Paraphilia (sexology)

According to DSM-5 , any intense and sustained sexual interest can be attributed to paraphilia, except for a sexual interest in genital stimulation or preparatory caresses with a phenotypically normal consonant mature human subject. Ray Blanchard, the head of the paraphilia working subgroup responsible for the compilation of the relevant part in DSM-5, gave the following examples of “ normophilia ” (there is no generally accepted term for non-paraphilic sexual interest): cunnilingus , fellatio , anal penetration with fingers ( fingering ), dildo , penis , vaginal penetration , mutual masturbation , kisses. Paraphilia Blanchard cited sexual interest in an enema , feces or urine , preference for amputees , paralyzed persons or persons with physical disabilities, sexual interest in bondage, flogging , hypoxia , sneezing or smoking people ^[3] .

Sexologist Charles Allen Mowser ( English Charles Allen Moser ) was sharply criticized the definition of Blanchard's paraphilia, in particular its definition through what it is not, an arbitrary focus on copulation (at the time of writing of the article, Moser in the definition of paraphilia mentioned copulatory instead of genital stimulation and preparatory caresses for it and precopulatory behavior), uncertainty about what a phenotypically “normal” subject is (for example, women with surgically enlarged breasts can be considered phenotypically abnormal subjects), as well as reference to the definition of consent, which is more legal in nature than medical. He also analyzed the list of sexual interests proposed by Blanchard as an example of "normophilia" and paraphilia, and concluded that they were not very successful. For example, why anal penetration with a dildo is normophilia, and an enema is paraphilia? In addition, sexism was also criticized by the American sexologist in DSM-5: a woman can wear beautiful lingerie to feel more sexually during genital stimulation, but if a man does it, then this is paraphilia ( transvestism ); if a woman sexually likes traditional relationships with a dominant man, then this is normophilia, but if a man enjoys a subordinate role with a dominant woman, then there is paraphilia ( masochism ). Moser in his article also expressed the opinion that, perhaps, the border between paraphilia and normophilia is only culturally determined, and therefore, objectively, it may not exist at all ^[4] .

It is worth noting that the problem of determining paraphilia is not the only problem of psychiatry, there are more fundamental ones, for example, the problem of determining mental disorder : what is mental health and illness? Authoritative psychiatrist Allen Francis ( English Allen Frances ) in 2010 stated that the modern definition of mental disorder is nonsense ( English there is no definition of a mental disorder. It's bullshit. I mean, you just can't define it ) ^[5] . Leaving the question of the validity of the modern definition of mental disorder aside, it is worth noting that paraphilia does not satisfy him. In this regard, the DSM-5 category of “paraphilic disorder” was introduced, which corresponds to it. But this category has been sharply criticized, including by American sexologist Mowser, Canadian sexologist Paul Fedoroff , and American philosopher of science Patric Singy ^{[6] [7] [8]} .

The idea of ​​distinguishing unusual sexual interest (paraphilia) from pathology (paraphilic disorder) is not new, it was already implicitly accepted in DSM-III-R (since paraphilia could be diagnosed by it only if there was suffering from its carrier or harm to others) and ICD-10 , and explicitly in DSM-IV , but there was no term for non-pathological unusual sexual interest. The unusual sex interest was distinguished from the pathological Polish sexologist Kazimierz Imełinski . He regarded sexual interest as a pathology when its harmonious integration into human life fails ^[9] .

Russian sexologist Mikhail Beilkin believes that the hallmark of healthy sexual interest is the ability to love. A similar mention of reciprocal tender sexual intercourse (“love”) exists in the DSM-III-R, DSM-IV, DSM-IV-TR in the context of the description of sexual pathology (sexually pathological people are not capable of such a relationship), as well as in the national a guide to psychiatry (the sexologist Tkachenko noted in it that paraphiliacs are characterized by a lack of empathy, depersonification) ^[10] .

The sexologist Mouser noted that it is unclear what a “reciprocal tender sexual relationship” is, and also expressed the view that the idea of ​​it, pathologizing most of the sexual history of mankind, is based on a bad romantic novel ( English bad romance novel ) ^[11] . Canadian psychologist Vernon Quinsey ( Eng. Vernon Quinsey ) noted that the male reproductive strategy devised by evolution is aimed at leaving as many offspring as possible from different women, which means that raptophilia (rape of women without any reciprocal gentle connection with them) is consistent with it ^{[ 12]} . Russian sexologist Alexei Perekhov believes that the border between unusual sexual interest and sexual pathology is the formation of dependence. For example, if a person likes sadomasochism, then this is not a disorder, but if he has developed a dependence on him, then this is already a pathology. This approach of Alexei Perekhov is not surprising, given that he is a student of Alexander Bukhanovsky , who considered paraphilia as a special case of a non-chemical disease of dependent behavior ^[13] .

The main groups of paraphilia are described in the Fifth Edition American Diagnostic and Statistical Manual of Mental Disorders ( DSM-5 ) and the Tenth Revision International Classification of Diseases ( ICD-10 ). In the group of diagnoses F 65. “Sexual preference disorders” included in “Class V: mental disorders and behavioral disorders”, ICD-10 classifies paraphilia as follows ^{[14] [15]} :

F 65. Disorders of sexual preference, including sexual deviation and paraphilia

• F 65.0 : fetishism - the object of sexual desire is a part of the body, clothing, or some other object symbolizing a sexual partner.
• F 65.1 : Fetish transvestism - sexual satisfaction is achieved by dressing in clothes of the opposite sex.
• F 65.2 : exhibitionism - sexual satisfaction is achieved by showing others their own naked body (usually the buttocks or genitals ) outside the context of sexual relations.
  • F65.21 : Exhibitionism, sadistic type - sexual satisfaction is achieved with the fear (fright) of the victim.
  • F65.22 : Exhibitionism, masochistic type - sexual satisfaction is achieved with the aggressive reaction of the victim.
• F 65.3 : voyeurism - the desire to spy on sexual intercourse , naked or partially naked objects of sexual preference.
• F 65.4 : pedophilia - sexual attraction to children of pre -puberty or early puberty.
• F 65.5 : sadomasochism (including sadism and masochism) - the desire to perform actions that cause pain , are degrading, showing the subordinate position of the person to whom they are directed, or to be the object of such actions.
• F 65.6 : multiple disorders of sexual preference - a combination of several paraphilia, none of which can be recognized as the main. Most often, fetishism, transvestism and sadomasochism are combined.
• F 65.8 : other disorders of sexual preference - all other disorders of sexual preference and sexual behavior, including frotterism (tendency to rub against women in a crowd or public transport), necrophilia , bestiality , hypoxifilia (using anoxia and strangulation asphyxia to enhance sexual arousal) , telephone scatology (obscene telephone calls related to voyeurism) and others.
• F 65.9 : unspecified disorders of sexual preference - sexual deviation without further specification.

In the International Classification of Diseases of the eleventh revision ( ICD-11 version of 2018): ^[16]

• 6D30 : exhibitionist disorder ;
• 6D31 : voyeuristic disorder ;
• 6D32 : pedophilic disorder ;
• 6D33 : coercive sexual sadism disorder - sexual sadism with the delivery of physical or psychological suffering to a partner who did not consent to this; voluntary sadistic practices exclude the diagnosis and are not paraphilia.
• 6D34 : froter disorder ;
• 6D35 : another paraphilic disorder affecting involuntary individuals ;
• 6D36 : paraphilic disorder characterized by solitary behavior or voluntary individuals ;
• 6D3Z : paraphilic disorder, unspecified .

Thus, in the classification of ICD-11, fetishism and fetish transvestism are eliminated, and sadomasochism is replaced by violent sexual sadistic disorder. BDSM practices within the framework of the SSC principle (an abbreviation for the English words safe , sane , consensual ) exclude the diagnosis of this paraphilia.

The second edition of the Diagnostic and Statistical Manual on Mental Disorders (DSM-II, 1968), developed by the American Psychiatric Association (APA), listed the following sexual deviations ( English sexual deviations ): homosexuality , fetishism, pedophilia, transvestism, exhibitionism, voyeurism, sadism , masochism ^[17] . In DSM-III (1980), “sexual deviations” were called paraphilia, bestiality was added to the classification, homosexuality was excluded, and sadism and masochism were renamed sexual sadism and sexual masochism ^[18] . Frotterism was added to DSM-III-R, and transvestism was replaced by fetish transvestism ^[19] .

In the fifth edition ( DSM-5 , 2013), which is currently used by psychiatrists and sexopathologists in the USA , the following paraphilic disorders are distinguished ^[1] :

• 302.82 (F65.3) : voyeuristic disorder.
• 302.4 (F65.2) : exhibitionist disorder ( English exhibitionistic disorder ).
• 302.89 (F65.81) : frotteuristic disorder .
• 302.83 (F65.51) : masochistic sexual disorder.
• 302.84 (F65.52) : sadistic sexual disorder.
• 302.2 (F65.4) : pedophilic disorder ( English pedophilic disorder ).
• 302.81 (F65.0) : fetishistic disorder.
• 302.3 (F65.1) : transvestic disorder.
  • 302.3 (F65.1) : transvestite disorder with fetishism ( eng. With fetishism , with sexual arousal from fabrics, materials or clothing).
  • 302.3 (F65.1) : transvestite disorder with autogynephilia ( Eng. ... with autogynephilia , with sexual arousal from the imagination of a woman in fantasies).
• 302.89 (F65.89) : another specified paraphilic disorder ( e.g. other specified paraphilic disorder , for example, telephone scatology, necrophilia, enemasophilia , bestiality , coprophilia , urofilia ).
• 302.9 (F65.9) : unspecified paraphilic disorder ( English unspecified paraphilic disorder ).

There are many other options for classifying paraphilia. Polish sexologist Zbigniew Lev-Starovich , for example, classified paraphilia according to the object of sexual desire ( fetishism , pedophilia , bestiality , etc.), according to the method of achieving sexual satisfaction ( sadomasochism , exhibitionism , etc.), and in addition to this, he also identified “complex sexual deviations” , “Atypical sexual deviations” (which, for example, included homosexuality , incest and prostitution ) and “violations of sexual auto-identification” ( transsexuality ) ^[20] .

The following criteria are called in the literature, in the presence of which sexual deviation is recognized as a disease in need of treatment ^[21] :

• Repeated repetition of deviant sexual experiences for at least 6 months.
• The commission of deviant actions or the presence of deviant fantasies causes the patient suffering, damages his social well-being (dismissal from work, punishment for committing antisocial acts).
• There are no signs of other mental disorders .
• The root cause of the deviations is not alcohol or drug abuse .
• Committing deviant actions in the face of loss of control over one’s own behavior , despite possible adverse consequences.

If there are no such signs, the diagnosis of paraphilia is not made; deviation of sexual behavior from social norms is recognized as not requiring medical intervention, if it does not harm the social well-being of the subject ^[22] .

Committing deviant sexual activities may also be due to the presence of mental disorders. Inadequate sexual actions are often combined with epileptic seizures , addictive behavior ( kleptomania , pyromania ), and are observed in subjects with organic brain damage ^[22] . In these cases, a diagnosis is made corresponding to the underlying disease, based on the nature of which the treatment is carried out. Some paraphilia from the group of excrementophilia ( urofilia , coprophilia ), as well as osfresiophilia (pathological sexual interest in body odors) do not appear as a primary diagnosis, and in the vast majority of cases they accompany other mental disorders ^[23] . Egodistonic sexual orientation and transsexualism , on the contrary, are almost never accompanied by paraphilia ^[23] .

In the literature there is evidence of the onset of paraphilia in childhood, usually up to 10 years (usually in the form of fantasies, and not explicit behavioral acts) ^[24] . But it is worth noting that the onset of heterosexuality and homosexuality is also, as a rule, up to 10 years old and is most likely associated not with increased secretion of androgens by gonads in puberty , but with the adrenal cortex to puberty (adrenarch) ^[25] .

The reasons for paraphilia remain unclear. But there is much evidence in favor of neurobiological reasons, especially for pedophilia. But psychosocial theories are also popular, for example John Mani 's theory of the map of love. An American sexologist in the seventies and eighties of the twentieth century actively promoted his theory that sexual interest and even gender identity are formed mainly under the influence of psychosocial factors. Putting this theory into practice led to the tragedy of David Reimer . But, despite the apparent impossibility of explaining paraphilia only by psychosocial factors, they cannot be ignored either. German sexologist Klaus Beyer ( German Klaus Beier ) stated that the formation of sexual preferences is a complex biopsychosocial process ^[26] .

Georgy Vasilchenko associated paraphilia with a violation of psychosexual development, which is a continuous process consisting of three stages: the formation of sexual identity, sexual role and psychosexual orientation. Violation (dysontogenesis) of psychosexual development may consist in its retardation or prematureness; if somatosexual development proceeds normally in these two cases, then there is a disharmony (asynchrony) of development. Persistent paraphilia according to Vasilchenko is formed with the disharmony of somatosexual and psychosexual development ahead of the latter. In this case, they begin to manifest themselves in childhood, merge with the core of the personality and practically do not lend themselves to therapeutic correction. A cerebral predisposition for this developmental feature is a low threshold of sexual excitability, which makes early sexualization of behavior possible ^[27] .

Georgy Vvedensky et al. Compared the characteristics of the psychosexual development of three groups: paraphiliacs, people with abnormal sexual behavior without paraphilia, and the normal group. It turned out that, indeed, paraphilic patients were more likely to experience disharmony of development ahead of psychosexual development than in the norm group, in which disharmony with delay in psychosexual development was more common. Moreover, in the group of paraphilic patients and in individuals with abnormal sexual behavior without paraphilia, not advancing, but total retardation of both psychosexual and somatosexual development prevailed ^[28] .

Andrei Tkachenko et al tried to connect the retardation of somatosexual development that was observed in most of the studied paraphilic patients, with the peculiarities of their neuropsychic processes (decreased plasticity) and personality traits (increased emotional-negative reactivity, reduced motivation to achieve socially encouraged goals), which can contribute to the formation of stereotypical patterns of abnormal sex drive. Russian scientists have suggested that retardation of somatosexual development can delay the process of elimination of synapses in the cerebral cortex , as well as slow down the growth of the left hemisphere and lead to compensatory growth of the right hemisphere, which will cause the corresponding features of EEG recorded in paraphilic drugs: an increase in interhemispheric coherence of EEG in all ranges in the temporal lobe and parietal areas, as well as hypoactivation of the left hemisphere (in individuals with pedophilia and exhibitionism) and hyperactivation of the right (in sadists). The latter feature may be associated with the above personality traits of paraphilic, and the first - with a decrease in the plasticity of neuropsychic processes. It is also worth noting that in patients with paraphilia on the EEG, in addition to the above features, hyperactivation of the fronto-central regions of the brain was recorded, which was associated with dysfunctional changes in the system of “basal ganglia-frontal lobes”. This feature can create the conditions for the realization of sexual activity in the form of automated obsessive actions. The authors of the study suggest that it is caused by a combination of certain variants of early organic brain damage with an individual genetic predisposition. Thus, early organic damage to the brain in combination with retardation of somatosexual development (it is possible that this retardation is caused by organic damage to the brain) can cause detected neurophysiological shifts, which, in turn, can lead to the formation of stereotypical compulsive patterns of abnormal sex drive. But these neurophysiological features do not explain the formation of paraphilia itself. Tkachenko et al noted the importance for their formation of psychosocial factors and pathology of the subcortical structures of the brain - the hypothalamus, amygdala ^[29] . However, according to this study, it is impossible to conclude about the pathology of these structures.

An alternative explanation for the formation of stereotypical compulsive schemes for the implementation of abnormal sex drive was proposed by George Kryzhanovsky and developed by Alexander Bukhanovsky. According to their theory, paraphilic disease gradually develops a pathological system, the core of which is a generator of pathologically enhanced excitation (GPUV) - an aggregate of spontaneously activated hyperreactive neurons. Over time, the pathological system progresses, which will manifest itself in the form of social maladaptation of a person, deactivation of areas of life that are not related to the sexual. Answering the question why not all paraphilic patients have such a clinical picture, Bukhanovsky et al noted that in this case an isolated low-power GPU appeared in the brain, which only determined the presence of special sexual needs (fetishism, sadomasochism), but did not cause the disease dependent behavior, as the person has not lost control over them ^{[30] [31]} . Thus, this theory well explains the dynamics of the development of a person’s dependence on paraphilia, the formation of stereotypical patterns of realization of paraphilic motives, but it does not explain why a person has this or that sexual preference.

Neurophenomenological model of sexual arousal

The results of modern studies of paraphilia using neuroimaging tools are often interpreted based on the neuro-phenomenological model of sexual arousal. According to this model, based on neurophysiological studies of the processing of visual sexual stimulus by the brain of healthy men, four main components of this process are distinguished: 1) cognitive, 2) motivational, 3) emotional, 4) vegetative. The parts of the brain responsible for the corresponding components of the processing of the visual sexual stimulus, as well as the structures inhibiting this process, were identified ^[32] .

The cognitive component of sexual arousal is associated with the recognition of a visual stimulus as a sexual stimulus, focusing attention on this stimulus and the imagination of motor activity with it. Recognition of visual sexual stimulus is provided by the right lateral orbitofrontal cortex, lower temporal gyrus. The activity of the upper and lower parietal lobes is associated with focusing attention on this stimulus. The lower parietal lobe, cerebellum , premotor ventral cortex, and additional motor cortex are responsible for the imagination of motor activity with him.

The emotional component of sexual arousal is associated with his subjective hedonistic experience. It is provided by the secondary and primary somatosensory cortex , tonsil , posterior islet lobe .

The motivational component of sexual arousal is responsible for inducing action with a sexual stimulus. It is provided by the hypothalamus , black substance , ventral striatum , anterior cingulate gyrus, posterior parietal cortex, claustrum .

The vegetative component of sexual arousal is associated with preparing the body for sexual activity: an increase in muscle tension, an increase in heart rate and respiration, a rush of blood to the genitals (erection), etc. It is provided by the hypothalamus, anterior cingulate gyrus, anterior islet lobe, and shell .

The left lateral orbitofrontal cortex and the lateral temporal cortex suppress the initiation of visual stimulus processing. Due to the activity of these brain structures, it is possible to inhibit the initiation of sexual activity in an inappropriate situation (in public places). The activity of the medial orbitofrontal cortex reduces the attractiveness of the sexual stimulus. The caudate nucleus, the anterior cingulate gyrus determine the rejection of the already begun sexual activity, that is, the situationally determined “switching” from sexual activity to another.

There are isolated reports that people developed abnormal sexual behavior due to a tumor of the frontal lobe of the brain, frontotemporal dementia, and stroke. These data are adequately explained by the neurophenomenological model, given the fact that according to these reports, patients mainly affected brain structures, which, in the framework of the model under consideration, are responsible for inhibiting the processing of sexual stimulus. Thus, interpreting the data of these reports on the basis of the neuro-phenomenological model, we can conclude that the brain lesions mentioned in them “slowed down” the existing paraphilia, which patients had in a latent form, and did not change their sexual preferences ^[33] .

There are neuroanatomical, neurophysiological studies of paraphilia, the results of which were interpreted on the basis of the neurophenomenological model. For example, Boris Schiffer showed that heterosexual pedophiles, unlike healthy individuals, do not observe activity in the orbitofrontal cortex with sexual arousal. He interpreted these data as a violation of the cognitive stage of sexual arousal ^[34] . Other authors note violations of the emotional component based on studies that revealed dysfunctional changes in the amygdala with pedophilia. In 2014, two neuroanatomical studies revealed abnormalities in the structures of the amygdala complex in pedophiles ^[33] . James Kantor et al. Suggested that the problem in the case of paraphilia is not in any one or several components of the sexual stimulus processing process and corresponding brain structures, but in the anomalous structure of the connections between them ^[35] . Interestingly, similar hypotheses are put forward with respect to other mental disorders: there are suggestions that autism spectrum disorders are associated with abnormal structural and functional connections between different brain regions (especially between the parts of the brain responsible for processing social stimuli). It is also curious that among people with an autism spectrum disorder, the prevalence of paraphilia is increased ^[36] .

Despite the modern means of neuroimaging, the same type of data processing protocols ( voxel-oriented morphometry ), the results of studies of paraphilia are very heterogeneous, which makes it difficult to unambiguous interpretation of the accumulated data on the basis of the neuro-phenomenological model. The authors of the 2014 paraphilia research survey found that research in this area is in its infancy, noted the methodological errors of the authors of the research (small main and control groups, non-differentiation of paraphilic from sexual offenders, mixing paraphilic of different sexual orientations in one group, for example heterosexual and homosexual pedophiles), criticized the traditional data processing protocols used in fMRI studies, and also suggested ways to overcome identified problems for future research ^[33] .

Paraphilia and homosexuality

There is empirical evidence indicating that nuclear homosexuality is associated with a violation of psychosexual ontogenesis, starting from the stage of formation of sexual identity , due to a failure of sexual differentiation of the brain during prenatal or neonatal development ^[37] . But the sexologist Andrei Tkachenko in his “Anomalous Sexual Behavior” suggested the idea that all sexual anomalies (both homosexuality and paraphilia) are associated with impaired defemination and masculinization of the brain ^[38] .

However, James M. Cantor in a comparative analysis of homosexuality and paraphilia conducted in 2012 on the basis of empirical studies of these two phenomena, showed that homosexuality and paraphilia probably have different etiologies (Cantor also admitted the possibility that each paraphilia has its own etiology): ^[39]

Data such as growth, IQ, percentage of left-handed people, although at first glance insignificant, are very important. For example, the increased prevalence of left-handed people among pedophiles indicates that already in the womb their brain was subjected to various harmful effects, since in most cases, under favorable conditions, with the exception of genetically conditioned left-handedness, a person is born right-handed, but when the brain is affected, redistribution of localization can occur brain functions to compensate for them, including motor functions ^[43] . A negative correlation of growth with the likelihood of developing various diseases, including mental ones, is also known. This is due to the fact that low growth may indicate unfavorable conditions for prenatal and early postnatal ontogenesis, as it is caused not only by genes, but also by the influence of the environment (for example, growth is less in those whose mothers smoked during pregnancy) ^[44] . IQ can roughly be regarded as an integral indicator of brain health, as well as blood pressure as an integral indicator of blood flow. The fact that pedophiles have lower than average IQs, but within normal limits, suggests that their brains could be exposed to various harmful effects, but in general the disorders were well compensated ^[45] .

The neuropsychological profile provides more accurate information about the functioning of the brain. The partially female neuropsychological profile of homosexuals suggests that they are worse than ordinary men, like women, with tasks that are related to spatial orientation, coordination and accuracy of movements, mathematical reasoning, but they are better able to cope, like women, with tasks that require good speech abilities, subtle instrumental movements of the hands and abilities associated with the identification of similar objects. Pedophiles cope with all tasks a little worse than ordinary men, that is, there is a general moderate neurodeficiency. Neuropsychological studies of other paraphilia are few. Neuroanatomical studies provide direct information on the structure of the brain, and they show that homosexuality can indeed be associated with impaired sexual differentiation of the brain, but not paraphilia; at least, there is no evidence to convincingly prove this ^[39] .

In the human population, it is estimated differently by various researchers. Assessing the prevalence of certain psychological phenomena varies greatly, depending on the group covered by the study, its social and national characteristics, as well as on the survey methodology, the structure of the questionnaire, etc.

Religion to Paraphilia

Many religions consider deviation a great sin, perceiving them as debauchery, perversion, unnatural behavior for a person. In the Dark Ages of the Middle Ages, people with deviations were often sent to be burned together with a partner (including an animal), with whom an act of perversion was committed.

Legal Settlement of Sexual Deviations

• List of Sexual Disabilities
• Sexual dysfunctions
• Sexomnia

• Article on the prevention of sexual dysfunctions and deviations