Voyeuristic Disorder

Voyeuristic disorder is defined as a condition in which a person experiences persistent (at least 6 months), recurrent, and intense sexual arousal from observing an unsuspecting person who is naked, disrobing, or engaging in sexual activity, as manifested by fantasies, urges, or behaviors. The prevalence of true voyeuristic disorder is estimated to be as high as 12% in men and 4% in women. This chapter discusses the Fifth edition of the Diagnostic and Statistical Manual of Mental Disorders and International Classification of Diseases diagnostic criteria for voyeuristic disorder, in addition to its diagnosis, treatment, and prognosis. The recent literature on these topics is reviewed.

Putting It All Together

Unconventional sexual interests and behaviors can be classified in four ways. The system that appeals most to each person depends on the person’s background and preferred working paradigm. Those who think of paraphilias from a medical perspective will tend to think of possible anatomic or physiologic pathologies. Those who think of paraphilias from a behavioral perspective will tend to think of learned interests and behaviors due to mechanisms such as unconditioned and conditioned primary and second-order responses, blocking, generalization, punishment, and extinction. Those who think of paraphilias as variations on the range of sexual interests and behaviors shared by diverse population samples of humans will be prone to depathologize paraphilias and avoid categories. Those who focus on understanding the meaning that the paraphilia has for the person with the paraphilia will tend to think in terms of the person’s life history. This chapter reviews perspectives and paradigms concerning the paraphilias. A new classification scheme for the paraphilias is presented. The benefits of a new paradigm for the paraphilias that explains the changes seen in people with paraphilias is presented. A plea is made for productive future collaborations.

Transvestic Disorder

Transvestic disorder is defined as a condition in which there is persistent (at least 6 months), recurrent, and intense sexual arousal from wearing clothes associated with the opposite gender as evidenced by fantasies, urges, or behaviors. The condition causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. The term “transvestism” is used in this chapter in recognition that most people with transvestic interests never seek or require psychiatric care. This chapter discusses the Fifth edition of the Diagnostic and Statistical Manual of Mental Disorders diagnostic criteria for transvestic disorder, along with the diagnosis, treatment, and prognosis. The recent literature on these topics is reviewed.

Frotteuristic Disorder

Frotteuristic disorder is a condition defined as recurrent and intense sexual arousal from touching or rubbing against a nonconsenting person, as manifested by fantasies, urges, or behaviors, or by rubbing against non-consenting people for sexual stimulation. It has been reported that up to 30% of adult males in the general population may have committed frotteuristic acts. This chapter reviews the Fifth edition of the Diagnostic and Statistical Manual of Mental Disorders and the International Classification of Diseases criteria for frotteurism. Conditions for consideration in the differential diagnosis are discussed. Treatment and prognosis are discussed, and the recent literature on these topics is reviewed.

Exhibitionistic Disorder

This chapter provides a brief description of the key diagnostic features of exhibitionistic disorder in addition to a historic review of changes in the criteria in the Fifth edition of the Diagnostic and Statistical Manual of Mental Disorders and the International Classification of Diseases. This is followed by a review of the differential diagnosis and the ways in which the disorder can take different forms or be confused with other disorders. The recent scientific literature on the disorder is summarized. A description of recommended approaches to the assessment and treatment of this disorder, including differential diagnosis and psychotherapeutic and pharmacologic treatments, is presented.

Assessment, Treatment, and Management of Paraphilic Disorders

Many books, chapters, and articles concerning the assessment and treatment of the paraphilias have been published. Most are limited due to a lack of clarity about what is being treated and a failure to fully recognize the heterogeneity of the treatment population(s). This chapter provides a review of the assessment methods and treatments that have been recommended for paraphilic disorders in general. They are presented together because assessments and treatments can be generalized across different paraphilic disorders and many assessment and treatment approaches are complementary. Treatment approaches specific to individual paraphilias are discussed in the chapters dealing with the specific paraphilias.

Perspectives and Paradigms

Paraphilias are sexual interests that differ from “normal.” There is a widespread belief that paraphilias cannot be changed and therefore can be at best, managed, with no hope of successfully treatment. This chapter reviews how problematic sexual interests have been dealt with by clinicians and the courts. It introduces the concepts of genes, gender, orientation, drive, and interests. The chapter also presents reasons for the persistence of the unproven belief that paraphilic interests cannot change. It concludes with an alternative paradigm in which paraphilic interests are seen as variants of non-paraphilic interests and therefore equally modifiable. This means that paraphilic disorders can be effectively treated, and the establishment of persistent harmful sexual interests can be prevented.

Sexual Masochism and Sexual Sadism Disorder

Sexual sadism and masochism encompass a wide range of sexual interests. The words “sadism” and “masochism” are also used to describe nonsexual situations. In this chapter, the concepts of sadism and masochism are discussed as they relate both to sexual sadism disorder and sexual masochism disorder and also to bondage and discipline, dominance and submission, sadism and masochism (BDSM). This chapter reviews the Fifth edition of the Diagnostic and Statistical Manual of Mental Disorders and the International Classification of Diseases diagnostic criteria for sadism and masochism and discusses their difference from consensual BDSM. Variations are presented. Treatments and prognosis are discussed. A review of the recent literature on these topics is presented.

Pedophilic Disorder

This chapter examines pedophilic disorder, which is defined as a condition lasting at least 6 months consisting of recurrent, intense sexual arousing fantasies, sexual urges, or behaviors involving sexual activity with a prepubescent child or children (generally aged 13 years or younger) or simply as a sexual preference for boys or girls or both, usually of prepubertal or early pubertal age. The Fifth edition of the Diagnostic and Statistical Manual of Mental Disorders and the International Classification of Diseases diagnostic criteria for pedophilia are presented and discussed in this chapter. Reporting requirements and treatments are also discussed. Reasons for reconceptualizing the prognosis of this disorder are presented. The chapter also presents a review of the recent literature on these topics.

Other Specified Paraphilic Disorders

The Fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has a category of disorders termed “other specified paraphilic disorders” (OSPD). The DSM-5 diagnostic criteria for these disorders are contradictory, on the one hand referring to symptoms characteristic of a paraphilic disorder and, on the other hand, referring to symptoms that do not meet the full criteria for any of the disorders in the paraphilic disorders class. In this chapter, paraphilias meeting diagnostic criteria for OSPD are presented and discussed. Telephone scatologia, necrophilia, and zoophilia are briefly discussed, and the recent literature on these topics is reviewed.