Paraphilia

Weird Love
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Let's talk about some of them[39]

The word ‘Paraphilia’ comes from the Greek words ‘para’ and ‘philia’ which refer to the abnormal and attraction aspects of this phenomenon[1], respectively. In other words, paraphilia is defined as a sexual attraction to what is considered outside the range of normal. There are many kinds of paraphilia, even if the definition of paraphilia itself is at times unclear. This ambiguity can be sourced by the fact that, as Dr. Howard Zonana of Yale University states “Distinguishing normal from abnormal sexual behaviours and fantasies is a challenging task,”[2] and not all people with a paraphilia require treatment[1].

Studies done to study distinguishing activity patterns and brain structure features often compare the brains of those with paraphilia and those without. There have been a number of studies that specifically look at the abnormalities present in paedophilia, also known as the sexual attraction to children. Even within paedophilia studies, it has been shown that various cortical areas and structures have a role in behaviour, supporting the idea that the brain processes linked to attraction and sex are present throughout the brain. For example, Sartorius et al. found that there was an increase in amygdala activation in pedophiles when presented with photos of children[4] while Pollok et al. looked at the primary and secondary somatosensory areas to find any abnormal activity in people with masochistic behaviours[3].

1. General Paraphilia

1.1 Background

1.1a Historical and Cultural Influences

A factor that often causes disagreement in the definition of paraphilia comes from the inconsistency of norms between cultures and across time. Social expectations vary depending on the culture and even among subcultures and thus so do the group of behaviours considered paraphilic. In ancient Greece, it has been found that love relationships between adolescent boys and older men were not just allowed but promoted[1]. Paraphilic behaviour has also been mentioned within texts on discipline written for the monks and nuns of Buddhism. Within these types of literature, paraphilias such as beastiality, necrophilia and fetishism have been referenced from over two thousand years ago[1].

1.1b Diagnosis

A person diagnosed with a paraphilic disorder will have fulfilled two criteria as defined by the DSM-IV-TR[7].

Criteria A: Over a period of six months or longer, recurrent and powerful fantasies that are sexually arousing along with sexual urges or behaviours that have to do with:

  1. Non-human objects
  2. Others or oneself suffering or being humiliated
  3. Children or other non-consenting persons

Criteria B: The behaviours in criteria A cause clinically noticeable distress or damage to one’s social, occupational or other significant areas of functioning.

Some paraphilic disorders are often linked with sexual offences. These specific types of paraphilia have additional criteria in order to be diagnosed. For example, in order to be diagnosed with voyeurism, exhibitionism or frotteurism, the person must have acted on the urges described in the criteria, or the person must have been greatly distressed by the urges and fantasies[6].

1.2 Chemicals and Paraphilia

1.2a Dopamine

Transvestic Fetishism
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Bugs Bunny exemplified
as a psychiatric disorder
that can be caused by
dopaminergic therapy[35]

The significance of dopamine in paraphilia can be concluded by the possible changes in sexual behaviour of Parkinson’s disease patients undergoing dopaminergic therapy. One case describes a man given selegiline for motor fluctuations who developed transvestisic fetishism, which stopped when selegiline was no longer given[8]. The change in the patient’s sexual behaviour is thought to have been the result of selegiline’s lowering of dopamine metabolism, resulting in an increase in dopamine[8]. Dopaminergic agents have also been thought to produce paraphilias and hypersexuality in Parkinson's disease patients by causing a reversal in the Parkinson’s disease personality profile. Traits included in this profile include extreme caution and introversion[9]. Thus a reversal would stimulate opposite behaviours such as greater risk taking.

1.2b Testosterone

It has been said that testosterone has great influence over many aspects of sexual behaviour[11]. In fact, androgen-lowering therapy is a currently used therapeutic approach which aims to relieve symptoms by lowering patient testosterone concentrations[10]. It has been found that child molesters have a positive correlation between novelty-seeking behaviours and testosterone levels[12]. Violent and non-violent rapists both have higher testosterone levels than child molesters, but no difference between each other[10].

2. The NOS Categories

Along with the broader diagnosis of paraphilia, there is also another category found in the more recent versions of the DSM known as “Not Otherwise Specified” (NOS)[7]. Under this category can be found diagnoses made during four types of situations:

  1. The presentation of the disorder follows the general outline of a mental disorder class, but the group of symptoms do not match the criteria for any specific disorder
  2. The presentation of the disorder does not match any symptom pattern described in the DSM but still causes a clinically substantial amount of distress or impairment for the person
  3. It is certain how the disorder developed
  4. There was not enough time to finish collecting data, or the information is inconsistent however there is enough information gathered to place the disorder into a diagnostic class

Many of the more specific types of paraphilia can be listed under this category, such as necrophilia, urophilia and partialism[6].

3. Masochism

Masochism is described as finding sexual gratification from physical or emotional abuse[1]. With evaluations of pain as being pleasant under certain circumstances, it has been tested if masochists have differences in their mechanisms involved with pain perception.

Indeed, masochists were found to have a higher pain threshold than controls along with higher pleasantness ratings of the laser stimulation used in a study[3]. These results show that masochists perceive pain as more pleasant even outside a sexual setting[3]. It has also been suggested that “sensory gating” is affected in masochism, with excitability being reduced[3]. Altered pain perception may indicate different cortical reactivity of S1 (the primary somatosensory cortex) in masochists, which would suggest that tactile processing is influenced by one’s experience of pain[3].

4. Necrophilia

Necrophilia
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"Necrophilia" directly translates to "love of the dead[13]" [36]

Necrophilia is commonly known as having real or fantasies about sexual relations with corpses[13]. It’s gained popularity in literature and has even appeared in ancient history[13]. A majority of the data gathered on this particular disorder have been from case studies and reviews of these case studies.

One particular study done by Rosman and Resnick found that the most frequent motivation behind necrophilia is the desire to have a completely compliant lover[14]. However, a more recent study done by Stein et al. suggests that this motive may not always be applicable when sexual murder is involved[13]. Many necrophiles have been found to have an occupation that would allow them to have contact with the dead, such as being a morgue attendant[14]. It was also found that some of these necrophiles still committed homicide despite having interaction with corpses in their occupation. These people may have killed in order to get a corpse in desperation of wanting to engage in necrophilia[13].

A case study done in 1960 has a description of what it was like for a patient during episodes of necrophilia[15]. Under hypnosis he said it was as if “something got a hold of me…something got in me and made me do it.[15]” This patient also frequently complained of headaches, although its connection to his necrophilia was unclear. At one point the patient described a pain between his ears, as if the area was swelling[15].

5. Paedophilia

5.1 Diagnosis

In order to be diagnosed with paedophilia, one must fulfill a certain criteria as stated in the DSM-IV-TR.

There is also a difference between the terms “paedophile” and “hebephile” which is based on the age of the children. A paedophile is defined as an adult who look at children twelve years old or younger as the object of their sexual desire. A hebephile is an adult who designate adolescents older than twelve years old as the target of their sexual advances[5].

5.2 Areas of Significant difference

5.2a Temporal Lobe

In some cases paedophilia has been known to appear with brain disease[16]. Cases of frontotemporal dementia and bilateral hippocampal sclerosis in particular have been studied[17]. These neuropathologies have been associated with neuron loss. Hypometabolism in the area of the right temporal lobe has been linked with two cases of paedophilia[17]. However, within these two cases, a preference for children was revealed to be present earlier in life. Therefore it was theorized that the abnormal right temporal lobe caused in increase in sexuality which “unmasked latent pedophilia[17].”

Abnormal Activity in the Temporal Lobe
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PET scan of a patient with hippocampal sclerosis, who displayed paraphilic behaviours.
Hypometabolism can be seen in the right temporal lobe.[37]

5.2b Frontostriatal system and Cerebellum

The brains of paedophiles have also been noted to have less grey matter in certain brain areas such as the ventral striatum, the orbitofrontal cortex and cerebellum[18]. Along with this difference in brain volume, subjects with paedophilia are observed to be, on average, less intelligent[17]. This correlation may in turn link paedophilia with neurodevelopment problems[19].

Abnormalities in these areas may also link paedophilia with other mental disorders such as OCD and depression[18]. Since the striatum and orbitofrontal cortex are engaged in reward processing, alterations in these areas may also indicate differences in the reward system of paedophiles[20].

5.2c Amygdala

It is well known that the amygdala has an important role in processing sensory stimuli and their emotional significance. Men and women are even shown to have different amygdala responses to visual sexual stimuli[22]. Pedophiles attracted to boys have been shown to have greater activity in the right amygdala when shown pictures of boys in swimsuits[21]. Greater activity in this area may also indicate a deficit in the limbic system that would normally reduce the salience of unfamiliar children. Chronic activation of the amygdala has also been linked to its volume loss[21].

The increased activity in the amygdala has also been proposed to be the result of a fear reaction which stems from knowledge that the attraction to this kind of visual stimuli is socially unacceptable[21].

6. Pharmacological Treatments

Drug Therapy
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The two most common types of drugs used
in the treatment of paraphilias are
SSRIs and LHRH agonists[28]" [38]

6.1 Medroxyprogesterone Acetate

Medroxyprogesterone acetate is known to have an “erotically calming effect[23].” It is commonly found in the drug Depo-Provera® which was demonstrated as an effective treatment for temporal lobe epilepsy by Blumer and Migeon, who used it to calm rage attacks[24].

Temporal lobe epilepsy has also been involved with cases of hypersexual and paraphilic disorders[25][26]. Patients diagnosed with temporal lobe epilepsy that had hypersexuality were also treated by Blumer and Migeon and given Depo-Provera®[24]. These patients improved, displaying decreased sexual symptoms, which is hypothesized to be the result of the drug’s sedative effect[24]. Medroxyprogesterone acetate has also been shown to be effective in treating a case of paraphilia arising from frontal brain damage[23].

6.2 Antiandrogen Therapy

Used of antiandrogen drugs can be traced back to the late 1960s[10]. It is thought that the sexual urges of sex offenders can be controlled by lowering testosterone levels, which would cause a decrease in sexual drive[10]. One such antiandrogen, acetateterone acetate, is known to work through three mechanisms[27]:

  1. By competing with testosterone and binding to receptors on target-organs
  2. By inhibiting testosterone and estrogen formation in the sex organs
  3. By lowering the secretion of gonadotropin-releasing hormone in the hypothalamus

One should also keep in mind that lowering testosterone concentration may not just result in lower sexual function since testosterone affects several organ systems[10].

6.3 Selective Serotonin Reuptake Inhibitors (SSRIs)

Serotonin can cause various effects depending on the type of serotonin receptor it is acting upon[29]. It is known, however, that serotonin is able to lower sexual arousal[30] in the treatment of paraphilia even though problems regarding serotonin metabolism or receptors have not been found in patients[28].
Numerous clinical trials have shown the effectiveness of SSRIs in reducing sexual fantasies and other paraphilic symptoms in patients[31][32][33] and one study showed that psychotherapy in combination with SSRIs was more effective than just psychotherapy[28]. Treatment outcome was not affected by which type of SSRI was used[34].

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