Norbert Konrad; Justus Welke; Annette Opitz-Welke

Disclosures

Curr Opin Psychiatry. 2015;28(6):440-444. 

In This Article

Abstract and Introduction

Abstract

Purpose of review The concept of paraphilia still carries an 'unwanted burden' of sexual norms because the pathologization of some sexual practices as paraphilic disorders is still based on the assumption that normal sexuality should be genitally organized with the aim of reproduction. The aim of this review is to give an impression of the ongoing discussion about the changes introduced with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) and the results of recent research in this area.

Recent findings The release of DSM-5 in the spring of 2013 introduced a distinction between paraphilias and paraphilic disorders, implying a destigmatization of consenting adults engaging in unusual sexual behaviour. According to DSM-5 diagnostic criteria, paedophilic disorder is the only paraphilic disorder without an 'in remission' and an 'in a controlled environment' specifier. Today, antiandrogen treatment is offered to sex offenders in many countries as an additional treatment strategy alongside psychotherapy.

Summary The introduction of DSM-5 offers the possibility to distinguish between paraphilia and paraphilic disorders. The aetiology of paraphilias is still unknown. Paraphilias are much more common in men than in women, but the reasons for this difference remain unknown. So far there is no clear consent on the best therapeutic approach for a paraphilic disorder.

Introduction

One hundred and ten years ago, neurologist Sigmund Freud revolutionized the understanding of paraphilia by offering a concept of paraphilia as interference with integrated genital sexuality.[1] Although attempts have been made since then to free the concept of paraphilia from the assumption of heterosexual normality, the concept itself still carries an 'unwanted burden' of sexual norms.[2] Discussion on what constitutes sexual aberration continues. Potter[3] argued that paraphilias in general have been described as 'deviant sexual interest and behaviour, exaggerations of sexual norms, violation of sexual mores, maladaptive evolutionarily acquired sexual behaviour, and abnormal sexual fixation or obsession', and emphasizes the importance of upholding the distinction between mental disorder and crime. Downing[4] is of the opinion that the change made in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) is mainly a change in name. She points out that the pathologization of some sexual practices as paraphilic disorders is still based on the assumption that normal sexuality should be genitally organized with the aim of reproduction. Therefore, labelling nonreproductive practices as paraphilic expresses 'repronormativity'.[4] Thus, paraphilias remain at the centre of controversy and political decisions.[5]

Between the 1930s and 1960s, forensic psychiatry developed an increasing interest in seeking psychological concepts to explain sexual assaultive behaviour, and the impact of forensic examinations on lawsuits and verdicts in cases of sexual assault grew.[6] Despite growing interest by forensic experts in understanding the conditions and course of deviant sexual interests, the aetiology of paraphilia remains unknown, and research examining the prevalence of paraphilic interest in the general population is very scarce. In some cases, exploring sadomasochistic dynamics in psychoanalytic psychotherapy can aid in understanding paraphilic elements as a defensive reaction to disappointing ministrations of caregivers earlier in life.[7] Recent research on the specificity of sexual arousal has revealed that sexual interest in masochism may not represent a narrowing in on a category of sexual activities, but on the contrary, a broadening of sexual repertoire.[8] Assessment of paraphilias in the general mental health context may be hindered by the fact that nearly every study of assessment instruments for paraphilias or paraphilic disorders has been conducted with sexual offender populations.[9]

Although sex has always played an important role in human lives all over the world, modern western cultures tend to view sexuality as recreational, whereas Asian cultures tend to treat sex as taboo and with the sole purpose of procreation. For this reason, very limited research on sexuality-related issues has been conducted on Asian populations, and it is not possible to extrapolate all findings from western studies to Asian populations.[10]

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