Review Article
NEURO RESEARCH
2019; 1(1): 4
Paraphilic Disorder: Definition, Contexts and Clinical
Strategies
Giulio Perrotta
¹Director, Department of Criminal and Investigative Psychology UNIFEDER, Italy
*
Corresponding author:
ABSTRACT
Giulio Perrotta
Starting from the concept of paraphilic disorder, we proceeded
Director, Department of Criminal and Investigative
Psychology UNIFEDER, Italy.
to list the individual forms envisaged by the DSM-V, with
a series of focus on clinical, psychodynamic, cognitivebehavioural and strategic profiles, focusing the analysis above
all on the resolving context of the problems analyzed.
Received : September 4, 2019
Published : September 24, 2019
KEYWORDS: Psychology; Neuroscience; Anxiety; Prefrontal
Cortex; Limbic System; Voyeurism; Paraphilia; Paraphilic
Disorder; Paraphiliac Disorders; Paedophilia; Rape; Sexology;
Exhibitionism; Frotteurism; Masochism; Sadism; Fetishism;
Transvestism; Psychotherapy; Psychopharmacology; MoodStabilizing Drugs; Antidepressants; Anxiety; Strategic
Approach.
DEFINITION AND CLINICAL CONTEXT OF PARAPHILIAC
DISORDERS
found in all adult sexual behaviour, but cause few problems
as they are not experienced as compulsive, or at least as
loss of control (so to speak, egodistoniche concerning the
external environment). He also suggested using the term
“neo-sexuality” to refer to paraphilias, to purify the subject of
moralistic and pejorative tones, children of an obscurantist
view of reason.
Definitions and preliminary distinctions
The evolution of the definition of perverted or paraphilic
sexual activity reveals how psychiatric nosography reflects
the society that expresses it. In the context of a culture that
considered sexuality in relatively narrow terms, Freud (1905)
first, in a closed socio-cultural context but eager to open up,
defined perverse sexual activity according to various criteria,
such as: focusing of body regions not necessarily genitals (eg:
neck, back, ...); the replacement of the usual sexual practice
exclusively focused on genital contacts with a partner of the
other sex, often for procreative purposes, according to the
religious direction; the tendency to be the exclusive practice of
the individual. From his first paper, however, cultural attitudes
relating to sexuality have changed radically, thanks to
globalization and the spread of telematics and social networks
capable of connecting individuals separated by oceans and
continents. Over the decades, from the first theorizations of
the beginning of the last century, not surprisingly, couples (in
their intimacy) have cleared a variety of sexual behaviours so
to speak “bizarre”, up to the removal of perverse behaviours
like anal penetration and homosexual orientation [1].
According to McDougall (1986), perverse fantasies are
Stoller (1975, 1985) suggested instead a narrower definition
of “sexual perversion”, meaning it as the erotic form of hatred.
In essence, he asserted that cruelty, the desire to humiliate
and degrade the sexual partner, and even themselves, are
crucial determinants for classifying perverse behaviour.
According to this perspective, the intention of the individual is
a critical variable in defining perversion. An individual is called
perverse, only when the erotic act is used to avoid a longterm, emotionally intimate relationship with another person.
The definition of the paraphilias of the DSM-IV [2], in an attempt
to be non-judgmental, suggested the restriction of the term
to situations in which non-human objects are used, actual
pain is inflicted on oneself, or one’s partner or humiliation, or
non-consenting children or adults are involved. To consider
the continuum between fantasy and action, the DSM-IV has
developed a spectrum of gravity:
a) in mild forms, patients are troubled by their
Citation: Perrotta G (2019). Paraphilic Disorder: Definition, Contexts and Clinical Strategies. Neuro Research 1(1): 4.
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paraphiliac sexual urges, but do not implement them;
b) in conditions of moderate severity, patients
translate thrust into action, but only occasionally;
c) in severe cases, patients repeatedly perform their
paraphiliac thrusts.
The genesis of the paraphilic disorder
The aetiology of paraphilias remains full mainly of mystery.
Although some studies have suggested that biological factors
contribute to the pathogenesis of perversions, the data are
currently conflicting. Even if biological factors are present
(which we will see in the paragraph dedicated to neural
correlates), it is undoubtedly the psychological reasons that
play a decisive role in the choice of paraphilia and the meaning
underlying the sexual acts.
The classical (or psychodynamic) vision [3] of perversions,
according to Freud’s (1905) drive theory, he believed that in
these disorders “instinct” and “object” were separated from
each other: “the sexual drive is probably at first independent
of its object”. Therefore, in perversions, according to this
orientation, fantasies become conscious and are expressed
directly as “pleasant” ego-syntonic activities.
Continuing on this theoretical orientation, according
to Fenichel (1945), the decisive factor that prevents the
achievement of an orgasm through the conventional genital
relationship is castration anxiety. Perversions, according to
this classical view, therefore perform the function of denying
castration.
Again, for Kohut (1971, 1977), father of the stream of selfpsychology, the perverse activity includes a desperate
attempt to restore the integrity and cohesion of the Self in
the absence of empathic responses from the Self-object by
the others. Sexual activity or fantasy can help the patient
feel alive and healthy when threatened by abandonment or
separation. A perverse behaviour in therapy can be a reaction
to failures of empathy on the part of the therapist, which lead
to a temporary disruption in the Self / object-Self matrix.
According to the scholar Stoller (1975, 1985), the essence of
perversion is the conversion “of childhood trauma into an adult
triumph”. Patients are driven by their fantasies of avenging
humiliating childhood trauma caused by their parents. Their
method of revenge is to humiliate or dehumanize the partner
during the fantasy or the perverse act.
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According to Michell (1988), however, perverse sexual activity
can also be an escape from object relationality. Many people
who suffer from paraphilias have separated and individualized
incompletely from their intrapsychic representations of
the mother. The result is that they feel that their identity as
separate people are constantly threatened by a merger of
internal or external objects. Sexual expression can thus be the
only area in which they can assert their independence.
McDougall (1986), as already mentioned, proposes the use of
the term “neo-sexuality” and suggests that sexual behaviour
should evolve from a complicated array of identifications and
counter-identifications with parents. Each child is involved
in an unconscious psychological theatre that arises from
the parents’ unconscious erotic desires and conflicts. So the
obligatory nature of every neo-sexuality is programmed by
parental scripts internalized by the child. Finally, according to
the author, certain sexual practices and objects become like
a drug that the patient uses to treat a sense of internal death
and a fear of disintegration of the Self.
Finally, as regards, specifically, the study of female perversions,
Kaplan (1991) emphasizes that they imply more subtle
dynamics than the more predictable sexuality of male
perversions. The themes of separation, abandonment and
loss are part of the sexual activities that derive from female
paraphilias.
In conclusion, before examining the dynamics of each
paraphilia, we must remember that the individual preference
of a perverse fantasy rather than another remains obscure.
Therefore, the psychodynamic understanding of a patient
involved in perverse sexual activity implies a comprehensive
understanding of how perversion interacts with the underlying
characterological structure of the patient:
1) In the case of exhibitionism, for Freud (1905) and Fenichel
(1945), the exhibitionist exposes his genitals in public
because in this way he is reassured of not being castrated,
as a sort of reaffirmation of his sexual dimension and his
social role. The shock reactions that these actions cause
help him to cope with castration anxiety and give him
a sense of power over the opposite sex. Fenichel has
also associated voyeuristic tendencies with a fixation
on the first infantile scene, in which the child attends or
hears a sexual relationship between the parents. This
early traumatic experience could stimulate the child’s
castration anxiety and then lead him, once an adult, to
re-enact the scene over and over again in an attempt to
Citation: Perrotta G (2019). Paraphilic Disorder: Definition, Contexts and Clinical Strategies. Neuro Research 1(1): 4.
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master a passively experienced trauma actively. Finally,
the scholar also identified an aggressive component in
looking, conceptualizing it as a shift in the desire to be
directly destructive to women, to avoid feelings of guilt.
The scholar Stoller (1985) instead pointed out that the
typically exhibitionistic actions follow a situation in which
the person responsible felt humiliated, often by a woman.
2) Furthermore, the act of showing his genitals allows a man
to regain some sense of value and positive male identity.
Often these men reveal deep insecurity concerning
their sense of masculinity. According to Mitchell (1988),
exhibitionists often feel that they have had no impact on
any person in their family and have, therefore had to resort
to extraordinary measures to be noticed. Even the other
side of exhibitionism, voyeurism, involves the violation
of the private life of an unknown woman, an aggressive
triumph, but secret over the female sex.
3) In the case of sadism and masochism, the discourse is
more articulated. Patients afflicted with sadism are often
unconsciously attempting to overturn childhood scenarios
in which they have been victims of physical or sexual abuse.
For Fenichel (1945), inflicting on others what happened
to them when they were children, they get revenge
and a sense of mastery over childhood experiences of
abuse at the same time. Masochistic patients may be
firmly convinced that they deserve punishment for their
conflicted sadistic desires and that the acceptance of a
sadistic act is a “lesser evil” than their fear of castration.
According to the current of self psychology, masochistic
behaviour can be experienced by the patient as capable
of restructuring the Self. In this regard, a masochistic
patient wrote to her therapist “physical pain is better than
spiritual death”. In relational terms, according to Michell
(1988), sadism often develops from a particular internal
relationship in which the rejecting and distant object
needs an energetic effort to overcome its resistance to its
representation of the Self. Even masochistic patients, who
need humiliation and even pain to achieve sexual pleasure,
maybe repeating childhood experiences of abuse. The
masochistic surrender is essentially the implementation
of an internal object relationship in which the object will
respond to the Self only when it is humiliated.
4) In fetishism, to achieve sexual excitement, fetishists need
to use an inanimate object, often an article of feminine
underwear, or a shoe, or a non-genital part of the body.
Freud initially explained fetishism as derived from
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castration anxiety. The object chosen as a fetish represents
the female penis, a shift that helps fetishists overcome
castration anxiety. Following the premise that the
masculine awareness of female genitalia increases man’s
fear of losing his genitals and becoming like a woman,
Freud thought that this unconscious symbolization
explained the relatively frequent presence of fetishism. The
founder of psychoanalysis used this theory to develop his
concept of splitting the ego (1938): in the fetishist’s mind,
two contradictory ideas coexist the denial of castration
and the affirmation of castration. The fetish represents
both. According to Greenacre (1979), fetishism derives
from severe problems in the mother-child relationship: the
child cannot be consoled by the mother or by transactional
objects. To experience bodily integrity, the child, therefore,
needs a fetish, a reassuring, hard, inflexible, immutable
and lasting object. These early pregenital disorders are
subsequently reactivated when the male child or adult is
concerned about genital integrity. Also, the scholar Kohut
(1977), argued for a relatively similar view of fetishism,
although expressed in terms of Self Psychology. In his view,
the fetishist, in contrast to feelings of helplessness towards
his mother, can have complete control over the nonhuman version of the self-object. Therefore, what appears
to be an intense sexual need for a narcissistic object may
reflect severe anxiety about the loss of one’s sense of self.
5) In paedophilia, again for Freud (1905) and Fenichel (1945),
the paedophile sees the child as an image that represents
himself; for this reason, paedophilia is considered as a
narcissistic object choice. In clinical practice, it is found
that sexual activity with prepubertal children can affect
fragile self-esteem. On the other hand, the paedophile
often idealizes children: sexual activity with them involves
the unconscious fantasy of fusion with an ideal object or
restructuring of a young, idealized self. At a deeper level,
the union with a child represents the desire to incorporate
the mother’s breast and therefore to compensate for the
practical absence of maternal care in early childhood.
Furthermore, paedophiles have frequently been victims
of child sexual abuse. Sadistic dynamics and a sense of
triumph and power can accompany the transformation of
a passive trauma into an actively perpetrated victimization.
6) In transvestism, the male patient dresses as a woman
to create in himself a sexual excitement that leads to a
heterosexual sexual relationship or masturbation. The
patient behaves traditionally masculine when dressing as a
man, but becomes effeminate when dressing as a woman.
Citation: Perrotta G (2019). Paraphilic Disorder: Definition, Contexts and Clinical Strategies. Neuro Research 1(1): 4.
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The classical psychoanalytic understanding of dressing
up as a woman involves the notion of a phallic mother.
Imagining that the mother has a penis, although this is not
visible, the male child overcomes his castration anxiety.
For Fenichel (1945), the act of dressing up as a woman can,
therefore, be an identification with the phallic mother. On
a more primitive level, the small child can identify with the
mother to avoid anxiety about separation. His awareness
of the sexual differences between him and his mother can
trigger the anxiety of losing her because they are separate
people.
Paraphilia and paraphilic disorder: Distinctions and
similarities
At the outset, a clear distinction must be made between
“paraphilia” and “paraphiliac disorder”. [4]
In the definition of Colombo [5], paraphilias are described
as “sexual disorders” because the objects or situations that
cause excitement deviate from those commonly found
in normality. The choice of the object or the deformation
of the act is manifested with characteristics of exclusivity,
continuity and compulsiveness. If paraphilias stabilize, they
can seriously influence the subject’s ability to establish mutual
and satisfying affectionate relationships, leading to a deviant
behaviour that is harmful to the well-being of the individual.
Conversely, those paraphilic or perverse behaviours that are
transiently manifested and remain circumscribed within
healthy sexuality and a couple of relationships are not to be
considered pathological. Not surprisingly, Colombo describes
paraphilias as behaviours marked by impulses, fantasies
or intense and recurrent sexual behaviours, which involve
unusual objects, activities or situations; in fact, among the
main diagnostic criteria we find the consequent presence of
clinically significant distress or impairment of the social, work,
or other important areas of individual functioning, for at least
a period exceeding six months.
Paraphilias involve sexual excitement for atypical objects,
situations and/or subjects (e.g., children, corpses, animals).
However, sexual activities that seem unusual to another
person or health professional do not constitute paraphilia
simply because they are unusual. People may have paraphiliac
interests even when they do not meet the criteria for a
paraphiliac disorder.
Unconventional sexual arousal patterns in paraphilias are
considered pathological disorders only when both of the
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following conditions are met:
a) are intense and persistent;
b) cause significant hardship or social or occupational
impairment or in other important areas of functioning
or damage, or have the potential to damage, others
(e.g., children, non-consenting adults);
c) paraphilias can present a compromised or non-existent
ability to become attached, to experience emotional
involvement and sexual intimacy with a consenting
partner.
The disturbed modes of sexual arousal are usually well
developed before puberty, and at least 3 mechanisms are
involved:
a) anxiety or early emotional trauma interfere with healthy
psychosexual development;
b) the typical pattern of excitement is replaced by
another model, sometimes through early exposure
to significant sexual experiences that reinforce the
subject’s experience of sexual pleasure;
c) the sexual arousal mode often acquires symbolic and
conditioning objects (e.g., a fetish symbolizes the
object of sexual excitement, but it can be chosen
because it has been randomly associated with curiosity,
desire and sexual excitement).
The definition of “paraphiliac disorder” instead applies
when a paraphilia begins to cause discomfort or
impairment in the person’s daily life or even causes damage
or danger to themselves or others, becoming for the person
who lives them of ego-dystonic behaviours concerning
the environment. Concerning the diagnostic criteria for
the disorder in question, the DSM-V identifies two: A
which specifies the qualitative nature of paraphilia (e.g.
addressing sexual attention towards children) and B which
specifies the negative consequences of paraphilia, i.e.
discomfort impairment or damage to others. The diagnosis
of paraphiliac disorder should, therefore, be reserved for
individuals who satisfy both Criteria A and B; if an individual
only satisfies Criterion A but not B for a particular paraphilia,
then it could be said that the individual has a paraphilia,
but not a paraphiliac disorder.
To be diagnosed with a paraphiliac disorder, the DSM V
requires that people with this interest live it with personal
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anguish, not merely resulting from social disapproval; or have
a sexual desire or behavior that leads to mental distress, injury
or the death of another person; or a desire for sexual behavior
involving other people unable to give valid consent or involved
without their knowledge. To further emphasize the boundary
between an atypical sexual desire and a mental disorder, the
working group redefined, for example, “Sexual Masochism”
from DSM IV in “Sexual Masochism Disorder”. The chapter
on paraphilias includes eight conditions: exhibitionistic
disorder, fetishistic disorder, frotteurism disorder, paedophile
disorder, sexual masochism disorder, sexual sadism disorder,
transvestism disorder, and voyeuristic disorder. An essential
difference from the DSM IV-R concerns transvestism disorder,
which identifies people who are sexually excited by dressing
as the opposite sex, but who experience significant discomfort
in their social or work life due to this behaviour. The DSM IV
limited this behaviour to heterosexual men: the DSM V has no
restrictions, opening this diagnosis to women or homosexual
men. In the first criticism that this change would widen the
people interested in the diagnosis, the working group pointed
out that to enter the category, individuals must experience
considerable discomfort due to their behaviour. To date,
paraphilias can be classified according to the “act” they replace
or to the “object” to which they are addressed. A further
subdivision concerns the sensory channel that is solicited:
a) in the part of the act there is a substitution of coitus or
sexual activity, with other practices;
b) in the part of the object there is a subrogation of the
normative object or displacement of the goal:
- the normative object is constituted by the sexual partner
(heterosexual or homosexual);
- The goal is represented by the achievement of sexual
pleasure (orgasm).
c) the sensory channels involved in paraphilias:
- the visual channel, sexual excitement is sought in the
display of the body or parts of it (exhibitionism), in
the observation of other subjects engaged in sexual
activities (voyeurism, mixoscopy) or physiological
bodily functions (coprophilia, urophilia);
- acoustic/verbal channel, excitement is obtained through
the practice of foul language, listening or pronouncing
scurrilous or vulgar words related to sexuality
(telephone scatology, coprolalia, pornolalia, mixacusi);
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-
olfactory channel, there are neurophysiological
connections between the vomeronasal organ and
certain areas of the brain, such as the limbic system
(emotional) and the BNST nucleus (nucleus of the
terminal strip); sexual excitement is given by the
perception of odours, even unpleasant ones, such
as urine, faeces, flatulence (flatulophilia), sweat
(ospressiophilia), this can be connected to pheromones
excreted with these substances;
- taste channel, sexual excitement is pursued through the
ingestion/spraying of body excretions (coprophagia,
spermatophore, pissing);
- the practice of unusual bodily activities gives tactile
channel, sexual pleasure: stuffing (penetration with
objects), percoxophilia, spanking (spanking with
violence), climatephilia (enema practice), basophilia,
rhinolagnia, urolagnia (stimulation of parts of the
body not classically erogenous, like the nostrils or the
urethra).
Paraphilias and the concept of abnormality
Until 2012, the psychiatric classification described with
the term “paraphilias” (from the Greek παρά=”beyond” and
φιλία=”love”) all those erotic impulses characterized by
intense and recurring fantasies or impulses that imply specific
activities that concern objects, which involve suffering and/
or humiliation, or that are directed towards minors and/or
non-consenting persons. It is with this term that classification
has replaced the classic and more widespread category of
perversions, thus attempting to reduce the negative judgment
connected to these disorders. It was later, in 2013, that the new
Diagnostic and Statistical Classification of Mental Disorders
(DSM V) further normalized some preferences, distinguishing
“paraphilias” from “paraphiliac disorders” [6]. The boundary
between normality and pathology would, therefore, reside
in this distinction. According to this definition, to diagnose
a paraphiliac disorder, people with this interest should
experience it with anguish, not merely deriving from social
disapproval, or having a desire or sexual behavior that leads to
mental distress, injury or death to another person, or a desire
for sexual behavior involving other people unable to give valid
consent or involved without their knowledge.
However, how much is there anomalous in the paraphilic
interests? Towards the end of 2014, a researcher Canadian
wrote a commentary on this subject, questioning the definition
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of paraphilia. In DSM V this term goes, in fact, to indicate every
intense and persistent sexual interest (fantasy or behaviour)
not included in the definition of those so-called neurotypical
ones, or genital stimulation with consenting human partners,
phenotypically normal (already understanding what is
going to mean in a way objective this attribute is somewhat
complicated), physically mature. The author, therefore,
underlines how much this type of definition depends more on
historical, political and socio-cultural factors than on medical
or scientific evidence.
In this regard, it is perhaps useful to recall that until relatively
recently, masturbation, anal sex and homosexuality were
considered “perverse” practices. Normality is therefore
continually subject to revisions and changes in time and space
and consequently also what is considered deviation from the
norm.
The distinction between paraphilias and paraphiliac disorders
is already a good step forward in the pathologization of nonpenetrative and non-criminal sexual interests such as fetishism,
masochism or consensual sadism. One could argue whether
these interests can even be considered non-paraphiliac, at
least when they are confined to sexual fantasies.
Two new diagnoses, “coercive paraphilic disorder” and
“hypersexual disorder”, have been proposed for inclusion in
the manual, but without being seriously considered.
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observed, without having any need to get in touch with the
victims to get pleasure. In the most severe forms, voyeurism
is the particular form of sexual activity.
Exhibitionistic disorder
Exhibitionistic disorder is a paraphiliac disorder that consists
of exhibiting one’s genitals or sexual organs to people who
do not agree and are often unknown and in inappropriate
situations. Usually, exhibitionism is prevalent in the male
gender, but in more rare cases, it can also occur in women.
As in other paraphilic disorders, the exhibitionist tends to
objectify the victim towards whom he projects his desires
and sexual impulses, while the victim lives and suffers
the fact as a violent act, not sought after and unwanted.
Exhibitionist men and women usually do not seek any
physical or sexual approach with the stranger who is the
victim of this attention. In more rare cases, exhibitionist
behaviour can also be accompanied by masturbation.
Frotteurism disorder
It’s characterized by intense and recurrent sexual excitement
manifested through fantasies, desires and/or real
behaviours related to touching, or rubbing against, a nonconsenting person. To satisfy the criterion of frotteuristico
disorder, these fantasies and/or behaviours must manifest
themselves for at least 6 months (alternatively the condition
can be defined paraphilia but not paraphilic disorder).
TIPOLOGIE E CLASSIFICAZIONI DEI DISTURBI
Sexual masochism disorder
According to the DSM V [7] Eight different types [8] of
paraphilic disorder can be identified [9]:
Voyeuristic disorder
In voyeurism, the person gets sexual excitement and
gratification from observing and watching the naked
bodies of people often not aware of being observed and
even engaged in sexual activities. A specific must be done if
the observer is aware and consenting: in this case, we speak
of troilism. Troilism consists of drawing sexual excitement
from observing-without hiding-individuals who have
sexual relations, who know they are being observed and
are therefore consenting. The real voyeur instead hides
from the sight of others and generally wants to reach
orgasm through masturbation, while it is observing or at
a later time through fantasies about what it has observed.
In action it is passive, and the pleasure derives from the
fact that it violates the intimacy of the subjects that are
In sexual masochism disorder, sexual arousal manifests
itself recurrently and intensely through fantasies, desires
or behaviours deriving from the act of being humiliated,
beaten, bound (bondage) by other acts inducing pain
and suffering (burns, perforation of the skin, flagellation,
application of electric shocks, ...). Such behaviours and
fantasies must cause clinically significant distress and must
last at least six months. Sexual masochism can often be a
form of paraphilia in most people who have masochistic
interests but do not meet the criteria for the diagnosis of
a paraphiliac disorder. Sadomasochistic sexual fantasies
and behaviours among consenting adults are persistent.
Masochistic activity tends to be ritualized and long-lasting.
The disorder can be accompanied by asphyxiation if the
subject is attracted by the practice of achieving sexual
excitation connected with the limitation of breathing
(see below the specification of asphyxia as an additional
paraphiliac disorder).
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Sexual sadism disorder
In sexual sadism disorder, sexual excitement manifests itself
in a recurring and intense way through desires, fantasies or
behaviours in which the physical or psychological suffering
of another person is deliberately and intentionally caused.
Most sexual sadists have persistent fantasies in which
sexual excitement is the result of suffering inflicted on
the partner, whether consenting or not. If the criteria for
sexual sadism disorder are not met, sexual sadism can be
considered a form of paraphilia; Moderate sadistic sexual
behaviour is a common sexual practice among consenting
adults, and is usually limited in scope and not harmful.
However, when such behaviour, fantasies or impulses of a
person cause clinically significant distress or behavioural
impairment and/or cause damage to others, one enters
the pathological area of the paraphiliac disorder. When
practised with non-consenting partners, sexual sadism is a
criminal activity. Sexual sadism is particularly severe when
it is associated with an antisocial personality disorder.
This combination of disorders is particularly resistant to
psychiatric and psychotherapeutic treatment.
Pedophilic disorder
Paedophilia is a form of paraphilia that causes harm to
others and is therefore considered a paraphilic disorder.
The clinical diagnosis of Pedophilic Disorder according to
DSM5 includes the following criteria: a) recurrent sexually
arousing fantasies, impulses or behaviours involving one
or more prepubertal children (usually ≤ 13 years) who
were present for ≥ 6 months; b) the person is driven by the
impulse or is firmly in difficulty or altered by impulses and
fantasies; c) the person is ≥ 16 years and ≥ 5 years older
than the child-targeted by fantasies or behaviours (but
older adults who are in continuous contact with a child of
12 or 13 must be excluded). For the diagnosis, therefore, it is
necessary to keep in mind that the subject must be at least
16 years old and his age must be at least 5 years greater
than the child (or children) towards whom the fantasies,
desires or pedophiliac behaviours manifest themselves. The
disorder can be exclusive when the patient is only attracted
to children or non-exclusive. Often subjects suffering from
paedophilia disorder can use force and physically threaten
the child if they reveal abuse.
Fetishistic disorder
The fetishist disorder consists of an intense and recurrent
sexual excitement, for at least six months, manifested
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through fantasies, desires or behaviours, deriving from the
use of inanimate objects or particular interest for one or
more non-genital parts of the body. The objects must not
be limited to items of clothing used for cross-dressing (as in
transvestic disorder) or to instruments designed explicitly
for tactile stimulation of the genitals (e.g. vibrator, rubber
fouls, ...). It can also be characterized as paraphilia without
the disturbance criteria being met.
Transvestism disorder
The transvestite disorder implies a recurrent and intense
sexual excitement, manifested with fantasies, desires
or behaviours, for at least six months, deviant by crossdressing, or by wearing clothing of the opposite sex. A
significant difference compared to the DSM IV-TR concerns
the transvestitism disorder, which identifies people who are
sexually excited by dressing like people of the opposite sex,
but who feel discomfort in their social or work life because
of this behaviour. The DSM IV considered concerning this
behaviour only heterosexual men, while the DSM 5 now
includes also homosexual men and women in this category.
There are also a series of paraphiliac disorders not
otherwise specified. For example, autoerotic asphyxia (also
called asphyxiophilia) is a paraphilia disorder not otherwise
specified associated with Sexual Masochism Disorder
(DSM V, 2013). Among the various types of atypical sexual
behaviour, probably the autoerotic asphyxia (once also
called hypoxifilia) is among the most dangerous (Prati,
2006). Erotic asphyxia (or auto-erotic) is a sexual practice
that through the deprivation of oxygen to the brain
increases sensitivity during masturbation and orgasm.
Oxygen deprivation can be implemented in various ways:
through the use of laces, plastic bags, chest compression,
suffocation instruments, the immersion of the head in
liquids, stunning by chemical inhalation, use of unique
masks (Myers et al., 2008). Focusing on the dangers of
this practice, the risk of sudden deaths is high, primarily if
implemented in solitude.
During oxygen deprivation, on the one hand, there is an
increase in pleasure sensations; on the other hand, reaction
times decrease. It often happens that the person is not
able to free himself from the grip that was created and
that he dies by suffocation. It is complicated to establish
the epidemiology of the phenomenon, both because
autoerotic asphyxia is a very private and socially little
accepted practice and because they are often mistaken for
Citation: Perrotta G (2019). Paraphilic Disorder: Definition, Contexts and Clinical Strategies. Neuro Research 1(1): 4.
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suicide cases. Among paraphilias not otherwise specified
may also include “devotes”. The “devotes” is a cultural
translation of the diagnostic category “acrotomophilia”,
which Money J, a psychologist and sexologist, explores
scientifically in the eighties, or the ability to experience
interest or sexual excitement only in the presence of
people who have deformations or amputations in the
limbs or as in the basophilia for aids such as wheelchairs,
plaster casts, prostheses ... The pathological component
of this phenomenon resides and takes shape in the fact
that the interest is directed only towards the amputated
part or the handicap and rarely towards the person and
his human qualities. In devotees, the social, occupational
and emotional and sexual intimacy with their partner is
often compromised. This type of paraphilia comes close to
fetishism, as a sexual drive directed towards an inanimate
object. As in the fetishist, the object is indispensable and
indispensable for excitement and sexual activity.
Devotees tend to avoid the intimate relationship with their
partner and make not a boot but erotic aids that the disabled
use or the impaired limb. In devoting, people ask to be able
to touch their legs, to watch while the person eats, they ask
to be able to comb their hair or be able to accompany her
to the bathroom, and treat the person as an object. Most
devotees belong to the group of “Amplovers” or amputee
lovers. Sexual attraction can reside in the stump itself, in
prostheses, or in the imagination of what exists under it.
Other paraphilic disorders not otherwise specified include,
among many others, sexual arousal related to zoophilia
(animals), necrophilia (cadavers), coprophilia (faeces),
chlimafilia (enemas) or urophilia (urine).
The Neural Correlates in Paraphiliac Disorders
The organization [10] of the sexual brain, circuits begin
during the fetal period, and the primordial basis is the female
one. The brain in male subjects masculinizes before birth
through the secretion of testosterone and its conversion into
the hormone estrogen. Masculinization means that some
regions of the brain, especially groups of neurons within
the hypothalamus, grow the most while other areas, such as
the corpus callosum, remain smaller. A subsequent turning
point is in puberty when there is the maturation of ovarian
estrogens and progestogen steroids for female subjects and
intense production of testosterone for male subjects. These
hormones bind to various receptors in different subcortical
regions of the brain, especially in men, in the preoptic area of
the anterior hypothalamus.
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Laboratory studies [11] show that male animal that loses their
testicles before sexual maturation does not develop strong
impulses to sexuality while maintaining social impulses. It
has been observed, however, that the impulse is preserved if
the testicles are lost by men who are already sexually active.
Testosterone is therefore of great importance for male libido,
above all because it activates various neuropeptides, such as
vasopressin, which in males is present in double the amount
of female subjects. Vasopressin in animals promotes courtship,
sexual ardour, territorial marking and aggressiveness among
males. Testosterone also activates nitric oxide (NO) which,
once again, promotes sexual ardour and aggression. From
these observations, it can be noted that testosterone plays an
important role both in male sexuality and in the impulse of
social dominance, even if these two systems remain, however,
distinct. In female subjects, impulses for sexual receptivity
originate in the ventromedial hypothalamus (VMH). Most of
them do not produce much testosterone and their sexuality
is controlled primarily by estrogen and progesterone. Sexual
activation is also governed by regular oestrous cycles.
Estrogens and progesterone also promote the production of
oxytocin, which would make female subjects emotionally more
receptive and more confident. This discourse is only partially
valid for human beings since sexuality in humans is much more
linked to the useful life of the mind and to the socio-cultural
aspects of what happens in other animals. Nevertheless, at
the level of primary processes, the circuits of sexual desire
are very similar. Panksepp (2012) notes that the dopaminedriven research system, especially in the search for a sexual
partner, is also involved in the promotion of sexual desire.
Concerning the gender difference, Panksepp emphasizes that
the two hormones, oxytocin and vasopressin, are the basis of
the most marked differences. Normally oxytocin encourages
attitudes of care, translating into the expression “take care and
be friendly”, while vasopressin is more aggressive attitudes,
translating into “attack and compete”. Oxytocin has been
commonly considered, according to a simplistic view, as the
“love hormone”. Panksepp remembers, in this regard, how
oxytocin does not act alone but works with the support of
many other chemical substances and environmental stimuli,
so it is likely that it will produce intense positive affective
experiences starting from concomitant social interactions.
Animal studies show that oxytocin provides comfort when
animals are alone, promotes confidence and facilitates
positive social interactions. Furthermore, it seems that these
results can also be extended to humans. In the system of
sexual desire, the homeostatic and sensory elements play a
strong role in sexual activation, nevertheless it is configured,
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for Panksepp, as an emotional system because it presents
a very evident readiness to act and its affective state can
perturb other systems. As for sexual development, Panksepp
makes an important distinction between the gender of the
body and the genus of the mind, in fact these develop in
a way, in some respects, independent: the sex hormones
that determine the sexual organization of the brain in
development fetal are different from those that make specific
the appearance of the genital apparatus. Biologically we call
females those born with chromosome XX and males those
born with XY chromosome and normally the female brain
circuit is stronger in biological females and that male in males.
However, this does not always happen in this way, and this
happens when, for example, the fetal sexual substances of the
brain are arranged in an atypical way. From this, it follows that
gender identity is not simply learned and cannot be altered by
persuasion. Panksepp reports the results of some experiments
in the laboratory, in which some female rats were injected
with estrogen generating female offspring with a male brain.
Other studies show that if testosterone cannot be converted
into estrogen during the last months of pregnancy, there is
a good chance that a male fetus is born with a female brain.
These latter cases would occur, for example, when the mother
experiences strong prenatal stress. It is hard to say how much
these data can be generalized even to humans, although
many cases seem to confirm them. However, it should not be
forgotten that biological phenomena must be combined with
personal, social and cultural phenomena, with tendencies
that are sometimes contrary to various levels, from primary
to third. The sexual desire system has emerged to promote
reproduction and preserve the animal species. It is a system
capable of pushing to the creation of the first bonds between
organisms: when the system is active, the animal looks for a
body connection with another that is sexually receptive, so
the tension can be positive or can become a stress factor if this
junction was denied. However, this system is also at the origin
of those bonds that, as happens in different species, can also
be exclusive and last a lifetime. The system of sexual desire is,
therefore, fundamental in the development of social life.
Post-mortem and Imaging studies with mass spectrometry
[12] over the last two decades have revealed the structural
brain related to sexuality and sexual disorders, including: the
hypothalamus, the thalamus, the amygdala.
Recently, however, new studies have found the substantial (or
structural) difference, from a neural point of view, between
hetero and homosexual sexual orientation:
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a) Hypothalamus: It is a portion of the brain that contains
several “nuclei” (discrete groups of cell bodies in the neuron
soma) [13]. Now, the term “nucleus” in neuroanatomy
must not be confused with the same use made of it in
cell biology: in the second case it refers to the organelles
found in eukaryotic cells that contain the genetic material
of the cell; while in the former it refers to discrete groups
of densely packed neuronal cell bodies in the central
nervous system [14]. In anatomical sections, a nucleus
appears as a region of grey substance surrounded by
white matter. It is known to be involved in sex differences
in reproductive behaviour, mediating menstrual cycle
responses: in particular, the anterior hypothalamus helps
regulate typical male sexual behaviour. In the mid-1990s,
it was also linked to gender identity and sexual orientation
[15]. Seminal research conducted by Simon LeVay
would have discovered that an interstitial nucleus of the
hypothalamus, INAH3, was dimorphic according to sexual
orientation but not according to gender. Specifically, the
INA3 of homosexual men was found to be lower in volume
than that of heterosexual men; these results were obtained
by post-mortem analysis of hypothalamic nuclei of known
homosexual subjects compared to heterosexual patients
[16]. Further research has shown that INH3 has a smaller
volume in homosexual men than in heterosexual men,
this because the former have a higher neuronal density
within it than the latter; there is no difference in the
number of the cross-sectional area of neurons in the INA3
of homosexual men compared to heterosexuals [17]. It has
also been discovered that there is no effect found from
HIV infection on the size of INAH3, i.e. it does not take into
account the difference observed in the volume between
homosexual and heterosexual men. The hypothalamus
is also linked to sexual orientation through discoveries
showing that aromatase activity-an important enzyme
that converts androgen into estrogen-is elevated in the
pre-optic hypothalamic region of the mammal during the
pre and neonatal periods. This is indeed related to sexual
differentiation and may be a basis in the structural and
functional sex differences that play a role in mediating
orientation development due to prenatal hormone
exposure. The suprachiasmatic nucleus of the anterior
hypothalamus (SCN) also refers to sexual orientation, being
larger and more elongated in homosexual males than in
heterosexual males and females. The cell sub-nucleus
containing the vasopressin of the SCN of homosexual
men is twice as large and has 2.1 times the number of cells
compared to the subgroup containing the vasopressin of
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the SCN in heterosexual men [18].
b) Thalamus: It is a symmetrical ovoid structure of the midline
within the human brain, located between the cerebral
cortex and the midbrain in both cerebral hemispheres.
A magnetic resonance imaging study compared
subcortical volumes of homosexual and heterosexual
men; found that while both groups did not differ in the
total volume of the brain, the volume of the thalamus (in
both hemispheres) was greater in heterosexual men [19].
Another study reported that the functional connectivity
involving the right thalamus and the right cuneus was
different between homosexual and heterosexual men
and also showed correlations with Kinsey scale scores
[20]; moreover the thalamus is involved in the process of
sexual excitement and reward; during the visually evoked
excitement both heterosexual men and homosexuals
activated the thalamus, but in contrast to the latter,
heterosexuals showed further activation in the lingual
gyrus [21]. The basal nucleus of the terminal stria (BNST)
is an area of the limbic system of the prosencephalon
which is involved in the control of the coupling behaviour;
it receives neuronal input from the medial amygdala and
the accessory olfactory bulb and sends projections both
to the medial preoptic area [22] and to the ventro-medial
nucleus of the hypothalamus [23]. The central part of the
BNST (the BNSTc) is greater than 44% in heterosexual men
compared to straight women and 62% in homosexual men
compared to them [24]. BNSTc is larger in homosexual men
than in straight men, although the size difference is not
statistically significant. It is therefore hypothesized that the
BNSTc of homosexual men is “hyper-masculinized” as it is
larger than the BNSTc of straight men and women.
c) Amygdala: It was discovered that both men and
homosexual women show connections with the amygdala
different from those of heterosexual men and women [25].
Specifically, the connections between homosexual men
and straight women were more widespread by the left
amygdala, while in straight men and lesbians functional
connections were more common in the right one [26].
d) Anterior commissure: It is a bundle of white matter fibers
that connects the two cerebral hemispheres. It was found
by Allen and Gorski to be significantly larger in homosexual
men and heterosexual women than in heterosexual men
[27]. This discovery provides a possible anatomical basis
for higher inter-hemispherical functional connections in
homosexuals, which explain why homosexual men and
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heterosexual women show a marked functional symmetry
of the linguistic circuit in comparison with heterosexual
men performing the same verbal tests [28].
e) Corpus callosum: Like the anterior commissure, it is an
essential neuronal connection that connects the two
hemispheres; however, unlike the commissura (which
is present in all types of vertebrates), CC is present only
in placenta animals (including therefore humans) [29].
An MRI study that compared the CC of homosexual and
heterosexual men found that all parts of CC are more
significant in gay people [30]. In particular, the isthmus
(a part of the CC present between the corpus callosum
and the splenius muscle of the head) is significantly more
abundant in homosexual men than in heterosexuals;
the size of CC has a strong genetic basis, with genetic
inheritance rates ranging between 82% and 94%. This
association of sexual orientation with a highly heritable
brain structure supports the thesis of a genetic and
neurobiological basis in the origin of the same orientation.
f) Gray substance [31]: It is an important part of the
central nervous system that is mainly composed of
neuronal cell bodies. While men generally have a greater
amount of grey and white matter than women (due to
the greater male body mass and consequently a greater
brain size), women generally have a greater grey matterto-substance ratio and larger layers of it in areas of the
cerebral cortex specific to men. It has been found that
homosexual women have relatively less grey matter than
straight women in the ventral cerebellum area, in the left
premotoreal cortex, in the temporal-basal cerebral cortex
and, more significantly, in the left perirhinal cortex of
the temporal lobe. No difference in the amount of grey
matter was found between straight and homosexual
men. These results are important because the perirhinal
cortex is located near the brain regions (entorhinal cortex,
hippocampus, parahippocampal gyrus and amygdala)
involved in olfactory and spatial processing, which have
been shown to determine differences in sexual orientationin particular, are notes in homosexual women superior
performance to straight women in spatial processing
tests. The perirhinal cortex itself is involved in functions
related to the processing of sexual stimuli such as olfactory
processing, memory coding and spatial processing itself;
it is also involved in detecting the identity of the object. It
is known that it modifies sexual attraction in humans, and
the olfactory system is able to differentiate pheromone-
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like compounds based on sexual orientation.
g) Brain asymmetry: The size of the telencephalon is a
sexually dimorphic trait in which men tend to show
asymmetry in the volumes of their hemispheres, while
women show a volumetric symmetry instead. It is also
a trait that is very unlikely to be influenced by learned
socio-environmental patterns [32]. A volumetric study
with magnetic resonance in 2008 indicated that gay
men and heterosexual women showed symmetrical
hemispheric volumes, while homosexual women and
straight men showed a right-hand asymmetry. These
results demonstrate a global neurological difference in
brain structures that show atypical sexual characteristics
associated with sexual orientation [33].
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triangularis of MtF people (and of heterosexual men) is
thicker than that of gays; moreover, in MtF it is thicker even
than that of straight men. In particular, in both studies, the
region concerned is the pars triangularis present in the
right hemisphere) [35].
Still, other studies have found functional differences, always
from a neural point of view, between hetero and homosexual
sexual orientation:
h) Cerebral cortex [34]: It is the outermost layer of the
human brain and is composed of nervous tissue. An RM
study compared the cortical thickness in various brain
regions of homosexual men, heterosexual men and
heterosexual women: he discovered that homosexual
men had thinner cortexes-compared to hetero-in the
lateral orbitolateral region of the right hemisphere, as
well as in the regions located in the visual cortex (lingual,
pericalcarin and wedge). The same regions showed a
thinner cortex in heterosexual women than straight men,
while no differences were found between heterosexual
women and homosexual men. Gay and hetero males did
not differ in total brain volumes, and it was determined
that the differences reported in cortical thickness were not
influenced by the years of education or the brain volume
of the subjects. Since the regions mentioned above show
sexual dimorphism, the authors hypothesized that the
biological processes frequently proposed to underestimate
the same, such as gene-dependent and sex-hormonedependent mechanisms during prenatal and postnatal
development, may interact with cortical architecture in
visual areas resulting in different cortical thicknesses in
gays compared to hetero.
a) Response
to
pheromones:
Two
proposed
human pheromones [the progesterone derivative
4,16-androstadienone-3-one (AND) and an ester-1,3-5
(10), 16-tetraen-3-ol (EST) (estrogen-like steroid] showed
specific responses to sexual orientation in the activation
of neural circuits of the anterior hypothalamus in both
homosexual and heterosexual subjects. The anterior
hypothalamus is involved in the processing of reproductive
functions, and recent evidence suggests that it helps to
integrate stimuli Hormonal and sensory involvement in
sexual behaviour and its preferences [36]. Recent functional
magnetic resonance imaging experiments have shown
that the presentation of AND, found in male sweating,
as an olfactory stimulus produced normal olfactory
responses in straight and lesbian men, while activating the
anterior hypothalamus in gay men and straight women
[37]. The EST proposal of the pheromone, found in the
urine of pregnant women, produces a normal activation
or olfactive in gay men and heterosexual women, while
lesbians and straight men have shown to have sexually
related hypothalamic responses. Gay men showed the
same sexually related functional responses to these
stimuli of heterosexual women, while homosexual women
responded as straight men. This research by Berglund and
Savic indicates on the whole that AND and EST induce
“specific effects of sexuality on the autonomic nervous
system” and that stimuli have produced a response path
that depended on the sexual orientation of the subject
rather than on the sex resulting from the phenotype.
i) Brodmann area 45: Homosexual men showed thinner
cortices than straight men and women both in the
triangular pars right (Brodmann area 45) and in the lower
temporal regions; this suggests that brain differences
related to male homosexuality may also be present in
regions that are not necessarily considered as sexually
dimorphic [35]. Another study showed that the cortical
thickness of the right triangular pars also differs among
MtFe transsexuals and gay men. Specifically, the pars
b) Response to visual sexual stimuli: Sexual arousal is a
highly coordinated process that prepares a person for
reproductive behaviour; widespread changes occur in
the person’s neurophysiological state during excitement
to obtain adaptive responses. The attention, affective
and motivational systems of the individual concerned
are optimized to allow the selection and successful use
of sexual stimuli. In response to visual sexual stimuli, men
show subjective and self-reported excitement of a specific
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category; their greatest excitement is directed to those
categories of people with whom they prefer to have sex:
homosexual men experience greater genital and subjective
excitement for men than for women (and therefore prefer
male sexual stimuli), while for heterosexual men the
reverse happens. It is believed that the hormone influences
the development of neural structures that regulate sexual
behaviour in the prenatal period; therefore it is believed
that some aspects of neuro-hormonal development in
homosexuals proceed differently from heterosexuals, with
consequent psychological differences such as distinct
triggers (or “stimuli”) for sexual excitement. A 2007 study
on functional magnetic resonance imaging (fMRI) [38] that
explored the neural mechanisms of sexual arousal in gay,
and straight men showed their subjects composite sexual
interactions; have shown that both male groups activate
the same brain regions after each is exposed to a sexual
stimulus that agrees with the sexual orientation of the
subject being examined. Another fMRI study [39] showed
that by observing both hetero and gay erotic visual stimuli,
only those videos corresponding to the subject’s sexual
orientation produced patterns of activation in the areas of
the brain associated with sexual arousal. The heterosexual
response showed the same pattern of neural sexual
processing that caused gay vision while displaying images
of the opposite orientation did not elicit the same response.
A significant correlation was therefore found between
excitation and neural activation in the hypothalamus, a
key region of the human brain due to its sexual function;
self-reported sexual arousal values were also equal in both
groups. However, the extent of hypothalamic activation
was lower in gay men than in straight men, a trait that is
also shared by straight women. A further fMRI study [40]
determined patterns of cerebral activation in homosexual
and heterosexual subjects, exposing them to gay, hetero
and lesbian visual stimuli; they then found that different
neuronal circuits were active in the two male groups: brain
regions such as the left angular gyrus, the right pale globe
and the left caudate nucleus were activated exclusively
in homosexual men while the bilateral lingual gyrus, the
right parahippocampal gyrus and l right hippocampus
were activated exclusively in heterosexual men. These
results indicate that the neural circuits (related to the
processing of visual sexual stimuli) that are active during
sexual arousal in homosexual and heterosexual men are
different. New fMRI research [41] has shown heterosexual
and homosexual women and men photos of male
genitalia and female genitalia; thus limiting the visual
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sexual stimulus to genital photographs, the authors have
minimized the neuronal activity related to the processing
of various stimuli such as faces, voices, body movements
and sexually exciting body parts in addition to genitals.
They found that the ventral striatum, the centromedian
thalamus and the bilateral premotoriavental cortex
showed a stronger response to the photos of the preferred
sex than those corresponding to non-preferred sex. Since
the ventral striatum and the centromedian thalamus are
known to be activated by innate preferences, the selective
response of these regions to the preferred sexual stimuli
seems to reflect a predetermined response pattern. This
notion is therefore used to support one of the tests that
want sexual orientation to be of a purely biological origin.
Another FMRI study [42] sought to verify whether subjects
responded more to faces (male or female) to whom they
were sexually-oriented and predicted this modulation in
the brain circuit of the reward system. Heterosexual and
homosexual men and women were shown photos of male
and female faces and therefore invited to evaluate their
visual attractiveness. Consistent with the hypothesis, it was
discovered that the reward circuit of homosexual males and
heterosexual females responded more to photographs of
male faces, while the reward circuits of homosexual females
and heterosexual males responded more to photographs
showing female faces. The interaction between the
subject’s gender stimulus (male or female face) and sexual
orientation (homosexual or heterosexual) was highly
significant in two brain regions: the mediodorsal nucleus
of the thalamus (MDT) and the medial orbitofrontal cortex
(OFC). The activation in the OFC is remarkable because it
is involved in the representation of the reward value of
various sensory stimuli, including attractive faces. It also
appears to play an important role in processing the facial
signals necessary for social communication, as this region
has selective neurons for the face and because patients
with OFC lesions are unable to identify emotional facial
expressions. The modulation of the response to faces
within the OFC through sexual orientation adds further
importance to its role in social behaviour; since mdT and
OFC receive neural projections from each other, the similar
activation patterns observed in these regions can be
attributed to their anatomical connections.
c) Response to serotonin: Serotonin is a neurotransmitter
found in the central nervous system that has various roles
in regulating sexual behaviour; its agonists and antagonists
have to activate or inhibiting effects depending on their
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concentration and the brain area involved. Fluoxetine
is a selective serotonin reuptake inhibitor that prolongs
its effect on neurons [43]. Kinnunen et al. administered
fluoxetine to their study subjects to see if the brain is
activated differently in homosexual and heterosexual men
through the action of serotonin [44]; after administration
of fluoroxin they measured glucose metabolism in the
brain using positron emission tomography (FDG-PET).
They found that the cerebral response to fluoxetine differs
between gay people and straight men, ie the former
show a lower reduction in glucose metabolism in the
hypothalamus than in the latter. Also, other areas of the
brain were also differentially activated: the associative
prefrontal cortex of homosexual men showed greater
activity after administration, while that of straight men
showed no change. The anterior lateral girdle and the
bilateral/parahippocampal gyrus of the straight men
showed greater activity, while a reduced one was observed
in portions of their anterior cingulate cortex. These results
suggest that homosexuals and heterosexuals may not
only differ in the total number of neurons in various areas
of their central nervous system but may also differ in the
distribution of certain types of them, such as serotonergic
and dopaminergic neurons.
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empathy. In general, the treatment is multiaxial and may
include specific cognitive-behavioural interventions to
modify dysfunctional sexual thoughts, behaviours and
emotions that are activated in front of a specific situation
training of social-relational skills and self-regulation of
impulses in the management of adult affective relationships
treatment of sexual dysfunctions to address dysfunctions
related to the sexual sphere.
With regard to pharmacological treatment, this is
considered very useful in the process of treating various
paraphiliac disorders because, for example, treatment with
antiandrogens helps to inhibit the response of sex hormones,
causing a decrease in desire and sexual excitement.
Antiandrogenic drugs, such as cyproterone acetate (CPA)
and medroxyprogesterone acetate (MPA, Depo-Provera),
and lutein hormone therapies [45], in addition to therapies
based on SSRIs (serotonin selective reuptake inhibitors) [46],
Are, therefore, common therapeutic tools, but their use is,
however, limited due to side effects on the patient’s health.
Finally, the problem of the low compliance of the products and
the fact that they do not resolve the deviation in itself is very
remarkable. If the drug is interrupted, the deviant behaviour
will reappear.
CLINICAL AND THERAPEUTIC STRATEGIES
CONCLUSION
As for therapeutic interventions, the most effective
treatments for paraphiliac disorders are those that involve
the integration between psychotherapy and adequate
drug therapy (if necessary, compared to the case under
consideration). Clearly, treatments will be more effective in
those situations where the discomfort experienced by the
subject is relevant, and the subject requires help. In the case
of many paraphiliac disorders, the treatment is less effective
instead when it is ordered by the court and the motivation
for the treatment is extrinsic, even if many subjects, even
in such cases, still benefit from treatments, such as group
psychotherapy associated with antiandrogens. Among
psychotherapeutic approaches, cognitive-behavioural
therapy has proven to be a very effective treatment in
helping the subject manage impulses and sexual fantasies.
This type of therapy aims to identify and modify beliefs
and thoughts, which lead the subject to implement
dysfunctional behaviour by replacing this behaviour with
other more functional behavioural modalities. Therapeutic
approaches generally support the patient and must take
a non-judgmental attitude, promoting acceptance and
Recent discoveries in the field of neuroscience have shown that
paraphilic disorder, and emotional sexuality in general, has
not only psychological but also biological and neurobiological
roots. Future studies will necessarily have to orientate in this
direction, favouring the study of the relationships between
hormones and sexuality, emotions and sexual orientations
and sexual preferences and neuronal circuits. Also from a
therapeutic point of view, the causal link between the binomial
“psychotherapy-pharmacology” and the resolution of the
paraphiliac disorder appears clear and demonstrated, even if
the most resistant form seems to be the paraphiliac disorder
of sadistic matrix, due to its intrinsic psychological qualities
linked to the first years and the first evolutionary stages of the
subject, stratified with irrational convictions now anchored in
the personality.
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Citation: Perrotta G (2019). Paraphilic Disorder: Definition, Contexts and Clinical Strategies. Neuro Research 1(1): 4.
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