Sexual Perversions

Sexual perversions are conditions in which sexual excitement or orgasm is associated with acts or imagery that are considered unusual within the culture. To avoid problems associated with the stigmatization of labels, the neutral term paraphilia,
derived from Greek roots meaning "alongside of" and "love," is used to describe what used to be called sexual perversions. A paraphilia is a condition in which a person's sexual arousal and gratification depend on a fantasy theme of an unusual situation or object that becomes the principal focus of sexual behavior.

Description

Paraphilias can revolve around a particular sexual object or a particular act. They are defined by DSM-IV as "sexual impulse disorders characterized by intensely arousing, recurrent sexual fantasies, urges and behaviors considered deviant with respect to cultural norms and that produce clinically significant distress or impairment in social, occupational or other important areas of psychosocial functioning." The nature of a paraphilia is generally specific and unchanging, and most of the paraphilias are far more common in men than in women.

Paraphilias differ from what some people might consider "normal" sexual activity in that these behaviors cause significant distress or impairment in areas of life functioning. They do not refer to the normal use of sexual fantasy, activity, or objects to heighten sexual excitement where there is no distress or impairment.

The most common signs of sexual activity that can be classified as paraphilia include: the inability to resist an impulse for the sexual act, the requirement of participation by non-consenting or under-aged individuals, legal consequences, resulting sexual dysfunction, and interference with normal social relationships.

Paraphilias include fantasies, behaviors, and/or urges which:

• involve nonhuman sexual objects, such as shoes or undergarments
• require the suffering or humiliation of oneself or partner
• involve children or other non-consenting partners

The most common paraphilias are:

• exhibitionism, or exposure of the genitals
• fetishism, or the use of nonliving objects
• frotteurism, or touching and rubbing against a nonconsenting person
• pedophilia, or the focus on prepubescent children
• sexual masochism, or the receiving of humiliation or suffering
• sexual sadism, or the inflicting of humiliation or suffering
• transvestic fetishism, or cross-dressing
• voyeurism, or watching others engage in undressing or sexual activity

A paraphiliac often has more than one paraphilia. Paraphilias often result in a variety of associated problems, such as guilt, depression, shame, isolation, and impairment in the capacity for normal social and sexual relationships. A paraphilia can, and often does, become highly idiosyncratic and ritualized.

Causes and symptoms

There is very little certainty about what causes a paraphilia. Psychoanalysts generally theorize that these conditions represent a regression to or a fixation at an earlier level of psychosexual development resulting in a repetitive pattern of sexual behavior that is not mature in its application and expression. In other words, an individual repeats or reverts to a sexual habit arising early in life. Another psychoanalytic theory holds that these conditions are all expressions of hostility in which sexual fantasies or unusual sexual acts become a means of obtaining revenge for a childhood trauma. The persistent, repetitive nature of the paraphilia is caused by an inability to erase the underlying trauma completely. Indeed, a history of childhood sexual abuse is sometimes seen in individuals with paraphilias.

However, behaviorists suggest, instead, that the paraphilia begins via a process of conditioning. Nonsexual objects can become sexually arousing if they are frequently and repeatedly associated with a pleasurable sexual activity. The development of a paraphilia is not usually a matter of conditioning alone; there must usually be some predisposing factor, such as difficulty forming person-to-person sexual relationships or poor self-esteem.

The following are situations or causes that might lead someone in a paraphiliac direction:

• parents who humiliate and punish a small boy for strutting around with an erect penis
• a young boy who is sexually abused
• an individual who is dressed in a woman's clothes as a form of parental punishment
• fear of sexual performance or intimacy
• inadequate counseling
• excessive alcohol intake
• physiological problems
• sociocultural factors
• psychosexual trauma

Diagnosis

Whatever the cause, paraphiliacs apparently rarely seek treatment unless they are induced into it by an arrest or discovery by a family member. This makes diagnosis before a confrontation very difficult.
Paraphiliacs may select an occupation, or develop a hobby or volunteer work, that puts them in contact with the desired erotic stimuli, for example, selling women's shoes or lingerie in fetishism, or working with children in pedophilia. Other coexistent problems may be alcohol or drug abuse, intimacy problems, and personality disturbances, especially emotional immaturity. Additionally, there may be sexual dysfunctions. Erectile dysfunction and an inability to ejaculate may be common in attempts at sexual activity without the paraphiliac theme.

Paraphilias may be mild, moderate, or severe. An individual with mild paraphilia is markedly distressed by the recurrent paraphiliac urges but has never acted on them. The moderate has occasionally acted on the paraphilic urge. A severe paraphiliac has repeatedly acted on the urge.

Treatment

The literature describing treatment is fragmentary and incomplete. Traditional psychoanalysis has not been particularly effective with paraphilia and generally requires several years of treatment. Therapy with hypnosis has also had poor results. Current interests focus primarily on several behavioral techniques that include the following:

Aversion imagery involves the pairing of a sexually arousing paraphilic stimulus with an unpleasant image, such as being arrested or having one's name appear in the newspaper.
Desensitization procedures neutralize the anxiety-provoking aspects of nonparaphilic sexual situations and behavior by a process of gradual exposure. For example, a man afraid of having sexual contact with women his own age might be led through a series of relaxation procedures aimed at reducing his anxiety.
Social skills training is used with either of the other approaches and is aimed at improving a person's ability to form interpersonal relationships.

Orgasmic reconditioning may instruct a person to masturbate using his paraphilia fantasy and to switch to a more appropriate fantasy just at the moment of orgasm.

In addition to these therapies, drugs are sometimes prescribed to treat paraphilic behaviors. Drugs that drastically lower testosterone temporarily (antiandrogens) have been used for the control of repetitive deviant sexual behaviors and have been prescribed for paraphilia-related disorders as well. Cyproterone acetate inhibits testosterone directly at androgen receptor sites. In its oral form, the usual prescribed dosage range is 50-200 mg per day.

Serotonergics (drugs that boost levels of the brain chemical serotonin) are prescribed for anxious and depressive symptoms. Of the serotonergic agents reported, fluoxetine has received the most attention, although lithium, clomipramine, buspirone, and sertraline are reported as effective in case reports and open clinical trials with outpatients. Other alternative augmentation strategies that may be effective include adding a low dose of a secondary amine tricyclic antidepressant to the primary serotonergics, but these reports are only anecdotal.

Prognosis

Despite more than a decade of experience with psychotherapeutic treatment programs, most workers in the field are not convinced that they have a high degree of success. Furthermore, because some cases involve severe abuse, many in the general public would prefer to "lock up" the sex offender than to have him out in the community in a treatment program or on parole after the treatment program has been completed.

Paraphilia and paraphilia-related disorders are more prevalent than most clinicians suspect. Since these disorders are cloaked in shame and guilt, the presence of these conditions may not be adequately revealed until a therapeutic alliance is firmly established. Once a diagnosis is established, appropriate education about possible behavioral therapies and appropriate use of psychopharmacological agents can improve the prognosis for these conditions.

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