| A paraphilia is a condition
in which a person's sexual arousal and gratification depend on fantasizing about
and engaging in sexual behavior that is atypical and extreme. A paraphilia can
revolve around a particular object (e.g., children, animals, underwear) or around
a particular act (e.g., inflicting pain, exposing oneself). Most of the paraphilias
are far more common in men than in women. The focus of a paraphilia is usually
very specific and unchanging. A paraphilia is distinguished by a preoccupation
with the object or behavior to the point of being dependent on that object or
behavior for sexual gratification. Paraphilias include sexual behaviors
that many people view as distasteful, unusual or abnormal and subsequently reject.
In descending order, the most common are pedophilia (sexual activity with
a child usually 13 years old or younger), exhibitionism (exposure of genitals
to strangers), voyeurism (observing private activities of unaware victims)
and frotteurism (touching, rubbing against a nonconsenting person), while
fetishism (use of inanimate objects), sexual masochism (being humiliated
or forced to suffer), sexual sadism (inflicting humiliation or suffering)
and transvestic fetishism (cross-dressing) are far less common. Some of
these behaviors are illegal and those who are under treatment for paraphilias
have often encountered legal situations surrounding their behaviors. There is
also a category called Paraphilia Not Otherwise Specified to cover paraphilias
not falling into the already named diagnoses such as those involving animals,
dead people, urine and feces, enemas and obscene phone calls. (American Psychiatric
Association, 1994; Morrison, 1994) Symptoms Although many of
the paraphilias seem foreign or extreme, they are easier to understand if one
thinks of those behaviors that, in less extreme versions, are quite common. For
instance, having a partner "talk dirty" may be a "turn-on"
for some people, but when talking dirty is the only way that sexual arousal or
satisfaction can occur, it would be considered a paraphilia. Others want to be
bitten, or spanked, or become aroused by watching their partner. Viewing a nude
person or watching sexually explicit videos can be arousing for most people. Paraphilias
are magnified to the point of psychological dependence.
top of page Causes It
is unclear what causes a paraphilia to develop. Psychoanalysts theorize that an
individual with a paraphilia is repeating or reverting to a sexual habit that
arose early in life. Behaviorists suggest that paraphilias begin through a process
of conditioning. Nonsexual objects can become sexually arousing if they are repeatedly
associated with pleasurable sexual activity. Or, particular sexual acts (such
as peeping, exhibiting, bestiality) that provide especially intense erotic pleasure
can lead the person to prefer that behavior. In some cases there seems to be a
predisposing factor such as difficulty forming person-to-person relationships. Nathan,
Gorman and Salkind (1999) provide the following survey of current theories regarding
the etiology of paraphilias. Behavioral learning models suggest that a child who
is the victim or observer of inappropriate sexual behaviors learns to imitate
and is later reinforced for the behavior. Compensation models suggest that these
individuals are deprived of normal social sexual contacts and thus seek gratification
through less socially acceptable means. Physiological models focus on the relationship
between hormones, behavior and the central nervous system with a particular interest
in the role of aggression and male sexual hormones. Treatment Treatment
approaches have included traditional psychoanalysis, hypnosis, and behavior therapy
techniques. More recently, a class of drugs called antiandrogens that drastically
lower testosterone levels temporarily have been used in conjunction with these
forms of treatment. The drug lowers the sex drive in males and reduces the frequency
of mental imagery of sexually arousing scenes. This allows concentration on counseling
without as strong a distraction from the paraphiliac urges. Increasingly, the
evidence suggests that combining drug therapy with cognitive behavior therapy
can be effective. Nathan et al. (1999) describe these treatment approaches
further here. First, they provide the following explanations regarding medication
as treatment for paraphilias. They point out that level of sex drive is not consistently
related to the behavior of paraphiliacs and also high levels of circulating testosterone
do not predispose a male to paraphilias. That said, hormones such as medroxyprogesterone
acetate (Depo-Provera) and cyproterone acetate decrease the level of circulating
testosterone thus reducing sex drive and aggression. These hormones result in
reduction of frequency of erections, sexual fantasies and initiations of sexual
behaviors including masturbation and intercourse. Hormones are typically used
in tandem with behavioral and cognitive treatments. Antidepressants such as fluoxetine
(Prozac) have also successfully decreased the sex drive but have not effectively
targeted sexual fantasies. The study also notes that research suggests that
cognitive-behavioral models are effective in treating paraphiliacs. They provide
the following explanation of different approaches. Aversive conditioning
involves using negative stimuli to reduce or eliminate a behavior. Covert sensitization
entails the patient relaxing, visualizing scenes of deviant behavior followed
by a negative event such as getting his penis stuck in the zipper of his pants.
Assisted aversive conditioning is similar to covert sensitization except
the negative event is made real most likely in the form of a foul odor pumped
in the air by the therapist. The goal is for the patient to associate the deviant
behavior with the foul odor and take measures to avoid the odor by avoiding said
behavior. Aversive behavioral reversal is commonly known as “shame therapy”
as the goal is to shame the offender into stopping the deviant behavior. For
example, the offender might be made to watch videotapes of their crime with the
goal that the experience will be distasteful and offensive to the offender. Vicarious
sensitization entails showing videotapes of deviant behaviors and their consequences
such as victims describing desired revenge or perhaps even watching surgical castrations. The
study describes positive conditioning approaches that might center on social skills
training and alternate behaviors the patient might take that are more appropriate.
Reconditioning techniques center around providing immediate feedback to the patient
so behavior will be changed right away. For example, a person might be connected
to a plethysmographic biofeedback machine that is connected to a light and taught
to keep the light within a specific range of color while the person is exposed
to sexually stimulating material. Or masturbation training might focus on separating
pleasure in masturbation and climax with the deviant behavior. Cognitive
therapies described include restructuring cognitive distortions and empathy training.
Restructuring cognitive distortions involves correcting erroneous beliefs by the
patient which may lead to errors in behavior such as seeing a victim and constructing
erroneous logic that the victim deserves to be party to the deviant act. Empathy
training involves helping the offender take on the perspective of the victim and
in identification with the victim, understand the harm that has been done. To
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