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Paraphilia

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Paraphilia
SpecialtyPsychiatry, psychology, sexology Edit this on Wikidata

Paraphilia (in Greek para παρά = beside and -philia φιλία = friendship, having the meaning of love) is a biomedical term used to describe sexual arousal to objects, situations, or individuals that are not part of normative stimulation and that may cause distress or serious problems for the paraphiliac or persons associated with him or her. A paraphilia involves sexual arousal and gratification towards sexual behavior that is atypical and extreme. [1] The term was coined by Wilhelm Stekel in the 1920s.[2] Controversial sexologist John Money later popularized the term as a nonpejorative designation for unusual sexual interests.[3][4][5][6] He described paraphilia as "a sexuoerotic embellishment of, or alternative to the official, ideological norm."[7]

Psychologists and psychiatrists codified paraphilias as disorders, as a replacement for the legal constructs of sodomy[8] and perversion.[9] American Journal of Psychiatry[10] describes paraphilia as "recurrent, intense sexually arousing fantasies, sexual urges, or behaviors generally involving:

  1. Non-human objects
  2. The suffering or humiliation of oneself or one's partner
  3. Children
  4. Non-consenting persons"[11]
  5. People of the same sex (until 1973)

Sexual arousal in association with objects that were designed for sexual purposes is not DSM diagnosable (DSM, p. 570).[11]

The view of paraphilias as disorders is not universal. 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.[12] Psychiatrist Glen Gabbard writes that despite efforts by Stekel and Money, "the term paraphilia remains pejorative in most circumstances." [13]

General concerns

Terminological

Paraphilial psychopathology is not the same as psychologically normative adult human sexual behaviors, sexual fantasy, and sex play. These terms have been used in interchangeable ways which can allow for cognitive and clinical diagnostic misjudgment to occur. Consensual adult activities and adult entertainment that may involve some aspects of sexual roleplay, novel, superficial, or trivial aspects of sexual fetishism, or may incorporate the use of sex toys are not necessarily paraphilic.[11]

Classificational

It is not known how many different kinds of paraphilias exist; one source lists as many as 547 paraphilias.[14] Because so many paraphilias exist, one needs to classify them in an orderly and meaningful way. It has long been argued that the Diagnostic and Statistical Manual of Mental Disorders (DSM) system of classification makes unjustified categorical distinctions between disorders, and between normal and abnormal. Although the DSM-5 may move away from this categorical approach in some limited areas, some argue that a fully dimensional, spectrum or complaint-oriented approach would better reflect the evidence.[15][16][17][18]

There is scientific and political controversy regarding the continued inclusion of sex-related diagnoses such as the paraphilias in the DSM.[19][20]

Homosexuality

Homosexuality was at one time categorized as a form of paraphilia.[21] Martin Kafka writes, "Sexual disorders once considered paraphilias (e.g., homosexuality) are now regarded as variants of normal sexuality."[22] Researcher Anil Aggrawal writes that the 1952 first edition of the Diagnostic and Statistical Manual of Mental Disorders considered it "deviant sexuality" and specified "the type of the pathological behavior, such as homosexuality, transvestism, pedophilia, fetishism, and sexual sadism, including rape, sexual assault, mutilation)."[23] It was coded as 000-x63. That classification was soon subjected to critical scrutiny in research, which consistently failed to produce a basis for regarding homosexuality as a disorder. As results from such research accumulated, professionals in various fields reached two conclusions. First, that the DSM classification reflected untested assumptions based on once-prevalent social norms, and on clinical impressions from unrepresentative samples comprising patients seeking therapy and individuals whose conduct brought them into the criminal justice system. Second, that it was inaccurate to classify homosexuality as a mental disorder. In recognition of the scientific evidence,[24] the American Psychiatric Association removed homosexuality from the DSM in 1973, stating that “homosexuality per se implies no impairment in judgment, stability, reliability, or general social or vocational capabilities.” After thoroughly reviewing the scientific data, the American Psychological Association adopted the same position in 1975, and urged all mental health professionals “to take the lead in removing the stigma of mental illness that has long been associated with homosexual orientations.” The National Association of Social Workers has adopted a similar policy.[25] The removal was accompanied by the intense pressure from the homosexual activists [26][27] who used evidence(what evidance was used?).[28]

Clinical views

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."[29]

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.[30][31] 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”)".[32]

Paraphilias are defined by DSM-IV-TR as sexual disorders characterized by "recurrent, intense sexually arousing fantasies, sexual urges or behaviors generally involving (1) nonhuman objects, (2) the suffering or humiliation of oneself or one's partner, or (3) children or other nonconsenting persons that occur over a period of 6 months" (Criterion A), which "cause clinically significant distress or impairment in social, occupational, or other important areas of functioning" (Criterion B). DSM-IV-TR describes 8 specific disorders of this type (exhibitionism, fetishism, frotteurism, pedophilia, sexual masochism, sexual sadism, voyeurism, and transvestic fetishism) along with a ninth residual category, paraphilia not otherwise specified (NOS).[33] 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.[11]

Some paraphilias may interfere with the capacity for sexual activity with consenting adult partners.[11] According to the DSM, "Paraphilias are almost never diagnosed in females,"[11] but some case studies of females with paraphilias have been published.[34]

The DSM provides clinical criteria for these paraphilias:

  • Exhibitionism: the recurrent urge or behavior to expose one's genitals to an unsuspecting person, or to perform sexual acts that can be watched by others.
  • Fetishism: the use of inanimate objects to gain sexual excitement. Partialism refers to fetishes specifically involving nonsexual parts of the body.
  • Frotteurism: recurrent urges of behavior of touching or rubbing against a nonconsenting person.
  • Pedophilia: a psychological disorder in which an adult experiences a sexual preference for prepubescent children,[35] or has engaged in child sexual abuse.[36][37][38]
  • Sexual Masochism: the recurrent urge or behavior of wanting to be humiliated, beaten, bound, or otherwise made to suffer for sexual pleasure.
  • Sexual Sadism: the recurrent urge or behavior involving acts in which the pain or humiliation of a person is sexually exciting.
  • Transvestic fetishism: arousal from "clothing associated with members of the opposite sex."[11][39]
  • Voyeurism: the recurrent urge or behavior to observe an unsuspecting person who is naked, disrobing, or engaging in sexual activities, or who is engaging in activities usually considered to be of a private nature.[40][41]

Under Paraphilia NOS, the DSM mentions telephone scatalogia (obscene phone calls), necrophilia (corpses), partialism (exclusive focus on one part of the body), zoophilia (animals), coprophilia (feces), klismaphilia (enemas), urophilia (urine), emetophilia (vomit). The DSM's Paraphilia NOS is equivalent to the ICD-9's Sexual Disorder NOS.

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).[42][43] See also List of paraphilias.

Intensity and specificity

Clinicians distinguish between optional, preferred and exclusive paraphilias,[11] though the terminology is not completely standardized. An "optional" paraphilia is an alternative route to sexual arousal. For example, a man with otherwise unremarkable sexual interests might sometimes seek or enhance sexual arousal by wearing women's underwear. In preferred paraphilias, a person prefers the paraphilia to conventional sexual activities, but also engages in conventional sexual activities. For example, a man might prefer to wear women's underwear during sexual activity, whenever possible. In exclusive paraphilias, a person is unable to become sexually aroused in the absence of the paraphilia.[citation needed]

Drug treatments

The treatment of paraphilias and related disorders has been challenging for patients and clinicians. In the past, surgical castration was advocated as a therapy for men with pedophilia, but has been abandoned for the time being because most governments consider it a cruel punishment where the express willingness and consent of the patient is not objectively indicated. Psychotherapy, self-help groups, and pharmacotherapy (including anti-androgen hormone therapy sometimes referred to as "chemical castration") have all been used. Other drug treatments for these disorders do exist, however.[44]

Hormonal

Antiandrogenic drugs such as medroxyprogesterone (also known as the long-acting contraceptive Depo Provera) have been widely used as therapy in these men to reduce sex drive. However, their efficacy is limited and they have many side effects, including breast growth, headaches, weight gain, and reduction in bone density. Even if compliance is good, only 60 to 80 percent of men benefit from this type of drug. Long-acting gonadotropin-releasing hormones, such as Triptorelin (Trelstar) which reduces the release of gonadotropin hormones, are also used. This drug is a synthetic hormone which may also lead to reduced sex drive.[44]

Psychoactive

Psychostimulants have been used recently to augment the effects of serotonergic drugs in paraphiliacs. In theory, the prescription of a psychostimulant without pretreatment with an SSRI might further disinhibit sexual behavior, but when taken together, the psychostimulant may actually reduce impulsive tendencies. Methylphenidate (Ritalin) is an amphetamine-like stimulant used primarily to manage the symptoms of attention deficit hyperactivity disorder (ADHD). Recent studies imply that methylphenidate may also act on serotonergic systems; this may be important in explaining the paradoxical calming effect of stimulants on ADHD patients. Amphetamine is also used medically as an adjunct to antidepressants in refractory cases of depression.[44]

See also

References

  1. ^ Diagnostic and Statistical Manual of Mental Disorders, 1994.
  2. ^ Stekel, Wilhelm (1930), Sexual Aberrations: The Phenomenon of Fetishism in Relation to Sex, translated from the 1922 original German edition by S. Parker. Liveright Publishing.
  3. ^ Weiderman M (2003). Paraphilia and Fetishism. The Family Journal, July 2003 vol. 11 no. 3 315-321
  4. ^ Bullough VL (1995). Science in the Bedroom: A History of Sex Research, p. 281. Basic Books, ISBN 9780465072590
  5. ^ Moser C (2001). Critiques of conventional models of sex therapy. in Kleinplatz PJ (ed.) New directions in sex therapy: innovations and alternatives. Psychology Press, ISBN 9780876309674
  6. ^ McCammon S, Knox D, Schacht C (2004). Choices in sexuality, p. 476. Atomic Dog Publishing, ISBN 9781592600502
  7. ^ Money, John (1990). Gay, Straight, and In-Between: The Sexology of Erotic Orientation. Oxford University Press ISBN 9780195063318
  8. ^ Dailey, Dennis M. (1989). The Sexually Unusual: Guide to Understanding and Helping. Haworth Press ISBN 9780866567862
  9. ^ Purcell, Catherine E. and Bruce A. Arrigo (2006). The psychology of lust murder: paraphilia, sexual killing, and serial homicide. Academic Press ISBN 9780123705105
  10. ^ 138:210-215.
  11. ^ a b c d e f g h American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author. Cite error: The named reference "DSM" was defined multiple times with different content (see the help page).
  12. ^ Moser C, Kleinplatz PJ (2005). DSM-IV-TR and the Paraphilias: An argument for removal. Journal of Psychology and Human Sexuality, 17(3/4), 91-109.
  13. ^ Gabbard GO (2007). Gabbard's Treatments of Psychiatric Disorders. American Psychiatric Press. ISBN 9781585622160
  14. ^ Aggrawal, Anil (2009). Forensic and Medico-legal Aspects of Sexual Crimes and Unusual Sexual Practices. Boca Raton: CRC Press. ISBN 1420043080. {{cite book}}: Cite has empty unknown parameter: |coauthors= (help); Unknown parameter |curly= ignored (help)
  15. ^ Spitzer, Robert L, M.D., Williams, Janet B.W, D.S.W., First, Michael B, M.D., Gibbon, Miriam, M.S.W., Biometric Research
  16. ^ Maser, JD & Akiskal, HS. et al. (2002) Spectrum concepts in major mental disorders Psychiatric Clinics of North America, Vol. 25, Special issue 4
  17. ^ Krueger, RF., Watson, D., Barlow, DH. et al. (2005) Toward a Dimensionally Based Taxonomy of Psychopathology Journal of Abnormal Psychology Vol 114, Issue 4
  18. ^ Bentall, R. (2006) Madness explained : Why we must reject the Kraepelinian paradigm and replace it with a 'complaint-orientated' approach to understanding mental illness Medical hypotheses, vol. 66(2), pp. 220-233
  19. ^ Alexander, B. (2008) What's ‘normal’ sex? Shrinks seek definition Controversy erupts over creation of psychiatric rule book's new edition MSNBC Today, May.
  20. ^ Kleinplatz, P. J., & Moser, C. (2005). Politics versus science: An addendum and response to Drs. Spitzer and Fink. Journal of Psychology and Human Sexuality, 17, 135-139.
  21. ^ Hutchinson GE (1959). A speculative consideration of certain possible forms of sexual selection in man. American Naturalist, Vol 93, no. 869 (March/April 1959, pp. 81-91
  22. ^ Kafka MP (1996). Therapy for Sexual Impulsivity: The Paraphilias and Paraphilia-Related Disorders. Psychiatric Times Vol. 13 No. 6
  23. ^ Aggrawal, Anil (2008). Forensic and medico-legal aspects of sexual crimes and unusual sexual practices, p. 47. CRC Press, ISBN 9781420043082
  24. ^ JAMA: Gay Is Okay With APA (American Psychiatric Association); available online: http://www.soulforce.org/article/642
  25. ^ Case No. S147999 in the Supreme Court of the State of California, In re Marriage Cases Judicial Council Coordination Proceeding No. 4365(…)
  26. ^ http://press.princeton.edu/titles/2535.html
  27. ^ http://www.inqueery.com/html/science_and_homosexuality.html
  28. ^ The rise and fall of homosexuality as a diagnosis, Professor Michael King (International Congress of the Royal College of Psychiatrists 2010 - Advancing Science, 21-24 June 2010, EICC, Edinburgh)
  29. ^ Eulenburg (1914). Ueber sexualle Perversionen. Ztschr. f. Sexualwissenschaft, Vol. I, No. 8. translated in Stekel, Wilhelm. (1940). Sexual aberrations: The phenomena of fetishism in relation to sex. New York: Liveright, p. 4. OCLC 795528
  30. ^ psyweb.com "Axis I. Clinical Disorders, most V-Codes and conditions that need Clinical attention". Retrieved: 23 November, 2007.
  31. ^ World Health Organization, International Statistical Classification of Diseases and Related Health Problems, (2007), Chapter V, Block F65; Disorders of sexual preference. Retrieved 2007-11-29.
  32. ^ Summary of Practice-Relevant Changes to the DSM-IV-TR from Diagnostic and Statistical Manual of Mental Disorders (DSM)
  33. ^ [http://www.psychiatrictimes.com/display/article/10168/55266 Paraphilias: Clinical and Forensic Considerations, April 15, 2007 Psychiatric Times. Vol. 24 No. 5] from Psychiatric Times
  34. ^ Fedoroff, J. P., Fishell, A., & Fedoroff, B. (). A case series of women evaluated for paraphilic sexual disorders. Canadian Journal of Human Sexuality, 8.
  35. ^ World Health Organization, International Statistical Classification of Diseases and Related Health Problems: ICD-10 Section F65.4: Paedophilia (online access via ICD-10 site map table of contents)
  36. ^ Finkelhor, David (1986). A Sourcebook on Child Sexual Abuse: Sourcebook on Child Sexual Abuse. Sage Publications. p. 90. ISBN 0803927495. {{cite book}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
  37. ^ "pedophilia". Encyclopædia Britannica.
  38. ^ medem.com
  39. ^ Hirschfeld, M. (1910). Die tranvestiten [Transvestites]. Berlin: Alfred Pulvermacher.
  40. ^ Hirschfeld, M. (1938). Sexual anomalies and perversions: Physical and psychological development, diagnosis and treatment (new and revised edition). London: Encyclopaedic Press.
  41. ^ Smith, R. S. (1976). Voyeurism: A review of the literature. Archives of Sexual Behavior, 5, 585-608.
  42. ^ Padmal de Silva (2007). "Sexual disorder and psychosexual therapy". Psychiatry. 6 (3). Elsevier Ltd: 130–134. doi:10.1016/j.mppsy.2006.12.009. {{cite journal}}: Unknown parameter |month= ignored (help)
  43. ^ King, M.B. (1990). "Sneezing as a fetish object". Sex Marital Therapy. 5: 69–72. doi:10.1016/j.mppsy.2006.12.009.
  44. ^ a b c M. Williams. Sexual Compulsivity: Defining Paraphilias and Related Disorders "Psychoactive Drug Treatments". Retrieved 23 November 2007

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