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 Sexual and Gender Identity Disorders

PARAPHILIA

I. INTRODUCTION

The term paraphilia is about 100 years old (the introduction of the term is credited to Friedrich
Salomon Krauss in 1903, but it was more generally suggested/introduced by Wilhelm Stekel in German
in 1908 and later in 1930). Its meaning and definition vary. The word paraphilia is a construction of
two Greek words. The first is para, the meaning of which could vary from “beside, side by side” to
“beyond, past, by” to “abnormal or defective” (e.g., in paranoia) to “irregular, altered.” The other term
-philia means love, friendship, brotherly love, affection. In “modern” language it could mean a whole
spectrum from a friendly feeling toward something or someone, to an abnormal feeling, depending on
the context. Thus, paraphilia in a general sense means love beyond the usual (less derogative term) to
abnormal love or sexuality (whatever the term normal sexuality means).

II. WHAT IS PARAPHILIA?

 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. 
 The unconventional sexual arousal patterns in paraphilias are considered pathologic disorders
only when both of the following apply:
 They are intense and persistent.
 They cause significant distress or impairment in social, occupational, or other important areas
of functioning, or they harm or have the potential to harm others (eg, children, nonconsenting
adults)
 Can revolve around a particular object (children, animals, underwear) or a particular behavior
(inflicting pain, exposing oneself) but is distinguished by a preoccupation with the object or
behavior to the point of being dependent on that object or behavior for sexual gratification.
 Most common in men than in women.
 Paraphilias include sexual behaviors society may view as distasteful, unusual, or abnormal.

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The pattern of disturbed erotic arousal is usually fairly well developed before puberty. At least 3
processes are involved:

 Anxiety or early emotional trauma interferes with normal psychosexual development.

 The standard pattern of arousal is replaced by another pattern, sometimes through early exposure
to highly charged sexual experiences that reinforce the person’s experience of sexual pleasure.
 The pattern of sexual arousal often acquires symbolic and conditioning elements (eg, a fetish
symbolizes the object of arousal but may have been chosen because the fetish was accidentally
associated with sexual curiosity, desire, and excitement).

III. TYPES OF PARAPHILIAS

 Most common are:

Pedophilia 
 psychiatric disorder in which an adult or older adolescent experiences a primary
or exclusive sexual attraction to prepubescent children (13 years old and below)
 a recurrent and intense sexually arousing fantasies, sexual urges, or behaviors
involving sexual activity with a prepubescent child or children.
 can be attracted to both sexes

Exhibitionism 
 getting sexual pleasure by exposure of genitals to strangers.
 feels a need to surprise, shock, or impress his or her victims.
 The victim is almost always a woman or a child of either sex.
 Actual sexual contact is almost never sought, so exhibitionists rarely commit
rape.

Voyeurism 
 is the practice of receiving sexual pleasure from looking at sexual objects or acts
(getting naked, undressing, engaging in sexual activities) mainly from secret.
 peeping tom
Frotteurism 
 touching or rubbing against a nonconsenting person usually in a crowded place.

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  specifically deals with the fantasy or actual behavior of making sexual contact
with others in a public place.
 Usually, this involves rubbing one’s pelvic area or erect penis against a
nonconsenting person.

 Less common.

Fetishism
 Inanimate objects (undergarments, stockings, rubber items, shoes, or boots) are
repeatedly or exclusively used in achieving sexual excitement.
 The person becomes sexually aroused by wearing or touching the object. 
 When the fetish becomes the sole object of sexual desire,  sexual
relationship  often are avoided.

Sexual masochism
 is intentional participation in an activity that involves being humiliated(verbal),
beaten, bound, or otherwise abused to experience sexual excitement.
Sexual sadism
 is the condition of experiencing sexual arousal in response to the extreme pain,
suffering or humiliation of others.
 psychological/physical

Transvestic disorder
 sexual arousal is strongly associated with the act of dressing in clothes of the
opposite sex.
IV. CAUSES

 It is unclear what causes paraphilic disorders to develop.

 Psychoanalysts theorize that an individual with a paraphilia is repeating or reverting to a sexual
habit that arose early in life.
 Behaviorists suggest that paraphilias begin through a process of conditioning: Nonsexual objects
can become sexually arousing if they are repeatedly associated with pleasurable sexual activity
or particular sexual acts (such as peeping, exhibiting, bestiality) that provide especially intense
erotic pleasure can lead the person to prefer that behavior.

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  In some cases there seems to be a predisposing factor, such as difficulty forming person-to-person
relationships.

V. RISK FACTORS

 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.
 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.

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.

VI. SYMPTOMS

 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.
 In order for a paraphilia to be diagnosed, the interest must be magnified to the point of
psychological dependence, and must cause the individual significant distress or cause harm to a
non-consenting party.

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VII. TREATMENT

Cognitive Behavioral

 Aversion therapy - for example, involves using negative stimuli to reduce or eliminate a
behavior. 
 Covert sensitization entails the patient relaxing, visualizing scenes of deviant behavior
followed by a negative event, such as getting his penis stuck in the zipper of his pants. 
 Assisted aversive conditioning is similar to covert sensitization except the negative event is
made real, most likely in the form of a foul odor pumped in the air by the therapist.
  Orgasmic reconditioning involves fantasizing about the paraphilic behavior while
masturbating, and at the moment just before orgasm, switching the fantasy to a more
acceptable stimulus, such as one’s partner. 
 Vicarious sensitization entails showing videotapes of deviant behaviors and their
consequences, such as victims describing desired revenge or perhaps even watching surgical
castrations.
 Empathy training involves helping the offender take on the perspective of the victim and
better identify with them, in order to understand the harm that has been done.

Drugs

 Antiandrogens:
 drastically lower testosterone levels temporarily.
 lowers sex drive in males
 reduces the frequency of mental imagery of sexually arousing scenes. 
 Antidepressants such as fluoxetine (Prozac) have also successfully decreased sex drive but
have not effectively targeted sexual fantasies.

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VIII. CASE

Clinical Presentation 

A 13-year-old boy presented with his mother due to concern of sexual interest in woman’s shoes and
feet. 

History of Present Illness 

 The mother reported that she first recognized his sexual interest in woman’s shoes six months ago
 The mother saw him while he was rubbing and smelling the shoes in a fascinated manner
 Son Making excuses to go out (takes shoes from neighborhood)
 Becomes restless and irritable
 Mother caught her son doing funny business in the toilet while keeping and rubbing her shoes in
his hands.
 Discovered videos of young woman’s feet with or without shoes

Developmental & Family History

 His developmental milestones were within normal limits. 

 The mother and the child denied any sexual abuse or exposure history. 
 The mother reported that he used to love his 4-years-old sister’s naked feet since her infancy.
 He was helping his sister to take her socks off and then rubbing and smelling her feet. He
expressed his admire several times saying, ‘Mom look at them, what lovely things they are’. 
 His academic achievement was below normal
 He was not a popular boy among his peers.
 He has spent most of his time on television, computer games or play-station. 
 There is no past or current history of sexual paraphilias in the family, including fetishism. There
is no significant history of any psychiatric or neurological disorders in the family. 

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Clinical Assessment & Follow Up

 It was found out that the patient has ADHD and was not compliant to his medication
 His cooperation and motivation for treatment (psychotherapeutic approach) was poor
 His sexual interest/behavior continued
 He reported that he used to masturbate three or four times in a week.
 He mostly needed his fetish object-female shoes- and he defined his masturbation as less
satisfactory without fetish object.
 He reported that he was rubbing, smelling and touching shoe to his genitalia while he was
imagining erotic contents during masturbation.
 He defined his fetishistic interest as ‘not so much abnormal and not harmful to anybody’. 
 Planned treatment: orgasmic reconditioning
 However he was lost to follow up again. The mother reported on a phone call six weeks later that
his fetishistic interest seems to be continued, but no unusual event happened. He did not use his
medications regularly. 

IX. CRTITICAL ANALYSIS

Having paraphilic fantasies or behavior, however, does not always mean the person has a mental
illness. The fantasies and behaviors can exist in less severe forms that are not dysfunctional in any way,
do not impede the development of healthy relationships, do not harm the individual or others, and do not
entail criminal offenses. They may be limited to fantasy during masturbation or intercourse with a partner.

X. REFERENCES:

https://www.msdmanuals.com/professional/psychiatric-disorders/sexuality,-gender-dysphoria,-and-
paraphilias/overview-of-paraphilic-disorders

https://www.psychologytoday.com/intl/conditions/paraphilias

https://www.medicinenet.com/paraphilia/article.htm#what_are_causes_and_risk_factors_for_paraphilia

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http://www.dusunenadamdergisi.org/ing/fArticledetails.aspx?MkID=942

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