(See E Sexual dysfunction in Chapter 7, pp. 345-9.)
DSM-5 defines paraphilias as conditions in which there is intense and persistent sexual interest, other than sexual interest in genital stimulation or preparatory fondling with phenotypically normal, physically mature, consenting human partners. The abnormality of the sexual interest lies in: (a) its object, (b) its intensity and fixity, (c) the process of engagement with the object, and (d) the absence of consent in practices that involve humans. The object of a paraphilia may be human or non-human; the process of a paraphilia may also involve the treatment of human persons as objects or things, rather than erotic partners.
Although most paraphilias are not synonymous with statutory crimes, and generally the overt intention of the paraphilic behaviour is to achieve sexual arousal, much paraphilic activity is also associated with an intention to cause hurt, distress, fear, or shame in others. When the paraphilic activity is associated with hostility and threat behaviours, this will bring the perpetrators to the attention of the criminal law, even if the paraphilia itself is not a crime.
DSM-5 specifies eight specific paraphilias and paraphilic disorders (see below), although many more have been described in the literature.
DSM-5 paraphilic disorders
- • Voyeuristic disorder (covert observation of others in private activities)
- • Exhibitionistic disorder (exposing the genitals)
- • Frotteuristic disorder (touching or rubbing against a non-consenting individual)
- • Sexual masochism disorder (undergoing humiliation, control, or suffering)
- • Sexual sadism disorder (inflicting humiliation, control, or suffering)
- • Paedophilic disorder (sexual arousal to images or contact with vulnerable or dependent children which may include involvement in child pornography)
- • Fetishistic disorder (using non-living objects or having a highly specific focus on non-genital body parts)
- • Transvestic disorder (engaging in sexually arousing cross-dressing)
- • Other specified paraphilic disorder (includes zoophilia (animals), scatalogia (obscene phone calls), necrophilia (corpses), coprophilia (faeces), klismaphalia (enemas), urophilia (urine)).
The definition of paraphilias is essentially normative, i.e. with reference to a so-called ‘normal’ sexuality. For this reason, defining paraphilias has historically been fraught with ethical confusion, cultural controversy, and legal debate. There is a general lack of knowledge, as well as disagreement, about what constitutes the full range of ‘normal’ human sexual behaviour; it is likely that many adults participate consensually in practices that might be considered harmful or aberrant by others but never seek any psychiatric or psychological help, until/unless they become identified as deviant by others. Significant difficulties remain with the classification of paraphilias, especially the the relationship between paraphilias, criminality, and sexual offending, and the lack of good-quality empirical research to inform the validity and reliability of diagnostic systems such as the DSM.
DSM-5 differentiates between atypical human behavior, that is not associated with a mental disorder or harm to others, and atypical behaviour that is or may be associated with a range of psychopathologies and causes harm. A distinction is made between a paraphilia (atypical sexual interest or behaviour, which may be associated with a variety of mental disorders, or none) and a paraphilic disorder (which gives rise to a mental disorder). Thus, to be diagnosed with a paraphilic disorder, the person must:
- • Feel personal distress about their interest, not merely distress resulting from society’s disapproval, and/or
- • Have a sexual desire or behaviour that involves another person’s psychological distress, injury, or death, or a desire for sexual behaviors involving unwilling persons or persons unable to give legal consent.