The Natural History of the Paraphilias

John M.W. Bradford, MD, DPM, FFPsych, DABFP, FRCPC, CMjohn.Bradford@theroyal.ca,     Institute of Mental Health Research, University of Ottawa, Brockville Mental Health Centre (BMHC), 1804 Highway 2 East, Brockville, Ontario, K6V 5W7, Canada

A.G. Ahmed, MBBS, LLM, MSc, MPsychMed, MRCPsych, FRCPCag.ahmed@theroyal.ca,     Institute of Mental Health Research, University of Ottawa, Brockville Mental Health Centre (BMHC), 1804 Highway 2 East, Brockville, Ontario, K6V 5W7, Canada

Human sexual behavior is partly the expression of a basic biological drive, the sex drive. Sex drive requires an internal hormonal environment that allows the physiologic expression of sexual behavior. Sexual behaviors principally are there to preserve the species, but in humans, sexual behavior is far more complicated and is associated with our complex social behavior, including emotional expression, emotional bonding, and even to a certain extent, part of recreational activity. Human sexual behavior is linked to and based on neurohormonal development starting in utero and continuing through puberty until the final expression of the behavior occurs in the postpubertal period. Without going into all the neurohormonal factors, androgenization of the male brain occurs at roughly the sixth week of intrauterine life and the male brain is primed differently for males as opposed to females. As androgenization of the brain only occurs in males and deviant sexual behavior is far more common in males at a theoretical level, the androgenization of the brain and the male sexual drive flowing from this neurohormonal process are most likely connected to deviant sexual behavior. Up until puberty, sexual behaviors are experimental and exploratory for the most part. At the time of puberty, with the surge of sexual hormones, sexual drive starts to increase and human sexual behavior becomes activated starting with seeking out a partner for sexual gratification. Individuals are most commonly heterosexual; some are homosexual and some are bisexual. Although this is not fully understood, it does not appear that sexual orientation is learned behavior but is most likely an innate process driven by some complex interactions between androgenization of the brain and neurohormonal changes. In most people sexual behavior then becomes part of their behavioral repertoire as they go forward in life, including establishing relationships and procreation.

A relatively small number of individuals have sexual behavior that deviates significantly from the norm. They go through the same prepubertal period and undergo the same increase in sexual drive as in normal individuals at the time of puberty. The direction of the sexual drive is outside of the normal and is regarded as a sexual deviation, such as the attraction to prepubertal children (pedophilia). This sexual preference manifests as deviant sexual behavior. Even today, we have no real idea as to the prevalence of the various sexual deviations, although some rough estimates have been made for pedophilia. It has always been difficult to estimate prevalence because these behaviors occur in a relatively small number of individuals. Second, as the behavior is deviant from the norm, the behaviors are usually hidden from others and also the behavior may modify with changes in the general structure of society. One of the most recent examples of this is the growth of individuals who seek out child pornography on the Internet. Before the Internet, child pornography was not readily available in print media format. Now, with the development of digital media and the development of the Internet specifically, the access and distribution of child pornography images and videos are much more widespread. One of the questions this raises is whether this is an indication of the prevalence of pedophilia in our current society or is this simply a product of individuals exploring the Internet to view a wide spectrum of digital media depicting sexual acts. Most likely there is a combination of motivations to view pornography on the Internet, including child pornography. Therefore, most likely, not all individuals who view child pornography on the Internet are pedophiles.

Most sexual deviations are regarded as problematic sexual behavior and often involve engaging with nonconsenting individuals, which means it becomes criminal in nature. This means that a number of individuals who have a problem with deviant sexual behavior are also sexual offenders. However, not all sexual offenders have a sexual deviation or paraphilia. In DSM II, sexual deviation was regarded as a personality disorder, but from the evolution of DSM III, it was classified as a psychiatric disorder on Axis I of DSM IIIR1 and then DSM IV and DSM IVTR.2 The development of the concept of paraphilia was based on the deviation (“para”) and the attraction to the deviation, which is defined by the “philia.” In DSM IIIR, paraphilias indicated that unusual or bizarre imagery or acts were necessary for sexual excitement and, in addition, these imagery and acts were persistent and involuntarily repetitive and involved (1) preference for use of nonhuman object; (2) repetitive sexual activity with humans involving real or simulated suffering or humiliation; or (3) repetitive sexual activity with nonconsenting partners. Clearly, this last operational definition involves criminal activity by definition. What was also not clearly defined is that many individuals who have a problem with a sexual deviation also have completely normal sexual behavior. Their sexual preference may be toward the sexual deviation as opposed to a normal sexual outlet but nonetheless both can exist in any given individual.

It also became clear early on that individuals suffering from a paraphilia usually had more than one paraphilia present.3 In fact, individuals often suffered from two or more paraphilias on a consistent basis and there was a considerable overlap between the different types of paraphilias.3 This clearly had implications for treatment. The most common form of treatment was psychological and, specifically, behavioral treatment. This type of approach required a specific treatment program for each paraphilia administered one at a time. Psychological treatment involving this technique therefore was more complicated and more prolonged. Pharmacologic treatment started to develop with the principal aim of treatment being the suppression of sexual drive. Sexual drive includes sexual fantasies and urges as well as behavior and all of these elements were suppressed with the pharmacologic intervention. Furthermore, the suppression of deviant sexual fantasies urges and behavior was across the board for any paraphilias that were present in any given individual. The expression of paraphilias also has some cultural dimensions. Frotteurism, inappropriate touching of the nonconsenting female, is not acceptable in North American culture, whereas in some European cultures it may be acceptable.

DSM IV principally maintained the definitions of the paraphilias in DSM III and DSM IIIR.1,2 However, with the development of DSM V, there has been a considerable shift from DSM IV.4 There is now differentiation between a paraphilia and a paraphilic disorder. Paraphilia denotes any intense and persistent sexual interest other than sexual interest in genital stimulation or preparatory fondling between phenotypically the normal physically mature, consenting partners.4 Paraphilic disorder is a paraphilia that is causing distress or impairment to the individual or a paraphilia whose satisfaction has entailed personal harm, or risk of harm, to others.4 The paraphilic disorders consist of voyeuristic disorder; exhibitionistic disorder; frotteuristic disorder; sexual masochism disorder; sexual sadism disorder; pedophilic disorder; fetishistic disorder; and transvestic disorder.4 There are other paraphilic disorders that are not specifically named.4 The first group of disorders is based on anomalous activity preferences.4 These are further divided into courtship disorders (voyeuristic disorder, exhibitionistic disorder, and frotteuristic disorder) and algolagnic disorders (sexual masochism disorder and sexual sadism disorder). The second group of disorders is based on anomalous target preferences (pedophilic disorder, fetishistic disorder, and transvestic disorder).4 The actual diagnostic criteria for paraphilic disorders remained mostly the same. The qualitative nature of the paraphilia (criterion A) means that recurrent and intense sexual arousal must be present for at least six months. Criterion B requires that the individual has acted on the sexual urges with a nonconsenting person, or the sexual urges or fantasies cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. In summary, deviant arousal patterns are accompanied by clinically significant distress or impairment. To meet the criteria for a paraphilic disorder, the individual must meet both criterion A and criterion B.

Although the etiology of the paraphilias is not understood, the possibility of neurohormonal difficulties and a genetic predisposition has been explored.5,6 At this time, the actual cause of the paraphilias is unknown.5,7

More recently, a task force of the World Federation...