Paraphilia | Urges, Fantasies, Fetishes, and More

January 24, 2018


Paraphilia | Urges, Fantasies, Fetishes, and More

Have you ever heard the term “paraphilia”? Perhaps it sounds familiar, perhaps you’ve never heard it before, but we’re willing to bet that you’ve encountered it in one way, shape, or form; the thing is, there’s a good chance you didn’t know. So, let’s cut right to the chase:

What is a Paraphilia?

Paraphilias are characterized by “recurrent, intense sexual urges, fantasies, or behaviors that involve unusual objects, activities, or situations and cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. The Paraphilias include Exhibitionism, Fetishism, Frotteurism, Pedophilia, Sexual Masochism, Sexual Sadism, Transvestic Fetishism, Voyeurism, and Paraphilia Not Otherwise Specified.”

However, the DSM leaves out some key points, as beautifully quoted below from Paraphilias Across Cultures: Contexts and Controversies:

It is important to note that notions of deviance, standards of sexual performance, and concepts of appropriate gender roles can vary from culture to culture.

The diagnosis of Paraphilias across cultures or religions is complicated by the fact that what is considered deviant in one cultural setting may be more acceptable in another setting.”

Some may like the term based on addressing the subset of “sexual advances” and having a certain neutrality to it but it’s frequently misused in the social sciences and other areas. To be quite frank, the term has many flaws; as quoted from the Library of Congresses: “The truth is that the term is anything but neutral, being a term that is authorized by the DSM IV-TR, pathologizing certain sexual behaviors. One might speculate that the neutrality derives from the fact that people aren’t familiar with this term and therefore it is rendered meaningless.”

Charles Moser, Ph.D., MD is a sex educator, sex researcher, clinical sexologist, and sexual medicine physician, and who has been a pioneer in the creation and practice of the new medical specialty of Sexual Medicine – The Medical Aspects of Sexual Concerns and Sexual Aspects of Medical Concerns and states the following:

“Creation of the diagnostic category of paraphilia, the medicalization of nonstandard sexual behaviors, is a pseudoscientific attempt to regulate sexuality.”


An Exploration


One study wanted to turn to the general public to see if people desire and actually experience paraphilic behaviors. The results?

Nearly half of their participants had interest in exploring at least one paraphilia.


One third had actually performed and acted on their desire in at least one of the paraphilic categories.

They also found:

  • Voyeurism, fetishism, frotteurism, and masochism interested both male and female participants.
  • Levels of interest in fetishism and masochism were not significantly different for men and women.
  • Masochism was significantly linked with higher satisfaction with one’s own sexual life.

These results call into question the current definition of normal (normophilic) versus anomalous (paraphilic) sexual behaviors.

Sexuality and sexual interests are not one size fits all. People like different things, and simply- penis in vagina shouldn’t be the only thing we consider “normal.” The inspiration for the in-depth look into the sociological, psychological, and physical implications of paraphilia and this article stems from our lack of understanding.

History of Paraphilic Disorders

Paraphilia (Greek para- beside + Philos love) first translated into English by Wilhelm Stekel in his book Sexual Aberrations in 1925.  We then saw Freud used the term, but it didn’t become used in psychiatric literature until the 1950s. 

The International Classification of Diseases (ICD) Revision 6 in 1948 included things such as exhibitionism, fetishism, pathologic sexuality, and sadism were listed as inclusion terms under the category Sexual Deviation. It wasn’t until  ICD-8, approved in 1965, had a vast expansion of these paraphilic categories in the chapter on Mental Disorders.

Sexual Deviation now includedHomosexuality, Fetishism, Paedophilia, Transvestitism, Exhibitionism, Masochism, Narcissism, Necrophilia, Sadism, and Voyeurism.

The ICD-9, approved in 1975, included a grouping of Sexual Disorders and Deviation in the chapter on Mental Disorders which included: Homosexuality, Bestiality, Paedophilia, Transvestism, Exhibitionism, Trans-Sexualism, Disorders of Psychosexual Identity, Frigidity and Impotence, Fetishism, Masochism, and Sadism.  This was also the first edition to include definitions for each “mental disorder.” Library of Congress in 2007 now uses the term “Paraphilias” which replaced “Sexual deviation,” which had previously replaced “Sexual perversion” in 1972. 

The official change of language to the term “Paraphilias,” was since used in Medical Subject Headings (MeSH), the Thesaurus of Psychological Index Terms, and Human Sexuality: An Encyclopedia in 1994. The justification for use of the term is quoted, “Paraphilia is defined as an erotosexual and psychological condition characterized by recurrent responsiveness to an obsessive dependence on an unusual or socially unacceptable stimulus. The term has become a legal synonym for perversion or deviant sexual behavior, and it is preferred by many over the other terms because it seems more neutral and descriptive rather than judgemental.

However, from the public to researchers and doctors- we can’t seem to agree on what actually counts as a sexual perversion or a paraphilia. Event the psychiatric community doesn’t agree on the definition and diagnosis of paraphilias. As “Paraphilias” was introduced into the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 198, which if you’re not familiar is the manual- think of it as the bible of diagnosing and treating mental disorders. 

Because it is a manual which is created by committees who are subject to personal and political influence. There are arguments that though the “DSM is the primary, standard-setting diagnostic tool for psychiatrists, it does not describe how decisions regarding inclusion and exclusion in the category were made.” as quoted from the Library of Congresses in-depth look into the word usage of paraphilia. 

Change is Inevitable

“The work of sexuality scholars depends on and contributes to an understanding of how categories have emerged, expanded, disappeared, and changed over time, as well as how these categories have been explained and defined in terms of identities, behaviors, conditions, and difference” as quoted from the Library of Congresses. They also go on to note, that we have simply just changed the word usage over time (from Sexual perversion to Sexual deviation and now to Paraphilias), “without any human review of the catalog records.”

One Major Example: The Case of Homosexuality.

Thomas Walter Laqueur, American historian, sexologist, and author of Making Sex: Body and Gender from the Greeks to Freud gave us an interesting look into how our perception of sex has changed over time. Men and women were once thought of to be the same sex, just different versions. Women were lesser and didn’t have separate anatomy rather the uterus and clitoris were believed to be an inverted penis and scrotum

“Sex as we know it was invented in the eighteenth century, with the production of a binary gender system.”

This concept of “normal and natural” gender distinctions went well through the nineteenth century and stemmed from the idea that “the middle-class family was a central organizing principle for society.”

His research goes on to note that from this point on doctors, psychologists and the general public have been keeping this notion that there are normative, deviant, and pathological sexual orientations. Fast forward to the early twentieth century, and homosexuality was viewed as a perversion or a medical and psychological problem. 

With pathologizing sexual and gender differences the medical community “new specification of individuals.” Michel Foucault was quoted, “The machinery of power that focused on this whole alien strain did not aim to suppress it, but rather to give it an analytical, visible, and permanent reality: it was implanted in bodies, slipped in beneath modes of conduct, made into a principle of classification and intelligibility, established as a raison d’etre and a natural order of disorder.”

The inclusion of sexual activity in the DSM, like homosexuality, once was pathologized has brought up the issue that the present classification of sexual disorders merely amounts to a modification of social mores.

Moser and Levitt, prominent sexuality researchers who have paced the way in S/M, and sexual subcultures research have argued that,

“Normal sexual activity is socially relative and that society becomes an agent of control over aberrant sexual expression; the difficulty in establishing objective criteria in the DSM for diagnosing hypersexuality and suggests that this concept is reflective of a negative environment and negative attitude towards sexuality.”

as quoted from The Paraphilic and Hypersexual Disorders: An Overview

Sex-Negative Culture 

Cultures define and describe what is normal and what is deviant. The thing is, cultures are different and are dependant on a multitude of factors like politics, religion and popular belief. Sex-negative culture is seen with the belief that sex should only be done for procreative purposes which hinders sex-positive culture, attempting to open up the conversation and allow for individual preferences and pleasure. 

The role and development of paraphilias across cultures is also variable, with cultures defining what is legal or illegal.

As we know, cultures change. There is no “one culture” nor “one belief system.” It’s up to those in power and those who use their voices to create change. We’re starting to see with increased industrialization and urbanization, families will become more nuclear, with attitudes toward sex and paraphilias changing. But with the differences in characteristics of cultures comes an influence the rate of reporting paraphilias, as well as the rate of paraphilias themselves. This makes a collection of data and comparison of paraphilias almost non-existent if not taken by the mandatory court. 

We can see from things like the  “sexual predator legislation” which was originally passed in the 1930s but has seen a resurgence with the Supreme Court decision Kansas v. Hendricks in 1996, and 17 states following that misinformation and stigma around sexuality can affect someone in trouble with the law, and for the rest of their lives. These sexual predator laws use civil commitment procedures in order to retain sex offenders after they have completed serving criminal sentences for their crimes which predict that future sexually harmful acts will be committed by the individual if he or she is not detained. 

The issue with condemning people to lifelong labels and even court-ordered sentences is we just don’t know enough about paraphilias to be making life-altering decisions for individuals and the public. Further research is needed to elucidate the etiology and prevalence of paraphilias and to develop and evaluate effective treatments for paraphilic disorders.

Sexual deviance is a moral construct that refers to sexual behaviors that contravene the mores of the particular society or culture. It is often equated with a sexual abnormality, although this may reflect the general perception of what should be normal rather than what people really do. Attempts to define sexual deviance in purely statistical terms are problematic: what is considered sexually deviant may change over time; (e.g. homosexuality); what many cultures consider deviant is the norm in certain subcultures and quantifying sexual behavior and determining an appropriate cut-off for abnormal behavior is difficult. 

The absence of a universally accepted theory regarding the development of normal sexuality makes any theorizing about deviant sexuality problematic.

Although a necessary starting point, a sole focus on paraphilic behaviors invites judgment rather than understanding and risks confounding the important distinction between sexual deviance (as defined socially and legally) and mental disorder. A more satisfactory model of paraphilias would be to describe and understand the phenomenology and psychopathology of sexual fantasy and desire.

To Each Their Own

As a paraphilia offers pleasure, many individuals affected do not seek psychiatric treatment. Individuals who feel distressed may still avoid confiding in a doctor or psychiatrist out of shame.

Going back to the issue of one “neutral” name, paraphilias are vastly different and have differently known prevalences. 

Research seems to show that masochism, sadism, and fetishism are most commonly encountered paraphilias. In comparison, within clinics that treat sex offenders who have criminal charges, the most commonly encountered paraphilia are pedophilia, voyeurism, and exhibitionism.

Given that the actual incidence of paraphilias involving non-consenting individuals or the number of paraphiliacs who fail to seek psychiatric help is not known, the incidence of any one of the paraphilias is underreported.

The prevalence of paraphilias is much higher in men than women. Research done in 2000 estimates the sex ratio of 30 to 1. For most, paraphilias start in adolescence. One study found that 58.4% reported the onset of deviant sexual arousal prior to the age of 18. Other studies have found that the age of onset ranged from 13 to 15.5 years.

Given the limited empirical research on paraphilias and atypical sexual behavior among girls, there are no theories explaining its etiology and maintenance.

Through research, we are starting to see that while psychological factors may well influence whether or not an individual will act on his or her sexual impulses, it is likely that biological factors are predisposing and modulating elements to aberrant sexual behavior.

Why do certain people have paraphilic sexual behaviors?

There are different theories.

Brain Damage

One connects brain damage, specifically to the temporal lobe whether it was due to an accident, surgery, epilepsy, or toxic substances leading to emerging paraphilias. Further research theorizes that brain abnormality reduces the individual’s control over sexual impulses, and releases sexual motivations otherwise repressed, and that could lead to paraphiliac motivations

But, a number of other studies show inconsistencies in these findings.

Evolutionary theory

Sexual behavior, based on evolutionary theory, is largely motivated by maximizing reproductive success and survival of offspring. One reason it’s thought that more men have paraphilias is potentially due to attempts to pass on their genes and could be thought to be more aggressive than women because of the lesser reproductive responsibilities. Men only need to produce sperm, where women have to take on pregnancy, childbirth, nursing of offspring) which in line with evolutionary theory makes those having the baby to be much more selective about mate selection than are those who do not. 

When it comes to sexual coercion and forceful sexual behavior, evolutionary theory connects these behaviors to having difficulty being chosen as a mate. Other theories link aggressive sexual behavior as a motivation for obtaining power, control or dominance. 

The Monoamine Hypothesis

Norepinephrine, dopamine, and serotonin metabolism may be responsible for paraphilic behaviors. Norepinephrine is important for the continuation of alertness, drive, and motivation whilst dopamine is vital for the experience of pleasure and reward and serotonin is involved in arousal, attention, and mood.

“Sensation seeking has been suggested as a personality characteristic influencing the motivation behind paraphilias. Sensation seekers have low levels of monoamine oxidase (MAO) which is equivalent to individuals with paraphilia. MAO is a limbic system enzyme involved in breaking down brain neurotransmitters such as dopamine and serotonin. Dopamine contributes to the experiences of reward and therefore facilitates approach behaviors). Serotonin contributes to a biological inhibition, and to the brains physiological “stop” system, which therefore inhibits approach behaviors. 

The results illustrated that reduced serotonin positively correlates with sensation seeking characteristics in paraphiliacs. Sensation seekers tend to have high levels of dopamine, hence their biochemistry favors approach over inhibition. They also tend to have relatively low levels of serotonin, hence their biochemistry fails to inhibit them from risks and new experiences. Furthermore, Gonadal hormones in males are related to sensation seeking and would also account for the sex differences in sensation seeking. Consequently, this can also suggest the sex differences in paraphiliacs, as paraphiliacs are predominately male.

However, a vast number of neurotransmitters and systems are important to sexual behavior, and we are aware of no human studies that have directly demonstrated abnormalities in neurotransmitters in either hypersexual or paraphilic populations.”  

as quoted from The Paraphilic and Hypersexual Disorders: An Overview


During sexual development, humans pick up on things and can have “imprints” of different ways to get around which can stick with us for life.  If someone has certain experiences while getting aroused this experience becomes imprinted and associated with sexual arousal.

Social Learning Theory

Social learning theory suggests that deviant sexual behaviors are learned. Major research findings show “that aspect of human sexual behavior are the product of learning and conditioning, with such learning coming about through cultural factors including observation and modeling of various behaviors, with this learning than being reinforced through masturbation and sexual activity,” says The Paraphilic and Hypersexual Disorders: An Overview

Social constructionism theory says that sociocultural factors and social context are essential in how individuals perceive themselves and their sexuality. Scripting theories of sexual conduct (structured patterns of sexual interactions that are embedded in each culture can shape our sexual behaviors. 

 Courtship Disorder

“The concept of “courtship disorder” to explain the paraphilias. Freund notes that 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. Freund and Kolarsky described an idealized sequence of courtship behaviors as involving four phases: first, a finding phase (looking for a potential partner; if a patient were “trapped” in this phase, he would become a voyeur); second, an affiliative phase (verbal and nonverbal communications with a prospective partner; with deviancy resulting in exhibitionism); third, a tactile phase (in which physical contact is made; with a deviation resulting in frotteurism), and, fourth, a copulatory phase (in which sexual intercourse occurs; with a deviancy resulting in rape.) “as noted by The Paraphilic and Hypersexual Disorders: An Overview

Psychodynamic Theories

“Psychoanalytic theory relates the causes of “perversion” to early childhood. Freud emphasized the notion that perversion may be a regression to perverse sexuality, an early state of sensual gratification. Stoller has hypothesized that a perversion is the result of unresolved intrapsychic conflicts emanating from an individual’s past; perversion is “the result of family dynamics, that, by inducing fear, force the child who yearns for the full immersion in the oedipal situation… to avoid it.” He theorizes that perversion is the erotic form of hatred, primarily motivated by hostility, and is a state in which one wishes to harm an object. According to Stoller, this “takes form in a fantasy of revenge hidden in the actions that make up the perversion and serves to convert childhood trauma to adult triumph.” While psychodynamic and personality factors are frequently important in the treatment of individuals with these disorders, there is a lack of organized studies exploring psychodynamic treatment” quoted from The Paraphilic and Hypersexual Disorders: An Overview


Changing the Criteria Away from Social Judgment:

The World Health Organization is currently developing the 11th revision of the International Classifications of Diseases and Related Health Problems (ICD-11) which should be implemented by 2018.

They are recommending that Disorders of sexual preference, be renamed to Paraphilic Disorders and be limited to disorders that involve sexual arousal patterns that focus on non-consenting others or are associated with substantial distress or direct risk of injury or death.

They also want to change the  ICD-10 categories of Fetishism, Fetishistic Transvestism, and Sadomasochism to be removed. With adding new categories of Coercive Sexual Sadism Disorder, Frotteuristic Disorder, Other Paraphilic Disorder Involving Non-Consenting Individuals, and Other Paraphilic Disorder Involving Solitary Behaviour or Consenting Individuals.

The basis of their changes is due to human rights standards endorsed by the United Nations.

In the context of Paraphilic Disorders, it is of central relevance from WHO’s perspective to distinguish conditions that are relevant to public health and indicate the need for health services from those that are merely descriptions of private behaviors that do not have an appreciable public health impact and for which treatment is neither indicated not sought.” quoted from the WHO proposal.


The ICD-10 classification of Disorders of sexual preference merely describes the sexual behavior involved does not address the issue of their public health relevance.Social deviance or conflict alone, without personal dysfunction, should not be included in mental disorder as defined here.


Research has pointed out that a variety of factors related to social environmental stressors and cultural norms related to sexuality (e.g., stigmatization, rejection, isolation, and criminalization) can have profound impacts on psychological experiences and behaviors that do not necessarily reflect an underlying sexual disorder.”

If a pattern of behaviors has no importance in terms of public health surveillance and reporting and does not have clinical importance in indicating a need for treatment or its association with distress or functional impairment, then the basis for defining that behavior pattern as a disease entity is highly questionable and may serve primarily to convey social judgment about that behavior.

Cochran et al. concluded that the social deviance exclusion was critically important in considering this issue: “If a disease label is to be attached to a social condition, it is essential that it has a demonstrable clinical utility, for example, by identifying a legitimate mental health need, and its use should not exacerbate existing stigma, violence and discrimination”  as quoted from the Proposals for Paraphilic Disorders in the International Classification of Diseases and Related Health Problems, Eleventh Revision (ICD-11).

The main points they are trying to get across is if the arousal pattern has a focus on non-concent, created significant distress on the person becoming aroused, or nature of the paraphilic behavior involves significant risk of injury or death then, yes, it should be considered a Paraphilic Disorders. What should not be included as distress leading to classification is “potentially negative social consequences (e.g., social exclusion) of having atypical sexual interests, so that harm emanating from such social stigmatization against those who have such interests” 


Our conclusion?

Shame and social stigma without distress should not hinder anyone from being their sexual self. As long as everyone involved is consenting and communication is open, what you want to explore with your partner(s) or by yourself is your business!



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