The video below is the section for Paraphilic Disorders from Part 3 of TSM’s lecture series on DSM-5 and the EPPP, followed by a transcript. This lecture series aims to equip those preparing for the EPPP with everything you need to know about the impact DSM-5 will be having on the EPPP. To watch all of Part 3, click HERE. To watch Part 1 and 2, or register for our webinar series on DSM-5 and the EPPP, click HERE.
Transcript of DSM-5 EPPP Lecture Video: Paraphilic Disorders
NARRATIVE DEFINITION: The DSM-5 explains that the term paraphilia refers to any “intense and persistent sexual interest other than sexual interest in genital stimulation or preparatory fondling with phenotypically normal, physically mature, consenting human partners. The presence of a paraphilia does not equal a diagnosis. A paraphilic disorder is a paraphilia that is causing current distress or impairment to the individual, or a paraphilia that is satisfied at the risk of harm to another. The Paraphilic Disorders listed in the DSM-5 are not an exhaustive list, but were included because they are more commonly seen than a number of other paraphilic disorders, including some which have the potential to be harmful to others and are classed as criminal offenses.
The DSM-5 identifies eight specific Paraphilias based on the stimuli associated with the sexual fantasies, urges, or behaviors: Exhibitionistic Disorder (exposure of one’s genitals); Fetishistic Disorder (use of nonliving objects, often involving a specific tactile sensation); Frotteuristic Disorder (rubbing against or touching a non-consenting person in a sexual manner); Pedophilic Disorder (attraction to prepubescent children); Sexual Sadism Disorder (infliction of pain, humiliation, or suffering); Sexual Masochism Disorder (experiencing pain, humiliation, or suffering); Voyeuristic Disorder (observing others’ sexual activity); and Transvestic Disorder (cross-dressing).
Paraphilias may be ego-dystonic or ego-syntonic. Some individuals with Paraphilia experience guilt, depression, or a sense of immorality, whereas others may view the disapproving reaction of others as the only negative aspect of their sexual proclivities. However, if individuals with a Paraphilia act out their sexual urges with a non-consenting partner (e.g., in cases of Exhibitionism, Frotteurism, Voyeurism, Pedophilia, or Sexual Sadism), they need not experience distress in order to meet criteria for diagnosis. These sexual fantasies, urges, or behaviors must be present for at least six months in order to meet diagnostic criteria.
Sexual Dysfunctions often co-occur with Paraphilias. The presence of the paraphilic stimulus may become necessary for any sexual arousal. Individuals diagnosed with a Paraphilia may seek out occupations or hobbies that allow them access to their preferred sexual stimuli. For example, individuals with Pedophilic Disorder a may work in a toy store or individuals with a fetish for lingerie may find a job in a women’s clothing store.
Paraphilic behavior tends to increase when a person is facing psychosocial stressors, in the presence of other mental disorders, and when there are increased opportunities to engage in the Paraphilia. As individuals grow older, their paraphilic fantasies, urges, and behaviors often decline. Paraphilic Disorders are, overall, diagnosed more frequently in men than in women, but prevalence for several diagnoses is unknown. Paraphilic tendencies often emerge during childhood or adolescence, but may not reach higher levels of elaboration and definition until adulthood. For some paraphilic disorders
The nature of Transvestism is often misunderstood, as it is commonly confused with Gender Dysphoria and homosexuality. In Transvestism, a man dresses in women’s clothing for the purpose of sexual arousal; arousal is usually due to the femininity of the attire; if arousal is associated with tactile sensations (e.g., the feel of silk undergarments) it is specified as “with fetishism.” In many cases, the man becomes aroused by imagining that he is female (specified as “with autogynephilia”). In some cases, cross-dressing may lose its erotic appeal over time and be employed as a means of combating depression, easing anxiety, or evoking a sense of peacefulness in the person. Additional course specifiers indicate “in a controlled environment” and “in remission.” The presence of fetishism makes it less likely that a man with transvestic disorder will experience gender dysphoria, while the presence of autogynephilia in a man with transvestic disorder increases the likelihood of simultaneous gender dysphoria.
The most effective primary interventions for Paraphilias include cognitive-behavioral techniques. In covert sensitization, the individual is taught to associate the sexually arousing stimulus with its negative consequences. Aversive conditioning occurs in the imagination rather than in vivo. In orgasmic reconditioning, the individual learns to become aroused in response to a more appropriate stimulus. This is accomplished by having the man masturbate to his typical, inappropriate stimulus, but immediately prior to ejaculation, the man switches his fantasy to a more appropriate sexual stimulus. With repetition, this practice helps a person think of the appropriate stimulus earlier and earlier in the masturbatory episode to the point that it replaces the inappropriate stimulus entirely. In satiation therapy, the man masturbates to orgasm while fantasizing about an appropriate stimulus, then continues to masturbate past the point of orgasm while fantasizing about paraphilic images. This eventually reduces the man’s arousal in response to the paraphilic stimulus. These methods are more effective in treating Paraphilias than is so-called “chemical castration,” in which sexual arousal and fantasies are eliminated through the administration of testosterone-reducing drugs. The paraphilic urges and fantasies return as soon as the drug is discontinued.
- Intense and recurrent sexual interest in genital sex with a physically mature, consenting human partner that causes significant distress or functional impairment
- If Paraphilias are acted out with non-consenting partners (for example children, objects of voyeurism), or if a paraphilia is satisfied at the risk or harm to another (with children, in sadomasochistic acts), there need not be experience of distress for diagnosis
- Occur almost exclusively in males; tendencies emerge during childhood
- Can be ego-dystonic or ego-syntonic
- Sexual Dysfunctions often co-occur with Paraphilias; the presence of the paraphilic stimulus may become necessary for any sexual arousal
- Individuals diagnosed with a Paraphilia may seek out occupations or hobbies that allow them access to their preferred sexual stimuli
- Psychosocial stressors, availability of stimuli or mental disorders may increase paraphilic behavior
- Eight specific kinds
- Exhibitionism (exposure of one’s genitals)
- Fetishism (use of nonliving objects, often involving a specific tactile sensation)
- Frotteurism (rubbing against or touching a non-consenting person in a sexual manner)
- Pedophilia (attraction to prepubescent children)
- Sexual Sadism (infliction of pain, humiliation, or suffering)
- Sexual Masochism (experiencing pain, humiliation, or suffering)
- Voyeurism (observing others’ sexual activity)
- Transvestic Fetishism (sexual arousal by cross-dressing). Can occur in heterosexual males who are aroused by the femininity of the clothing or by imagining being female
Mostly CBT techniques, including aversive conditioning, with the goal of learning to become aroused in response to a more appropriate stimulus:
a. Covert sensitization: The individual is taught to associate the sexually arousing stimulus with its negative consequences, inducing aversive conditioning (in the imagination rather than in vivo).
b. Orgasmic reconditioning: The person masturbates to his typical, inappropriate stimulus, but immediately prior to ejaculation, the man switches his fantasy to a more appropriate sexual stimulus. With repetition, this practice helps the person think of the appropriate stimulus earlier and earlier in the masturbatory episode until it replaces the inappropriate stimulus entirely.
c. Satiation therapy: The man masturbates to orgasm while fantasizing about an appropriate stimulus, then continues to masturbate past the point of orgasm while fantasizing about paraphilic images. This eventually reduces the man’s arousal in response to the paraphilic stimulus.
A man who dresses in women clothing for the purpose of sexual arousal is most likely to be diagnosed with:
B. Gender Identity Disorder.
C. Transvestic Fetishism.
D. Sexual Masochism.
RATIONALE: C is correct, as men who dress in women clothing for the purpose of sexual arousal are defined as having Transvestic Fetishism. Answers A and B are both incorrect, as a transsexual person identifies with a gender not his/her own. Although Gender Identity Disorder (or transsexualism) is often confused with Tranvestic Fetishism, it’s not a paraphilia. Answer D is incorrect: Sexual masochism is a paraphilia, but entails to derive satisfaction from experiencing pain, humiliation, and suffering during sex.