Section 7. Mental Health Disorders

Chapter 104. Sexuality

Topics: Introduction | Gender Identity | Paraphilias

Paraphilias

Paraphilias are attractions that in extreme forms are socially unacceptable deviations from the traditionally held norms of sexual relationships and attractions.

The key features of a paraphilia include repetitive, intense, sexually arousing fantasies or behaviors that usually involve objects (for example, shoes, underwear, leather or rubber products), the infliction of suffering or pain on oneself or one's partner, or having sex with nonconsenting people (for example, with children, with helpless people, or in rape situations). Once these arousal patterns are established, usually in late childhood or near puberty, they are often lifelong.

Some degree of variety is very common in healthy adult sexual relationships and fantasies. When people mutually agree to engage in them, noninjurious sexual behaviors of an unusual nature may be an intrinsic part of a loving and caring relationship. When taken to the extreme, however, such sexual behaviors are paraphilias, psychosexual disorders that seriously impair the capacity for affectionate, reciprocal sexual activity. Partners of people with a paraphilia may feel like an object or as if they are unimportant or unnecessary in the sexual relationship.

Paraphilias may take the form of fetishism, transvestic fetishism, pedophilia, exhibitionism, voyeurism, masochism, or sadism, among others. Most people with paraphilias are men, and many have more than one type of paraphilia.

Fetishism

In fetishism, sexual activity makes use of physical objects (the fetish), sometimes in preference to contact with humans. People with fetishes may become sexually stimulated and gratified by wearing another person's undergarments, wearing rubber or leather, or holding, rubbing, or smelling objects, such as high-heeled shoes. People with this disorder may not be able to function sexually without their fetish.

Transvestic Fetishism

In transvestic fetishism, a man prefers to wear women's clothing, or, far less commonly, a woman prefers to wear men's clothing (cross-dressing). In neither case, however, does the person wish to change his or her sex, as transsexuals do. Cross-dressing is not always considered a mental health disorder and may not adversely affect a couple's sexual relationship.

Transvestic fetishism is a disorder only if it causes distress, results in impairment of some type, or involves "daredevil" behavior likely to lead to injury, loss of a job, or imprisonment. Transvestites also cross-dress for reasons other than sexual stimulation, for example, to reduce anxiety, to relax, or, in the case of male transvestites, to experiment with the feminine side of their otherwise male personalities.

Pedophilia

Pedophilia is a preference for sexual activity with young children. In Western societies, pedophilia is defined as sexual fantasy about or sexual relations with a child younger than 13 by a person 16 or older. Some pedophiles are attracted only to children, often of a specific age range or developmental stage, whereas others are attracted to both children and adults.

Although state laws vary, the law generally considers a person older than 18 to be committing statutory rape if the victim is 16 or younger. Statutory rape cases often do not meet the definition of pedophilia, highlighting the somewhat arbitrary nature of selecting a specific age cutoff point in a medical or legal definition.

Pedophilia is much more common among men than among women. Both boys and girls can be victims, although more reported cases involve girls. Pedophiles may focus only on children within their families (incest), or they may prey on children in the community. Force or coercion may be used to engage children sexually, and threats may be invoked to prevent disclosure by the victim.

Pedophilia can be treated with psychotherapy and drugs that alter the sex drive, with varying results. Such treatment may be sought voluntarily or only after criminal apprehension and legal action. Incarceration, even long-term, does not change pedophilic desires or fantasies.

Exhibitionism

In exhibitionism, a person (usually male) exposes his genitals to unsuspecting strangers and becomes sexually excited when doing so. Further sexual contact is almost never sought, so exhibitionists rarely commit rape. Most exhibitionists are younger than 40 and may or may not be married. Exposure of genitals to unsuspecting strangers for sexual excitement is rare among women. Provocative dressing by women is increasingly accepted by society as normal. In addition, social venues in which women can expose themselves are not uncommon, and such behavior may not constitute a mental health disorder.

Voyeurism

In voyeurism, a person becomes sexually aroused by watching someone who is disrobing, naked, or engaged in sexual activity. It is the act of observing (peeping) that is arousing, not sexual activity with the observed person. Some degree of voyeurism is particularly common, more among boys and men but increasingly among women. Society often regards mild forms of this behavior as normal. As a disorder, voyeurism is much more common among men; it may become the preferred method of sexual activity and consume countless hours of watching. The amount and variety of sexually explicit materials and shows available to men and women have increased significantly, but engaging in these activities lacks the element of secret observation that is the hallmark of voyeurism. The Internet has made voyeurism easier to engage in without the neighborhood prowling traditionally associated with this behavior.

Sexual Masochism and Sadism

Sexual masochism involves acts in which a person derives sexual excitement from being humiliated, beaten, bound, or otherwise abused. Sexual sadism involves acts in which a person derives sexual pleasure from inflicting physical or psychologic suffering on another person. Some people act out their sadistic urges with a consenting partner (who may have sexual masochism); rarely, some act them out on nonconsenting victims. Fantasies of total control and dominance are often important, and the sadist may bind and gag the partner in elaborate ways.

Some amount of sadism and masochism is commonly play-acted in healthy sexual relationships, and mutually compatible partners often seek one another out. For example, the use of silk handkerchiefs for simulated bondage and mild spanking during sexual activity are common practices between consenting partners and are not considered sadomasochistic.

In contrast, the disorder of sexual masochism or of sexual sadism takes these acts to an extreme and can result in severe bodily or psychologic harm and even death. For example, masochistic sexual activity may involve asphyxiophilia, whereby the person is partially choked or strangled (either by a partner or by the self-application of a noose around the neck). A temporary decrease in oxygen to the brain at the point of orgasm is sought as an enhancement to sexual release, but the practice may accidentally result in death.