Paraphilic Disorder
What is abnormal sexual behavior? There is great variability from one culture to the next, making it difficult to come up with a reasonable set of criteria for what is abnormal. Some of the approaches are statistical definition, sociological approach, psychological approach, and medical approach.

A paraphilia is an atypical source of sexual attraction, arousal, or gratification. That is recurring, unconventional sexual behavior that is obsessive and compulsive. There are over 500 types of paraphilias.

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Paraphilia matching game.JPG

(2007, Dustin Glick) (Masheka Wood & Mikhela Reid)

Paraphilic Disorder is a paraphilia that is currently causing distress or impairment to the individual or a paraphilia whose satisfaction has entailed personal harm or risk of harm, to others. A Paraphilia is a necessary but not a sufficient condition for having a Paraphilic disorder, and a paraphilia by itself does not necessarily justify or require clinical intervention.

Know the Difference


Fetish/Fetishes is an attraction to body parts or inanimate objects, is actually a type of paraphilia however not all Paraphilias are fetishes, but all fetishes are Paraphilias. We will be discussed more in depth below

Kink/Kinky is an unconventional sexual taste or behavior, a non-disordered Paraphilia.
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(Jamie Hewlett) (Monstar)




DSM-5
Diagnostic Criteria for Paraphilic Disorders

Criterion A specifies the qualitative nature of the Paraphilia (e.g., an erotic focus on children or on exposing the genitals to strangers)

Criterion B specifies the negative consequences of the paraphilia (i.e., distress, impairment, or harm to others).

The DSM focuses on 8 Paraphilic disorders

The Big 8

  1. Voyeuristic disorder
  2. Exhibitionistic disorder
  3. Frotteuristic disorder
  4. Sexual masochism disorder
  5. Sexual sadism disorder
  6. Pedophilic disorder
  7. Fetishistic disorder
  8. Transvestic disorder


Fun Fact: A recent German population sample found that 62.4% of men reported sexual arousal to at least one of the DSM-5 paraphilias (Ahlers, 2011).


Anomalous Activity Preferences(deviating from what is standard)

Courtship disorders(Dysfunctional human courtship)

Voyeuristic Disorder

Spying on others in private activities

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(DSM5)
  • Most common law breaking sexual behavior
  • The highest possible lifetime prevalence for voyeuristic disorder is approximately 12% of males and 4% of females. (Långström & Seto, 2006).
  • Male-to-female ratio for single sexually arousing voyeuristic acts might be 3:1(Långström & Seto, 2006).
  • Minimum age for diagnosis is 18 due to differentiation between sexual curiosity of adolescence or puberty and a disorder


Etiology:
  • Childhood sexual abuse
  • Substance misuse
  • Hypersexuality


Exhibitionistic Disorder

Exposing the genitals

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(DSM5)
  • Highest possible prevalence for exhibitionistic disorder in the male population is 2%–4 % (Murphy & Page, 2008).

Etiology:
  • The history of antisocial behavior
  • Alcohol misuse
  • Pedophilic sexual preference
  • Sexual or emotional abuse (childhood)
  • Hypersexuality

Literature Review:


  • Horley, J. (1995). Cognitive-behavioral therapy with an incarcerated exhibitionist.
International Journal of Offender Therapy and Comparative Criminology, 39(4),
335-339

Case study using CBT was found to be similarly effective with child molesters, with an adult male, incarcerated, exhibitionist. Of the paraphilias, exhibitionism manifests infrequent offenses although minimal trauma for victims. One-third of all sexual offenses in the US, Canada, and UK involve exhibitionism. The first component of CBT was a relapse prevention approach that highlighted negative emotions, victim empathy, trigger avoidance, decision-making, and creating a network of support. Addressing inappropriate sexual fantasies and sexual responses, as well as family work, comprised the second phase of CBT, including assessing his level of appropriate and inappropriate arousal. Fantasies were phased out through covert sensitization. Post-assessment shows a decrease in inappropriate arousal, but a marked increase inappropriate arousal.


Frotteuristic Disorder

Touching or rubbing against a non-consenting individual

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(DSM5)
    • May occur in up to 30% of adult males in the general population (Långström, 2010; Lussier & Piché, 2008).
    • Approximately 10%–14% of adult males seen in outpatient settings for paraphilic disorders and Hypersexuality have a presentation that meets diagnostic criteria for frotteuristic disorder (Abel et al., 1988; Kafka, 2010).

Etiology:
    • A history of antisocial behavior
    • Hypersexuality



Algolagnic Disorders(Pain and suffering)


Sexual Masochism Disorder

Undergoing humiliation, bondage, or suffering

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(DSM5)
    • In Australia, it has been estimated that 2.2% of males and 1.3% of females had been involved in bondage and discipline, sadomasochism, or dominance and submission in the past 12 months (Richters et al., 2008).
    • (Abel et al. 1993) have reported a mean age at onset for masochism of 19.3 years
    • Masochists are at risk of accidental death while practicing asphyxiophilia (Hucker, 2011). or other autoerotic procedures (Cairns & Ranier, 1981).

Etiology:
    • Hypersexuality
    • Sexual impulsivity
    • Psychosocial impairment
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(Le Lievre)


Literature Review


    • Abrams, M., & Stefan, S. (2012). Sexual abuse and masochism in women: Etiology And
the treatment. Journal of Cognitive and Behavioral Psychotherapies, 12(2),
231-239.
Approaches sexual masochistic disorders from a Biopsychosocial framework to determine etiology. This case study looks at three female clients who experienced sexual abuse as children. All three achieve arousal through pain and humiliation experienced during sex. Examined the hypothesis that masochism became an adaptive response to the stimulus of the abuse or a manifestation of Money’s theory of a love map of sexual symbols that cause arousal extraneous from a person. The women in this case were treated with Rational Emotive Behavior Therapy (REBT), which is similar to Dialectical Behavioral Therapy (DBT). All three women had a comorbidity of borderline personality disorder (BPD) and DBT is the gold standard treatment for BPD. Each case showed an improvement in their desire for masochistic sexual acts after an improvement of emotional control and self-regulation was achieved.

    • Khodayarifard, M., Pritz, A., Alavi, S. M., & Abedini, Y. (2013). A case study of
cognitive-behavior therapy in Iran: Treatment of sexual masochism along with
co-morbid disorders in a collectivist society. International Journal of
Psychotherapy, 17(1), 53-63.
This article specifically looks at the traits specific to masochism, which involves the suffering or humiliation of oneself or one's partner. This sexual partner can be children, non-consenting persons, and non-human objects. Research in this demographic suggests that psychotherapy consisting of behavior therapy, cognitive therapy, or CBT are effective. Commonly used instruments for assessment within the study are the Beck Depression Inventory (BDI), Minnesota Multiphasic Personality Inventory (MMPI), and the Symptom Checklist-90-Revised (SCL-90-R) to determine the effectiveness of treatment.


Sexual Sadism Disorder

Inflicting humiliation, bondage, or suffering

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(DSM5)


    • Depending on the criteria for sexual sadism, prevalence varies widely, from 2% to 30% (Krueger, 2010).
    • Among civilly committed sexual offenders in the United States, less than 10% have sexual sadism. Among individuals who have committed sexually motivated homicides, rates of sexual sadism disorder range from 37% to 75% (Krueger, 2010).
    • Individuals with sexual sadism in forensic samples are almost exclusively male (Krueger, 2010), but a representative sample of the population in Australia reported that 2.2% of men and 1.3% of women said they had been involved in bondage and discipline, “sadomasochism,” or dominance and submission in the previous year (Richters et al., 2008).
    • (Abel et al., 1988). reported that the mean age at onset of sadism in a group of males was 19.4 years


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(Someecards)


Know the Difference


BDSM-Bondage Discipline Sadism Masochism

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(Spankart)


Bondage and discipline (B-D)—Sexual bondage, the use of restraining devices that have a sexual significance, has been a staple of erotic fiction and art for centuries.

Dominance and submission (D-S)—The D-S act is not a wild outbreak of violence, but rather role-playing where people act as master, slave, naughty child, etc.

What do you think? BDSM activists object to receiving any kind of diagnosis for behavior that is judged as pathological based on social prejudice as opposed to empirical evidence. Do you agree? Could the same be said for Fetishistic Disorder and Transvestic Disorder?

    • Parents have lost custody disputes or individuals who have lost jobs or civil rights due to DSM diagnoses object strongly to the diagnosis of paraphilias, particularly given that most paraphilias cause no distress or dysfunction
    • Fun fact: In over 400,000,000 visits to primary care physicians in the U.S., not one case was diagnosed sexual sadism or Sexual masochism (Krueger, 2009).
    • Most of the BDSM community has stated that not only is Fifty Shades of Grey is NOT a good representation of BDSM, but also crosses legal lines of consent and stalking. Here are some examples from the book.

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(Quotes from Fifty Shades of Grey by EL James, Photo Still from Fifty Shades of Grey Motion Picture, compiled by Angie Aker)



Anomalous target preferences
(Targeted at other people)

Pedophilic Disorder

Sexual focus on children

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(DSM5)
    • Involving sexual activity with a prepubescent child or children
    • The highest possible prevalence for pedophilic disorder in the male population is approximately 3%–5 % ( Seto, 2008b; Seto, 2009).
    • Adult males with pedophilia often report that they were sexually abused as children (Cohen & Galynker, 2002; Hall & Hall, 2007; Seto, 2008b).
    • Minimum age for diagnosis is 16 due to differentiation between sexual curiosity of adolescence or puberty and a disorder
    • Also distinction of 5 years age difference

Etiology:
    • Childhood sexual abuse
    • Substance misuse
    • Hypersexuality
    • Antisocial behavior
    • Neurodevelopment perturbation in utero

Know the Difference


Hebephilia is the primary or exclusive adult sexual interest in pubescent individuals

Ephebophilia is the primary or exclusive adult sexual interest in mid-to-late adolescents, generally ages 15 to 19

Teleiophlie is the primary sexual interest in adults

Pedophile has pedophilic disorder and is exclusively attracted to children sexual interest

Child Molester is a person who actually touches a child sexually; criminal offense

Gold Star Pedophile (Savage, 2010) is a pedophile that never acts on his interest and spends life actively resisting it.

Not all pedophiles are child molesters and not all child molesters are pedophiles



Don't Offend: Therapeutic treatment of people who feel sexually attracted to children is effective to prevent child sexual abuse.



This scene is from "The Woodsman" movie, during which Kevin Bacon plays the role of a child molester trying to recover

Facts:
(Cantor & Blanchard, 2004)
    • There is no data that suggests a pedophile might be converted
    • Pedophiles Perform lower on IQ and other Neuropsychological tests
    • Pedophiles have a significant difference in the gray and white matter of the brain
    • Majority Pedophiles have a history of head injuries during childhood
    • Are usually shorter in height indicating developmental issues
    • More likely to be right-handed indicating issues with prenatal brain development
    • The was a study where sex offender were first asked if sexually abused during childhood 67% said yes, they were then told that they would be asked the same question but with a polygraph (lie detector) then only 29% then claimed to have been abused. (Hindman, 1998).

Literature Review:


    • Seto, M. C., & Ahmed, A. G. (2014). Treatment and management of child Pornography

use. Psychiatric Clinics of North America, 37(2), 207-214.

Approach to treating individuals who access child pornography are the same regardless if whether it is a part of (a) their pattern of hypersexual or compulsive behavior or (b) their sexual interests in children. This treatment consists of emphasizing increased self-regulation skills in the sexual domain through CBT, as well as utilizing sex drive–reducing medications. Sexual self-regulation deficits are the one domain where child pornography offenders have been found to score higher than contact sex offenders.

    • Saleh, F. M. (2005). Issues to Consider in the Assessment and Treatment of Paraphilic

Patients. Journal of Clinical Psychiatry, 66(6), 802-803.



Case study of a patient with pedophilic disorder who relapsed during hormone treatment. This looks at the ethical considerations for therapists treating this population.

    • Jahnke, S., Philipp, K., & Hoyer, J. (2015). Stigmatizing attitudes towards people With

pedophilia and their malleability among psychotherapists in training. Child Abuse

& Neglect, 4093-102.


This research addresses stigma around working with clients with pedophilic disorder and the importance of reducing that stigma in an effort to prevent child sexual abuse. Despite the significance of therapy in helping pedophilics refrain from acting on their desires, a survey done in Germany showed that 9% of therapists were unwilling to work with that demographic. A US survey of people with pedophilia listed expectations of negative treatment as their number one reason for not seeking care. A stigma reduction program was implemented online for therapists in training for CBT. Effectiveness of reducing stigma was determined through the Stigma Inventory, which has a Cronbach’s of .82 and the Therapy Motivation Scale, Cronbach’s a of .85. Although results were unclear as to whether beliefs around remission changed within the therapist, results for the effect of the therapist improved towards the person with pedophilia.

    • Walter, M., Witzel, J., Wiebking, C., Gubka, U., Rotte, M., Schiltz, K., Bermpohl, F.,

Tempelmann, C., Bogerts, B., Heinze, H.J., & Northoff, G. (2007). Pedophilia is

linked to reduced activation in the hypothalamus and lateral prefrontal cortex

during visual erotic stimulation. Biological Psychiatry, 62.698-701.


Looks at thirteen different brain images to examine the deficits in the sexual and emotional arousal towards adults within people with pedophilia. Results showed a decrease in activations during sexually appropriate stimulus that could indicate impairment that causes this sexual dysfunction.


Fetishistic Disorder

Using nonliving objects or having a highly specific focus on non-genital body parts


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    • Fetishistic disorder associated with an inanimate object (e.g., female undergarments) or an exclusive focus on an intensely eroticized body part (e.g., feet, hair), or their fetishistic interest may meet criteria for various combinations of these specifiers (e.g., socks, shoes and feet).
    • Although fetishistic disorder is relatively uncommon among arrested sexual offenders with paraphilias (Abel & Osborn, 1992; Gebhard et al., 1965a; Gebhard et al., 1965b), males with fetishistic disorder may steal and collect their particular fetishistic objects of desire (Chalkley & Powell, 1983; Gebhard et al., 1965b). Such individuals have been arrested and charged for nonsexual antisocial behaviors (e.g., breaking and entering, theft, burglary) that are primarily motivated by the fetishistic disorder.
    • Fetishistic disorder is not diagnosed when fetish objects are limited to articles of clothing exclusively worn during cross-dressing (as in transvestic disorder), or when the object is genitally stimulating because it has been designed for that purpose (e.g., a vibrator).
    • Multisensory experience; during masturbation or during sexual encounters

Fun Facts:
    • As of 2012 fetlife.com listed 1,243,518 members Fetlife
    • A pair of high heels may be the world's favorite fetish, according to the largest ever study of sexual kinks. Asked to name their favorite body parts, sexually speaking, 47% of those asked named feet and toes; where objects related to the body were concerned, footwear polled 64%. Other objects that people were turned on by included hearing aids and pacemakers
    • Whiplr is Tinder for the fetish-driven Whiplr


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(Bedsider.org)


TLC: Strange Sex

Fetish Wrestler




Date with Feet Aroma Fetishist:




Literature Review:


    • Firoz, K., Sankar, V. N., Rajmohan, V., Kumar, G. M., & Raghuram, T. M. (2014).
Treatment of fetishism with naltrexone: A case report. Asian Journal Of
Psychiatry, 867-68


Case report of a 40-year-old married man who had persistent urges to masturbate into women’s undergarments. He was able to have intercourse with his wife daily but reported having more sexually gratifying orgasms when he acted on his fetish. He and his wife were seen as inpatients, where he was put on a daily regimen of fluoxetine and naltrexone. Therapist also ascertained a detailed history of sexual fantasies, experiences, cues and triggers for fetish behaviors, and previous attempts at solution. Following discharge, client reported a significant decrease in his urges, however also had a decreased libido and DE, which interfered with his normal sex life with his wife. They withdrew the fluoxetine and continued him on a dose of naltrexone. Results suggest there is room to research naltrexone as a substitute for antiandrogens that have adverse effects, and SSRI’s that reduce their normal sex drive.

    • Sarver, N. W., & Gros, D. F. (2014). A modern behavioral treatment to address fetishism
and associated functional impairment. Clinical Case Studies, 13(4),

Reports utilizing CBT and sensate focus therapy on a 57-year-old male veteran. Client self-reported having urges regarding women’s feet before joining the Army. While overseas he looked for ways to fulfill his urges but was alarmed by the prevalence of STI’s among the prostitutes. Therefore, he hired these prostitutes to step on his stomach while he masturbated in order to engage in safe sex. However, this repetitive act is believed to have conditioned him to achieve sexual arousal and satisfaction by this means of “stomach trampling.” Despite the extensive history of clinical care due to PTSD and anxiety/depression, no clinician has ever talked to him about his fetish regardless of him reporting distress. The cognitive portion of CBT was not highlighted due to his difficulty with attention and concentration, however values-based behavioral activation approach and sensate focused therapy were used to increase socially appropriate activities again and increase appropriate sexual behaviors with his wife. The final session of this brief therapy model consisted of couples work to improve communication, including making a list of sexual activities and ranking them from most arousing to least arousing to find a common list of mutually satisfying activities. Results suggest that fetishism was successfully treated to the extent that the client reported no more distress and an increased involvement in appropriate activities.

    • Widerman, M. W. (2003). Paraphilia and fetishism. The Family Journal, 11, 315-323.

review of available treatments, including a look into etiology. Highlighted.


Transvestic Disorder

Engaging in sexually arousing cross-dressing

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    • The presence of fetishism decreases the likelihood of gender dysphoria in men with a transvestic disorder (Blanchard, 2010). The presence of autogynephilia increases the likelihood of gender dysphoria in men with a transvestic disorder (Blanchard, 2010).
    • Fewer than 3% of males report having ever been sexually aroused by dressing in women’s attire (Långström & Zucker, 2005).
    • Transvestic disorder may begin in childhood, in the form of strong fascination with a particular item of women’s attire

Fun facts:
    • Most cross dressers are not homosexual; they are attracted to women and strive for their approval
    • There is a company that makes lingerie just for men: hommemystere

Commercial for that company



    • Famous crossdressers include Iggy Pop, Eddie Izzard, and Dennis Rodman.


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(Randee St. Nicholas) (FCKH8.com)(MommeMystere)


Know the Difference


Gender Dysphoria - People who experience significant dysphoria (discontent) with the sex and gender they were assigned at birth

Drag queens- homosexuals who dress up for the stage

Crossdressers -want to actually look and act like natural women

Transgender -is a gender identity or gender expression not matching one's assigned sex.

Transsexual -A person who has undergone hormone treatment and surgery to attain the physical characteristics of the opposite sex

Autogynephilia- is a male’s paraphilic tendency to be sexually aroused by the thought or image of himself as a woman. Fantasies and behaviors may focus on the idea of exhibiting female physiological functions (e.g., lactation, menstruation), engaging in stereotypically feminine behavior (e.g., knitting), or possessing female anatomy (e.g., breasts).

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(still from the motion picture Silence of the Lambs)


Literature Review

    • Twohig, F., & Furnham, A. (1998). Lay beliefs about overcoming four sexual paraphilias:
fetishism, pedophilia, sexual sadism, and voyeurism. Personality and Individual
Differences, 24(2), 267-278.

Study looks at the fact that three major factors; self-reliance, seeking help, and external control, play into the successful treatment of sexual sadism and voyeurism (among other paraphilic disorders.) This also addresses if personality can predict attitudes towards sex, sexual issues, and receiving treatment.

    • Wright, S. (2014). Kinky parents and child custody: The effect of the DSM-5
differentiation between the paraphilias and paraphilic disorders. Archives Of Sexual Behavior, 43(7), 1257-1258.

Almost identical to the article below, however goes into more detail about child custody cases for individuals who had their children removed for paraphilias. The National Coalition for Sexual Freedom reports roughly 115 people within a year sought assistance for custody cases and divorce proceedings, mostly with BDSM behavior.

    • Wright, S. (2010). Depathologizing consensual sexual sadism, sexual masochism,
transvestic fetishism and fetishism. Archives Of Sexual Behavior, 39(6),
1229-1230.

Reviews the importance of differentiating between paraphilias and paraphilic disorders, as well as the need for the DSM-5 to operationally define “distress” for the criteria of paraphilic disorders. Explored this concept further by referencing a case regarding a mother who was a self-disclosed “domme” in a sexual sadism community. Her children were removed from her care questioning her mental health due to the fact that she received sexual arousal by inflicting pain and suffering on another person. Wright argues that the pathologizing of individuals who engage in consensual alternative sexual activity has unnecessary legal implications and has been misused to represent people as unable to control their behavior to a distressing degree, despite distress being societal stigma.


The DSM Also includes


Other Specified Paraphilic Disorder

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(such as):
  • Telephone scatologia (obscene phone calls)
  • Necrophilia (corpses)
  • Zoophilia (animals) also known as Bestiality
  • Coprophilia (feces) also known as scat
  • Klismaphilia (enemas)
  • Urophilia (urine) also know as golden shower
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(Online Dating University)

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(infogr.am)

Fun Facts:
  • Necrophilia is legal in Louisiana, North Carolina, Kansas, Kentucky, New Mexico, Nebraska and Vermont. However anal and oral sex is illegal in Louisiana and North Carolina, Only straight couples may engage in oral sex in Kansas and Kentucky.
  • Zoophilia/ Bestiality is legal in New Hampshire, Vermont, Kentucky, Hawaii, Nevada, New Mexico, New Jersey, Ohio, Texas, West Virginia, and Wyoming.
  • Coprophilia, klismaphilia, and urophilia are all legal in the USA.
  • The non-violent serial offender: Exhibitionism, frotteurism, and telephone scatologia.



Unspecified Paraphilic Disorder

(insufficient information for diagnosis)
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Objectum-Sexuality


Members of the community argue that OS is not a fetish. Fetishist must have their desired objects present to achieve sexual gratification. For OS the love for their object is not based on a sexual response or arousal; it encompasses many levels. Fetishists do not view the object of their sexual attraction as animate, whereas OS do which aids them in forming a loving relationship with the object. They communicate with the essence of their object and have committed, loving relationships.
Animists- non-human entities (animals, plants, and inanimate objects or phenomena) possess a spiritual essence
https://peoplewholoveobjects.wordpress.com/objectum-sexuality-os/
A look at animism and people who love objects.

Dr. Amy Marsh is a sexologist who devoted her practice to understanding the OS community. She asserts that OS is not a fetish because the experience isn’t strictly of a sexual driver. Is It Love, Or Is It Object Personification Synesthesia?

Resources:

Online community for OS-Internationale
http://www.objectum-sexuality.org/


Self-report survey conducted by Dr. Amy Marsh by the OS-Internationale community that differentiates itself from paraphilia due to its emotional components.
LOVE AMONG THE OBJECTUM SEXUALS

Study looking at the correlation between autism spectrum and asperser’s syndrome with objectum sexuality attachments:
Objectum Sexuality Asperger's Intimacy Counseling & Education Project

Two sites that look at the Biopsychosocial implications for objectum sexuality.
1) Objectophilia, Fetishism and Neo-Sexuality: Falling in Love with Things
2) Intimate and Inanimate A brief look at objectum sexuality
“The objectophiles aren’t hurting anyone. They’re not abusing or traumatizing other people,” he judges. And then he asks mildly: “who else can you say that about?”- Sexologist Dr. Sigusch

“The objectophiles aren’t hurting anyone. They’re not abusing or traumatizing other people,” he judges. And then he asks mildly: “who else can you say that about?”- Sexologist Dr. Sigusch



Changes from DSM-IV to DSM-5
  • An overarching change from DSM-IV is the addition of the course specifiers “in a controlled environment” and “in remission” to the diagnostic criteria sets for all the paraphilic disorders.
  • These specifiers are added to indicate important changes in an individual’s status.
  • In DSM-5, paraphilias are not ipso facto mental disorders. There is a distinction between paraphilias and paraphilic disorders.
  • The change proposed for DSM-5 is that individuals who meet both Criteria A and Criteria B would now be diagnosed as having a paraphilic disorder. A diagnosis would not be given to individuals whose symptoms meet Criterion A but not Criterion B—that is, to individuals who have a paraphilia but not a paraphilic disorder
  • Most people with atypical sexual interests do not have a mental disorder. To be diagnosed with a paraphilic disorder, DSM-5 requires that people with these interests: feel personal distress about their interest, not merely distress resulting from society’s disapproval; OR have a sexual desire or behavior that involves another person’s psychological distress, injury, or death, or a desire for sexual behaviors involving unwilling persons or persons unable to give legal consent

  • Names of disorders revised to differentiate between the behavior itself and the disorder stemming from that behavior (i.e., Sexual Masochism in DSM-IV is titled Sexual Masochism Disorder in DSM-5).
  • Transvestic disorder opened to apply to women females and gay men, not just heterosexual men.
  • Pedophilia changed to pedophilic disorder to maintain consistency with the chapter’s other listings.


Literature Review


  • McManus, M. A., Hargreaves, P., Rainbow, L., & Alison, L. J. (2013). Paraphilias:

definition, diagnosis and treatment.

  • Describes recent progress in diagnosing and treating paraphilias
  • Controversy concerning paraphilia and defining what is normal versus deviant or disordered behavior
  • Stems from the malleability of sexual norms across time and cultures, which creates problems for those defining and diagnosing paraphilia
  • Paraphilias are difficult to define, contentious as a basis for legal processes, and their classification is not short of criticism
  • Definitions are based on perceived deviations from inappropriate perfectionist ideals of sexual norms
  • All World Health Organization (WHO) member countries (including the United States) are required to follow the WHO International Classification of Diseases and Related Health Problems but since the creation of DSM-IV-TR, there are significant differences between the two manuals regarding the disorders included, disorder names and definitions, and the organization of categories.
  • DSM-5 definition of paraphilia: “any powerful and persistent sexual interest other than sexual interest in copulatory or pre-copulatory behaviour with phenotypically normal, consenting adult human partners
  • “The major issue within this area is how to balance societal norms and public perception with the human rights of an individual who could be negatively impacted by diagnosis of paraphilia.”
  • Those advocating the removal of paraphilias from the DSM argue that functioning may be impaired as a result of significant others discovering such sexual interest, therefore it is inappropriate to conclude that the ‘paraphilia’ per se is the cause of the dysfunction.
  • Abundance of small studies and case reports regarding a variety of pharmacological and psychological treatments within sex offender populations, but treatment of other non-criminal paraphilias is negligible and is reliant on voluntary disclosure, which is very rare.
  • Cognitive behavioral therapy shows mixed results for sex offender population
  • Psychotropic drugs and anti-androgens showed very poor evidence of effective treatment.
  • Only gonadotropin-releasing hormone treatment showed high efficacy, working in a similar way to physical castration.
  • Research into all treatments of paraphilia is ruined by small sample sizes, short duration of follow-up, open and retrospective studies, lack of controls and biases, and its associated co-morbidity with other disorders. Thus, the effectiveness of treatments is inconclusive.
  • The ability to imprison and/or commit an individual based on their future “dangerousness” using a mental disorder or psychiatric criterion as justification may potentially violate due process rights.
  • At the heart of the issues still lies the much-debated question: “What justifies the classification of a source of sexual pleasure or a type of sexual activity as a mental disorder?”


  • Becker, J. V., Johnson, B. R., & Perkins, A. (2014). Paraphilic disorders. In R. E.
Hales, S. C. Yudofsky, L. W. Roberts, R. E. Hales, S. C. Yudofsky, L. W. Roberts (Eds.) , The American Psychiatric Publishing textbook of psychiatry (6th ed.) (pp. 895-925). Arlington, VA, US: American Psychiatric
Publishing, Inc.

Stresses the importance of distinguishing with the client between having urges and fantasies versus actually acting on them. In treating a client presenting with paraphilic behavior it is important to understand that remission, as stated by the DSM, does not mean the interest is gone. It just means that the interest is not currently problematic for the client or causing the distress required by Criteria B.

  • Joyal, C. C. (2014). How anomalous are paraphilic interests? Archives Of Sexual
Behavior, 43(7), 1241-1243.

Analyzes of definition of “normophilic sexuality.” Notes that term depends heavily on historical, political, and sociocultural factors, much more than medical or scientific evidence. Other terms such as “intense” and “persistent” are also not operationalized. Article questions “distress” criteria due to the fact only those paraphilics who are distressed are considered to have the disorder.

  • Wakefield, J. C. (2011). DSM-5 proposed diagnostic criteria for sexual paraphilias:
Tensions between diagnostic validity and forensic utility. International Journal Of Law And Psychiatry, 34(3), 195-209.

The concept of paraphilic disorders is fuzzy and controversial and thus open to abuse for social control purposes. With the passing of laws allowing civil commitment of sexual offenders whose behavior is the outcome of a mental disorder and the declaring of such laws as constitutional by the Supreme Court, the diagnosis of paraphilic disorders has also become central to the future of civil liberties in our country.



Origin

  • Most literature and research on Paraphilias is it’s geared towards forensics, not sex therapy. Most Research is on sex offenders who had court ordered therapy which causes false data. So, as a result, there is little information on the causes of paraphilias, let alone data on the paraphilias themselves
  • Because of the lack of reliable research there is no consistent evidence for a distinct biological basis for paraphilias.


Three Theoretical Explanations:

Learning Theory is information that is absorbed, processed, and retained during learning.

Cognitive Theory is concerned with the development of a person's thought processes. It also looks at how these thought processes influence how we understand and interact with the world.

Addiction Model describes an addiction as a disease by understanding the biological basis of addiction, along with the broader social and psychological aspects of addictive behavior.

Vandalized Love Maps

  • One theory for the origin of Paraphilias is By Doctor John Money (yes the same one from the David Reimer Story) and is called Vandalized Love Maps
  • During early childhood sexual interactions/ sex play-acting was paired with a trauma, disapproval, ridicule or consequences causing the developmental process to go awry and resulting a Vandalized love map

Literature Review


  • Labelle, A., Bourget, D., Bradford, J.M.W., Alda, M., & Tessier, P. (2012). Familial

paraphilia: A pilot study with the construction of genograms. International Scholarly Research Network Psychiatry




Looks at the pedigree of five families, with one member currently seeking care for pedophilia. Within all five, genograms demonstrate a genetic predisposition. See figure 2, which shows the occurrence of heterosexual pedophilia running the course of four generations of males.
geno.png



Assessments
  • Clinical Interviews such as a developmental and sexual history, genogram, and history of the paraphilia.
  • Determine if it is a Paraphilic disorder or just a paraphilias. To see if treatment needs to be sought out for a paraphilic disorder, Shame and guilt or desire discrepancy.
  • Erotic Preferences Examination Scheme (EPES



Treatments


Most who undergo treatment are court order sex offenders and others may not seek treatment due to shame.


Many question if treatments are even effective due to

  • The factor that sexual pleasure is hard to relinquish
  • Many physical and psychological effects of treatment and medications
  • Little attention to client’s feelings


Literature Review

  • Thibaut, F. de la Barra, F., Gordon, H., Cosyns, P., & Bradford, J. M. W. (2010). The World

Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for the biological treatment of paraphilias. The World Journal of Biological Psychiatry, 11, 604–655.


Evaluation of a paraphiliac: demographic and clinical characteristics to be asked about: age, gender, current and past marital status, number of children, current and past employment status, education level, conventional and paraphiliac sexual fantasies and activity (frequency and type), exclusive or non-exclusive paraphiliac behaviour, age at onset of paraphiliac behaviour, type and number of paraphilia, gender and age of victims, intra-familial or not (known or unknown victim), internet use or video use, violence, previous convictions for sexual or non-sexual offenses, family and personal history of sexual disorders, previous treatments, or sexual offending and compliance, alcohol or illicit drug consumption before paraphiliac sexual behaviour, age of puberty, family and personal history of psychiatric disorders, suicide attempts, history of brain trauma, current dementia, previous or current psychiatric or non-psychiatric diseases and treatment, previous history of sexual abuse or use of violence, empathy, coping with stress, impulsivity, interpret- sonal relationships, insight, motivation for treatment, cognitive distortions, denial, degree of mental retardation if any.





Recommended Treatments


Pharmacological intervention

  • Anti-androgens (penile plethysmography and vaginal photoplethysmography)
  • SSRI (Selective serotonin re-uptake inhibitors)
Chemical Castration

Results
  • Reduction of erections
  • Sexual fantasies
  • Initiating sexual behavior



Cognitive Behavioral Therapy

Victim Identification:
(Murphy & Page, 2008).

  • Therapist helping the client to realize that the person they are doing the behavior to (i.e., exposing themselves, exhibiting sadist-type behaviors) is a victim.
  • The client may be encouraged to identify the harm they cause to the person they are exposing themselves to.
  • Exercises such as role reversal may be used and the client may be asked how the victim might feel both during and after the victimizing act.
  • The goal of this therapeutic approach is for the client to develop empathy towards their victims.
  • If the client is able to develop sufficient empathy toward their victims, they may reduce or discontinue the behavior because it is less pleasurable.
  • Many sex offenders may also have a personality disorder called Anti-Social Personality Disorder. This disorder is characterized by a lack of empathy. Thus, treatments that depend on increasing empathy may have limited effectiveness for certain people.



Covert conditioning:
(Morin & Levenson, 2008)

  • Undesirable behavior becomes less desirable and is eventually eliminated.
  • The client is asked to imagine feeling shame when friends or family members observe him engaging in the behavior associated with the paraphilia.
  • Help the client not engage in the behavior or to find the behavior less pleasurable.


Orgasmic reconditioning:
(Plaud, 2007).

  • The client is first asked to identify a fantasy that involves the paraphilia in question.
  • encouraged to engage in masturbation at home with specific instructions to become aroused by the fantasy associated with their paraphilia, but to complete the masturbation exercise (orgasm) while looking at an appropriate object (i.e., a picture of an adult partner).
  • The client is instructed not to incorporate the fantasy at all.
  • The idea behind this treatment is simple: they are redirecting their arousal pattern and providing themselves positive reinforcement (orgasm) while looking at an “appropriate” object.


Masturbatory Extinction:
(Plaud, 2007).

  • Includes the instruction to masturbate.
  • Client is encouraged to masturbate and orgasm to an appropriate fantasy.
  • Then after orgasm (i.e., ejaculation) they are encouraged to continue masturbating but to the deviant sexual fantasy.
  • This causes the appropriate fantasy to be reinforced with an orgasm, but the inappropriate fantasy to not be reinforced at all.


Masturbatory Satiation:
(Plaud, 2007).

  • The client is encouraged to masturbate with the deviant fantasy in mind.
  • When the client reaches orgasm they must continue to masturbate to the deviant fantasy for one hour.
  • Since this activity does not end in reinforcing ejaculation, the client may eventually lose interest in such fantasies.


Aversion therapies:
(Plaud, 2007).

  • Pairing arousal to the deviant fantasy with either mild electric shock or unpleasant smells.
  • The pairing of deviant fantasies with unpleasant sensations is thought to decrease both fantasies and behaviors.

What do you think: Is this ethical?


Group Therapy:
(Morin & Levenson, 2008).

  • The focus may be on taking responsibility for actions, victim impact and empathy, establishing family support, building relationship and social skills and cognitive restructuring.
  • The individual may lack social skills and have difficulty establishing relationships with others.
  • Treatment that focuses on building social skills may be helpful.


Community support groups


Sex Addict Anonymous
Suggested for

  • Voyeuristic disorder
  • Exhibitionistic disorder
  • Frotteuristic disorder
  • Telephone scatologia (obscene phone calls)



Transvestic disorder

Suggested transgender support groups

Transgendered tapestry


Pedophilic disorder




Sex Offender treatment Programs





Recidivism

(Thibaut, F. de la Barra, F., Gordon, H., Cosyns, P., & Bradford, J. M. W. 2010).

  • Recidivism is a major concern, in the treatment of paraphilia, especially in pedophilia.
  • Most people recognize that incarceration alone will not solve sexual violence.
  • Treating the offenders is critical in an approach to preventing sexual violence and reducing victimization.
  • In sex offenders, the recidivism rate rose by about 3% per year, and at the end of the follow- up period (22 years), 48% had recidivated.
  • Treated offenders had less reconviction than non-treated offenders, both at 2-year (5.5 and 12.5%, respectively) and at 4-year follow-up (25 and 64%, respectively)



The Experiential Model

(Mahrer, 1996-2011)

  • In the treatment, the client is encouraged to open up about recurring fantasy, disturbing desire, fear of being discovered, or anything that causes the most painful feelings toward their Paraphilia.
  • The therapist does not interrupt, that the client open up and feel.
  • There is the shift for the client because through sharing their shameful feelings about their desire, then what seemed menacing becomes less apprehensive.
  • The client is then Contemplates and rehearses how to be this “qualitatively new person" in the real world



Successful Experiential Sessions Result in

  • Eliminating the original sources of pain in the in the initial painful scene
  • Allowing the individual to become whatever is deeper within


Orchiectomy


Literature Review:


  • Assumpção, A. A., Garcia, F. D., Garcia, H. D., Bradford, J. W., & Thibaut, F. (2014).

Pharmacologic treatment of paraphilias. Psychiatric Clinics Of North

America, 37(2), 173-181.

This article examines paraphilic disorders emphasizing that they are often comorbid with other sexual, mood, and personality disorders. Given that the gold standard of treatment for severe paraphilias in the adult male population is a two-pronged approach of antiandrogen treatment with CBT, this case study looks at the treatment of a 35-year-old Iranian male. The structure of his CBT treatment consisted of cognitive restructering, behavior analysis, problem solving, relaxation, self-management, and positivism, which was shown to decrease the severity of his disorder.

  • Greenberg, D. M., & Bradford, J. W. (1997). Treatment of the paraphilic disorders:

A review of the role of the selective serotonin reuptake inhibitors. Sexual Abuse: Journal Of Research And Treatment, 9(4), 349-360.



Examines the deficits in the treatment options if clients presenting with paraphilic and nonparaphilic disorders are to be approached biopsychosocially. Although options have progressed from doing aversion conditioning and surgical castration, there is cause to question if medications that alter hormones are legal or even ethical. The available medications, although reducing the sexual drive associated with the paraphilic urges or hypersexuality, tend to eliminate the appropriate sex that clinicians want to reinforce. This review cites Kafka’s articles on treating sex offenders with the SSRI fluoxetine, as well as numerous others that report an improvement in target symptoms, however experience adverse effects such as anorgasmia or DE. A research experiment comparing a control group who received only psychosocial therapy to those who received SSRIs and psychosocial showed a significant improvement with combined treatment.

  • Grubin, D. (2004). Sexual offending and treatment of sex offenders. Psychiatry

3(11), 17-21.

A review of the current practices of treatment in the UK for sex offenders, and discusses



the significance of assessment for identifying treatment targets. These targets can be looked at in three parts, (a) static risk factors, (b) dynamic stable risk factors, and (c) dynamic acute risk factors. Another way to look at these is static represents the bio, or the history of the client, dynamic stable is the psycho, or how they think and self-regulate emotions, or social, or the current environment that is likely to change. High degree of sexuality can be determined with various tests available, including the Multiphasic Sex Inventory. Commonly used, and effective, treatment is a group format of CBT, with the sexually deviant component being treated one on one, and SSRI or antiandrogen.

  • Krueger, R. B., & Kaplan, M. S. (2012). Cognitive-behavioral treatment of the

paraphilias. The Israel Journal Of Psychiatry and Related Sciences, 49(4),

291-296.



Dr. Kaplan and Dr. Krueger look at the effective treatment for sex offenders diagnosed with paraphilias with CBT and relapse prevention therapy. The goal of treating individuals with paraphilias is to reduce inappropriate sexual arousal and increase appropriate arousal. Three components of decreasing inappropriate arousal consists of (a) covert sensitization, or pairing urges with aversive images that emulate the consequences, (b) satiation, or masturbating to the sexual fantasy for 55 minutes after achieving orgasm, and (c) systematic desensitization, or decreasing anxiety. In an effort to increase appropriate sexual behavior to adult partners, orgasmic reconditioning, or masturbating to fantasies of normative behavior, or fading, which is changing from the paraphilic fantasy to one of more appropriate sexual activity mid fantasy, are also effective techniques. Some other components used are cognitive restructuring, assertive skills training, psychoeducation, empathy, sexual history on personal victimization, and relapse prevention.

  • Krueger, R. B., & Kaplan, M. S. (2002). Behavioral and psychopharmacological

treatment of the paraphilic and hypersexual disorders. Journal Of Psychiatric

Practice, 8(1), 21-32.



Reviews the ethical considerations in the assessment and treatment of individuals with paraphilias, with assessment including the use of penile plethysmography or phallometry, polygraphy, and viewing time assessments. Krueger and Kaplan explores a clinician ability to be subjective, as well as the legal implications for some assessment and treatment modalities. Authors give a detailed treatment algorithm consisting of cognitive-behavioral techniques for decreasing and/or controlling sexual urges (e.g., satiation, covert sensitization, fading, cognitive restructuring, victim empathy therapy.) In addition, they addess using methods for enhancing appropriate sexual interest and arousal (e.g., social skills training, assertiveness skills training, sex education, couples therapy.)

When approaching a client with paraphilic disorders, they suggest beginning with less restrictive treatments (e.g., behavioral or verbal therapies), if possible, and moving to more restrictive alternatives (e.g., biological therapies, institutionalization) as needed.

  • Seto, M. C., Kingston, D. A., & Bourget, D. (2014). Assessment of the paraphilias.

Psychiatric Clinics Of North America, 37(2), 149-161.

Accurate clinical assessment of paraphilic disorders requires multiple sources, such as self-report, clinical interview, and questionnaires. Due to the fact that paraphilias are comorbid with other sexual, mood, and personality disorders all should be determined for effective treatment. Phallometric testing is also used to assess the severity of the paraphilia.

  • Thilbaut, F. (2011). Pharmacological treatment of sex offenders. Sexologies, 20,

166-168



Sex offenders in French national prisons comprise 14.3% of their prisoners; with only 2% of those being female. The reported reoffending rate is 15-27%, however, men attracted to boys have a 35% higher risk of reoffense to the 16% of those attracted to girls. This high reoffense rate further highlights the need for effective treatment of sex offenders from a biopsychosocial approach. SSRI’s, specifically fluoxetine and setraline, have been shown to effectively treat exhibitionists, compulsive masturbators, non-acting paedophiles, and adolescents with paraphilic desires. Guidelines for treatment are proposed consisting of therapy, specifically CBT, and either an antiandrogen or SSRI.



Non-Paraphilic Hypersexuality
Hypersexuality - extremely frequent or suddenly increased sexual urges or sexual activity

Hypersexual Disorder (HD) - Disinhibited or exaggerated expressions of human sexual arousal and appetites …involving sexual behaviors that are culturally considered within the range of normal or conventional (Kafka)

Also known as
  • Hypersexual disorder
  • Sexual addiction
  • Love Addiction
  • Sexaholic
  • Sexual compulsivity
  • Don Juanisum
  • Nymphomania

Not in DSM-5 but is referenced and mentioned in comorbidity or dual diagnosis for all paraphilias. Not in DSM-5 because requires more empirical research, is not paraphilias or sexual dysfunction.



Prevalence
Male to female estimated ratio 5:1 (Black, 1997).

Presents in females
  • Compulsive masturbation
  • Protracted promiscuity (prostitution)
  • Sexual masochism,
  • Pathological crushes, obsessions, fixations, or love addictions

Often accompanied by
  • Paraphilias
  • Server relationship distress
  • Bipolar spectrum & Bipolar Disorder
  • Depression
  • Social anxiety disorder,
  • ADHD
  • Psychoactive Substance abuse disorders
  • Dependence syndrome
  • Behavioral addiction
  • Impulse control
  • Conduct disorder
  • Dysthymic disorders
  • Low Desire
  • Hypoactive sexual disorder
  • Female arousal disorder
  • Erectile Dysfunction
  • Sexual aversion
  • Brain injury
  • Dementias
  • Huntington’s disease
  • Kline-Levin syndrome
  • Medications and drugs that increase dopamine.
  • Temporal lobe epilepsy
  • Tourette’s Syndrome
  • Stroke





Assessments
  • Ask specific clinically relevant questions without significant other
  • Sexual histories
Figure 13.1.jpg
Scales

Female
Male

Each of us took this test can you tell whose results are whose?
guess who V.png
guess who L.png


guess who e.png

Critique

  • Kafka, M. P. Krueger, R. B. (2011). Response to Moser’s (2010) critique of hypersexual
disorder for DSM5. Sexual Behavior, 40(2), 231-232.

-Some researchers believe people have difficulty controlling their sexual fantasies, urges, and behaviors who may benefit from psychiatric intervention but the current diagnosis of Hypersexual Disorder does not describe these individuals (no counter diagnosis provided)
-Hypersexual Disorder may be better explained as an associated symptom of other principal disorders of the individual – such comorbid disorders could then cause the reported symptoms/consequences of Hypersexual Disorder (i.e., sexually transmitted diseases, unwanted pregnancies)


Literature Review

  • Kafka, M. P. (2010). Hypersexual Disorder: A Proposed Diagnosis for DSM-V. Archival of
Sex Behavior, 39, 377–400.

-Hypersexual Disorder is conceptualized as primarily a non-paraphilic sexual desire disorder with an impulsivity component
-In one study, “impersonal sex” components used to identify “hypersexuality:” frequency
of masturbation/month, frequency of pornography use/year, number of sexual partners in past year and per active year, having extra-partnered sex while in a stable partnered relationship, and ever participating in group sex, preferring a casual sexual lifestyle
-Results: for hypersexual males: more likely to be younger, have experienced separation from parents, live in major urban areas, more likely to have started sexual behavior at an earlier age, reported a greater diversity of sexual experiences (including same-sex behaviors), paying for sex, exhibitionism, voyeurism, and masochism/sadism, for females: similar to males in the aforementioned variables but were also more likely to report a history of sexual abuse and had sought psychiatric care in the last year
-From clinically derived data, hypersexual desire in adult males was defined as seven or more orgasms per week for at least six consecutive months after the age of 15 years
-Persons with combinations of either low inhibition and/or high on measures of sexual excitation and arousal, accompanied by anxious or depressive affect, could be sexual risk-takers who are prone to promiscuous behavior and/or increased masturbation
-There is adequate empirical evidence for several specifiers (non-exclusive subtypes) for Hypersexual Disorder: masturbation, pornography, sexual behavior with consenting adults (protracted promiscuity), and cybersex. There is less confirmatory evidence, however, for telephone sex, strip clubs, and severe sexual desire incompatibility.
-great majority of subjects with Hypersexuality Disorder have multiple lifetime comorbid mood, anxiety, psychoactive substance abuse, and/or other impulse disorder diagnoses.
-Five most common comorbid personality disorders: paranoid, passive aggressive, narcissistic, avoidant, and obsessive–compulsive
-If Hypersexual Disorder as Impulsivity Disorders were to be placed in the next DSM, it would beg the question of whether a behavioral addiction/impulsivity model should also be applied to other excesses of human appetitive behaviors such as over eating, over drinking, over sleeping
-Paraphilias are characterized by deviant forms of sexual preference arousal (e.g., pedophilia, fetishism, exhibitionism) while Hypersexual Disorder is a disinhibited or excessive appetite for culturally adapted sexual behaviors.
-Male:female prevalence ratio of Hypersexual Disorder, estimated at 5:1
-several empirical studies have reported that persons presenting for clinical treatment for paraphilias or Hypersexual Disorder commonly self-report the presence of multiple rather than a single paraphilic or hypersexual behavior over the course of a lifetime



Hypotheses and Treatments
  • Kaplan, M. S. & Krueger, R. B. (2010). Diagnosis, assessment, and treatment of
hypersexuality. Journal of Sex Research, 47(2–3), 181–198.

-Etiology of hypersexuality is unknown

-Medical conditions associated with hypersexuality include dementia, temporal lobe epilepsy, Tourette’s Syndrome, brain injury, stroke, use of methamphetamine and cocaine, bipolar disorder

Psychodynamic theory: at the core of sexual compulsion is an attempt to recover from early negative childhood experiences

Addiction model: the addictive process can be defined as an enduring and strong tendency to engage in some form of pleasure producing behavior as a means of relieving painful affects, regulating one’s sense or self, or both.

Dual-control model: sexual response and arousal ultimately determined by the balance between
the sexual activation or excitation system and the sexual inhibition system in brain

Sexual Impulsivity Model: compulsive sexual behavior, sexual addiction, or hypersexuality should be viewed as a manifestation of an atypical impulse control disorder

Obsessive–Compulsive Spectrum Disorder: hypersexual behavior driven by lack of impulse control and anxiety reduction mechanisms

-CRITIQUE: “The real danger in labeling hypersexuality is that we do not know what constitutes excessive sexual behavior, and yet we are applying a label which may have pathological symptoms inappropriately associated with it,” “In any given society, sexual scripts provide the standards determining erotic control and normalcy. What one society regards as being sexually ‘out of control’ or deviant may or may not be viewed as such in another.”
-TREATMENT: cognitive-behavioral therapy, relapse-prevention therapy, psychodynamic psychotherapy, and psychopharmacological treatment, individual, group, and couples therapy. Treatment should be based on a thorough assessment and tailored to the specific needs of the patient


  • Krueger, R. B. & Kaplan, M. S. (2001). The paraphilic and hypersexual disorders: An
overview. Journal of Psychiatric Practice, 7, 391-403.

-The Monoamine Hypothesis: disturbance involving monoamine (norepinephrine,
dopamine, and serotonin) metabolism may be responsible for pathological sexual behavior

-The Imprinting Hypothesis: suggests that, in adolescence, humans, as do animals, progress through a certain period of sexual development during which they are vulnerable to the imprinting of various methods or stimuli for sexual arousal into their repertoire of sexual arousal

- Social Learning Theory: suggests that deviant sexual behaviors are learned in the same manner by which normative sexual behaviors and expressions are learned

- Courtship Disorder: explain the paraphilias, usually courtship is characterized by a set of
preferences for a sequence of erotic sensory stimuli and erotic activities and suggests that in paraphiliacs this has been disrupted, idealized sequence of courtship behaviors involves
four phases: a finding phase (looking for a potentialpartner; if a patient were “trapped” in this phase, he would become a voyeur); an affiliative phase (verbal and nonverbal communications with a prospective partner; with deviancy resulting in exhibitionism); a tactile phase (in which physical contact is made; with a deviation resulting in frotteurism), and a copulatory phase (in which sexual intercourse occurs; with a deviancy resulting in rape)

-Genetics: X-linked gene plays a role in male homosexuality, others have suggested that dopamine receptor genes and pathways may be involved in a “reward deficiency syndrome” and various addictive behaviors, including the paraphilias.


table 13.2.jpg
(Binik & Hall)



Psychodynamic psychotherapy

Self-help groups:


Cognitive Behavioral Therapies
Relapse Prevention Model
(Marat & Gordon, 1980)
  1. Identifying and modifying cognitive distortions and beliefs that rationalize hypersexual behavior
  2. Helping the patient to recognize and the anticipate high-risk situation
  3. Identifying specific behavioral-affective-cognitive precursors to relapse
  4. Extensive behavior rehearsal of new comprehensive problem-solving techniques, as well as social and sexual skills training


Behavioral Therapy Techniques
Aversive techniques- reported imaginal desensitization was effective as covert sensitization in reducing compulsive sexual behaviors in a group of 20 men (McConaghy & Armstrong, 1985)

Psychopharmacology
  • Mood stabilizer
  • Antidepressants
  • Atypical narcoleptic
  • Psychostimulants
  • Opiate antagonists
  • Anti-androgen


The Pair Bond(Marshall, 1989)
Significant other may suffer from
• Low self-esteem
• Depression
• Overly dependent behavior
• Enabling behaviors
  • Mutual trust has been severely breached and needs to be regained.
  • Whenever possible include significant other during ascents and early treatments to assess disclosure on pair bond
  • Contain the relationship crisis that follows
  • Send significant other to individual or group therapy
  • Patient should get tested for STD if infidelity occurred (and Significant other depending on results)
  • Explain that this is going to take years not months
  • Need time to heal and reestablish trust

IMG_3132.JPG
(Candeo)

IMG_3133.JPG
(The Ranch)

Literature Review


Lothstein, L. M. (1996). Antiandrogen treatment for sexual disorders: Guidelines for
establishing a standard of care. Sexual Addiction & Compulsivity, 3(4), 313-331.

-There is no treatment program for the wide range of paraphilic and nonparaphilic “excessive sexual” disorders (e.g., compulsive or addictive)
-Relies heavily on pharmacotherapy alone to manage the complex issues of controlling the sexual aggression


Turner, D., Schöttle, D., Bradford, J., & Briken, P. (2014). Assessment methods and
management of hypersexuality and paraphilic disorders. Current Opinion In Psychiatry, 27(6), 413-422.

-“Currently existing instruments can validly assess hypersexual behaviors in different populations (e.g. college students, gay and bisexual men, and patients with neurodegenerative disorders) and cultural backgrounds (e.g. Germany, Spain, and USA”
-Combining assessments increase ability to distinguish between patients
-Two-pronged treatment: psychotherapy, pharmacological agents aimed at reducing testosterone


  • Fong, T. W., De La Garza, R. I., & Newton, T. F. (2005). A Case Report of Topiramate in
the Treatment of Nonparaphilic Sexual Addiction. Journal Of Clinical
Psychopharmacology, 25(5), 512-514.

-Non-paraphilic sexual addictions involve participation in conventional sexual behaviors and may include prostitution, extramarital affairs, compulsive masturbation, or the excessive use of pornography.
-Traditional treatment approaches to sexual addictions include cognitive behavioral treatment, 12-step groups, individual therapy, and family therapy
-Investigational treatments of paraphilic disorders have included gonadotropin releasing hormone, chemical castration agents, and medications that reduce sexual drive. Topiramate (Topamax) has been gathering evidence as an “anti-impulsivity” medication
-Case report demonstrates the potential efficacy of Topiramate in the treatment of sexual addiction/hypersexuality





Treatment Considerations for Paraphilic/Non Paraphilic

When treating paraphilic and non paraphilic hypersexuality disorders there are unique biopsychosocial factors to consider for all. However, the gold-standard for treatment is Cognitive-Behavioral Therapy (CBT) by itself, or in conjunction with pharmacotherapy. The most commonly prescribed medications are either antiandrogens, which reduce sexual aggression, or SSRIs, which have been shown to decrease libido. Antiandrogens can have severe adverse effects, including reduced self-esteem, and therefore may have a higher noncompliance rate. Additionally, SSRIs have been shown to not only diminish the deviant sexual behavior, but the appropriate sexual activity with their partners as well, even resulting in a sexual dysfunction. It is important to recognize when treating that the content of distress can be a recurring fantasy, a disturbing desire, fear of being discovered, or really anything.





Treatment Algorithm
by Dr. Krueger and Dr. Kaplan


  1. Ascertain a detailed sexual history of paraphilic/nonparaphilic behaviors
    1. Inquire about the content of sexual fantasies from childhood to present
    2. Determine frequency of behavior, including how often they masturbate
    3. Ask specific, detailed, questions regarding each paraphilia
    4. Find out the age of onset
    5. Quantity of fantasies or acts over their lifetime
    6. Scaling question: 1-100 on having control over the paraphilic behavior
    7. Current symptoms: ask what has been the content of their masturbatory fantasy over the past 5-10 instances of masturbation
    8. Can administer a sexual addiction screening test
  2. CBT Part I: Decrease the inappropriate arousal
    1. Sexual psychoeducation on what appropriate behavior is
    2. Enhancement of victim empathy
    3. Personal victimization/Work through past sexual trauma if any
    4. Identify the permission-giving statements or rationalizations-cognitive restructuring
    5. Review consequences of behavior
    6. Aversive techniques, such as satiation or visualizing consequences
    7. Repeating the fantasy
    8. Fading- fantasize about atypical sexual stimuli and then shift the fantasy to acceptable sexual activity
  3. CBT Part II: Enhance appropriate sexual arousal to adult partners.
    1. Including a multi-systemic tx to look at the needs of the family/partner
    2. Orgasmic reconditioning
    3. Couples therapy
      1. Improve the couple’s sexual experience
      2. Healing of wounds
    4. Social skills training
      1. Therapists will demonstrate modeling, rehearsing, and social feedback to practice assertiveness
    5. Psychoeducation
  4. Relapse prevention
    1. Identify high-risk situations
    2. Identify triggers
    3. Anticipate relapse, and instill skills for coping
    4. Abstinence contracts
    5. SSRI’s
    6. 12 Step programs/Sponsors

* Throughout the session try to conclude whether or not the client is a customer, and identify their motivation for change, especially if court ordered or there because of their spouse. Also pay attention to the cognitive distortions that are influencing this behavior and may be a contributing reason to withhold information.

Vignette
Scott (31) and Kourtney (35) came in for couples counseling. Scott reported distress over the fact that his and Kourtney’s “sex drives never appear to be on the same page.” Kourtney said that at the beginning of their relationship, Scott had a period of time where he was unfaithful and highly sexually active; however she attributed it to his younger age and the fact that he’s just a “dude.” They’ve been together for almost 6 years, and in that time Kourtney has given birth to three of his children. She’s noted that the amount of time they have sex together seems to decrease with each year, which she’s always thought just had to do with the pregnancies and her time spent with the two oldest children, Mason, and Penelope. However, recently she’s beginning to notice that Scott seems preoccupied with sex, just not with her. She catches him masturbating frequently and questions whether these trips to strip clubs with his “boys” result in more infidelity. She is also concerned about the content of the pornography Scott chooses to watch and the impact that might one day have on their children.


Although the components of CBT for treating paraphilia are unique and intensive, we wanted to highlight the differences between conducting a normal sexual history interview and one geared towards assessing hypersexuality and paraphilic disorders. Therefore, in our treatment video we emphasized the different kinds of questions that would be asked, including language choices, and how to navigate the nuance of working with a couple in this context. We begin the intake after doing a comprehensive biopsychosocialsexual interview as we have seen in the previous presentations, and skip the therapist’s one on one time with Kourtney. If we adhere to the treatment model, the following sessions would continue to work through part I of the CBT, including homework surrounding fading out his sexual fantasies of voyeurism and frotteurism for more acceptable fantasies with his wife.

Things to look for in our video:

  • Couples work; healing of the wounds or at least identifying them
  • Assessing control over urges, fantasies, and behavior (and level of distress)
  • Determining which paraphilias are present
  • Highlighting legality/ethics as well as duty to report** unique to our disorder due to the legal ramifications; necessary if pedophilic disorder may be present
  • Underlying rationale/cognitive distortions
  • Psychoeducation about appropriate sex
  • Victim empathy, which is an introduction to part I of CBT
  • Reviewing consequences, another introduction to part 1 of CBT
  • Relapse prevention: triggers and high-risk situations
  • SAA; further psychoeducation and introduction to potentially helpful community





References:

Abrams, M., & Stefan, S. (2012). Sexual abuse and masochism in women: Etiology and treatment. Journal Of Cognitive And Behavioral Psychotherapies,
12(2), 231-239.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5thed.). Arlington, VA: American Psychiatric Publishing.

Assumpção, A. A., Garcia, F. D., Garcia, H. D., Bradford, J. W., & Thibaut, F. (2014).Pharmacologic treatment of paraphilias. Psychiatric Clinics Of North
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