Sexual Disorders

 
Taken from DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (Third Edition) published by the American Psychiatric Association, 1987. Pgs 279-281 Sexual Disorders.
 

SEXUAL DISORDERS

The Sexual Disorders are divided into two groups. The Pharaphilias are characterized by arousal in response to sexual objects or situations that are not part of normative arousal activity patterns and that in varying degrees may interfere with the capacity for reciprocal, affectionate sexual activity. The Sexual Dysfunctions are characterized by inhibitions in sexual desire or the psycho physiologic changes that characterize the sexual response cycle. Finally, there is a residual class, Other Sexual Disorders, for disorders in sexual functioning that are not classifiable in any of the specific categories.

PHARAPHILIAS

The essential feature of disorders in this subclass is recurrent intense sexual urges and sexually arousing fantasies generally involving either (1) nonhuman objects, (2) the suffering or humiliation of oneself or one's partner (not merely simulated), or (3) children or other non consenting persons. The diagnosis is made only if the person has acted on these urges, or is markedly distressed by them. In other classifications these disorders are referred to as Sexual Deviations. The term Pharaphilia is preferable because it correctly emphasizes that the deviation (para) lies in that to which the person is attracted (philia). For some people with a Pharaphilia, paraphiliac fantasies or stimuli may always be necessary for erotic arousal and are always included in sexual activity, if not actually acted out alone or with a partner. In other cases the paraphiliac preferences occur only episodically, for example, during periods of stress; at other times the person is able to function sexually without paraphiliac fantasies or stimuli. The imagery in a paraphiliac fantasy is frequently the stimulus for sexual excitement in people without a Pharaphilia. For example, female undergarments are sexually exciting for many men; such fantasies and urges are paraphiliac only when the person acts on them or is markedly distressed by them.

The imagery in a Pharaphilia, e.g., of being humiliated by one's partner, may be relatively harmless and acted out with a consenting partner. More likely it is not shared by the partner, who consequently feels erotically excluded from the sexual interaction. In more extreme form, paraphiliac imagery is acted out with a non consenting partner, and may be injurious to the partner (as in Sexual Sadism) or to the self (as in Sexual Masochism). The Pharaphilias included here are, by and large, conditions that have been specifically identified by previous classifications. Some of them are relatively common in clinics that specialize in the treatment of Pharaphilias and other sexual behavior problems (e.g., Pedophilia, Voyeurism, and Exhibitionism); others are much less commonly seen in such settings (e.g., Sexual Masochism and Sexual Sadism). Because some Of these disorders are associated with non consenting partners, they are of legal and social significance. People with these disorders tend not to regard themselves as ill, and usually come to the attention of mental health professionals only when their behavior has brought them into conflict with sexual partners or society. The specific Pharaphilias described here are: (1) Exhibitionism, (2) Fetishism, (3)Frotteurism, (4) Pedophilia, (5) Sexual Masochism, (6) Sexual Sadism, (7) Transvestic Fetishism, and (8) Voyeurism. Finally, there is a residual category, Pharaphilia Not Otherwise Specified, for noting the many other Pharaphilias that are less commonly encountered, or have not been sufficiently described to date to warrant inclusion as specific categories.

People with a Pharaphilia commonly suffer from several varieties: in clinical settings that specialize in the treatment of Pharaphilias, people with these disorders have an average of from three to four different Pharaphilias. People with Pharaphilias may also have other mental disorders, such as Psychoactive Substance Use Disorders or various Personality Disorders. In such cases multiple diagnoses should be made. Criteria for the severity of the manifestations of a specific Pharaphilia are provided. These guidelines distinguish, first, people who do not act on their paraphiliac urges from those who do. It is recognized, however, that this distinction in some cases may be more a function of various personality traits (such as the presence or absence of antisocial personality traits), the severity of psychosocial stressors, and the presence of a Psychoactive Substance Use Disorder than of factors inherent in the Pharaphilia itself. The second distinction made in these guidelines is between people who have occasionally acted on a paraphiliac urge and those who repeatedly do so. Again, the factors noted above rather than ones inherent in the Pharaphilia itself may be involved in this distinction.

Among other clinical considerations besides severity of the manifestations are the degree to which the person requires the paraphiliac imagery or fantasy for sexual arousal, the extent to which the person has harmed others or himself or herself, the degree of subjective distress, and, finally, the social or occupational impairment that is the direct result of Pharaphilia-related behavior. Associated features. Specific paraphiliac imagery is selectively focused on and sought out by people with one or more Pharaphilias. The person may select an occupation or develop a hobby or volunteer work that brings him into contact with the desired stimuli (e.g., selling women's shoes or lingerie in Fetishism, working with children in Pedophilia, or driving an ambulance in Sexual Sadism). The person may selectively view, read, purchase, or collect photographs, films, and textual depictions focusing on his preferred type of paraphiliac stimulus. The preferred stimulus, even within a particular Pharaphilia, may be highly specific such as ten-year-old blond boys with a light complexion and thin habitué. People who do not have a consenting partner with whom their fantasies can be acted out may purchase the services of prostitutes or others who provide specialized Pharaphilia related services (e.g., "bondage and domination" or "cross-dressing lessons") or may act out their fantasies with unwilling victims. Frequently people with these disorders assert that the behavior causes them no distress and that their only problem is the reaction of others to their behavior. Others report extreme guilt, shame, and depression at having to engage in an unusual sexual activity that is socially unacceptable or that they regard as immoral. There is often impairment in the capacity for reciprocal, affectionate sexual activity, and Sexual Dysfunctions may be present. Personality disturbances, particularly emotional immaturity, are also frequent, and may be severe enough to warrant an Axis 11 diagnosis of a Personality Disorder. Impairment. Social and sexual relationships may suffer if others, such as a spouse (approximately one-half of the people with Pharaphilias seen clinically are married), become aware of the unusual sexual behavior. In addition, if the person engages in sexual activity with a partner who refuses to cooperate in the unusual behavior, such as fetishistic or sadistic behavior, sexual excitement may be inhibited and the relationship may suffer. In some instances the unusual behavior, e.g., exhibitionistic acts or the collection of fetishes, may become the major sexual activity in the person's life. Complications. In Sexual Masochism, the person may suffer serious physical damage. Pharaphilias involving another person, particularly Voyeurism, Exhibitionism, Frotteurism, Pedophilia, and Sexual Sadism, often lead to arrest and incarceration. Sexual offenses against children constitute a significant proportion of all reported criminal sex acts. People with Exhibitionism, Pedophilia, and Voyeurism make up the majority of apprehended sex offenders. Predisposing factors. With the exception of Pedophilia (see p. 285) and Transvestic Fetishism (see p. 289), there is no information about predisposing factors. Prevalence. The disorders are rarely diagnosed in general clinical facilities. However, judging from the large commercial market in paraphiliac pornography and paraphernalia, the prevalence in the community is believed to be far higher than that indicated by statistics from clinical facilities. Because of the highly repetitive nature of paraphiliac behavior, a large percentage of the population has been victimized by people with Pharaphilias. Sex ratio. Except for Sexual Masochism, in which the sex ratio is estimated to be 20 males for each female, the other Pharaphilias are practically never diagnosed in females, but some cases have been reported.

Familial pattern. No information. Criteria for severity of manifestations of a specific Pharaphilia Mild: The person is markedly distressed by the recurrent paraphiliac urges but has never acted on them. Moderate: The person has occasionally acted on the paraphiliac urge. Severe: The person has repeatedly acted on the paraphiliac urge.

 

THERAPIES FOR THE PHARAPHILIAS

In the earliest stages of behavior therapy, pharaphilias were narrowly viewed as attractions to inappropriate objects and activities. Looking to experimental psychology for ways to reduce these attractions, workers fixed on aversion therapy. Thus a boot fetishist would be given shock or an emetic when looking at a boot, a transvestite when cross-dressing, a pedophile when gazing at a photograph of a nude child, and so on. Sometimes these negative treatments were supplemented by training in social skills and assertion, for many of these individuals only poorly relate to others in ordinary social situations and even more poorly if at all through conventional sexual intercourse. There is some reason to believe that aversion therapy can alter pedophilia, transvestism, exhibitionism, and fetishism (Marks and Gelder, 1967; Marks, Gelder, and Bancroft, 1970) although to what extent the improvements are achieved through the placebo effect is unclear.

More recently the aversive stimulus has been presented in imagination, via covert sensitization (Cautela, 1966). Instead of being shocked or made nauseous with a drug while confronting the objects or situations to which he is inappropriately attracted, the paraphiliac, with assistance and encouragement from the therapist, pairs in imagination the pleasurable but unwanted arousal and an aversive stimulus. In a variation called covert punishment, the fantasized aversive stimulus may concern the aftermath of his act. The pedophile may imagine that his wife and daughter catch him fondling a little girl, that the police arrest him in the street, that his crime is reported in the newspapers, that he loses his job and goes to jail. Paraphiliacs have also been behaviorally treated by orgasmic reorientation, which attempts to help them respond sexually to stimuli or situations that for them do not have the accustomed appeal. Individuals are confronted with a conventionally arousing stimulus while they are responding sexually for other, undesirable reasons.

From: Abnormal Psychology Chapter 12 Psychosexual Disorders, pgs 305-306

Davison & Neal 1986