Source of information about DSM diagnoses: American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). American Psychiatric Publishing.

overview

Paraphilic disorders are characterized by intense, persistent sexual interests that deviate from typical sexual behaviors involving consenting, physically mature human partners. While the term paraphilia refers broadly to these atypical interests, a paraphilic disorder is diagnosed only when the behavior causes significant distress, functional impairment, or involves harm or risk of harm to others.

DSM Chapter Sections:

Voyeuristic Disorder: Sexual arousal from observing unsuspecting individuals naked or engaged in sexual activity.
Exhibitionistic Disorder: Arousal from exposing one’s genitals to unsuspecting strangers.
Frotteuristic Disorder: Arousal from touching or rubbing against a nonconsenting person.
Sexual Masochism Disorder: Arousal from being humiliated, bound, or made to suffer.
Sexual Sadism Disorder: Arousal from inflicting humiliation, bondage, or suffering on others.
Pedophilic Disorder: Sexual focus on prepubescent children.
Fetishistic Disorder: Arousal from nonliving objects or specific non-genital body parts.
Transvestic Disorder: Arousal from cross-dressing, typically in men.

Voyeuristic disorder

Voyeuristic disorder involves repeated, intense sexual arousal from secretly observing others who are naked, undressing, or engaging in sexual activity. This arousal can manifest through thoughts, urges, or behaviors. The disorder is diagnosed when the person either acts on these urges with someone who has not consented or experiences distress or problems in daily life due to these urges. It is important to differentiate between someone who has a voyeuristic interest and someone whose interest rises to the level of a diagnosable disorder. To receive this diagnosis, the person must be at least 18 years old.

Criteria:

A. For at least six months, the individual has experienced recurrent and intense sexual arousal from watching an unsuspecting person who is naked, changing clothes, or having sex. This arousal is shown through fantasies, urges, or actions.

B. The individual has either:

• Acted on these urges with someone who did not consent, or

• Feels significant distress or has difficulty functioning in important areas of life (social, work, etc.) because of these urges or fantasies.

C. The person must be 18 years or older.

Specifiers

• In a controlled environment: The individual is in a setting (like a hospital or prison) where opportunities to engage in voyeuristic behavior are limited.

• In full remission: For at least 5 years in a non-restrictive environment, the person has neither acted on the urges nor experienced distress or functional impairment.

exhibitionistic disorder

Exhibitionistic disorder is marked by a persistent, intense sexual arousal from exposing one’s genitals to an unsuspecting person. This behavior is not consensual and may be acted on, or it may cause significant distress or disruption in a person’s life. The disorder is only diagnosed if these behaviors or urges persist for at least six months and either cause harm or impairment or involve a nonconsenting person. It is important to distinguish between someone who has a paraphilic interest in exhibitionism and someone whose behavior meets clinical criteria for a disorder.

Criteria:

A. For at least six months, the individual has repeatedly experienced intense sexual arousal from exposing their genitals to an unsuspecting person, shown through fantasies, urges, or behaviors.

B. The person has either:

• Acted on these urges with a nonconsenting individual, or

• Experienced significant distress or functional problems in important areas of life (such as work or social relationships) due to these urges or fantasies.

Specify Whether:

• The person is aroused by exposing genitals to prepubertal children.

• The person is aroused by exposing genitals to physically mature individuals.

• The person is aroused by exposing genitals to both prepubertal children and physically mature individuals.

Specify If:

• In a controlled environment: The person is in a setting where the opportunity to expose oneself is limited (e.g., institutional care).

• In full remission: The individual has not acted on the urges and has had no related distress or impairment for at least five years while not in a controlled setting.

Frotteuristic Disorder

Frotteuristic disorder involves repeated, intense sexual arousal from touching or rubbing against someone who has not given consent. This arousal can occur through fantasies, urges, or actual behaviors. For a clinical diagnosis, these behaviors or urges must persist for at least six months and either cause distress or problems in daily life, or involve acting on these urges with a nonconsenting person. Simply having the interest is not enough for a diagnosis; it must lead to harm or significant impairment.

Criteria:

A. For at least six months, the individual experiences ongoing and intense sexual arousal from touching or rubbing against a nonconsenting person, as shown by recurring fantasies, urges, or behaviors.

B. The person has either:

• Acted on these urges with a nonconsenting person, or

• Experienced significant distress or functional difficulties in important areas of life due to these urges or fantasies.

Specify If:

• In a controlled environment: The person is in a setting where opportunities to engage in the behavior are limited (e.g., incarceration, residential care).

• In full remission: For at least five years in a non-controlled setting, the person has not acted on the urges and has not experienced distress or impairment due to them.

sexual masochism disorder

Sexual masochism disorder involves a recurring and intense sexual arousal from being humiliated, hurt, restrained, or made to suffer. This arousal may be experienced through thoughts, fantasies, urges, or actions. A diagnosis is given only if these interests cause serious distress or disrupt important aspects of the individual’s life. People with these interests who do not experience impairment or distress should not be diagnosed with the disorder. This condition is sometimes associated with participation in BDSM activities, but not all individuals who participate in such practices have a disorder.

Criteria:

A. For at least six months, the individual has had ongoing and intense sexual arousal from being humiliated, beaten, bound, or otherwise made to suffer. This is evident through fantasies, urges, or behaviors.
B. These fantasies, urges, or behaviors cause clinically significant distress or difficulties in social, work, or other key areas of life.

Specify If: With asphyxiophilia: The person seeks sexual arousal through restriction of breathing.

Specify If:

• In a controlled environment: The person is in a setting where opportunities for masochistic behavior are limited.

• In full remission: There has been no distress or impairment for at least five years while living outside of a controlled environment.

sexual sadism disorder

Sexual sadism disorder is defined by recurring, intense sexual arousal from causing physical or emotional pain or suffering to another person. This arousal may occur through fantasies, urges, or actual behaviors. The disorder is diagnosed when the individual either acts on these urges with someone who has not consented, or experiences serious distress or impairment in daily life because of them. Some individuals may admit these urges; others may deny them even when there is strong evidence. A diagnosis is not made if there is no harm, distress, or nonconsensual behavior.

Criteria:

A. For at least six months, the individual experiences recurrent and intense sexual arousal from inflicting physical or psychological suffering on another person. This arousal is shown through fantasies, urges, or behaviors.

B. The individual has either:

• Acted on these urges with a nonconsenting person, or

• Experienced significant distress or disruption in key areas of functioning due to these urges or fantasies.

Specify If:

• In a controlled environment: The person is in a setting where opportunities to engage in sadistic behavior are limited.

• In full remission: The person has not acted on these urges and has had no related distress or impairment for at least five years while in a non-restrictive environment.

pedophilic disorder

Pedophilic disorder involves ongoing, intense sexual interest in prepubescent children, typically age 13 or younger. This interest may appear in fantasies, urges, or actual behaviors. A diagnosis is made if the person acts on these urges or if the interest causes significant distress or social difficulties. The person must be at least 16 years old and at least five years older than the child or children involved. An individual may have a pedophilic sexual interest without meeting the full criteria for the disorder, especially if there is no distress or harmful action.

Criteria:

A. For at least six months, the individual has experienced repeated, intense sexual fantasies, urges, or behaviors involving sexual activity with a prepubescent child or children, generally age 13 or younger.
B. The person has either:

• Acted on these sexual urges

• Experienced significant distress or problems in relationships due to the urges or fantasies

C. The individual is at least 16 years old and at least five years older than the child or children involved.

Specify Whether:

• Exclusive type (only attracted to children)

• Nonexclusive type

Specify If:

• Sexually attracted to males

• Sexually attracted to females

• Sexually attracted to both

Specify If:

• Limited to incest

Associated Features:

• Emotional identification with children, sometimes stronger than with adults.

• Preference for socializing with children over adults.

• Career or volunteer choices that increase access to children.

• This emotional alignment is linked to both pedophilic interest and increased risk of reoffending among individuals who have sexually offended.

Fetishistic Disorder

Fetishistic disorder involves a persistent, intense sexual arousal focused on nonliving objects or a very specific part of the body that is not the genitals. These interests are expressed through fantasies, urges, or behaviors. A clinical diagnosis is given only when these interests cause significant distress or interfere with daily functioning. Not all individuals with fetishistic interests have a disorder. The diagnosis excludes interests that are limited to cross-dressing items or objects made specifically for genital stimulation.

Criteria:

A. For at least six months, the individual has had recurring and intense sexual arousal from using nonliving objects or focusing on highly specific nongenital body parts. This is shown through fantasies, urges, or behaviors.
B. These fantasies, urges, or behaviors cause significant distress or interfere with important areas of life, such as work or relationships.
C. The fetish is not limited to clothing used for cross-dressing or objects designed specifically for genital stimulation, such as sex toys.

Specify:

• Body part(s)

• Nonliving object(s)

• Other

Specify If:

• In a controlled environment

• In full remission

Associated Features:

• Individuals may engage multiple senses with fetish objects (e.g., touching, smelling, inserting).

• Some may prefer their partners to wear or use the fetish object during sex.

• Many individuals can enjoy sexual experiences without the fetish object, although some find it enhances satisfaction.

• For a minority, the fetish object is necessary to achieve arousal or satisfaction.

• Some individuals may accumulate large collections of fetish-related items.

• Fetish interests often include both nonliving objects and body parts.

Transvestic Disorder

Transvestic disorder involves repeated, intense sexual arousal from cross-dressing. This arousal may be expressed through thoughts, fantasies, urges, or behaviors. The diagnosis is appropriate only if this pattern causes significant distress or interferes with important parts of a person’s life. Simply cross-dressing, even habitually, does not meet the criteria unless it is consistently tied to sexual arousal and accompanied by emotional or functional difficulties.

Criteria:

A. For at least six months, the individual has experienced recurrent and intense sexual arousal from cross-dressing, shown by fantasies, urges, or behaviors.
B. These fantasies, urges, or behaviors cause significant distress or impair functioning in social, occupational, or other important areas of life.

Specify If:

• With fetishism: If arousal is linked to fabrics, garments, or textures

• With autogynephilia: If arousal comes from imagining oneself as a woman

Specify If:

• In a controlled environment

• In full remission

other specified paraphilic disorder

This diagnosis applies when an individual shows symptoms of a paraphilic disorder that cause significant distress or problems in daily life but do not fully match any specific paraphilic disorder. The clinician names the reason by stating the specific focus, such as “zoophilia.”

Examples include sexual arousal involving:

• Obscene phone calls

• Corpses

• Animals

• Feces

• Enemas

• Urine

The interest must last at least six months and cause emotional distress or impair functioning. The disorder can also be noted as in remission or occurring in a controlled environment.

unspecified paraphilic disorder

This diagnosis is used when a person shows signs of a paraphilic disorder that causes significant distress or problems but does not meet full criteria for a specific disorder. It is applied when the clinician does not specify the reason or when there is not enough information to make a more precise diagnosis.

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