INTRODUCTION:

Paraphilia:

Definition:

¹The term paraphilia is used to identify repetitive or preferred sexual fantasies or behaviors that involve any of the following:

1. The preference for use of a nonhuman object

2. Repetitive sexual activity with humans that convoluted real or simulated suffering or humiliation

3. Repetitive sexual activity with non-consenting partners

Historical Aspect:

¹Historically, some restrictions on human sexual expression have always existed. Under the code of Orthodox Judaism, masturbation was punishable by death. Inancient Catholicism it was considered a carnalsin.In the late 19thcentury, masturbation was viewed as a major cause of insanity.

¹Oral–genital, anal, homosexual, and animal sexual contacts were viewed by the early Christian church has unnatural and, in fact, were considered greater transgressions than extramarital sexual activity because they did not lead to biological reproduction.

²Epidemiological Statistics:

· Pedophilia (45 percent),

· Exhibitionism (25 percent)

· Voyeurism (12 percent).

Thebehaviorpeaksbetweenages15and25andgraduallydeclinessothat, byage 50, the occurrence of paraphilic acts is very low, except for those paraphilic behaviors that occur in isolation or with a cooperative partner.²

Etiology:

1. Biological Factor:

Some animal studies and Autopsy studies shows

· Destruction of parts of the limbic system in animals has been shown to cause hypersexual behaviour.

· _T_{emporal lobe diseases,
such as psychomotor
seizures or temporal lobe
tumors,}

· _{Abnormal levels
of androgens also may contribute to in
appropriate sexualarousal.}

· Biological issues thought to be risk factors for paraphilias comprise some differences in brain activity during sexual arousal, as well as general brain structure².

2. Psychoanalytical Approach:

The psychoanalytical approach defines aparaphilia casone who has failed the normal developmental process toward heterosexual adjustment.¹

Oedipal Crisis:

When the individual fails to sort out the Oedipalcrisis and either identifies with the parent of the opposite gender or selects an inappropriate object for libidocathexis. The following disorder suggest unresolved oedipal crisis¹.

Fetishism and transvestitism:

Behind the behaviour of Fetishism and transvestitism has severe castration anxiety during the Oedipalphase of development leads to the substitution of a symbolic object (inanimateor an anatomicpart) for them other¹

Pedophilia and zoophilia:

Anxiety over arousal to them other canlead to the choice of “safe,” inappropriate sexual partners so they prefer children and non harmful animal.

Psychologically, pedophiles who act on their urges by sexually offending tend to engage in gro Psychologically, pedophiles who act on their urges by sexually offending tend to engage in grossly distorted thinking, in that they use their position of power and view offending as an suitable way to meet their needs, think about children as equal sexual beings to adults, and consider their sexual needs as uncontrollable.²

Exhibitionism and voyeurism:

In this sexual disorder the person prefer safe sexual behaviors in which there is no sexual contact Mental health professionals have found that male pedophiles have lower IQ scores on psychological testing compared to men who are not pedophiles.¹

3. BehavioralTheory:

· Wrong reinforcement

· _M_{odeling behaviour
of others who have
carried
out paraphilic
acts,}

· Mimicking sexual behaviour depictedin the media,

· _R_{ecalling
past trauma such as one’s own molestation2}

4. Theoretical Integration:

Socio cultural factors, and biologic processes must occur to account for these deviant sexual behaviors. A combination of biological, psychosocial, and cultural factors, along with aspects of the learning paradigm previously described, probably provides the most comprehensive etiological explanation for paraphilias to date.⁴

Further more another theory about paraphilia risk factors is that they are linked to stages of childhood psychological development like temperament, early relationship formation, trauma repetition, and disrupted development of sexuality, as follows:

· Temperament: a tendency to be overly inhibited or uncontrolled with emotions and behaviors

· Early relationship formation: a lack of stable self-awareness, problem managing emotions, and in seeking help and comfort from others⁴

· Trauma repetition: People, who are the victim of sexual or other forms of abuse, especially if it occurs during childhood, may identify with the abuser such that they act out what was impose on them by victimizing others in some way. They may also act out the trauma by somehow harming themselves.⁴

· Disrupted development of sexuality: The patterns of what brings one sexual pleasure tend to form by adolescence. People raised in a household that is either extremely sexually permissive or inhibited are at higher risk for developing a paraphilia.⁴

Family risk factors for paraphilia development:

These are include high conflict between parents or low supervision by parents, a lack of affection from the mother, and generally not feeling treated well by their parents. People with paraphilia tend to have trouble making and keeping friends and other relationships.

Types Of Paraphilia³

1. Abaisophilia- Impaired mobility

2. Acrotomophilia – Amputated Part

3. Agamatophilia – Stautues, Mannequins

4. Algolagnia – Pain Expects in an erogenous zone.

5. Andromimetophilia – trans men

6. Anililagnia- focus on older women.

7. Asphyxiophilia- focused strangled

8. Atagonistophilia- Focus on camera

9. Autassassinophilia- Erotic feeling life threatening situation

10. Autogynephilia- Sexual arousal on male by imagined himself as female.

11. Auto-haemofetishism- Bleeding oneself

12. Autonepiophilia- The image of one's self in the form of an infant

13. Autopedophilia-The image of one's self in the form of a child

14. Autoplushophilia -The image of one's self in the form of a plush or anthropomorphized animal

15. Autoerotic asphyxiation- Self-induced asphyxiation, sometimes to the point of near unconsciousness

16. Biastophilia- Raping a person, Rape fantasy

17. Capnolagnia- Smoking

18. Chremastistophilia- Being robbed

19. Chronophilia- Focus on differing chronological age.

20. Coprophilia- Feces (scatophiliac)

21. Dacryphilia- tears or crying

22. Diaper fetishism- Diaper

23. Dendrophilia- trees

24. Emetophilia- vomit

25. Eproctophilia- Flatulence

26. Erotic Asphyxiation – Asphyxia of oneself or others

27. Erotophonophilia- Murder, (dacnolagnomania)

28. Exhibitionism- Exposing one's genitals to unsuspecting and nonconsenting others

29. Feederism- Eating, feeding, and weight gain.

30. Formicophilia- Being crawled on by insects

31. Forniphilia- Turning a human being into a piece of furniture

32. Frotteurism- Rubbing against a non-consenting person

33. Gerontophilia- Elderly people

34. Gynandromorphophilia- Transsexual or transgender women-

35. Hematolagnia- Drinking or looking at blood

36. Heterophilia- Idealization of heterosexuality and/or people who are "straight-acting", especially by non-heterosexual people.

37. Homeovestism- Wearing clothing emblematic of one's own sex

38. Hoplophilia- Firearms, guns

39. Hybristophilia- Criminals

40. Kleptophilia- Stealing

41. Klismaphilia- Enemas

42. Lactophilia - Breast milk

43. Liquidophilia- Immersing genitals in liquids

44. Macrophilia- Giant beings

45. Maschalagnia- Armpits

46. Mazophilia- female breasts

47. Masochism- Suffering or humiliation; being beaten, bound or otherwise abused

48. Mechanophilia- Cars or other machines

49. Melolagnia- Music

50. Menophilia- Menstruation

51. Metrophilia- Poetry

52. Microphilia- small people

53. Morphophilia- Particular body shapes or sizes

54. Mucophilia- Mucus

55. Mysophilia- Dirtiness

56. Narratophilia -Obscene words.

57. Nasophilia- Nose

58. Necrophilia- Corpes

59. Objectophilia- inanimate objects

60. Oculophilia- Eyes

61. Olfactophilia- Smells

62. Omorashi - Arousal from having a full bladder and/or wetting oneself or others

63. Partialism-Specific, non-genital body parts

64. Pedophilia- Prepubescent children, also spelled paedophilia; often confused with hebephilia, ephebophilia, and pederasty Peodeiktophilia - Exposing one's penis

65. Pedovestism- Dressing like a child

66. Podophilia- Feet

67. Pictophilia- pornography

68. Piquerism- Stabbing or cutting others

69. Plushophilia- Stuffed toy animal

70. Pygophilia- Buttocks

71. Salirophilia- Soiling or dirtying others

72. Sexual fetishism- Nonliving objects

73. Sexual sadism- Inflicting pain on others

74. Shoe fetishism- Shoes, such as high heels

75. Somnophilia- Sleeping or unconscious people

76. Sophophilia – Learning

77. Sthenolagnia- Muscles and displays of strength

78. Stigmatophilia- Body piercings and tattoos

79. Symphorophilia- Witnessing disasters

80. Telephone scatologia- Obscene phone calls, particularly to strangers; also known as telephonicophilia.

81. Teratophilia - Deformed or monstrous people. The term is also sometimes used in a more literal sense (from ancient greek τέρας, teras, meaning monster) for attraction to monstrous mythical and fictional creatures such as werewolves.

82. Transvestic fetishism - Wearing clothes associated with the opposite sex; also known as transvestism

83. Trichophilia- Hair

84. Urolagnia- Urination, particularly in public, on others, and/or being urinated on.

85. Vorarephilia- The idea of one person or creature eating or being eaten by another; usually swallowed whole, in one piece; also known as vore

86. Voyeurism- observing others while naked or having sex, generally without their realization; also known as scopophilia or scoptophilia, window peepers

87. Zoophilia- Animals

Diagnostic criteria:

DSM Criteria:

Sexual fantasies or behaviours are recurrent over a period of at least 6 months and cause the individual clinically significant distress or impairment in social, occupational or other important areas of functioning⁵

Any powerful and persistent sexual interest other than sexual interest in copulatory or pre- copulatory behaviour with phenol typically normal consenting adult human partner.⁵

TREATMENT:

Studies have shown that treatment only tends to work if the person with pedophilia is motivated and committed to controlling his or her behavior and when treatment combines psychotherapy and medication.

Cognitive-behavioral therapy:

It is used to disrupt learned paraphiliac patterns and modify behavior to make it socially acceptable.

· The interventions include

· Social skills training

· Sex education

· Cognitive restructuring (confronting and destroying the rationalizations used to support victimization of others) development of victim empathy.

· Imaginal desensitization,

· Relaxation technique,

· In modified aversive behavior rehearsal, perpetrators are videotaped acting out their paraphilia with a mannequin. Then the patient with paraphilia is confronted by a therapist and a group of other offenders who ask questions about feelings, thoughts, motives associated with the act and repeatedly try to correct cognitive distortions and point out lack of victim empathy to the patient.⁶

Insight-oriented psychotherapy is a long-standing treatment approach. Patients have the opportunity to acknowledge their dynamics and the events that caused the paraphilia to develop. In particular, they become aware of the daily events that cause them to act on their impulses (e.g., a real or fantasized rejection). Treatment helps them deal with life stresses better and enhances their capacity to relate to a life partner.⁶

Psychotherapy:

It also allows patients to regain self-esteem, which in turn allows them to approach a partner in a more normal sexual manner.

Sex therapy is an appropriate adjunct to the treatment of patients who suffer from specific sexual dysfunctions when they attempt non deviant sexual activities.⁶

Medication:

Medications that defeat production of the male hormone testosterone reduce the frequency or intensity of sexual desire in pedophiles. It may take three to 10 months for testosterone suppression to reduce sexual desire. Studies of the effectiveness of selective serotonin reuptake inhibitors (SSRIs) in treating pedophilia and other paraphilias vary in their findings on their effectiveness. However, SSRIs may be a helpful adding to other treatments, because they tend to decrease sexual obsessiveness and urges associated with paraphilias and may help with increasing the paraphile's ability to control his or her impulses. Examples of SSRI medications include fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa), escitalopram (Lexapro), and vortioxetine (Trintellix).

There is some preliminary research that stimulant medications like methylphenidate (Ritalin) can increase the effectiveness of SSRIs, and naltrexone can decrease some of the sexual obsessiveness associated with paraphilias.

Antiandrogens are used in more severe cases. Similar to physical castration, they work by reducing androgen levels, and have thus been described as chemical castration. The antiandrogen cyproterone acetate has been shown to substantially reduce sexual fantasies and offending behaviors. anti-androgens, also associated with many side effects including hot flushes, leg cramps, hair loss, bone mineral loss and cardio issues, with the benefit/risk ratio not favoring use of such drugs.Medroxyprogesterone acetate and gonadotropin-releasing hormone agonists (such as leuprorelin) have also been used to lower sex drive. Only gonadotropin-releasing hormone treatment showed high efficacy, working in a similar way to physical castration. It rapidly desensitises gonadotropin-releasing hormone receptors, resulting in reduction of luteinizing hormone, which is responsible for the stimulation for release of testosterone in the testes. Due to the side effects, the World Federation of Societies of Biological Psychiatry recommends that hormonal treatments only be used when there is a serious risk of sexual violence, or when other methods have failed. Surgical castration has largely been abandoned because these pharmacological alternatives are similarly effective and less invasive^{. 6}

Prognosis:

Good prognostic indicators include the presence of only one paraphilia, normal intelligence, the absence of substance abuse, the absence of nonsexual antisocial personality traits, and the presence of a successful adult attachment. Paraphilias, however, remain significant treatment challenges even under these circumstances.⁶

REFERENCES:

1. Townsend, M. C. (2014). Essentials of psychiatric mental health nursing: concepts of care in evidence-based practice. 6th ed. Philadelphia: F.A. Davis Co.

2. "Paraphilic Disorders". Diagnostic and Statistical Manual of Mental Disorders (Fifth ed.). Philadelphia, Pennsylvania: American Psychiatric Publishing. 2013. pp. 685–686.

3. American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). pp. 569-570, 572, 574, Washington, DC: Author.

4. Stuart RS. Constructing Perversions: The DSM and the classification of sexual paraphilias and disorders. Electronic J Hum Sex. 2012;15 [Google Scholar] http://f1000.com/prime/718074542

5. Wakefield JC. DSM-5 proposed diagnostic criteria for sexual paraphilias: tensions between diagnostic validity and forensic utility. Int J Law Psychiatry. 2011; 34: 195–209. doi: 10.1016/j.ijlp.2011.04.012.

6. Marshall WL, Marshall LE. Psychological Treatment of the Paraphilias: a Review and an Appraisal of Effectiveness. Curr Psychiatry Rep. 2015 Jun;17(6):47.

Received on 01.07.2020 Modified on 10.09.2020

Int. J. of Advances in Nur. Management. 2021; 9(2):225-229.

DOI: 10.5958/2454-2652.2021.00051.2