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Paraphilias: Clinical and Forensic Considerations

Paraphilias: Clinical and Forensic Considerations

Paraphilias are defined by DSM-IV-TR as sexual disorders characterized by "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 6 months" (Criterion A), which "cause clinically significant distress or impairment in social, occupational, or other important areas of functioning" (Criterion B). DSM-IV-TR describes 8 specific disorders of this type (exhibitionism, fetishism, frotteurism, pedophilia, sexual masochism, sexual sadism, voyeurism, and transvestic fetishism) along with a ninth residual category, paraphilia not otherwise specified (NOS).

It has been estimated that some 50 paraphilias have been identified and described in the literature. Many, like klismaphilia (erotic arousal to enemas) are not illegal and therefore do not often come to the attention of therapists even though they may fulfill DSM Criteria A and B requirements. Thus, the category paraphilia NOS comprises most of the paraphilias described in the literature, although not necessarily the largest number of individuals with paraphilias. The sheer variety of erotic material available on the Internet and other adult entertainment venues lends credence to this assumption. A content analysis of these materials would likely provide a reasonably accurate indication of the prevalence of these paraphilias—at least the legal ones.

With the exception of those who are in legal trouble, most, but not all, persons with paraphilia probably do not seek treatment. Indeed, it has been argued that the impact of the mandatory reporting laws enacted for certain sexual crimes has further decreased the number of individuals seeking voluntary treatment.1,2

To the layperson, paraphilias are commonly regarded as "kinky sex." Both canon law and common law proscribed most paraphilic thoughts and behaviors long before they came to be regarded by medical science as indicators of possible mental illness. By the time of Richard von Krafft-Ebing at the turn of the 20th century, medicine's interest in "abnormal" sexual behavior had come into full flower, and Krafft-Ebing made liberal use of such legal terminology as "perversion" and "deviancy" in his case studies.

An attempt to move away from such legally pejorative terminology eventually succeeded in the adoption of the term paraphilia, from the Greek prefix para meaning "around" or "beside" (within the context, implying "altered" or "missing the mark") and philia, 1 of 3 ancient Greek words for love. Benjamin Karpman gets credit for introducing English speakers to the term paraphilia.3

In the end, however, paraphilia and paraphile may be destined to join the pejorative ranks of such descriptors as perversion or pervert. Many well-educated individuals confuse paraphile with pedophile. Perhaps worse, because of a lack of understanding or disregard for the phenomenology of the paraphilias, physicians, lawyers, journalists, and other professionals readily conflate the medical term pedophile with the term child molester. It is a small jump from that error to conceptualizing all persons with paraphilia as sex offenders.

DSM nosology, and to some extent, therefore, psychiatry's understanding of the paraphilias, has not been consistent. The term paraphilia first appeared in DSM-III. The enumerated paraphilias included zoophilia but not frotteurism and specified a category for atypical paraphilias. DSM-III-R dropped zoophilia but added frotteurism and renamed the residual atypical class paraphilias NOS. The 1987 categories remain, with minor semantic changes, the same in the DSM-IV and DSM-IV-TR editions.

In addition, DSM has not always classified paraphilias as sexual disorders. Beginning with the first DSM published in 1952, sexual deviations, as the paraphilias were then called, were conceptualized as a subclass of sociopathic personality disturbances—a category that included most diagnoses "formerly classed as psychopathic personality with pathologic sexuality," adding that the diagnosis should specify the "type of the pathologic behavior, such as homosexuality, transvestism, pedophilia, fetishism, and sexual sadism (including rape, assault, mutilation)."

The personality disorders of the first DSM were distinguished from psychophysiological autonomic and visceral disorders that were believed to be more physiologically based than certain other mental disorders. As such, they were differentiated from sexual dysfunctions and gender disturbances. The subcategory, psychophysiologic genitourinary reaction appears to have been the rough equivalent of the sexual dysfunctions subcategory of the sexual and gender identity disorders category of DSM-IV-TR.

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