International Journal of Medical Reviews

Review Article

A Review on Paraphilias
Seyed Hassan Saadat1*

Abstract
Sexual deviations are disorders in which the individual has fantasies, sexual desires or 1. Behavioral sciences research center,
behaviors that are repetitive and sexually provocative and often include inhumane is- Baqiyatallah University of Medical Sciences,
sues for at least 6 months. Since these people usually make various legal problems Tehran, Iran
for both themselves and others, this disorder is of special interest. Different models
have discussed on the etiology of sexual deviations among of which the special psy-
choanalysis of Freud have investigated this disorder more comprehensively. In Freud- * Corresponding Author
ians psychoanalysis, sexual deviation has a neurosis structure and shows that sexual Seyed Hassan Saadat, Behavioral sciences
deviated has in fact accepted the deprivation of the mother, but is still trying to return research center, Baqiyatallah University of
to the bosom of the mother and the denying father. Also, in self-psychology the sexual Medical Sciences, Tehran, Iran
deviant who has had wrong repeating scenarios in regards to his/hers relationship with E-mail: [email protected]
parents or as a sadistic seeks to create a temporary and false glorious sense of confi-
dence, to create a grandiose "self" who is self- sufficient and does not need anyone.
In many cases body organ justifications are also considered for sexual deviations.
Among the examined patients in psychiatric clinics, 74% had hormone level disorders,
27% had neurologic symptoms, 24%, had chromosomal disorders, 9% had epilepsy,
4% had abnormal EEG, 4% had major psychiatric disorders , and 4% had mental
retardation .Some sources propose 9 identifications for sexual deviation which in-
clude: Fetishism, Pedophilia, Exhibitionism, Voyeurism, Sexual Masochism, Sexual
Sadism, Transvestic fetishism, Frotteurism and Paraphilias. The treatment of sexual
deviations has great complexity due to its coincidnce with psychiatric disorders such
as personality disorders, as well as other factors such as the patients shame and mod-
esty and not stating their problems. The treatment of sexual deviation is considered to
have four general purposes including a) reducing sexual desires b) giving insight and
understanding to the patient c) controlling external stimuli d) treating concurrent dis-
orders.The treatment of sexual deviation involves extensive ranges of biological ther-
apies to mental therapies. One of the major approaches to psychotherapy in the treat-
ment of sexual deviations is the insight oriented approach that causes a person to im-
prove his interpersonal skills and to find an acceptable method for sexual gratification.
Treatment in groups through specific procedures and guidelines and practices can also
help the patients. When a person has other psychiatric disorders, pharmacotherapy can
treat concurrent biological problems of the individual as well as reducing sexual and
obsessive desires. In rare cases where the problem is very serious or causes legal con-
flicts, surgical treatment is recommended. Submission Date: 10/09/2014
Accepted Date: 12/16/2014
Keywords: Review, Paraphilias, Transvestic, Justice, Frotteurism

Introduction and the cause of it has not yet been determined exactly (3).
Investigations related to paraphiliac behaviors have existed Sexual deviation includes uncontrolled or excessive sexual
from centuries ago, but this type of behaviors have only at- behaviors or sexual thoughts and knowledge which causes
tracted attention of the psychologists since 1905. Freud also mental suffering, impaired job social performance or legal
believed that paraphiliac behaviors are caused by the devia- conflicts for the person affected (4). Sexual deviation, in its
tion of sexual identity. In 1905 paraphilia was referred to common sense, is sexual behavior and fantasies against
any sexual behavior other than ordinary intercourse , that is public morality. Since the time of Freud, sexual deviation
penetration of the penis into vagina, but now paraphilia is has meant dominance of one state and sexual fantasy on the
referred to everyone whether woman or man showing ab- whole sexual and love action of the patient. This is instead
normal behaviors such as harming self or sexual partner of erotic moods and behaviors like exhibition, romantic or
during proximity (1). erotic looking to the beloved. these people have behaviors
Sexual deviation or paraphiliac is a biomedical word for de- like ogling the beloved, fantasies and masochism and sad-
fining sexual arousal by objects, people, or situations as ab- ism in erotic and love like biting the beloved, power play in
normal and a Paraphili with a sense of pleasure in unusual sex, and sexual love at different stages of a sex to reach or-
and extreme situations. Of course the term Paraphili was gasm and unity themselves to target the sexual relationship
first used in 1920 by an Austrian psychologist Wilhelm (2). or in a broader meaning love action.
Paraphilic disorders are specified by momentum, fantasies But the problem is that the sexual deviant organizes his en-
or sexual actions that are unusual, strange and deviational. joyment and pleasure, thus has an inner strength, though
Paraphilia is more common in men in compared to women pathological. Therefore, on one hand, he must pass through

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 Saadat, SH, A Review on Paraphilias

part of this pathological enjoyment and hallucinations, and transformable and create new fantasies. Hence, sexual de-
on the other hand is able to change his pathological passions viant , by stabling in previous oedipal conditions and re-
to modern sadistic, masochist and desires which are trans- peating these states like sadistic and exhibition, is in fact
formable and have borders (1). repeating his oedipal fears and childish fantasies, is
doomed to repeat until achieving these transformations and
Definition: turning these fantasies to modern and mortal desires (7).
In dictionaries, sexual deviation is sexual pleasure or satis- In the second generation of psychology, self-psychology"
faction through maladaptive and unusual ways. The prob- and Psychoanalyst like kohot and Kohlberg and others are
lem with this definition is that it is called "diversion" in one focused on. These psychologists see the symptoms of deep
time and place and may be considered as normal in an- Narrsisitc disorders and inability to create a healthy "self"
other time and place. in order to be able to love him and others as a consequence
For a comprehensive definition of sexual deviation, there is of false childhood relationships. Sexual deviant in this sense
not any exact and universal principle and sociologists, eth- is repeating scenarios of wrong old relationships with par-
ics, scholars and psychologists that generally agree. If pleas- ents or as a sadistic seeks to create a temporary and false
ure or sexual satisfaction is not accepted by the society, it is sense of glorious confidence, creates a grandiose "self" who
considered as deviation by sociologists. Biologists just fo- is needless to others.
cus on reproduction and survival of the kind in sexual rela- In this sense, sexual deviation indicates a "lack" or, as the
tions; and any type of sexual intercourse that is not the way famous psychoanalyst Ashtvlr says, in cases like the sadis-
to achieve it, in their view, would be considered as a devia- tic there is "a form of erotic hatred" and repeating childhood
tion. Ethics scholars call sexual deviation any sexual satis- nightmares and denying his beloved and turning to the other
faction that is condemned, and immediately gives the per- objects of his hatred. (3).
son remorse (5)
The American Psychiatric Association has also considered (2) Biological factors:
sexual deviation including features of severe regressive de- In Many cases, body organ explanations have been consid-
sires, fantasy, or sexual behavior that are associated with ered for sexual deviations. Among the patients studied in
unusual objects, activities or situations resulting in distress the psychiatric clinics, 74% had hormone level disorders,
or major clinical impairment in social, occupational func- 27% had neurologic symptoms, 24%, chromosomal disor-
tioning or other important areas that lasts for at least 6 ders, 9% epilepsy, 4% abnormal EEG, 4% major psychiatric
months. disorders, and 4% had mental retardation. Also there is a
Also, the term sexual deviation means deviation that in- high correlation between sexual deviance and brain abnor-
volves the issue of sexual attraction (3). Sexual deviations malities that first may be a direct result of brain disorders
are disorders that due to them, the individual has fantasies, secondly, abnormal brain may harm the social judgments of
sexual desires or repetitive behaviors that are sexually pro- the person and thirdly the person loses control over social
vocative and include the following: impulses due to the abnormal brain (8).
(1) Non- human subjects
(2) children or other unhappy people Diagnosis:
(3) suffering or humiliation of oneself or sexual partner (3) Criteria for the diagnosis of sexual deviation include: spe-
However, it is important to note that sexual deviations are cial and effective imagination and sense of severe need to
not fleeting desires or fantasies about unusual sexual activ- act on the mentioned fantasies and their impact on individ-
ities, but are disorders that last at least 6 months. Also, pa- ual behavior.
tients with long periods of sexual abnormalities often feel Clinical features can be divided into two groups: 1-charac-
that they have to think about their unusual behavior or do teristics common to all the disorders of the class, 2-those
that, even if they do not actually fulfill their desires or fan- related to specific sub-classes (9).
tasies. Psychological tests have been made for measuring the size
These people do not see any objectives other than achieving of the penis in response to paraphiliac and non-paraphiliac
sexual satisfaction, (6) sexual abnormalities, by definition, that may be useful for diagnosis and treatments. However,
create an intense personal distress or disturb social, occupa- the validity of their diagnosis is controversial because some
tional performance, and other fields of life (3). people are able to inhibit their erectile response. (6)
Etiology: Classification: Sexual deviation includes a wide range.
Different models have discussed the etiology of sexual de- Some sources have cited 9 diagnoses for sexual deviation
viation, some of which are discussed here. (8) including:
(1) Psychological factors: Fetishism
In Freud psychoanalysis and school of "ego psychology", Pedophilia
sexual deviation has proven to be in fact a neurosis structure Exhibitionism
and shows that sexual deviant has accepted the deprivation Voyeurism
of the mother, eternal paradise, and positive oedipal adopted Sexual Masochism
legislation. But still he tries to return to his mother and de- Sexual Sadism
nies his father that cannot promote them and turns into his Transvestic fetishism
modern and individual desire. These sort of desires that are Frotteurism

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 Saadat, SH, A Review on Paraphilias

Paraphilias that are characterized in other ways (NOS) or 1) It is related to real or pretended acts in which creating
Bad Paraphilias physical and psychological suffering for the victim is sex-
Necrophilia ually stimulating.
Zoophilia 2) Over a period of at least 6 months, there are provocative
Partialism behavior and sexual desires related to real actions (pretend-
Telephone Scatalgia ing). During the victim's suffer from mental or physical dis-
Coprophilia orders (verbal humiliation), sexual stimulations also attack
Urophilia the person. 3) Sexual desires, behaviors and fantasies cause
Klismaphilia clinically significant distress or impairment in social, occu-
pational performances or other important areas (3).
Diagnostic criteria for Fetishism
(1) During a 6 months period of sexual desires, extreme Diagnostic criteria for Transverstic fetishism
sensational arousing fantasies, or behaviors related to the 1) during at least a 6 month period, a non-gay man has
function of inanimate objects like womens underwear are repeatedly sexual behaviors, desires or provocative fanta-
seen. sies about cross dressing.
2) Memento objects such as pieces of female clothing used 2) Sexual desires, behaviors and fantasies cause clinically
in cross dressing, it is not like Transvestic Fetishism or a significant distress or impairment in social, occupational
tactile stimulus (such as a vibrator). performances or other important areas (3)
3) Sexual Fantasies, desires and behaviors cause clinically
significant distress or impairment in social, occupational Diagnostic criteria for frotteurism
performances or other important areas.
1) During at least a 6 month period, there is a tendency to
Diagnostic criteria for pedophilia touch or rub the limbs and organs of another person without
a) During a period of at least 16 months of sexually arousing his or her consent.
behaviors, desires or fantasies related to sex with a child or 2) Sexual desires, behaviors and fantasies cause clinically
children under the maturity age, commonly 13. significant distress or impairment in social, occupational
b) The person is at least 16 years old and is at least 5 years performances or other important areas (3).
older than the child or children listed in criterion (b).
Note: Individuals in ages of late teens and having sex with Treatment:
a 12 or 13 year old person is not considered in this disorder. Treatment of sexual deviations due to its coincidence with
[3] psychiatric disorders such as personality disorders and also
other factors such as the shame and modesty of patient and
Diagnostic criteria for Exhibitionism also not talking about the problems has great complexity. In
1) In a 6 month period of arousing fantasies, strong sexual addition to these factors, other factors like the therapist him-
desires and intense and recurrent sexual urges, there are dis- self can cause a problem in the treatment of this disorder. It
playing the person's genitals to an unexpected stranger. is said that one of the good conditions of treatments is health
2) Sexual desires or behaviors create clinically significant care alliances, understanding, empathy and good communi-
distress or impairment in social, occupational performance cation with the patients (8).
or other important areas. (3) Treatment of sexual deviations like other sexual disorders
has a wide variety. In all these treatments four goals are gen-
Diagnostic criteria for Voyearism erally considered, including A) reduction of sexual desires
1) Over a period of at least 6 months, there are recurrent b) giving awareness to patient, c) control of external stim-
strong sexual fantasies and arousing sexual desires or be- uli, d) treatment of concurrent disorders. The treatment of
haviors involving the act of observing an unexpected person sexual deviations also include a wide range of biological
and seeing someone naked or changing clothes or engaged and mental therapies which are as followed (8):
in the sexual act. 1-insight-oriented psychotherapy:
2) Sexual desires or behaviors bring clinically significant It is the most common approach to the treatment of sexual
distress or impairment in social, occupational performances deviations and in this treatment, the patients have an oppor-
or other important areas. tunity to realize their dynamics and incidents causing their
Diagnostic criteria for sexual Masochism sexual deviations. They are also aware of the everyday
A) During a period of at least 6 months there are frequent, events that cause them to act on their impulses. It also al-
strong sexual arousing fantasies, behaviors, desires or ac- lows the patients to resolve their concerns.
tions related to the actual (not pretending) actions of hu- It helps providing a proper way and regaining self-esteem
miliation, beatings, fettered, or any other violent or painful and improving the persons interpersonal skills and finding
action. acceptable techniques for sexual gratification. (9)
B) Sexual desires, behaviors and fantasies cause clinically 2-other mental therapies
significant distress or impairment in social, occupational Psychoanalysis provides the opportunity to track the status
performances or other important areas (3). of the disease from its core. This method becomes effective
through the revival of transmitting emotions and focused re-
Diagnostic criteria for sexual sadism

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 Saadat, SH, A Review on Paraphilias

lationships in sexual deviation. [10] Dynamic psychother- that is severely recurrent. They also believe that it has rela-
apy is probably the most useful treatment. Reducing and tionship with unusual objects, activities or situations and re-
balancing the pressure resulting from deviation and helping sults in distress or clinical impairment in social, occupa-
restoration of other aspects of life is in a way that is free tional performances or other important areas that lasts at
from the interference of deviation as far as possible. It also least for 6 months.
has methods for determining the behavior in coverage for In the etiology of this disorder, we deal with different mod-
detoxification of behavior in case of severe and debilitating els among which Psychoanalysis has fully discussed this is-
deviations. (11) sue. Also according to statistics, biological factors can have
3 - Group Therapy an important role in the development of sexual deviations.
Group Therapy also after insight -oriented psychotherapy is Considering the factors that have been mentioned about the
very common. Group Therapy with specific procedures and etiology of sexual deviation, it can be said that sexual devi-
guidelines and practices are very much useful for patients. ations are a result of biological, psychological and social
4- Drug and hormone therapy: factors. This leads to the fact that the treatment of sexual
If the deviation is associated with schizophrenia or depres- deviation includes a wide range of biological and psycho-
sion, antipsychotics and antidepressants may also be logical treatments. This means much attention should be
needed. Strong sedatives may also be used in serious, ob- paid to concurrent psychiatric disorders of people.
sessed and dangerous deviations (13). In addition to the above factors, there are other factors af-
Antiandrogen drugs in Europe and Medroxyprogesterone fecting treating parafilaic patients such as the therapist him-
Acetate in America have been used experimentally. Cyprot- self.
erone Acetate in deviations with sexual activities have re- Therapeutic alliance, understanding, empathy, and effective
duced hypersexual behavior. communication are one of the most effective factors in treat-
Medroxyprogesterone Acetate appears to be useful in se- ing this disorder.
vere Hypersexuals such as masturbation and sex at every Overall, it can be said that the factors that might not create
opportunity, dangerous, violent and uncontrollable, obses- a good treatment prognosis for a Parafiliac include: lack
sive sex behavior (14). Serotonergic agents such as flouxe- of attention to concurrent disorders, lack of appropriate
tine (Prozac) have been effective in some cases of sexual therapeutic relationships and a lack of a good Patient care
deviation in a limited degree (15). team (including Psychiatristic, psychologist, social
In rare cases, surgery may be considered which consists of worker,).
two interventions:
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