Paraphilia: Difference between revisions

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__NOTOC__
{{SI}}                                                                 
{{CMG}}; {{AE}} {{Sharma}}
{{SK}} Fetishism, Voyeurism, Zoophilia, Pedophilia, Sexual perversion, Zoophilism, Abnormal sexual activity
==Overview==
==Overview==
Paraphilias are characterized by severe deviant sexual desire or urge resulting in actions that may cause significant impairment in functioning as well as [[distress]] (for oneself and/or others). Paraphilic behavior may occur intermittently or may persist for the entire life. To begin with, paraphilia occurs in the form of fantasy, and the paraphilic behavior manifests later in life. Mostly the individuals with this condition do not seek [[treatment]] themselves due to the pleasure they obtain from it and in some cases, the associated stigma. Paraphilias are not illegal but the resulting behaviors are. Timely [[treatment]] is important to prevent sexual offenses like pedophilia or serial rapes. Patients may have more than one type of paraphilia and therefore, it is essential to evaluate them thoroughly to provide optimal management.


==Historical Perspective==
==Historical Perspective==
[Disease name] was first discovered by [name of scientist], a [nationality + occupation], in [year]/during/following [event].
The association between [important risk factor/cause] and [disease name] was made in/during [year/event].
In [year], [scientist] was the first to discover the association between [risk factor] and the development of [disease name].
In [year], [gene] mutations were first implicated in the pathogenesis of [disease name].


There have been several outbreaks of [disease name], including -----.
*The term 'Paraphilia' is Greek in origin and is derived from the words-'Para'(deviation) and 'philia'(attraction).<ref name="SeligmanHardenburg2000">{{cite journal|last1=Seligman|first1=Linda|last2=Hardenburg|first2=Stephanie A.|title=Assessment and Treatment of Paraphilias|journal=Journal of Counseling & Development|volume=78|issue=1|year=2000|pages=107–113|issn=07489633|doi=10.1002/j.1556-6676.2000.tb02567.x}}</ref>
 
*From biblical times, human societies across the world, have placed restrictions on many types of sexual behaviors. The level of acceptability is based on cultural variations across the globe.
In [year], [diagnostic test/therapy] was developed by [scientist] to treat/diagnose [disease name].
*There is controversy in what should be called sexual deviation, mainly based on various factors like the degree of consent, age of the involved individuals, degree of [[distress]] caused, location of sexual behavior, degree of unacceptable by others, etc. <ref name="Gordon2008">{{cite journal|last1=Gordon|first1=Harvey|title=The treatment of paraphilias: An historical perspective|journal=Criminal Behaviour and Mental Health|volume=18|issue=2|year=2008|pages=79–87|issn=09579664|doi=10.1002/cbm.687}}</ref>
*The term 'Sadism' originated from Marquis de Sade (1740-1814). He was placed in a lunatic asylum multiple times and ultimately, died there. His mental instability is considered to have resulted in this pattern of sexual behavior. <ref name="Gordon2008">{{cite journal|last1=Gordon|first1=Harvey|title=The treatment of paraphilias: An historical perspective|journal=Criminal Behaviour and Mental Health|volume=18|issue=2|year=2008|pages=79–87|issn=09579664|doi=10.1002/cbm.687}}</ref>
*The term 'Masochism' came from  Baron Leopold von Sacher Masoch (1835-1895), who was of European origin.<ref name="Gordon2008">{{cite journal|last1=Gordon|first1=Harvey|title=The treatment of paraphilias: An historical perspective|journal=Criminal Behaviour and Mental Health|volume=18|issue=2|year=2008|pages=79–87|issn=09579664|doi=10.1002/cbm.687}}</ref>
*With the publication of Psychopathia Sexualis at the end of the nineteenth century, sexual deviance was considered a medical condition. Psychopathia Sexualis was written by a German [[psychiatrist]] Krafft-Ebing, who described the sexual murders in this publication.  <ref name="Gordon2008">{{cite journal|last1=Gordon|first1=Harvey|title=The treatment of paraphilias: An historical perspective|journal=Criminal Behaviour and Mental Health|volume=18|issue=2|year=2008|pages=79–87|issn=09579664|doi=10.1002/cbm.687}}</ref><ref name="GarciaThibaut2011">{{cite journal|last1=Garcia|first1=Frederico D.|last2=Thibaut|first2=Florence|title=Current Concepts in the Pharmacotherapy of Paraphilias|journal=Drugs|volume=71|issue=6|year=2011|pages=771–790|issn=0012-6667|doi=10.2165/11585490-000000000-00000}}</ref>


==Classification==
==Classification==
There is no established system for the classification of [disease name].
*Earlier the non-reproductive sexual behaviors were considered [[pathological]] and criminalized. However, over years the boundaries of pathology have been confined to the absence of sexual consent. <ref name="Giami2015">{{cite journal|last1=Giami|first1=Alain|title=Between DSM and ICD: Paraphilias and the Transformation of Sexual Norms|journal=Archives of Sexual Behavior|volume=44|issue=5|year=2015|pages=1127–1138|issn=0004-0002|doi=10.1007/s10508-015-0549-6}}</ref>
 
*The inclusion of the pathological classification of paraphilias in the [[DSM]] and [[ICD]] has been criticized for a long time. It is based on the thin line of difference between something that is a normal variation or just unusual, and something that is [[pathological]].  
OR
*According to [[DSM-III]], a patient could have more than one paraphilias but the extent of the multiplicity was not described until later editions.<ref name="BradfordBoulet2017">{{cite journal|last1=Bradford|first1=John M.W.|last2=Boulet|first2=J.|last3=Pawlak|first3=A.|title=The Paraphilias: A Multiplicity of Deviant Behaviours*|journal=The Canadian Journal of Psychiatry|volume=37|issue=2|year=2017|pages=104–108|issn=0706-7437|doi=10.1177/070674379203700206}}</ref>
 
*Till [[DSM-IV-TR]], the diagnostic category of paraphilia was scrutinized for logic, clarity, and consistency. <ref name="MoserKleinplatz2006">{{cite journal|last1=Moser|first1=Charles|last2=Kleinplatz|first2=Peggy J.|title=DSM-IV-TRand the Paraphilias|journal=Journal of Psychology & Human Sexuality|volume=17|issue=3-4|year=2006|pages=91–109|issn=0890-7064|doi=10.1300/J056v17n03_05}}</ref>
[Disease name] may be classified according to [classification method] into [number] subtypes/groups: [group1], [group2], [group3], and [group4].
*DSM-IV-TR included paraphilias in the chapter ‘Sexual and Gender Identity Disorders’.<ref name="GarciaThibaut2011">{{cite journal|last1=Garcia|first1=Frederico D.|last2=Thibaut|first2=Florence|title=Current Concepts in the Pharmacotherapy of Paraphilias|journal=Drugs|volume=71|issue=6|year=2011|pages=771–790|issn=0012-6667|doi=10.2165/11585490-000000000-00000}}</ref>
 
*There were proposals to remove paraphilias as a [[diagnostic]] category from [[DSM]]-5. Some considered the concept of paraphilic disorder as more ideological than scientific. <ref name="Downing2015">{{cite journal|last1=Downing|first1=Lisa|title=Heteronormativity and Repronormativity in Sexological “Perversion Theory” and the DSM-5’s “Paraphilic Disorder” Diagnoses|journal=Archives of Sexual Behavior|volume=44|issue=5|year=2015|pages=1139–1145|issn=0004-0002|doi=10.1007/s10508-015-0536-y}}</ref><ref name="Spitzer2006">{{cite journal|last1=Spitzer|first1=Robert L.|title=Sexual and Gender Identity Disorders|journal=Journal of Psychology & Human Sexuality|volume=17|issue=3-4|year=2006|pages=111–116|issn=0890-7064|doi=10.1300/J056v17n03_06}}</ref>
OR
*Despite the ongoing controversies, in [[DSM]]-5, the paraphilias have been assigned a separate chapter and are termed Paraphilic disorders. <ref name="pmid23585461">{{cite journal| author=Krueger RB, Kaplan MS| title=Paraphilic diagnoses in DSM-5. | journal=Isr J Psychiatry Relat Sci | year= 2012 | volume= 49 | issue= 4 | pages= 248-54 | pmid=23585461 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23585461  }} </ref>
 
*According to [[DSM]]-5, paraphilia as such does not require psychiatric intervention. Paraphilia causing harm to others or severe [[distress]] to oneself, is termed paraphilic disorder and needs treatment. <ref name="GarciaThibaut2011">{{cite journal|last1=Garcia|first1=Frederico D.|last2=Thibaut|first2=Florence|title=Current Concepts in the Pharmacotherapy of Paraphilias|journal=Drugs|volume=71|issue=6|year=2011|pages=771–790|issn=0012-6667|doi=10.2165/11585490-000000000-00000}}</ref>
[Disease name] may be classified into [large number > 6] subtypes based on [classification method 1], [classification method 2], and [classification method 3].
*It has been found that DSM-5 diagnostic criteria for paraphilias can increase the false-positive rates by diagnosing without assessing the underlying motivation (may not necessarily be paraphilic sexual arousal). As a result, attaining this [[diagnosis]] can produce many legal consequences. <ref name="pmid24986346">{{cite journal| author=First MB| title=DSM-5 and paraphilic disorders. | journal=J Am Acad Psychiatry Law | year= 2014 | volume= 42 | issue= 2 | pages= 191-201 | pmid=24986346 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24986346  }} </ref>
[Disease name] may be classified into several subtypes based on [classification method 1], [classification method 2], and [classification method 3].
*[[ICD-10]] does not comprise a clear-cut definition of paraphilia. It simply refers to paraphilia as a disorder of sexual preference. <ref name="McManusHargreaves2013">{{cite journal|last1=McManus|first1=Michelle A.|last2=Hargreaves|first2=Paul|last3=Rainbow|first3=Lee|last4=Alison|first4=Laurence J.|title=Paraphilias: definition, diagnosis and treatment|journal=F1000Prime Reports|volume=5|year=2013|issn=20517599|doi=10.12703/P5-36}}</ref><ref name="AbdullahiJafojo2015">{{cite journal|last1=Abdullahi|first1=Halilu|last2=Jafojo|first2=Racheal Olayemi|last3=Udofia|first3=Owoidoho|title=Paraphilia Among Undergraduates in a Nigerian University|journal=Sexual Addiction & Compulsivity|volume=22|issue=3|year=2015|pages=249–257|issn=1072-0162|doi=10.1080/10720162.2015.1057662}}</ref>
 
OR
 
Based on the duration of symptoms, [disease name] may be classified as either acute or chronic.
 
OR
 
If the staging system involves specific and characteristic findings and features:
According to the [staging system + reference], there are [number] stages of [malignancy name] based on the [finding1], [finding2], and [finding3]. Each stage is assigned a [letter/number1] and a [letter/number2] that designate the [feature1] and [feature2].
 
OR
 
The staging of [malignancy name] is based on the [staging system].
 
OR
 
There is no established system for the staging of [malignancy name].


==Pathophysiology==
==Pathophysiology==
The exact pathogenesis of [disease name] is not fully understood.
===Monoamine Hypothesis===
 
*[[Norepinephrine]], [[serotonin]], and [[dopamine]] are the [[monoamine]]s involved in the physiology of sexual behavior.<ref name="Kafka1997">{{cite journal|last1=Kafka|first1=Martin P.|journal=Archives of Sexual Behavior|volume=26|issue=4|year=1997|pages=343–358|issn=00040002|doi=10.1023/A:1024535201089}}</ref>
OR
*[[Side effects]] of certain medications like [[antidepressants]] and [[neuroleptics]] show that the alteration of [[monoamine]] levels can adversely affect sexuality.<ref name="Kafka1997">{{cite journal|last1=Kafka|first1=Martin P.|journal=Archives of Sexual Behavior|volume=26|issue=4|year=1997|pages=343–358|issn=00040002|doi=10.1023/A:1024535201089}}</ref>
 
*[[Monoamine]]s modulate [[impulsivity]], [[anxiety]], [[depression]], and [[antisocial]] behavior. Dysregulation of the [[neurotransmitters]] may also produce these conditions in patients with paraphilic disorders. <ref name="Kafka1997">{{cite journal|last1=Kafka|first1=Martin P.|journal=Archives of Sexual Behavior|volume=26|issue=4|year=1997|pages=343–358|issn=00040002|doi=10.1023/A:1024535201089}}</ref>
It is thought that [disease name] is the result of / is mediated by / is produced by / is caused by either [hypothesis 1], [hypothesis 2], or [hypothesis 3].
*The [[medications]] that act by increasing the [[serotonergic]] function have been found to suppress the paraphilic behavior. This further supports the [[monoamine]] hypothesis. <ref name="Kafka2006">{{cite journal|last1=Kafka|first1=Martin P.|title=The Monoamine Hypothesis for the Pathophysiology of Paraphilic Disorders: An Update|journal=Annals of the New York Academy of Sciences|volume=989|issue=1|year=2006|pages=86–94|issn=00778923|doi=10.1111/j.1749-6632.2003.tb07295.x}}</ref>
 
OR
 
[Pathogen name] is usually transmitted via the [transmission route] route to the human host.
 
OR


Following transmission/ingestion, the [pathogen] uses the [entry site] to invade the [cell name] cell.
===Role of Testosterone===
Sex-steroid [[genetic]]s influences both [[antisocial]] traits, and sexual behavior. The relationship between [[testosterone]] and paraphilia is further evident by the positive response seen in these patients with antiandrogen therapy.<ref name="JordanFromberger2011">{{cite journal|last1=Jordan|first1=Kirsten|last2=Fromberger|first2=Peter|last3=Stolpmann|first3=Georg|last4=Müller|first4=Jürgen Leo|title=The Role of Testosterone in Sexuality and Paraphilia—A Neurobiological Approach. Part II: Testosterone and Paraphilia|journal=The Journal of Sexual Medicine|volume=8|issue=11|year=2011|pages=3008–3029|issn=17436095|doi=10.1111/j.1743-6109.2011.02393.x}}</ref>


OR
==Differential Diagnosis==
 
It is important to differentiate paraphilias from others like<ref name="SchneiderIrons1996">{{cite journal|last1=Schneider|first1=Jennifer P.|last2=Irons|first2=Richard|title=Differential diagnosis of addictive sexual disorders using the dsm-iv|journal=Sexual Addiction & Compulsivity|volume=3|issue=1|year=1996|pages=7–21|issn=1072-0162|doi=10.1080/10720169608400096}}</ref><ref name="GarciaThibaut2011">{{cite journal|last1=Garcia|first1=Frederico D.|last2=Thibaut|first2=Florence|title=Current Concepts in the Pharmacotherapy of Paraphilias|journal=Drugs|volume=71|issue=6|year=2011|pages=771–790|issn=0012-6667|doi=10.2165/11585490-000000000-00000}}</ref>
 
*Impulse disorder not otherwise specified (NOS)
[Disease or malignancy name] arises from [cell name]s, which are [cell type] cells that are normally involved in [function of cells].
*[[Bipolar affective disorder]]
 
*[[Cyclothymic disorder]]
OR
*Substance-induced anxiety disorder
 
*Substance [[intoxication]] (like [[cocaine]], or [[alcohol]])
The progression to [disease name] usually involves the [molecular pathway].
*[[Dissociative disorder]]
 
*[[Delusional disorder]] ([[erotomania]])
OR
*[[Gender identity disorder]]
 
*[[Obsessive-compulsive disorder]]  
The pathophysiology of [disease/malignancy] depends on the histological subtype.
*Cognitive disorders like [[dementia]]
 
*[[Delirium]]
==Causes==
*[[Parkinson’s disease]]
Disease name] may be caused by [cause1], [cause2], or [cause3].
*Other neurological disorders
 
OR
 
Common causes of [disease] include [cause1], [cause2], and [cause3].
 
OR
 
The most common cause of [disease name] is [cause 1]. Less common causes of [disease name] include [cause 2], [cause 3], and [cause 4].
 
OR
 
The cause of [disease name] has not been identified. To review risk factors for the development of [disease name], click [[Pericarditis causes#Overview|here]].
 
==Differentiating ((Page name)) from other Diseases==
[Disease name] must be differentiated from other diseases that cause [clinical feature 1], [clinical feature 2], and [clinical feature 3], such as [differential dx1], [differential dx2], and [differential dx3].
 
OR
 
[Disease name] must be differentiated from [[differential dx1], [differential dx2], and [differential dx3].


==Epidemiology and Demographics==
==Epidemiology and Demographics==
The incidence/prevalence of [disease name] is approximately [number range] per 100,000 individuals worldwide.
*The exact [[prevalence]] of Paraphilic Disorders is difficult to estimate.<ref name="JoyalCarpentier2016">{{cite journal|last1=Joyal|first1=Christian C.|last2=Carpentier|first2=Julie|title=The Prevalence of Paraphilic Interests and Behaviors in the General Population: A Provincial Survey|journal=The Journal of Sex Research|volume=54|issue=2|year=2016|pages=161–171|issn=0022-4499|doi=10.1080/00224499.2016.1139034}}</ref>
 
*Only a few patients seek [[treatment]] and most of the data is obtained from the paraphilic cases caught up in the legal system.<ref name="HallHall2007">{{cite journal|last1=Hall|first1=Ryan C.W.|last2=Hall|first2=Richard C.W.|title=A Profile of Pedophilia: Definition, Characteristics of Offenders, Recidivism, Treatment Outcomes, and Forensic Issues|journal=Mayo Clinic Proceedings|volume=82|issue=4|year=2007|pages=457–471|issn=00256196|doi=10.4065/82.4.457}}</ref><ref name="AbelOsborn1992">{{cite journal|last1=Abel|first1=Gene G.|last2=Osborn|first2=Candice|title=The Paraphilias: The Extent and Nature of Sexually Deviant and Criminal Behavior|journal=Psychiatric Clinics of North America|volume=15|issue=3|year=1992|pages=675–687|issn=0193953X|doi=10.1016/S0193-953X(18)30231-4}}</ref>
OR
 
In [year], the incidence/prevalence of [disease name] was estimated to be [number range] cases per 100,000 individuals worldwide.
 
OR
 
In [year], the incidence of [disease name] is approximately [number range] per 100,000 individuals with a case-fatality rate of [number range]%.
 
 
 
Patients of all age groups may develop [disease name].
 
OR
 
The incidence of [disease name] increases with age; the median age at diagnosis is [#] years.
 
OR
 
[Disease name] commonly affects individuals younger than/older than [number of years] years of age.
 
OR
 
[Chronic disease name] is usually first diagnosed among [age group].
 
OR
 
[Acute disease name] commonly affects [age group].
 
 
 
There is no racial predilection to [disease name].
 
OR
 
[Disease name] usually affects individuals of the [race 1] race. [Race 2] individuals are less likely to develop [disease name].
 
 
 
[Disease name] affects men and women equally.
 
OR
 
[Gender 1] are more commonly affected by [disease name] than [gender 2]. The [gender 1] to [gender 2] ratio is approximately [number > 1] to 1.
 
 


The majority of [disease name] cases are reported in [geographical region].
===Age===
*Although discrepancies in studies exist, on average no specific age group has been predisposed to develop Paraphilia.
*Literature has revealed that paraphilias mostly begin in [[childhood]] and are manifested later in [[adolescence]]. <ref name="MoneyPranzarone1993">{{cite journal|last1=Money|first1=John|last2=Pranzarone|first2=Galdino F.|title=Development of Paraphilia in Childhood and Adolescence|journal=Child and Adolescent Psychiatric Clinics of North America|volume=2|issue=3|year=1993|pages=463–475|issn=10564993|doi=10.1016/S1056-4993(18)30552-2}}</ref>


OR
===Gender===
*Paraphilic behavior is seen mostly in men. However, there are studies that show no prominent gender-differences.<ref name="AbdullahiJafojo2015">{{cite journal|last1=Abdullahi|first1=Halilu|last2=Jafojo|first2=Racheal Olayemi|last3=Udofia|first3=Owoidoho|title=Paraphilia Among Undergraduates in a Nigerian University|journal=Sexual Addiction & Compulsivity|volume=22|issue=3|year=2015|pages=249–257|issn=1072-0162|doi=10.1080/10720162.2015.1057662}}</ref><ref name="JoyalCarpentier2016">{{cite journal|last1=Joyal|first1=Christian C.|last2=Carpentier|first2=Julie|title=The Prevalence of Paraphilic Interests and Behaviors in the General Population: A Provincial Survey|journal=The Journal of Sex Research|volume=54|issue=2|year=2016|pages=161–171|issn=0022-4499|doi=10.1080/00224499.2016.1139034}}</ref><ref name="DawsonBannerman2014">{{cite journal|last1=Dawson|first1=Samantha J.|last2=Bannerman|first2=Brittany A.|last3=Lalumière|first3=Martin L.|title=Paraphilic Interests|journal=Sexual Abuse: A Journal of Research and Treatment|volume=28|issue=1|year=2014|pages=20–45|issn=1079-0632|doi=10.1177/1079063214525645}}</ref>


[Disease name] is a common/rare disease that tends to affect [patient population 1] and [patient population 2].
===Race===
*Limited studies have been done about racial predilection.
*Most studies present mixed results and it can be concluded that no specific race is predisposed to develop paraphilia.<ref name="LeeHanson2019">{{cite journal|last1=Lee|first1=Seung C.|last2=Hanson|first2=R. Karl|last3=Calkins|first3=Cynthia|last4=Jeglic|first4=Elizabeth|title=Paraphilia and Antisociality: Motivations for Sexual Offending May Differ for American Whites and Blacks|journal=Sexual Abuse|volume=32|issue=3|year=2019|pages=335–365|issn=1079-0632|doi=10.1177/1079063219828779}}</ref>


==Risk Factors==
==Risk Factors==
There are no established risk factors for [disease name].
*Noxious [[child]]-rearing experiences, non-sexual and sexual both<ref name="MoneyPranzarone1993">{{cite journal|last1=Money|first1=John|last2=Pranzarone|first2=Galdino F.|title=Development of Paraphilia in Childhood and Adolescence|journal=Child and Adolescent Psychiatric Clinics of North America|volume=2|issue=3|year=1993|pages=463–475|issn=10564993|doi=10.1016/S1056-4993(18)30552-2}}</ref>
 
*Childhood emotional [[abuse]]<ref name="LeeJackson2002">{{cite journal|last1=Lee|first1=Joseph K.P.|last2=Jackson|first2=Henry J.|last3=Pattison|first3=Pip|last4=Ward|first4=Tony|title=Developmental risk factors for sexual offending|journal=Child Abuse & Neglect|volume=26|issue=1|year=2002|pages=73–92|issn=01452134|doi=10.1016/S0145-2134(01)00304-0}}</ref>
OR
*Childhood sexual [[abuse]]<ref name="LeeJackson2002">{{cite journal|last1=Lee|first1=Joseph K.P.|last2=Jackson|first2=Henry J.|last3=Pattison|first3=Pip|last4=Ward|first4=Tony|title=Developmental risk factors for sexual offending|journal=Child Abuse & Neglect|volume=26|issue=1|year=2002|pages=73–92|issn=01452134|doi=10.1016/S0145-2134(01)00304-0}}</ref>
 
The most potent risk factor in the development of [disease name] is [risk factor 1]. Other risk factors include [risk factor 2], [risk factor 3], and [risk factor 4].
 
OR
 
Common risk factors in the development of [disease name] include [risk factor 1], [risk factor 2], [risk factor 3], and [risk factor 4].
 
OR
 
Common risk factors in the development of [disease name] may be occupational, environmental, genetic, and viral.
 
==Screening==
There is insufficient evidence to recommend routine screening for [disease/malignancy].
 
OR
 
According to the [guideline name], screening for [disease name] is not recommended.
 
OR
 
According to the [guideline name], screening for [disease name] by [test 1] is recommended every [duration] among patients with [condition 1], [condition 2], and [condition 3].


==Natural History, Complications, and Prognosis==
==Natural History, Complications, and Prognosis==
If left untreated, [#]% of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].
OR
Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].


OR
*Patients with paraphilias have high chances of relapse.<ref name="SeligmanHardenburg2000">{{cite journal|last1=Seligman|first1=Linda|last2=Hardenburg|first2=Stephanie A.|title=Assessment and Treatment of Paraphilias|journal=Journal of Counseling & Development|volume=78|issue=1|year=2000|pages=107–113|issn=07489633|doi=10.1002/j.1556-6676.2000.tb02567.x}}</ref>
*After 15 years, pedophiles attracted to boys are likely to commit the crime again (35%) as compared to those attracted to girls (16%).<ref name="AbelOsborn1992">{{cite journal|last1=Abel|first1=Gene G.|last2=Osborn|first2=Candice|title=The Paraphilias: The Extent and Nature of Sexually Deviant and Criminal Behavior|journal=Psychiatric Clinics of North America|volume=15|issue=3|year=1992|pages=675–687|issn=0193953X|doi=10.1016/S0193-953X(18)30231-4}}</ref>
*Good [[prognostic]] factors are<ref name="SeligmanHardenburg2000">{{cite journal|last1=Seligman|first1=Linda|last2=Hardenburg|first2=Stephanie A.|title=Assessment and Treatment of Paraphilias|journal=Journal of Counseling & Development|volume=78|issue=1|year=2000|pages=107–113|issn=07489633|doi=10.1002/j.1556-6676.2000.tb02567.x}}</ref>
**Early [[treatment]]
**Individuals with good ego strength and high motivation for [[treatment]]
**Patients with normal [[adult]] sexual experiences
*Poor [[prognostic]] factors are<ref name="SeligmanHardenburg2000">{{cite journal|last1=Seligman|first1=Linda|last2=Hardenburg|first2=Stephanie A.|title=Assessment and Treatment of Paraphilias|journal=Journal of Counseling & Development|volume=78|issue=1|year=2000|pages=107–113|issn=07489633|doi=10.1002/j.1556-6676.2000.tb02567.x}}</ref>
**Coexisting  mental  disorders
**Early-onset of paraphilic behaviors
**Lack of remorse for their behaviors
**Substance misuse
**Pedophilia with a sexual interest in boys
*The risk of recurrence depends on<ref name="AbelOsborn1992">{{cite journal|last1=Abel|first1=Gene G.|last2=Osborn|first2=Candice|title=The Paraphilias: The Extent and Nature of Sexually Deviant and Criminal Behavior|journal=Psychiatric Clinics of North America|volume=15|issue=3|year=1992|pages=675–687|issn=0193953X|doi=10.1016/S0193-953X(18)30231-4}}</ref>
**Static risk factors (history of sexual [[abuse]]) - The factors that do not change during [[treatment]]
**Dynamic risk factors ([[impulsivity]], [[hypersexuality]], or [[personality disorders]]) - These can be addressed during [[psychotherapy]]


Prognosis is generally excellent/good/poor, and the 1/5/10-year mortality/survival rate of patients with [disease name] is approximately [#]%.
==Comorbidities==
Various comorbid conditions exist with paraphilias like<ref name="AbdullahiJafojo2015">{{cite journal|last1=Abdullahi|first1=Halilu|last2=Jafojo|first2=Racheal Olayemi|last3=Udofia|first3=Owoidoho|title=Paraphilia Among Undergraduates in a Nigerian University|journal=Sexual Addiction & Compulsivity|volume=22|issue=3|year=2015|pages=249–257|issn=1072-0162|doi=10.1080/10720162.2015.1057662}}</ref><ref name="FisherCastellini2015">{{cite journal|last1=Fisher|first1=Alessandra D.|last2=Castellini|first2=Giovanni|last3=Casale|first3=Helen|last4=Fanni|first4=Egidia|last5=Bandini|first5=Elisa|last6=Campone|first6=Beatrice|last7=Ferruccio|first7=Naika|last8=Maseroli|first8=Elisa|last9=Boddi|first9=Valentina|last10=Dèttore|first10=Davide|last11=Pizzocaro|first11=Alessandro|last12=Balercia|first12=Giancarlo|last13=Oppo|first13=Alessandro|last14=Ricca|first14=Valdo|last15=Maggi|first15=Mario|title=Hypersexuality, Paraphilic Behaviors, and Gender Dysphoria in Individuals with Klinefelter's Syndrome|journal=The Journal of Sexual Medicine|volume=12|issue=12|year=2015|pages=2413–2424|issn=17436095|doi=10.1111/jsm.13048}}</ref><ref name="SeligmanHardenburg2000">{{cite journal|last1=Seligman|first1=Linda|last2=Hardenburg|first2=Stephanie A.|title=Assessment and Treatment of Paraphilias|journal=Journal of Counseling & Development|volume=78|issue=1|year=2000|pages=107–113|issn=07489633|doi=10.1002/j.1556-6676.2000.tb02567.x}}</ref>
*[[Major Depressive Disorder]]
*[[Anxiety disorders]]
*[[Substance abuse]]
*[[Erotomania]]
*Suicidality
*[[Gender identity disorder]]
*Autism Spectrum Disorder (ASD)
*[[Mental Retardation]]
*[[Antisocial]] Personality Disorder
*[[Personality]] change due to General Medical Condition


==Diagnosis==
==Diagnosis==
===Diagnostic Study of Choice===
The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met: [criterion 1], [criterion 2], [criterion 3], and [criterion 4].
OR
The diagnosis of [disease name] is based on the [criteria name] criteria, which include [criterion 1], [criterion 2], and [criterion 3].
OR
The diagnosis of [disease name] is based on the [definition name] definition, which includes [criterion 1], [criterion 2], and [criterion 3].
OR
There are no established criteria for the diagnosis of [disease name].
===History and Symptoms===
The majority of patients with [disease name] are asymptomatic.
OR
The hallmark of [disease name] is [finding]. A positive history of [finding 1] and [finding 2] is suggestive of [disease name]. The most common symptoms of [disease name] include [symptom 1], [symptom 2], and [symptom 3]. Common symptoms of [disease] include [symptom 1], [symptom 2], and [symptom 3]. Less common symptoms of [disease name] include [symptom 1], [symptom 2], and [symptom 3].
===Physical Examination===
Patients with [disease name] usually appear [general appearance]. Physical examination of patients with [disease name] is usually remarkable for [finding 1], [finding 2], and [finding 3].
OR
Common physical examination findings of [disease name] include [finding 1], [finding 2], and [finding 3].
OR
The presence of [finding(s)] on physical examination is diagnostic of [disease name].
OR
The presence of [finding(s)] on physical examination is highly suggestive of [disease name].
===Laboratory Findings===
An elevated/reduced concentration of serum/blood/urinary/CSF/other [lab test] is diagnostic of [disease name].
OR
Laboratory findings consistent with the diagnosis of [disease name] include [abnormal test 1], [abnormal test 2], and [abnormal test 3].
OR
[Test] is usually normal among patients with [disease name].
OR
Some patients with [disease name] may have elevated/reduced concentration of [test], which is usually suggestive of [progression/complication].
OR
There are no diagnostic laboratory findings associated with [disease name].
===Electrocardiogram===
There are no ECG findings associated with [disease name].
OR
An ECG may be helpful in the diagnosis of [disease name]. Findings on an ECG suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].


===X-ray===
===DSM-5 Diagnostic Criteria===
There are no x-ray findings associated with [disease name].


OR
*Following conditions have been described in the chapter on Paraphilia
# Exhibitionistic Disorder
# Fetishistic Disorder
# Frotteuristic Disorder
# Paedophilic Disorder
# Sexual Masochism Disorder
# Sexual Sadism Disorder
# Voyeuristic Disorder
# Transvestic Disorder
# Other specified Paraphilic Disorder
# Unspecified Paraphilic Disorder


An x-ray may be helpful in the diagnosis of [disease name]. Findings on an x-ray suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
====Voyeuristic Disorder====
*A. Over a minimum period of six months, the existence of recurrent and intense sexual arousal from observing an unsuspected naked person.
*B. Action has been taken on the urges with a non-consenting person, or significant [[distress]]/ socio-occupational functioning impairment is caused by these sexual urges or fantasies.
*C. The individual is at least 18 years old.


OR
Specify if:
*In a controlled environment(the individual is living in an institution etc).
*In full remission (individual has not acted on these urges and has not resulted in [[distress]] over the last 5 years, while in an uncontrolled environment).


There are no x-ray findings associated with [disease name]. However, an x-ray may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].
====Exhibitionistic Disorder====
*A. Over a minimum period of six months, the existence of recurrent and intense sexual arousal from exposure of one's genitals to an unsuspected person.
*B. Action has been taken on these urges with a non-consenting person, or significant [[distress]]/ socio-occupational functioning impairment is caused by these sexual urges or fantasies.


===Echocardiography or Ultrasound===
Specify whether:
There are no echocardiography/ultrasound  findings associated with [disease name].
*Sexually aroused by exposing genitals to the prepubertal [[children]].
*Sexually aroused by exposing genitals to physically mature individuals.
*Sexually aroused by exposing genitals to the prepubertal [[children]] as well as physically mature individuals.


OR
Specify if:
*In a controlled environment(the individual is living in an institution etc).
*In full remission (individual has not acted on these urges and has not resulted in distress over the last 5 years, while in an uncontrolled environment).


Echocardiography/ultrasound  may be helpful in the diagnosis of [disease name]. Findings on an echocardiography/ultrasound suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
====Frotteuristic Disorder====
*A. Over a minimum period of six months, the existence of recurrent and intense sexual arousal from touching or rubbing against a non-consenting person, as manifested by fantasies, or behavior.
*B. Action has been taken on these urges with a non-consenting person, or significant [[distress]]/ socio-occupational functioning impairment is caused by these sexual urges or fantasies.


OR
Specify if:
*In a controlled environment(the individual is living in an institution etc).
*In full remission (individual has not acted on these urges and has not resulted in distress over the last 5 years, while in an uncontrolled environment).


There are no echocardiography/ultrasound  findings associated with [disease name]. However, an echocardiography/ultrasound may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].
====Sexual Masochism Disorder====
*A. Over a minimum period of six months, the existence of recurrent and intense sexual arousal from being beaten, bound, humiliated, or made to suffer; is manifested in the form of fantasies, urges, or behaviors.
*B. Significant [[distress]]/ socio-occupational functioning impairment is caused by these sexual urges or fantasies.


===CT scan===
Specify if:
There are no CT scan findings associated with [disease name].
With asphyxiophilia: If the individual experiences sexual arousal due to restriction of breathing.


OR
Specify if:
*In a controlled environment(the individual is living in an institution etc).
*In full remission (individual has not acted on these urges and has not resulted in distress over the last 5 years, while in an uncontrolled environment).


[Location] CT scan may be helpful in the diagnosis of [disease name]. Findings on CT scan suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
====Sexual Sadism Disorder====
*A. Over a minimum period of six months, the existence of recurrent and intense sexual arousal from the [[psychological]] or physical suffering of another person; is manifested in the form of urges, fantasies, or behaviors.
*B. Significant [[distress]]/ socio-occupational functioning impairment is caused by these sexual urges or fantasies.


OR
Specify if:
*In a controlled environment(the individual is living in an institution etc).
*In full remission (individual has not acted on these urges and has not resulted in distress over the last 5 years, while in an uncontrolled environment).


There are no CT scan findings associated with [disease name]. However, a CT scan may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].
====Pedophilic Disorder====


===MRI===
*A. Over a minimum period of six months, the existence of recurrent and intense sexually arousing fantasies, urges, or behavior involving sexual activity with a [[child]] or many [[children]] of age 13 or younger.
There are no MRI findings associated with [disease name].
*B. Significant distress/ interpersonal difficulty is caused by these sexual urges or fantasies, or the individual has acted on these sexual [[urge]]s.
*C. The individual is at least 16 years old and a minimum of 5 years older than the child.


OR
Specify whether:
*Exclusive type (attracted to children only).
*Non-exclusive type.


[Location] MRI may be helpful in the diagnosis of [disease name]. Findings on MRI suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
Specify if:
*Sexually attracted to males only.
*Sexually attracted to females only.
*Sexually attracted to both.


OR
Specify if:
*Limited to incest.


There are no MRI findings associated with [disease name]. However, a MRI may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].
====Fetishistic Disorder====


===Other Imaging Findings===
*A. Over a minimum period of six months, the existence of recurrent and intense sexually arousing fantasies, urges, or behavior from the use of non-living objects, or a focus on non-genital body part/parts.
There are no other imaging findings associated with [disease name].
*B. Significant [[distress]]/ socio-occupational functioning impairment is caused by these sexual urges or fantasies, or behavior.
*C. The fetish objects are not limited to clothing or objects designed for tactile genital stimulation.


OR
Specify if:
*Body part/parts.
*Non-living object/objects.
*Other.


[Imaging modality] may be helpful in the diagnosis of [disease name]. Findings on an [imaging modality] suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
Specify if:
*In a controlled environment(the individual is living in an institution etc).
*In full remission (individual has not acted on these urges and has not resulted in distress over the last 5 years, while in an uncontrolled environment).


===Other Diagnostic Studies===
====Transvestic Disorder====
There are no other diagnostic studies associated with [disease name].
*A. Over a minimum period of six months, the existence of recurrent and intense sexually arousing fantasies, urges, or behavior from cross-dressing.
*B. Significant [[distress]]/ socio-occupational functioning impairment is caused by these sexual urges or fantasies, or behavior.


OR
Specify if:
*With fetishism.
*With autogynephilia - Sexual arousal by thoughts or images of self as a female.


[Diagnostic study] may be helpful in the diagnosis of [disease name]. Findings suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].
Specify if:
*In a controlled environment(the individual is living in an institution etc).
*In full remission (individual has not acted on these urges and has not resulted in distress over the last 5 years, while in an uncontrolled environment).


OR
====Other Specified Paraphilic Disorder====
*Significant [[distress]]/ socio-occupational functioning impairment is caused by the symptoms characteristic of a paraphilic disorder but does not completely fulfill the criteria of any of the categories in the Paraphilic Disorders.


Other diagnostic studies for [disease name] include [diagnostic study 1], which demonstrates [finding 1], [finding 2], and [finding 3], and [diagnostic study 2], which demonstrates [finding 1], [finding 2], and [finding 3].
====Unspecified Paraphilic Disorder====
*Used in the conditions where the clinician chooses not to mention the reason that the criteria are not fulfilled for a specific paraphilic disorder.


==Treatment==
==Treatment==
===Medical Therapy===
*A [[treatment]] plan comprising of [[psychotherapy]], and/or [[pharmacotherapy]] is usually needed to suppress the paraphiliac fantasies and behaviors.  
There is no treatment for [disease name]; the mainstay of therapy is supportive care.
*The [[treatment]] depends on the intensity and frequency of paraphiliac sexual fantasies as well as the risk of sexual violence. <ref name="Thibaut2015">{{cite journal|last1=Thibaut|first1=Florence|title=Paraphilias|year=2015|pages=1–5|doi=10.1002/9781118625392.wbecp242}}</ref>  
 
*The very severe conditions may lead to sexual offenses, like rape and it is necessary to manage such patients aggressively with [[hormonal]] intervention.<ref name="Thibaut2015">{{cite journal|last1=Thibaut|first1=Florence|title=Paraphilias|year=2015|pages=1–5|doi=10.1002/9781118625392.wbecp242}}</ref>
OR
*The [[treatment]] regime consists of six levels with escalating degrees of medical intervention, based on the severity of the disorder.<ref name="pmid26800994">{{cite journal| author=Holoyda BJ, Kellaher DC| title=The Biological Treatment of Paraphilic Disorders: an Updated Review. | journal=Curr Psychiatry Rep | year= 2016 | volume= 18 | issue= 2 | pages= 19 | pmid=26800994 | doi=10.1007/s11920-015-0649-y | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26800994  }} </ref>
 
Supportive therapy for [disease name] includes [therapy 1], [therapy 2], and [therapy 3].
 
OR
 
The majority of cases of [disease name] are self-limited and require only supportive care.
 
OR
 
[Disease name] is a medical emergency and requires prompt treatment.
 
OR
 
The mainstay of treatment for [disease name] is [therapy].
 
OR
The optimal therapy for [malignancy name] depends on the stage at diagnosis.
 
OR
 
[Therapy] is recommended among all patients who develop [disease name].
 
OR
 
Pharmacologic medical therapy is recommended among patients with [disease subclass 1], [disease subclass 2], and [disease subclass 3].
 
OR
 
Pharmacologic medical therapies for [disease name] include (either) [therapy 1], [therapy 2], and/or [therapy 3].
 
OR
 
Empiric therapy for [disease name] depends on [disease factor 1] and [disease factor 2].
 
OR
 
Patients with [disease subclass 1] are treated with [therapy 1], whereas patients with [disease subclass 2] are treated with [therapy 2].
 
===Surgery===
Surgical intervention is not recommended for the management of [disease name].
 
OR
 
Surgery is not the first-line treatment option for patients with [disease name]. Surgery is usually reserved for patients with either [indication 1], [indication 2], and [indication 3]
 
OR
 
The mainstay of treatment for [disease name] is medical therapy. Surgery is usually reserved for patients with either [indication 1], [indication 2], and/or [indication 3].
 
OR
 
The feasibility of surgery depends on the stage of [malignancy] at diagnosis.
 
OR
 
Surgery is the mainstay of treatment for [disease or malignancy].
 
===Primary Prevention===
There are no established measures for the primary prevention of [disease name].
 
OR
 
There are no available vaccines against [disease name].
 
OR
 
Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].
 
OR
 
[Vaccine name] vaccine is recommended for [patient population] to prevent [disease name]. Other primary prevention strategies include [strategy 1], [strategy 2], and [strategy 3].
 
===Secondary Prevention===
There are no established measures for the secondary prevention of [disease name].
 
OR
 
Effective measures for the secondary prevention of [disease name] include [strategy 1], [strategy 2], and [strategy 3].
 
==References==
{{reflist|2}}
 
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{{WikiDoc Sources}}
 
'''Paraphilia''' (previously known as '''sexual perversion''' and '''sexual deviation'''<ref>{{Cite journal|last=Janssen|first=Diederik F|date=2020-06-30| title=From Libidines nefandæ to sexual perversions|journal=History of Psychiatry|language=en|pages=0957154X2093725|doi=10.1177/0957154X20937254|pmid=32605397|issn=0957-154X|doi-access=free}}</ref>)<!--NOTE: These alternative terms are here because of the WP:Alternative title policy; although they are less used and/or have been superseded, these are alternative names for this topic. --> is the experience of intense [[sexual arousal]] to atypical objects, situations, fantasies, behaviors, or individuals.<ref name="DSM-5, intro">{{cite book| title = Diagnostic and Statistical Manual of Mental Disorders | edition = Fifth | chapter = Paraphilic Disorders| year = 2013 | publisher = [[American Psychiatric Publishing]] | location=Philadelphia, Pennsylvania| pages = 685–686}}</ref><ref name="DSMTR">{{cite book | publisher= [[American Psychiatric Publishing]]| authorlink = American Psychiatric Association | title = Diagnostic and Statistical Manual of Mental Disorders-IV (Text Revision) | volume = 1 | pages = [https://books.google.com/books?id=3SQrtpnHb9MC&pg=PA566 566–76] | date =2000 |location = Philadelphia, Pennsylvania| isbn = 978-0-89042-024-9| doi = 10.1176/appi.books.9780890423349 | title-link = Diagnostic and Statistical Manual of Mental Disorders }}</ref>
 
No consensus has been found for any precise border between [[Kink (sexuality)|unusual sexual interests]] and paraphilic ones.<ref>{{Cite journal|title = How Anomalous Are Paraphilic Interests?|journal = [[Archives of Sexual Behavior]]|publisher=[[Springer Science + Business Media]]| location=New York City| date = 20 June 2014|issn = 0004-0002|pages = 1241–1243|volume = 43|issue = 7|doi = 10.1007/s10508-014-0325-z|pmid = 24948423|first = Christian C.|last = Joyal|s2cid = 34973560}}</ref><ref>{{Cite journal |doi = 10.1111/jsm.12734|pmid = 25359122|title = What Exactly is an Unusual Sexual Fantasy?|journal = [[The Journal of Sexual Medicine]]|publisher=[[Elsevier]]|location=Amsterdam, Netherlands|volume = 12|issue = 2|pages = 328–340|year = 2015|last1 = Joyal|first1 = Christian C.|last2 = Cossette|first2 = Amélie|last3 = Lapierre|first3 = Vanessa}}</ref> There is debate over which, if any, of the paraphilias should be listed in diagnostic manuals, such as the ''[[Diagnostic and Statistical Manual of Mental Disorders]]'' (DSM) or the [[International Classification of Diseases]] (ICD).
 
The number and [[Taxonomy (general)|taxonomy]] of paraphilia is under debate; one source lists as many as 549 types of paraphilia.<ref>{{Cite book | first=Anil | last=Aggrawal | authorlink=Anil Aggrawal | title=Forensic and Medico-legal Aspects of Sexual Crimes and Unusual Sexual Practices | date=2008 | pages=369–382 | chapter=Appendix 1 | chapter-url=https://books.google.com/books?id=uNkNhPZQprcC&lpg=PA369| publisher=[[CRC Press]] | location=Boca Raton, Florida| isbn=978-1-4200-4308-2}}</ref> The [[DSM-5]] has specific listings for eight paraphilic disorders.<ref name="DSM-5, intro"/> Several sub-classifications of the paraphilias have been proposed, and some argue that a fully dimensional, spectrum or complaint-oriented approach would better reflect the evidence.<ref>{{cite journal | first1 = Jack D.|last1= Maser | date = 2002 | title = Spectrum concepts in major mental disorders | journal = Psychiatric Clinics of North America| volume = 25 | issue = 4 | pages = xi–xiii| first2 = Hajop S.|last2=Akiskal|pmid = 12462854 | doi=10.1016/S0193-953X(02)00034-5}}</ref><ref>{{cite journal |first1=Robert F.|last1=Krueger|first2=David|last2=Watson|first3=David H.|last3=Barlow | title = Introduction to the Special Section: Toward a Dimensionally Based Taxonomy of Psychopathology | journal = [[Journal of Abnormal Psychology]]| publisher=[[American Psychological Association]]| location=Washington, DC|volume = 114 | issue = 4 | pages = 491–3 | year = 2005 | pmid = 16351372 | pmc = 2242426 | doi = 10.1037/0021-843X.114.4.491 | url = http://content.apa.org/journals/abn/114/4 }}</ref>
 
==Terminology==
Many terms have been used to describe atypical sexual interests, and there remains debate regarding technical accuracy and perceptions of stigma. [[Sexologist]] [[John Money]] popularized the term ''paraphilia'' as a non-[[pejorative]] designation for [[Kink (sexuality)|unusual sexual interests]].<ref name="wiederman2003">{{cite journal |first=Milan|last=Weiderman |date=2003 |title=Paraphilia and Fetishism |journal=[[The Family Journal]] |publisher=[[SAGE Publications]]| location=Thousand Oaks, California| volume=11 |issue=3 |pages=315–321 |doi=10.1177/1066480703252663 |s2cid=146788566 }}</ref><ref name="bullough1995">{{cite book | first=Vern L.|last = Bullough | authorlink=Vern Bullough| date = 1995 | url = http://www2.hu-berlin.de/sexology/GESUND/ARCHIV/LIBRO.HTM | title = Science in the Bedroom: A History of Sex Research | page = 281 | publisher = [[Basic Books]] | location= New York City| isbn = 978-0-465-07259-0 | url-status = dead | archiveurl = https://web.archive.org/web/20061022080700/http://www2.hu-berlin.de/sexology/GESUND/ARCHIV/LIBRO.HTM | archivedate = 22 October 2006 }}</ref><ref name="moser2001">{{cite book | last = Moser | first = Charles| date = 2001 | chapter = Critiques of conventional models of sex therapy | editor-first= Peggy J.|editor-last=Kleinplatz | title = New directions in sex therapy: innovations and alternatives | publisher = [[Taylor & Francis|Psychology Press]] | location=London, England| isbn = 978-0-87630-967-4}}</ref><ref name="mccammon2004">{{cite book | last1 = McCammon | first1 = Susan |last2=Knox|first2=David|last3=Schacht|first3=Caroline| date = 2004 | title = Choices in sexuality | page = 476 | publisher = Atomic Dog Publishing | location=Mason, Ohio| isbn = 978-1-59260-050-2 }}</ref> Money described paraphilia as "a sexuoerotic embellishment of, or alternative to the official, ideological norm."<ref name="money1990">{{cite book | last = Money | first = John | authorlink = John Money | date = 1990 | title = Gay, Straight, and In-Between: The Sexology of Erotic Orientation | publisher = [[Oxford University Press]] | location=Oxford, England| isbn = 978-0-19-506331-8 | pages = [https://archive.org/details/gaystraightinbet0000mone/page/139 139]}}</ref> Psychiatrist [[Glen Gabbard]] writes that despite efforts by Stekel and Money, "the term ''paraphilia'' remains pejorative in most circumstances."<ref name="gabbard2007">{{cite book | last = Gabbard | first = Glen O.| authorlink=Glen O. Gabbard| date = 2007| title = Gabbard's Treatments of Psychiatric Disorders| publisher = American Psychiatric Press | location=Philadelphia, Pennsylvania| page=581| isbn = 978-1-58562-216-0 }}</ref>
 
Coinage of the term ''paraphilia'' (''paraphilie'') has been credited to [[Friedrich Salomon Krauss]] in 1903, and it entered the English language in 1913, in reference to Krauss by [[urology|urologist]] [[William J. Robinson]].<ref name="janssen">{{Cite journal|last=Janssen|first=Diederik F.|date=2014|title=How to "Ascertain" Paraphilia? An Etymological Hint|journal=[[Archives of Sexual Behavior]] |publisher=[[Springer Science + Business Media]]| location=New York City| volume=43|issue=7|pages=1245–1246|doi=10.1007/s10508-013-0251-5|pmid=24464548|s2cid=44650160}}</ref> It was used with some regularity by [[Wilhelm Stekel]] in the 1920s.<ref name="stekel">{{cite book| last = Stekel | first =Wilhelm | authorlink = Wilhelm Stekel | origyear = 1930 |year= 2004| title = Sexual Aberrations: The Phenomenon of Fetishism in Relation to Sex | edition = translated from the 1922 original German | translator-first = S.|translator-last= Parker | publisher = [[Boni & Liveright]]|location=New York City |isbn=978-1417938346}}</ref> The term comes from the [[Ancient Greek|Greek]] παρά (''para'') "beside" and φιλία (''[[-phil-|-philia]]'') "friendship, [[love]]".
 
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 of [[sodomy]]<ref name="dailey1989 ">{{cite book|last=Dailey|first=Dennis M.|date=1989|title=The Sexually Unusual: Guide to Understanding and Helping|publisher=[[Haworth Press]]|location=Philadelphia, Pennsylvania|isbn=978-1417938346|pages=15–16}}</ref> and [[perversion]].<ref name="purcell2006">{{cite book | last1 = Purcell | first1 = Catherine E. |last2=Arrigo | first2= Bruce A.| date = 2006 | title = The psychology of lust murder: paraphilia, sexual killing, and serial homicide | publisher = [[Academic Press]] | location= Cambridge, Massachusetts| isbn = 978-0-12-370510-5 | page = 16}}</ref> Before the introduction of the term ''paraphilia'' in the DSM-III (1980), the term ''sexual deviation'' was used to refer to paraphilias in the first two editions of the manual.<ref>Laws & O'Donohue, p. 384</ref> In 1981, an article published in ''[[American Journal of Psychiatry]]'' described paraphilia as "recurrent, intense sexually arousing fantasies, sexual urges, or behaviors generally involving:<ref name="AJP">{{cite journal | last1 = Spitzer | first1 = Robert L. | authorlink=Robert Spitzer (psychiatrist)| title = The diagnostic status of homosexuality in DSM-III: A reformulation of the issues | journal = [[The American Journal of Psychiatry]] | publisher= [[American Psychiatric Association]]| location=Philadelphia, Pennsylvania|volume = 138 | issue = 2 | pages = 210–215 | date = February 1981 | pmid = 7457641 | doi=10.1176/ajp.138.2.210}}</ref>
* [[Object sexuality|Non-human objects]]
* [[BDSM|The suffering or humiliation of oneself or one's partner]]
* [[Pedophilia|Children]]
* [[Rape|Non-consenting persons]]
 
===Homosexuality and non-heterosexuality===
[[Homosexuality]], now widely accepted to be a normal variant of human sexuality, was at one time discussed as a sexual deviation.<ref name="hutchinson">{{cite journal | last = Hutchinson | first = Gerald E.| authorlink=Gerald Hutchinson| date= 1959 | title = A speculative consideration of certain possible forms of sexual selection in man | journal = [[American Naturalist]] | publisher=[[University of Chicago Press]]| location=Chicago, Illinois| volume = 93 | issue = 869 | pages = 81–91 | doi = 10.1086/282059 }}</ref> [[Sigmund Freud]] and subsequent [[psychoanalysis|psychoanalytic]] thinkers considered homosexuality and paraphilias to result from [[Psychosexual development|psychosexual]] non-normative relations to the [[Oedipal complex]].<ref name="Lacan, Jacques. Le Séminaire. Livre IV. La relation d'objet, 19566-57. Ed. Jacques-Alain Miller. Paris: Seuil, 1991. p. 201">{{cite journal | last1 = Karpman | first1 = Benjamin| title = The sexual psychopath | journal = [[Journal of the American Medical Association]] | publisher=[[American Medical Association]]| location=Chicago, Illinois| volume = 146 | issue = 8 | pages = 721–726 | date = June 23, 1951 | pmid = 14832048 | doi=10.1001/jama.1951.03670080029008}}</ref> As such, the term ''sexual perversion'' or the [[epithet]] ''pervert'' have historically referred to [[gay]] men, as well as other [[non-heterosexual]]s (people who fall out of the perceived norms of sexual orientation).<ref name="hutchinson"/><ref name="Lacan, Jacques. Le Séminaire. Livre IV. La relation d'objet, 19566-57. Ed. Jacques-Alain Miller. Paris: Seuil, 1991. p. 201"/><ref name="kafka1996">{{cite journal | last = Kafka | first = Martin P.| authorlink=Martin Kafka|year = 1996 | title = Therapy for Sexual Impulsivity: The Paraphilias and Paraphilia-Related Disorders | journal = [[Psychiatric Times]] | publisher=MJH Associates|location=New York City|volume = 13 | issue = 6}}</ref><ref name = Cantor2012>{{cite journal | last1 = Cantor | first1=James M.| author-link = James M. Cantor | title = Is Homosexuality a Paraphilia? The Evidence for and Against | journal = [[Archives of Sexual Behavior]] | publisher=[[Springer Science + Business Media]]| location= New York City| volume = 41 | issue = 1 | pages = 237–247 | date = February 2012 | pmid = 22282324 | pmc = 3310132 | doi = 10.1007/s10508-012-9900-3 }}</ref>
 
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 the [[American 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."<ref name="kafka1996"/>
 
A 2012 literature study by clinical psychologist [[James 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 effect|fraternal birth order]], [[handedness]], [[IQ]] and [[cognitive profile]], and [[neuroanatomy]]". 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.<ref name = Cantor2012/>
 
==Causes==
The causes of paraphilic sexual preferences in people are unclear, although a growing body of research points to a possible prenatal neurodevelopmental 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:4D [[digit ratio]] (which would indicate excessive prenatal estrogen exposure), and an elevated probability of being [[Left-handedness|left-handed]], suggesting that disturbed hemispheric [[Lateralization of brain function|brain lateralization]] may play a role in deviant attractions.<ref>{{cite journal |last1 = Quazi| first1= Rahman|last2= Symeonides|first2= Deano J.| title = Neurodevelopmental Correlates of Paraphilic Sexual Interests in Men | journal = [[Archives of Sexual Behavior]] | publisher= [[Springer Science + Business Media]]| location=New York City| volume = 37 | issue = 1 | pages = 166–172 | date = February 2007 | pmid = 18074220 | doi = 10.1007/s10508-007-9255-3 | s2cid= 22274418}}</ref>
 
[[Behaviorism|Behavioral]] explanations propose that paraphilias are [[Classical conditioning|conditioned]] early in life, during an experience that pairs the paraphilic stimulus with intense sexual arousal.<ref name="Nolen-Hoeksema2013">{{cite book | last=Nolen-Hoeksema|first=Susan | authorlink=Susan Nolen-Hoeksema|date = 2013 | url = http://connect.customer.mheducation.com/products/connect-for-nolen-hoeksema-abnormal-psychology-6e/ | title = Abnormal Psychology | edition = 6th | location = Boston, Massachusetts | publisher = [[McGraw-Hill]] | isbn = 978-0078035388 | page = 385}}</ref> [[Susan Nolen-Hoeksema]] suggests that, once established, [[masturbatory]] fantasies about the stimulus reinforce and broaden the paraphilic arousal.<ref name="Nolen-Hoeksema2013" />
 
==Diagnosis==
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.<ref>{{Cite book | last = Kleinplatz | first = PJ |author2=Moser C | year = 2005 | url = https://books.google.com/?id=gcZDghztlpMC&pg=PA135#v=onepage&q&f=false | title = Politics versus science: An addendum and response to Drs. Spitzer and Fink | journal = Journal of Psychology and Human Sexuality | volume = 17 | issue = 3/4 | pages = 135–139 | doi = 10.1300/J056v17n03_09 | isbn = 9780789032140 | s2cid = 142960356 }}</ref>
 
Some groups, seeking greater understanding and acceptance of [[sexual 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.<ref name="moser2005">{{Cite journal |vauthors=Moser C, Kleinplatz PJ | year = 2005 | title = DSM-IV-TR and the Paraphilias: An argument for removal | url = | journal = Journal of Psychology and Human Sexuality | volume = 17 | issue = 3/4| pages = 91–109 | doi=10.1300/j056v17n03_05| s2cid = 7221862 }}</ref>
 
===Typical versus atypical interests===
[[Albert Eulenburg]] (1914) noted a commonality across the paraphilias, using the terminology of his time, "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."<ref>[[Albert Eulenburg|Eulenburg]] (1914). ''Ueber sexualle Perversionen. Ztschr. f. Sexualwissenschaft,'' Vol. I, No. 8. translated in [[Wilhelm Stekel|Stekel, Wilhelm]]. (1940). ''Sexual aberrations: The phenomena of fetishism in relation to sex.'' New York: Liveright, p. 4. {{OCLC|795528}}</ref>
 
The clinical literature contains reports of many paraphilias, only some of which receive their own entries in the diagnostic taxonomies of the [[American Psychiatric Association]] or the [[World Health Organization]].<ref>{{cite web|url=http://psyweb.com/Mdisord/DSM_IV/jsp/Axis_I.jsp |title="Axis I. Clinical Disorders, most V-Codes and conditions that need Clinical attention". Retrieved: 23 November, 2007 |publisher=Psyweb.com |accessdate=2013-03-14}}</ref><ref>World Health Organization, International Statistical Classification of Diseases and Related Health Problems, (2007), [http://www.who.int/classifications/apps/icd/icd10online/ Chapter V, Block F65; Disorders of sexual preference.] Retrieved 2007-11-29.</ref> There is disagreement regarding which sexual interests should be deemed paraphilic disorders versus normal variants of sexual interest. For example, as of May 2000, per [[DSM-IV-TR]], "Because some cases of Sexual Sadism may not involve harm to a victim (e.g., inflicting humiliation on a consenting partner), the wording for sexual sadism involves a hybrid of the [[DSM-III-R]] and [[DSM-IV]] wording (i.e., "the person has acted on these urges with a non-consenting person, or the urges, sexual fantasies, or behaviors cause marked distress or interpersonal difficulty").<ref>[http://www.dsmivtr.org/2-3changes.cfm Summary of Practice-Relevant Changes to the DSM-IV-TR] {{webarchive|url=https://web.archive.org/web/20080511220758/http://www.dsmivtr.org/2-3changes.cfm |date=11 May 2008 }} from [http://www.dsmivtr.org/ Diagnostic and Statistical Manual of Mental Disorders (DSM)] {{webarchive|url=https://web.archive.org/web/20080517004926/http://www.dsmivtr.org/ |date=17 May 2008 }}</ref>


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”.<ref name="auto">American Psychiatric Association. (2000). ''Diagnostic and statistical manual of mental disorders'' (4th ed., text rev.). Washington, DC: Author.</ref> Some argue that [[cultural relativism]] is important to consider when discussing paraphilias, because there is wide variance concerning what is sexually acceptable across cultures.<ref>{{cite journal|first1=Dinesh|last1=Bhugra|first2=Dmitri|last2=Popelyuk|first3=Isabel|last3=McMullen|title=Paraphilias Across Cultures: Contexts and Controversies|journal=[[Journal of Sex Research]]|publisher=[[Routledge]]|location=London, England|date=March 30, 2010|volume=2|issue=47|pages=242–256|doi=10.1080/00224491003699833|pmid=20358463|s2cid=40452769}}</ref>
===Pharmacotherapy===


[[Consent|Consensual]] adult activities and [[adult entertainment]] involving [[sexual roleplay]], novel, superficial, or trivial aspects of [[sexual fetishism]], or incorporating the use of [[sex toys]] are not necessarily paraphilic.<ref name="auto"/> Paraphilial [[psychopathology]] is not the same as [[psychology|psychologically]] normative adult [[human sexual behavior]]s, [[sexual fantasy]], and sex play.<ref>{{Cite journal|title = Defining "Normophilic" and "Paraphilic" Sexual Fantasies in a Population-Based Sample: On the Importance of Considering Subgroups|journal = Sexual Medicine|publisher=[[Wiley (publisher)|Wiley]]|location=Hoboken, New Jersey|date = November 1, 2015|issn = 2050-1161|pages = 321–330|doi = 10.1002/sm2.96|pmid = 26797067|pmc = 4721032|first = Christian C.|last = Joyal|volume=3|issue = 4}}</ref>
*Three main classes of [[medications]] used in paraphilias are [[antidepressants]], hormones, and gonadotrophin-releasing hormone (GnRH) analogs.<ref name="AbelOsborn1992">{{cite journal|last1=Abel|first1=Gene G.|last2=Osborn|first2=Candice|title=The Paraphilias: The Extent and Nature of Sexually Deviant and Criminal Behavior|journal=Psychiatric Clinics of North America|volume=15|issue=3|year=1992|pages=675–687|issn=0193953X|doi=10.1016/S0193-953X(18)30231-4}}</ref>
*[[Treatment]] of comorbidities is very important to improve the quality of life.
*[[Treatment]] with antiandrogens has the drawback that it may increase psychotic symptoms and [[depression]] risk.<ref name="GarciaThibaut2011">{{cite journal|last1=Garcia|first1=Frederico D.|last2=Thibaut|first2=Florence|title=Current Concepts in the Pharmacotherapy of Paraphilias|journal=Drugs|volume=71|issue=6|year=2011|pages=771–790|issn=0012-6667|doi=10.2165/11585490-000000000-00000}}</ref>


===Intensity and specificity===
====Antidepressants====
Clinicians distinguish between optional, preferred and exclusive paraphilias,<ref name=DSM/> though the terminology is not completely standardized. An "optional" paraphilia is an alternative route to sexual arousal. In preferred paraphilias, a person prefers the paraphilia to conventional sexual activities, but also engages in conventional sexual activities.
*Antidepressants are used to treat paraphilias because of their action on involved [[neurotransmitters]]. The mechanism of action is supported by the [[monoamine]] hypothesis. <ref name="AbelOsborn1992">{{cite journal|last1=Abel|first1=Gene G.|last2=Osborn|first2=Candice|title=The Paraphilias: The Extent and Nature of Sexually Deviant and Criminal Behavior|journal=Psychiatric Clinics of North America|volume=15|issue=3|year=1992|pages=675–687|issn=0193953X|doi=10.1016/S0193-953X(18)30231-4}}</ref>
*The [[comorbidities]] such as obsessive-compulsive spectrum disorders share the dysfunction of similar [[neurotransmitters]]. Therefore, [[antidepressants]] can treat both the disorders simultaneously.
*[[Antidepressants]] commonly used are
**Selective Serotonin Reuptake Inhibitors([[SSRI]]) such as Fluoxetine, Paroxetine, and Escitalopram act on [[serotonergic]] (5-HT2) receptors and have become the standard of care. Additionally, [[SSRIs]] treat the comorbid conditions like [[depression]], [[OCD]], or [[anxiety disorders]].<ref name="pmid26800994">{{cite journal| author=Holoyda BJ, Kellaher DC| title=The Biological Treatment of Paraphilic Disorders: an Updated Review. | journal=Curr Psychiatry Rep | year= 2016 | volume= 18 | issue= 2 | pages= 19 | pmid=26800994 | doi=10.1007/s11920-015-0649-y | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26800994  }} </ref>
**Tricyclic Antidepressants(TCA) such as Imipramine, Clomipramine, and Desipramine.


The literature includes single-case studies of exceedingly 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).<ref>{{cite journal|journal=Psychiatry|volume=6|issue=3|date=March 2007|pages=130&ndash;134|title=Sexual disorder and psychosexual therapy|author=Padmal de Silva|doi=10.1016/j.mppsy.2006.12.009}}</ref><ref>{{cite journal|first=Michael B.|last=King|title=Sneezing as a fetish object|journal=[[Sexual and Marital Therapy]]|publisher=[[Routledge]]|location=London, England|volume=5|year=1990|pages=69&ndash;72|doi=10.1080/02674659008407999|issue=1}}</ref>
====Hormones====
*[[Estrogen]]
*Steroid antiandrogens
**[[Medroxyprogesterone]]- It is synthetic [[progesterone]] and acts by reducing the [[testosterone]] levels. They act by suppressing the hypothalamic-pituitary-gonadal axis, reducing the Luteinizing hormone(LH) release and further compromising the [[androgen]] production. <ref name="pmid26800994">{{cite journal| author=Holoyda BJ, Kellaher DC| title=The Biological Treatment of Paraphilic Disorders: an Updated Review. | journal=Curr Psychiatry Rep | year= 2016 | volume= 18 | issue= 2 | pages= 19 | pmid=26800994 | doi=10.1007/s11920-015-0649-y | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26800994  }} </ref><ref name="pmid28337576">{{cite journal| author=Radkani P, Joshi D, Barot T, Williams R| title=Robotic video-assisted thoracoscopy: minimally invasive approach for management of mediastinal tumors. | journal=J Robot Surg | year= 2018 | volume= 12 | issue= 1 | pages= 75-79 | pmid=28337576 | doi=10.1007/s11701-017-0692-2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28337576  }} </ref>
**[[Cyproterone]] acetate is a synthetic steroid, similar in structure to [[progesterone]]. It acts as an antiandrogen by binding to androgen [[receptor]]s and reducing the cellular uptake of [[testosterone]].<ref name="pmid26800994">{{cite journal| author=Holoyda BJ, Kellaher DC| title=The Biological Treatment of Paraphilic Disorders: an Updated Review. | journal=Curr Psychiatry Rep | year= 2016 | volume= 18 | issue= 2 | pages= 19 | pmid=26800994 | doi=10.1007/s11920-015-0649-y | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26800994  }} </ref>  


===Diagnostic and Statistical Manual of Mental Disorders===
====[[Gonadotrophin Releasing Hormone Analogue]] (GnRH Analogue)====
{{main|Diagnostic and Statistical Manual of Mental Disorders}}
*They reduce the circulating [[testosterone]], in turn, reducing aggression and [[hypersexuality]].<ref name="pmid26800994">{{cite journal| author=Holoyda BJ, Kellaher DC| title=The Biological Treatment of Paraphilic Disorders: an Updated Review. | journal=Curr Psychiatry Rep | year= 2016 | volume= 18 | issue= 2 | pages= 19 | pmid=26800994 | doi=10.1007/s11920-015-0649-y | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26800994  }} </ref> <ref name="pmid11973119">{{cite journal| author=Czerny JP, Briken P, Berner W| title=Antihormonal treatment of paraphilic patients in German forensic psychiatric clinics. | journal=Eur Psychiatry | year= 2002 | volume= 17 | issue= 2 | pages= 104-6 | pmid=11973119 | doi=10.1016/s0924-9338(02)00635-1 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11973119  }} </ref>
==== DSM-I and DSM-II ====
In American psychiatry, prior to the publication of the DSM-I, paraphilias were classified as cases of "[[psychopathy|psychopathic]] personality with pathologic sexuality". The DSM-I (1952) included sexual deviation as a [[personality disorder]] of [[Antisocial personality disorder|sociopathic]] 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 as [[schizophrenia|schizophrenic]] 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.<ref>Laws and, O'Donohue (2008) pp. 384-385 citing DSM-I pp. 7, 38-39</ref> Researcher [[Anil Aggrawal]] writes that the now-obsolete DSM-I listed examples of supplementary terms for pathological behavior to include "homosexuality, [[transvestism]], [[pedophilia]], [[fetishism]], and [[sexual sadism]], including [[rape]], [[sexual assault]], mutilation."<ref>{{Cite book | last=Aggrawal | first=Anil | authorlink=Anil Aggrawal | year=2008 | title=Forensic and Medico-legal Aspects of Sexual Crimes and Unusual Sexual Practices | page=47 | chapter=Chapter 2: Pedophillia and Child Sexual Abuse | publisher=[[CRC Press]] | location=Boca Raton, Florida| isbn=978-1-4200-4308-2}}</ref>


The DSM-II (1968) continued to use the term ''sexual deviations'', but 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 (sic), [[exhibitionism]], [[voyeurism]], [[sadistic personality disorder|sadism]], [[Sadomasochism|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 with [[coitus]], or toward coitus performed under bizarre circumstances, as in [[necrophilia]], pedophilia, sexual sadism, and fetishism."<ref>Laws and, O'Donohue (2008) p. 385 citing DSM-II p. 44</ref> 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.<ref name="Laws and, O'Donohue 2008 p. 386">Laws and O'Donohue (2008) p. 386</ref>
===Psychotherapy===
*In subjects that are not at high risk of victimization, [[cognitive behavioral therapy]](CBT) is the first-line treatment.
*[[CBT]] addresses the cognitive distortions, along with empathy training, relapse prevention, sexual impulse control training, and biofeedback. <ref name="HallHall2007">{{cite journal|last1=Hall|first1=Ryan C.W.|last2=Hall|first2=Richard C.W.|title=A Profile of Pedophilia: Definition, Characteristics of Offenders, Recidivism, Treatment Outcomes, and Forensic Issues|journal=Mayo Clinic Proceedings|volume=82|issue=4|year=2007|pages=457–471|issn=00256196|doi=10.4065/82.4.457}}</ref>


==== DSM-III through DSM-IV ====
===Combined Pharmacotherapy and Psychotherapy===  
The term ''paraphilia'' was introduced in the DSM-III (1980) as a subset of the new category of "psychosexual disorders."
*The combination therapy has a better response compared to either therapy used alone.<ref name="HallHall2007">{{cite journal|last1=Hall|first1=Ryan C.W.|last2=Hall|first2=Richard C.W.|title=A Profile of Pedophilia: Definition, Characteristics of Offenders, Recidivism, Treatment Outcomes, and Forensic Issues|journal=Mayo Clinic Proceedings|volume=82|issue=4|year=2007|pages=457–471|issn=00256196|doi=10.4065/82.4.457}}</ref>
 
Very few evidence-based [[treatment]] options are available for a complex condition like paraphilia, and further research is warranted to effectively prevent the relapses.
The DSM-III-R (1987) renamed the broad category to [[sexual disorder]]s, renamed atypical paraphilia to paraphilia NOS (not otherwise specified), renamed transvestism as [[transvestic fetishism]], added [[frotteurism]], and moved [[zoophilia]] to the NOS category. It also provided seven nonexhaustive examples of NOS paraphilias, which besides zoophilia included [[telephone scatologia]], necrophilia, [[partialism]], [[coprophilia]], [[klismaphilia]], and [[urophilia]].<ref>Laws and, O'Donohue (2008) p. 385</ref>
 
The DSM-IV (1994) retained the sexual disorders classification for paraphilias, but added an even broader category, "sexual and [[gender identity disorder]]s," 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.<ref name="Laws and, O'Donohue 2008 p. 386"/>
 
====DSM-IV-TR====
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]], [[Sexual fetishism|fetishism]], [[frotteurism]], [[pedophilia]], [[Sexual masochism disorder|sexual masochism]], [[Sexual sadism disorder|sexual sadism]], [[voyeurism]], and [[transvestic fetishism]], plus a residual category, [[Paraphilia not otherwise specified|paraphilia—not otherwise specified]]).<ref>{{cite web|url=http://www.psychiatrictimes.com/display/article/10168/55266|title=Paraphilias: Clinical and Forensic Considerations|website=psychiatrictimes.com}}</ref> 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.<ref name = DSM>American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). pp. 569-570, 572, 574, Washington, DC: Author.</ref> [[Sexual arousal]] in association with objects that were designed for sexual purposes is not diagnosable.<ref name = DSM/>
 
Some paraphilias may interfere with the capacity for sexual activity with consenting adult partners.<ref name = DSM/>
 
In the current version of the [[Diagnostic and Statistical Manual of Mental Disorders]] (DSM-IV-TR), a paraphilia is not diagnosable as a [[psychiatric disorder]] unless it causes distress to the individual or harm to others.<ref name = "DSMTR"/>
 
==== DSM-5 ====
The [[DSM-5]] adds a distinction between ''paraphilias'' and ''paraphilic disorders'', stating that paraphilias do not require or justify psychiatric treatment in themselves, and defining ''paraphilic 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".<ref name="DSM-5, intro" />
 
The DSM-5 Paraphilias Subworkgroup reached a "consensus that paraphilias are not ''ipso facto'' psychiatric disorders", and proposed "that the DSM-V make a distinction between ''paraphilias'' and paraphilic ''disorders''. [...] One would ''ascertain'' a paraphilia (according to the nature of the urges, fantasies, or behaviors) but ''diagnose'' 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 become [[Sexual sadism disorder|Sexual Sadism Disorder]]; Sexual Masochism would become [[Sexual masochism disorder|Sexual Masochism Disorder]], and so on."<ref name=dsm5>{{cite web|url=http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid%3D186 |title=302.2 Pedophilia |website=DSM-5 |access-date=2012-02-10 |url-status=dead |archive-url=https://web.archive.org/web/20100215165810/http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=186 |archivedate=15 February 2010 }}</ref>
 
[[Bioethics]] professor [[Alice 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."<ref>Alice Dreger (19 Feb 2010) ''[http://www.thehastingscenter.org/of-kinks-crimes-and-kinds-the-paraphilias-proposal-for-the-dsm-5 Of Kinks, Crimes, and Kinds: The Paraphilias Proposal for the DSM-5]'', [[Hastings Center]]</ref>
 
[[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.<ref>{{cite journal | author = Moser C | year = 2010 | title = Problems with Ascertainment | url = | journal = Archives of Sexual Behavior | volume = 39 | issue = 6| pages = 1225–1227 | doi = 10.1007/s10508-010-9661-9 | pmid = 20652734 | s2cid = 11927813 }}</ref> 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 to [[ego-dystonic homosexuality]], which was removed from the DSM because it was realized not to be a mental disorder.<ref>{{cite journal|first=Andrew Clinton|last=Hinderliter|authorlink=Andrew Clinton Hinderliter| year=2010|title=Defining paraphilia: excluding exclusion|journal=Open Access Journal of Forensic Psychology|volume=2|pages=241–271|url=http://web.me.com/gregdeclue/Site/Volume_2__2010_files/Hinderliter%202010.pdf}}</ref>
 
The DSM-5 acknowledges that many dozens of paraphilias exist, but only has specific listings for eight that are forensically important and relatively common. These are voyeuristic disorder, exhibitionistic disorder, [[frotteuristic disorder]], sexual masochism disorder, sexual sadism disorder, pedophilic disorder, fetishistic disorder, and transvestic disorder.<ref name="DSM-5, intro" /> Other paraphilias can be diagnosed under the [[Other Specified Paraphilic Disorder]] or Unspecified Paraphilic Disorder listings, if accompanied by distress or impairment.<ref>{{cite book | title = Diagnostic and Statistical Manual of Mental Disorders | edition = Fifth | chapter = Other Specified Paraphilic Disorder; Unspecified Paraphilic Disorder | editor = American Psychiatric Association | year = 2013 | publisher = American Psychiatric Publishing | page = 705}}</ref>
 
==Management==
Most clinicians and researchers believe that paraphilic sexual interests cannot be altered,<ref name="SetoAhmed2014">{{cite journal |vauthors=Seto MC, Ahmed AG |title=Treatment and management of child pornography use |journal=Psychiatric Clinics of North America |volume=37 |issue=2 |pages=207–214 |year=2014 |pmid=24877707 |doi=10.1016/j.psc.2014.03.004}}</ref> although evidence is needed to support this.<ref name="SetoAhmed2014" /> Instead, the goal of therapy is normally to reduce the person's discomfort with their paraphilia and limit any criminal behavior.<ref name="SetoAhmed2014" /> Both [[psychotherapeutic]] and pharmacological methods are available to these ends.<ref name="SetoAhmed2014" />
 
[[Cognitive behavioral therapy]], at times, can help people with paraphilias develop strategies to avoid acting on their interests.<ref name="SetoAhmed2014" /> Patients are taught to identify and cope with factors that make acting on their interests more likely, such as stress.<ref name="SetoAhmed2014" /> It is currently the only form of psychotherapy for paraphilias supported by randomized double-blind trials, as opposed to case studies and consensus of expert opinion.<ref name="thibaut2010" /><!-- p. 646 -->
 
===Medications===
[[Pharmacology|Pharmacological]] treatments can help people control their sexual behaviors, but do not change the content of the paraphilia.<ref name="thibaut2010" /> They are typically combined with [[cognitive behavioral therapy]] for best effect.<ref name="assumpcao2014">{{cite journal |last1=Assumpção|first1=Alessandra Almeida|last2=Garcia|first2=Frederick Duarte|last3=Garcia|first3=Heloise Delavenne|last4=Bradford|first4=John M.W.|last5=Thibaut|first5=Florence|title=Pharmacologic treatment of paraphilias |journal=[[Psychiatric Clinics of North America]]|publisher=[[Elsevier]]|location=Amsterdam, Netherlands|volume=37 |issue=2 |pages=173–181 |year=2014 |pmid=24877704 |doi=10.1016/j.psc.2014.03.002}}</ref>
 
====SSRIs====
[[Selective serotonin reuptake inhibitor]]s (SSRIs) are used, especially with exhibitionists, non-offending pedophiles, and compulsive masturbators. They are proposed to work by reducing sexual arousal, [[compulsivity]], and depressive symptoms.<ref name="assumpcao2014" /> They have been well received and are considered an important pharmacological treatment of paraphilia.<ref>{{Cite journal |vauthors=Kraus C, Strohm K, Hill A, Habermann N, Berner W, Briken P |date=June 2007|title=Selective serotonine reuptake inhibitors (SSRI) in the treatment of paraphilia|journal=Fortschritte der Neurologie-Psychiatrie|volume=75|issue=6|pages=351–356|doi=10.1055/s-2006-944261|issn=0720-4299|pmid=17031776}}</ref>
 
====Antiandrogens====
[[Antiandrogen]]s are used in more severe cases.<ref name="assumpcao2014" /> Similar to physical [[castration]], they work by reducing [[androgen]] levels, and have thus been described as [[chemical castration]].<ref name="assumpcao2014" /> The antiandrogen [[cyproterone acetate]] has been shown to substantially reduce sexual fantasies and offending behaviors.<ref name="assumpcao2014" /> [[Medroxyprogesterone acetate]] and [[gonadotropin-releasing hormone agonist]]s (such as [[leuprorelin]]) have also been used to lower sex drive.<ref name="assumpcao2014" /> 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.<!-- p. 647 --><ref name="thibaut2010">{{cite journal |vauthors=Thibaut F, De La Barra F, Gordon H, Cosyns P, Bradford JM |title=The World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the biological treatment of paraphilias |journal=The World Journal of Biological Psychiatry|volume=11 |issue=4 |pages=604–655 |year=2010 |pmid=20459370 |doi=10.3109/15622971003671628|s2cid=14949511 }}</ref> Surgical [[castration]] has largely been abandoned because these pharmacological alternatives are similarly effective and less invasive.<ref>{{cite book |vauthors = Camilleri JA, Quinsey VL |date= 2008 | title = Sexual Deviance: Theory, Assessment, and Treatment | edition = 2nd | publisher = The Guilford Press | pages = 199–200 | chapter = Pedophilia: Assessment and Treatment | veditors = Laws DR, O'Donohue WT}}</ref>
 
==Epidemiology==
Research has shown that paraphilias are rarely observed in women.<ref>{{cite book|author=American Psychiatric Association|title=Diagnostic and Statistical Manual of Mental Disorders: Fourth Edition|date=1994|page=594|edition=IV|id= {{ASIN|0890420629|country=uk}}}}</ref><ref name="DSM-V">{{Citation | last = American Psychiatric Association| title = Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition | journal = | date = 2013| pages = 685–706 | edition = 5th| id = {{ASIN|0890425558|country=uk}}}}</ref> However, there have been some studies on females with paraphilias.<ref>{{cite journal|author=Eva W. C. Chow|author2=Alberto L. Choy|last-author-amp=yes|title=Clinical Characteristics and Treatment Response to SSRI in a Female Pedophile|journal=Archives of Sexual Behavior|date=April 2002|volume=31|issue=2|pages=211–215|accessdate=14 March 2015|doi=10.1023/A:1014795321404|pmid=11974646|s2cid=20845516|url=http://0-download.springer.com.mercury.concordia.ca/static/pdf/886/art%253A10.1023%252FA%253A1014795321404.pdf?auth66=1425842757_14e2bfac5512359c2fbdb237bd2d809b&ext=.pdf}}</ref> Sexual masochism has been found to be the most commonly observed paraphilia in women, with approximately 1 in 20 cases of sexual masochism being female.<ref name=DSM/><ref name="DSM-V" />
 
Many acknowledge the scarcity of research on female paraphilias.<ref name="Hunsley">{{Citation| first = John| last = Hunsley | title = A Guide to Assessments That Work | place = New York | publisher = [[Oxford University Press]]| series = | volume = | edition = | year = 2008| pages = 496–497 | doi = | isbn = 978-0-19-531064-1 | mr = | zbl = }}</ref> The majority of paraphilia studies are conducted on people who have been convicted of [[Sex and the law|sex crimes]].<ref name="Duncan">{{Citation | first = Karen A. | last = Duncan | title = Female Sexual Predators: Understanding Them to Protect Our Children and Youths | place = Santa Barbara | publisher = [[Praeger Publishing|Praeger]] | year = 2010| isbn = 978-0-313-36629-1 | zbl = }}</ref> Since the number of male convicted sex offenders far exceeds the number of female convicted sex offenders, research on paraphilic behavior in women is consequently lacking.<ref name="Duncan" /> Some researchers argue that an underrepresentation exists concerning pedophilia in females.<ref name="Cohen">{{cite magazine|author=Lisa J. Cohen, PhD|author2=((Igor Galynker, MD, PhD))|author2-link=Igor Galynker|last-author-amp=yes|title=Psychopathology and Personality Traits of Pedophiles |magazine=[[Psychiatric Times]] |date= 8 June 2009|accessdate=14 March 2015|url=http://www.psychiatrictimes.com/articles/psychopathology-and-personality-traits-pedophiles}}</ref> Due to the low number of women in studies on pedophilia, most studies are based from "exclusively male samples".<ref name="Cohen" /> This likely underrepresentation may also be attributable to a "societal tendency to dismiss the negative impact of sexual relationships between young boys and adult women".<ref name="Cohen"/> [[Michele Elliott]] has done extensive research on child sexual abuse committed by females, publishing the book ''Female Sexual Abuse of Children: The Last Taboo'' in an attempt to challenge the gender-biased discourse surrounding sex crimes.<ref name="Elliott">{{Citation | first = Michele | last = Elliott | title = Female Sexual Abuse of Children: The Last Taboo | place = New York | publisher = Guilford Publications, Inc. | series = | volume = | edition = | year = 1994 | page = | doi = | isbn = 9780898620047| mr = | zbl = }}</ref> John Hunsley states that physiological limitations in the study of [[female sexuality]] must also be acknowledged when considering research on paraphilias. He states that while a man's sexual arousal can be directly measured from his erection (see [[penile plethysmograph]]), a woman's sexual arousal cannot be measured as clearly (see [[vaginal photoplethysmograph]]), and therefore research concerning female sexuality is rarely as conclusive as research on men.<ref name="Hunsley" />
 
==Legal issues==
In the United States, since 1990 a significant number of states have passed [[sexually violent predator law]]s.<ref name="First 2014">{{cite journal | last=First | first=Michael B. | title=DSM-5 and paraphilic disorders. | journal=The Journal of the American Academy of Psychiatry and the Law | volume=42 | issue=2 | year=2014 | issn=1093-6793 | pmid=24986346 | pages=191–201 | url=http://jaapl.org/content/42/2/191 }}</ref> Following a series of landmark cases in the [[Supreme Court of the United States]], persons diagnosed with paraphilias, particularly pedophilia (''[[Kansas v. Hendricks]]'', 1997) and exhibitionism (''[[Kansas v. Crane]]'', 2002), with a history of [[anti-social behavior]] and related criminal history, can be held indefinitely in [[civil confinement]] under various state legislation generically known as [[sexually violent predator laws]]<ref>{{cite journal | last1 = First | first1 = M. B. | last2 = Halon | first2 = R. L. | title = Use of DSM paraphilia diagnoses in sexually violent predator commitment cases | journal = The Journal of the American Academy of Psychiatry and the Law | volume = 36 | issue = 4 | pages = 443–454 | year = 2008 | pmid = 19092060 | url = http://www.jaapl.org/cgi/reprint/36/4/443.pdf }}</ref><ref>{{Cite book | publisher = Jones & Bartlett Learning | pages = [https://books.google.com/books?id=6MQj-mjHgBIC&pg=PA248 248] | title = Legal aspects of corrections management | isbn = 978-0-7637-2545-7 | last1 = Cripe | first1 = Clair A | last2 = Pearlman | first2 = Michael G | year = 2005}}</ref> and the federal [[Adam Walsh Act]] (''[[United States v. Comstock]]'', 2010).<ref name=apabc>JESSE J. HOLLAND, [https://abcnews.go.com/Politics/wireStory?id=10666088 Court: Sexually dangerous can be kept in prison], [[Associated Press]]. Retrieved 16 May 2010.</ref><ref>{{cite web|url=http://capcentral.org/civil/svpa/svpa_article_USsupreme.asp |title=Civil: SVPA - CCAP |publisher=Capcentral.org |accessdate=2013-03-14}}</ref>
 
==See also==
{{Portal|Psychology|Human sexuality|Psychiatry}}
*[[List of paraphilias]]
*[[Perversion]]
*[[-phil-]] (list of philias)
*[[Courtship disorder]]
*[[Dorian Gray syndrome]]
*[[Erotic target location error]]
*[[Human sexuality]]
*[[Lovemap]]
*[[Object sexuality]]
*[[Psychosexual development]]
*[[Richard von Krafft-Ebing]]
*[[Sex and the law]]
*[[Sexual ethics]]


==References==
==References==
;Citations
{{Reflist|2}}
{{Reflist}}
[[Category:Psychiatry]]
 
;Bibliography
* D. Richard Laws, [[William T. O'Donohue]] (ed.), ''Sexual Deviance: Theory, Assessment, and Treatment'', 2nd ed., Guilford Press, 2008, {{ISBN|978-1-59385-605-2}}
 
==Further reading==
* Kenneth Plummer, ''Sexual stigma: an interactionist account'', Routledge, 1975, {{ISBN|0-7100-8060-3}}
* [[Elisabeth Roudinesco]], ''Our Dark Side, a History of Perversion'', Polity Press, 2009, {{ISBN|0-7456-4593-3}}
* [[David Morgan (psychoanalyst)]], ''[[Married to the Eiffel Tower]]''. [http://documentaryheaven.com/married-to-the-eiffel-tower]
* {{Cite web|url=https://dl.uswr.ac.ir/bitstream/Hannan/73816/1/2018%20JSM%20Volume%2015%20Issue%209%20September%20(9).pdf|title=Deviance or Normalcy? The Relationship Among Paraphilic Thoughts and Behaviors, Hypersexuality, and Psychopathology in a Sample of University Students|work=[[Journal of Sexual Medicine]]|archive-url=https://web.archive.org/web/20200324020113/https://dl.uswr.ac.ir/bitstream/Hannan/73816/1/2018%20JSM%20Volume%2015%20Issue%209%20September%20(9).pdf|archive-date=24 March 2020}}
 
== External links ==
{{Medical resources
|  DiseasesDB    = 
|  ICD10          ={{ICD10|F|65}}
|  ICD9          = 
|  ICDO          = 
|  OMIM          = 
|  MedlinePlus    = 
|  eMedicineSubj  = 
|  eMedicineTopic = 
|  MeshID        = D010262
}}
{{Wiktionary}}
{{Commons category|Paraphilias}}
*[https://web.archive.org/web/20031003103449/http://www.behavenet.com/capsules/disorders/paraphilias.htm DSM-IV and DSM-IV-TR list of paraphilias]
*[https://web.archive.org/web/20100316063851/http://www.dsm5.org/ProposedRevisions/Pages/SexualandGenderIdentityDisorders.aspx Proposed diagnostic criteria for sex and gender section of DSM5]
 
<!--spacing-->
 
{{paraphilia}}
{{Human sexuality}}
{{Sex}}
 
[[Category:Paraphilias| ]]
[[Category:Psychiatric diagnosis]]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Vatsala Sharma; M.B.B.S[2]

Synonyms and keywords: Fetishism, Voyeurism, Zoophilia, Pedophilia, Sexual perversion, Zoophilism, Abnormal sexual activity

Overview

Paraphilias are characterized by severe deviant sexual desire or urge resulting in actions that may cause significant impairment in functioning as well as distress (for oneself and/or others). Paraphilic behavior may occur intermittently or may persist for the entire life. To begin with, paraphilia occurs in the form of fantasy, and the paraphilic behavior manifests later in life. Mostly the individuals with this condition do not seek treatment themselves due to the pleasure they obtain from it and in some cases, the associated stigma. Paraphilias are not illegal but the resulting behaviors are. Timely treatment is important to prevent sexual offenses like pedophilia or serial rapes. Patients may have more than one type of paraphilia and therefore, it is essential to evaluate them thoroughly to provide optimal management.

Historical Perspective

  • The term 'Paraphilia' is Greek in origin and is derived from the words-'Para'(deviation) and 'philia'(attraction).[1]
  • From biblical times, human societies across the world, have placed restrictions on many types of sexual behaviors. The level of acceptability is based on cultural variations across the globe.
  • There is controversy in what should be called sexual deviation, mainly based on various factors like the degree of consent, age of the involved individuals, degree of distress caused, location of sexual behavior, degree of unacceptable by others, etc. [2]
  • The term 'Sadism' originated from Marquis de Sade (1740-1814). He was placed in a lunatic asylum multiple times and ultimately, died there. His mental instability is considered to have resulted in this pattern of sexual behavior. [2]
  • The term 'Masochism' came from Baron Leopold von Sacher Masoch (1835-1895), who was of European origin.[2]
  • With the publication of Psychopathia Sexualis at the end of the nineteenth century, sexual deviance was considered a medical condition. Psychopathia Sexualis was written by a German psychiatrist Krafft-Ebing, who described the sexual murders in this publication. [2][3]

Classification

  • Earlier the non-reproductive sexual behaviors were considered pathological and criminalized. However, over years the boundaries of pathology have been confined to the absence of sexual consent. [4]
  • The inclusion of the pathological classification of paraphilias in the DSM and ICD has been criticized for a long time. It is based on the thin line of difference between something that is a normal variation or just unusual, and something that is pathological.
  • According to DSM-III, a patient could have more than one paraphilias but the extent of the multiplicity was not described until later editions.[5]
  • Till DSM-IV-TR, the diagnostic category of paraphilia was scrutinized for logic, clarity, and consistency. [6]
  • DSM-IV-TR included paraphilias in the chapter ‘Sexual and Gender Identity Disorders’.[3]
  • There were proposals to remove paraphilias as a diagnostic category from DSM-5. Some considered the concept of paraphilic disorder as more ideological than scientific. [7][8]
  • Despite the ongoing controversies, in DSM-5, the paraphilias have been assigned a separate chapter and are termed Paraphilic disorders. [9]
  • According to DSM-5, paraphilia as such does not require psychiatric intervention. Paraphilia causing harm to others or severe distress to oneself, is termed paraphilic disorder and needs treatment. [3]
  • It has been found that DSM-5 diagnostic criteria for paraphilias can increase the false-positive rates by diagnosing without assessing the underlying motivation (may not necessarily be paraphilic sexual arousal). As a result, attaining this diagnosis can produce many legal consequences. [10]
  • ICD-10 does not comprise a clear-cut definition of paraphilia. It simply refers to paraphilia as a disorder of sexual preference. [11][12]

Pathophysiology

Monoamine Hypothesis

Role of Testosterone

Sex-steroid genetics influences both antisocial traits, and sexual behavior. The relationship between testosterone and paraphilia is further evident by the positive response seen in these patients with antiandrogen therapy.[15]

Differential Diagnosis

It is important to differentiate paraphilias from others like[16][3]

Epidemiology and Demographics

  • The exact prevalence of Paraphilic Disorders is difficult to estimate.[17]
  • Only a few patients seek treatment and most of the data is obtained from the paraphilic cases caught up in the legal system.[18][19]

Age

  • Although discrepancies in studies exist, on average no specific age group has been predisposed to develop Paraphilia.
  • Literature has revealed that paraphilias mostly begin in childhood and are manifested later in adolescence. [20]

Gender

  • Paraphilic behavior is seen mostly in men. However, there are studies that show no prominent gender-differences.[12][17][21]

Race

  • Limited studies have been done about racial predilection.
  • Most studies present mixed results and it can be concluded that no specific race is predisposed to develop paraphilia.[22]

Risk Factors

Natural History, Complications, and Prognosis

  • Patients with paraphilias have high chances of relapse.[1]
  • After 15 years, pedophiles attracted to boys are likely to commit the crime again (35%) as compared to those attracted to girls (16%).[19]
  • Good prognostic factors are[1]
    • Early treatment
    • Individuals with good ego strength and high motivation for treatment
    • Patients with normal adult sexual experiences
  • Poor prognostic factors are[1]
    • Coexisting mental disorders
    • Early-onset of paraphilic behaviors
    • Lack of remorse for their behaviors
    • Substance misuse
    • Pedophilia with a sexual interest in boys
  • The risk of recurrence depends on[19]

Comorbidities

Various comorbid conditions exist with paraphilias like[12][24][1]

Diagnosis

DSM-5 Diagnostic Criteria

  • Following conditions have been described in the chapter on Paraphilia
  1. Exhibitionistic Disorder
  2. Fetishistic Disorder
  3. Frotteuristic Disorder
  4. Paedophilic Disorder
  5. Sexual Masochism Disorder
  6. Sexual Sadism Disorder
  7. Voyeuristic Disorder
  8. Transvestic Disorder
  9. Other specified Paraphilic Disorder
  10. Unspecified Paraphilic Disorder

Voyeuristic Disorder

  • A. Over a minimum period of six months, the existence of recurrent and intense sexual arousal from observing an unsuspected naked person.
  • B. Action has been taken on the urges with a non-consenting person, or significant distress/ socio-occupational functioning impairment is caused by these sexual urges or fantasies.
  • C. The individual is at least 18 years old.

Specify if:

  • In a controlled environment(the individual is living in an institution etc).
  • In full remission (individual has not acted on these urges and has not resulted in distress over the last 5 years, while in an uncontrolled environment).

Exhibitionistic Disorder

  • A. Over a minimum period of six months, the existence of recurrent and intense sexual arousal from exposure of one's genitals to an unsuspected person.
  • B. Action has been taken on these urges with a non-consenting person, or significant distress/ socio-occupational functioning impairment is caused by these sexual urges or fantasies.

Specify whether:

  • Sexually aroused by exposing genitals to the prepubertal children.
  • Sexually aroused by exposing genitals to physically mature individuals.
  • Sexually aroused by exposing genitals to the prepubertal children as well as physically mature individuals.

Specify if:

  • In a controlled environment(the individual is living in an institution etc).
  • In full remission (individual has not acted on these urges and has not resulted in distress over the last 5 years, while in an uncontrolled environment).

Frotteuristic Disorder

  • A. Over a minimum period of six months, the existence of recurrent and intense sexual arousal from touching or rubbing against a non-consenting person, as manifested by fantasies, or behavior.
  • B. Action has been taken on these urges with a non-consenting person, or significant distress/ socio-occupational functioning impairment is caused by these sexual urges or fantasies.

Specify if:

  • In a controlled environment(the individual is living in an institution etc).
  • In full remission (individual has not acted on these urges and has not resulted in distress over the last 5 years, while in an uncontrolled environment).

Sexual Masochism Disorder

  • A. Over a minimum period of six months, the existence of recurrent and intense sexual arousal from being beaten, bound, humiliated, or made to suffer; is manifested in the form of fantasies, urges, or behaviors.
  • B. Significant distress/ socio-occupational functioning impairment is caused by these sexual urges or fantasies.

Specify if: With asphyxiophilia: If the individual experiences sexual arousal due to restriction of breathing.

Specify if:

  • In a controlled environment(the individual is living in an institution etc).
  • In full remission (individual has not acted on these urges and has not resulted in distress over the last 5 years, while in an uncontrolled environment).

Sexual Sadism Disorder

  • A. Over a minimum period of six months, the existence of recurrent and intense sexual arousal from the psychological or physical suffering of another person; is manifested in the form of urges, fantasies, or behaviors.
  • B. Significant distress/ socio-occupational functioning impairment is caused by these sexual urges or fantasies.

Specify if:

  • In a controlled environment(the individual is living in an institution etc).
  • In full remission (individual has not acted on these urges and has not resulted in distress over the last 5 years, while in an uncontrolled environment).

Pedophilic Disorder

  • A. Over a minimum period of six months, the existence of recurrent and intense sexually arousing fantasies, urges, or behavior involving sexual activity with a child or many children of age 13 or younger.
  • B. Significant distress/ interpersonal difficulty is caused by these sexual urges or fantasies, or the individual has acted on these sexual urges.
  • C. The individual is at least 16 years old and a minimum of 5 years older than the child.

Specify whether:

  • Exclusive type (attracted to children only).
  • Non-exclusive type.

Specify if:

  • Sexually attracted to males only.
  • Sexually attracted to females only.
  • Sexually attracted to both.

Specify if:

  • Limited to incest.

Fetishistic Disorder

  • A. Over a minimum period of six months, the existence of recurrent and intense sexually arousing fantasies, urges, or behavior from the use of non-living objects, or a focus on non-genital body part/parts.
  • B. Significant distress/ socio-occupational functioning impairment is caused by these sexual urges or fantasies, or behavior.
  • C. The fetish objects are not limited to clothing or objects designed for tactile genital stimulation.

Specify if:

  • Body part/parts.
  • Non-living object/objects.
  • Other.

Specify if:

  • In a controlled environment(the individual is living in an institution etc).
  • In full remission (individual has not acted on these urges and has not resulted in distress over the last 5 years, while in an uncontrolled environment).

Transvestic Disorder

  • A. Over a minimum period of six months, the existence of recurrent and intense sexually arousing fantasies, urges, or behavior from cross-dressing.
  • B. Significant distress/ socio-occupational functioning impairment is caused by these sexual urges or fantasies, or behavior.

Specify if:

  • With fetishism.
  • With autogynephilia - Sexual arousal by thoughts or images of self as a female.

Specify if:

  • In a controlled environment(the individual is living in an institution etc).
  • In full remission (individual has not acted on these urges and has not resulted in distress over the last 5 years, while in an uncontrolled environment).

Other Specified Paraphilic Disorder

  • Significant distress/ socio-occupational functioning impairment is caused by the symptoms characteristic of a paraphilic disorder but does not completely fulfill the criteria of any of the categories in the Paraphilic Disorders.

Unspecified Paraphilic Disorder

  • Used in the conditions where the clinician chooses not to mention the reason that the criteria are not fulfilled for a specific paraphilic disorder.

Treatment

  • A treatment plan comprising of psychotherapy, and/or pharmacotherapy is usually needed to suppress the paraphiliac fantasies and behaviors.
  • The treatment depends on the intensity and frequency of paraphiliac sexual fantasies as well as the risk of sexual violence. [25]
  • The very severe conditions may lead to sexual offenses, like rape and it is necessary to manage such patients aggressively with hormonal intervention.[25]
  • The treatment regime consists of six levels with escalating degrees of medical intervention, based on the severity of the disorder.[26]

Pharmacotherapy

  • Three main classes of medications used in paraphilias are antidepressants, hormones, and gonadotrophin-releasing hormone (GnRH) analogs.[19]
  • Treatment of comorbidities is very important to improve the quality of life.
  • Treatment with antiandrogens has the drawback that it may increase psychotic symptoms and depression risk.[3]

Antidepressants

  • Antidepressants are used to treat paraphilias because of their action on involved neurotransmitters. The mechanism of action is supported by the monoamine hypothesis. [19]
  • The comorbidities such as obsessive-compulsive spectrum disorders share the dysfunction of similar neurotransmitters. Therefore, antidepressants can treat both the disorders simultaneously.
  • Antidepressants commonly used are
    • Selective Serotonin Reuptake Inhibitors(SSRI) such as Fluoxetine, Paroxetine, and Escitalopram act on serotonergic (5-HT2) receptors and have become the standard of care. Additionally, SSRIs treat the comorbid conditions like depression, OCD, or anxiety disorders.[26]
    • Tricyclic Antidepressants(TCA) such as Imipramine, Clomipramine, and Desipramine.

Hormones

Gonadotrophin Releasing Hormone Analogue (GnRH Analogue)

Psychotherapy

  • In subjects that are not at high risk of victimization, cognitive behavioral therapy(CBT) is the first-line treatment.
  • CBT addresses the cognitive distortions, along with empathy training, relapse prevention, sexual impulse control training, and biofeedback. [18]

Combined Pharmacotherapy and Psychotherapy

  • The combination therapy has a better response compared to either therapy used alone.[18]

Very few evidence-based treatment options are available for a complex condition like paraphilia, and further research is warranted to effectively prevent the relapses.

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 Seligman, Linda; Hardenburg, Stephanie A. (2000). "Assessment and Treatment of Paraphilias". Journal of Counseling & Development. 78 (1): 107–113. doi:10.1002/j.1556-6676.2000.tb02567.x. ISSN 0748-9633.
  2. ↑ 2.0 2.1 2.2 2.3 Gordon, Harvey (2008). "The treatment of paraphilias: An historical perspective". Criminal Behaviour and Mental Health. 18 (2): 79–87. doi:10.1002/cbm.687. ISSN 0957-9664.
  3. ↑ 3.0 3.1 3.2 3.3 3.4 Garcia, Frederico D.; Thibaut, Florence (2011). "Current Concepts in the Pharmacotherapy of Paraphilias". Drugs. 71 (6): 771–790. doi:10.2165/11585490-000000000-00000. ISSN 0012-6667.
  4. ↑ Giami, Alain (2015). "Between DSM and ICD: Paraphilias and the Transformation of Sexual Norms". Archives of Sexual Behavior. 44 (5): 1127–1138. doi:10.1007/s10508-015-0549-6. ISSN 0004-0002.
  5. ↑ Bradford, John M.W.; Boulet, J.; Pawlak, A. (2017). "The Paraphilias: A Multiplicity of Deviant Behaviours*". The Canadian Journal of Psychiatry. 37 (2): 104–108. doi:10.1177/070674379203700206. ISSN 0706-7437.
  6. ↑ Moser, Charles; Kleinplatz, Peggy J. (2006). "DSM-IV-TRand the Paraphilias". Journal of Psychology & Human Sexuality. 17 (3–4): 91–109. doi:10.1300/J056v17n03_05. ISSN 0890-7064.
  7. ↑ Downing, Lisa (2015). "Heteronormativity and Repronormativity in Sexological "Perversion Theory" and the DSM-5's "Paraphilic Disorder" Diagnoses". Archives of Sexual Behavior. 44 (5): 1139–1145. doi:10.1007/s10508-015-0536-y. ISSN 0004-0002.
  8. ↑ Spitzer, Robert L. (2006). "Sexual and Gender Identity Disorders". Journal of Psychology & Human Sexuality. 17 (3–4): 111–116. doi:10.1300/J056v17n03_06. ISSN 0890-7064.
  9. ↑ Krueger RB, Kaplan MS (2012). "Paraphilic diagnoses in DSM-5". Isr J Psychiatry Relat Sci. 49 (4): 248–54. PMID 23585461.
  10. ↑ First MB (2014). "DSM-5 and paraphilic disorders". J Am Acad Psychiatry Law. 42 (2): 191–201. PMID 24986346.
  11. ↑ McManus, Michelle A.; Hargreaves, Paul; Rainbow, Lee; Alison, Laurence J. (2013). "Paraphilias: definition, diagnosis and treatment". F1000Prime Reports. 5. doi:10.12703/P5-36. ISSN 2051-7599.
  12. ↑ 12.0 12.1 12.2 Abdullahi, Halilu; Jafojo, Racheal Olayemi; Udofia, Owoidoho (2015). "Paraphilia Among Undergraduates in a Nigerian University". Sexual Addiction & Compulsivity. 22 (3): 249–257. doi:10.1080/10720162.2015.1057662. ISSN 1072-0162.
  13. ↑ 13.0 13.1 13.2 Kafka, Martin P. (1997). Archives of Sexual Behavior. 26 (4): 343–358. doi:10.1023/A:1024535201089. ISSN 0004-0002. Missing or empty |title= (help)
  14. ↑ Kafka, Martin P. (2006). "The Monoamine Hypothesis for the Pathophysiology of Paraphilic Disorders: An Update". Annals of the New York Academy of Sciences. 989 (1): 86–94. doi:10.1111/j.1749-6632.2003.tb07295.x. ISSN 0077-8923.
  15. ↑ Jordan, Kirsten; Fromberger, Peter; Stolpmann, Georg; Müller, Jürgen Leo (2011). "The Role of Testosterone in Sexuality and Paraphilia—A Neurobiological Approach. Part II: Testosterone and Paraphilia". The Journal of Sexual Medicine. 8 (11): 3008–3029. doi:10.1111/j.1743-6109.2011.02393.x. ISSN 1743-6095.
  16. ↑ Schneider, Jennifer P.; Irons, Richard (1996). "Differential diagnosis of addictive sexual disorders using the dsm-iv". Sexual Addiction & Compulsivity. 3 (1): 7–21. doi:10.1080/10720169608400096. ISSN 1072-0162.
  17. ↑ 17.0 17.1 Joyal, Christian C.; Carpentier, Julie (2016). "The Prevalence of Paraphilic Interests and Behaviors in the General Population: A Provincial Survey". The Journal of Sex Research. 54 (2): 161–171. doi:10.1080/00224499.2016.1139034. ISSN 0022-4499.
  18. ↑ 18.0 18.1 18.2 Hall, Ryan C.W.; Hall, Richard C.W. (2007). "A Profile of Pedophilia: Definition, Characteristics of Offenders, Recidivism, Treatment Outcomes, and Forensic Issues". Mayo Clinic Proceedings. 82 (4): 457–471. doi:10.4065/82.4.457. ISSN 0025-6196.
  19. ↑ 19.0 19.1 19.2 19.3 19.4 Abel, Gene G.; Osborn, Candice (1992). "The Paraphilias: The Extent and Nature of Sexually Deviant and Criminal Behavior". Psychiatric Clinics of North America. 15 (3): 675–687. doi:10.1016/S0193-953X(18)30231-4. ISSN 0193-953X.
  20. ↑ 20.0 20.1 Money, John; Pranzarone, Galdino F. (1993). "Development of Paraphilia in Childhood and Adolescence". Child and Adolescent Psychiatric Clinics of North America. 2 (3): 463–475. doi:10.1016/S1056-4993(18)30552-2. ISSN 1056-4993.
  21. ↑ Dawson, Samantha J.; Bannerman, Brittany A.; Lalumière, Martin L. (2014). "Paraphilic Interests". Sexual Abuse: A Journal of Research and Treatment. 28 (1): 20–45. doi:10.1177/1079063214525645. ISSN 1079-0632.
  22. ↑ Lee, Seung C.; Hanson, R. Karl; Calkins, Cynthia; Jeglic, Elizabeth (2019). "Paraphilia and Antisociality: Motivations for Sexual Offending May Differ for American Whites and Blacks". Sexual Abuse. 32 (3): 335–365. doi:10.1177/1079063219828779. ISSN 1079-0632.
  23. ↑ 23.0 23.1 Lee, Joseph K.P.; Jackson, Henry J.; Pattison, Pip; Ward, Tony (2002). "Developmental risk factors for sexual offending". Child Abuse & Neglect. 26 (1): 73–92. doi:10.1016/S0145-2134(01)00304-0. ISSN 0145-2134.
  24. ↑ Fisher, Alessandra D.; Castellini, Giovanni; Casale, Helen; Fanni, Egidia; Bandini, Elisa; Campone, Beatrice; Ferruccio, Naika; Maseroli, Elisa; Boddi, Valentina; Dèttore, Davide; Pizzocaro, Alessandro; Balercia, Giancarlo; Oppo, Alessandro; Ricca, Valdo; Maggi, Mario (2015). "Hypersexuality, Paraphilic Behaviors, and Gender Dysphoria in Individuals with Klinefelter's Syndrome". The Journal of Sexual Medicine. 12 (12): 2413–2424. doi:10.1111/jsm.13048. ISSN 1743-6095.
  25. ↑ 25.0 25.1 Thibaut, Florence (2015). "Paraphilias": 1–5. doi:10.1002/9781118625392.wbecp242.
  26. ↑ 26.0 26.1 26.2 26.3 26.4 Holoyda BJ, Kellaher DC (2016). "The Biological Treatment of Paraphilic Disorders: an Updated Review". Curr Psychiatry Rep. 18 (2): 19. doi:10.1007/s11920-015-0649-y. PMID 26800994.
  27. ↑ Radkani P, Joshi D, Barot T, Williams R (2018). "Robotic video-assisted thoracoscopy: minimally invasive approach for management of mediastinal tumors". J Robot Surg. 12 (1): 75–79. doi:10.1007/s11701-017-0692-2. PMID 28337576.
  28. ↑ Czerny JP, Briken P, Berner W (2002). "Antihormonal treatment of paraphilic patients in German forensic psychiatric clinics". Eur Psychiatry. 17 (2): 104–6. doi:10.1016/s0924-9338(02)00635-1. PMID 11973119.
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