Therapy for Sexual Impulsivity: The Paraphilias and Paraphilia-Related Disorders

Paraphilias as defined by DSM-IV, are sexual impulse disorders characterized by intensely arousing, recurrent sexual fantasies, urges and behaviors (of at least six months' duration) that are considered deviant with respect to cultural norms and that produce clinically significant distress or impairment in social, occupational or other important areas of psychosocial functioning. The common paraphilias described include exhibitionism (exposure of genitals to a stranger), pedophilia (sexual activity with a prepubescent child, generally 13 years of age or younger), voyeurism (observing others' sexual activities), fetishism (use of inert objects, such as female undergarments), transvestic fetishism (cross-dressing), sexual sadism (inflicting suffering or humiliation), sexual masochism (being humiliated, beaten, bound or made to suffer) and frotteurism (touching, rubbing against a nonconsenting person). Although several of these disorders can be associated with aggression or harm, others are neither inherently violent nor aggressive (e.g., fetishism, transvestic fetishism). Paraphilias are predominantly male sexuality disorders with an estimated sex differences ratio of 20:1 in sexual masochism. (The other paraphilias are almost never diagnosed in females, although some cases have been reported-Ed.) There is a second group of sexual impulse disorders not currently classified as paraphilias because the particular sexual behaviors affected are not considered "deviant" with respect to contemporary cultural norms. I have proposed to designate these disorders as paraphilia-related disorders (Kafka 1994a) based on the following clinical data: