There are many types of atypical sexual behaviors, defined as sexual activities that do not commonly occur in society. These behaviors are motivated by paraphilias, defined as recurrent sexual fantasies and urges to engage in unusual sexual activities.

There does not at present appear to be generally accepted agreement among mental health professionals as to the etiology for each of the many different kinds of paraphilias. There may be clusters of personality traits that correlate with the presence of paraphilias, as well as a history of life events that interact with these personality traits in ways that contribute to the development of paraphilias. However, the exact mechanisms through which the paraphilias develop currently remain to some degree a mystery.

For clinicians who specialize in the treatment of sexual issues, this is an important – and difficult – understanding. Without clear information about the causes of a set of urges and behaviors, it can be more difficult to devise change strategies for those behaviors.

Treatment for paraphilias should probably only be attempted by mental health professionals who possess adequate education and training in this specialty area. The details of what would be involved in such treatment is outside the purview of this course. However, it is important for clinicians to possess at least a basic knowledge of paraphilias, as clients with paraphilias may appear from time to time in your practice.

In the DSM-5, there has been a significant change to how paraphilias have been conceptualized. In the DSM-5, certain paraphilias are not automatically considered mental disorders and are not automatically considered to warrant clinical intervention. In order for a paraphilia to be considered a mental disorder under DSM-5, the paraphilia must 1) be causing distress or impairment to the person exhibiting the paraphilia, and/or 2) the paraphilia must be presenting itself in a way that can create personal harm or the risk of harm to others.
 
Paraphilias are diagnosed by the presence of two criteria. Criterion A specifies the nature of the paraphilia, and Criterion B specifies whether the paraphilia causes distress or impairment to the person with the paraphilia, and/or creates harm or the risk of harm to others. Only those individuals who meet both Criterion A and Criterion B would now be diagnosed with a Paraphilic Disorder.

People whose sexual behaviors include paraphilias in the absence of these two criteria will no longer be automatically labeled as sexually deviant. While their sexual preferences are non-normative and different than socially mainstream behaviors, alternative or different sexual behaviors will no longer automatically demand a diagnosis.

Paraphilias are divided into two general types: non-coercive paraphilias (partners are willing participants) and coercive paraphilias (individuals are sexually aroused by fantasies or urges to inflict pain, either physical or emotional, on other people). Therapists may have varying degrees of willingness and expertise in working with all or certain of these, particularly if they involve coercion.

Generally, non-coercive paraphilias are harmful only if they bother the person’s partner, serve as a substitute for human contact, are dangerous, or become the only method a person has for achieving sexual pleasure. Coercive paraphilias can certainly be dangerous if a person acts out a violent fantasy on someone who is not a willing participant (University of California at Santa Barbara, 2008b).

For an accurate diagnosis to be made concerning whether a paraphilia is considered a disorder or simply sexual difference, the clinician must determine that distress or impairment is occurring to the client or harm is occurring to others from the presence of the paraphilia.

As noted very early in this course, one of the most important considerations in handling the sexual concerns of our clients is an ability to examine the material presented in a secure, confident and non-judgmental manner. For clinicians who have not had much experience with paraphilias, this can represent a difficult challenge.

The decision by the committee responsible for the DSM-5 to remove the label of sexual deviancy from the non-traditional sexual practices represented by the paraphilias does not mean that our culture as a whole is comfortable in viewing paraphilias as falling within the range of normal and accepted sexual practices.

To the degree that we clinicians have been raised within the larger culture, we are likely to have absorbed a significant degree of negative bias with regard to non-traditional sexual practices. Our initial reaction when a client discusses their sexual life and the existence of a paraphilia may reveal our own level of discomfort – unless there has been some preparation on the part of the clinician to address this discomfort.

This can be viewed as just another area in which clinicians must learn to become aware, knowledgeable, and, ultimately, skilled in handling issues of cultural diversity in order to “meet the client where he/she is at”. However, because sex and sexuality are so emotionally loaded within our culture, this can be a more difficult emotional challenge for clinicians that confronting many other areas dealing with cultural diversity.

Being confronted with a paraphilia for the first time as a clinician can be a jarring experience. It can push us to the limit in terms of maintaining control over our initial emotional response. However, the capacity to exercise emotional control is one of our most important core skills as a clinician. We must prepare a context in which the client feels safe, not judged. Without that capacity, we cannot invite the client into a relationship in which we can explore with him/her the problems – sexual or otherwise – that are creating the need for treatment.

Towards this end, it is helpful to increase our own awareness and knowledge about paraphilias. In addition to the material in this course, the University of California at Santa Barbara (2008) has an excellent website that gives information on each of the following paraphilias. See http://www.soc.ucsb.edu/sexinfo

NON-COERCIVE PARAPHILIAS

Fetishism

Fetishism is a paraphilia that involves a person’s becoming sexually aroused by inanimate objects. Common objects are shoes and underwear. Without these specific objects, present in either reality or fantasy, the person is often unable to become aroused. Males are far more likely than females to develop fetishes.

There are two different types of fetishes. In a form fetish, the object itself (e.g. shoes, underwear, diapers) is important. In a media fetish, the arousing factor is the material from which the object is made (e.g. rubber or leather (UCSB, 2008c).

Sadomasochism

Sadomasochism can actually be divided into two different paraphilias, sadism and masochism. Sadists experience sexual pleasure and arousal from inflicting some degree of pain (or mock pain), suffering, or humiliation on others. The majority of the time, this activity occurs with a willing partner.

The counterpart to the sadist is the masochist. A masochist experiences sexual pleasure and arousal from being the recipient of the pain, suffering, or humiliation. Sadomasochism, or S&M, is fairly common in its less extreme forms.


Sexuality Factoid

14% of men and 11% of women have had some sexual experience with sadomasochism

Source: Janus, S., and Janus, C. The Janus Report on Sexual Behavior. 1993. New York: John Wiley & Sons


Bondage and discipline, or B&D, is a type of S&M where one partner ties or restrains the other and then pretends to "punish" or "discipline" the person who is in bondage. This activity often does not involve any physical pain. Another type of activity that typically does not involve actual violence is Dominance and Submission. In this activity, participants act out roles such as the teacher and naughty student or the master and slave (UCSB, 2008d).

There is some very preliminary research that has found some degree of correlation between a history of being spanked as a child and increased interest in masochistic sexual relationships (Straus, MA, 2001) However, additional research in this area must be conducted for a more definitive picture to emerge concerning this relationship.


Coprophilia and Urophilia

Coprophilia is a paraphilia in which the individual derives sexual gratification from activities involving feces. Slang terms for this activity include hard sports, brown showers, scat fetishism, scat play, and scatophilia. Contact with feces should be kept to a minimum due to the many pathogens contained in feces (UCSB, 2008e).

Urophilia involves deriving sexual excitement from urine, as when doing "golden showers" or “watersports” (urinating on or in front of another person) (UCSB, 2008f). These two paraphilias are most often acted out with a willing participant, although they can take place without a person’s consent.

Transvestism and Crossdressing

Transvestism involves dressing like a member of the opposite gender. This dressing may be an expression of transgender feelings or may involve experiencing sexual arousal and pleasure.

Today the term transvestic fetishism refers to dressing for sexual arousal and pleasure. Males are more likely than females to sexualize crossdressing and do it for sexual arousal. Female crossdressers may be less obvious, since women are allowed to wear male clothing in our society.

Most crossdressers identify themselves as heterosexual (UCSB, 2008g). Interestingly, a male client who was a crossdresser requested to come to counseling sessions dressed as a female, because he said he felt more emotionally open when he was dressed as a woman.

Autoerotic Asphyxiophilia

Some people learn that they can heighten their sexual arousal and orgasmic pleasure by cutting off their oxygen supply via strangulation or suffocation. People who get "hooked" on this practice develop the paraphilia called autoerotic asphyxiophilia.

The practice can be done alone or with a partner. Either way, it is very dangerous, because people may accidentally kill themselves if they lose consciousness and are not able to release themselves from the strangulation device they have created (UCSB, 2008h).

The practice sometimes occurs in an escalating domino pattern among adolescents. A young person may be found hanging and his parents are left having to wonder if he committed suicide OR if he accidentally killed himself while masturbating.

COERCIVE PARAPHILIAS

Exhibitionism

Exhibitionism is a paraphilia in which a person (usually a man) obtains sexual pleasure from exposing his or her genitals to strangers (usually women), generally in a public place. The exhibitionist derives pleasure from the expressions of shock or disgust on his victim’s face.

Many exhibitionists maintain their innocence in doing this behavior (“I was in my own apartment in front of a window with an open curtain—they didn’t have to look”), and they say their victims enjoy the experience. Exhibitionists often masturbate before or after exposing themselves, while recalling the event (UCSB, 2008i).


Frotteurism

A frotteur intentionally rubs up against people and derives sexual pleasure by touching them in sexual ways without their consent and sometimes without their knowledge. These types of activities commonly occur in crowded public places, such as elevators, where the victim might assume the touching was accidental (UCSB, 2008j).

Scatolophilia

Scatolophilia is the clinical term for obscene phone calls. People who make these types of calls (scatolophiles) typically make sexual suggestions and receive sexual pleasure from the shock and discomfort of the people they call.

Scatolophiles may attempt to keep their victim on the phone through the use of persuasive manipulation or frightening threats. The behavior has decreased in recent years due to the increasing use of phone technologies such as caller ID (UCSB, 2008k).

Zoophilia

Zoophilia is the paraphilia in which a person becomes sexually aroused by fantasies of or actual sexual contact with an animal. The practice of having sex with animals is commonly known as "bestiality."

Most males with zoophilia tend to direct their activities to farm animals, whereas most females engage in sexual behavior with household pets. Bestiality is considered a form of animal cruelty, and in many parts of the world it is illegal (UCSB, 2008l).

Necrophilia

Necrophilia is the paraphilia in which an individual (known as a necrophile or a necrophiliac) becomes sexually aroused by fantasies of having, or actually having, sexual contact with a dead person. This sexual contact could range from intercourse, to oral sex, or simply masturbation in the presence of a corpse. Necrophilia is relatively rare (UCSB, 2008m).

Voyeurism

A voyeur is a person who derives sexual pleasure from watching other people who are naked and who are not aware they are being viewed. Heightened excitement usually comes from the fact that the person is not aware she or he is being watched. Voyeurs, usually males, are commonly known as "Peeping Toms." An example of a voyeur could be someone who spies on girls showering or dressing in a locker room.

Although many average people derive some sexual arousal from accidentally seeing an attractive person naked, peeping and watching become atypical when a person repeatedly seeks or resorts to peeping and eroticizes these experiences by masturbating during the viewing or afterwards. Voyeurism is usually an illegal act (UCSB, 2008n).

A slight variation of voyeurism is scoptophilia. In this paraphilia, sexual pleasure is derived from watching other people engaged in sexual acts or viewing other people’s genitals without their knowledge.

A scoptophile’s urges for these activities would not be satisfied by a pornographic movie or going to a strip club, because these activities lack the exciting elements of risk and forbiddenness (UCSB, 2008n).

Pedophilia

A pedophile is a person who derives sexual pleasure from fantasizing or engaging in sexual behavior with prepubescent children. Pedophiles are usually men, and they can be attracted to male children, female children, or both. Pedophilic behavior is child molestation and is illegal in every state of the USA.

Many people equate pedophilia and homosexuality, but these are NOT the same. The distinction is age. For example, adult males who are attracted to other adult males are homosexual; adult males who are attracted to children are pedophiles.

The causes of pedophilia are unknown, and current treatment modalities have had limited success. Pharmaceutical treatments with anti-androgens (drugs that reduce male sex hormone levels) and medications that increase serotonin (e.g., Prozac) continue to be investigated, and cognitive-behavioral therapy models, frequently accompanied by aversive and positive conditioning approaches, have demonstrated effectiveness in some cases (Psychology Today, 2006; WebMD, 2002).

Child Sexual Abuse/Molestation

Childhood sexual abuse refers to sexual relations that occur between a child and an immediate family member, any other adult, or an older child. This type of abuse is a problem all over the world. Females are most commonly the victims of child molestation, although males can also be victimized.

Estimates are that one in three girls and one in four to six boys are sexually abused before the age of 18. Abuse behaviors can include verbal abuse, exposure to sexual acts or pornography, genital touching, and vaginal or anal penetration. The vast majority of abusers (80%) are men, and usually these men are relatives or family friends of the victim (Parents United International, 2008).

Sexuality Factoid

There is evidence emerging that as many as one in three incidents of child sexual abuse are not remembered by adults who experienced them, and that the younger the child was at the time of the abuse, and the closer the relationship to the abuser, the more likely one is not to remember.

Source: Jim Hopper, Ph.D., Child Abuse Statistics, Research and Resources. www.jimhopper.com, 2004


Incest

Incest refers to sexual activity between close family members, specifically those family members who are not allowed to marry, e.g. parents and children, brothers and sisters, grandparents and grandchildren, aunts and nephews, uncles and nieces, and half brothers and half sisters. Incest is forbidden in a majority of cultures, and in most Western societies is illegal and punishable by law.

Authorities believe that because many cases of incest are unreported, the incidence of incest is more common than current statistics indicate (UCSB, 2008o).

Sex Offenders

A sex offender is a person who has been convicted of a sex crime, i.e. a sexual act which is prohibited by law (e.g. rape, molestation, sexual harassment, pornography production or distribution, downloading child pornography from the internet, etc.). Convicted sex offenders are often incarcerated for varying lengths of time and are required to register on the local sex offender registry, a database open to the public. Many do not.

In the past, treatment of sex offenders consisted largely of pharmacologic therapies, typically with anti-androgens and SSRIs. In recent years, new types of treatment programs have shown effectiveness in reducing recidivism rates for sex offenders. These programs offer psychological treatments with individual and group therapy, using a variety of modalities aimed at relapse prevention (Kersting, 2003). Ideally the treatment of sex offenders should be conducted by persons with specialized training in this area.

Paraphilias Updates and Summary Sheets

For the benefit of trainees, we will present some additional detail in this area, with summary sheets for each of the paraphilic disorders found in the DSM-5.

Voyeuristic Disorder Summary Page

DSM-5 Code: F65.3 Voyeuristic Disorder


Common Specifiers:
• In a controlled environment
• In full remission

Etiology of Voyeuristic Disorder: The exact cause of this disorder is not yet fully understood. While various theories have been proposed, none have been sufficiently explanatory to be considered evidence based. Some theories propose that the viewing of erotic materials is intrinsically interesting and rewarding, but most persons develop sufficient degrees of impulse control and internalized pro-social values to avoid violating the privacy of others in ways that would constitute nonconsensual instances of voyeurism. There are some theories that assume that there is a reinforcing quality to the successful completion of a sexually gratifying act that will perpetuate the repetition of the act. Accordingly, this disorder may occur concurrently with problems with personality formation, impulse control problems – including attention deficit hyperactivity disorder - and difficulties with intimate adult sexual relationships. There are also theories that persons with this disorder may suffer from some form of hyper-sexuality.
Prevalence: Prevalence rates for this disorder are uncertain, however they are estimated to be much higher than one might imagine based upon police reports for incidences that have led to legal action. The American Psychiatric Association reports that the prevalence estimates are a maximum of 12% for men and 4% for women. One 1991 study noted that up to 42% of men had engaged in voyeuristic behaviors at some point in time, however this includes men at all stages of psychosexual development and does not differentiate those who met full clinical criteria for the disorder.
Clinical Manifestations: Clinical manifestations include the compulsive seeking out of opportunities to view unsuspecting individuals, usually strangers, who are naked, in the process of disrobing, or engaging in sexual activity, accompanied by a significant degree of sexual arousal. This must occur in adults over age 18, for a period exceeding 6 months and accompanied by emotional distress or resulting in nonconsensual violations of the privacy of others.
Best Practices Diagnostic Approaches: An accurate diagnosis of Voyeuristic Disorder will generally include a careful diagnostic interview that performs a comprehensive mental status screening and gathers a thorough history of the client, including a detailed history of psychosexual development and disturbances thereof, voyeuristic episodes, and any intersection with the legal system. Because this disorder is frequently comorbid with impulse control disorders, compulsive disorders, anxiety, depression, and personality disorders, the assessment and diagnostic process should include gathering of information about family history, a history of parenting practices and attachment concerns, a family history of emotional, physical, and/or sexual abuse, violence, and other kinds of family disruptions and dysfunction. Any family history of impulse control or compulsive disorders, anxiety or depressive disorders, or substance use disorders should also be gathered. Referral to a specialist in sexual and paraphilic disorders is also recommended, as this disorder may be difficult to assess, diagnose and treat.
Best Practices Treatment Approaches: Treatment approaches for Voyeuristic Disorder typically include CBT oriented therapy to modify their behavioral choices, combined with medication, which may include SSRI medications to reduce the compulsive aspect of this condition, perhaps combined with medications that reduce their sexual urges. It is not unusual for treatment to be provided concurrently with the participation of the legal system. If secondary or comorbid conditions exist that may contribute to the expression of this condition, then treatment would also involve addressing those other conditions. Treatment for this disorder should only be attempted by persons who have extensive knowledge and skill in treatment of this disorder.
Other Conditions to Rule Out: This disorder must be distinguished from other kinds of impulse control and compulsive disorder, taking into the consideration that Voyeuristic Disorder may occur comorbidly with many other impulse control disorders and compulsive disorders. This disorder must also be distinguished from the Cluster B Personality Disorders, while also taking into consideration that these disorders may also exist comorbidly with Voyeuristic Disorder. This disorder must also be differentiated from substance use disorders that create disturbances in judgment and/or impulse control and lead to instances of voyeurism while intoxicated.
Comments: This disorder should generally not be diagnosed by Master’s level mental health clinicians unless that person is a specialist in paraphilias and this specific disorder. Treatment for this disorder will often involve coordination with the legal system.



Exhibitionistic Disorder Summary Page

DSM-5 Code: F65.2 Exhibitionistic Disorder

Common Specifiers:
• In a controlled environment
• In full remission
• Sexually aroused by exposing genitals to prepubertal children
• Sexually aroused by exposing genitals to physically mature individuals
• Sexually aroused by exposing genitals to prepubertal children and physically mature individuals

Etiology of Exhibitionistic Disorder: The exact cause of this disorder is not yet fully understood. While various theories have been proposed, none have been sufficiently explanatory to be considered evidence based. There are some theories that assume that there is a reinforcing quality to the successful completion of a sexually gratifying act that will perpetuate the repetition of the act. Because this disorder is frequently comorbid with antisocial personality disorder, some theorists believe that it is one of many manifestations of problems with socialized impulse control, as it allows for sexual self-gratification without concern for the experience of the target of the behavior. There are also theories that persons with this disorder may suffer from some form of hyper-sexuality, and/or may have been the victims of sexual and emotional abuse during childhood.
Prevalence: Prevalence rates for this disorder are reported by the American Psychiatric Association to be approximately 2-4%.
Clinical Manifestations: Clinical manifestations include the compulsive seeking out of opportunities to present one’s genitals or one’s sexual activities to unsuspecting, non-consenting individuals, usually strangers, accompanied by a significant degree of sexual arousal. This must occur for a period exceeding 6 months and be accompanied by emotional distress or result in nonconsensual violations of the privacy of others.
Best Practices Diagnostic Approaches: An accurate diagnosis of Exhibitionistic Disorder will generally include a careful diagnostic interview that performs a comprehensive mental status screening and gathers a thorough history of the client, including a detailed history of psychosexual development and disturbances thereof, exhibitionistic episodes, and any intersection with the legal system. Because this disorder is frequently comorbid with impulse control disorders, compulsive disorders, anxiety, depression, and personality disorders, the assessment and diagnostic process should include gathering of information about family history, a history of parenting practices and attachment concerns, a family history of emotional, physical, and/or sexual abuse, violence, and other kinds of family disruptions and dysfunction. Because substance abuse also frequently is comorbid, a complete substance use history should be taken. Any family history of impulse control or compulsive disorders, anxiety or depressive disorders, or substance use disorders should also be gathered. Examination of any history of a criminal record should also be conducted. Referral to a specialist in sexual and paraphilic disorders is also recommended, as this disorder may be difficult to assess, diagnose and treat.
Best Practices Treatment Approaches: Treatment approaches for Exhibitionistic Disorder typically include CBT oriented therapy to modify their behavioral choices, combined with medication, which may include SSRI medications to reduce the compulsive aspect of this condition, perhaps combined with medications that reduce their sexual urges. It is not unusual for treatment to be provided concurrently with the participation of the legal system. If secondary or comorbid conditions exist that may contribute to the expression of this condition, then treatment would also involve addressing those other conditions. Treatment for this disorder should only be attempted by persons who have extensive knowledge and skill in treatment of this disorder.
Other Conditions to Rule Out: This disorder must be distinguished from other kinds of impulse control and compulsive disorder, taking into the consideration that Exhibitionistic Disorder may occur comorbidly with the Cluster B Personality Disorders, most notably Antisocial Personality Disorder, while also taking into consideration that this disorder may also exist comorbidly with Exhibitionistic Disorder. This disorder must also be differentiated from substance use disorders that create disturbances in judgment and/or impulse control and lead to instances of voyeurism while intoxicated.
Comments: This disorder should generally not be diagnosed by Master’s level mental health clinicians unless that person is a specialist in paraphilias and this specific disorder. Treatment for this disorder will often involve coordination with the legal system, as people with this disorder do not typically seek out treatment without external pressure from the legal system and/or family members who are concerned about the behaviors.


Frotteuristic Disorder Summary Page

DSM-5 Code: F65.81 Frotteuristic Disorder

Common Specifiers:
• In a controlled environment
• In full remission

Etiology of Frotteuristic Disorder: The exact cause of this disorder is not yet fully understood. While various theories have been proposed, none have been sufficiently explanatory to be considered evidence based. There are some theories that assume that there is a reinforcing quality to the successful completion of a sexually gratifying act that will perpetuate the repetition of the act. Some theories propose that the engaging in sexually gratifying actions is intrinsically interesting and rewarding, but most persons develop sufficient degrees of impulse control and internalized pro-social values to avoid violating the personal rights and boundaries of others in ways that would constitute nonconsensual instances of frotteurism. Accordingly, this disorder may occur concurrently with problems with personality formation, impulse control problems – including attention deficit hyperactivity disorder - and difficulties with intimate adult sexual relationships. There are also theories that persons with this disorder may suffer from some form of hyper-sexuality.
Prevalence: Prevalence rates for this disorder are unknown, but as reported by the American Psychiatric Association they are believed to be below 10%. The vast majority of persons with this disorder are male.
Clinical Manifestations: Clinical manifestations include the compulsive seeking out of opportunities to rub one’s genitals up against unsuspecting, nonconsenting individuals or fondle the breasts, buttocks, or genitals of unsuspecting, nonconsenting individuals, usually strangers, in public settings where opportunities exist to either vacate the location of the offense, or excuse the action as accidental, accompanied by a significant degree of sexual arousal. This must occur for a period exceeding 6 months and accompanied by emotional distress or resulting in nonconsensual violations of the privacy of others.
Best Practices Diagnostic Approaches: An accurate diagnosis of Frotteuristic Disorder will generally include a careful diagnostic interview that performs a comprehensive mental status screening and gathers a thorough history of the client, including a detailed history of psychosexual development and disturbances thereof, frotteuristic episodes, and any intersection with the legal system. Because this disorder is frequently comorbid with other paraphilic disorders, and antisocial personality disorder and conduct disorder, the assessment and diagnostic process should include gathering of information about family history, a history of parenting practices and attachment concerns, a family history of emotional, physical, and/or sexual abuse, violence, and other kinds of family disruptions and dysfunction. Because substance abuse also frequently is comorbid, a complete substance use history should be taken. A thorough history of mood disorders and any family history of mood disorders should also be gathered. Examination of any history of a criminal record should also be conducted. Referral to a specialist in sexual and paraphilic disorders is also recommended, as this disorder may be difficult to assess, diagnose and treat.
Best Practices Treatment Approaches: Treatment approaches for Frotteuristic Disorder typically include CBT oriented therapy to modify their behavioral choices, combined with medication, which may include SSRI medications to reduce the compulsive aspect of this condition, perhaps combined with medications that reduce their sexual urges. It is not unusual for treatment to be provided concurrently with the participation of the legal system. If secondary or comorbid conditions exist that may contribute to the expression of this condition, then treatment would also involve addressing those other conditions. Treatment for this disorder should only be attempted by persons who have extensive knowledge and skill in treatment of this disorder.
Other Conditions to Rule Out: This disorder must be distinguished from other kinds of impulse control and compulsive disorders, taking into the consideration that Frotteuristic Disorder may occur comorbidly with other impulse control disorders and compulsive disorders. This disorder must also be distinguished from the Cluster B Personality Disorders, while also taking into consideration that these disorders may also exist comorbidly with Frotteuristic Disorder. This disorder must also be differentiated from substance use disorders that create disturbances in judgment and/or impulse control and lead to instances of frotteurisim while intoxicated. If instances of frotteurism occur only during periods of intoxication, then the person may not meet criteria for this diagnosis.
Comments: This disorder should generally not be diagnosed by Master’s level mental health clinicians unless that person is a specialist in paraphilias and this specific disorder. Treatment for this disorder will often involve coordination with the legal system, as people with this disorder do not typically seek out treatment without external pressure from the legal system and/or family members who are concerned about the behaviors.


Sexual Masochism Disorder Summary Page

DSM-5 Code: F65.51 Sexual Masochism Disorder

Common Specifiers:
• In a controlled environment
• In full remission
• With asphixiophilia

Etiology of Sexual Masochism Disorder: The exact cause of this disorder is not yet fully understood. While various theories have been proposed, none have been sufficiently explanatory to be considered evidence based. Some theories propose sexual masochism expresses a fundamental conflict around issues related to sexuality, with repression of the urges and needs that are in conflict causing increased arousal and stimulation when they are ultimately expressed, creating a context for reinforcement of the expressed behaviors. Other researchers have reported some potential correlation between a history of corporal punishment and nontraditional sexual practices, including Bondage and Discipline, which has connections to sexual masochism and sexual sadism. It is thought that the association between love for a caretaker and corporal punishment may establish conditions for the development of an emotional connection between pain and intimate relations.
Prevalence: Prevalence rates for this disorder are unknown, but estimated to be approximately 2.2% for males and 1.3% for females.
Clinical Manifestations: Clinical manifestations include the sexual arousal from the act of being humiliated, bound or otherwise made to suffer, as manifested by fantasies, urges, or behaviors, for a period exceeding 6 months and accompanied by emotional distress or resulting in impairment in social, occupational, and other important areas of function. This clinical definition must be distinguished from sexual behaviors of a similar nature that do not result in distress or impairments in functioning. A significant component of Sexual Masochism Disorder consists of an erotic interest in a substantial degree of power discrepancy between partners.
Best Practices Diagnostic Approaches: An accurate diagnosis of Sexual Masochism Disorder will generally include a careful diagnostic interview that performs a comprehensive mental status screening and gathers a thorough history of the client, including a detailed history of psychosexual development and disturbances thereof, and sadomasochistic episodes. The assessment and diagnostic process should also include gathering of information about family history, a history of parenting practices and attachment concerns, including the use of corporal punishment, a family history of emotional, physical, and/or sexual abuse, violence, and other kinds of family disruptions and dysfunction. Any family history of impulse control or compulsive disorders, anxiety or depressive disorders, or substance use disorders should also be gathered. Referral to a specialist in sexual and paraphilic disorders is also recommended, as this disorder may be difficult to assess, diagnose and treat.
Best Practices Treatment Approaches: Treatment approaches for Sexual Masochism Disorder typically include CBT and/or insight oriented therapy to modify their behavioral choices and the action urges that underlie the disordered behavioral choices, combined with medication, which may include SSRI medications to reduce the compulsive aspect of this condition, perhaps combined with medications that reduce their sexual urgesIf secondary or comorbid conditions exist that may contribute to the expression of this condition, then treatment would also involve addressing those other conditions. Treatment for this disorder should only be attempted by persons who have extensive knowledge and skill in treatment of this disorder.
Other Conditions to Rule Out: This disorder must first be distinguished from activities engaged in as part of the “kink” and BDSM subculture, the distinguishing feature consisting of the absence of emotional distress or impairments in major life roles. This disorder must also be distinguished from Borderline or Dependent Personality Disorders where the willingness to tolerate abusive behavior is part of a disordered relationship pattern. This disorder must also be distinguished from Intimate Partner Violence with PTSD or a Dissociative Disorder whereby the abused partner is unable to resist or escape from an abusive relationship. This disorder must also be differentiated from substance use disorders that create disturbances in judgment and/or impulse control and lead to instances of engaging in abusive interactions while intoxicated.
Comments: This disorder should generally not be diagnosed by Master’s level mental health clinicians unless that person is a specialist in paraphilias and this specific disorder and familiar with the sub-cultural associated with “kink” and BDSM activities. There are substantial physical and medical risks associated with this disorder, as participants in the associated behaviors may endure physical injury from beatings, and reductions in oxygen intake from auto-erotic asphyxia due to neck compression, plastic bags, and/or chemicals that reduce oxygen intake. There are numerous occasions in which asphyxiation leads to death in the midst of sexual actitivies.


Sexual Sadism Disorder Summary Page

DSM-5 Code: F65.52 Sexual Sadism Disorder

Common Specifiers:
• In a controlled environment
• In full remission

Etiology of Sexual Sadism Disorder: The exact cause of this disorder is not yet fully understood. While various theories have been proposed, none have been sufficiently explanatory to be considered evidence based. Some theories propose sexual sadism expresses a fundamental conflict around issues related to sexuality, with repression of the urges and needs that are in conflict causing increased arousal and stimulation when they are ultimately expressed, creating a context for reinforcement of the expressed behaviors. Other researchers have reported some potential correlation between a history of corporal punishment and nontraditional sexual practices, including Bondage and Discipline, which has connections to sexual masochism and sexual sadism. It is thought that the association between love for a caretaker and corporal punishment may establish conditions for the development of an emotional connection between pain and intimate relations.
Prevalence: Prevalence rates for this disorder are uncertain, however the prevalence estimates among a forensic sample are between 2 and 30%. Amongst sexual offenders, the rate is estimated to be approximately 37%. Among sexual predators, the prevalence rate is up to 75%
Clinical Manifestations: Clinical manifestations include the sexual arousal from the act of humiliating, binging or otherwise making recipients to suffer, as manifested by fantasies, urges, or behaviors, for a period exceeding 6 months and accompanied by emotional distress or resulting in impairment in social, occupational, and other important areas of function. This clinical definition must be distinguished from sexual behaviors of a similar nature that do not result in distress or impairments in functioning. A significant component of Sexual Sadism Disorder consists of an erotic interest in a substantial degree of power discrepancy between partners.
Best Practices Diagnostic Approaches: An accurate diagnosis of Sexual Sadism Disorder will generally include a careful diagnostic interview that performs a comprehensive mental status screening and gathers a thorough history of the client, including a detailed history of psychosexual development and disturbances thereof, episodes of sexual sadism, and any intersection with the legal system. Because this disorder is frequently comorbid with personality disorders, the assessment and diagnostic process should include gathering of information about family history, a history of parenting practices and attachment concerns, a family history of emotional, physical, and/or sexual abuse, corporal punishment, violence, and other kinds of family disruptions and dysfunction. Any family history of impulse control or compulsive disorders, anxiety or depressive disorders, or substance use disorders should also be gathered. Referral to a specialist in sexual and paraphilic disorders is also recommended, as this disorder may be difficult to assess, diagnose and treat.
Best Practices Treatment Approaches: Treatment approaches for Sexual Sadism Disorder typically include CBT oriented therapy to modify their behavioral choices, combined with medication, which may include SSRI medications to reduce the compulsive aspect of this condition, perhaps combined with medications that reduce their sexual urges. There are also indications that empathy training may be helpful. It is not unusual for treatment to be provided concurrently with the participation of the legal system. If secondary or comorbid conditions exist that may contribute to the expression of this condition, then treatment would also involve addressing those other conditions. Treatment for this disorder should only be attempted by persons who have extensive knowledge and skill in treatment of this disorder.
Other Conditions to Rule Out: This disorder must first be distinguished from activities engaged in as part of the “kink” and BDSM subculture, the distinguishing feature consisting of the absence of emotional distress or impairments in major life roles. This disorder must also be distinguished from Narcissistic, Antisocial, or Borderline Personality Disorders where the willingness to inflict abusive behavior is part of a disordered relationship pattern. This disorder must also be distinguished from Intimate Partner Violence. This disorder must also be differentiated from substance use disorders that create disturbances in judgment and/or impulse control and lead to instances of engaging in abusive interactions while intoxicated. This disorder must be distinguished from other kinds of impulse control and compulsive disorder, taking into the consideration that Sexual Sadism Disorder may occur comorbidly with many other impulse control disorders and compulsive disorders.
Comments: This disorder should generally not be diagnosed by Master’s level mental health clinicians unless that person is a specialist in paraphilias and this specific disorder. Treatment for this disorder may involve coordination with the legal system if the disorder results in death or injury of a sexual partner or exists comorbidly with a personality disorder that involves other kinds of antisocial behaviors.


Pedophilic Disorder Summary Page

DSM-5 Code: F65.4 Pedophilic Disorder

Common Specifiers:
• Exclusive type
• Nonexclusive type
• Sexually attracted to males
• Sexually attracted to females
• Sexually attracted to both
• Limited to incest

Etiology of Pedophilic Disorder: The exact cause of this disorder is not yet fully understood. While various theories have been proposed, none have been sufficiently explanatory to be considered evidence based. There is some evidence that neurological abnormalities may be present in persons who have this disorder, specifically decreased gray matter volume in the ventral striatum (also extending into the nuclues accumbens), the orbitofrontal cortex and the cerebellum. Some of the brain abnormalities are similar to those seen in the brains of persons with Obsessive-Compulsive and Related Disorders, suggesting that there may be a neurologically driven compulsion in effect with this disorder. Behavioral models propose that persons who are themselves victims of sexual exploitation as children may imitate the behaviors and experience reinforcement for those behaviors in ways that generate and solidify the compulsive quality to pedophilia. Other theorists propose that both of these conditions predispose a person to the development of this disorder.
Prevalence: Prevalence rates for this disorder are uncertain, however the prevalence estimates suggest a maximum prevalence rate of between 3 and 5% for males, with rates for females at only a small fraction of that.
Clinical Manifestations: Clinical manifestations include sexual arousal related to engaging in sexual relations with minor children, as manifested by fantasies, urges, or behaviors, for a period exceeding 6 months. A diagnosis is warranted if 1) they are accompanied by emotional distress or 2) they lead to sexual activity with this population. This diagnosis would not be warranted if a person in their late adolescence engaged in sexual relations with a child 12-13 or older.
Best Practices Diagnostic Approaches: An accurate diagnosis of Pedophilic Disorder will generally include a careful diagnostic interview that performs a comprehensive mental status screening and gathers a thorough history of the client, including a detailed history of psychosexual development and disturbances thereof, episodes of sexual relations with prepubescent children, and any intersection with the legal system. Because this disorder appears to have some overlap with other compulsive disorders, a family history of impulse control or compulsive disorders, anxiety or depressive disorders, or substance use disorders should also be gathered. Referral to a specialist in the treatment of Pedophilic Disorder is also recommended, as this disorder has proven be difficult to assess, diagnose and treat, and there may be substantial liability issues for any clinician who diagnoses and treats this population.
Best Practices Treatment Approaches: Treatment approaches for Pedophilic Disorder typically include CBT oriented therapy to modify their behavioral choices, combined with medication, which may include SSRI medications to reduce the compulsive aspect of this condition, perhaps combined with medications that reduce their sexual urges. Behavioral conditioning elements of treatment may include aversive conditioning or positive conditioning – including with the use of biofeedback approaches - where the goal is to reshape associations between the sexually stimulating cues and the physiological and behavioral responses. There are also indications that empathy training may be helpful. It is not unusual for treatment to be provided concurrently with the participation of the legal system with this population. If secondary or comorbid conditions exist that may contribute to the expression of this condition, then treatment would also involve addressing those other conditions. Treatment for this disorder should only be attempted by persons who have extensive knowledge and skill in treatment of this disorder.
Other Conditions to Rule Out: This disorder must first be distinguished from Obsessive-Compulsive and Related Disorders, with the understanding that there are physiological and neurological overlaps and there may be comorbidity. This disorder must also be distinguished from Narcissistic, Antisocial, or Borderline Personality Disorders where the willingness to engage in exploitative behavior is part of a larger disordered relationship pattern. This disorder must also be differentiated from substance use disorders that create disturbances in judgment and/or impulse control and lead to instances of engaging in sexually exploitative interactions while intoxicated. This disorder must be distinguished from other kinds of impulse control disorder, taking into the consideration that this disorder may occur comorbidly with many impulse control disorders.
Comments: This disorder should generally not be diagnosed by Master’s level mental health clinicians unless that person is a specialist in this specific disorder. Treatment for this disorder will frequently involve coordination with the legal system. Treatment for Pedophilic Disorder should be considered a lifelong prospect, as it is believed that there is not a complete cure for this disorder. In addition to SSRI medication, two other medications are frequently used in treatment: luteinizing hormone-releasing hormone (LHRH), and leuprolide acetate (LA).


Fetishistic Disorder Summary Page

DSM-5 Code: F65.0 Fetishistic Disorder

Common Specifiers:
• In a controlled environment
• In full remission
• Body part(s)
• Non-living object(s)
• Other

Etiology of Fetishistic Disorder: The exact cause of this disorder is not yet fully understood. While various theories have been proposed, none have been sufficiently explanatory to be considered evidence based. Some theories propose a dysfunction in the temporal lobe and its sub-cortical connections in the client who exhibits this disorder. Other researchers have looked to psychodynamic or behavioral explanations for the association of sexual arousal and gratification with non-sexual body parts or inanimate objects, but these theories can only be considered speculative at this time.
Prevalence: Prevalence rates for this disorder are unknown, but estimated to be less than 1% of the general population who meet criteria for this diagnosis.
Clinical Manifestations: Clinical manifestations include sexual arousal from the use of nonliving objects or a highly specialized focus on nongenital body parts, as manifested by fantasies, urges, or behaviors, for a period exceeding 6 months and accompanied by emotional distress or resulting in impairment in social, occupational, and other important areas of function. This clinical definition must be distinguished from sexual behaviors of a similar nature that do not result in distress or impairments in functioning, and/or do not violate the rights or body boundaries of others.
Best Practices Diagnostic Approaches: An accurate diagnosis of Fetishistic Disorder will generally include a careful diagnostic interview that performs a comprehensive mental status screening and gathers a thorough history of the client, including a detailed history of psychosexual development and disturbances thereof, and development of the fetishistic behaviors. The assessment and diagnostic process should also include gathering of information about family history, a history of parenting practices and attachment concerns, including the use of corporal punishment, a family history of emotional, physical, and/or sexual abuse, violence, and other kinds of family disruptions and dysfunction. Any family history of impulse control or compulsive disorders, anxiety or depressive disorders, or substance use disorders should also be gathered. Referral to a specialist in sexual and paraphilic disorders is also recommended, as this disorder may be difficult to assess, diagnose and treat.
Best Practices Treatment Approaches: Treatment approaches for Fetishistic Disorder typically include CBT oriented therapy to modify their behavioral choices, combined with medication, which may include SSRI medications to reduce the compulsive aspect of this condition, perhaps combined with medications that reduce their sexual urges. Behavioral conditioning elements of treatment may include aversive conditioning or positive conditioning – including with the use of biofeedback approaches - where the goal is to reshape associations between the sexually stimulating cues and the physiological and behavioral responses. If secondary or comorbid conditions exist that may contribute to the expression of this condition, then treatment would also involve addressing those other conditions. Treatment for this disorder should only be attempted by persons who have extensive knowledge and skill in treatment of this disorder.
Other Conditions to Rule Out: This disorder must first be distinguished from activities engaged in as part of the “kink” subculture, the distinguishing feature consisting of the absence of emotional distress or impairments in major life roles from engagement in the sexual practices. This disorder must also be distinguished from Personality Disorders or psychotic disorders where the fetishistic behavior is part of a disordered relationship pattern or disordered thinking. This disorder must also be differentiated from substance use disorders that create disturbances in judgment and/or impulse control and lead to instances of engaging in unusual sexual practices.
Comments: This disorder should generally not be diagnosed by Master’s level mental health clinicians unless that person is a specialist in paraphilias and this specific disorder and familiar with the sub-cultural associated with “kink” and BDSM activities in order to differentiate signs and symptoms that meet criteria and activities that are acceptable within the community with which sexual minority clients engage.



Transvestic Disorder Summary Page

DSM-5 Code: F65.1 Transvestic Disorder

Common Specifiers:
• In a controlled environment
• In full remission
• With fetishism
• With autogynephilia

Etiology of Transvestic Disorder: The exact cause of this disorder is not yet fully understood. While various theories have been proposed, none have been sufficiently explanatory to be considered evidence based. Some researchers have looked to psychodynamic or behavioral explanations for the association of sexual arousal and gratification with dressing in the clothing of the opposite sex but these theories can only be considered speculative at this time.
Prevalence: Prevalence rates for this disorder are unknown, but estimated to be less than 1% of the general population who meet criteria for this diagnosis.
Clinical Manifestations: Clinical manifestations include sexual arousal from dressing in the clothing of the opposite sex, as manifested by fantasies, urges, or behaviors, for a period exceeding 6 months and accompanied by emotional distress or resulting in impairment in social, occupational, and other important areas of function. This clinical definition must be distinguished from sexual behaviors of a similar nature that do not result in distress or impairments in functioning, and/or do not violate the rights or body boundaries of others.
Best Practices Diagnostic Approaches: An accurate diagnosis of Transvestic Disorder will generally include a careful diagnostic interview that performs a comprehensive mental status screening and gathers a thorough history of the client, including a detailed history of psychosexual development and disturbances thereof, and development of the transvestic behaviors. The assessment and diagnostic process should also include gathering of information about family history, a history of parenting practices and attachment concerns, including the use of corporal punishment, a family history of emotional, physical, and/or sexual abuse, violence, and other kinds of family disruptions and dysfunction. Any family history of impulse control or compulsive disorders, anxiety or depressive disorders, or substance use disorders should also be gathered. Referral to a specialist in sexual and paraphilic disorders is also recommended, as this disorder may be difficult to assess, diagnose and treat.
Best Practices Treatment Approaches: Unless the behaviors associated with this disorder cause distress in the person’s life, then someone with this paraphilia may not seek help on their own account. Most often, treatment requests are initiated by a significant other or romantic partner who is concerned with the behaviors. Treatment approaches for Transvestic Disorder typically include CBT oriented therapy to modify behavioral choices, combined with medication, which may include SSRI medications to reduce the compulsive aspect of this condition. If secondary or comorbid conditions exist that may contribute to the expression of this condition, then treatment would also involve addressing those other conditions. Treatment for this disorder should only be attempted by persons who have extensive knowledge and skill in treatment of this disorder.
Other Conditions to Rule Out: This disorder must first be distinguished from a diagnosis of gender dysphoria, in which the driving force for the urge to dress in the clothing of the opposite sex is related to a sense of difference between the patient’s birth gender and experienced gender. This disorder must also be differentiated from activities engaged in as part of the “kink” subculture, the distinguishing feature consisting of the absence of emotional distress or impairments in major life roles from engagement in the cross-dressing practices. This disorder must also be distinguished from gender fluidity and experimentation among adolescent who are still exploring their sexual identity. This must also be differentiated from Personality Disorders or psychotic disorders where the fetishistic behavior is part of a disordered relationship pattern or disordered thinking. This disorder must also be differentiated from substance use disorders that create disturbances in judgment and/or impulse control and lead to instances of engaging in unusual sexual practices.
Comments: This disorder should generally not be diagnosed by Master’s level mental health clinicians unless that person is a specialist in paraphilias and this specific disorder and familiar with the sub-cultural associated with “kink” and BDSM activities in order to differentiate signs and symptoms that meet criteria and activities that are acceptable within the community with which sexual minority clients engage.


Other Specified Paraphilic Disorder Summary Page

DSM-5 Code: F65.89 Other Specified Paraphilic Disorder

Examples of other paraphilic disorders:
• Zoophilia (bestiality)
• Scatologia (obscene phone calls)
• Necrophilia (sex with corpses)
• Coprophilia (arousal from feces)
• Urophilia (arousal from urine)

Etiology of Other Specified Paraphilic Disorders: The exact cause of these other specified paraphilic disorders is not yet fully understood. While various theories have been proposed, none have been sufficiently explanatory to be considered evidence based. Other researchers have looked to psychodynamic or behavioral explanations for the association of sexual arousal and gratification with non-normative objects of sexual interest, but these theories can only be considered speculative at this time.
Prevalence: Prevalence rates for this disorder are unknown.
Clinical Manifestations: Clinical manifestations include sexual arousal from behaviors in which the fetishistic object is the focus of attention, as manifested by fantasies, urges, or behaviors, for a period exceeding 6 months and accompanied by emotional distress or resulting in impairment in social, occupational, and other important areas of function. This clinical definition must be distinguished from sexual behaviors of a similar nature that do not result in distress or impairments in functioning, and/or do not violate the rights or body boundaries of others, including animals (zoophilia).
Best Practices Diagnostic Approaches: An accurate diagnosis of this disorder will generally include a careful diagnostic interview that performs a comprehensive mental status screening and gathers a thorough history of the client, including a detailed history of psychosexual development and disturbances thereof, and development of the paraphilic behaviors. The assessment and diagnostic process should also include gathering of information about family history, a history of parenting practices and attachment concerns, including the use of corporal punishment, a family history of emotional, physical, and/or sexual abuse, violence, and other kinds of family disruptions and dysfunction. Any family history of impulse control or compulsive disorders, anxiety or depressive disorders, or substance use disorders should also be gathered. Referral to a specialist in sexual and paraphilic disorders is also recommended, as this disorder may be difficult to assess, diagnose and treat.
Best Practices Treatment Approaches: Treatment approaches for this disorder typically include CBT oriented therapy to modify behavioral choices, combined with medication, which may include SSRI medications to reduce the compulsive aspect of this condition. If secondary or comorbid conditions exist that may contribute to the expression of this condition, then treatment would also involve addressing those other conditions. Treatment for this disorder should only be attempted by persons who have extensive knowledge and skill in treatment of this disorder.
Other Conditions to Rule Out: This disorder must also be differentiated from activities engaged in as part of the “kink” subculture, the distinguishing feature consisting of the absence of emotional distress, impairments in major life roles, or boundary violations from engagement in the defined sexual practices. This disorder must also be distinguished Personality Disorders or psychotic disorders where the fetishistic behavior is part of a disordered relationship pattern or disordered thinking. This disorder must also be differentiated from substance use disorders that create disturbances in judgment and/or impulse control and lead to instances of engaging in unusual sexual practices.
Comments: This disorder should generally not be diagnosed by Master’s level mental health clinicians unless that person is a specialist in paraphilias and this specific disorder and familiar with the sub-cultural associated with “kink” and BDSM activities in order to differentiate signs and symptoms that meet criteria and activities that are acceptable within the community with which sexual minority clients engage.

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