Sexual Perversion

Paraphilia (previously known as sexual perversion and sexual deviation[1]) is the experience of intense Emotional arousal to atypical objects, situations, fantasies, behaviors, or individuals.[2][3] It has also been defined as sexual interest in anything other than a consenting human partner.[4][5]

There is no scientific consensus for any precise border between unusual sexual interests and paraphilic ones.[6][7] There is an ongoing debate over which, if any, of the paraphilias should be listed in diagnostic manuals, such as the Diagnostic and Statistical Manual of Mental Disorders (DSM) or the International Classification of Diseases (ICD).

Many terms have been used to describe atypical sexual interests, and there remains debate regarding technical accuracy and perceptions of stigma. Sexologist John Money popularized the term paraphilia as a non-pejorative designation for unusual sexual interests.[11][12][13][14] Money described paraphilia as "a sexuoerotic embellishment of, or alternative to the official, ideological norm."[15] Psychiatrist Glen Gabbard writes that despite efforts by Stekel and Money, "the term paraphilia remains pejorative in most circumstances."[16]

In the late 19th century, psychologists and psychiatrists started to categorize various paraphilias as they wanted a more descriptive system than the legal and religious constructs of sodomy[19] and perversion.[20] Before the introduction of the term paraphilia in the DSM-III (1980), the term sexual deviation was used to refer to paraphilias in the first two editions of the manual.[21] In 1981, an article published in American Journal of Psychiatry described paraphilia as "recurrent, intense sexually arousing fantasies, sexual urges, or behaviors generally involving" the following:[22]

Homosexuality, now widely accepted as a variant of human sexuality, was at one time discussed as a sexual deviation.[23] Sigmund Freud and subsequent psychoanalytic thinkers considered homosexuality and paraphilias to result from psychosexual non-normative relations to the Oedipal complex.[24] As such, the term sexual perversion or the epithet pervert have historically referred to gay men, as well as other non-heterosexuals (people who fall outside the perceived norms of sexual orientation).[23][24][25][26]

By the mid-20th century, mental health practitioners began formalizing "deviant sexuality" classifications into categories. Originally coded as 000-x63, homosexuality was the top of the classification list (Code 302.0) until the American Psychiatric Association removed homosexuality from the DSM in 1973. Martin Kafka writes, "Sexual disorders once considered paraphilias (e.g., homosexuality) are now regarded as variants of normal sexuality."[25]

A 2012 literature study by clinical psychologist James Cantor, when comparing homosexuality with paraphilias, found that both share "the features of onset and course (both homosexuality and paraphilia being life-long), but they appear to differ on sex ratio, fraternal birth order, handedness, IQ and cognitive profile, and neuroanatomy". The research then concluded that the data seemed to suggest paraphilias and homosexuality as two distinct categories, but regarded the conclusion as "quite tentative" given the current limited understanding of paraphilias.[26]

The causes of paraphilias in people are unclear, but some research points to a possible prenatal neurodevelopmental correlation. A 2008 study analyzing the sexual fantasies of 200 heterosexual men by using the Wilson Sex Fantasy Questionnaire exam determined that males with a pronounced degree of fetish interest had a greater number of older brothers, a high 2D:4D digit ratio (which would indicate excessive prenatal estrogen exposure), and an elevated probability of being left-handed, suggesting that disturbed hemispheric brain lateralization may play a role in paraphilic attractions.[27]

Behavioral explanations propose that paraphilias are conditioned early in life, during an experience that pairs the paraphilic stimulus with intense sexual arousal.[28] Susan Nolen-Hoeksema suggests that, once established, masturbatory fantasies about the stimulus reinforce and broaden the paraphilic arousal.[28]

Some groups, seeking greater understanding and acceptance of sexual diversity, have lobbied for changes to the legal and medical status of unusual sexual interests and practices. Charles Allen Moser, a physician and advocate for sexual minorities, has argued that the diagnoses should be eliminated from diagnostic manuals.[30]

Albert Eulenburg (1914) noted a commonality across the paraphilias, using the terminology of his time, "All the forms of sexual perversion...have one thing in common: their roots reach down into the matrix of natural and normal sex life; there they are somehow closely connected with the feelings and expressions of our physiological erotism. They are...hyperbolic intensifications, distortions, monstrous fruits of certain partial and secondary expressions of this erotism which is considered 'normal' or at least within the limits of healthy sex feeling."[31]

The clinical literature contains reports of many paraphilias, only some of which receive their own entries in the diagnostic taxonomies of the American Psychiatric Association or the World Health Organization.[32][33] There is disagreement regarding which sexual interests should be deemed paraphilic disorders versus normal variants of sexual interest. For example, as of May 2000, per DSM-IV-TR, "Because some cases of Sexual Sadism may not involve harm to a victim (e.g., inflicting humiliation on a consenting partner), the wording for sexual sadism involves a hybrid of the DSM-III-R and DSM-IV wording (i.e., "the person has acted on these urges with a non-consenting person, or the urges, sexual fantasies, or behaviors cause marked distress or interpersonal difficulty")".[34]

Consensual adult activities and adult entertainment involving sexual roleplay, novel, superficial, or trivial aspects of sexual fetishism, or incorporating the use of sex toys are not necessarily paraphilic.[35] Paraphilial psychopathology is not the same as psychologically normative adult human sexual behaviors, sexual fantasy, and sex play.[37]

Clinicians distinguish between optional, preferred and exclusive paraphilias,[38] although the terminology is not completely standardized. An "optional" paraphilia is an alternative route to sexual arousal. In preferred paraphilias, a person prefers the paraphilia to conventional sexual activities, but also engages in conventional sexual activities.

In American psychiatry, prior to the publication of the DSM-I, paraphilias were classified as cases of "psychopathic personality with pathologic sexuality". The DSM-I (1952) included sexual deviation as a personality disorder of sociopathic subtype. The only diagnostic guidance was that sexual deviation should have been "reserved for deviant sexuality which [was] not symptomatic of more extensive syndromes, such as schizophrenic or obsessional reactions". The specifics of the disorder were to be provided by the clinician as a "supplementary term" to the sexual deviation diagnosis; there were no restrictions in the DSM-I on what this supplementary term could be.[41] Researcher Anil Aggrawal writes that the now-obsolete DSM-I listed examples of supplementary terms for pathological behavior to include "homosexuality, transvestism, pedophilia, fetishism, and sexual sadism, including rape, sexual assault, mutilation."[42]

The DSM-II (1968) continued to use the term sexual deviations, but no longer ascribed them under personality disorders, but rather alongside them in a broad category titled "personality disorders and certain other nonpsychotic mental disorders". The types of sexual deviations listed in the DSM-II were: sexual orientation disturbance (homosexuality), fetishism, pedophilia, transvestitism (sic), exhibitionism, voyeurism, sadism, masochism, and "other sexual deviation". No definition or examples were provided for "other sexual deviation", but the general category of sexual deviation was meant to describe the sexual preference of individuals that was "directed primarily toward objects other than people of opposite sex, toward sexual acts not usually associated with coitus, or toward coitus performed under bizarre circumstances, as in necrophilia, pedophilia, sexual sadism, and fetishism."[43] Except for the removal of homosexuality from the DSM-III onwards, this definition provided a general standard that has guided specific definitions of paraphilias in subsequent DSM editions, up to DSM-IV-TR.[44]

The DSM-III-R (1987) renamed the broad category to sexual disorders, renamed atypical paraphilia to paraphilia NOS (not otherwise specified), renamed transvestism as transvestic fetishism, added frotteurism, and moved zoophilia to the NOS category. It also provided seven nonexhaustive examples of NOS paraphilias, which besides zoophilia included exhibitionism, necrophilia, partialism, coprophilia, klismaphilia, and urophilia.[45]

The DSM-IV (1994) retained the sexual disorders classification for paraphilias, but added an even broader category, "sexual and gender identity disorders," which includes them. The DSM-IV retained the same types of paraphilias listed in DSM-III-R, including the NOS examples, but introduced some changes to the definitions of some specific types.[44]

The DSM-5 acknowledges that many dozens of paraphilias exist, but only has specific listings for eight that are forensically important and relatively common. These are voyeuristic disorder, exhibitionistic disorder, frotteuristic disorder, sexual masochism disorder, sexual sadism disorder, pedophilic disorder, fetishistic disorder, and transvestic disorder.[2] Other paraphilias can be diagnosed under the Other Specified Paraphilic Disorder or Unspecified Paraphilic Disorder listings, if accompanied by distress or impairment.[51] 781b155fdc