Byline: H. Martin Malin, PhD and Fabian M. Saleh, MD

Paraphilias are defined by DSM-IV-TR as sexual disorders characterized by "recurrent, intense sexually arousing fantasies, sexual urges or behaviors generally involving (1) nonhuman objects, (2) the suffering or humiliation of oneself or one's partner, or (3) children or other nonconsenting persons that occur over a period of 6 months" (Criterion A), which "cause clinically significant distress or impairment in social, occupational, or other important areas of functioning" (Criterion B). DSM-IV-TR describes 8 specific disorders of this type (exhibitionism, fetishism, frotteurism, pedophilia, sexual masochism, sexual sadism, voyeurism, and transvestic fetishism) along with a ninth residual category, paraphilia not otherwise specified (NOS).

It has been estimated that some 50 paraphilias have been identified and described in the literature. Many, like klismaphilia (erotic arousal to enemas) are not illegal and therefore do not often come to the attention of therapists even though they may fulfill DSM Criteria A and B requirements. Thus, the category paraphilia NOS comprises most of the paraphilias described in the literature, although not necessarily the largest number of individuals with paraphilias. The sheer variety of erotic material available on the Internet and other adult entertainment venues lends credence to this assumption. A content analysis of these materials would likely provide a reasonably accurate indication of the prevalence of these paraphilias-at least the legal ones.

With the exception of those who are in legal trouble, most, but not all, persons with paraphilia probably do not seek treatment. Indeed, it has been argued that the impact of the mandatory reporting laws enacted for certain sexual crimes has further decreased the number of individuals seeking voluntary treatment.1,2

To the layperson, paraphilias are commonly regarded as "kinky sex." Both canon law and common law proscribed most paraphilic thoughts and behaviors long before they came to be regarded by medical science as indicators of possible mental illness. By the time of Richard von Krafft-Ebing at the turn of the 20th century, medicine's interest in "abnormal" sexual behavior had come into full flower, and Krafft-Ebing made liberal use of such legal terminology as "perversion" and "deviancy" in his case studies.

An attempt to move away from such legally pejorative terminology eventually succeeded in the adoption of the term paraphilia, from the Greek prefix para meaning "around" or "beside" (within the context, implying "altered" or "missing the mark") and philia, 1 of 3 ancient Greek words for love. Benjamin Karpman gets credit for introducing English speakers to the term paraphilia.3

In the end, however, paraphilia and paraphile may be destined to join the pejorative ranks of such descriptors as perversion or pervert. Many well-educated individuals confuse paraphile with pedophile. Perhaps worse, because of a lack of understanding or disregard for the phenomenology of the paraphilias, physicians, lawyers, journalists, and other professionals readily conflate the medical term pedophile with the term child molester. It is a small jump from that error to conceptualizing all persons with paraphilia as sex offenders.

DSM nosology, and to some extent, therefore,...