The concept of sexual perversion (paraphilia) is not necessarily a medical problem. Perversion can be understood in a statistical sense, and therefore as something “unusual,” or as a “deviation” in relation to the purpose assigned to sexual activity (reproduction, or sharing, reciprocity, and complementarity).
On another level, the term perversion can refer either to a “state” or to a “developmental process”: that is, a perverse sexual constitution present from the earliest formation of sexual preferences, or a shift toward an abnormal form of sexuality in a person who previously had a normal sex life.
With regard to the dynamics of the sexual relationship, one can consider where the element that produces arousal is located. The arousing element may be the role assumed by the person (Type I), the role assumed by the partner or shared with the partner (Type II), or particular characteristics of an object or of the environment, even without another person’s participation (Type III).
Sexual behaviors for which people seek medical help are more often Type III. Behaviors involving lack of consent, and therefore potentially criminal implications, are more often Type I, whereas Type II dynamics are the ones most often associated with satisfaction of one’s own sexual inclinations.
Leaving aside the usual lists of various sexual preferences, some more common and others rarer or more unusual, let us look more closely at when and how sexual drive can cause distress and become difficult to control.
“Unbalanced” sexual behaviors tend to resemble a model in which the partner, even when physically present, has no real independence or initiative of their own. Arousal takes place entirely within one participant, or in solitude in relation to an object, without communication with any partner.
In some cases, sexual activities without a partner, such as masturbation, are practiced as a substitute for the preferred sexual relationship when that relationship is not possible; alternatively, they may be used to cultivate fantasies that are considered acceptable or feasible only during masturbation, or as an addition to sexual activity with a partner.
From a medical perspective, the concept of “deviation” (paraphilia) should always be defined on the basis of a clinical element, namely the presence of significant distress associated with an inability to change one’s sexual behavior.
In practice, if there is no individual distress, the term paraphilia should not be used. Instead, the behavior should be described as a variant—not in relation to a presumed norm, but simply as a particular “type of sexual behavior.”
If a paraphilia is no longer under control, it tends to become intrusive, impairing, and a source of risk, or simply a source of frustration because of a deterioration in the quality of one’s sexual life.
Paraphilia, therefore, when considered pathological because it leads intrinsically to overall dissatisfaction or distress related to sexual behavior, would derive its pathological nature from its own sexual dynamics: it is directed toward orgasm but excludes a component that enriches the orgasm itself or makes it satisfying, namely the gratification arising from the sexual relationship, understood as complicity and mutual participation in the expression of sexuality.
Paraphilias of Excess
One can distinguish paraphilias of excess, characterized by sexuality that is excessively impulsive, voracious, rapid, and explosive, to the point of making satisfying sexual relationships impossible or problematic even for the individual themselves.
Sexual addiction: a continuous and obsessive pursuit of orgasm, accompanied by loss of control over the type of sexual relationships, partners, and risks involved, and which drives the person to obtain orgasm at the expense of the quality of the sexual relationship. It may be predominantly autoerotic (compulsive masturbation) or may involve partners.
Paraphilias of “Perversion”
There are also paraphilias of “perversion,” in which the object or partner that produces sexual arousal is unusual and restricted to a particular type.
In reality, however, the more severe paraphilias tend to become increasingly impulsive, and therefore increasingly become a problem of “excess,” whether the behavior itself is conventionally sexual or “perverse” in the way the sexual relationship is structured.
In other words, the category of impulsive sexuality and sexual addiction includes both cases involving conventional sexuality and cases involving perverse sexuality.
Primary and Secondary Paraphilias
Paraphilia can also be distinguished as primary—the only form of sexual activity the person has ever experienced—or secondary, meaning a deviation from their previous sexuality.
When secondary, it may be secondary to exposure to stimuli different from those normally encountered (induced paraphilia), or secondary to obstacles that make it difficult to engage in sexual activity in the otherwise preferred manner (substitute paraphilia).
An example of a secondary paraphilia resulting from exposure is one that develops through the consumption of pornographic material. This may initially occur out of ordinary sexual curiosity, in association with masturbation, or as a substitute for the absence of sexual relationships with other people.
At a later stage, the attachment to pornography, or to specific genres of pornography, may become not merely a variant that can optionally be incorporated into relationships with real-life partners, but rather a preferred mode of sexual activity pursued at the expense of the normal process of seeking out and engaging in sexual relationships, to such an extent that it interferes with overall sexual satisfaction, which consequently tends to decline.
Over time, the association between the orgasmic response and the stimulus surrounding it may therefore “shift” the pursuit of pleasure toward the “alternative” stimulus, while the pathway through which sexual satisfaction is achieved does not shift accordingly.
The result is a conflict between the sex that the person consciously “wants” and actually seeks, and the gratification that is ultimately produced.
Characteristics of Paraphilias from a Medical Perspective
A) Sexual behavior characterized by excessive involvement in sexual practices that differ from the individual’s usual sexual orientation or from the type of sexual activity previously associated with gratification.
B) A decline in sexual gratification over time, occurring in parallel with the increasing predominance of the behavior that has become the focus of concern. A progressive divergence develops between the anticipated idea of gratification and the actual experience of gratification.
C) The behavior is unwanted by the individual, who has developed a personal intention to avoid or limit it.
D) A subjective sense of loss of control, accompanied by fear of the consequences, in the context of heightened internal alignment with the behavior that prevents the person from avoiding or limiting potential harm and instead tends to amplify it through the pursuit of increasingly extreme conditions in anticipation of gratification.
Medical Treatment of Pathological Paraphilia
The purpose of medical treatment for pathological paraphilia is to enable the person to have a more satisfying sexual life without being constrained by an impulse toward a sexually impairing or harmful behavior, whether because of the object involved or because of the way the behavior is carried out.
Because there is a correspondence between behavioral change and the definition of the problem, it follows logically that if a paraphilia is not pathological in the medical sense—that is, if the person does not feel that they have lost control over it—there is no concrete basis for a doctor-patient relationship aimed at treating the behavior.
There is no imbalance to restore between intention and control over action.
In such cases, there may instead be issues of legal or social concern, and these situations may perhaps also benefit from some form of medical “treatment.” However, they cannot be defined as illnesses of the individual.