What the Heck is a Paraphiliac?
Within the therapeutic community there is considerable confusion as to what constitutes sexual addiction, what constitutes paraphilic behavior, and what constitutes sexual offending. In part this is caused by our collective inability as sexual addiction professionals, sex therapists, and sex offender treatment providers to engage in useful, integrated discourse, perform research, create conferences, and most of all to work together. Complicating matters is the APA’s lamentable inability/unwillingness (so far) to provide diagnostic criteria defining Hypersexual Disorder (sexual addiction), despite the way our twenty year tech-connect boom has dramatically increased the average person’s ability to affordably and anonymously access endless amounts of highly graphic pornography, casual sex, online prostitution, and information about and/or depictions of fetishistic and illegal sexual behaviors. As those of us working in the field are well aware, this proliferation of access has led to and/or escalated problematic sexual behavior – be it addictive, paraphilic, illegal, or some combination thereof – in numerous individuals with pre-existing addictive or other psychological disorders such as social inhibition, profound childhood or adult trauma, depression, anxiety, etc.
To clarify the discussion that follows, basic definitions of sexual addiction, paraphilic behavior, and sexual offending are provided.
Sexual Addiction (Hypersexual Disorder, proposed addition to the DSM-5): Sex addiction is typically defined as repetitive patterns of compulsive or impulsive sexual activity with self or others that is shameful, oftentimes secretive, and causes negative consequences to the individual and his/her spouse and family. Sex addicts typically engage in impulsive or planned patterns of emotionally arousing sexual rituals and behaviors to escape or tolerate uncomfortable feelings and emotions. For these individuals, sexual acting out is used to emotionally self-regulate. Addictive sexual behavior can create relationship, career, legal, emotional, and physical problems both short- and long-term. Sex addicts often continue to engage in their compulsive sexual behaviors despite repeated attempts to limit or eliminate those behaviors, and despite their inevitable negative consequences. The recently released film Shame (now on video and available for download) does a very good job of demonstrating the typical struggles of an unidentified male sex addict. It is important to note that sexual addiction as a diagnosis is not defined by religious, moral, or ethical standards, nor is it defined by the presence of an ego-dystonic (unwanted) arousal pattern related to fetish objects or same-sex orientation. Instead, sexual addiction is related to:
- Obsession and preoccupation with sexual fantasy, urges, and behavior
- Loss of control over sexual behaviors, meaning the inability to commit and maintain behavior change despite promises made to self and others
- Ongoing negative life consequences arising directly from the sexual behaviors
Typical sex addict behaviors include:
- Compulsively masturbating to porn, social media, and other online experiences for multiple hours daily
- Going to strip clubs and/or seeing prostitutes as a primary source of “intimate” connection
- Anonymous sex with partners found online, via smartphone apps, or in sexual environments
- Multiple affairs and sexual acting out while married or in an otherwise committed relationship
- Fusing drug abuse and sexual acting out
- Living a compartmentalized, secret sexual life
- Crossing professional boundaries for sex
Paraphilic Behavior: Paraphilias are recurrent, intense, sexually arousing fantasies, sexual urges, or behaviors, occurring occur over a period of at least six months, involving nonhuman objects, the suffering of oneself or one’s sex partner (as in BDSM,) or initiating a sexual act with a non-consenting person. Paraphilias are only considered pathologic when: 1) they become obligatory for sexual functioning; 2) they involve inappropriate partners (meaning minors or unwilling participants); or 3) they cause significant distress and/or impairment of social, occupational, or other important areas of functioning. Common paraphilic behaviors include:
- Sexual masochism
- Sexual sadism
- Transvestic fetishism
Sexual Offending: Sexual offending is a legal term. In that respect, sexual offending is somewhat subjective, as sexual behavior that is legal in Thailand may very well be illegal in Iowa. From a clinical perspective, we look at sexual offending as engaging in a sexual act that is nonconsensual. If both partners do not fully agree to engage in the sexual act, or if both partners do not have the ability/capacity to fully consent to a sexual act (because one partner is too young, inebriated, mentally challenged, etc.) and the sexual act is carried out anyway, a sexual offense has taken place. Common sexual offending behaviors (several of which are also listed in the DSM-IV-TR as paraphilias) include:
- Sexual behavior with children
Are Sex Addiction, Paraphilia, and Sexual Offending Interrelated?
The majority of sex addicts do not have fetish behaviors, are not paraphilic, and do not cross the line into offending. Similarly, not all paraphiliacs or sex offenders demonstrate sexually addictive behavior patterns. However, as clinicians gain awareness of the relationship between sexual addiction and sexual offending, as well as the relationship between sexual addiction and sexual paraphilias, we are beginning to see a significant crossover among these populations. It is likely (research is needed on this topic) that many of these crossover individuals started out with only one issue, with their behavior expanding over time – spurred on by the accessibility and anonymity of the Internet – into one or both of the others. Sexual addiction in particular has progressive features that may lead to such escalation. The simple fact is sex addicts seek to expand and/or intensify their behavior over time, which is necessary if they wish to achieve the same neurochemical high – adrenaline, serotonin, oxytocin, and dopamine release – as their addiction progresses. (This tolerance/escalation phenomenon is characteristic in all forms of addiction.)
While most sex addicts do not move beyond self-destructive activities (that may also harm their spouse and family) such as compulsive use of pornography and masturbation, others escalate their fantasies and behaviors to paraphilic activities such as transvestitism and consensual BDSM, or offending behaviors such as exhibitionism, voyeurism, and viewing child pornography. In fact, recent studies looking at the compulsive use of pornography – a common form of sexual addiction – indicate that our “love maps” (who and what we are attracted to), once thought to be established during our formative years and thereafter fixed, are actually somewhat malleable, allowing individuals to develop paraphilic and/or offending arousal patterns over time related to their escalating, compulsive use of porn or other sexual behaviors. For evidence, one needs only to look at the emerging population being prosecuted for child pornography with no history – before their Internet sexual addiction – of sexual fantasy or behavior involving minors.
Max grew up in a conservative, upper-middle class household in which sex was never discussed. As this was before the advent of the Internet, his “knowledge” of sex was limited to the locker room braggadocio of his friends and a few pictures glimpsed in random magazines. When Max was in his mid-twenties, the Internet arrived, and with it came easy access to pornography. Intrigued, he bought a home computer and signed up for Internet access – provided by a screechy dial-up modem. He set up his personal email account, even though none of his friends or family as yet had email, and then he went looking for porn, which was not hard to find.
As the first image slowly downloaded, revealing itself one digital line at a time, Max felt as if he’d injected himself with a large dose of adrenaline. Before he realized it, he was hooked, spending hours each night downloading image after image, and with each new image he got a fresh jolt of adrenaline (though none of those jolts were as big as the first one). And then it happened. On one of Max’s favorite websites a clothed but still sexy image of a minor popped up. That image, even with clothes, provided a rush that was bigger than any he’d previously experienced, and even though he’d never really thought about or fantasized about sex with a minor, he suddenly wanted more. He sent an email to the site’s webmaster, asking if there were other pictures of the model. The webmaster politely replied that he didn’t have any on the website since the model was “probably underage,” but if Max was looking for that sort of thing he could find it by following X, Y, and Z instructions.
Suddenly, Max was hooked on images of teenagers – with each new image reinforcing his constant adrenaline high. His non-paraphilic, non-offending sex addiction had progressed to paraphilia and offending. As this happened, he withdrew socially, ignoring friends and social engagements in favor Internet porn. He also began to drink heavily as a way to cope with the guilt he felt about his sexual behavior. Within a year he was locked in a downwardly spiraling cycle of illegal porn and alcohol – miserable, but unable to stop. And eventually the images weren’t enough. Max started fantasizing about “seducing” a minor, and then he started “cruising” a notorious boulevard, looking for prostitutes and picking up any that appeared to be underage. Inevitably, he was arrested and the full extent of his behavior was discovered.
Addicted vs. Non-Addicted Offenders
For many years, sex offender specialists have emphasized the nonsexual components of sex offending behaviors while minimizing the role of arousal and sex itself. A need for power, dominance, control, revenge, sadistic satisfaction, and the expression of anger have been the most frequently cited causes for sexual assaults and other sexual offenses. And while this manner of assessment is accurate in many cases, an improved understanding of addictive sexual patterns and their mood-altering functions demonstrates additional sexual offender motivators. For example, non-sexually addicted sex offenders – driven by hatred, a need for control, and related emotional issues (along with a lack of empathy and remorse) – consciously attempt to inflict pain, do harm, and attack, whereas sexually addicted sex offenders are motivated to use others for self-gratification (as objects) in a maladaptive attempt to cope with loneliness, shame, past trauma, and poor social functioning. Like all sex addicts, sex-addicted sex offenders (such as Max in the example above) utilize the intensity of the sexual experience to escape internal stressors while denying or ignoring rather than reveling in the harm or pain those acts inflict.
Note: It is perfectly clear to those of us who treat sex addicts and sex offenders that a diagnosis of sexual addiction should never be used to “take off the hook” or “give excuses for bad behavior” to those men and women whose sexual activities cause harm of any kind. Sexual addiction as a diagnosis does not imply that a sex addict or sexually addicted offender is somehow not responsible for his/her actions or the consequences that follow. However, as we come to understand the role that addictive sexual disorders play in many sexual offenses, it is imperative that sex offender treatment specialists and counseling facilities (be they in prisons or elsewhere) become open to incorporating appropriate sexual addiction assessment, 12-step support, and other sexual addiction treatment methodologies into their work. A failure to accurately assess and treat a sexually addicted offender adds unnecessary risk for recidivism and may result in additional victimization. Interestingly, both state of the art sexual addition and sexual offender treatment approaches focus on dealing with repetitive sexual behavior patterns, developing relapse prevention skills, building social skills, etc. There is a lot more in common than most clinicians realize.
Finally, a shout out to those in the sex therapy world: We need you! Sex addicts and many sexually addicted offenders are accustomed to finding pleasure and escape in non-relational, non-intimate, person-as-object driven sexuality. Once sexually sober, the vast majority of these individuals struggle with an underlying intimacy disorder. Typically they experience great difficulty engaging, maintaining, and enjoying truly intimate sexual experiences. Helping people overcome this intimacy barrier is “stage two” of sex addiction treatment – offering hope to sex addicts (and sexually addicted offenders) that they can enjoy a sexual life free of obsessive, compulsive, and harmful behavior.