Motivation and emotion/Book/2017/Paraphilia motivations

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Paraphilia motivations:
What motivates paraphilias?

Overview[edit]

Given the creative nature of human sexuality, classifying a sexual pleasure as normal or abnormal is controversial (Wakefield, 2011). Many explanations for the motivation of this behavior are proposed. Psychoanalytic theories propose that paraphilia stems from childhood experiences such as repression of sexual impulses, which is later expressed in adulthood (Thibaut, Barra, Gordon, Cosyns & Bradford, 2010). Biological theories emphasize the role of chemical and hormonal imbalance, and brain lesions or injuries (Wakefield, 2011). Social theories, however state that the individual's environment such as childhood abuse and trauma, parenting styles, and cultural factors predispose an individual to develop paraphilia (Bhugra, Popelyuk & McMullen, 2010). Despite several explanations, motivations for paraphilia stem from a combination of biopsychosocial factors.

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Key Questions
  • What is the definition of paraphilia?
  • What are the different types of paraphilia? 
  • What is the prevalence of paraphilia?
  • What factors motivate paraphilias?
  • What are the treatment options for paraphilia?

What is Paraphilia?[edit]

The term paraphilia originated from the Greek prefix “para” meaning around and “philia” meaning love or affiliation (Wakefield, 2011).

Figure 1: Zoophilia is a type of paraphilia that involves engaging in sexual intercourse or having a sexual fixation with animals

Definition[edit]

  • The DSM-V defines paraphilia as "unusual sexual interests that involve many intense and persistent sexual interests other than sexual interests in genital stimulation or stroking phenotypically normal, physically mature, consenting human partners" (Marshall & Marshall, 2015).
  • Mosby's Medical Dictionary (1998) states that paraphilic acts are expressed in socially prohibited ways (e.g. paedophilia), result in behaviour which is considered socially unacceptable (e.g. coprophilia), or are biologically adverse (e.g. zoophilia).

Types[edit]

  • Money (1999) has identified over 136 types of paraphilias, while Aggrawal (2009) estimated 547 categories of paraphilia (Beech & Harkins, 2012). The DSM-IV outlines the following types:   

Voyeurism: sexual fantasies or behaviours that involve observing a person who is naked, while engaging in sexual activity. 

Exhibitionism: Exposing ones genitals to a non-consenting individual.

Frotteurism: Touching or rubbing one’s genitals against a non-consenting individual.    

Transvestic fetishism: Engaging in cross-dressing for sexually arousing purposes.   

Fetishism:  sexual fantasies or behaviours that involve non-living objects, and non-genital body parts   

Sexual masochism: sexual fantasies, or behaviours that involve being humiliated, bondage, or suffering.   

Sexual sadism: sexual fantasies, or behaviours involving  the infliction of humiliation, bondage, or suffering that is exciting to the person   

Pedophilia: sexual activity involving prepubescent children, generally aged 13 years or younger.   

Paraphilias not otherwise specified: include, but they are not limited to: telephone scatologia (obscene telephone calls), necrophilia (corpses), partialism (exclusive focus on part of a body), zoophilia (animals), coprophilia (feces), klismaphilia (enemas) and urophilia (urine) (Thibaut et al, 2010; Wakefield, 2011)

Prevalence and Incidence[edit]

Figure 2: Transvestic fetishism is when an individual engages in cross-dressing for sexually arousing purposes. 

Individuals have been found to engage in paraphilic behaviour, from benign to clinical degrees, with a prevalence of 5 to 30% (Agnew, 2001). Thibaut et al, (2010) reported over 50 paraphilias, mostly evident in men.

Results from a cross-sectional study on paraphilia-associated sexual arousal patterns (PASAP) amongst a male sample (367) aged 40 to79 years, in Germany, also revealed that 62.4% of men reported one PASAP, in 1.7% of cases causing distress. This was associated with being single, masturbating once per week, or having a low general subjective health score (Ahlers, Schaefer, Mundt, Roll, Englert, Willich & Beier, 2011).

Furthermore, 9.5% and 3.8% of paedophilic PASAP in sexual fantasies and in real-life sociosexual behaviour was reported by participants, respectively. 50 to 70% of paedophiles were found to have more than one paraphilia, with many having their paraphilias identified as beginning before the age of 18 (Ahlers, Schaefer, Mundt, Roll, Englert, Willich & Beier, 2011).

Further research in a population of 193 students, showed 21% of subjects as having paedophilic fantasies, mostly evident in men (Thibaut et al, 2010). Research by Cantor (2012), in a sample (n = 2450) of the general population also reported 2.8% of men and 0.4% of women to have at least one episode of transvestic fetishism, with at least one incident of voyeurism occurring in 11.5% of men and 3.9% of women.

Etiology[edit]

Etiology aims to explain the causation of a behavior. In regards to paraphiliac disorders, a combination of biopsychosocial factors have been proposed that explains the motivation behind paraphilia. Furthermore this has been linked with other theories of motivation and empirical literature that provide support for the paraphiliac behaviors.

Biological factors[edit]

Biological factors are seen as the primary determinants of human behavior. These include factors such as brain lesions, hormonal and chemical imbalance, and genetic dispositions. This section will address these factors and theories of motivation that cause paraphiliac behaviors.

Drive Reduction Theory[edit]

Figure 3: Drive reduction theory proposes that individuals seek to satisfy basic biological drives, such as sex, thirst, and hunger. When paraphilics engage in acts to satisfy their sexual impulses, find this behavior rewarding, and associate positive feelings with the outcome, they are motivated to keep engaging in this behavior

According to this [what?] theory, individuals are driven by basic biological needs such as sex and hunger. A disturbance in these needs causes the individual to engage in behaviors that bring the body back to its homeostatic state.

In regards to paraphilia, paraphilics are likely to engage in behaviours that provide immediate gratification for their urge and an escape from internal discomfort. Each time a paraphilic engages in behaviour that is associated with a fantasy (drive), and they find this rewarding and irresistible (reduction), they will be likely to continue this pattern[factual?]. Furthermore, individuals with paraphilia often have non-sexual motivations and drives, thus perceive their own actions as a sense of self, having feelings of power and a direction and meaning to their lives, which reinforces this behaviour (Seligman & Hardenburg, 2000).

Lovemap Theory[edit]

Paraphilias involve elevated levels of sexual arousal[factual?]. The performance of a paraphilia is connected to high levels autonomic arousal where external stimuli are blocked due to the intense focus on the paraphilic act. Lehne’s Lovemap Theory explains that every individual has a distinct and individualized Lovemap exemplifying the variety of features of partners and activities that are sexually arousing to them. According to Lehne, paraphilias are unique forms of “vandalized Lovemaps” personified by very high specificity of sexual content and an elevated sexual drives. He also states that paraphilics spend their lives exploring these lovemaps as they are diverse, because of the diverse nature of human sexuality (Carstens & Stevens, 2016). This theory integrates out understanding about paraphila[spelling?] and helps us understand the motivators behind on-going paraphilic acts. As human sexuality is malleable and distinct, based on this theory, paraphilic behavior will be reinforced when paraphilics spend most of their time exploring and trying to understand their fantasies. When the outcomes associated with exploring these acts is positive, this further reinforces the behavior as paraphilics do not associate negative feelings with these outcomes, rather a rewarding experience during this exploration.

Chemical Imbalance (Testosterone, Dopamine, and Serotonin)[edit]

Figure 4: A decrease in testosterone levels is correlated with paraphilic behaviors

Testosterone plays a major role in the regulation of sexuality, aggression, cognition, emotion, and personality. It is a major determinant of sexual desire, fantasies and behaviour, and controls the frequency, duration and magnitude of spontaneous erections. The impact of testosterone on human sexual behavior is integrated into two neurobiological theories of sexual behavior: the four-component model and the dual-control model (Jordan, Fromberger, Stolpmann & Müller, 2011).

The wide distribution of androgen receptors throughout the whole brain and their numerous mechanisms demonstrate that androgens modulate almost every aspect of sexual behaviour[factual?]. Testosterone participates in excitatory and inhibitory processes of sexual functions by modulating the activity of dopaminergic neurotransmitter systems. Differences in this signalling thus contribute to abnormal sexual functions, such as acting out paraphiliac fantasies that are against the norm. The effects of serotonin and dopamine on sexual behaviour are evident in animal and human studies[factual?]. Enhancing central serotonin activity in the hypothalamus has shown to inhibit sexual behaviour. For example, paedophilia is accompanied by increased plasma concentrations of catecholamines (Jordan, Fromberger, Stolpmann & Müller, 2011).

A study by Maes et al (2001) showed that paedophiles had a greater magnitude of cortisone and prolactin level responses to metachlorophenylpiperazine vs. controls. This indicates that serotoninergic disturbance might motivate and contribute to paraphiliac acts, where a decrease in serotonin in the brain is more likely to motivate paraphiliac behavior (Thibaut et al, 2010).

Brain Damage[edit]

Specific brain regions are associated with sexual behaviour[factual?]. Animal studies have shown that lesions to the medial preoptic area, which is connected to the limbic system and brainstem, impair the male copulatory behaviour through inability to recognize a sexual partner[factual?]. Studies in humans show that paraphilias have been reported as the result of brain trauma during childhood, temporal or frontal lobe damage, Kluver-Bucy syndrome or epilepsy, especially in men[factual?]. Stol é ru et al. (1999) showed that brain areas activated in eight adult healthy males during childhood visually evoked sexual arousal. Cantor (2008) has also reported that in the left and right temporal and parietal brain regions a decreased white matter volume in 44 male paedophiles compared to 53 subjects convicted for non-sexual crimes. Schiltz et al. (2007) further observed a decreased right amygdala volume in 13 male paedophiles compared to 15 controls (Bhugra et al., 2010). This abnormality arose early in life due to environmental or hormonal factors that were later associated with changes in sexual interest, with some of the changes resulting from life experiences such as being physically or sexually abused as children. This lead to abnormal sexual development later in adulthood, where results from these studies provided support for these factors motivating paraphilias.

Psychological factors[edit]

Psychological factors and theories are used to explain the mental well-being of an individual, as well as why an inbalance  in an individuals[grammar?] psychology can motivate paraphiliac behavior. These include theories such as Freud's theory of sexual development, early childhood abuse and trauma, maladaptive parenting, and emotional loneliness.

Freud's Theory of Sexual Development[edit]

Figure 5: Based on Freud's psychodynamic theory, paraphiliac motivations are the result of the ego repressing the id's sexual impulses during childhood development. The repressed impulses are then expressed later in adulthood, but in the form of unaccepted behaviors (e.g. paedophilia)

Freud's theory of sexuality attempts to explain the psychoanalytic motivations behind paraphilia. According to this theory, abnormal sexual behavior arises from abnormal psychological development related to sexual maturation. This is evident in Freud's stages of sexual development, where fixation at some stages results in abnormal sexual development in later life. Paraphiliac disorders further result from an individual's abnormal psychological development such as the id's repression of sexual impulses during childhood due to the superego. This causes the individual to act out these impulses in later stages of their development, which is then harmful (Thibaut et al, 2010).  For example, individuals who are sexually abused as children, are likely to develop paraphilia[factual?]. Their behavior is seen to result from the individual's discrepancy in thinking where they think they are raising awareness about sexual abuse through their behavior. This positive thinking then reinforces and further motivates this behavior. Due to this, paraphilias typically begin in childhood, and develop well into adolescence starting out as solitary behaviors such as frequently masturbating with paraphiliac fantasies, that develop into disorders such as exhibitionism and voyeurism (Seligman & Hardenburg, 2000).

Early childhood factors[edit]

Feierman and Feierman (2000) provided anecdotal evidence for life events occurring at around four to six years of age that influence the specific' development of a particular paraphilia. They further stated that most paraphilias develop before puberty. Results from Weinberg, Williams and Cahan (1995) also showed that their subjects reported being first erotically aroused by shoes at 12 years of age. Feierman and Feierman (2000) also highlighted that puberty coincides with the last major step of brain development and maturation of the neural synapses, which effects learned behavior, such as developing paraphiliac urges (Agnew, 2001). Furthermore, Maniglio’s (2010) review of seven studies examining the relationship between deviant sexual fantasies and sexual homicide suggested that a combination of early traumatic experiences (child abuse), deviant fantasy, and social/sexual dysfunction lead to an increased chance of wanting to engage in paraphiliac fantasies (Woodworth, Freimuth, Hutton, Carpenter, Agar & Logan, 2013). Additionally, results from a study in Sweden in 1996, found that 3.1% of participants reported being sexually aroused by exposing their genitals to a stranger, and 7.7% disclosed at-least one incident of being sexually aroused by spying on others having sex. These behaviours were related with ongoing psychological problems, such as lower satisfaction with life, and greater drug and alcohol use. Langstrom and Zucker (2005) further reported 2.8% of men and 0.4% of women having at-least one episode of transvestic fetishism. Again, separation from parents, same-sex sexual experiences, getting easily sexually aroused, pornography use, and higher frequency of masturbation were associated with this fetish and these individuals were also more likely to have been separated from parents in childhood, sexually abused, and reported other paraphiliac behaviors such as exhibitionism and voyeurism. 

Other psychological factors[edit]

Human sexual instincts can become fixated on targets, resulting in behaviours from harmless fetishism to child abuse (Gross, 2014). Hyde and DeLamater (1997) proposed three theories to explain the development of paraphiliac behaviour. The first is learning theory, which emphasizes that paraphiliac behaviour is a learned behaviour pattern due to positive reinforcement gained by repeating the behaviour. The second is cognitive disorder theory, which states that individuals engaging in paraphiliac behaviours have distorted cognitions that result in perceiving eccentric objects as arousing. The third is compulsive behaviour theory, which states that a sexual addiction is like a drug addiction, where the individual develops a need towards engaging in the behaviour and is driven towards repeating it (Marshall, 2007).

Berridge and Kringlebach (2008) also state that brain mechanisms of affect, motivation, and emotion are influenced by developmental experiences. Pleasure requires the activity of hedonic brain systems to give a "hedonic gloss" onto a sensation to make it liked. They saw this as consistent, as pleasure's role has a "reward" sensation attached to it. Thus some stimuli have a greater ability to generate pleasure or displeasure than others, which is consistent with survival and procreation. They stated that the pleasure derived from engaging in and acting out paraphiliac fantasies is rewarding from both a behavioural and cognitive view, as it satisfies paraphiliacs urges. This further reinforces this behaviour. Disruption of neural systems such as the orbitofrontal cortex and other systems (e.g. dopamine) and structures (e.g. subcrtical[spelling?]) is also linked to paraphilia. In a case study involving two paraphilics, Casanova, Mannheim, and Kruesi (2002) found pathological changes in the hippocampus similar to those reported after persistent stress or long-term chronic glucocorticoid administration in a case study (Jordan et al., 2011).

Furnham & Haraldsen (1998) also suggests that paraphilia develops from a combination of intertwining factors. These include cognitive dissonance, fear of the opposite sex, and sexual abuse as a child, having dominating parents, and brain or nervous system damage. Their research showed that parent abandonment in childhood accounted for 50% variance to develop paraphilia. They proposed this phenomenon could be due to the individual trying to increase awareness of childhood abuse and implications for interpersonal relationships later in life, which in turn motivates their paraphilic behavior. Furthermore, factors such as repressed emotions in childhood and a lack of empathy accounted for 10% variance and biological and physiological factors accounted for 7%. Other findings provided support for childhood onset for a wide range of paraphilias, including rubber fetishism, cross-dressing, apotemnophilia, and acrotomophilia (Cantor, 2012).

Social factors[edit]

Social factors explain motivation and causation of a behavior through things that affect lifestyle, such as cultural norms, religion and morals, and family expectations. This section addresses these factors and how they motivate paraphilic behaviors.

Figure 6: Paraphilia is more common in individualistic in contrast to collectivist cultures.

Cultures mediate what is normal and what is deviant, with normality varying across cultures. Characteristics of society play important roles in paraphilia. Paraphilias are common in egocentric and sex-positive cultures where sexual intercourse is practiced for pleasure and arousal is a predominant theme (Bhugra, Popelyuk & McMullen, 2010). Paraphilias can be seen as culture-bound syndromes. Sexual behaviors in the non-procreative tradition differ across partners; depend on the availability of partners, fantasies, and opportunities; and are influenced by cultural norms, morals, religion, types of societies, and expectations of its members. Societies that stress egocentric or individualistic values, social mores are more likely to be constrained by legal factors than norms, thereby making paraphilias appear more common because they are more likely to be reported to and seen by clinicians. Hofstede (1980, 1984) broadly divided cultures into sociocentric (collectivist) or egocentric (individualistic), where he observed that sociocentric cultures are integrated into strong cohesive in-groups, and egocentric cultures emphasize individualism. Hofstede (2001) stated that cultures with specific combinations of his five dimensions pose greater risk for fetishes and other problem-related sexual behaviors. Cultures that are masculine, individualistic, have low power distance, have low short-term orientation, and have low uncertainty avoidance may present a combination of conditions to motivate paraphiliac behaviour (Bhugra et al., 2010).

Case study analysis: Paraphilia

The accused's father was bad-tempered and cruel to animals. His mother drank excessively and deserted his father. He was traumatized when his father assaulted his mother. At 12 years of age he had intercourse with a woman of 18 or 19 and thereafter he had frequent intercourse with women. When he was 7 or 8 he had a homosexual experience. He exposed his person to native women and had intercourse with them. He masturbated, and during the act pictured himself as having intercourse with a woman and then strangling her, or driving her over a cliff in a car, or stabbing her to death. He shot his own dog and killed two house cats, one by hanging and the other by throwing a pair of pliers at it, in both cases he cut the corpse of the cat to pieces with a knife. These acts of killing made him feel excited. Later he also smothered a cat that used to lie on his bed, an act which gave him a feeling of excitement which he described as a nice feeling. At the age of 15 he used to telephone women and asked them to have intercourse with him. On a few occasions he aroused feelings of excitement in himself by dressing as a woman. He started drinking wine and beer at age 14 and the effect of liquor was to arouse a desire for intercourse with women accompanied by an urge to do violence to them. One evening he filled a handkerchief with sand and prowled about the lonely streets looking for an unprotected woman in order to assault her with his sandbag and then to have intercourse with her. He raped a native woman in a field near a station (Bianchi-Demicheli, Rollini, Lovblad & Ortigue, 2010). 

This case study integrated the research and theories mentioned in this chapter, providing support that motivations for paraphilia stem from a combination of biopsychosocial factors. The paraphilias evident in this case study were sexual sadism, rapism, lust murderism, transvestic fetishism, and telephone scatophilia that were the result of not one, but several factors evident throughout the paraphilics childhood which further developed into adulthood.

Treatment[edit]

Paraphilics sometimes develop a tolerance or a need to increase the frequency and intensity of the behaviors and may experience withdrawal if they do not yield to their urges to perform the behaviors (Seligman & Hardenburg, 2000). Treatment for paraphilia aims to target a number of factors that contribute to the behavior. These include insecure attachment styles, lack of intimacy and empathy, emotional loneliness, poor self-regulation, sexual preoccupation, deviant sexual interests, emotional congruence with children, lack of concern for others, attitudes supportive of sexual offending, and hostility toward women (Marshall & Marshall, 2015).  Although research on treatment options is on-going, the following treatments have yielded somewhat positive results in managing paraphilic fantasies and behaviors.

Biological treatments[edit]

Biological treatments are used to treat severe paraphilias. Guay (2009) provided an in-depth review of the clinical pharmacology of the main antiandrogens used in the treatment of the paraphilias. Animal studies showed that serotonin and prolactin inhibit sexual arousal, while norepinephrine, dopamine, acetylcholine, enkephalins, oxytocin, gonadotropin-releasing hormone, follicle-stimulating hormone, luteinizing hormone, testosterone/dihydrotestosterone, and estrogen/progesterone stimulate it. Thus pharmacologic treatments of paraphilias have serotonin and testosterone/dihydrotestosterone as their targets. 

Another biological approach involved is the use of luteinizing hormone releasing hormone agonists. These are used to reduce testosterone levels resulting in the individual to dissociate with carrying out their paraphilic behaviour. Furthermore, the use of psychotropic medications such as selective serotonin reuptake inhibitors (SSRIs), benperidol, thioridazine, clomipramine, and lithium have also been used in the reduction in male libido as a treatment alternative to surgical castration. However, a combination of cognitive behavioral therapy and anti-libido medication provided within a psychotherapeutic frameworks has been the most effective for paraphilias (Thibaut et al., 2010).  

However, in recent work medication has been used to help paraphilics by reducing the strength and decreasing motivation to carry out their urges, which helps the individual to control these latter urges in the presence of triggers and cues that provoke the desires. The drugs commonly used are medroxyprogesterone acetate and cyproterone acetate. Cyproterone acetate, widely used in Canada, the UK and Europe, is an anti-androgen which combines a specific blocking of androgen effects with an anti-gonadotrophic action. Both of these reduce the male sexual drive, as demonstrated by a reduction of erections, sexual fantasies, masturbation and other self-initiated sexual behaviors (de Silva, 2007).

Psychological and Cognitive treatments[edit]

Psychodynamic or insight-oriented treatment seeks to help people resolve their childhood experiences and current issues that maintain the paraphilic behavior (Kaplan et al., 1994). This approach to also seeks to help improve impulse control, interpersonal skills, and self-esteem so that healthier routes to sexual gratification can be developed. Cognitive-behavioral techniques also are widely used in treating paraphilias. These techniques include identification of erotic triggers and substitution of alternative behaviors, stress reduction, and aversion therapy that pairs paraphilic urges with negative experiences, such as electric shocks or unpleasant odors, covert extinction in which the paraphilic behavior is imagined but without the anticipated reinforcement or positive feeling, orgasmic reconditioning, thought stopping, cognitive restructuring, and encouragement of empathy for the victim. Improvement of social and assertiveness skills as well as education on sexuality and relationships can encourage people to engage in more appropriate and peer-oriented activities. Group counseling with these individuals is also vital as it offers people the opportunity to reduce their isolation, to learn and practice communication skills, to have models for coping with their urges, and to be confronted and encouraged by people who have similar difficulties. Fear of closeness, secrecy, and shame related to paraphilic behaviors also can be reduced by participation in group counseling (de Silva, 2007). Furthermore, another technique called orgasmic reconditioning involves reinforcing non-paraphiliac arousal and desires. During this technique, the individual is asked to masturbate with his paraphilic fantasies. When orgasm is imminent, the individual switches to a fantasy of a more accepted sexual stimulus. The ensuing orgasm then powerfully reinforces the non-paraphilic desire. (de Silva, 2007).

Quiz questions[edit]

  • To help consolidate the knowledge read

Choose the correct answers and click "Submit":

1

How many types of paraphilias exist?

11
9
4

2

Sexual sadism can be defined as

recurrent, intense, sexually arousing fantasies, sexual urges or behaviours involving acts (real, not simulated) in which the psychological or physical suffering (including humiliation) of the victim is sexually exciting to the person
sexual urges of observing an unsuspecting person
feet fetish

3

Biological treatments for paraphilia have utilized

serotonin and prolactin for inhibiting arousal
serotonin and testosterone as their main pharmacological treatments
resolving individuals childhood experience that involve paraphiliac behavior

4

Etiology for paraphilias

have only supported cultural factors that motivate paraphiliac behaviors
is explained using a combination of biopsychosocial factors
cannot be explained by anything


Conclusion[edit]

This chapter addressed the key motivators for paraphilias. Research showed that paraphilia stems from a biopsychosocial factors, with not one factor completely explaining this behavior. Paraphilics are motivated to engage in and continue their behavior because they associate this behavior with this positive feelings and outcomes. Moreover, engaging in such behavior provides immediate gratification for their abnormal sexual fantasies and urges, which in turn reinforces and motivates them to keep engaging in this behavior as a solution to their sexual impulses. While evidence is still limited on what factors or antecedents motivate paraphilias, there are reliable treatment options for managing paraphiliac urges. These included biological, psychological, and cognitive treatments.

See also[edit]

References[edit]

Abdullahi, H., Jafojo, R. O., & Udofia, O. (2015). Paraphilia among undergraduates in a nigerian university. Sexual Addiction & Compulsivity, 22(3), 249-257. doi:10.1080/10720162.2015.1057662

Ahlers, C. J., Schaefer, G. A., Mundt, I. A., Roll, S., Englert, H., Willich, S. N., & Beier, K. M. (2011). How unusual are the contents of paraphilias? paraphilia-associated sexual arousal patterns in a community-based sample of men. The Journal of Sexual Medicine, 8(5), 1362.

Agnew, J. (2001). An overview of paraphilia. Venereology, 14(4), 148-56.

Beech, A. R., & Harkins, L. (2012). DSM-IV paraphilia: Descriptions, demographics and treatment interventions. Aggression and Violent Behavior, 17(6), 527-539. doi:10.1016/j.avb.2012.07.008

Bianchi-Demicheli, F., Rollini, C., Lovblad, K., & Ortigue, S. (2010). "sleeping beauty paraphilia": Deviant desire in the context of bodily self-image disturbance in a patient with a fronto-parietal traumatic brain injury. Medical Science Monitor : International Medical Journal of Experimental and Clinical Research, 16(2), CS15.

Bhugra, D., Popelyuk, D., & McMullen, I. (2010). Paraphilias across cultures: Contexts and controversies. Journal of Sex Research, 47(2-3), 242-256. doi:10.1080/00224491003699833

Carstens, P., & Stevens, P. (2016). Paraphilia and sex offending - A south african criminal law perspective. International Journal of Law and Psychiatry, 47, 93-101. doi:10.1016/j.ijlp.2016.02.04

de Silva, P. (2007). paraphilias. Psychiatry, 6(3), 130-134. doi:10.1016/j.mppsy.2006.12.009

Fedoroff, J. P., Di Gioacchino, L., & Murphy, L. (2013). Problems with paraphilias in the DSM-5. Current Psychiatry Reports, 15(8), 1-6. doi:10.1007/s11920-013-0363-6

Furnham, A., & Haraldsen, E. (1998). Lay theories of etiology and "cure" for four types of paraphilia: Fetishism; pedophilia; sexual sadism; and voyeurism. Journal of Clinical Psychology, 54(5), 689.

Gross, M. (2014). Paraphilia or perversion? Current Biology : CB, 24(17), R777-R780. doi:10.1016/j.cub.2014.07.047

Guay, D. R. P. (2009). Drug treatment of paraphilic and nonparaphilic sexual disorders. Clinical Therapeutics, 31(1), 1-31. doi:10.1016/j.clinthera.2009.01.009

Jordan, K., Fromberger, P., Stolpmann, G., & Müller, J. L. (2011). The role of testosterone in sexuality and paraphilia--a neurobiological approach. part I: Testosterone and sexuality. The Journal of Sexual Medicine, 8(11), 2993.

Marshall, W. L., & Marshall, L. E. (2015). Psychological treatment of the paraphilias: A review and an appraisal of effectiveness. Current Psychiatry Reports, 17(6), 1-6. doi:10.1007/s11920-015-0580-2

Marshall, W. L. (2007). Diagnostic issues, multiple paraphilias, and comorbid disorders in sexual offenders: Their incidence and treatment. Aggression and Violent Behavior, 12(1), 16-35. doi:10.1016/j.avb.2006.03.001

Seligman, L., & Hardenburg, S. A. (2000). Assessment and treatment of paraphilias. Journal of Counseling & Development, 78(1), 107-113. doi:10.1002/j.1556-6676.2000.tb02567.x

Thibaut, F., Barra, F. D. L., Gordon, H., Cosyns, P., Bradford, J. M. W., WFSBP Task Force on Sexual Disorders, & the WFSBP Task Force on Sexual Disorders. (2010). The world federation of societies of biological psychiatry (WFSBP) guidelines for the biological treatment of paraphilias. World Journal of Biological Psychiatry, 11(4), 604-655. doi:10.3109/15622971003671628

Wakefield, J. C. (2011). DSM-5 proposed diagnostic criteria for sexual paraphilias: Tensions between diagnostic validity and forensic utility. International Journal of Law and Psychiatry, 34(3), 195-209. doi:10.1016/j.ijlp.2011.04.012

Woodworth, M., Freimuth, T., Hutton, E. L., Carpenter, T., Agar, A. D., & Logan, M. (2013). High-risk sexual offenders: An examination of sexual fantasy, sexual paraphilia, psychopathy, and offence characteristics. International Journal of Law and Psychiatry, 36(2), 144-156. doi:10.1016/j.ijlp.2013.01.007

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