Understanding paraphilias including paedophilia
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Establish Session Values
What will make this class a safe space for everyone to talk, share and discuss freely? Talk about things that are close to our heart? Things that bother us to make us sad? How do we want others to behave? How will we behave? How can we make it easy for all of us to understand as well as enjoy these sessions together? Some values - based off behaving - that may support us in sharing and discussing openly are:
Listening to each other with respect
Speaking with respect for each other
Trust each other
Any other value on which we all want to mutually agree?
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Paraphilia - what is it?
What’s true?
Paraphilias = unusual / atypical sexual behaviour
Paraphilia = mental disorder
Paraphilia = criminal sexual acts
Paraphilia = curable disease
Paraphilia (n.) Greek para- "beside, aside" (see para- (1)) + philos "loving" (see -phile)
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Beliefs around paraphilia
Prevailing socio- cultural beliefs | DSM Classification | What is included |
Sexual deviations are unlawful, criminal acts | prior to DSM-I "psychopathic personality with pathologic sexuality" | |
Sexual deviations are a personality disorder - not psychotic | DSM-I (1952) - personality disorder of sociopathic subtype. - not symptomatic of more extensive syndromes like schizophrenia. �The DSM-II (1968) - “personality disorders and certain other nonpsychotic mental disorders.” | DSM-I "homosexuality, transvestism, pedophilia, fetishism, and sexual sadism, including rape, sexual assault, mutilation ��DSM II sexual orientation disturbance (homosexuality), fetishism, pedophilia, transvestitism, exhibitionism, voyeurism, sadism, masochism, and "other sexual deviation". |
Psychosexual disorders. | DSM-III - the term paraphilias was introduced | The DSM-III-R (1987), provided seven nonexhaustive examples of NOS paraphilias, zoophilia. telephone scatologia, necrophilia, partialism, coprophilia, klismaphilia, and urophilia. |
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Beliefs around paraphilia
Prevailing socio- cultural beliefs | DSM Classification | What is included |
Sexual and gender identity disorders | The DSM-IV (1994) retained the sexual disorders classification for paraphilias, but added an even broader category. | DSM-IV-TR names 8 disorders: exhibitionism, fetishism, frotteurism, pedophilia, sexual masochism, sexual sadism, voyeurism, and transvestic fetishism, plus paraphilia—NOS not otherwise specified |
Sexual interest, sexual rights, rights of others, harm | DSM-5 (2013): distinction between paraphilias and paraphilic disorders. paraphilias do not require or justify psychiatric treatment in themselves. �Disorder - when it is currently causing distress or impairment to the individual or a paraphilia whose satisfaction has entailed personal harm, or risk of harm, to others | Names 8 disorders - exhibitionistic disorder, fetishistic disorder, frotteuristic disorder, pedophilic disorder, sexual masochism disorder, sexual sadism disorder, transvestic disorder,voyeuristic disorder. |
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The term paraphilia
In DSM-5 the term paraphilia is defined as “any intense and persistent sexual interest other than sexual interest in genital stimulation or preparatory fondling with phenotypically normal, physiologically mature, consenting human partners.”
People with paraphilias have recurrent, intense sexually arousing fantasies, sexual urges, or behaviours that generally involve:
Non-human objects
The suffering or humiliation of oneself or one’s partner, or
Children or other non-consenting persons
Paraphilias - where the preferred sexual interest(s) are greater than nonparaphilic sexual interests.
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Disorder vs Behaviour
DSM V - paraphilic disorders includes eight conditions:
exhibitionistic disorder,
fetishistic disorder,
frotteuristic disorder,
pedophilic disorder,
sexual masochism disorder,
sexual sadism disorder,
transvestic disorder,
voyeuristic disorder.
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Paraphilic disorder
DSM-5 requires that the person to
…feel personal distress about their interest, not merely distress resulting from society’s disapproval;�or
…have a sexual desire or behavior that involves another person’s psychological distress, injury, death, �or
…have a desire for sexual behaviors involving unwilling persons or persons unable to give legal consent.
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Paedophilia, paedophilic disorder
A
B
According to DSM V (APA 2013) :�Paedophilia (criteria A only) and Paedophilic disorder (where criteria A and B are met)
Paedophilia may be:
exclusive (attracted to children alone) or non exclusive (attracted to children and adults)
attracted to females, or males or both.
An adult, for at least 6 months has recurrent, intense sexual urges or fantasies about sexual activity with a pre-pubescent (less than 14 years old) child(ren). (acting on these desires is not necessary for the diagnosis)
The individual has acted on the sexual urges or the fantasies or urges cause marked distress or interpersonal difficulties.
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Paedophilia
Paedophilia is defined by body maturity, not the age, of the preferred partner.
Paedophilia frequently involves fondling or manipulation of the child’s genitals and occasionally penetration.
Injuries may result from the sexual act - and are usually a by product rather than the goal.
Pedophilia - primary or exclusive sexual interest in prepubescent children - (the DSM-5 extends the prepubescent age to 13) .
Hebephilia is the strong, persistent sexual interest by adults in pubescent children who are in early adolescence, typically ages 11–14 and showing Tanner stages 2 to 3 of physical development.
Pedohebephilia - attracted to both above
Ephebophilia is the primary sexual interest in mid-to-late adolescents, generally ages 15 to 19. Partly because puberty varies, some definitions show overlap between pedophilia, hebephilia and ephebophilia. For example, the DSM-5 extends the prepubescent age to 13, the ICD-10 includes early pubertal age in its definition of pedophilia and some definitions of ephebophilia include age 14.
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Paedophilia and child sexual abuse
All perpetrators of child sexual abuse are not pedophilic.
Many pedophilic persons do not sexually abuse children. They manage their sexual urges towards children in other ways.
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The difference between pedophilia and child sexual abuse
Pedophilia
Child Sexual Abuse
Research is tilting towards considering pedophilia as an orientation - it describes the sexual interest in children and/ or adolescents
Child sexual abuse is a behaviour
Many have feelings of guilt about their sexual urges and fantasies.
It is illegal and harmful -involves physical or psychological coercion or at least one individual who cannot reasonably consent to the act.
Distress often extends to and affects their personal, social and occupational life and relationships
The perpetrator usually does not feel guilt/ distress
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The difference between pedophilia and child sexual abuse
Pedophilia
Child Sexual Abuse
Many persons with paedophilia never act out on their impulses and abstain from abusing a child
Perpetrators groom children
Sexual activity with a person in late adolescence may not concern a person with pedophilic disorder
Includes actions performed by people with pedophilic disorder
Defined by body maturity (for instance, Tanner’s stages of pubertal changes), and not the age of the sexual partner
Defined by age of the child, not body maturity
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Pedophilia - a sexual orientation?
(Are paedophiles' brains wired differently? 24 November 2015, BBC News Source�Cornwell, R. E., Law Smith, M. J., Boothroyd, L. G., Moore, F. R., Davis, H. P., Stirrat, M., Tiddeman, B., & Perrett, D. I. (2006). Reproductive strategy, sexual development and attraction to facial characteristics. Philosophical transactions of the Royal Society of London. Series B, Biological sciences, 361(1476), 2143–2154. https://doi.org/10.1098/rstb.2006.)
"It's as if, in these people, when they perceive a child, it's triggering the sexual instincts instead of triggering the nurturing instincts," says Dr. Cantor.
According to Dr James Cantor, of the Centre for Addiction and Mental Health in Toronto, Canada, "Paedophilia is something that we are essentially born with, does not appear to change over time and it's as core to our being as any other sexual orientation is". Cornwell et al studied brain MRI scans of pedophiles and non-paedophiles and found that:
There were differences in the neural networks of paedophilic individuals as compared to non-pedophiles.
There seemed to be "cross-wiring" in the brain.
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Face perception and motivation in humans
J. Ponseti, O. Granert, T. van Eimeren, O. Jansen, S. Wolff, K. Beier, G. Deuschl, H. Bosinski and H. Siebner �Published:01 May 2014https://doi.org/10.1098/rsbl.2014.0200
Human faces depict age cues including cues to sexual maturity. �This stimulates the appropriate reproductive behaviour: either caretaking (nurturing) or mating (sexual behaviour) when adults see a child or an adult face, respectively. (J Ponseti et al)
Human face processing is tuned to sexual age preferences. Brain networks that normally are tuned to mature faces of the preferred gender show an abnormal tuning to sexual immature faces in paedophilia.
They used (fMRI) to test for the existence of a network which is tuned to face cues of sexual maturity. During fMRI, participants sexually attracted to either adults or children were exposed to various face images. In individuals attracted to adults, adult faces activated several brain regions significantly more than child faces. These brain regions comprised areas known to be implicated in face processing, and sexual processing. The same regions were activated in paedophiles, but with a reversed preferential response pattern.
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Neurotransmitters in pedophilic disorder
Pedophilic sex offenders are characterised by reduced GABA concentration in dorsal anterior cingulate cortex - Author links open overlay pane lInkaRistowabMengLiacLejlaColicabVanessaMarrabCarinaFödischabFeliciavon DüringabKoljaSchiltzdmKrasimiraDrumkovaeJoachimWitzeleHenrikWalterfKlausBeiergTillmann H.C.KrugerhJorgePonsetiiBorisSchifferjkMartinWalterabclmno
A pedophilic disorder is characterised by abnormal sexual urges towards prepubescent children.
Child abusive behavior is frequently a result of lack of behavioral inhibition
Authors studied if there is decreased inhibitory neurotransmitters - GABA - in brain regions involved in attentional control of behavior and perception of salient stimuli in 13 pedophilic sex offenders and 13 matched controls
In a region related to cognitive control and salience mapping, pedophilic sex offenders showed reduction of the inhibitory neurotransmitter GABA which may be seen as a neuronal correlate of inhibition and behavioral control.
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A person with pedophilia
(Are paedophiles' brains wired differently? 24 November 2015, BBC News)
Person with paedophilia
…often feels guilty about their sexual urges and fantasies
…faces the possibility of social rejection
…carries the burden of disclosing/ seeking help.
… feel their orientation affects their personal, social and occupational life and relationships
“People, they think 'why should we help the paedophile? We should be prosecuting them, throwing them in jail, having them castrated'. But if we offer help to paedophiles we might save children who might have been abused.”
- Paul Jones, father of April Jones who was abducted and murdered by a paedophile in October 2012.
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KEMHRC – Primary Prevention Program
The KEM Hospital Research Centre (KEMHRC) offers ‘Programme for Primary Prevention of Sexual Violence (PPPSV)’, providing treatment for individuals sexually attracted towards children.
The programme has been culturally and socio-legally adapted from ‘Prevention Project Dunkelfeld’ (PPD) introduced in 2005 by Klaus Beier, Charité University Clinic, Germany. For the past 12 years, PPD has been successfully working towards providing assessment and treatment to individuals with a sexual interest in children.
The initiative aims at providing assessment and treatment for persons with a sexual interest in children and/ or young adolescents who have just entered puberty.
Studies conducted abroad specify that possibly one in a hundred persons might have paedophilic characteristics.
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KEMHRC Primary Prevention – public awareness through advertisements
Troubled Desire offers online self-management for people who feel attracted to children and early adolescents and don't have the chance to get in real contact with therapists. They would like to alleviate the distress experienced by those who have a sexual attraction towards children or young adolescents and to ultimately prevent child sexual abuse and the use of child abuse images.
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KEMHRC - treatment
It is our basic understanding that no person with pedophilia and/or hebephilia has chosen their sexual preference and that an offence-free life with pedophilia/hebephilia is possible. We believe that no one is guilty for their desires, but everyone is responsible for their behaviour.
In person treatment is currently available in two cities; Pune (KEM Hospital Research Centre) and Mumbai (individual therapists). It is completely confidential and free of cost. The goal of the therapy is to overcome problems in dealing with one's sexual preference. Especially noteworthy is the ability to control one's behavior in such a way that sexual offences against children are entirely avoided.
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KEMHRC - treatment
The treatment takes place in individual sessions. It follows a structured therapy plan, It integrates sexological and psychological approaches as well as the option of medication when necessary and wished for by the participant. In addition, the individual can decide to involve the partner, friends or family members.
Some components of the therapy include:
Having an appropriate perception and evaluation of sexual desires and needs
Developing the ability to identify and cope with risky situations
Improving interpersonal relationships
Improving quality of life
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Fetishism
Fetish (n.) "material object regarded with awe as having mysterious powers..," 1610s, Portuguese feitiço "charm, sorcery, allurement," noun use of an adjective meaning "artificial."
Almost any body part or object can be a Fetish - hair, ears, hands, underclothing, shoes, perfume, and similar objects associated with the opposite sex.
The mode of using these objects to achieve sexual excitation and gratification varies considerably, but it commonly involves masturbating while kissing, fondling, tasting, or smelling the objects.
Fetishistic Disorder - a diagnosis under DSM 5:
For at least 6 months, recurrent, intense sexually arousing fantasies, urges, or behaviours involving the use of non-living objects or a specific part of the body which is not typically regarded as erotic.
The fantasies, urges, or behaviours cause distress or impairment in functioning
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Transvestic disorder
Transvestic disorder - identifies people who are sexually aroused by dressing as the opposite sex but who experience significant distress or impairment in their lives—socially or occupationally—because of their behavior.
DSM-IV limited this behavior to heterosexual males; DSM-5 has no such restriction, opening the diagnosis to women or gay men who have this sexual interest.
Transvestite - 1920s: from German Transvestit, from Latin trans- ‘across’ + vestire ‘clothe’.
Magnus Hirschfeld coined the word transvestite in 1910 to refer to the sexual interest in cross-dressing. He used it to describe persons who habitually and voluntarily wore clothes of the opposite sex.
DSM 5
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Frotteurism
"Frottage" derives from the French verb frotter, meaning "to rub". The term frotteur, originally meaning "floor polisher", entered police jargon around 1882. ... Clifford Allen later coined frotteurism in his 1969 textbook of sexual disorders.
Frotteurism is a paraphilic interest in rubbing, usually one's pelvic area or erect penis, against a non-consenting person for sexual pleasure. It may involve touching any part of the body, including the genital area.
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Sadism, Masochism
Masochism - the tendency to derive sexual gratification from one's own pain or humiliation. late 19th century: named after Leopold von Sacher-Masoch (1835–95), the Austrian novelist who described it.
sadism (n.) "love of cruelty," 1888, from French sadisme, from the name of Count Donatien A.F. de Sade (1740-1815) notorious for cruel sexual practices he described in his novels.
Sadism - The enjoyment of inflicting pain without pity.
DSM 5 - Sexual Sadism - the person experiences persistent and intense sexual arousal from causing or fantasizing about the physical or mental suffering of another person, with or without their consent.
BDSM - includes various sexual practices or roleplaying that have elements of bondage or discipline, dominance and submission, sadomasochism, and other related interpersonal dynamics. Consent, safety precautions are essential. It is not a clinical diagnosis - people self-identify.
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What causes paraphilias?
Male greater vulnerability to paraphilias - greater dependence on visual sexual imagery, and physical stimulus than emotional context as compared to females
Usually begin around puberty. More in men than in women.
Result of classical and instrumental conditioning and/or social learning that occurs through observation and modelling.
Classical conditioning - Pavlov’s reflex / avoiding dentists!
Instrumental conditioning - a voluntary response is strengthened �or weakened, depending on its favourable or unfavourable consequences
Conditioning explains many of the reactions we have to stimuli in the world around us - you might have a particular fondness for the smell of a certain perfume or aftershave lotion because the feelings and thoughts of an early lover come rushing back whenever you encounter it
Fetishism - Pavlovian association between an erotic sensation or anticipation, and objects which become mentally associated with that activity.
Neurological differences - region processing sensory input from the feet are right next to the region processing genital stimulation. ?link between these regions - foot fetishism.
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Management: reducing distress, preventing crime
Current understanding - The content of paraphilia is neurobiological - and cannot be changed. Aim - reduce discomfort/ distress and prevent criminal behaviour. Person rarely seeks help unless someone becomes an unwilling partner or is injured
Psychotherapy - first choice
Pharmacological agents (medicines)
SSRIs - Selective serotonin reuptake inhibitors (SSRIs) reduce sexual arousal, compulsivity, and depressive symptoms - exhibitionists, non-offending pedophiles, and compulsive masturbators.
Antiandrogens / MPA / GnRH Agonists in more severe cases; they work by reducing androgen levels - has been shown to substantially reduce sexual fantasies and offending behaviors.Due to the side effects, the World Federation of Societies of Biological Psychiatry recommends that hormonal treatments only be used when there is a serious risk of sexual violence, or when other methods have failed.
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Psychotherapy
Some of the effective interventions are:
Cognitive-behavioural therapy (CBT)
develop strategies to avoid acting on their interests.
identify and cope with factors that make acting on their interests more likely, such as stress.
Orgasmic reconditioning
person is instructed to masturbate to their typical stimulus. Just before orgasm, the person is told to concentrate on a more acceptable fantasy
Social skills training
working on issues such as developing intimacy, carrying on conversations with others
Group therapy
helps individuals break through the denial
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Slide 4
This PowerPoint is part of a project to prevent gender based violence. This project is supported by Ford Foundation.
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Slide 9
Thank You!
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