Destructive or damaging to the subject who displays it and to those who get involved in it
Not oriented to the other in a strict sense
Excludes the stimulation of the own genital organs and those of the partner
Is inappropriately associated with feelings of guilt and/or anxiety
Shows a repetitive nature of a compulsive kind
The paraphilia or sexual perversion is defined by a set of fantasies, needs or unusual sexual behavior, generally repetitive, that produce sexual arousal in some people, and that are clearly far away from the previous precepts.
In the past, a much more extensive view of perversion was held regarding the diagnosis of modern paraphilias. It is worth mentioning it because some doctors continue to have the same beliefs as before. This means that in some places we can still talk about perversion when orgasm is reached with different sex objects, with different parts of the body (not only the genitals), or when orgasm is subject to certain non-genital extrinsic conditions that cannot provide sexual pleasure by themselves.
These attitudes lead to a double view of sexuality among doctors: the “official” opinion, advocated by the scientific and research societies, defining paraphilias as very specific clinical situations, and another, “unofficial” view of some professionals still sticking to approaches of 40 or 50 years ago that leave a strong sociocultural and religious mark.
Laplanche and Pontalis [4] further extend the field to designate as perversions the whole range of psychosexual activities accompanying the previously explained atypia in obtaining sexual pleasure. According to Spanish psychoanalyst Coderch [5] perverse individuals exclude genital union with a person of the opposite sex from the fact of obtaining sexual pleasure, or they even subject it to certain acts that do not belong to sexual intercourse, such as the presence of a third individual, cruelty, harm to the couple, the use of a particular type of clothing to have sexual relations, sexual relations with minors or sexual relations related by blood.
The main element for the diagnosis of a paraphilia is the presence in these individuals of specific and repetitive sexual fantasies with a double conscious and unconscious component, in which both excitation and sexual practice and attainment of orgasm are associated. The influence of these fantasies and of their behavioral manifestations are beyond strictly sexual arousal, and come to invade all spheres of an individual’s living and fantasies, making them the preferred or the only ways of obtaining sexual satisfaction.
The presence of a sexuality that is called perverse based on the most classical psychopathological criteria is a constant in much of universal art and literature. For western civilization from Sade to Von Sacher-Masoch, from Henry Miller to Lucian Freud, from Robert Mapplethorpe to Helmut Newton, from Bernardo Bertolucci to Federico Fellini, from Pier Paolo Pasolini to Stanley Kubrick, sexuality often diverts from that ideal encounter that is considered to be “normal,” and this also indicates the great variety of artistic evidence since the origins of humanity.
In fact, is art possible without violence or eroticism? Do sex and blood not form the basis of any artistic work? Camille Paglia [6], a specialist in art history and disciple of Harold Bloom, claims that sex and violence are always close to the social and personal surface. In her opinion all culture, even in the highest expression of art, is but a means by which the human being protects itself from nature, which is cruel and merciless. And nature is blood and semen, violence and sex, which hovers inevitably over every cultural product. For Paglia, “all the roads which arise from Rousseau take to Sade.” Sexuality and eroticism are an inevitable result of the intersection between nature and culture.
11.4 Epidemiological Aspects
In a study in which 94 men are interrogated (a general, not a clinical population) about their sexual fantasies during masturbation or intercourse: 61.7 % say they fantasize about initiating a girl into sexuality; 33 % describe fantasizing about raping adult women; 11.7 % describe masochistic fantasies; 5.3 % fantasize about having sex with animals; and 3.2 % describe fantasies about initiating a boy [7].
Meanwhile, another study on a non-clinical population comprising 60 male college students shows that 42 % admits having practiced voyeurism; 35 % frotteurism; 8 % have made obscene phone calls; 5 % have participated in coercive sexual practices; 3 % have had sexual contact with girls under 12; and 2 % has practiced exhibitionism. In total, 65 % say that they have participated in some form of paraphilic behavior. In this same group 54 % recognize that they have an interest in practicing voyeurism; 7 % want to practice exhibitionism, and 5 % crave sexual contact with children under 12 years of age [8].
With regard to clinical populations, the data collected over 90 treatment programs in the United States relating to 2,129 cases of individuals seeking psychiatric evaluation, we can conclude the following: 37.1 % have been involved in child abuse; 20.2 % in voyeurism; 13.8 % in indecent exposure; 13.3 % in fetishism; 11.2 % in frotteurism; and 10.7 % in public masturbation [7].
Meanwhile another study of 561 paraphilic people (mostly men) who have committed more than 291,000 such acts against more than 195,000 victims, indicates that 37.3 % were victims of exhibitionism; 28.6 % of frotteurism; 13.6 % of voyeurism; 11.8 % of child abuse outside of the home; 3.5 % of public masturbation; 2.3 % of abuse of girls outside of the home; 1 % were victims of obscene phone calls; 0.9 % of bestiality; 0.5 % of the rape of adult women; 0.2 % of child abuse at home; another 0.2 % of urophilia; and 0.1 % of sadism, fetishism, masochism or coprophilia [7].
The true prevalence of sexual perversions is unknown to us. The best estimations derive from cases of legal claims, according to which the most widespread paraphilia is pedophilia [9]. Such disorders are practically confined to the male sex. Half of them have symptoms before they are 18 years old, and decline significantly (at least from a criminal point of view) past the 50s. Frequently, the same individual of up to three or four different paraphilias, depending on the biographical timeline considered. In the latter case the adjective “polymorphous perverse” is applied to describe the coexistence of multiple sexual deviations in the same person [10].
According to new edition of the American Psychiatric Association’s DSM-5 [11]:
“Voyeuristic acts are the most common of potentially law-breaking sexual behaviors. The population prevalence of Voyeuristic Disorder is unknown. However, based on voyeuristic sexual acts in nonclinical samples, the highest possible lifetime prevalence for Voyeuristic Disorder is approximately 12 % in males and 4 % in females (ratio male–female 3:1).
“The prevalence of Exhibitionistic Disorder is also unknown. However, based on exhibitionistic sexual acts in nonclinical or general populations, the highest possible prevalence for Exhibitionistic Disorder in the male population is 2–4 %. The prevalence of this disorder in females is even more uncertain, but it is generally believed to be much lower than in males.
“The prevalence of frotteuristic acts, including the uninvited sexual touching of or rubbing against another individual may occur in up to 30 % of adult males in the general population. Approximately 10–14 % of adult males seen in outpatient settings for Paraphilic Disorders and hypersexuality have a presentation that meets diagnostic criteria for Frotteuristic Disorder. Hence, whereas the population prevalence of Frotteuristic Disorder is unknown, it is not likely that it exceeds the rate found in selected clinical settings.
“The population prevalence of Sexual Masochism Disorder is once again unknown. In Australia, it has been estimated that 2.2 % of males and 1.3 % of females had been involved in bondage and discipline, sadomasochism, or dominance and submission in the past 12 months. Community individuals with paraphilias have reported a mean age at onset for masochism of 19.3 years, although earlier ages, including puberty and childhood, have also been reported for the onset of masochistic fantasies. Very little is known about persistence of this disorder over time.
“The population prevalence of Sexual Sadism Disorder is equally unknown and it is largely based on individuals in forensic settings. Depending on the criteria for sexual sadism, prevalence varies widely from 2 to 30 %. Among civilly committed sexual offenders in the United States, less than 10 % have sexual sadism. Among individuals who have committed sexually motivated homicides, rates of sexual sadism disorder range from 37 to 75 %. Individuals with sexual sadism in forensic samples are almost exclusively male, but a representative sample of the population in Australia reported than 2.2 % of men and 1.3 % of women said they had been involved in bondage an discipline, sadomasochism, or dominance and submission in the previous year. Information on the development and course of Sexual Sadism Disorder is extremely limited. One study reported that females became aware of their sadomasochistic orientation as young adults, and another reported that the mean age at onset of sadism in a group of males was 19.4 years. Whereas sexual sadism is probably a lifelong characteristic, Sexual Sadism Disorder may fluctuate according to the individual’s subjective distress or his or her propensity to harm nonconsenting others. Advancing age is likely to have the same reducing effect on this disorder as it has on other paraphilic or normophilic sexual behavior.
“The population prevalence of Pedophilic Disorder is once again unknown. The highest possible prevalence for Pedophilic Disorder in the male population is approximately 3–5 %. The population prevalence of Pedophilic Disorder in females is even more uncertain, but it is likely a small fraction of the prevalence in males.
“The population prevalence of Fetishistic Disorder is unknown, and in clinical samples this disorder is nearly exclusively reported for males. Usually paraphilias have an onset during puberty, but fetishes can develop prior to adolescence. Once established, Fetishistic Disorder tends to have a continuous course that fluctuates in intensity and frequency of urges or behavior.
“The prevalence of Transvestic Disorder is unknown. Transvestic Disorder is rare in males and extremely rare in females. Fewer than 3 % of males report having ever been sexually aroused by dressing in women’s attire. The percentage of individuals who have cross-dressed with sexual arousal more than once or a few times in their lifetimes would be even lower. The majority of males with Transvestic Disorder identify themselves as heterosexuals, although some individuals have occasional interaction with other males, especially when they are cross-dressed. In males, the first signs of Transvestic Disorder may begin in childhood, in the form of strong fascination with a particular item of women’s attire. Prior to puberty, cross-dressing produces generalized feelings of pleasurable excitement. With the arrival of puberty, dressing in women’s clothes begins to excite penile erection, and in some cases, leads directly to first ejaculation. In many cases, cross-dressing elicits less and less sexual excitement as the individual grows older. Eventually it may produce no discernible penile response at all. The desire to cross-dress, at the same time, remains the same or grows even stronger. Individuals who report such a diminution of sexual response typically report that the sexual excitement of cross-dressing has been replaced by feelings of comfort or well-being. In some cases, the course of Transvestic Disorder is continuous, and in others is episodic. Some cases of transvestic disorder progress to Gender Dysphoria. The males in these cases, who may be indistinguishable from other with Transvestic Disorder in adolescence or early childhood, gradually develop desires to remain in the female role for longer periods and to feminize their anatomy. The development of Gender Dysphoria is usually accompanied by a self-reported reduction or elimination of sexual arousal in association with cross-dressing.” This topic will be widely examined in the correspondent chapter on this book.
It is important to emphasize the fact that these data should be understood with considerable caution and as a mere orientation toward reality for several reasons. Surveys attempt to capture behaviors considered to be negative by society, and sometimes clearly criminal cases, which must be clarified and not obscured. There are behaviors in certain situations and with certain intensity and frequency that cannot be classified as paraphilias in a clinical sense. Normal sexuality includes partial aspects that overlap with what we call perversions, differing only by the context, intensity, exclusivity, compulsion or other aspects. The young man or woman who enjoys watching the naked body of his/her partner is not a voyeur in the clinical sense; the boy or girl picking sexy lingerie for his/her partner is not an exhibitionist, and so on. Sexual behaviors that include some specific aspects of paraphilias should be distinguished from other behaviors that meet the diagnostic criteria.
11.5 Etiopathogenesis
Among the main hypothesis about the origin of disorders of sexual preferences there are biological factors involved, such as alterations in the neurodevelopment, in the levels of sexual hormones in plasma, mild neurological symptoms, certain chromosomal abnormalities, electroencephalographic alterations, epilepsy and mental impairment [9]. In general, all are extremely unspecific and inadequate from an epistemological point of view.
This group of disorders has been associated with a higher prevalence of severe psychiatric pathology as well as with cluster B Personality Disorders [11]. Also, the influence of the social and cultural environment of the individual, as well as his particular biographical moment, must not be ignored as a clear role in its sexual preferences.
Paraphilic disorders have also been related to childhood sexual abuse, substance misuse and sexual preoccupation/hypersexuality as risk factors, although the causal relationship with paraphilias is uncertain and the specificity unclear.
Male gender and the male domination paradigm is core to the construction of perversions, which are a predominantly male field, with the exception of masochism. In this way, sexuality becomes social, relational, determined and built by power. Sexuality becomes a factory of domination and passivity.
Pornography is a clear example of an exercise of domination. It makes women become objects for sexual use and transaction, and makes its potential consumers desire them as objects but also crave to possess or dominate them, often in a cruel and ruthless way. Gender inequality, submission, the hierarchical position and the objectification that results from an explicit denial of self-determination and the apparent consent of sexual desire, are the most appealing traits of these object-women.
Andrea Dworkin claims that the main subject of pornography is male power. In general terms, the role of a woman in pornography is to be raped and possessed by men, either through a camera or a script, always in the name of the watcher. This sexuality of observation, of visual intromission, of domination and access, of entertainment, turns sex into a kind of sport for its audience [12].
11.6 The Dynamics of Perversion: Origin and Development
Over the past few years the term “sexual perversion” has been substituted for others such as “paraphilia” (which etymologically has its origin in Greek: “further” and “love”) [11], disorder of sexual behavior or disorders of sexual preferences (International Classification of Diseases version 10 [ICD-10]) [8], with a more sociological than a clinical base, given that these disorders suppose a behavioral deviation from statistical normality. The main point is to avoid moral judgments regarding the pathological origin of these aforementioned disorders.
Coderch claims that traditionally and from a clinical point of view the term “perversion” has been used to define any function or instinct that deviates from its natural goal (for example, pica can be considered a perversion of the instinct of nutrition). That a certain phenomenon may not be in line with the statistical norm does not necessarily bestow upon it a pathological nature (for example, the influenza infection is a pathological phenomenon from a medical point of view, although it may be considered normal from a statistical point of view during certain seasons of the year; running 100 m in 10 s is also a deviation of the statistical norm, although it has no medical pathological connotation by any means) [5]. This author defends preserving the term “perversion” to refer to this kind of disorders.
Castilla del Pino [13], another Spanish psychiatrist, considers that physicians in their daily routine either openly or covertly corrupt their medical judgments with their own moral judgments: men (and women) are social beings, with their own problems regarding themselves and their relationships (dependence on social class, group, personal expectations) and therefore they are often tendentious concerning the direction of their own moral, religious, political or cultural convictions. This author criticizes the evolution of these medical and psychopathological concepts, as he claims that the substitution of moral/immoral for normal/abnormal is nothing but a deletion of terms with no changes in the hidden attitude toward the concepts they represent. He adds that no action can be considered inherently moral or immoral, mainly because it is its application within a context that confers the said quality upon the action. Empathizing with the context of the individuals in their relationships, not in our own context, that is the key. This fact becomes decisive in judging our own or other people’s sexual behaviors.
The concept of “perversion,” semantic traits aside, has been modified through time owing to the contributions granted by psychoanalysis. Before Freud, and throughout the twentieth century, research carried out by several authors on deviations of sexual behavior was focused on descriptive and nosological contributions.
Freud [14] considers that the main aspects of pathological sexual behavior consist in the exclusivity, repetitive and persistent substitution of adult genital sexual relationships for other activities with an infantile and pre-genital nature, as a result of a defensive mechanism toward the unbearable castration anxiety experienced during the “Oedipal period.” This author places perversions as the reverse of neurotic disorders, with infantile drives surpassing the defense mechanisms of the Ego and transforming them into neurotic symptoms.
Freud interprets perversions as the product of a fixation that results in a disorder of the maturative evolution of normal sexual impulses. He later changes his point of view, giving perversions a more defensive (and therefore neurotic) connotation, in which regression and repression play a determinant role against a conflictive “Oedipus complex” [15].
In the specific case of Leonardo Da Vinci, a Renaissance figure whose “pure homosexuality” Freud has no doubt about, the father of psychoanalysis thinks that the accidental circumstance of his illegitimate birth and the excessive tenderness of his mother had a decisive influence on the development of his personality and his consequent fate, which led his libido to be sublimated into a desire to know, determining the sexual inactivity of his life [15].
However, precautions must be taken with the creation of myths (and the “Oedipus complex” represents one of them). From a psychoanalytical perspective we find authors who demonstrate that self-awareness and other-awareness evolve through the possibility that separate minds may implicate sharing feelings and intentions within a process of mutual recognition. This recognition may be established in a mother/son dyad, or father/daughter, or in any other asymmetrical relationship, as long as there is no falsification of the other person’s needs through fabrications or representations that justify or hide domination [16].
Robert Graves dissects the double function of the myth: on the one hand, its attempt to give sense to the enigmas of life; on the other one, the concealment of violence to justify a certain social system. This author also remarks on its power, which becomes part of the same definition of myth: allegoric fiction that contains a creative or even magical force in which the people that created it are included, ruling their lives and behavior [17].
The Oedipus complex is a myth built from psychoanalytical theory. It excludes the concealment, the masking of a relationship of power, and participates in its dilution. Historically, adults have not been conscious of the generational transmission of the drama that results from the father–mother/son–daughter relationships. What is being hidden in the theory that portrays Oedipus as a representation of the recognition of the difference between the two sexes? Basically, Oedipus is not a normal child, but someone who has suffered extreme parental violence. Son of Laius and Jocasta, Oedipus lacks parents as he is abandoned (by them) in the mountains. In the play by Sophocles the chorus says: “Is he son of Pan, of Apollo, of Hermes, of Bacchus, of one of Helicon’s nymphs?” [18]. The abandoned boy may become everything or nothing. He is an enigma. A naked man, alone, and nobody knows how he came into the world. He is the most intimate essence of a man, even lacking the social shield that should protect him (his parents). His only protection comes from the mercy of a man, a stranger, a shepherd that decides to nurture him. A defenseless child, saved from doom. We already have a naked man introduced into the world of humanity. What will become of him? Because the loneliness of a man is, in Oedipus’ case, notable because of his irregular family situation: a birth that should not have been, parents who should not have been parents, and conflict and constant risk for everyone.
Oedipus does not really represent any children. The androcentrism of the psychoanalytical theory about differences between the sexes starts here, in the double absence of the father toward the mother and daughter, thus, they both find the path to developing their own subjectivity [16].
Femininity and masculinity are not roles or intended behaviors, but an organizing principle of the whole subjectivity: ego, super-ego, and sexual desire. The object of desire is not an anatomical body, but a body built by all the inter-subjective thoughts and practices. Both boys and girls organize themselves through their relationships with other objects (for example, their mother), which are not just objects as both boys and girls can recognize those objects as different from them and similar to them at the same time. This way, inter-subjectivity has an effect in the structuration of the psyche.
The application of a sexual double standard on women leads them to find it increasingly difficult to achieve a mental balance because they only find admiration and recognition through their physical appearance, and their psyche endures extra effort to reconcile the multiple requests of their motivational systems [19].
Since these fantasies and behaviors are not shared with other people and are kept secret for fear of reprisal or punishment, they remain in time until the individual becomes aware of the incompatibility of his (her) interests with the social and cultural rules and conditions of the times in which he (she) lives. Once this moment arrives, those activities have already become a repetitive and compulsive personality pattern with an effect on the basic needs of the individual, who is unable to discard them [9].
McDougall [20] and Chasseguet-Smirgel [21, 22] agree with regard to pointing out the importance of perversion as a creation of a new reality in which the barriers between generations and sexes are removed, providing an escape from anguish with a new reality. Both authors consider perversion to be an individual’s reaction to a narcissistic injury connected to the “primary scene” and the perception of the difference between the two sexes.
With his viewpoint, Stoller keeps a distance from this classical approach to perversion to remark on an alternative origin of this narcissistic injury: questioning sexual identity during childhood. As a reaction, the adult develops a sexual relationship defined by a need to control the object, and therefore with a sadomasochistic trait regardless of the final form of the perverse behavior. Stoller considers aggression to be the common basic factor among all perversions, which allows revenge for all the pain suffered during childhood. In some of these behaviors the aggression is expressed in a conscious and direct way, as in sadomasochistic practices [23].
One of the most relevant authors with the current psychoanalytical outlook, Otto Friedemann Kernberg [24], agrees with Stoller on targeting sadomasochistic traits as the basis for all perversions, and even for “normal” sexual relationships. Kernberg points out the existence of different dynamics depending on the expression of perversions in the context of the different organization of personality. He retains the basic concept for stable perversions that appear within a neurotic structure. He assigns a dynamic such as that described by the British object relations school to perversions that are found in borderline organizations of personality. And he considers Chasseguet-Smirgel’s concepts appropriate for their application to perversions that appear within a narcissistic structure, especially when applied to a malignant narcissism.
According to Kernberg [25] the core affect of severe psychopathological conditions (that include perversions) is hatred, an aggressive, complex, chronic, and stable affect with regard to its cognitive component, with a powerful characterological basis, accompanied by a rationalizing habit and severe distortions of personality concerning the function of the Ego and the Superego of the individual. Hate, intensified by some unconscious motivations (such as a search for revenge rooted in early affective experiences) claims to destroy of the object, both as an unconscious fantasy and in its conscious dimension. However, paradoxically the object that the individual wants to destroy is also needed and desired, which results in a circular dynamic of perversion.
According to González Torres [26], the most significant contribution by Otto Kernberg in this field is based on his opinion that polymorphic perverse sexuality plays a necessary role in the normal sexual relationships. He retains the inquisitiveness set by Stoller years before in this field. Kernberg states that the perverse traits of a normal sexual life assume a way to express aggressive impulses within a couple, avoiding the progression from what is strictly sexual toward a mechanic and unpleasant activity. The capability to unconsciously integrate love and hatred into a polymorphous sexual behavior provides a way of allowing the “use” or “exploitation” of the partner within sex play, safeguarding the object-relation at the same time. This supposes a “splitting” or duplication of sex play, in which the reality of the object-relation is sustained while the other reality of the object, regressive and fantastic, is performed playfully as part of sexual desire and arousal.
In reference to this last point, it should be mentioned that authors such as Oyebode [10] reserve the term “polymorphous perverse” for those people who show all deviations of sexual behavior or paraphilias, while from a psychoanalytical perspective the approach is different, and perverse and polymorphous sexuality are inseparable parts of the sexual life of boys and girls in the early stages of their libidinal development, establishing a basis for the integration of the said behaviors into normal sexual relationships, affective relationships and fantasies in adulthood, in a pleasant way.
Castilla del Pino suggests that a large part of the prodromal behavior of normal sexual activity, and even a greater share in the case of pathological activity, is demonstrated by rituals that reveal the existence of traces of fixations that took place before the stages of libidinal development, making kisses or bites “benign” oral expressions. Even keeping the focus strictly on genital sexual relationships with the desired object, a sublimation of pre-genital object-relationships appears frequently, granting a significant role to hidden fantasies [13].
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