The debate continues as to whether paraphilias are best conceptualized as sexual disorders unto themselves or are simply a special kind of obsessive disorder, anxiety disorder, or even addiction disorder. Because they are sexually motivated behaviors and their phenomenology is experienced as intensely driven eroticism, it seems appropriate to continue to classify them as sexual and gender identity disorders, as in DSM-IV.
Types of paraphilias
While DSM-IV-TR does not classify paraphilias other than by erotic focus, it is clear from clinical practice that they may be either exclusive or nonexclusive as well as egosyntonic or egodystonic. Patients with the exclusive form of a paraphilia may not be able to be sexually aroused by anything other than their paraphilic imagery or behavior. By contrast, patients with the nonexclusive form may be aroused by other sexual fantasies, stimuli, and behaviors, although their paraphilias may interfere with their overall sexual experiences.
Similarly, any given patient may find his or her paraphilia either congruent with his values and beliefs or at odds with them. Persons with paraphilic phenomenology that does not disturb core personal values are said to have egosyntonic paraphilias, while those who feel their sexual phenomenology is wrong and is not congruent with their internal moral compasses are said to have egodystonic paraphilias. Clearly, better treatment results can be expected with patients who have paraphilias that are egodystonic.
Physicians and patients alike often wrestle with whether some seemingly harmless, egosyntonic paraphilia (for example, fetishistic cross-dressing) should be viewed simply as different—part of the rainbow of sexual diversity—or should be treated as pathological. Each case is different, but the physician should be mindful that when, for example, an individual is driven by his paraphilic urges to steal shoes or undergarments, the picture changes dramatically. Similarly, consensual bondage/ discipline, which some clinicians see as part of the sadism/masochism spectrum, may or may not need to be treated depending on degree.4
The paraphilias do not always occur in the absence of other psychopathology. Many paraphilic patients show evidence of major Axis I mental illnesses including affective disorders, substance abuse disorders, schizophrenia, other psychotic disorders, dementia, and other cognitive disorders. Paraphilias can occur within the context of Axis II disorders such as borderline or antisocial personality disorders and mental retardation, and Axis III disorders, such as temporal lobe epilepsy or brain trauma. For example, Mitchell and colleagues5 described the case of a patient with temporal lobe epilepsy and transvestic fetishism whose paraphilic behaviors decreased following temporal lobectomy. Similarly, Mendez and associates6 presented data on 2 men with right temporal lobe hypometabolism and late onset pedophilia. In such cases it can be quite difficult to tease out the discrete disorders; however, treating one co-occurring condition may not always render it unnecessary to treat the other disorder.
For example, the pedophile who also has bipolar disorder may need different kinds of both pharmacological and psychological intervention for each of the disorders. The paraphilia may need to be treated with a testosterone-lowering drug such as leuprolide in conjunction with psychotherapy such as relapse prevention therapy, while the mood disorder might require mood stabilizers and other pharmacological agents in combination with cognitive-behavioral therapy. These combinations are some of many that may be used in treatment modalities that recognize the need to treat each co-occurring condition separately.
There are no reliable data with respect to the incidence of paraphilias and co-occurring mental health conditions. The nature of these co-occurring disorders, however, in addition to the dangers associated with paraphilic disorders, has profound implications for treatment stratagems for the paraphilic component.7 In any event, patients with paraphilias who have a co-occurring condition will require psychiatric treatment for both the paraphilia and any other mental-health conditions.
The cause of paraphilias is unclear. Early theorists postulated that paraphilias, as well as other psychiatric conditions such as feeble mindedness, were part and parcel of brain degeneracy, a significant cause of which was overtaxing the nervous system by such phenomena as masturbation, or "nocturnal pollutions." Degeneracy went hand in glove with "hereditary taint," which was thought to accumulate through the generations. Although mechanisms were not clearly elucidated, exposure to excessive sexual stimulation outside socially sanctioned heterosexual marriage was believed to put individuals at risk for sexual deviations. Why such deviations developed in some individuals and not others was explained by the postulate that less tainted individuals were at less risk than more degenerate individuals for sexual perversions.
Moreover, such excessive stimulation need not always be intentional. For example, one theory enjoying some degree of acceptance in early psychoanalytic circles was that infants born to hereditarily tainted mothers were predisposed to develop a fur fetish by coming into contact with their mother's pubic hair during birth (W. B. Pomeroy, personal communication; 1982). While such explanations seem naive today, the notion that the development and maintenance of paraphilias must be a combination of genetic susceptibility and environmental trauma persists. In reality, we still know very little about the genesis of paraphilias.
The data that have been collected, however, do support at least 1 biological marker for vulnerability: men account for the vast majority of paraphilias. Among the paraphilias specifically delineated by DSM-IV, paraphilias are much more infrequently diagnosed in women than in men. Except for sexual masochism, which is still about 20 times less likely to affect men than women, paraphilias are quite unlikely to be diagnosed in women.
Paraphilias, or at least conditions that look very much like paraphilias, have also been reported as the result of brain trauma, neoplasms, temporal lobe damage, or epilepsy and may manifest as hyposexuality or hypersexuality, particularly in men. Lehne8 described a case of a frontal lobe injury in a man who suddenly developed a paraphilic interest in his stepdaughter's breasts. Treatment with conventional methods, including anticonvulsant administration, cognitive-behavioral therapy, and individual/family therapy failed to address his illness adequately but antiandrogens brought his symptoms under control.