REVIEW

CURRENT
OPINION Paraphilias
Norbert Konrad, Justus Welke, and Annette Opitz-Welke

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.
Keywords
antiandrogen treatment, paraphilia, paraphilic disorder

INTRODUCTION genitally organized with the aim of reproduction.

One hundred and ten years ago, neurologist Sig-
mund 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 gen-
eral have been described as ‘deviant sexual interest
and behaviour, exaggerations of sexual norms, vio-
lation of sexual mores, maladaptive evolutionarily
acquired sexual behaviour, and abnormal sexual
fixation or obsession’, and emphasizes the import-
ance of upholding the distinction between mental
disorder and crime. Downing [4] is of the opinion
that the change made in the Diagnostic and Stat-
istical 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
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 psychia-
try 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 para-
philia remains unknown, and research examining
the prevalence of paraphilic interest in the general
Institute of Forensic Psychiatry, Charité – University Medicine Berlin,
Berlin, Germany
Correspondence to Norbert Konrad, Institute of Forensic Psychiatry,
Charité – University Medicine Berlin, Oranienburger Str 285, 13437
Berlin, Germany. Tel: +49 30 8445-1411; fax: +49 30 8445-1440;
e-mail: norbert.konrad@charite.de
Curr Opin Psychiatry 2015, 28:440–444
DOI:10.1097/YCO.0000000000000202

www.co-psychiatry.com Volume 28
Number 6
November 2015

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.


KEY POINTS

Introduction of DSM-5 offers the possibility to
distinguish between paraphilia and paraphilic
disorders.

Aetiology of paraphilia remains unknown.

Functional neuroimaging has yet to reveal a sound
theory about the underlying cerebral process.

For medical staff, it is important to realize that
paraphilias sometimes emerge in neurodegenerative
disorders such as Parkinson’s disease, in some cases as
a side-effect of treatment.

So far there is no clear consent on the best therapeutic
approach for a paraphilic disorder. In forensic
samples, the best treatment responses have been
achieved by the combination of psychotherapy and
chemical castration.
population is very scarce. In some cases, exploring
sadomasochistic dynamics in psychoanalytic psy-
chotherapy 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 popu-
lations [9].
Although sex has always played an important
role in human lives all over the world, modern west-
ern 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].
DIAGNOSTIC APPROACH
The release of DSM-5 in the spring of 2013 intro-
duced a distinction between paraphilias and para-
philic disorders, implying a destigmatization of
consenting adults engaging in unusual sexual
behaviour [11]. The rejection of paraphilic coercive
disorder from the main body of the DSM was
approved by Agalaryan and Rouleau [12], who
pointed out that the proposed criteria still lack
0951-7367 Copyright ß 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Paraphilias Konrad et al.
precision. Turner et al. [9] argued that although
hypersexual disorder was not included in DSM-5,
the construct of hypersexuality can be validly
assessed, and there is a valid screening test available
for hypersexual behaviours in patients with neuro-
degenerative disorders. DSM-5 defines paraphilic
interests as ‘nonnormophilic’ or ‘anomalous’ sexual
interests, but the definition of atypical sexual inter-
est remains a point of discussion. A survey of sexual
fantasies among college students revealed that only
a minority of sexual fantasies could be considered
&&
typical [13 ]. The authors recommend focusing less
on the content of fantasies than on the effect, and
Agalaryan and Rouleau [12] pointed out that coer-
cive sexual fantasies can be experienced without
individuals ever acting them out. On the contrary,
Chan and Beauregard [14] revealed that a higher
percentage of homicidal sexual offenders showed
paraphilic interests when compared with non-
homicidal sexual offenders. The homicidal sexual
offenders also exhibited a higher percentage of mal-
adaptive personality traits [14].
Paraphilias are much more common in men
than in women, but the reasons for this difference
remain unknown. Various factors have been dis-
&&
cussed. Dawson et al. [15 ] examined a nonclinical
sample of men and women for the prevalence of
paraphilic interests. Their findings suggested a cor-
relation of sex drive and paraphilic interests that
provided the best explanation for the observable
gender difference in paraphilic interests. They also
found comorbidity of different paraphilic interests
&&
[15 ]. Recent results of a systematic review by Solla
&
et al. [16 ] of paraphilias and paraphilic disorders
in Parkinson’s disease patients revealed that both
could emerge as a rare iatrogenic consequence in
Parkinson’s disease treatment. Typically, any
paraphilias or paraphilic disorders appear during
treatment with dopaminomimetic medication.
Aberrant sexual behaviour observed included exhi-
bitionism, frotteurism, paedophilia, sexual maso-
chism, and transvestism. Because hypersexuality is
often described as a neuropsychiatric complication
of Parkinson’s disease, this leads to the assumption
that hypersexuality and paraphilias may be the
phenotypical expressions of different degrees of a
&
common pathophysiological process [16 ].
PAEDOPHILIA
From what we know today, paedophilia affects
around 1% of the male population. Nevertheless,
paedophilia is the paraphilia that gets virtually all
media coverage, although human sexual interest
can become fixated on a wide variety of targets
[17]. After a century of broad clinical discussion
www.co-psychiatry.com 441
Sexual disorders
about paraphilia in the western world, only paedo-
philia is to be excluded from the ‘fun-and games,
plug and play laundry list of healthy kink interests’
[18]. Hence, it is not surprising that most research
on the prevalence of paedophilia involves samples
of individuals in forensic settings. As a result, almost
nothing is known about ways of living with that
sexual interest without causing harm [17].
The DSM-5 diagnostic criteria for paedophilia
and paedophilic disorder have been criticized by
numerous experts for a variety of reasons. There
has been a controversial discussion about the fact
that no diagnostic category for individuals with a
preference for pubertal adolescents – so-called hebe-
philia – was created [19]. Criticism has also been
expressed that according to DSM-5, paedophilia is
the only paraphilic disorder without an ‘in remis-
sion’ and an ‘in controlled environment’ specifier
[20]. The latter is noteworthy because recent
research has challenged the assumption that paedo-
philic interest is unchangeable [20], and scientific
evidence on the immutability of paedophilic dis-
order is lacking [5].
Some results of neuropsychological research and
neuroimaging provide evidence of brain abnormal-
ities in individuals with paedophilia [21]. Neverthe-
less, functional neuroimaging has been able to
support neither the association of paedophilic
behaviour with frontal lobe disorder [22], nor the
hypothesis that paedophilic individuals show defi-
cits in cognitive or perceptual categorization of
sexual stimuli [21].
SEXUAL SADISM AND SEXUAL
MASOCHISM
Robertson and Knight [23] conducted an empirical
analysis of criminal behaviours showing that sadism
and psychopathy consistently predicted sexual and
nonsexual violence. An analysis of the correlation of
sadism and Psychopathy Checklist scores revealed
that sadism and psychopathy are covariate, but are
not coextensive [23]. Sexual sadism and antisocial
personality disorder are common among sexual
homicide offenders. Comparing single victim and
serial victim homicide offenders, Chan et al. [24]
noted that serial offenders are more likely to
show narcissistic, schizoid and/or obsessive–com-
pulsive personality traits. Furthermore, serial victim
offenders were more likely to engage in sexual mas-
ochism, partialism, homosexual paedophilia, exhi-
bitionism and/or voyeurism. As the authors point
out, it remains unclear whether the reported maso-
chistic behaviour was connected to behavioural
strategies used to select a victim and to commit a
homicide [24].
442 www.co-psychiatry.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
RARE PARAPHILIAS
Scientifically sound information about unusual para-
philia is very scarce. One rare paraphilic topic is
characterized by the erotic desire to consume or be
consumed by another person or creature (vorare-
philia). Evidence from case studies suggests that vor-
arephilia appears to have close connection to sadism
and masochism [25]. Referring to the results of a
&
systematic literature review, Solla et al. [16 ] reported
the incidence of rare paraphilic behaviour, such as
telephone scatology, zoophilia and klismaphilia, as a
side-effect of Parkinson’s disease treatment with
&
dopaminomimetic medication [16 ]. Schenk et al.
[26] examined juvenile sex offenders for the inci-
dence of bestiality by comparing polygraph results
when asked about bestiality with self-reported
results. They reasoned that self-reported measuring
of juvenile sex offenders might underreport the pre-
valence of bestiality. The authors present two main
theories to explain bestiality. One postulates that
bestiality is a generalized pattern of sexual behaviour
comparable with offending human victims. The
other conceptualizes bestiality as the beginning of
a progression to more deviant sexual behaviour [26].
Hong and Kim [27] report the self-insertion of foreign
bodies into the urethra to obtain sexual gratification
as an uncommon paraphilia. They point out that
there may be other common motivations beside
autoerotic stimulation, including psychiatric dis-
orders, self-mutilation, intoxication and curiosity.
As Clark et al. [28] report, acts of frotteurism and
exhibitionism are frequent, but the number of per-
petrators seems to be much smaller because of the
fact that perpetrators report exceptionally high
numbers of victims. Hence, victim self-reports
estimate lifetime victimization rates ranging from
33–52% for women. Frotteurism and exhibitionism
are conceptualized as courtship disorders which
mean that both are distortions of normal courtship
interaction phases [28].
THERAPEUTIC APPROACH
Although the offer of counselling and psychotherapy
for patients with paedophilia is often a core part of
prevention strategies, motivation among healthcare
professionals to work with this group is low [29]. A
survey by Robles et al. [30] of mental health pro-
fessionals in eight countries revealed agreement in
assessing paraphilias as stigmatizing diagnoses
because the boundaries between normal behaviour
and psychopathology are unclear. Therefore, there is
need for ongoing discussion about the conceptualiz-
ation of paraphilia which apparently has implica-
tions for the treatment of those with paraphilic
disorders [3].
Volume 28
Number 6
November 2015

Today, antiandrogen treatment is offered to sex
offenders in many countries as an additional treat-
ment strategy alongside psychotherapy. Since the
1940s, there have been efforts to use hormonal
manipulation for the prevention of sexual offences,
including the use of the antiandrogen cyproterona-
cetat and various gonadotropin-releasing hormone
agonists. An evaluation of the outcomes of chemical
castration of sex offenders has revealed that the
associated decrease of serum testosterone levels
leads to a reduction in the frequency and intensity
of sexual thoughts. After cessation of chemical
castration, the kinetics of serum testosterone recov-
ery vary with treatment duration [31]. Although
chemical castration is not considered the preferred
treatment for paraphilia for ethical reasons, in some
cases, such as mental retardation, the adminis-
tration of antiandrogen medication may be used
as an alternative therapeutic method [32]. Evidence
concerning other biomedical treatment options for
paraphilia is very scare, especially for individuals
with comorbid psychiatric disorders. Firoz et al.
[33] reported a case of fetishism with comorbid
substance abuse that was successfully treated with
naltrexone. Ingves et al. [34] reported the successful
treatment of a 67-year-old man suffering from
depression, obsessive–compulsive disorder, and
signs of frontotemporal dementia with a course of
electroconvulsive therapy. Because of the coinci-
dence of Parkinson’s disease and compulsive sexual
behaviour, the potential case of an individual with
Parkinson’s disease and paedophilia is an example
for an ethical treatment dilemma. In this case,
administering an effective treatment to an individ-
ual may have an unwanted side-effect of impulse
control impairment, with the consequence of
potential harm to others. Muller et al. [35] dis-
cussed the ethical implications of potential treat-
ment of a peadophilic patient with Parkinson’s
disease using principles of biomedical ethics, and
emphasized that foresight and caution are strongly
recommended in this difficult field of divergent
interests.
There is evidence that sex offenders who are
detained or civilly committed exhibit below-aver-
age cognitive function, a fact that must be con-
sidered when planning a therapeutic approach
[36]. As Brouillette-Alarie et al. [37] point out, clini-
cians in many countries now routinely use risk tools
to assess a sex offender’s risk of recidivism. The
most popular scales consist of historical items that
cannot be modified by treatment or intervention.
Analyzing common risk assessment tools reveals
that the construct of persistent paraphilia was
related to sexual criminality, especially of the
paedophilic type [37].
0951-7367 Copyright ß 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Paraphilias Konrad et al.
CONCLUSION
The introduction of DSM-5 offers the possibility to
distinguish between paraphilia and paraphilic dis-
orders. Nevertheless, discussion on what exactly
constitutes sexual aberration continues. Critics of
DSM-5 emphasize that there is still a tendency to
devalue sexual practices that are not genitally organ-
ized with the aim of reproduction.
The aetiology of paraphilias is still unknown. Just
as little we know why paraphilias in general are less
common in women in spite of the fact that research
revealed prevalence of paraphilic sexual fantasies in
female samples. Because there is some evidence of a
correlation of sex drive and paraphilic interest, the
difference in sex drive between men and women may
be one explanation for the observable gender differ-
ence. Focusing on forensic samples, there is evidence
of a correlation between paraphilia and aggression.
For medical staff, it is important to realize that para-
philias sometimes emerge in neurodegenerative dis-
orders such as Parkinson’s disease, in some cases as a
side-effect of treatment. Although the coincidence of
neurodegenerative disorders and paraphilias seems
to suggest a correlation between cerebral pathology
and paraphilia, functional neuroimaging has yet to
reveal a sound theory about the underlying cerebral
process.
So far there is no clear consent on the best
therapeutic approach for a paraphilic disorder. In
forensic samples, the best treatment responses have
been achieved by the combination of psychother-
apy and chemical castration. But because we do not
yet know enough about the frequency of paraphilia
in nonforensic samples, there is a possibility that
even coercive paraphilic sexual fantasies may exist
in individuals who never act them out. In this field,
further research is urgently needed.
Acknowledgements
None.
Financial support and sponsorship
None.
Conflicts of interest
There are no conflicts of interest.
REFERENCES AND RECOMMENDED
READING
Papers of particular interest, published within the annual period of review, have
been highlighted as:
& of special interest
&& of outstanding interest
1. Kulish N, Holtzman D. The widening scope of indications for perversion.
Psychoanal Q 2014; 83:281–313.
www.co-psychiatry.com 443
Sexual disorders
2. Moss D. Introduction: ‘‘the sexual aberrations’’ – where do we stand today?
Psychoanal Q 2014; 83:241–247.
3. Potter NN. Philosophical issues in the paraphilias. Curr Opin Psychiatry 2013;
26:586–592.
4. Downing L. Heteronormativity and repronormativity in sexological ‘‘perversion
theory’’ and the DSM-5’s ‘‘paraphilic disorder’’ diagnoses. Arch Sex Behav
2015; 44:1139–1145.
5. Balon R. Politics of diagnostic criteria: specifiers of pedophilic disorder in
DSM-5. Arch Sex Behav 2014; 43:1235–1236.
6. Bergenheim A. Sexual assault, irresistible impulses, and forensic psychiatry in
Sweden. Int J Law Psychiatry 2014; 37:99–108.
7. Hall DA. The fate of aggression in maso-masochistic relationships. Psycho-
anal Q 2014; 83:345–373.
8. Chivers ML, Roy C, Grimbos T, et al. Specificity of sexual arousal for sexual
activities in men and women with conventional and masochistic sexual
interests. Arch Sex Behav 2014; 43:931–940.
9. Turner D, Schottle D, Bradford J, Briken P. Assessment methods and
management of hypersexuality and paraphilic disorders. Curr Opin Psychiatry
2014; 27:413–422.
10. Kalra G, Tandon A, Sathyanarayana Rao TS. Sexual disorders in Asians: a
review. Asian J Psychiatr 2014; 7:80–82.
11. Wright S, Kinky parents, child custody. the effect of the DSM-5 differentiation
between the paraphilias and paraphilic disorders. Arch Sex Behav 2014;
43:1257–1258.
12. Agalaryan A, Rouleau JL. Paraphilic coercive disorder: an unresolved issue.
Arch Sex Behav 2014; 43:1253–1256.
13. Joyal CC, Cossette A, Lapierre V. What exactly is an unusual sexual fantasy?
&& J Sex Med 2015; 12:328–340.
This survey of sexual fantasies among college students revealed that only a minority
of sexual fantasies could be considered typical.
14. Chan HC, Beauregard E. Non-homicidal and homicidal sexual offenders:
prevalence of maladaptive personality traits and paraphilic behaviors. J Inter-
pers Violence 2015. [Epub ahead of print]
15. Dawson SJ, Bannerman BA, Lalumiere ML. Paraphilic interests: an examina-
&& tion of sex differences in a nonclinical sample. Sex Abuse 2014. [Epub ahead
of print]
The authors of this study examined a nonclinical sample of men and women for the
prevalence of paraphilic interests. Their findings suggested a correlation of sex
drive and paraphilic interests that provided the best explanation for the observable
gender difference in paraphilic interests.
16. Solla P, Bortolato M, Cannas A, et al. Paraphilias and paraphilic disorders in
& Parkinson’s disease: a systematic review of the literature. Mov Disord 2015;
30:604–613.
A summary of case reports of paraphilias according to the DSM-V categories of
N¼31 patients suffering from Parkinson’s disease is provided based on a sys-
tematic literature search.
17. Gross M. Paraphilia or perversion? Curr Biol 2014; 24:R777–R780.
18. Janssen DF. How to ‘‘ascertain’’ paraphilia? An etymological hint. Arch Sex
Behav 2014; 43:1245–1246.
19. Mongeau V, Rouleau JL. DSM-5 pedophilic disorder: are the age and number
of victims significant variables? Arch Sex Behav 2014; 43:1247–1252.
444 www.co-psychiatry.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
20. Briken P, Fedoroff JP, Bradford JW. Why can’t pedophilic disorder remit?
Arch Sex Behav 2014; 43:1237–1239.
21. Polisois-Keating A, Joyal CC. Functional neuroimaging of sexual arousal: a
preliminary meta-analysis comparing pedophilic to nonpedophilic men. Arch
Sex Behav 2013; 42:1111–1113.
22. Habermeyer B, Esposito F, Handel N, et al. Response inhibition in pedophilia:
an FMRI pilot study. Neuropsychobiology 2013; 68:228–237.
23. Robertson CA, Knight RA. Relating sexual sadism and psychopathy to one
another, nonsexual violence, and sexual crime behaviors. Aggress Behav
2014; 40:12–23.
24. Chan HC, Beauregard E, Myers WC. Single-victim and serial sexual homicide
offenders: differences in crime, paraphilias and personality traits. Crim Behav
Ment Health 2015; 25:66–78.
25. Lykins AD, Cantor JM. Vorarephilia: a case study in masochism and erotic
consumption. Arch Sex Behav 2014; 43:181–186.
26. Schenk AM, Cooper-Lehki C, Keelan CM, Fremouw WJ. Underreporting of
bestiality among juvenile sex offenders: polygraph versus self-report. J For-
ensic Sci 2014; 59:540–542.
27. Hong S, Kim HJ. Two young men who complained of voiding difficulty after
stuffing odd materials into the urethra to obtain sexual gratification. Int
Neurourol J 2014; 18:98–100.
28. Clark SK, Jeglic EL, Calkins C, Tatar JR. More than a nuisance: the prevalence
and consequences of frotteurism and exhibitionism. Sex Abuse 2014. [Epub
ahead of print]
29. Jahnke S, Philipp K, Hoyer J. Stigmatizing attitudes towards people with
pedophilia and their malleability among psychotherapists in training. Child
Abuse Negl 2015; 40:93–102.
30. Robles R, Fresan A, Medina-Mora ME, et al. Categories that should be
removed from mental disorders classifications: perspectives and rationales
of clinicians from eight countries. J Clin Psychol 2015; 71:267–281.
31. Koo KC, Shim GS, Park HH, et al. Treatment outcomes of chemical castration
on Korean sex offenders. J Forensic Leg Med 2013; 20:563–566.
32. Park WS, Kim KM, Jung YW, Lim MH. A case of mental retardation with
paraphilia treated with depot leuprorelin. J Korean Med Sci 2014; 29:1320–
1324.
33. Firoz K, Nidheesh Sankar V, Rajmohan V, et al. Treatment of fetishism with
naltrexone: a case report. Asian J Psychiatr 2014; 8:67–68.
34. Ingves MV, Lau T, Fedoroff JP, Levine S. A man with urethral polyembolo-
koilamania successfully treated with electroconvulsive therapy. Arch Sex
Behav 2014; 43:1203–1207.
35. Muller S, Walter H, Christen M. When benefitting a patient increases the risk
for harm for third persons: the case of treating pedophilic Parkinsonian
patients with deep brain stimulation. Int J Law Psychiatry 2014; 37:295–
303.
36. Azizian A, Hutton S, Hughes D, Sreenivasan S. Cognitional impairment: is
there a role for cognitive assessment in the treatment of individuals civilly
committed pursuant to the sexually violent predator act? Sex Abuse 2015.
[Epub ahead of print]
37. Brouillette-Alarie S, Babchishin KM, Hanson RK, Helmus LM. Latent con-
structs of the static-99R and static-2002R: a three-factor solution. Assess-
ment 2015. [Epub ahead of print]
Volume 28
Number 6
November 2015