Question

2. Accurately and appropriately diagnosing a sexual disorder or paraphilia can be among the most challenging tasks in clinical practice. Thinking about the 4 Ds as discussed in Week 1 of the course, choose ONE sexual disorder and ONE paraphilia covered in your text and discuss how applying those criteria could prove troublesome to a clinician. In addition, be sure to discuss any relevant gender and or cultural factors in terms of the diagnosis or the behavior itself. Please answer in 600 words or more.

Answer 1

Paraphilia

Paraphilias are emotional disorders defined as sexually arousing fantasies, urges, or behaviors that are recurrent, intense, occur over a period of at least six months, and cause significant distress or interfere with important areas of functioning.

Except for masochism, medical professionals almost exclusively diagnose paraphilias in men.

There are a number of different types of paraphilic disorders, each of which has a different focus of the sufferer’s sexual arousal.

There are biological, psychological, and social risk factors for developing paraphilias.

While the desired sexual stimulant for the paraphilia sufferer depends on the specific paraphilia, the characteristics of the illness are often very similar, as described in the most current standard reference for mental health diagnoses, the DSM-5.

In order to establish the diagnosis of a paraphilia, mental health professionals usually conduct or refer the person for a medical interview, physical examination, and routine laboratory tests. The professional will assess for any history of mental health symptoms.

Treatment of paraphilic sexual disorders usually involves the combination of psychotherapy and medication.

Paraphilias are quite chronic, such that a minimum of two years of treatment is recommended for even the mildest paraphilia.

Prevention for the development of any paraphilic behavior usually involves alleviating the psychosocial risk factors for its development.

What is a paraphilia? What are the different types of paraphilias?

The word paraphilia derives from Greek; para means around or beside, and philia means love. The definition of paraphilia is any emotional disorder characterized by sexually arousing fantasies, urges, or behaviors that are recurrent, intense, occur over a period of at least six months, and cause significant distress or interfere with the sufferer’s work, social function, or other important areas of functioning. This is as opposed to sexual variants, which are sexual behaviors that are not typical but are not a part of any illness.

The number of people who suffer from a paraphilia is difficult to gauge for a number of reasons. Many people with one of these disorders suffer in secret or silence out of shame, and some engage in sexually offensive behaviors and so are invested in not reporting their paraphilia. Therefore, many of the estimates on the prevalence of paraphilic disorders come from the number of people involved with the criminal-justice system due to pedophilia. Most individuals with this sexual deviation are men (3%-5% of the male population), with just 1%-6% of those individuals being women. However, women tend to be under-diagnosed with paraphilias, wrongfully given the benefit of the doubt by those assessing their sexual behaviors.

Except for masochism, which is 20 times more common in women than men, paraphilias are almost exclusively diagnosed in men. Many people who suffer from one paraphilia have more than one. For example, about one-third of pedophiles also have another paraphilia. More than half engage in three or four such kinds of behaviors rather than just one. Most people who develop a paraphilia begin having fantasies about it before they are 13 years old.

According to the most current standard reference for mental disorders, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), preceded by the DSM-IV and DSM-IV-TR, there are a number of different types of paraphilias, each of which has a different focus of the sufferer's sexual arousal:

Voyeurism: watching an unsuspecting/non-consenting individual who is either nude, disrobing, or engaging in sexual activity

Exhibitionism: exposing one’s own genitals to an unsuspecting person

Frotteurism: touching or rubbing against a non-consenting person

Sexual masochism: being humiliated, beaten, bound, or otherwise suffering

Sexual sadism: the physical or emotional suffering of another person

Pedophilia: sexual activity with a child that is prepubescent (usually 13 years old or younger)

Fetishism: sexual fascination with nonliving objects or highly specific body parts (partialism). Examples of specific fetishisms include somnophilia (sexual arousal by a person who is unconscious) and urophilia (deriving sexual pleasure from seeing or thinking about urine or urinating)

Transvestism: cross-dressing that is sexually arousing and interferes with functioning

Autogynephilia is a subtype of transvestism that refers specifically to men who become aroused by thinking or visualizing himself as a woman.

Other specified paraphilia: some paraphilias do not meet full diagnostic criteria for a paraphilic disorder but may have uncontrolled sexual impulses that cause enough distress for the sufferer that they are recognized. Examples of such specific paraphilias include necrophilia (corpses), scatologia (obscene phone calls), coprophilia (feces and defecation), and zoophilia (animals).

Urges to engage in coercive or otherwise aggressive sex like rape are not symptoms of a mental illness. Such sexual offending is therefore not considered a paraphilia.

What are causes and risk factors for paraphilia?

Biological issues thought to be risk factors for paraphilias include some differences in brain activity during sexual arousal, as well as general brain structure. Mental health professionals have found that male pedophiles have lower IQ scores on psychological testing compared to men who are not pedophiles. Research has also determined that they tend to have a history of earning lower grades in school than their non-pedophilic counterparts, regardless of intellectual abilities and learning styles.

There are a number of psychological theories about how paraphilias develop. Some view these disorders as a manifestation of arrested psychosexual development, with the paraphilic behaviors defending the person's psyche against anxiety (defense mechanisms). Others believe paraphilias are the result of the sufferer associating something with sexual arousal and interests, or by having unusual early life sexual experiences reinforced by having an orgasm. Some view these disorders as another form of obsessive-compulsive disorder.

Psychologically, pedophiles who act on their urges by sexually offending tend to engage in grossly distorted thinking, in that they use their position of power and view offending as an appropriate way to meet their needs, think about children as equal sexual beings to adults, and consider their sexual needs as uncontrollable.

Another theory about paraphilia risk factors is that they are linked to stages of childhood psychological development like temperament, early relationship formation, trauma repetition, and disrupted development of sexuality, as follows:

Temperament: a tendency to be overly inhibited or uncontrolled with emotions and behaviors

Early relationship formation: a lack of stable self-awareness, trouble managing emotions, and in seeking help and comfort from others

Trauma repetition: People who are the victim of sexual or other forms of abuse, especially if it occurs during childhood, may identify with the abuser such that they act out what was inflicted on them by victimizing others in some way. They may also act out the trauma by somehow harming themselves.

Disrupted development of sexuality: The patterns of what brings one sexual pleasure tend to form by adolescence. People raised in a household that is either excessively sexually permissive or inhibited are at higher risk for developing a paraphilia.

Family risk factors for paraphilia development include high conflict between parents or low supervision by parents, a lack of affection from the mother, and generally not feeling treated well by their parents. People with paraphilia tend to have trouble making and keeping friends and other relationships.

What are paraphilia symptoms and signs?

While the desired sexual stimulant for the paraphilia sufferer depends on the specific paraphilia, the characteristics of the illness are often very similar. Specifically, people with a paraphilia tend to experience arousal by the stimulant to the exclusion or near exclusion of more common sources of sexual interest, like an attractive person of similar age. The intensity of the sexual attraction can be overwhelming enough to cause distress. The unusual or forbidden nature of a paraphilia often causes symptoms of guilt and fear of punishment.

Symptoms of paraphilia can include preoccupation to the point of obsessiveness that may intrude on the person's attempts to think about other things or engage in more conventional sexual activity with an age-appropriate partner. Paraphilia sufferers may experience depression or anxiety that is temporarily relieved by engaging in paraphilic behavior, thus leading to an addictive cycle.

How do health professionals diagnose paraphilias?

Usually providers of mental health care help make the diagnosis of paraphilias, including licensed mental health therapists, psychiatrists, psychologists, psychiatric nurses, physician assistants, and social workers. One of these professionals will likely conduct or refer the person with paraphilia for an extensive medical interview and physical examination as part of establishing the diagnosis. To ensure that the paraphilic individual does not suffer from a medical condition that could complicate the assessment or treatment of their mental health condition, medical professionals often perform routine laboratory tests during the initial evaluation.

As part of this examination, the sufferer may be asked a series of questions from a standardized questionnaire or self-test to help assess the presence of paraphilic symptoms. A mental health professional will conduct a thorough exploration for any history or presence of all mental health symptoms such that paraphilia can be distinguished from other types of mental disorders. People with pedophilia may also suffer from a personality disorder or mood disorder, and about 60% have an additional paraphilia, like exhibitionism, voyeurism, or sadism.

In order to qualify for the diagnosis of a paraphilic disorder, the individual has to experience recurrent, significant sexual arousal by the object of their attraction; act on that attraction in urges, fantasies, or actions; and experience the symptoms for at least six months to the point that the individual suffers significant levels of distress or interference with his or her work, social function, or other important aspects of life.

What is the treatment for paraphilia?

Research on the treatment for paraphilias focuses on pedophilia, due to the terrible impact of this behavior on victims and due to the involvement of pedophilic sex offenders with the justice system. Those studies have shown that treatment only tends to work if the person with pedophilia is motivated and committed to controlling his or her behavior and when treatment combines psychotherapy and medication.

Psychotherapy for pedophilia and other paraphilias tends to use cognitive behavioral therapy. The focus of psychotherapy tends to be helping the person with pedophilia recognize and combat rationalizations about his or her behavior, as well as training the pedophilia sufferer in developing empathy for the victim and in techniques to control their sexual impulses. This therapy tends to take an approach to treating sexual offenders using a relapse prevention model that is similar to treating people with a drug addiction. This approach tries to help the paraphilic person anticipate situations that increase their risk of sexually acting out and finding ways to avoid or more productively respond to those triggers. People with paraphilia may also benefit from social skills training to help them develop age-appropriate, reciprocal relationships.

Medications that suppress production of the male hormone testosterone reduce the frequency or intensity of sexual desire in pedophiles. It may take three to 10 months for testosterone suppression to reduce sexual desire. Studies of the effectiveness of selective serotonin reuptake inhibitors (SSRIs) in treating pedophilia and other paraphilias vary in their findings on their effectiveness. However, SSRIs may be a helpful addition to other treatments, because they tend to decrease sexual obsessiveness and urges associated with paraphilias and may help with increasing the paraphile's ability to control his or her impulses. Examples of SSRI medications include fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa), escitalopram (Lexapro), and vortioxetine (Trintellix).

There is some preliminary research that stimulant medications like methylphenidate (Ritalin) can increase the effectiveness of SSRIs, and naltrexone can decrease some of the sexual obsessiveness associated with paraphilias.

What is the prognosis of paraphilia?

Paraphilias are quite chronic such that a minimum of two years of treatment is recommended for even the mildest paraphilia. While most people with a paraphilia do not sexually offend, and sexual offending is not a mental illness, people who commit sexual offenses sometimes also have a paraphilia.

Is it possible to prevent paraphilias?

Given that paraphilic behavior tends to be highly stigmatized and some paraphilic behaviors are illegal, tracking how successful treatment often involves rates of criminal recidivism. Therefore, prevention of future paraphilic behavior often focuses on preventing sexual offenders from having access to potential victims. Prevention for the development of any paraphilic behavior usually involves alleviating the psychosocial risk factors for its development.