Sexual deviation

Paraphilia (in Greek para παρά = besides and -philia φιλία = love)&mdash;in psychology and sexology, is a term that describes a family of persistent, intense fantasies, aberrant urges, or behaviors involving sexual arousal to nonhuman objects, pain or humiliation experienced by oneself or one's partner, children, or nonconsenting individuals or unsuitable partners. Paraphilias may interfere with the capacity for reciprocal affectionate sexual activity. Paraphilia is also used to imply non-mainstream sexual practices without necessarily implying dysfunction or deviance; see Clinical warnings section. Also, it may describe sexual feelings toward otherwise non-sexual objects.

Clinical context
Clinical literature discusses eight major paraphilias individually. According to the Diagnostic and Statistical Manual of Mental Disorders, the activity must be the sole means of sexual gratification for a period of six (6) months, and either cause "clinically significant distress or impairment in social, occupational, or other important areas of functioning" or involve a violation of consent to be diagnosed as a paraphilia.


 * Exhibitionism: the recurrent urge or behavior to expose one's genitals to an unsuspecting person. (Can also be the recurrent urge or behavior to perform sexual acts in a public place, or in view of unsuspecting persons.)
 * Fetishism: the use of inanimate objects to gain sexual excitement. Partialism refers to fetishes specifically involving nonsexual parts of the body.
 * Frotteurism: the recurrent urges of behavior of touching or rubbing against a nonconsenting person.
 * Pedophilia: the sexual attraction to prepubescent or peripubescent children.
 * Sexual Masochism: the recurrent urge or behavior of wanting to be humiliated, beaten, bound, or otherwise made to suffer for sexual pleasure.
 * Sexual Sadism: the recurrent urge or behavior involving acts in which the pain or humiliation of a person is sexually exciting.
 * Transvestic fetishism: a sexual attraction towards the clothing of the opposite gender. (Compare to autogynephilia.)
 * Voyeurism: the recurrent urge or behavior to observe an unsuspecting person who is naked, disrobing or engaging in sexual activities, or may not be sexual in nature at all.

Other rarer paraphilias are grouped together under Other paraphilias not otherwise specified (ICD-9-CM equivalent of "Sexual Disorder NOS") and include telephone scatalogia (obscene phone calls), necrophilia (corpses), partialism (exclusive focus on one part of the body), zoophilia (animals), coprophilia (feces), klismaphilia (enemas), urophilia (urine), emetophilia (vomit).

Some exceedingly rare paraphilias are sometimes encountered and have been reported in the literature. These include an adolescent male who had a strong fetishistic interest in the exhaust pipes of cars, a young man with a similar interest in a specific type of car, and a man who had a fetishistic interest in sneezing (both his own and the sneezing of others).

Clinical procedures
Observation of paraphiliac behavior has provided valuable scientific information on the mechanisms of sexual attraction and desire, such as behavioral imprinting. Investigation has also led to the tentative conclusions that biological processes may sometimes be manifested in idiosyncratic ways in at least some of the paraphilias, and that these manifestations are frequently associated with (and especially traumatic) events associated with early sexual experience. They tend to be caused by classical conditioning in that a sexual stimulus has been paired with stimuli and situations that do not typically result in sexual response and has then been perpetuated through operant conditioning because the sexual response is its own reward or positive reinforcement.

According to Dr. Joseph Merlino, Senior Editor of the book Freud at 150: 21st Century Essays on a Man of Genius and psychiatry adviser to the New York Daily News, a paraphilia is by definition a disorder. "It's the blurring of what I might do that is a turn-on for me, and what might get me into problems with others," said Merlino in an interview. "Once you cross that line, it exists as a problem....the term itself is a diagnosis and if you look at the current listing of diagnoses, the one thing you will find as a qualifier on every one of them for it to be considered a disorder is that it must interfere with functioning, personal interrelationships, career, etc. Absent that, we can't give it a diagnosis."

Intensity and specificity
Clinicians distinguish between optional, preferred and exclusive paraphilias, though the terminology is not completely standardized. An "optional" paraphilia is an alternative route to sexual arousal. For example, a man with otherwise unremarkable sexual interests might sometimes seek or enhance sexual arousal by wearing women's underwear. In preferred paraphilias, a person prefers the paraphilia to conventional sexual activities, but also engages in conventional sexual activities. For example, a man might prefer to wear women's underwear during sexual activity, whenever possible. In exclusive paraphilias, a person is unable to become sexually aroused in the absence of the paraphilia.

Optional paraphilias are far more common than preferred paraphilias, which are, in turn, far more common than exclusive paraphilias.

Optional paraphilias sometimes disrupt stable relationships when discovered by an unsuspecting partner. Preferred paraphilias often disrupt otherwise stable relationships. Open communication and mutual support can minimize or prevent such disruption in both of these cases. Exclusive paraphilias often preclude normal courtship and committed romantic relationships, even when the person in question desires such a relationship. Loneliness or social isolation are common consequences. In extreme cases, preoccupation with a preferred or exclusive paraphilia completely displaces the more typical desire for loving human relationships.

Drug treatments
The treatment of paraphilias and related disorders has been challenging for patients and clinicians. In the past, surgical castration was advocated as a therapy for men with paraphilias, but it was abandoned because it is considered a cruel punishment and is now illegal in most countries. Psychotherapy, self-help groups, and pharmacotherapy (including the controversial hormone therapy sometimes referred to as "chemical castration") have all been used but are often unsuccessful.[citation needed] Here are some current drug treatments for these disorders.

Hormone drug treatments
In humans, testosterone has a crucial role not only in the development and maintenance of male sexual characteristics but also in the control of sexuality, aggression, cognition, emotion, and personality. Testosterone is a major determinant of sexual desire, fantasies, and behavior, and it increases the frequency, duration, and magnitude of spontaneous and nocturnal erections. The deviant sexual fantasies, urges, and behavior of men with paraphilias also appear to be triggered by testosterone. Therefore, reducing testosterone secretion or inhibiting its action is believed to control these symptoms.

Antiandrogenic drugs such as medroxyprogesterone (also known as the long-acting contraceptive Depo Provera) have been widely used as therapy in these men to reduce sex drive. However, their efficacy is limited and they have many unpleasant side effects, including breast growth, headaches, weight gain, and reduction in bone density. Even if compliance is good, only 60 to 80 percent of men benefit from this type of drug. Long-acting gonadotropin-releasing hormones, such as Triptorelin (Trelstar) which reduces the release of gonadotropin hormones, are also used. This drug is a synthetic hormone which may also lead to reduced sex drive.

Psychoactive drug treatments
Selective serotonin reuptake inhibitor (SSRI) class of antidepressants such as fluoxetine (Prozac), sertraline (Zoloft), fluvoxamine (Luvox), and paroxitine (Paxil), have all been used to treat paraphilias and related disorders by reducing impulse control problems and/or sexual obsessions with some success.

Tricyclic antidepressants (TCA), such as imipramine (Tofranil) and desipramine (Norpramin), are also used.

Lithium, the mood-stabilizing drug also known as Eskalith is typically used for the treatment of mania in bipolar disorder. There are some reports of reduced sexual compulsive behavior and a reduction in obsessive sexual thoughts in patients, which they attribute to the drug's enhancement of serotonergic functioning.

Anxiolytics are not considered a typical treatment for these type of disorders, however the efficacy of buspirone (BuSpar) has been clinically demonstrated.

Psychostimulants have been used recently to augment the effects of serotonergic drugs in paraphiliacs. In theory, the prescription of a psychostimulant without pretreatment with an SSRI might further disinhibit sexual behavior, but when taken together, the psychostimulant may actually reduce impulsive tendencies. Methylphenidate (Ritalin) is an amphetamine like stimulant used primarily to manage the symptoms of attention deficit hyperactivity disorder (ADHD). Recent studies imply that methylphenidate may also act on serotonergic systems; this may be important in explaining the paradoxical calming effect of stimulants on ADHD patients. Amphetamine is also used medically as an adjunct to antidepressants in refractory cases of depression.

Religion and morality
Various religious adherents view various paraphilias as deviations from a divine plan for human sexuality, as understood through their religious tradition or laws. Depending in part on the nature of the paraphilia in question, judgements can differ as to whether religiously it should be considered a case of sexual sin, mental illness, or simply harmless sexual variation. Another variable is whether it is the acting out, or (less commonly) just the desirous thought alone, which is critically viewed in such cases. In any event, several paraphilias, such as bestiality or pedophilia, are viewed negatively by various religions.

Some religious traditions include forms of extreme asceticism, such as whipping, which, when practiced as sexual activities, would usually be considered masochism and popularly viewed as paraphilias. When practiced for non-sexual reasons, they are usually valued by the religious groups concerned as a part of their religious observance and submission to God.

Controversy over the term
The definition of various sexual practices as paraphilias has been met with opposition. Advocates for changing these definitions stress that there is nothing inherently pathological about non-criminal paraphilic practices, and they are stigmatized by being lumped together with crimes. Those who profess such a view hope that, much as with the removal of homosexuality from the Diagnostic and Statistical Manual of Mental Disorders (see homosexuality and psychology), future psychiatric definitions will not include most of these practices, or that consensual paraphilias will be clearly separated from nonconsensual paraphilias.

Legality
As a general rule, the law in many countries often intervenes in paraphilias involving young or adolescent children below the legal age of consent and sex with animals due to duty of care issues and general public abhorance of the practice. There is also legal intervention concerning nonconsensual deliberate displays or illicit watching of sexual activity, illegal manipulation of dead people, harassment, nuisance, fear, injury, or assault of a sexual nature. Separately, it also usually regulates or controls censorship of pornographic material.

Exhibitionism, in cases where people who have not previously agreed to watch are exposed to sexual display, is also an offense in most jurisdictions, as is voyeurism when unarranged (see indecent exposure and peeping tom).

Non-consensual sadomasochistic acts may legally constitute assault and therefore belong in the list below. Some jurisdictions criminalize some or all sadomasochistic acts, regardless of legal consent, and impose liability for any injuries caused. For these purposes, non-physical injuries are included in the definition of grievous bodily harm in English law. (See Consent (BDSM), Operation Spanner)

List of paraphilias
Used in a sexual context, terms with the -philia suffix refer to conditions in which the person's primary sexual interest involves the stimulus or situation mentioned (the suffix is also used for non-sexual interest in or admiration of a subject). Terms with the -lagnia suffix refer to an action involving the stimulus or situation. For example, someone who is consistently sexually excited by feces would have coprophilia; any sexual act involving feces, even by someone for whom that is not a primary interest, would be coprolagnia.