Before considering specific treatment modalities for PAs and PRDs, it is useful to recognize the commonalties among these conditions. Both PAs and PRDs affect predominantly men, but published research as well as clinical data characterizing men with PAs are primarily limited to describing sexually aggressive men, mainly adult rapists and pedophiles. Although women may be diagnosed with the PAs sexual masochism or pedophilia, the incidence of these paraphilias in women is low, especially in comparison with that in men. In the consideration of PRDs, women can be diagnosed with compulsive masturbation, protracted promiscuity, or severe sexual desire incompatibility; however, males still predominate in clinical samples.
The following descriptive characteristics of paraphilic sexuality describe PRDs as well. The majority of males with PAs and PRDs have the onset of unconventional sexual arousal during adolescence (Abel and Rouleau 1990; Abel et al. 1985; Kafka 1997a). While paraphilic individuals may have a favored unconventional sexual outlet, multiple studies have reported that the presence of a single diagnosed PA in sex offenders tends to predict the presence of multiple (2-5) paraphilic outlets over the course of a lifetime (Abel et al. 1988; Bradford et al. 1992). In addition, the “typical” male with a PRD who seeks treatment is likely to develop several of these behaviors serially or concurrently (Black 1998; Carnes 1983, 1989; Kafka and Hennon 1999).
In both PA and PRDs, sexual arousal and associated behaviors may wax and wane, may be either ego-syntonic or ego-dystonic (Berlin et al. 1995), and are more likely to occur or intensify during periods of stress or in response to dysphoric affects (Carnes 1983; Laws 1989). Both males and females with these conditions commonly describe their sexual behaviors as obligatory, repetitive, and stereotyped, and most will report that such behaviors are time-consuming as well (American Psychiatric Association 1994; Carnes 1983). Both PAs and PRDs may be accompanied by cognitive distortions - that is, overvalued ideas related to disinhibited sexual arousal (Carnes 1983; Johnston and Ward 1996; Laws 1989). In addition, many males (and, presumably, females) with PAs or PRDs could be characterized as hypersexual - that is, as persistently engaging in appetitive sexual behavior leading to orgasm more frequently than population norms (Brotherton 1974; Carnes 1983, 1989; Cooper 1981; Davies 1974; Kafka 1997b; Kafka and Prentky 1992a).
Although many men and women with PAs and PRDs are married, some utilize unconventional sexual fantasy for arousal when engaged in socially conventional sexual activities. Indeed, a preference for PA or PRD sexual activities is a common cause of relationship dysfunction and may precipitate help-seeking behavior. For example, it is not uncommon for paraphilic men to report situational impotence, loss of conventional sexual desire, and/or dysphoria if they try to suppress intensified paraphilic fantasies during reciprocal sexual relations with an established partner (Kaplan 1995). In addition, many married men and woman with PRDs preferentially depend on masturbation, pornography, protracted promiscuity, and PRD-associated sexual outlets. Reliance on these unconventional sexual activities may precipitate repetitive extramarital encounters, marital dysfunction, and divorce. Not only do some of these clinical similarities between PAs and PRDs lend credence to the hypothesis that such behaviors could be closely related clinically; the similarities also imply that treatment modalities targeting the clinical attributes shared by PAs and PRDs could be applied to ameliorate both conditions.
Although considerably more empirically derived data exist on PAs than on PRDs, there is some evidence suggesting that PRDs may be more prevalent than PAs (Kafka 1997a; Kafka and Hennon 1999; Kafka and Prentky 1992a) and may be underdiagnosed in males with PAs. Thus, it is possible to consider that PAs are the proverbial “tip of the iceberg” of a larger group of sexual behaviors, all of which are characterized by intensified and disinhibited sexual arousal (i.e., paraphilic and nonparaphilic hypersexuality).
Revision date: June 20, 2011
Last revised: by Jorge P. Ribeiro, MD