preferred type of paraphilic stimulus. Many individuals with these disorders assert that the behavior causes them no distress and that their only problem is social dysfunction as a result of the reaction of others to their behavior. Others report extreme guilt, shame, and depression at having to engage in an unusual sexual activity that is socially unacceptable or that they regard as immoral. There is often impairment in the capacity for reciprocal, affectionate sexual activity, and Sexual Dysfunctions may be present. Personality disturbances are also frequent and may be severe enough to warrant a diagnosis of a Personality Disorder. Symptoms of depression may develop in individuals with Paraphilias and may be accompanied by an increase in the frequency and intensity of the paraphilic behavior.
Associated laboratory findings. Penile plethysmography has been used in research settings to assess various Paraphilias by measuring an individual’s sexual arousal in response to visual and auditory stimuli. The reliability and validity of this procedure in clinical assessment have not been well established, and clinical experience suggests that subjects can simulate response by manipulating mental images.
Associated general medical conditions. Frequent, unprotected sex may result in infection with, or transmission of, a sexually transmitted disease. Sadistic or masochistic behaviors may lead to injuries ranging in extent from minor to life threatening.
Specific Culture and Gender Features
The diagnosis 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. Except for Sexual Masochism, where the sex ratio is estimated to be 20 males for each female, the other Paraphilias are almost never diagnosed in females, although some cases have been reported.
Prevalence
Although Paraphilias are rarely diagnosed in general clinical facilities, the large commercial market in paraphilic pornography and paraphernalia suggests that its prevalence in the community is likely to be higher. The most common presenting problems in clinics that specialize in the treatment of Paraphilias are Pedophilia, Voyeurism, and Exhibitionism. Sexual Masochism and Sexual Sadism are much less commonly seen. Approximately one-half of the individuals with Paraphilias seen clinically are married.
Course
Certain of the fantasies and behaviors associated with Paraphilias may begin in childhood or early adolescence but become better defined and elaborated during adolescence and early adulthood. Elaboration and revision of paraphilic fantasies may continue over the lifetime of the individual. By definition, the fantasies and urges associated with these disorders are recurrent. Many individuals report that the fantasies are always present but that there are periods of time when the frequency of the fantasies and intensity of the urges vary substantially. The disorders tend to be chronic and lifelong, but both the fantasies and the behaviors often diminish with advancing age in adults. The behaviors may increase in response to psychosocial stressors, in relation to other mental disorders, or with increased opportunity to engage in the Paraphilia.
Differential Diagnosis
A Paraphilia must be distinguished from the nonpathological use of sexual fantasies, behaviors, or objects as a stimulus for sexual excitement in individuals without a Paraphilia. Fantasies, behaviors, or objects are paraphilic only when they lead to clinically significant distress or impairment (e.g., are obligatory, result in sexual dysfunction, require participation of nonconsenting individuals, lead to legal complications, interfere with social relationships).
In Mental Retardation, Dementia, Personality Change Due to a General Medical Condition, Substance Intoxication, a Manic Episode, or Schizophrenia, there may be a decrease in judgment, social skills, or impulse control that, in rare instances, leads to unusual sexual behavior. This can be distinguished from a Paraphilia by the fact that the unusual sexual behavior is not the individual’s preferred or obligatory pattern, the sexual symptoms occur exclusively during the course of these mental disorders, and the unusual sexual acts tend to be isolated rather than recurrent and usually have a later age at onset.
The individual Paraphilias can be distinguished based on differences in the characteristic paraphilic focus. However, if the individual’s sexual preferences meet criteria for more than one Paraphilia, all can be diagnosed. Exhibitionism must be distinguished from public urination, which is sometimes offered as an explanation for the behavior. Fetishism and Transvestic Fetishism both often involve articles of feminine clothing. In Fetishism, the focus of sexual arousal is on the article of clothing itself (e.g., panties), whereas in Transvestic Fetishism the sexual arousal comes from the act of cross-dressing. Cross-dressing, which is present in Transvestic Fetishism, may also be present in Sexual Masochism. In Sexual Masochism, it is the humiliation of being forced to cross-dress, not the garments themselves, that is sexually exciting.
Cross-dressing may be associated with gender dysphoria. If some gender dysphoria is present but the full criteria for Gender Identity Disorder are not met, the diagnosis is Transvestic Fetishism, With Gender Dysphoria. Individuals should receive the additional diagnosis of Gender Identity Disorder if their presentation meets the full criteria for Gender Identity Disorder.
