Sexual perversions and paraphilias: Compulsion, obsession or addiction?

Back in 1986, during the second year of my undergraduate psychology degree, we had a psychiatrist called Dr Alex Oswald come in give a guest lecture on sexual paraphilias. It was the best (and most interesting) lecture I have ever seen. I had always taken an interest in human sexual behaviour but this was unlike any lecture I had ever had before. It was also the stimulus for my (now) lifelong academic interest in extreme sexual behaviours.

The German psychiatrist Richard Von Krafft-Ebing is usually credited with first identifying paraphilias in his 1886 book Psychopathia Sexualis (Sexual Psychopathy). Paraphilias (from the Greek “beyond usual or typical love”) are uncommon types of sexual expression and often more commonly described as sexual deviations, sexual perversions or disorders of sexual preference. To many people, the may appear bizarre and/or socially unacceptable, and represent the extreme end of the sexual continuum. They are typically accompanied by intense sexual arousal to unconventional and/or non-sexual stimuli. In some cases, the behaviour may only occur sporadically whereas for others it may be compulsive and/or addictive. Many sexologists (such as the late Professor John Money of the John Hopkins University) have described some paraphilic behaviours as “fixated” and for those affected the desire is insistent and demanding.

It is thought that paraphilias are rare and affect only a very small percentage of adults. It has been difficult for researchers in the field to estimate the proportion of the population that experience paraphilic behaviours because much of the scientific literature is based on case studies (which suffer from problems around reliability because of their self-report nature). As paraphilias typically offer pleasure, many individuals affected do not seek psychiatric treatment. Furthermore, reliable statistics are further compounded by the fact that many paraphilic acts are illegal. Because of the illegality, paraphiliacs often experience high levels of shame and guilt and (like those who experience pleasure from the behaviour) may not seek medical or psychiatric help. For those that do seek professional help the disorders are often difficult to treat. Therapeutic success is more likely to be related to curbing or suppressing the behaviour rather than eliminating it altogether.

Although the statistics are biased by differential reporting and prosecution, there is general agreement among the psychiatric community that all paraphilias are male dominated (with at 90% of all those affected being men and with some estimates suggesting the ratio is as high as 30 to 1). Research also indicates that some paraphilias appear to be more common than others. For instance, the most common paraphilias reported in the scientific literature appear to be masochism, sadism and fetishism. Within clinics that treat sex offenders, the most common paraphilias are (perhaps unsurprisingly) paedophilia, voyeurism and exhibitionism.

It is also known that atypical sexual behaviours often cluster and/or overlap (either simultaneously or sequentially). For instance, some research has reported that paraphiliacs commonly experience two to three concurrent paraphilas with around 5% experiencing up to 10 concurrently. The onset of paraphilic behaviour is typically initiated during early adolescence through a complex biopsychosocial network of causes. The behaviour usually reaches its full development by the age of 20 years. Some of the causes of paraphilic behaviour are known to include various genetic and hormonal abnormalities, pre-natal neuro-developmental factors, neuro-cognitive and brain dysfunctional, maladaptive learning, and dysfunctional family life during childhood.

Paraphilas are rarely described as addictions as most of the debate surrounds whether they are impulse control disorders or whether they fall within the spectrum of obsessive-compulsive disorders. Arguably, the best criteria for diagnosis of a paraphilia is found in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). In the DSM-IV-TR, a paraphilic disorder has to meet two essential criteria. The first criterion is that the essential features of a paraphilia are recurrent, intense sexually arousing fantasies, sexual urges or behaviors generally involving (i) non-human objects, (ii) the suffering or humiliation of oneself or one’s partner, or (iii) children or other non-consenting persons that occur over a period of at least six months. The second criterion is that a diagnosis is made if the behaviour, sexual urges, and/or fantasies cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

The element of coercion is another key distinguishing characteristic of paraphilias. Some paraphilias (e.g., sadism, masochism, fetishism, hypoxyphiilia, urophilia, coprophilia, klismaphilia) – which I will be discussing in future blogs – are engaged in alone, or include consensual adults who participate in, observe, or tolerate the particular paraphiliac behaviour. These atypical non-coercive behaviours are considered by many in the psychiatric community to be relatively benign or harmless because there is no violation of anyone’s rights. Atypical coercive paraphilic behaviours are considered much more serious and almost always require therapeutic intervention (e.g., exhibitionism, voyeurism, frotteurism, necrophilia, zoophilia).

Finally, it is also worth noting that some practitioners working in the field have made distinctions between what are referred to as optional, preferred and exclusive paraphilias. An optional paraphilia is a behaviour that provides an alternative route to becoming sexually aroused. For instance, a male with fairly normal sexual interests might occasionally enhance their sexual arousal by wearing women’s high-heeled shoes and fishnet stockings while having sex. In preferred paraphilias, a person prefers the paraphilia to conventional sexual activities, but is still able to engage in conventional sex. For instance, a male might prefer – whenever possible – to wear women’s high-heeled shoes and fishnet stockings during sex. In exclusive paraphilias, a person is unable to become sexually aroused in the absence of the paraphilia. In this case, a male would be unlikely to get sexually aroused during sex unless he was wearing high-heeled shoes and fishnet stockings.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Abel, G. G., & Osborn, C. (1992). The paraphilias: The extent and nature of sexually deviant and criminal behavior. Psychiatric Clinics of North America, 15, 675–689.

Abel, G. G., Becker, J. V., Cunningham-Rathner, J., Mittelman, M., & Rouleau, J.-L. (1988). Multiple paraphilic diagnoses among sex offenders. Bulletin of the American Academy of Psychiatry and the Law, 16, 153–168.

American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders (4th ed., Text Revised). Washington, DC: Author.

Krueger, R. B., Kaplan, M. (2001). The paraphilic and hypersexual disorders: An overview. Journal of Psychiatric Practice, 7, 391-403.

Money, J. (1994). Principles of Developmental Sexology. New York: Continuum.

Raymond, N.C., & Grant, J.E. (2008). Sexual disorders: Dysfunction, gender identity, and paraphilias. The Medical Basis of Psychiatry, 1, 267-283.

Wiederman, M.W. (2003). Paraphilia and fetishism. The Family Journal: Counseling and Therapy for Couples and Families, 11, 315-321.