Rebecca Puchkors; Jeanne Saunders; David Sharp

Learning Objectives

By the end of this section, you will be able to:

Discuss terminology from the DSM-5-TR relative to paraphilias
Describe stressors reported by clients due to paraphilias
Identify nurses’ potential reactions to clients with paraphilias
Apply evidence-based nursing management of client/family distress as related to these conditions

A paraphilia is a sexual desire or behavior involving inanimate objects or nonconsenting other persons, or including subjugation. For example, some people are aroused and find sexual pleasure and gratification by fantasizing about or actually engaging with articles of clothing. Other people may be aroused and find sexual pleasure and experience orgasm by exhibiting their genitalia to nonconsenting individuals. Still others may find sexual pleasure dressing up differently than they typically would, such as dressing as a different gender. Most of these paraphilic fantasies and behaviors are more common in males than in females (APA, 2022); often, such thoughts and behaviors begin in childhood and may be exacerbated by adverse childhood experiences.

There is still debate as to whether some of these uncommon phenomena exist on a continuum of normal sexual arousal and behavior or whether they should be considered deviant (Castellini et al., 2018). Some of these paraphilic behaviors, such as pedophilia or sexual sadism, are illegal because they result in harm to other people. Others, such as fetishes (e.g., being sexually aroused by a person's shoes), do not necessarily harm other people, thus may be considered along a continuum of normalcy. Regardless of these classifications, there are situations in which the personal fantasies, thoughts, and behaviors associated with paraphilias rise to the level of psychiatric diagnoses, requiring psychiatric nursing and medical care.

DSM-5-TR Terminology Related to Paraphilias

A variety of uncommon sexual practices are considered paraphilias and may be diagnosable psychiatric disorders. To rise to the level of psychiatric diagnosis, a paraphilia must cause intense distress or impairment to oneself and/or to others (APA, 2022; Castellini et al., 2018). In the DSM-5, the eight specific paraphilic disorders identified are:

fetishistic disorder
transvestic disorder
voyeuristic disorder
exhibitionistic disorder
frotteuristic disorder
sexual masochism disorder
sexual sadism disorder
pedophilic disorder

Two other categories identified in the DSM-5 are other specific paraphilic disorder and unspecified paraphilic disorder (APA, 2022). For all these disorders, the diagnostic criteria are that the sexual arousal experienced by the client is both intense and recurrent for a minimum of six months and that the feelings, urges, and behaviors create marked distress or impairment in the client’s social functioning. “Other” and “unspecified” paraphilia means they do not meet all the diagnostic criteria for the other paraphilic disorders or that there is insufficient information to make a complete diagnosis (APA, 2022). The category of diagnosable psychiatric disorders known as paraphilias may refer to behaviors carried out by a person alone, in a consensual relationship with another person, or in a nonconsensual relationship that often carries legal consequences with it.

Solitary Behaviors

In the period after World War II, the so-called “sexual revolution” of the 1960s and 1970s led to changing attitudes about what sexual topics and behaviors were increasingly tolerated in American society (Crooks & Baur, 2017). With the increase in scientific study of sexual attitudes and behaviors (i.e., sexology), topics that had previously been taboo in society began to be understood in a more permissive light. For example, the sexology team of Masters, Johnson, and Kolodny (1988) clarified that masturbation, the process of providing sexual pleasure to oneself, was a solitary sexual behavior that provided comfort and gratification to adults and children alike. They confirmed that it was a phenomenon also seen in other members of the animal kingdom. They also debunked several previous myths about masturbation, including beliefs that it could be habit-forming, or unnatural. As the sexual revolution unfolded in America and sexologists began to publish the results of their research, much more is now known about the difference between sexual fantasies and behaviors as well as the difference between what sexual behaviors are “common” and healthy versus those that are unusual, offensive, and illegal. The human sexual repertoire is not a simple continuum from common to extreme, but there is much variation. Paraphilias in solitary behavior may involve a pattern of thoughts or actions specific to sexual arousal. Unless the thoughts or behaviors are distressful or harmful to the person, intervention is not required.

Fetishism

A fetishistic disorder refers to a paraphilia in which an individual has had intense and recurring sexual arousal from the use of nonliving objects, such as garments, or a highly specific focus on nongenital body parts. The individual with this disorder acts on fantasies, sexual urges, or behaviors that result in great distress or social impairment. When making the diagnosis, the disorder may be specified with a body part (typically not genitalia), with an inanimate object(s), or with combinations of these. For example, a person may have a foot fetish as well as a shoe fetish, deriving sexual arousal and gratification from both a specific part of the body and a related garment. Another person may have a fetish involving wearing female undergarments while engaging in foreplay with a female. If this person is not distressed by this behavior and the sexual partner views this as consensual, however, it would not meet the diagnostic criteria of a fetishistic disorder. A client with a diagnosable disorder may be aroused by more than one object or situation; some individuals acquire vast collections of the desired inanimate objects, such as shoes or leather boots.

Transvestism

A transvestic disorder refers to a paraphilia in which the person becomes sexually aroused or has urges and fantasies about becoming sexually aroused from cross-dressing (i.e., dressing in items usually worn by a different sex) and the person experiences great distress and social impairment from this situation. Some people enjoy dressing up as the opposite sex, but do not meet the diagnostic criteria of having this disorder because they lack the emotional distress and social impairment associated with the diagnostic category. This practice, and the mental disorder, may be more common in males than in females and often has its origin in childhood (Zucker et al., 2012). In some cases where cross-dressing is habitual in a male, it may also be accompanied by gender dysphoria (see Gender Dysphoria).

Behaviors Involving Others

Sexual fetishes are often experienced only as urges or fantasies. As such, they do not involve behaviors that are enacted with or toward another person. The behaviors that do involve others are, in general, enacted without the consent of the other. This lack of consent may lead to legal consequences. For example, pornographic depiction of children as sexual objects is illegal and can result in incarceration of the adult in possession of pictures, videos, etc. (Crooks & Baur, 2017). Examples of these behaviors are voyeurism, in which one is sexually aroused and satisfied from watching others, against their knowledge, as they undress or are in the nude; exhibitionism, in which one exposes their external genitalia to another, nonconsenting individual; frotteurism, in which one rubs against another person’s body for sexual gratification; and pedophilia, in which one engages in sexual behavior with a child (who is unable to consent). Sadism also is a sexual behavior that involves another person and brings harm to them because the perpetrator inflicts physical or psychological suffering.

In a study of young adults attending six universities in Italy, Castellini et al. (2018) found that 68 percent of the sample admitted to having experienced paraphilic fantasies at some time during their lives. These researchers found that voyeurism was the most common paraphilia reported by males and females, whereas females tended to act on fetishism and masochism more often than males. These behaviors can be subject to criminal prosecution if injury or death occurs, regardless of consent status of the participants.

Voyeurism

The term voyeurism means the experience of intense and recurring sexual arousal from observing another person, who is unsuspecting and nonconsenting, naked, undressing, or engaging in sexual activity. The person diagnosed with a voyeuristic disorder acts on the sexual urges involving a nonconsenting other person or in fantasies. Moreover, the person who engages in such behavior also experiences great distress or social impairment. This is one of the most common illicit paraphilias and is found more often among males than among females. A person must be at least eighteen years of age to receive this diagnosis to distinguish it from the natural curiosity associated with puberty. Although the exact cause of this disorder is unknown, there is evidence that it is associated with childhood sexual abuse, hypersexuality, and substance misuse; comorbid conditions may include attention-deficit hyperactivity disorder, depression, bipolar disorder, and anxiety (APA, 2022).

Voyeurism also has legal implications. With the advancement in technology has come a new form of voyeurism known as “video voyeurism.” In this situation, the perpetrator may place a small camera in a public or private bathroom and record strangers’ genitalia during urination. Or they may place the camera on the ceiling of a room and record sexual activity of others. In addition to their own sexual gratification, they may sell the videos to others. Currently, almost all states have laws to prohibit these activities, but the laws are difficult to enforce (Crooks & Baur, 2017).

Exhibitionism

Sexual arousal that comes from displaying one’s external genitalia to another nonconsenting person is called exhibitionism. If the nonconsenting “other” is a child, then it is possible that the client also has a pedophilic disorder (APA, 2022). An individual diagnosed with exhibitionistic disorder has both intense and recurring sexual arousal from the exposure of their genitals to an unsuspecting and nonconsenting other person (child, adult, or both) for a period of at least six months and has acted on the urges or experiences great distress and social impairment as a result. A person could have an exhibitionistic sexual interest, but not act on the interest and, therefore, would not meet the criteria for the psychiatric diagnosis.

Although the diagnosis may be found in both males and females, it is far more common in males than in females. Among males, the interest in this behavior may arise in adolescence and eventually wane in older age. Antisocial behaviors or antisocial personality disorder may be a precursor or increase the risk for developing this disorder. Alcohol use and pedophilic disorder are also commonly associated with exhibitionistic disorder. High rates of comorbidity have been found in bipolar disorder, depression, anxiety, and substance use disorder as well (APA, 2022).

Frotteurism

The term frotteurism is the sexual arousal that comes from touching or rubbing against another nonconsenting person. As with other paraphilic disorders, to meet the DSM-5 criteria for psychiatric diagnosis, the behavior must be exhibited at least three times over six months and the client must experience great distress (e.g., shame, guilt, anxiety) and social impairment (e.g., difficulty working). Most studies indicate that approximately 8 to 9 percent of males in North America may have this tendency (Savoie et al., 2021), but most do not meet the diagnostic criteria (APA, 2022). Frotteurism has been associated with various neurocognitive disorders, including schizophrenia, and substance intoxication. The condition may also be seen in individuals with conduct disorder and antisocial personality.

Sexual Masochism

The paraphilia sexual masochism disorder is where an individual has intense and recurring sexual arousal from being made to suffer from being beaten, bound, or humiliated. The sexual urges, behaviors, or fantasies lead to the individual feeling great distress or impairment in social or other important situations. This type of paraphilia may be specified as “with asphyxophilia” or “autoerotic asphyxia” when an individual achieves sexual arousal from restricted breathing (Crooks & Baur, 2017).

Sexual Sadism

Sexual sadism is sexual arousal that results from inflicting physical or psychological suffering on another person. The diagnosis in which an individual has intense sexual arousal from the suffering of another person and is distressed and socially impaired by this arousal is called sexual sadism. Sadistic behaviors may include those that are gentle and playful, such as soft biting, but they may also be highly violent, such as the intense pain inflicted with violent rape or torture (Masters et al., 1988), which would have legal implications.

The term bondage-domination-sadism-masochism (BDSM) is broadly used to refer to a wide range of behaviors that individuals with sexual masochism and/or sexual sadism (as well as other individuals with similar sexual interests) engage in, such as restraints or restriction, discipline, spanking, slapping, sensory deprivation (e.g., using blindfolds), and dominance-submission role-play involving themes, such as master/enslaved person, owner/pet, or kidnapper/victim (APA, 2022).

Pedophilia

Pedophilia is the intense sexual arousal of an adult by a child or children. The paraphilia in which an individual, age sixteen years or older, is intensely attracted to a child or children and may engage in actual sexual behavior, including vaginal or rectal penetration is called pedophilic disorder. To reach the level of psychiatric diagnosis, the intense attraction, fantasies, urges, and/or actual behaviors must have continued for a period of at least six months, the child victim must be at least five years younger than the perpetrator, and the perpetrator must have been very distressed by this behavior, or the behavior must have resulted in great social problems (APA, 2022). Criminal law varies by state under statutory rape, child abuse, or sex offender categories. It is possible that an adult has a pedophilic sexual interest, which means that they are sexually aroused by children or engage in sexual fantasies involving children, but they do not overtly behave in a sexual way with children.

Pedophilia is considered a crime in the United States, so the individual with this psychiatric diagnosis requires particular attention. A condition known as emotional congruence with children is often an attribute found in persons who have either pedophilic sexual interest or pedophilic disorder. Emotional congruence in this sense means that the individual (adult) has feelings and thoughts that may be more like those of children than of adults. Moreover, this type of individual tends to prefer to spend more time with children than adults, including working in occupational or volunteer roles involving children in a variety of settings. Although it is uncommon in females, the prevalence in males is estimated to be about 3 percent. The intensity of the actual disorder may fluctuate throughout one’s life, generally with onset in puberty. Many males may have been sexually abused as children themselves. Other attributes that may be found in the person with a paraphilic disorder include impulsivity, antisocial personality, substance intoxication, and a high degree of willingness to take risks. This disorder may occur with other paraphilic disorders, such as exhibitionistic disorder or may be diagnosed concurrently with obsessive-compulsive disorder, depression, anxiety, or bipolar disorder (APA, 2022).

Stressors Reported by Clients Associated with Paraphilias

As noted earlier, not all paraphilias are illegal or deviant. Rather, many individuals may experience erotic stimulation and arousal from any number of different inanimate objects. When the fantasy or urge to act on these feelings is translated into actual behavior that is harmful to oneself or others, paraphilias become problematic. As with all the paraphilias identified in the DSM-5-TR, two criteria must be met for the diagnosis. The first criterion is the recurrent nature of the behavior, urge, or fantasy over a period of six or more months, and the second criterion is that the urge, fantasy, or behavior “cause marked distress or interpersonal difficulty” (APA, 2022, p. 792). When behaviors cause harm or distress, they may become diagnosable psychiatric disorders. Some also have associated legal implications. The distress that one experiences with the diagnosis of a paraphiliac disorder may include anxiety, depression, guilt, shame, stigma, and loneliness. The stressors associated with paraphilic disorders may create psychological pain for which a client seeks relief through other behaviors, such as excessive gambling, eating, or drinking (Crooks & Baur, 2017).

Comorbid conditions that have been associated with paraphilias include dysthymia (a mood disorder), major depressive disorder, substance misuse, and childhood attention-deficit hyperactivity disorder (Pang, 2023). Clients with these disorders are often managed with selective serotonin reuptake inhibitor (SSRI) medications to reduce excessive fantasizing. Cognitive behavioral therapy may provide some assistance with the motivation to engage in associated compulsive behaviors (Pang, 2023).

Nurses’ Potential Reactions to Clients with Paraphilias

Nurses may exhibit a wide range of responses to clients who have paraphilias or who may be diagnosed with paraphilic disorders. Nurses’ responses to clients with paraphilias may depend upon whether the paraphilia is illegal and/or if it reaches the level of a psychiatric disorder. A particularly salient aspect of paraphilias is the individual client’s behavior. Many people may have urges or fantasies that involve a paraphilia, but they do not actually act out that urge or fantasy. Such thoughts and feelings are not illegal. Exhibitionism, pedophilia, and voyeurism, if enacted, however, are illegal (Yakeley & Wood, 2014).

Initially, nursing students may be curious and intrigued by the description of sexual arousal and other sexual behaviors that are different from or similar to their own. This is a normal response, and they should be encouraged to read and learn about differences in sexual interests and behaviors as much as any other area of human attributes that may be different from or similar to their own.

Link to Learning

Read this report of original research done with university students in Italy to learn more about the relationship between paraphilias, hypersexuality, and adverse childhood sexual experiences.

Nurses are cautioned to be nonjudgmental in their attitudes about those whose behavior is drastically different from their own, and this applies also to clients who have been diagnosed with paraphilic disorders. What may add to confusion in this particular area of human behavior, however, is the lack of consensus about what is normal, abnormal, or how criminal penalties apply. Some of the paraphilic disorders (e.g., pedophilic disorder) are against the law, because of the harm they can do to children. The nursing student, faculty, and practitioner should know the laws of the state in which they work so that reporting suspected or actual criminal behaviors, especially when they pertain to children, can be done consistently and without reservation. It is also important to remember the difference between urges and fantasies versus actual behaviors. It is not criminal to experience urges or fantasies about sexual expression, but it may be criminal to enact such expressions.

Some nursing students and practicing nurses may find some of their own sexual arousal described in the paraphilias. This attests to the view that sexual arousal may exist along a continuum in many cases rather than a clearly dichotomized prevalence of normal versus deviant. Wherever one’s arousal and preferences lie, it is essential that nursing students learn to be self-aware and self-reflective. When attitudes and beliefs lie outside one’s consciousness, they have the potential to be misunderstood and create havoc in one’s daily lives. If a student or practitioner discovers that their sexual behaviors are congruent with the diagnosable paraphilic disorders, it is imperative that they seek help from another health professional with specialized training in sexual dysfunction therapy, psychiatric advanced practice nursing, or other similar certifications (e.g., American Association of Sex Educators, Counselors, and Therapists [AASECT]).

Nursing Interventions and Management

Nurses who work in psychiatric or mental health settings may encounter clients with paraphilias; similarly, those who work in prisons or juvenile detention settings may also encounter clients who have enacted these behaviors and are now serving the criminal or sex offender punishments as a result. Nursing education at both entry level and graduate, advanced practice seeks to promote quality and safety through adherence to basic competencies. One of the most helpful of these competencies for nurses adjusting to rapid changes in sexuality content is to understand the concept of evidence-based practice (EBP).

The process to achieve EBP is a growing conversation. Bell (2020) reflects upon progress made. Themes identified by Bell (2020) through study of the literature include that nurses must:

begin with a sense of inquiry and determine a clinical question
locate research evidence to address the clinical question and think critically about application of the evidence
implement practice change that incorporates nursing expertise and client preference with the evidence
evaluate the outcome of the change
work to share and sustain EBP

These themes are aspects of the nursing process and nurses’ clinical judgment. EBP is a model for building nursing expertise. To paraphrase anthropologist and scholar, Margaret Mead (1901–1978), who found that culture, not biology, determines gender, nurses should learn how to think, rather than what to think. Due to rapid developments in science and diversity awareness, nurses can no longer depend on tradition and routine for practice guidance.

Some topics of concern to nurses do not have published literature review or meta-analyses. With respect to the topic of paraphilias, the nursing literature does not provide much guidance, so one must venture into databases outside nursing to obtain evidence about this population and the health issues they experience. Nurses in clinical practice may develop a journal club in which they can find and evaluate current literature to enhance their basic understanding of human sexual functioning and behaviors.