Managing Sexual Paraphilias and Fetishes

The word paraphilia derives from the Greek para or beside and philia meaning friend or love. In this sense, the concept is used to designate a love that is “beyond the usual.” Paraphilias are specifically defined as “frequent, intense, sexually arousing fantasies or behaviors that involve humans or inanimate objects” (Brown, 2021). According to the DSM-5 (American Psychiatric Association, 2013), a paraphilia is not considered pathological unless it causes unmanageable stress or does harm to the self or others. It is only then that it would be considered a “disorder.”

In support of this notion, many people have paraphilias and use them productively to enhance their sex life (e.g., a man with a shoe fetish prefers his wife to wear high heels when they have sex). But others have paraphilias that result in an unlawful breach of boundaries (e.g., the paraphilia of exhibiting or exposing one’s genitals in public). The following eight paraphilias are considered by the DSM-5 to be the most common:

1. Exhibitionism – exposing one’s genitals to the unsuspecting
2. Fetishism – interest in inanimate objects (e.g., diapers, shoes, stockings)
3. Frotteurism – rubbing against nonconsenting parties
4. Masochism – suffering or humiliation
5. Pedophilia – interest in prepubescent children
6. Sadism – inflicting pain or humiliation on others
7. Transvestism – wearing clothes of the other sex
8. Voyeurism – watching unsuspecting people unclad or engaged in sexual activities

Access

Sex therapists know that when treating a problematic paraphilia, the Internet is not always their friend. In fact, this medium makes access to one’s paraphilia of choice easier than ever, for good or evil. For example, if you have something as esoteric as a smoking fetish or prefer that you or your partner smokes during sexual activity (i.e., capnolagnia), you can find others that are equally turned on with the click of your mouse. And no matter what your sexual delicacy might be, there is a good chance you can find an organization on the Internet to support it. While this type of access can be helpful to those feeling alienated or embarrassed—whether their paraphilia is harmless or problematic—it can also serve as a feeding system for those who will use it to support a dangerous compulsion.

Incidence and Causes

While nobody seems to know why, there are more men with paraphilias (3% to 5%) than women (1% to 6%) (Dryden-Edwards & Stöppler, 2022). Some studies suggest men tend to be more impulsive or sensation-seeking, while others believe that men have greater testosterone levels and thus higher libidos (Dawson, Bannerman, Lalumière, 2016). I find these explanations plausible but limiting in that they discount sociocultural influences. For example, women have historically been raised to value sexual activity in conjunction with relationships. Simply put, women have been discouraged from compartmentalizing or separating sex from intimacy.

Treatment

If a client presents with a problematic paraphilia, I first conduct an extensive sexual history to help uncover the origin of the paraphilia and connect it to the client’s present symptom. This allows the client more control over his or her behavior. For example, a male client learned that he could not function sexually unless his wife woman wore a French Maid’s outfit. At first his wife did not mind dressing up, but she eventually began to feel controlled by the process. The man’s family of origin revealed that his mother was French, and although she was not a house cleaner, she was especially flirtatious with men. The client claimed that his mother’s accent easily seduced men, and that he was a witness to these interactions.

At some point in the therapeutic process the client will have to consider some tough questions: Can they face how destructive the paraphilia is in their lives? How committed are they to treatment? How bad do they want to gain control over their paraphilia? What are they prepared to give up to get this control? If the client is in court-ordered treatment, clients will have no choice in the matter. But most are not and must therefore make the difficult decision to save themselves and their family, or to continue to risk everything in the service of their paraphilia.

Sometimes, however, all that is needed in treatment is a compromise or negotiation on a couple’s part as to how the paraphilia is used in the relationship. For example, after a man was caught wearing his wife’s favorite dress (i.e., tranvestism), the couple decided to clothes shop together. Another couple negotiated how often to indulge their paraphilia.

I do realize there are other methods of treating paraphilias, and I am not opposed to incorporating, for example, medication into my model. Research indicates that medication in conjunction with ongoing psychotherapy is most effective in treating paraphilias (Rice & Harris, 2011). I have had several cases in which specific serotonin reuptake inhibitors (SSRIs) have proven successful in curbing a variety of obsessive-compulsive sexual behavior. And many clinicians who treat pedophilia have found that the use of gonadotropin-releasing hormone agonists to inhibit testosterone helpful, and with limited side effects (Landgren, Malki, Bottai, Arver, & Rahm, 2020).