Disorders of sexual preference

Disorders of sexual preference are sometimes known as paraphilias. A sexual preference can be said to be abnormal by three criteria.

1 Most people in a society regard the sexual preference as abnormal.

2 The sexual preference can be harmful to other people (e.g. sadistic sexual practices).

3 The person with the preference suffers from its consequences (e.g. from a conflict between sexual preferences and moral standards).

Doctors may be concerned with these conditions in three circumstances: they may be asked for help by the person with the abnormal sexual preference; they may be approached by the sexual partner; or they may be asked for an opinion when a person has been charged with an offence against the law—for example, exhibitionism or a sexual act with a child.

Disorders of sexual preference are divided into (i) abnormalities of the sexual ‘object’ and (ii) disorders of the sexual act. The aetiology of these conditions is not known, and the various theories will not be discussed. They may, however, be associated with the presence of other disorders, including depression, alcohol abuse, and dementia. Treatment is described after the descriptions of the disorders.

Disorders of preference of the sexual object

 

Fetishism

In this condition, an inanimate object is the preferred or only means of achieving sexual excitement. Almost all fetishists are men and most are heterosexual. Among the many objects that can evoke arousal in different people, common examples are rubber garments, women’s underclothes, and high-heeled shoes. The smell and texture of these objects is often as important as their appearance in evoking sexual arousal. Some fetishists buy the objects, but others steal them and so come to the notice of the police. Sometimes the behaviour is carried out with a willing partner or with a paid prostitute, but often it is a Solitary accompaniment of masturbation.

 

Fetishistic transvestism

In this condition, the person repeatedly wears clothes of the opposite sex as the preferred or only means of sexual arousal. It can be thought of as a special kind of fetishism. Nearly all transvestites are men. The clothing varies from a single garment to a complete set of clothing. Cross dressing nearly always begins after puberty. At first, the clothes are worn only in private; a few people, however, go on to wear the clothes in public, usually hidden under male outer garments, but occasionally without precautions against discovery. A few transvestites wear a complete set of female garments; the condition then has to be distinguished from Trans sexualize. The essential difference is that transvestites are sexually aroused by wearing the clothing, while transsexuals are not.

 

Paedophilia

Paedophilia is repeated sexual activity or fantasy of such activity with prepubertal children as the preferred or only means of sexual excitement. Most paedophiles are men. Few paedophiles seek the help of doctors; those who do are mostly of middle age although the behaviour has often started earlier. From the ready sale of pornographic material depicting sex with children, it is likely that paedophilic fantasies are not rare, although paedophilia as an exclusive form of sexual behaviour is infrequent. The child is usually above the age of 9 years but prepubertal, and may be of the same or opposite sex to the paedophile. The sexual contact may involve fondling, masturbation, or full coitus with consequent injury to the child.

 

Disorders of preference of the sexual act

The second group of disorders of sexual preference involves variations in the behaviour carried out to obtain sexual arousal. Generally, the acts are directed towards other adults but sometimes towards children (e.g. by  some exhibitionists or sadists).

 

Exhibitionism

In this condition, sexual arousal is obtained repeatedly by exposure of the genitalia to an unprepared stranger. Nearly all exhibitionists are men. The act of exposure is usually preceded by a period of mounting tension which is released by the act. Usually, the exhibitionist seeks to shock or surprise a female. Most exhibitionists fall into two groups. The first consists of men with inhibited temperament who generally expose a flaccid penis and feel much guilt after the act. The second consists of men with aggressive personality traits who expose an erect penis while masturbating, and feel little guilt afterwards. In Britain, exhibitionists who are arrested are charged with the offence of indecent exposure.

When exhibitionism begins in middle or late life the possibility of organic brain disorder, depressive disorder, or alcoholism should be considered since these conditions occasionally ‘release’ this pattern of behaviour. In other people, the exhibitionism may start during a period of temporary stress.

 

Voyeurism

Voyeurism is observing others as the preferred and repeated way of obtaining sexual arousal. Most voyeurs are inhibited heterosexual men. Some voyeurs spy on couples who are having intercourse, others on women who are undressing or naked.

 

Sexual sadomasochism

Sadomasochism is a preference for sexual activity that involves bondage or inflicting pain on another person. If the individual prefers to receive such stimulation, the disorder is called masochism. If the individual prefers to administer such stimulation, the disorder is called sadism.

Beating, whipping, and tying are common forms of such activity. Sometimes the acts are symbolic and cause

 

Management of disorders of sexual

Preference

All cases of this kind should be referred to a specialist if possible, although the referring clinician should first cassess the problem as follows.

 

Assessment

The first step is to identify the problem and record its course. The second step is to exclude any mental disorder which may have released the sexual behaviour in a person who previously experienced sexual fantasies but did not act on them. It is particularly important to seek these causes when the abnormal sexual behaviour appears for the first time in middle or late life. The third requirement is to assess normal sexual functioning since one of the main aims of treatment is to strengthen this. Whenever possible the patient’s sexual partner should be interviewed. If normal sexual behaviour is inadequate, appropriate treatment is given.

Next, an assessment is made of the role of the abnormal behaviour in the patient’s life. As well as providing sexual arousal such behaviour may be used as a way of coping with loneliness, depression, or anxiety. If so, the patient should be helped to find adaptive ways of coping with these states.

Finally, motivation for treatment is assessed. Often the patient has been urged to attend by another person, usually the partner or the police. In such cases the patient may have no wish to change. Other patients seek help when they become temporarily depressed or guilty, either because the sexual behaviour has caused a problem, or because of some other reason. Such people may lose their motivation quickly when their mood returns to normal