Thinking Out Loud About Paraphilias

Defining pathology is one of the hardest challenges in mental health. “Normal” is a broad spectrum. Reliable biomarkers are rare. Culture influences the perception and manifestation of symptoms. Even when you do everything right, the creation of a new diagnosis can cause unexpected harm. Our current method of diagnosis—codified in The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5)—is widely considered to be grossly inadequate [1].

Classification of sexual disorders carries an additional challenge: it is almost impossible to divorce morality from sexuality. Some diagnoses carry explicit moral biases—like the thankfully discarded disorder of homosexuality. Other labels carry more subtle moral judgments. For example, female orgasmic disorder assumes that a woman’s sexual function should be robust regardless of the efforts of her partner. An astute clinician will assess the ways that interpersonal and cultural factors modify sex, but there is nothing in the core criteria for female orgasmic disorder that would help a non-specialist understand this nuance.

In contrast to the sexual disorders, almost all other psychiatric diagnoses take a relatively soft stance towards moral considerations. Depression may result in impaired function, but there is no moral judgment around failure to perform necessary tasks. Psychosis may cause erratic and sometimes illegal actions, but social norms are not used as a benchmark for pathology. Opioid use disorder does not consider whether a person's behavior is morally right or wrong. We only assess whether symptoms are present and causing clinically significant distress and impairment. 

Before I go further, I want to be clear that I am not arguing that a moral perspective is wrong. There are implicit, generally inoffensive, moral judgments in the way we define all illnesses. I am suggesting that our attempts to define pathology need to come from a shared moral framework. Our failure to do this is most apparent in disorders related to human sexuality. 

I hope we can agree that explicit consent to sexual activity is a basic moral framework worth building around. You may have additional moral beliefs you would consider—and they may even be near globally shared. You may also want me to flesh out the meaning of phrases like “explicit consent” or “sexual activity,” which is beyond the scope of this post. My goal today is not to describe a perfect moral or diagnostic framework. Far from it. My goal isn’t even to talk about “weird” sex. What I really want to talk about is perceived sexual addiction—a deeply flawed but immensely interesting topic. But because almost every formal definition of sexual addiction is explicitly non-paraphilic, it makes sense to talk first about paraphilias.

Defining Paraphilias

A paraphilia is an abnormal sexual desire that is so significant that it causes distress or impairment in the person’s life [2]. But which sexual desires count as abnormal, and who gets to decide what normal means?

The DSM-5 is not particularly helpful. DSM-5 paraphilias are “intense and persistent sexual interest[s]” for anything other than “genital stimulation or preparatory fondling with phenotypically normal, physically mature, consenting human partners.”

There is so much to unpack here. Reducing sexual activity to "preparatory fondling" and "genital stimulation" is only slightly more open-minded than “missionary position when attempting conception [3].” And why must our interest in partners be derived from them appearing "phenotypically normal?" Isn’t it healthy to be attracted to a partner’s unique characteristics [4]? While I agree with the DSM-5 committee that physical maturity is important in a sexual partner, why aren't emotional, intellectual, and spiritual maturity considered similarly important? Although “intense and persistent sexual interest” seems like a good bar for concern, these vague terms have major flaws. Every good clinician knows that many people who experience intense and persistent desires are perfectly normal, no matter how strange they may sound to others. At the same time, more than momentary pedophilic interests need to be assessed carefully—regardless of their intensity.

Even without all these caveats, the DSM-5 fails to consistently apply these principles. Paraphilic disorders are only included if they are 1) relatively common or 2) potentially criminal. The relative commonality criteria has an obvious problem: if a desire or behavior is common, why would we consider it abnormal? You might find a foot fetish unusual, but a large proportion of the population is really into feet. Maybe that means that foot people are normal. On the other hand, rare but clearly pathological paraphilias like necrophilia aren’t included as separate disorders.

Potential criminality is a flawed criteria for a different reason. Crimes are based upon legal definitions, and I don’t recommend that anyone pattern their sexuality around the whims of legislators. A better standard would be a strong desire for atypical, nonconsensual sexual contact with another person. Inadequate consent—not current legal definitions—is a much more reasonable line when considering pathology.

The Currently Accepted Paraphilias

As I describe the core arousal target in each of these paraphilias, please note that a simple desire to engage in these behaviors alone is insufficient for diagnosis. There are clear overlaps between some paraphilias and normal sexuality (e.g. BDSM play could be mischaracterized as masochism or sadism). It is also very common for these desires to be present in children and adolescents without persistence to adulthood. In addition, there are important rule-outs which must be considered when making the diagnosis. For example, behaviors that only occur during substance use or mania would not typically be considered paraphilic. Likewise, people with obsessive-compulsive disorder may experience thoughts that sound paraphilic to an untrained observer. Because of these complexities, a skilled clinician is needed to confirm the clinically significant features which are core to each diagnosis. 

The DSM-5 describes eight specific paraphilias alongside a waste basket category of “other specified paraphilias.”

Voyeuristic disorder describes arousal from watching unsuspecting people undress or have sex. It is not clear from the text whether this same disorder would apply to simulated situations, such as voyeur-related pornography viewing.

Exhibitionistic disorder describes arousal related to exposing your genitals to others without their consent. Please note that this disorder applies to the display of genitals only and not other body parts. This may be related to the fact that paraphilias are almost exclusively described in men. I suspect—but can’t support with data—that most unsolicited dick pics are misguided rather than paraphilic. (Fellas, does that ever actually work? Let’s be better than that.)

Frotteuristic disorder describes arousal from touching or rubbing up against nonconsenting people. This behavior typically occurs in public settings, such as a crowded subway.

Sexual masochism disorder describes arousal from being “humiliated, beaten, bound, or otherwise made to suffer.” Erotic asphyxiation would be included in this category. Again, this disorder—like sexual sadism below—is not designed for people who enjoy consensual BDSM. Most cases of sexual masochism disorder occur in situations where it limits flexibility around sex in a partnered relationship.

Sexual sadism disorder describes arousal from causing pain to others. There is an ocean of gray area in the diagnosis of this disorder, as serial rape alone is generally not considered sufficient to meet criteria for this diagnosis. It’s too complex to dig deeply into this today, but the general idea is that rape occurs for many different reasons. A desire for power over someone is not enough for sexual sadism; the diagnosis requires a core pattern of sexual arousal from deeply hurting other human beings. Not surprisingly, many other paraphilic behaviors are also related to power more than sex, and so there is common recognition among clinicians that someone who has sexually assaulted a child may not experience pedophilia.

Pedophilic disorder describes arousal from potential sexual activity with prepubescent children. This differs from the common usage of the word pedophilia, which typically means sex between an adult and anyone who is underage. DSM-5 and ICD-11 pedophilic disorder only describes attraction to prepubescent children.

Fetishistic disorder describes arousal specifically focused on non-genital body parts or objects. Specificity here is lacking. It is not clear to me why breasts, pecs, abs, and butts—which are not genitals—do not appear to count as fetishes, while arousal in response to ankles and hair—which are also not genitals—is considered abnormal. Not surprisingly, the use of devices like vibrators do not count as object fetishes. The plain language used in the description lacks specificity, and cultural norms around sexual attraction are heavily implied.

Transvestic disorder describes arousal from cross-dressing. It is critical to note that transvestic disorder and transgender identity are unrelated ideas. Trans people are not trans because they are turned on by their gender identity. There has been a longstanding, deeply misguided suggestion by some researchers that a subset of trans women experience autogynephilia—sexual arousal from imagining themselves as women. The DSM-5 propagates this absurd concern by including autogynephilia as a potential specifier for transvestic disorder. This simply does not matter. How many cisgender people are turned on simply by existing in the sex they were assigned at birth? No one suggests that autophallophilia in cisgender men is a problem, despite it being an extraordinarily common phenomenon [5].

Other specified paraphilic disorder describes a poorly defined wastebasket of disorders that includes necrophilia (arousal from corpses), zoophilia (arousal from animals), urophilia (arousal from urine), and coprophilia (arousal from feces) among others. 

Two Surprising Omissions from the Paraphilias 

Despite all these efforts to classify paraphilias, there are two especially notable omissions: hebephilia and ephebophilia.

Hebephilia describes attraction to children who are in the midst of puberty. In my opinion, this always constitutes a harmful attraction, as a child undergoing puberty is never able to provide consent for a sexual relationship with an adult. The decision to not include hebephilia as its own paraphilic disorder was likely made due to a lack of data, but the failure to specifically include hebephilia under the heading “other specified paraphilic disorder” is surprising.

Ephebophilia describes attraction to adolescents who have already completed puberty. In essence, ephebophilia is attraction to youth who have mature, physical sexual characteristics, but who have not yet reached emotional, cognitive, spiritual, or cultural maturity. There is a reasonable evolutionary argument that physical attraction to young, fertile humans is a normal human trait. At the same time, the age and power mismatch between a mature adult and an adolescent is a cause for concern. Proposed ephebophilia definitions acknowledge that adolescence persists much longer than the statutory age of consent in most jurisdictions. It’s not my business whether a consensual, legal, relationship is appropriate, but I also find that our whole-human attractions tend to age with us. The complexity of defining ephebophilia is a reasonable argument for excluding it from the DSM-5, but I mourn the implication that healthy sex is primarily connected to physical maturity.

Reimagining Paraphilias

As I said before, I’m not interested in creating an absolutely coherent, perfect definition of maladaptive sexuality. That may not even be possible. However, I do think that there is room for improvement in the way that we approach paraphilic desires.

Rather than creating distinct categories of disorder, it may be more useful to think in shades of gray. We often call this form of measurement dimensional [6]. One example of a dimensional approach is the Kinsey Scale, which asks participants to rate their sexual attraction to the same or opposite sex on a scale of 0 to 6. A rating of 0 would correspond to someone who identifies as straight, while a 6 would be given by someone who is gay or lesbian. Scores between 1 and 5 represent variable levels of bisexuality. This score alone only describes one dimension of a person’s experience, and the measurement of additional dimensions (such as romantic attraction or libido) would help to describe a fuller picture of sexual orientation than gay, straight, or bisexual. Dimensional approaches do not claim to explain everything, but they can carry much more nuance than the DSM model of simple categorization.

What dimensions matter in describing paraphilias? I would like to suggest that two dimensions must be present to even consider an attraction pathological. First, a paraphilic desire must be atypical. Under this dimension, a belly button fetish might score so low as to be unremarkable, while hebephilia would be clearly atypical. Second, paraphilic desires must be for nonconsensual sexual activity. For the sake of clarity, I note that some paraphilic behaviors are always nonconsensual—as children and unsuspecting victims cannot consent to sex. When consent is impossible, this paraphilia always falls on the extreme end of this dimension. A more nuanced approach needs to be taken when behaviors can be either consensual or sexual assault. For example, private exhibitionism by a dancer in a club is consensual and should never be considered paraphilic, while it would not be appropriate to display your genitals publicly in most western cultures. In short, behaviors that are typical or always consensual should never be considered paraphilic—no matter how unusual they may sound to others.

There are two other dimensions that are worth exploring: enactment and exclusivity. These dimensions are not needed to determine the presence of pathology, but they give us critical information about how the paraphilia is manifest. Enactment measures how often an individual has engaged in paraphilic behavior. We all appreciate that someone who experiences pedophilia and has never harmed a child is very different from someone who has sexually assaulted children. The innocent person with maladaptive attractions deserves non-judgmental care and support, while a person who has perpetrated must be approached with an even sharper eye towards public safety. The stigma and legal risk to acknowledging a pedophilic desire has made it almost impossible to determine the prevalence of pedophilia, but I’d be willing to bet that the vast majority of people with pedophilia never assault a child. For those at risk of offending, it is critical that we develop preventative tools that help to manage pedophilia effectively. Legal consequences—while necessary when abuse happens—cannot reverse the consequences of childhood sexual assault.

Exclusivity measures whether someone experiences paraphilic desires alone or as part of a spectrum that also includes healthy sexual behaviors. Abstinence from sex is rarely consistent with a full life, and someone who cannot experience sex outside of atypical, nonconsensual behaviors is at high risk of harm to others. On the other hand, non-exclusive paraphilias may raise additional concerns. For example, someone who experiences attraction to both adults and children is more likely to have children of their own, placing them in close proximity to potential targets for sexual assault. The DSM-5 does attempt to describe exclusivity in the case of pedophilia, but this domain should be considered in the assessment of all paraphilias.

These dimensions are just a rough sketch. I’m well aware that there are additional dimensions that need to be explored, and that sexuality cannot be described with any real rigidity. I’m also aware that suggesting dimensions and obtaining accurate, validated measurements of these dimensions are entirely different processes. But without a dimensional approach, we end up with the thoroughly broken system we currently have.

Conclusion

Why do I care? It’s a fair question, and one I don’t have a complete answer to. Perhaps it is because I treat two distinct groups of people: those who desire or engage in normal sexual expression that is often stigmatized, and those who are at high risk of future offenses towards others. Our current descriptions of paraphilias label too many normal people as disordered, and fail to adequately address the very real struggles of people who experience dangerous paraphilias. Both groups deserve compassionate care and human dignity, but only people who engage in nonconsensual sexual behaviors as a result of atypical sexual desires require legal rehabilitation [7].

With this groundwork out of the way, we can begin talking about sex addiction—a construct which I will argue is much, much harder to define than paraphilias. Please consider subscribing to get my next post in your inbox.

Footnotes

[1]: The World Health Organization publishes a similar book of diagnoses called the International Classification of Diseases 11th Revision (ICD-11). The ICD-11 is more expansive than the DSM-5 as it includes both physical and mental health diagnoses. With regards to mental health, it is not necessarily better than the DSM-5. It has its own strengths and shortcomings, but the same general problems with diagnosis can be applied here. 

[2]: The DSM-5 distinguishes between paraphilia and paraphilic disorder by suggesting that a paraphilia only becomes a disorder when it is intense enough to cause harm to others or clinically significant distress or impairment. I will break tradition here by using both terms interchangeably, as I will disagree with some of the conclusions the DSM-5 makes about the pathology of many paraphilic disorders.

[3]: You don’t need to be a psychoanalyst to feel the repression in “genital stimulation or preparatory fondling.” It’s a phrase that makes the perpetual 14-year old in me giggle.

[4]: I am well aware of what the DSM-5 means here: it is fine to be attracted to your partner’s amputated limb, but it may be a problem when you are only attracted to people with amputations. I don’t think that matters. Even if it did, greater precision of language is necessary.

[5]: I’m aware that autoandrophilia is more congruent to autogynephilia than autophallophilia. Gyn- is a root suggestive of women, and so andro- (meaning men) would be more congruent. Many men mistakenly think that gyn- is primarily related to the vagina, and what kind of psychiatrist would I be if I walked by a good penis reference?

[6]: The dimensional perspective is not a unique viewpoint for mental health diagnosis, although I will confess that I intentionally chose not to deeply explore the literature on dimensionality in paraphilias before writing this post. This allows me to think out loud—right or wrong—without being overtly influenced by the predominant models that have been proposed. I’m also approaching this as a critic of both sex addiction models and paraphilias, which may not be the typical approach of paraphilia researchers.

[7]: I’m deeply aware of the brokenness of the legal system in the United States and much of the world. Our current system doesn’t usually result in rehabilitation. I’m remarking on what people need from our legal system, not what they currently get.