ArticlePDF Available


Atypical sexual behavior is intriguing to many people, yet the empirical research on paraphilia and fetishism is relatively lacking. Nonetheless, clinicians are often called on to intervene in such cases, particularly when the paraphilia involves nonconsenting partners. This review article is structured around a brief historical overview of the diagnostic classification of atypical sexual behavior in the United States, descriptions of the types of atypical sexual behavior that receive clinical attention, an overview of the models that have been proposed to explain the development of atypical sexual behavior, and finally a summary of the most common treatments for these problems.
The Family Journal
DOI: 10.1177/1066480703252663
2003; 11; 315 The Family Journal
Michael W. Wiederman
Paraphilia and Fetishism
The online version of this article can be found at:
Published by:
On behalf of:
International Association of Marriage and Family Counselors
can be found at:The Family Journal Additional services and information for Email Alerts: Subscriptions:
© 2003 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.
by Michael Wiederman on August 17, 2007 http://tfj.sagepub.comDownloaded from
v Sex Therapy
Paraphilia and Fetishism
Michael W. Wiederman
Columbia College
Atypical sexual behavior is intriguing to many people, yet the empir-
ical research on paraphilia and fetishism is relatively lacking. None-
theless, clinicians are often called on to intervene in such cases,
particularly when the paraphilia involves nonconsenting partners.
This review article is structured around a brief historical overview of
the diagnostic classification of atypical sexual behavior in the
United States, descriptions of the types of atypical sexual behavior
that receive clinical attention, an overview of the models that have
been proposed to explain the development of atypical sexual behav-
ior, and finally a summary of the most common treatments for these
Keywords: paraphila; fetishism; sexuality; sex therapy
exual deviance has long held the public’s attention and
roused people’s curiosity. People seem forever intrigued
by what peculiar sexual activities others might perform. If
you find yourself reading this article at the expense of other
articles in this issue of the journal, perhaps it is because of the
curiosity surrounding this topic, and it just shows you are
human. Given the apparently high human interest, it might
seem plausible that a large army of researchers would be
working to further the collective understanding of sexual
deviance. It might be surprising, then, to learn the reality. Rel-
atively little empirical work has been done regarding unusual
sexual activities and preferences, and precious little is known
for sure in this area. Perhaps part of the reason for the compar-
ative lack of research attention is the common assumption
that sexuality researchers investigate topics of personal rele-
vance, and presumably few researchers want to be thought of
as sexual deviants (Okami, 2002).
The phenomena reviewed here fall under the Diagnostic
and Statistical Manual of Mental Disorders (DSM) (Ameri-
can Psychiatric Association [APA], 1952, 1980, 1987, 1994)
classification of atypical sexual behavior. The term sounds
generic and seems to refer to sexual behavior that is statisti-
cally in the minority. However, there is more to the story. Cer-
tainly, there are many sexual behaviors that are not part of the
statistical norm as to what people tend to “do” sexually. The
key to being a disorder is that the sexual behavior in question
results in subjective distress or impairment in the individual’s
functioning or it involves nonconsenting partners. In practice,
the diagnosis of atypical sexual behavior can be ambiguous
and controversial. The remainder of this article is structured
around a brief historical overview of the diagnostic classifica-
tion of atypical sexual behavior in the United States, descrip-
tions of the types of atypical sexual behavior that receive clin-
ical attention, an overview of the models that have been
proposed to explain the development of atypical sexual
behavior, and finally a summary of the most common treat-
ments for these problems.
The term paraphilia was coined by Stekel (1924). The first
part of the word, para, translates as “other” or “outside of, as
in the term paranormal, and philia is defined as “loving. So,
the term paraphilia translates loosely into loving something
outside of the norm or love of the perverse. Of course, one can
ask, “What does love have to do with it? Aren’t we talking
about lust or sex?” Perhaps the term paraphilia is a misnomer.
Moser (2001) proposed that a more accurate term would be
paralagnia, because lagnia translates into “lust. In any case,
the term paraphilia was popularized by Money (1980, 1984)
as a nonpejorative designation for unusual sexual interests
and became part of the DSM in the 1980 edition (APA, 1980).
Some writers have pointed to the potentially dubious
nature of paraphilia as a clinical diagnosis. For example,
Moser (2001) proposed that pathologizing atypical sexual
interests is merely a method of social control of sexual behav-
ior. There is little controversy over the observation that what
is considered normal or acceptable sexual behavior varies
according to the culture, historical period, dominant political
party, and so forth. Accordingly, the diagnosis of atypical sex-
ual behavior has undergone revision over the 50 years the
DSM has existed. In the first edition of the DSM (APA, 1952),
the diagnostic category was listed as “sexual deviation. Five
particular forms of sexual deviation were noted: homosexual-
ity, transvestism, pedophilia, festishism, and sexual sadism
(pp. 38-39). The second edition of the DSM (APA, 1968)
DOI: 10.1177/1066480703252663
© 2003 Sage Publications
© 2003 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.
by Michael Wiederman on August 17, 2007 http://tfj.sagepub.comDownloaded from
retained the designation “deviant sexuality” but now speci
fied the following: “This category is for individuals whose
sexual interests are directed primarily toward objects other
than people of the opposite sex, toward sexual acts not usually
associated with coitus, or toward coitus performed under
bizarre circumstances” (p. 44). What was considered
“bizarre” may very well have been a value judgment on the
part of the clinician, and presumably masturbation or oral sex
could have been included in this definition of “deviant sexual-
ity. Perhaps to qualify this assumption, there was the addi-
tional criterion that individuals experiencing sexual devia-
tions “remain unable to substitute normal sexual behavior for
them” (p. 44).
The third edition of the DSM (APA, 1980) included the
term paraphilia and emphasized that a defining characteristic
was that the “unusual or bizarre imagery or acts are necessary
for sexual excitement” (p. 266). In other words, the individual
with paraphila was defined by a reliance on deviant stimuli to
attain sexual arousal. By the time the third edition of the DSM
was revised (APA, 1987), however, research had shown that
individuals with diagnosed paraphilia were often responsive
to normative sexual stimuli as well (Moser, 2001). The crite-
rion that deviant sexual imagery or acts were necessary for
sexual arousal was dropped in favor of reference to a sexual
arousal pattern that is “not part of normative arousal activity
patterns and . . . may interfere with the capacity for reciprocal,
affectionate sexual activity” (APA, 1987, p. 279). Deter-
mining what “normative arousal activity patterns” are, and
then using those as the standard for making a judgment of sex-
ual deviance, was potentially problematic (McDougall,
The fourth edition of the DSM (APA, 1994) provided a
major change, and many might say an improvement (e.g.,
Moser, 2001), by specifying that “a paraphilia must be distin-
guished from the non-pathological use of sexual fantasies,
behaviors, or objects as a stimulus for sexual excitement” (p.
525). According to the fourth edition of the DSM (APA,
1994), the essential clinical features of paraphilia are
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) chil-
dren or other nonconsenting persons that occur over a period
of at least 6 months. (pp. 522-523).
The second criterion is that these fantasies, urges, or behav-
iors cause significant distress or functional impairment. Sev-
eral particular types of paraphilia are provided as specific
diagnoses. Each will be described in the next section.
An interesting feature of all of the forms of paraphilia is
that they are virtually the exclusive domain of males. Other
than biological sex, there are few characteristics that distin
guish individuals with and without paraphilia. All races and
socioeconomic groups are represented among those with
paraphilia, and the interest, if not the behavior, typically
appears fairly early in development (sometimes in childhood,
and usually by adolescence). The nature of the paraphilic fan-
tasies and behaviors typically becomes more elaborate by late
adolescence and early adulthood, and individuals commonly
experience more than one form of paraphilia (e.g., Freund &
Blanchard, 1986).
Another commonality among the various forms of
paraphilia is that the individual experiences the sexual inter-
ests as ego syntonic, or something inherent in his or her being.
In other words, individuals with paraphilia rarely experience
their sexual fantasies or urges as distressing. Instead, the fan-
tasies and urges feel natural. Of course, these individuals typi-
cally recognize that their sexual interests lie outside the norm
and may go to great lengths to conceal them. Treatment seek-
ing is generally precipitated by interpersonal or legal pres-
sure, and the individual is more or less forced to undergo
treatment because he or she has been caught. Also, the indi-
vidual in treatment is likely to experience strongly conflicting
feelings over the prospect of “losing” the paraphilia. On one
hand, life would be easier and the threat of discovery or prose-
cution would abate. However, loss of the paraphilia equates to
losing one’s sexuality and a tremendous source of motivation
and pleasure.
Given the compelling nature of the sexual urges, individu-
als with paraphilia may choose occupations or avocations to
increase their access to the objects or people needed to carry
out their paraphilia. For example, an individual may choose to
work in rental properties so as to have opportunities to “peep”
on unsuspecting people who may be nude or engaged in sex-
ual activity. Similarly, an individual with pedophilia may vol-
unteer to work with Boy Scouts or at a summer camp to
increase access to children of the preferred age. Even if the
paraphilia involves consenting partners or inanimate objects,
much time and energy might be spent locating potential part-
ners or locating and viewing pornography that depicts the
individual’s paraphilia.
Paraphilia involving nonhuman objects include fetishism
and transvestic fetishism. Fetishism in general refers to the
fixation on a nonliving object (such as a particular type of gar-
ment). According to the DSM (APA, 1994), the most common
fetishes involve women’s undergarments and shoes. A man
with the paraphilia may masturbate while rubbing or sniffing
the fetish object, or he may require that his partner wear the
object or in some way interact with it during sexual activity.
Typically, the fetish object is necessary or preferred for sexual
functioning. Absence of the object may result in lack of an
erection or ejaculation. Accordingly, many male actors in
pornographic films are presumed to have a fetish, which hap-
pens to aid in their occupational functioning. That is, having a
fetish allows the actor to engage in vaginal or anal intercourse
virtually indefinitely. When the director calls for the required
© 2003 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.
by Michael Wiederman on August 17, 2007 http://tfj.sagepub.comDownloaded from
ejaculation, the actor mentally focuses on imagery associated
with his particular fetish, thereby allowing him to become
aroused enough to achieve orgasm (Faludi, 1995).
Virtually any object has the potential to serve as a fetish,
and probably someone at some time has experienced just
about every conceivable object as his or her fetish. Steele
(1996, p. 26) lists some of the objects she encountered as
fetishes in her investigation: hairbrushes, artificial limbs,
safety pins, snails, cockroaches, whips, roses, eyeglasses, and
the handlebars of an Italian racing bike. Still, some objects are
much more likely to be a fetish than are others. For example,
garments are overwhelmingly the most common type of
fetish object (Steele, 1996). The individual may have a very
specific garment that he or she experiences as a fetish, with a
particular appearance or odor, or it may be the general texture
of the garment that is most important. Such garment fetishes
have been divided into two types: hard (leather, rubber) and
soft (fluffy or frilly). The hard fetish items tend to be tight,
constricting garments that are shiny and black, whereas the
soft fetish items tend to consist of lingerie or furs.
If the fetish involves sexual arousal in response to actually
wearing the traditional clothing of the other gender, the sepa-
rate diagnosis of transvestic fetishism is used. Although theo-
retically both men and women, straight or gay, may experi-
ence transvestic fetishism, in practice only heterosexual
males have been described as having this fetish (APA, 1994).
The public and mass media often confuse the motivations of
those individuals who may engage in cross-dressing. Individ-
uals with problematic gender identity issues may cross-dress
in an attempt to live (or “pass”) as a member of the other gen-
der, and hence the primary motivation is not sexual. In con-
trast, “drag queens” are typically gay men who dress as
women for the attention, aesthetic appeal, and dramatic
effect. Men experiencing transvestic fetishism tend to be tra-
ditionally masculine in their gender role identity and presen-
tation, and many are involved in long-term heterosexual rela-
tionships. These men may engage in cross-dressing to various
degrees and either consistently or only intermittently (e.g.,
during times of stress). Often the cross-dressing is accompa-
nied by fantasy in which the individual imagines being both
the male and female participants in sexual activity.
With regard to paraphilia based on humiliation or suffering
of oneself or one’s partner, the distinction is made between
sexual sadism, or sexual arousal in response to the infliction
of humiliation or pain on a partner, and sexual masochism, or
sexual arousal in response to being the target of humiliation or
pain from one’s partner. Importantly, clinical diagnosis is
reserved for those individuals whose paraphilic focus is on
actual (rather than simulated) sadistic or masochistic activity
(APA, 1994). Individuals who only role play sadomasochistic
activities are not deemed to experience this form of
paraphilia. The severity of the sadomasochistic acts needed to
achieve sexual arousal may remain stable over years or a life
time, but some individuals apparently need increasingly
strong stimuli over time to achieve the same sexual result.
Certain masochistic acts may be self-inflicted, but usually
sadomasochism involves finding a partner with similar inter
ests. Accordingly, an elaborate sadomasochistic (S/M) sub-
culture exists in the United States in which “bottoms” (mas-
ochists) look for “tops” (sadists). Also, S/M practitioners may
have specific preferences regarding mode of humiliation or
suffering. For example, he or she may find urinating on or
being urinated on by a partner to be arousing, whereas another
individual may focus on defecation. Other sadomasochistic
activities include binding, gagging, blindfolding, spanking,
whipping, choking, cutting, and piercing. Alternatively, an
individual could be forced to cross-dress and/or beg for sex-
ual access to one’s own body or one’s partner or could be
treated like an animal or infant, all of which could be experi-
enced as forms of subjugation or humiliation. Perhaps
because of the diversity of activities included in the S/M sub-
culture, practitioners are commonly tolerant of the prefer-
ences of other S/M devotees, even if they themselves do not
find a particular activity appealing (Moser, 2001).
The remaining DSM classifications of paraphilia (exhibi-
tionism, voyeurism, frotteurism, and pedophilia) share the
fact that they involve nonconsenting victims. Exhibitionism
(or “flashing” in common parlance) involves exposing one’s
genitals to an unsuspecting stranger. The individual might
masturbate during the exposure or replay the incident in his
head during a subsequent episode of masturbation. Common
fantasies among exhibitionists are that the unsuspecting
stranger will be shocked or will become sexually aroused and
desirous of sexual activity with the exhibitionist (APA, 1994).
Voyeurism (or peeping) is exhibitionism’s complementary
form of paraphilia with the exception that sexual arousal
occurs in response to watching an unsuspecting person, usu-
ally a stranger, while the stranger is nude or engaged in sexual
activity. Similar to exhibitionism, the voyeur might mastur-
bate during the experience of voyeurism or mentally replay
the experience during subsequent masturbation. The voyeur
oftentimes fantasizes about engaging in sexual activity with
the victim yet rarely experiences such activity (APA, 1994). A
feature of both exhibitionism and voyeurism seems to be the
unsuspecting nature of the victims. Engaging in or viewing
nude dancing (“stripping”) in a nightclub designed for that
purpose does not offer the same thrill as engaging in the
paraphilic activities surreptitiously.
Frotteurism involves rubbing one’s genitals on an unsus-
pecting stranger or groping an unsuspecting victim’s breasts,
buttocks, or crotch. Frottage requires a physical setting in
which the paraphilic individual has access to victims and can
either perform the activity undetected or escape quickly once
detected. So crowded subways, sidewalks, and other public
events where people are packed together provide opportuni
ties for frotteurism. Accordingly, this activity is virtually non
existent in rural areas, and when it does exist, it may be played
© 2003 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.
by Michael Wiederman on August 17, 2007 http://tfj.sagepub.comDownloaded from
out with victims who are sleeping or otherwise unaware of
their surroundings. In terms of accomplishing the activity, the
individual may wear a long overcoat or long baggy shirt so
that his penis can be hidden yet easily accessible. Fantasies of
a sexual relationship with the victim are common, although
actual sexual activity with victims is rare (APA, 1994).
Pedophilia involves sexual interest in prepubescent chil-
dren, usually age 13 years or younger. An individual may sex-
ually molest a child yet not be generally attracted to sexual
activity with children per se. This distinction makes research
on pedophilia, and subsequent characterization of
pedophiles, a difficult task. DSM diagnostic criteria include
recurrent fantasies, urges, or behavior, yet the offending indi-
vidual may deny pedophilic fantasies and urges and insist that
the behavior was limited. Pedophiles are also known to
exhibit denial, rationalize their behavior, and minimize its
consequences (Cohen & Galynker, 2002). Given that legal
penalties are heaviest for this form of paraphilia, there is the
added incentive to deceive others regarding the true nature
and extent of the paraphilia.
Some pedophiles are attracted exclusively to children,
whereas others are also attracted to adults. As for the gender
of victims, some pedophiles are exclusively attracted to girls,
some exclusively to boys, and some to both boys and girls.
Although the most common pattern is exclusive attraction to
girls, those individuals attracted to boys report substantially
larger numbers of different victims (Cohen & Galynker,
2002). Pedophiles also tend to each exhibit a preferred age
range of victims (APA, 1994). All ages of victims have been
represented among pedophiles, but most commonly those
individuals attracted to girls prefer ages 8 to 10 years, and
those attracted to boys tend to prefer a slightly older age range
(APA, 1994).
Pedophilic interests typically first appear in late adoles-
cence, sometimes making diagnosis and prosecution prob-
lematic during that developmental phase. Because childhood
sexual play and curiosity is normative, each case needs to be
evaluated in terms of the relative ages and maturity level of
the alleged pedophile and alleged victim. A minimum age of
16 years for the pedophile and a perpetrator-victim age differ-
ence of at least 5 years has been offered as a guideline,
although the DSM also notes that someone in “late adoles-
cence” who is engaged in an ongoing sexual relationship with
a 12- or 13-year-old should not be diagnosed as paraphilic
(APA, 1994, p. 528).
The eight categories of atypical sexual behavior outlined
above are all of those included in the DSM. What about sexual
interest in animals (bestiality or zoophilia) or sexual interest
in corpses (necrophilia)? These forms of paraphilia seem to
capture the public imagination and have been the focus of
numerous jokes. Each is rare, although apparently they do
exist. For example, a recent review of bestiality and zoophilia
included new data gathered from 82 men and 11 women who
had had sexual contact with animals (Miletski, 2002). For
such paraphilic behavior not included specifically in the eight
categories described in the DSM, there is the diagnosis of
“paraphilia not otherwise specified” (APA, 1994). The DSM
lists as examples of this category zoophilia, necrophilia, tele-
phone scatalogia (obscene telephone calls), partialism
(exclusive sexual focus on a body part, such as the feet),
urophilia (urine), coprophilia (feces), and klismaphilia (ene-
mas). Most recently, paraphilic-like behavior of clinical inter-
est and discussion includes the compulsive use of the Internet
to access pornography, perform sexually explicit chat, or
secure potential sex partners (Cooper, 2002).
What causes or leads to paraphilia? If you can definitively
answer that question, your working days are over. Several
models have been offered, but the lack of empirical data
results in questions as to the accuracy of each theory (Wincze,
2000). To complicate the picture, some theories are meant to
apply only to particular forms of paraphilia or to particular
subgroups within one category of paraphilia. The existing
explanations for paraphilia tend to fall into the more general
categories of biological explanations, psychoanalytic expla-
nations, and cognitive-behavioral or conditioning explanations.
Biological explanations have included the notion that per-
haps paraphilia is related to hormones. However, research has
failed to show relationships between circulating hormonal
levels and atypical sexual fantasies, urges, or behaviors
(Krueger & Kaplan, 2002). Relatively increased levels of
androgens (testosterone) are related to more frequent sexual
fantasies and urges, but that is true regardless of the gender of
the individual or the focus of his or her sexual desires. In other
words, testosterone is related to the quantity but not the qual-
ity of sexual interest. Instead of focusing on hormonal levels,
more recent biological explanations involve altered brain
functioning in individuals with paraphilia, perhaps as a result
of early developmental trauma (Cohen & Galynker, 2002).
Such research is still in its infancy.
Psychoanalytic explanations date back to Freud and were
focused primarily on development of fetishes. Initially, these
explanations relied on the notion of castration anxiety
aroused when a young boy first discovered that his mother did
not have a penis (and therefore the young boy has the potential
to lose his). The fetish object is seen as an unconscious substi-
tute for the mother’s “lost” penis (Steele, 1996). By fixating
on the fetish object and perhaps requiring that sexual partners
wear or associate themselves with the object, the individual
with the fetish gets to maintain the unconscious fantasy that
his female partner has a penis, thereby not rousing his uncon-
scious castration anxiety. Why the particular fetish object
chosen by the individual? The theory is that it relates to the
last moment before the boy learned of his mother’s castrated
state. So, women’s undergarments or women’s shoes might
be the last object noticed at that crystallizing moment when
© 2003 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.
by Michael Wiederman on August 17, 2007 http://tfj.sagepub.comDownloaded from
the boy saw his mother’s genitals. Similarly, a fur fetish might
be based on the symbolism between fur and pubic hair, or a
silk stocking fetish symbolically represents the mother’s
shaved legs. Typically the moment of realization that mother
does not have a penis happens early enough in the boy’s
development that, as an adult, he is unable to recall the experi-
ence and the accompanying details.
More contemporary explanations of paraphilia in the psy-
choanalytic vein have focused more on object relations and
possible problematic childhood attachment as a developmen-
tal precursor to paraphilia (e.g., McCormack, Hudson, &
Ward, 2002). The popular assumption that someone with
paraphilia experienced childhood sexual abuse or trauma is
based on an object relations perspective (a developmental
outgrowth of psychoanalytic thought). In essence, the expla-
nation is that such abuse in early relationships with caregivers
manifests itself as subsequent problems in the ability to estab-
lish and maintain healthy, intimate relationships. Instead, the
individual seeks to satisfy sexual urges through nonrelational
means (e.g., by reliance on a fetish object), pseudorelationships
(e.g., exhibitionism, voyeurism, or frotteurism), or relation-
ships with partners that are based on disproportionate power
(e.g., S/M).
Cognitive-behavioral and learning explanations also
emphasize early sexual experiences, but the emphasis is on
subsequent thoughts and behaviors and their consequences.
For example, a classical conditioning explanation of
paraphilia is based on the simple principle that whatever stim-
uli were present during initial sexual experiences (typically
sexual arousal accompanied or followed by masturbation)
become paired with the sexual arousal and orgasm. There-
fore, an individual who, typically during childhood or adoles-
cence, happens to look into someone’s open window and wit-
ness nudity or sexuality activity may become sexually
aroused. If the individual continues to look and begins to mas-
turbate or replays the experience in his mind later while mas-
turbating, the experience of voyeurism has now been associ-
ated with sexual arousal and pleasure. The experience of
orgasm reinforces the voyeuristic behavior or fantasy, making
reliance on the voyeurism more likely in the future (operant
conditioning). Each time the individual returns to voyeuristic
behavior or imagery during episodes of sexual arousal and
orgasm, the association is strengthened (classical
The behavioral explanation of paraphilia does beg the
question why some individuals with a particular early sexual
experience elaborate that experience into a paraphilic inter-
est, whereas others do not. Part of the answer may lie in bio-
logical predispositions toward being more motivated by sex-
ual risk taking versus inhibition (Janssen, Vorst, Finn, &
Bancroft, 2002) or to experiencing the initial sexual experi
ences during certain critical developmental windows
(Wincze, 2000). Another part of the answer may lie in
whether that initial sexual experience was evaluated as posi
tive or negative by the individual. To return to the voyeurism
example, if the boy had noticed the nudity or sexual activity
and experienced embarrassment, he may have been motivated
to look away and not think of the incident again. Perhaps this
combination of factors explains why males are so much more
likely than females to develop paraphilia. Relative to girls,
boys have few proscriptions regarding sexuality, and having a
penis and erections rather than a vagina and lubrication
allows boys to be more aware of their sexual arousal.
The classical conditioning explanation for the origination
of paraphilia seems to be the most widely accepted (Hall,
2000). It seems to offer a plausible explanation that frequently
fits with the experience of individuals with paraphilia, most of
whom can recall an early experience or series of experiences
that seemed to spawn the current association to sex (Kaplan,
1991). However, it is probably not sufficient to explain the
elaborate evolution of some forms of paraphilia over the
course of the individual’s lifetime or the intense motivational
state that often accompanies paraphilia. Recently, authors
have proposed that a classic cognitive phenomenon, the
Zeigarnik effect, may help explain the ongoing motivation
underlying paraphilia (Munroe & Gauvain, 2001). The
Zeigarnik effect refers to our tendency to remember and rumi-
nate over interrupted tasks to a greater degree than completed
tasks. In other words, thwarted goals produce a psychological
tension that motivates the individual to return, at least men-
tally, to the unmet goal.
As applied to paraphilia, being raised in a sexualized envi-
ronment (which may be said to characterize contemporary
Western cultures) provides numerous opportunities to experi-
ence titillation and sexual arousal without satisfaction. An
unmet need or goal results in attempts to return to the task to
obtain satisfaction. Assuming continued frustration, as the
individual matures, the experiences of thwarted sexual
arousal remain in the past, where they cannot be completed,
thus becoming a part of the person’s permanent repertoire
(Munroe & Gauvain, 2001). This explanation fits with the
observation that paraphilia as we currently conceive of it
appears to be exclusively a Western phenomena that seems to
have originated in the 19th century, as contemporary Western
culture may be unique in its abundance of sexually explicit
stimuli combined with widespread prohibitions about deviant
sexual behavior (Munroe & Gauvain, 2001; Steele, 1996).
This explanation might also at least partially explain the
male-female difference in the likelihood of paraphilia. Most
sexual stimuli in Western culture are aimed at a male audi-
ence, and having a penis may make it more noticeable when
one is sexually aroused but not satisfied.
As is apparent, the existing theories to explain the develop-
ment and continuation of paraphilia are speculative and in
need of additional elaboration and empirical data. Unfortu
nately, the lack of powerful explanatory models does not
relieve clinicians from the need for effective treatments for
those individuals who are distressed by their paraphilia or
© 2003 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.
by Michael Wiederman on August 17, 2007 http://tfj.sagepub.comDownloaded from
whose paraphilia is harmful to others. This review concludes
with a brief introduction to the predominant treatments for
Just as the primary models for explaining paraphilia fall
into psychoanalytic, biological, and cognitive-behavioral
domains, so do the proposed treatments. In brief, psychoana-
lytic approaches involved discovering the developmental/
intrapsychic source and working through those underlying
conflicts or unresolved issues. Biological approaches involve
suppressing sexual drive and decreasing compulsivity. Cog-
nitive-behavioral approaches involve breaking the associa-
tion between unacceptable stimuli and sexual arousal, rein-
forcing more appropriate sexual stimuli, and relapse
prevention. The most common treatment regimen combines
biological and cognitive-behavioral interventions and will be
described in more detail.
In general, androgens increase sexual interest, whereas
estrogens and estrogenlike compounds suppress sexual
desire. Sexual offenders are commonly administered
antiandrogenic substances for just such a purpose (Gijs &
Gooren, 1996; Rosler & Witztum, 2000). For example, Depo
Provera has been commonly used because it reduces sexual
drive in men and is administered by a health care professional
rather than by the patient (Wincze, 2000). Although effective,
treatment compliance has been a problematic issue due to
side effects. More recently, gonadotropin-releasing hormone
agonists have been used with promising results (Krueger &
Kaplan, 2002). These substances can be administered in
depot formulations and exhibit fewer side-effects than tradi-
tional antiandrogenic drugs. The use of serotonin reuptake
inhibitors (SRIs) has also shown promise (Rosler & Witztum,
2000). At this point, it is unclear whether SRIs are effective
due to the effects on decreasing compulsivity associated with
the paraphilia or due to the common side-effect of reduced
sexual interest (Cohen & Galynker, 2002). These drugs are
only available in self-administered forms, but they typically
result in higher patient compliance than the antiandrogenic
substances because of the lower rates of side-effects (Krueger
& Kaplan, 2002). The SRIs have the added advantage of treat-
ing depression and anxiety that may also be part of the clinical
picture in many cases.
Behaviorally, the task of treatment is to “unlearn” the asso-
ciation between the inappropriate stimulus and sexual
arousal. Typically, that inappropriate association has been
strengthened over a substantial period of time and a large
number of instances. The opposite of sexual arousal is either
lack of arousal or an aversive experience. If treatment
involves pairing the stimulus with lack of arousal, the term
satiation is used. Typically, the individual is instructed to
masturbate to the preferred stimulus or fantasy images, then
to continue to do so for a prescribed period of time after
orgasm. After orgasm, the paraphilic interest and the addi
tional physical stimulation will hardly hold the attraction they
did prior to orgasm. The idea is that the stimulus will eventu
ally be paired with boredom and/or annoying stimulation.
If the treatment involves pairing the inappropriate stimu-
lus with an aversive experience, the terms covert sensitization
or aversion training are used. Covert sensitization involves
mentally pairing the preferred stimulus with negative imag-
ery. For example, when a man fantasizes about women in
high-heeled shoes walking on his chest and becomes aware
that he is beginning to have such fantasies, he is to switch to
aversive imagery, such as the woman vomiting first, followed
by his vomiting. Aversion training involves the more direct
association of the inappropriate stimulus and an actual nega-
tive experience, such as electric shock or an aversive odor.
The individual is instructed to begin to fantasize about the
preferred stimulus, and then is either administered a shock or
exposed to a noxious odor. The hope is that eventually the
inappropriate stimulus will fail to be sexually arousing as the
individual attains a negative association to the stimulus. Aver-
sion training has been shown to be effective in at least some
cases, but its use is controversial because of the infliction of
pain or noxious stimuli (Krueger & Kaplan, 2002).
Other components of the cognitive-behavioral treatment
of paraphilia involve behavioral monitoring by significant
others in the individual’s life and maintaining a daily log to
record instances of particularly strong sexual urges so that
precursors or triggers can be identified. Cognitively, thought
stopping may be of some use. When the individual is aware of
a thought about the inappropriate stimulus or behavior, he or
she shouts “Stop!” either in actuality or internally, thereby
interrupting the problematic thought. With paraphilia involv-
ing nonconsenting partners, cognitive work might entail vic-
tim empathy and critical examination of the distorted percep-
tions and beliefs the individual likely holds. That is, sexual
offenders often hold distorted perceptions as to the desires of
their victims, the effects of the offender’s behavior on his vic-
tims, and so forth (Cohen & Galynker, 2002).
On the more positive side, cognitive-behavioral treatments
may include building skills to establish and maintain appro-
priate sexual relationships. These interventions are based on
the observation that individuals with forms of paraphilia that
involve nonconsenting partners often demonstrate deficits in
the normative courtship process (Freund & Blanchard, 1986).
Such interventions include addressing possible sexual dys-
function and ignorance as well as working on social skills,
communication, and assertiveness (Krueger & Kaplan,
2002). The overall goal is to improve the ability to engage in
mature relationships with consenting adult partners, thereby
decreasing the need to rely on paraphilic behavior for sexual
arousal and satisfaction.
As improvement occurs, the focus of intervention may
shift to include relapse prevention as employed in the treat
ment of other disorders such as substance abuse and eating
© 2003 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.
by Michael Wiederman on August 17, 2007 http://tfj.sagepub.comDownloaded from
disorders. Specifically, the individual is guided to (a) identify,
anticipate, and avoid high-risk situations; (b) identify behav-
ioral chains that lead up to the problematic behavior; and (c)
anticipate strategies to intervene and disrupt the behavioral
chain at various points.
Paraphilia and fetishism represent a class of disorders that
is both intriguing and controversial yet socially important.
Whenever sexuality is involved, issues of value judgment and
what is acceptable versus unacceptable come into play. It is
important to remember that diagnosis of a clinical problem in
this area must include the criterion that the sexual fantasies,
urges, or behaviors cause the individual distress or involve
nonconsenting partners. Even still, assessment may be diffi-
cult due to the secretive nature of the relevant experiences and
the reliance on self-report of symptoms. Typically, the indi-
vidual with paraphilia will be reluctant to give up his pre-
ferred sexual outlets, so treatment is likely to occur under
duress, legal or otherwise. Other than biological interven-
tions, treatment relies on the cooperation of the paraphilic
individual. All of these issues and others make the assess-
ment, diagnosis, and treatment of paraphilia challenging for
the clinician.
American Psychiatric Association. (1952). Diagnostic and statistical man-
ual of mental disorders. Washington, DC: Author.
American Psychiatric Association. (1968). Diagnostic and statistical man-
ual of mental disorders (2nd ed.). Washington, DC: Author.
American Psychiatric Association. (1980). Diagnostic and statistical man-
ual of mental disorders (3rd ed.). Washington, DC: Author.
American Psychiatric Association. (1987). Diagnostic and statistical man-
ual of mental disorders (3rd ed. rev.). Washington, DC: Author.
American Psychiatric Association. (1994). Diagnostic and statistical man-
ual of mental disorders (4th ed.). Washington, DC: Author.
Cohen, L. J., & Galynker, I. I. (2002). Clinical features of pedophilia and
implications for treatment. Journal of Psychiatric Practice, 8, 276-289.
Cooper, A. (Ed.) (2002). Sex and the Internet: A guidebook for clinicians.
New York: Brunner-Routledge.
Faludi, S. (1995, October 30). The money shot. The New Yorker, pp. 64-87.
Freund, K., & Blanchard, R. (1986). The concept of courtship disorder. Jour-
nal of Sex & Marital Therapy, 12, 79-92.
Gijs, L., & Gooren, L. (1996). Hormonal and psychopharmacological inter-
ventions in the treatment of paraphilias: An update. Journal of Sex
Research, 33, 273-290.
Hall, G. C. N. (2000). Fetishism. In A. Kazdin (Ed.), Encyclopedia of psy-
chology (Vol. 3, pp. 364-365). Washington, DC: American Psychological
Janssen, E., Vorst, H., Finn, P., & Bancroft, J. (2002). The Sexual Inhibition
(SIS) and Sexual Excitation (SES) Scales: II. Predicting
psychophysiological response patterns. Journal of Sex Research, 39,
Kaplan, L. (1991). Female perversions: The temptations of Emma Bovary.
New York: Doubleday.
Krueger, R. B., & Kaplan, M. S. (2002). Behavioral and psychopharmaco
logical treatment of the paraphilic and hypersexual disorders. Journal of
Psychiatric Practice, 8, 21-32.
McCormack, J., Hudson, S. M., & Ward, T. (2002). Sexual offenders’percep-
tions of their early interpersonal relationships: An attachment perspec-
tive. Journal of Sex Research, 39, 85-93.
McDougall, J. (1992). Plea for a measure of abnormality. New York: Brun-
Miletski, H. (2002). Understanding bestiality & zoophilia. Bethesda, MD:
Money, J. (1980). Love and love sickness: The science of sex, gender differ-
ence, and pair bonding. Baltimore, MD: Johns Hopkins University Press.
Money, J. (1984). Paraphilias: Phenomenology and classification. American
Journal of Psychotherapy, 38, 164-179.
Moser, C. (2001). Paraphilia: A critique of a confused concept. In P. J.
Kleinplatz (Ed.), New directions in sex therapy: Innovations and alterna-
tives (pp. 91-108). Philadelphia: Taylor & Francis.
Munroe, R. L., & Gauvain, M. (2001). Why the paraphilias? Domesticating
strange sex. Cross-Cultural Research, 35, 44-64.
Okami, P. (2002). Causes and consequences of a career in sex research. In M.
W. Wiederman & B. E. Whitley (Eds.), Handbook for conducting
research on human sexuality (pp. 505-512). Mahwah, NJ: Lawrence
Erlbaum Associates.
Rosler, A., & Witztum, E. (2000). Pharmacotherapy of paraphilias in the next
millennium. Behavioral Science and the Law, 18, 43-56.
Stekel, W. (1924). Sexual aberrations: The phenomenon of fetishism in rela-
tion to sex (2 vols.). New York: Liveright.
Steele, V. (1996). Fetish: Fashion, sex, & power. New York: Oxford Univer-
sity Press.
Wincze, J. P. (2000). Assessment and treatment of atypical sexual behavior.
In S. R. Leiblum & R. C. Rosen (Eds.), Principles and practice of sex
therapy (3rd ed.). New York: Guilford.
Michael Wiederman, Ph.D., is an associate professor in the Depart-
ment of Human Relations at Columbia College. He has been an
active member of the Society for the Scientific Study of Sexuality
(SSSS) and is currently the book review editor for The Journal of Sex
Research. His recent publications include Understanding Sexuality
Research (2001, Wadsworth), The Complete Guide to Graduate
School Admission,2nd Ed. (2000, Erlbaum), and The Handbook for
Conducting Research on Human Sexuality (2002, Erlbaum). He
may be reached by e-mail at
© 2003 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.
by Michael Wiederman on August 17, 2007 http://tfj.sagepub.comDownloaded from
... The model focuses on three features of fetishistic behaviors: conditioned copulatory or consummatory responses (CCR) (sexual behavior directed towards a terry-cloth CS object), failure to extinguish the acquired CCR, and individual differences involved in the development of this type of fetishism. Another important feature of paraphilias is their (repetitive) and compulsive quality (Wiederman, 2003). We think that our model can also incorporate this aspect of paraphilias. ...
... An important feature of the paraphilia subcategory is an increase in sexual behavior, usually with compulsive, impulsive, or addictive qualities. Research findings show that compulsive masturbation is one of the main problem areas in hypersexuality disorder (both paraphilic and non-paraphilic subtypes) (Briken, Habermann, Berner, & Hill 2007;Kafka & Hennen, 1999;Kaplan & Krueger, 2010;Raymond, Coleman, & Miner, 2003;Reid, Carpenter, & Lloyd, 2009;Wiederman, 2003). Compulsive musturbation has been found to be related to lower intimate relatedness, higher dissatisfaction with romantic relationships, and less love with partners (Brody, 2010;Brody & Costa, 2009). ...
Full-text available
Previous experiments showed that following acquisition of an association between a terry-cloth object conditioned stimulus (CS) and a live female unconditioned stimulus (US), male quail increased the frequency of their copulations with the inanimate CS during subsequent CS-alone (extinction) trials. The present experiment was conducted to identify the potential factors responsible for this unexpected increase in conditioned sexual behavior during extinction. A total of 57 naïve male quail were given pairings of a terry-cloth CS with a live female during acquisition. A total of 36 of these quail (the approach responders) showed only conditioned approach response to the CS object, whereas the remaining 21 quail (the consummatory responders) also displayed copulatory or consummatory responses to the CS. In the extinction phase, these two sets of quail were divided into two subgroups: one subgroup received a female in their home cages while the other did not. Consummatory responders that were not exposed to a female quail in the home cage showed a significant increase in conditioned consummatory responding as the extinction trials progressed (i.e., compulsive conditioned sexual responding), whereas the other subgroup showed no change. However, both subgroups showed resistance to extinction in both conditioned approach and consummatory behavior. These findings indicate that the increase in copulation with the terry-cloth CS during extinction is possibly caused by US deprivation. The findings also suggest that conditioned copulation with the terry-cloth CS may lead to partial drive satisfaction, which may contribute to persistence of the behavior. Implications of these findings for paraphilias and compulsive sexual behavior are discussed.
... (Yakeley & Wood, 2014). Η μέθοδος με την οποία ένα θύμα γίνεται θύτης νοείται ως ταύτιση με τον επιτιθέμενο που ξαναζεί ένα τραύμα τοποθετώντας τον εαυτό του στη θέση εξουσίας (Wiederman, 2003). Η αίσθηση ενθουσιασμού και ισχύος που προσφέρει η παραφιλία μπορεί να θεωρηθεί ως αντίδοτο στα συναισθήματα αδυναμίας, αδυναμίας ή ανεπάρκειας. ...
Full-text available
Η παρούσα εργασία ανασκοπεί μερικές από τις ψυχαναλυτικές συνεισφορές στην κατανόηση των παραφιλικών διαταραχών. Από την ανασκόπηση αυτή προκύπτει ότι οι κυριότερες απόψεις αποδίδουν την αιτιολογία σε ψυχοσεξουαλικές συγκρούσεις, προβληματικές αντικειμενότροπες σχέσεις, δομικά ελλείμματα του Εγώ, και σε πρώιμες τραυματικές εμπειρίες. Αν και οι θεωρητικές διαφορές είναι σημαντικές, σημείο σύγκλισης αποτελεί αναγνώριση της εγω-δυστονικής φύσης των παραφιλιών και η ανάγκη διερεύνησης του υποκείμενου νοήματός τους.
... Among the paraphilic interests described by the DSM-5, one of the most common is fetishism. While previous versions of the DSM described fetishism as the fixation on a nonliving object (such as a particular type of garment; Wiederman, 2003), the fifth version added the particular fixation on nongenital body parts as a common fetishistic target (partialism;Beech et al., 2016). Joyal and Carpentier (2017) found that, among the general population, fetishism is the second most prevalent paraphilia (after voyeurism), with as much as 44.5 and 26.3% of the respondents expressing desire, respectively experiences with fetishistic behaviors. ...
Objectives: With this research, we aimed to assess the level of fetishism in Romania, to explore the gender and sexual orientation differences and to inspect its relationship with sexual satisfaction and well-being. Methods: This study analyses data from 525 participants from the non-clinical population. Results: The analyses showed that some levels of fetishism are present in almost 70 % of the sample, that queer participants report higher scores and that it does not impact sexual satisfaction and well-being. Conclusion: These findings can be used for a better understanding of fetishism and its impact by both clinicians and individuals with fetishes.
In this chapter we review some of the sexual behaviors that are not regarded as common or “normal.” By attempting to understand them, we hope to gain a better understanding of behaviors that are normally practiced.
Research and clinical practice tends to focus on the solitary aspect of sexual object fetishism. In the current studies, we explore the interpersonal aspect of sexual object fetishism. Study 1 was an online survey of individuals with self-identified clothing fetishes (N = 57). Results suggested that most participants had engaged in fetish sexual activities with another person and that a majority of participants preferred the fetishised clothing item being worn by another person. Participants were also highly specific when describing the characteristics of their preferred partner for fetish sexual activities, including the relationship to the participant, gender, age and attractiveness. Study 2 was another online survey of participants with self-identified sexual object fetishes (N = 195). The majority of participants reported having engaged in both solitary and partnered fetish behaviour. Solitary fetish activity was, on average, rated as sexually satisfying and partnered fetish activity was, on average, rated as very sexually satisfying. This research contributes to the generation of a more accurate picture of sexual fetishism by revealing that there is an interpersonal aspect to fetish sexual activity. Moreover, this research has clinical implications, which will be discussed.
The diversity of sexual urges and behaviors underlying the term “paraphilia” becomes problematic not only when defining the term, but also in attempting to create a unified etiological theory. In the paraphilia and sexual offending literature, refusing treatment or dropping out of treatment has been linked to higher recidivism rates. Medical treatments of paraphilias and sexual offenders attempt to reduce deviant sexual arousal and to inhibit acting on these deviant urges by affecting hormone and neurotransmitter levels. The relapse prevention model of sex offender treatment focuses primarily on reducing risk for future offenses. The good lives approach to offender treatment is focused on helping the offender build strengths, as opposed to the typical risk management or relapse prevention approach. Treatment consisted of one intake session and group sessions that addressed victim empathy, irrational beliefs regarding sexual abuse, sex education, and assertiveness skills.
Fetishistic disorder is a DSM-5 recognized paraphilic disorder that is less likely to involve illegal behavior or victimization, but is essential in characterizing the versatility of the human sexual imagination. This disorder is demarcated by a distressing and persisting pattern of sexual arousal involving the use of nonliving objects or atypical, nongenital body parts. In the field of cultural anthropology, the term fetish refers to idols and talismans that have symbolic religious meaning. In medical usage the term delineates an object, commonly an item of clothing, which is used by an individual to attain sexual arousal and orgasm. Sexual fetishists frequently need to be touching, smelling, or looking at their unique object, or engaging in fantasy about it in order to function sexually alone or with a partner. Like the religious fetish, the sexual fetish can have significant meaning, but it is a meaning held only by the individual and is not shared by the larger community. Fetishism has been recognized as a sexual variation for over 100 years, and has very often been considered a disorder in all of its presenting forms. Recent and ongoing social developments through the exposure of the internet have confirmed the high incidence of fetishistic behavior. We see eccentric behaviors that are met with acceptance by online communities of like minded individuals, and ready availability of means for adaptation and integration into the mental and sexual lives of individuals so affected. Clinical distress of affected individuals, when present and persisting, can now be highlighted as an essential diagnostic feature of fetishistic disorder, and can be considered as a potential target for treatment.
Sexual addiction is an unfamiliar disorder to many social workers, who, consequently, are uncomfortable when treating clients who exhibit such problems. This literature review provides a summary of the ongoing discussions on how to define sexual addiction, and describes two behavioral treatment approaches, cognitive behavioral therapy and covert sensitization, for working with such clients. Because most social workers might not be familiar with covert sensitization, examples are offered showing how this treatment modality can be implemented in therapy when working with clients with sexual addiction. More empirical studies, including the use of single-subject designs, are needed to help address a gap in the literature.
Human sexuality consists of a great variety of practices and identities pursued with differing levels of passion and vigour and which are classed with differing degrees of moral, political, and personal acceptance or opprobrium according to time and place (Laws & Donohue, 2008). While many cultures and moral/ethical systems assert that their boundaries around what is acceptable and what is not are drawn from some firmament of truth — be it ecclesiastical, pragmatic, natural, historical, etc. — practices and identities, nonetheless, inevitably vary and intersect in ways which people within those cultures may find difficult to comprehend. As cultural anthropologist Gayle Rubin writes, Most people find it difficult to grasp that whatever they like to do sexually will be thoroughly repulsive to someone else, and that whatever repels them sexually will be the most treasured delight of someone, somewhere.
Full-text available
Four phases of normal human male courtship behavior may be differentiated: location and initial appraisal of a potential partner; pretactile interaction (e.g., smiling at, posturing for, or talking to a prospective partner); tactile interaction (e.g., embracing, petting); and effecting genital union. A particular class of erotic anomalies may be seen as distorted counterparts of the four normal phases: voyeurism; exhibitionism and obscene telephoning; toucheurism and frotteurism; and the preferential rape pattern. Data from male samples are presented that show that two or more of these anomalies are often found in the same individual. These data suggest the existence of a discrete syndrome which may be described as a courtship disorder.
Paraphilias (e.g., pedophilia, fetishism) are said to be virtually ineradicable once established. The authors propose that the motivational state known as the Zeigarnik effect, according to which interrupted tasks are better recalled than completed tasks, may provide understanding of this process, especially its later addictive-compulsive quality. Reasoning from Zeigarnik-type research, the authors predict a relation between early sexual arousal, its frustration, and subsequent events associated with such arousal. The paraphilias are thus seen as an unusual by-product of a normal adaptive process, that is, a tendency to privilege the recollection of unfinished over finished activities. The authors discuss why paraphilias are associated nearly exclusively with males, and why paraphilic tendencies are apparently quite rare in traditional societies. They also propose new research on the processes and outcomes entailed by the Zeigarnik effect, such research including, but not being limited to, sexuality.
Interest in the pharmacotherapeutic treatment of paraphilias is growing. Two classes of drugs have been tested: drugs that interfere with the normal production and action of androgens and psychotropic medications, in particular, anti‐depressants. We present a review of the supposed modes of action, the usual dosages, and the effectiveness of these drugs. Although the empirical validation of pharmacological interventions shows many methodological shortcomings, we conclude that pharmacological strategies as part of a “complete” psychotherapeutic programme can make a limited, yet relevant contribution to the treatment of paraphilias. More specifically, and provided that there is informed consent, antiandrogens should seriously be considered in the case of paraphilias, which are characterized by intense and frequent sexual desire and sexual arousal predisposing someone strongly to paraphilic behavior. Psychopharmacological interventions, also on the condition of informed consent, can be considered in the case of paraphilias, which are associated with obsessive‐compulsive or depressive disorders. Nonetheless, methodologically well‐designed studies remain a prerequisite for a definitive assessment of pharmacotherapy for paraphilias.
This groundbreaking book is the first of its kind to thoroughly explore the topic of cybersex and the effects of Internet use on sexuality. Focusing on treatment and assessment issues and the clinical implications of cybersex, this authoritative volume provides mental health professionals with an analysis of the most recent empirical evidence along with research specific to the impact of Internet use on couples and families, gay men, people with disabilities, children, and the workplace. Edited by one of the leading researchers, clinicians, and authors in the emerging field of sex and the Internet, this book addresses the growing complexity of Internet sex issues and their impact on psychological functioning. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
DSM-III incorrectly designates the majority of paraphilias as atypical. Only eight are named, and those because of their forensic history, rather than their pathology and therapeutic need. In this paper, thirty-odd paraphilias are subdivided into six categories on the basis of their phenomenological dynamics. The new concept of the developmental lovemap is introduced for the first time. A new treatment originated by the author in 1966 combines an androgen agonist with counseling therapy.