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There are many types of atypical sexual behaviors, defined as sexual activities that do not commonly occur in society. These behaviors are motivated by paraphilias, defined as recurrent sexual fantasies and urges to engage in unusual sexual activities.

There does not at present appear to be generally accepted agreement among mental health professionals as to the etiology for each of the many different kinds of paraphilias. There may be clusters of personality traits that correlate with the presence of paraphilias, as well as a history of life events that interact with these personality traits in ways that contribute to the development of paraphilias. However, the exact mechanisms through which the paraphilias develop currently remain to some degree a mystery.

For clinicians who specialize in the treatment of sexual issues, this is an important – and difficult – understanding. Without clear information about the causes of a set of urges and behaviors, it can be more difficult to devise change strategies for those behaviors.

Treatment for paraphilias should probably only be attempted by mental health professionals who possess adequate education and training in this specialty area. The details of what would be involved in such treatment is outside the purview of this course. However, it is important for clinicians to possess at least a basic knowledge of paraphilias, as clients with paraphilias may appear from time to time in your practice.

In the DSM-5, there has been a significant change to how paraphilias have been conceptualized. In the DSM-5, certain paraphilias are not automatically considered mental disorders and are not automatically considered to warrant clinical intervention. In order for a paraphilia to be considered a mental disorder under DSM-5, the paraphilia must 1) be causing distress or impairment to the person exhibiting the paraphilia, and/or 2) the paraphilia must be presenting itself in a way that can create personal harm or the risk of harm to others.
Paraphilias are diagnosed by the presence of two criteria. Criterion A specifies the nature of the paraphilia, and Criterion B specifies whether the paraphilia causes distress or impairment to the person with the paraphilia, and/or creates harm or the risk of harm to others. Only those individuals who meet both Criterion A and Criterion B would now be diagnosed with a Paraphilic Disorder.

People whose sexual behaviors include paraphilias in the absence of these two criteria will no longer be automatically labeled as sexually deviant. While their sexual preferences are non-normative and different than socially mainstream behaviors, alternative or different sexual behaviors will no longer automatically demand a diagnosis.

Paraphilias are divided into two general types: non-coercive paraphilias (partners are willing participants) and coercive paraphilias (individuals are sexually aroused by fantasies or urges to inflict pain, either physical or emotional, on other people). Therapists may have varying degrees of willingness and expertise in working with all or certain of these, particularly if they involve coercion.

Generally, non-coercive paraphilias are harmful only if they bother the person’s partner, serve as a substitute for human contact, are dangerous, or become the only method a person has for achieving sexual pleasure. Coercive paraphilias can certainly be dangerous if a person acts out a violent fantasy on someone who is not a willing participant (University of California at Santa Barbara, 2008b).

For an accurate diagnosis to be made concerning whether a paraphilia is considered a disorder or simply sexual difference, the clinician must determine that distress or impairment is occurring to the client or harm is occurring to others from the presence of the paraphilia.

As noted very early in this course, one of the most important considerations in handling the sexual concerns of our clients is an ability to examine the material presented in a secure, confident and non-judgmental manner. For clinicians who have not had much experience with paraphilias, this can represent a difficult challenge.

The decision by the committee responsible for the DSM-5 to remove the label of sexual deviancy from the non-traditional sexual practices represented by the paraphilias does not mean that our culture as a whole is comfortable in viewing paraphilias as falling within the range of normal and accepted sexual practices.

To the degree that we clinicians have been raised within the larger culture, we are likely to have absorbed a significant degree of negative bias with regard to non-traditional sexual practices. Our initial reaction when a client discusses their sexual life and the existence of a paraphilia may reveal our own level of discomfort – unless there has been some preparation on the part of the clinician to address this discomfort.

This can be viewed as just another area in which clinicians must learn to become aware, knowledgeable, and, ultimately, skilled in handling issues of cultural diversity in order to “meet the client where he/she is at”. However, because sex and sexuality are so emotionally loaded within our culture, this can be a more difficult emotional challenge for clinicians that confronting many other areas dealing with cultural diversity.

Being confronted with a paraphilia for the first time as a clinician can be a jarring experience. It can push us to the limit in terms of maintaining control over our initial emotional response. However, the capacity to exercise emotional control is one of our most important core skills as a clinician. We must prepare a context in which the client feels safe, not judged. Without that capacity, we cannot invite the client into a relationship in which we can explore with him/her the problems – sexual or otherwise – that are creating the need for treatment.

Towards this end, it is helpful to increase our own awareness and knowledge about paraphilias. In addition to the material in this course, the University of California at Santa Barbara (2008) has an excellent website that gives information on each of the following paraphilias. See



Fetishism is a paraphilia that involves a person’s becoming sexually aroused by inanimate objects. Common objects are shoes and underwear. Without these specific objects, present in either reality or fantasy, the person is often unable to become aroused. Males are far more likely than females to develop fetishes.

There are two different types of fetishes. In a form fetish, the object itself (e.g. shoes, underwear, diapers) is important. In a media fetish, the arousing factor is the material from which the object is made (e.g. rubber or leather (UCSB, 2008c).


Sadomasochism can actually be divided into two different paraphilias, sadism and masochism. Sadists experience sexual pleasure and arousal from inflicting some degree of pain (or mock pain), suffering, or humiliation on others. The majority of the time, this activity occurs with a willing partner.

The counterpart to the sadist is the masochist. A masochist experiences sexual pleasure and arousal from being the recipient of the pain, suffering, or humiliation. Sadomasochism, or S&M, is fairly common in its less extreme forms.

Sexuality Factoid

14% of men and 11% of women have had some sexual experience with sadomasochism

Source: Janus, S., and Janus, C. The Janus Report on Sexual Behavior. 1993. New York: John Wiley & Sons

Bondage and discipline, or B&D, is a type of S&M where one partner ties or restrains the other and then pretends to "punish" or "discipline" the person who is in bondage. This activity often does not involve any physical pain. Another type of activity that typically does not involve actual violence is Dominance and Submission. In this activity, participants act out roles such as the teacher and naughty student or the master and slave (UCSB, 2008d).

There is some very preliminary research that has found some degree of correlation between a history of being spanked as a child and increased interest in masochistic sexual relationships (Straus, MA, 2001) However, additional research in this area must be conducted for a more definitive picture to emerge concerning this relationship.

Coprophilia and Urophilia

Coprophilia is a paraphilia in which the individual derives sexual gratification from activities involving feces. Slang terms for this activity include hard sports, brown showers, scat fetishism, scat play, and scatophilia. Contact with feces should be kept to a minimum due to the many pathogens contained in feces (UCSB, 2008e).

Urophilia involves deriving sexual excitement from urine, as when doing "golden showers" or “watersports” (urinating on or in front of another person) (UCSB, 2008f). These two paraphilias are most often acted out with a willing participant, although they can take place without a person’s consent.

Transvestism and Crossdressing

Transvestism, most commonly referred today as crossdressing, involves dressing like a member of the opposite gender. This dressing may be an expression of transgender feelings or may involve experiencing sexual arousal and pleasure.

Today, the term crossdressing is generally used for the expression of transgender feelings, and the term transvestic fetishism refers to dressing for sexual arousal and pleasure. Males are more likely than females to sexualize crossdressing and do it for sexual arousal. Female crossdressers may be less obvious, since women are allowed to wear male clothing in our society.

Most crossdressers identify themselves as heterosexual (UCSB, 2008g). Interestingly, a male client who was a crossdresser requested to come to counseling sessions dressed as a female, because he said he felt more emotionally open when he was dressed as a woman.

Autoerotic Asphyxiophilia

Some people learn that they can heighten their sexual arousal and orgasmic pleasure by cutting off their oxygen supply via strangulation or suffocation. People who get "hooked" on this practice develop the paraphilia called autoerotic asphyxiophilia.

The practice can be done alone or with a partner. Either way, it is very dangerous, because people may accidentally kill themselves if they lose consciousness and are not able to release themselves from the strangulation device they have created (UCSB, 2008h).

The practice sometimes occurs in an escalating domino pattern among adolescents. A young person may be found hanging and his parents are left having to wonder if he committed suicide OR if he accidentally killed himself while masturbating.



Exhibitionism is a paraphilia in which a person (usually a man) obtains sexual pleasure from exposing his or her genitals to strangers (usually women), generally in a public place. The exhibitionist derives pleasure from the expressions of shock or disgust on his victim’s face.

Many exhibitionists maintain their innocence in doing this behavior (“I was in my own apartment in front of a window with an open curtain—they didn’t have to look”), and they say their victims enjoy the experience. Exhibitionists often masturbate before or after exposing themselves, while recalling the event (UCSB, 2008i).


A frotteur intentionally rubs up against people and derives sexual pleasure by touching them in sexual ways without their consent and sometimes without their knowledge. These types of activities commonly occur in crowded public places, such as elevators, where the victim might assume the touching was accidental (UCSB, 2008j).


Scatolophilia is the clinical term for obscene phone calls. People who make these types of calls (scatolophiles) typically make sexual suggestions and receive sexual pleasure from the shock and discomfort of the people they call.

Scatolophiles may attempt to keep their victim on the phone through the use of persuasive manipulation or frightening threats. The behavior has decreased in recent years due to the increasing use of phone technologies such as caller ID (UCSB, 2008k).


Zoophilia is the paraphilia in which a person becomes sexually aroused by fantasies of or actual sexual contact with an animal. The practice of having sex with animals is commonly known as "bestiality."

Most males with zoophilia tend to direct their activities to farm animals, whereas most females engage in sexual behavior with household pets. Bestiality is considered a form of animal cruelty, and in many parts of the world it is illegal (UCSB, 2008l).


Necrophilia is the paraphilia in which an individual (known as a necrophile or a necrophiliac) becomes sexually aroused by fantasies of having, or actually having, sexual contact with a dead person. This sexual contact could range from intercourse, to oral sex, or simply masturbation in the presence of a corpse. Necrophilia is relatively rare (UCSB, 2008m).


A voyeur is a person who derives sexual pleasure from watching other people who are naked and who are not aware they are being viewed. Heightened excitement usually comes from the fact that the person is not aware she or he is being watched. Voyeurs, usually males, are commonly known as "Peeping Toms." An example of a voyeur could be someone who spies on girls showering or dressing in a locker room.

Although many average people derive some sexual arousal from accidentally seeing an attractive person naked, peeping and watching become atypical when a person repeatedly seeks or resorts to peeping and eroticizes these experiences by masturbating during the viewing or afterwards. Voyeurism is usually an illegal act (UCSB, 2008n).

A slight variation of voyeurism is scoptophilia. In this paraphilia, sexual pleasure is derived from watching other people engaged in sexual acts or viewing other people’s genitals without their knowledge.

A scoptophile’s urges for these activities would not be satisfied by a pornographic movie or going to a strip club, because these activities lack the exciting elements of risk and forbiddenness (UCSB, 2008n).


A pedophile is a person who derives sexual pleasure from fantasizing or engaging in sexual behavior with prepubescent children. Pedophiles are usually men, and they can be attracted to male children, female children, or both. Pedophilic behavior is child molestation and is illegal in every state of the USA.

Many people equate pedophilia and homosexuality, but these are NOT the same. The distinction is age. For example, adult males who are attracted to other adult males are homosexual; adult males who are attracted to children are pedophiles.

The causes of pedophilia are unknown, and current treatment modalities have had limited success. Pharmaceutical treatments with anti-androgens (drugs that reduce male sex hormone levels) and medications that increase serotonin (e.g., Prozac) continue to be investigated, and cognitive-behavioral therapy models, frequently accompanied by aversive and positive conditioning approaches, have demonstrated effectiveness in some cases (Psychology Today, 2006; WebMD, 2002).

Child Sexual Abuse/Molestation

Childhood sexual abuse refers to sexual relations that occur between a child and an immediate family member, any other adult, or an older child. This type of abuse is a problem all over the world. Females are most commonly the victims of child molestation, although males can also be victimized.

Estimates are that one in three girls and one in four to six boys are sexually abused before the age of 18. Abuse behaviors can include verbal abuse, exposure to sexual acts or pornography, genital touching, and vaginal or anal penetration. The vast majority of abusers (80%) are men, and usually these men are relatives or family friends of the victim (Parents United International, 2008).

Sexuality Factoid

There is evidence emerging that as many as one in three incidents of child sexual abuse are not remembered by adults who experienced them, and that the younger the child was at the time of the abuse, and the closer the relationship to the abuser, the more likely one is not to remember.

Source: Jim Hopper, Ph.D., Child Abuse Statistics, Research and Resources., 2004


Incest refers to sexual activity between close family members, specifically those family members who are not allowed to marry, e.g. parents and children, brothers and sisters, grandparents and grandchildren, aunts and nephews, uncles and nieces, and half brothers and half sisters. Incest is forbidden in a majority of cultures, and in most Western societies is illegal and punishable by law.

Authorities believe that because many cases of incest are unreported, the incidence of incest is more common than current statistics indicate (UCSB, 2008o).

Sex Offenders

A sex offender is a person who has been convicted of a sex crime, i.e. a sexual act which is prohibited by law (e.g. rape, molestation, sexual harassment, pornography production or distribution, downloading child pornography from the internet, etc.). Convicted sex offenders are often incarcerated for varying lengths of time and are required to register on the local sex offender registry, a database open to the public. Many do not.

In the past, treatment of sex offenders consisted largely of pharmacologic therapies, typically with anti-androgens and SSRIs. In recent years, new types of treatment programs have shown effectiveness in reducing recidivism rates for sex offenders. These programs offer psychological treatments with individual and group therapy, using a variety of modalities aimed at relapse prevention (Kersting, 2003). Ideally the treatment of sex offenders should be conducted by persons with specialized training in this area.

This completes the course on sexuality. You may now proceed to the references and test section. Thank you for choosing