The article will talk about the following points:
- What are Paraphilic Disorders?
- Author’s Note☺
- Breaking News: Confusion Reigns
- Case Study: Exhibitionism
- Definition, etiology and sex crime
What are Paraphilic Disorders?
Paraphilias are defined as ‘’any intense and persistent sexual interest OTHER THAN genital stimulation or preparatory fondling with phenotypically normal, physically mature, consenting human partners’’ [2]. It sounds very puzzling, especially since it is difficult to define what is normal, physically mature and consenting (read our article on consent for more). However, The DSM-5 section of Sexual and Gender Identity Disorders had to draw a line between harmless atypical behaviours, and those that cause mental distress or threat to the psychological and physical well- being of the affected individual and those around them. That is why a diagnosis for Paraphilic Disorders (and not Paraphilia) requires the individual to experience significant distress or impairment, or the satisfaction of the paraphilia has to entail personal harm, or risk of harm to others. Thus, the difference lies in this last point.
Something important to note is that in DSM-4-TR, the previous version of the manual, contrary to the newer DSM-5, “paraphilic disorder” was nonexistent. Sexual deviations were simply termed paraphilias. However, a paraphilia by itself would not automatically justify nor require psychiatric intervention. On the other hand, the distress and harm dimensions of a paraphilic disorder imply that one can be psychiatrically treated. Lastly, two other requirements were added for diagnosis, which are:
- The person has to seek sexual stimulation from the paraphilic act;
- The person had at least three episodes of paraphilic behaviour [7].
There are eight paraphilic disorders that we know of today, and they are: voyeuristic disorder, exhibitionistic disorder, sexual sadism disorder, sexual masochist disorder, pedophilic disorder, fetihistic disorder, transvestic disorder and frotteuristic disorder. There are, of course, more than these that are characterized as ‘’other specified paraphilic disorders’’ including rare manifestations such as zoophilic disorder and necrophilia [2].
Author’s Note ☺
Here, I feel the urge to make a personal comment. It is really important to comprehend why these definitions exist. The human mind has to make distinctions between what is desirable and acceptable and what is not. When behaviors, or ideas, appear different or when we are unable to understand a phenomenon, we label them as different, and often as wrong. These automatic judgments happen along a spectrum, and this is why some different behaviors have come to be accepted, while others haven’t. It is important that we don’t judge or discriminate against someone else’s experience solely because it differs from ours. However, when differences become threatening to mental or physical health (of the individual or others), we must be cautious in accepting them.
Scoop and Breaking News: Confusion Reigns
Challenging the common viewpoint, in 2018 Charles Moser published ‘’DSM-5, Paraphilias, and the Paraphilic Disorders: Confusion Reigns” [3]. Essentially, he challenged the decision made by the DSM-5 Manual board of including the paraphilias as disorders. What is interesting though, is that he reveals how the group devoted to paraphilias (PSWG*) were not satisfied with the final version of the DSM-5 section concerning Paraphilic Disorders. Naturally, these comments reached the APA**, which silenced these concerns. Additionally, participants of the APA review process were required to sign confidentiality pledges to maintain secrecy.
The science field, in particular social sciences, struggles a lot with transparency. Therefore, the confidentiality pledges of the APA raise mystery and question marks, as they imply that their internal processes may be influenced by external factors like political agendas. This information limits the validity of the DSM-5 section of Paraphilic Disorders.
Critical thinking is always good to understand the world we live in. Keep your eyes open and do not hesitate to get to look up both sides of disputes or of scientific research ☺
Case Study: Exhibitionism
It is not uncommon for paraphilias to lead to sexual crimes and offenses. Acts such as exhibitionism and voyeurism, which imply a non-consensual recipient, are among the most common law breaking sexual behaviours [4].
This case study focuses on exhibitionism, inspired by a recent incident taking place in Athens, Greece [5,6]. The event goes as follows: a 22 years old man followed a girl from the metro station close to her house, to then expose his genitals. He was not able to enter the building, and luckily the girl entered her home safely. He was caught on camera through the building’s security system, and so the next day she shared the video on the Internet, Soon after, more girls started recognizing him and one accused him of trying to rape her. The court case is still ongoing. One would think that there is nothing new or interesting about this incident, but I disagree. However, after the girl made the information public, more and more exhibitionism cases were reported to the police. It inspires great hope that people are more and more sensitized to incidents of sexual violence and assault, making the paraphilic discussion a relevant one.
Definition, etiology and sex crime
Now that the relevancy of paraphilic disorders is clear, I will move on to explain exhibitionism a bit more in depth. Exhibitionism, as most paraphilic disorders, is mostly prevalent among males. Still, and righteously, the diagnostic criteria are gender neutral, and these are:
- Exposing one’s genitals to an unsuspecting and unconsenting subject or
- ‘’Recurrent and intense sexual fantasies from the exposure of one’s genitals to an unsuspecting person, as manifested by fantasies, urges, or behaviours’’ [4].
Recent research of exhibitionism is scarce, but a large sample of sex offenders from courts, state hospitals and forensic clinics were studied around the 50s, 60s and 70s. Langstorm thinks that exhibitionism is understudied because it’s sexually offensive nature may have not been perceived as serious compared to other paraphilic disorders. Its prevalence, however, is extremely high compared to the other disorders. Additionally, Murphy and Page commented that reports made to the police on exhibitionism incidents underestimate its true prevalence. We can assume that this happens because of the general stigma it carries to talk about incidents of sexual offense, especially for the victim [4].
One aspect I believe is of great interest is the etiology of exhibitionism. Most of the explanations proposed reflect psychodynamic theories, with castration anxiety as the main reason. Others view exhibitionism as a distortion or extreme intensification of the affiliative phase of courtship, meaning the phase where potential partners flirt. Another curious fact is that one cannot “test” the arousal extent of exhibitionism, as penile erections are not a requirement, and female exhibitionists could not be tested.
There is an interesting observation, made by Moser [3], stating that in the DSM-5 the mental disorders that predispose individuals to engage in criminal acts are included in a separate section, which does not include sex offenses. Yet, non-consenting victims are usually a requirement for the diagnosis of paraphilic disorders, creating a strong paradox. So, the APA suggest that people who commit specifically sex crimes are in a sense “justified” by their disorder. Personally, I find this absurd. Let’s hope that in the future, research and interventions will clear the picture.
Let us know what you think!
*Paraphilias SubWork Group
**American Psychological Association
References
[2] Holoyda, B. J., & Kellaher, D. C. (2016). The Biological Treatment of Paraphilic Disorders: an Updated Review. Current Psychiatry Reports, 18(2). doi:10.1007/s11920-015-0649-y
[1] Garcia, F. D., & Thibaut, F. (2011). Current Concepts in the Pharmacotherapy of Paraphilias. Drugs, 71(6), 771–790. doi:10.2165/11585490-000000000-00000
[4] Balon, R. (2016). Exhibitionistic Disorder. Practical Guide to Paraphilia and Paraphilic Disorders, 77–91. doi:10.1007/978-3-319-42650-1_6
[3] Moser C. DSM-5, Paraphilias, and the Paraphilic Disorders: Confusion Reigns. Arch Sex Behav. 2019 Apr;48(3):681-689. doi:
10.1007/s10508-018-1356-7. Epub 2019 Feb 21. PMID: 30790206.
[7] Garcia, F. D., Delavenne, H. G., Assumpção, A. de F. A., & Thibaut, F. (2013). Pharmacologic Treatment of Sex Offenders With Paraphilic Disorder. Current Psychiatry Reports, 15(5). doi:10.1007/s11920-013-0356-5