Scientists have the tendency to describe behaviour in terms of normal or abnormal. Abnormal sexual behaviour is described with the following terms: sexual deviance, sexual variance, paraphilias and perversion.

When can sexual behaviour be classified as abnormal?

One approach in describing abnormal behaviour is the statistical definition, it classifies rare and uncommon sexual behaviour as abnormal. In the sociological approach the dependence on culture is acknowledged. Abnormal sexual behaviour is described as deviant in the society. The psychological approach (Buss, 1966) describes abnormal sexual behaviour as inefficient, bizarre and discomforting. The medical approach is classified by the DSM. It recognises eight forms of abnormalities: sexual masochism, frotteurism, sexual sadism, fetishism, voyeurism, transvestism, pedophilia and exhibitionism.

The definition of paraphilia is the intense sexual interest in sexual stimulation other than with normal human partners. Paraphilia is not necessarily a mental disorder but might require intervention. When the person feels great distress either caused by societal pressure or unwilling sexual partners the paraphilia can be classified a disorder. The general diagnostic criteria described in the DSM are:

1. The urges or fantasies must last over a period of at least six months
2. The urges or fantasies cause clinical impairment or distress that affects occupational or social functioning.

It can be difficult to distinguish normal from abnormal sexual behaviour. Many people hold mild fetishes, such as the fetish for exciting lingerie. Also, forty-two percent of people reported they engaged in voyeurism and thirty-five percent engaged in frottage, this is sexual rubbing against a woman while in a crowd (Templeman & Stinnett, 1991). The fetish becomes abnormal when it gets more extreme or when it becomes a necessity.

What is fetishism?

Fetishism means having a sexual fixation on an object other than a human. Also, a great erotic significance is attached to this object. A fetishistic disorder is when urges, behaviour or fantasies for a non-living object enhances or produces sexual desire without or with the partner. It should last for at least six months and cause significant distress. In some cases, people are unable to get an orgasm unless the object is present. There are two types of fetishes: media fetishes and form fetishes. There are three theoretical explanations of why people develop fetishes: learning theory, the sexual addiction model and cognitive theory.

• According to learning theory a fetish is the learned association between an object and sexual arousal or an orgasm. They are formed as a result of classical conditioning.
• The cognitive psychology explanation stresses the importance of cognitive distortion where people perceive a non-human object as erotic. Not only the perception of the object, but also the perception of arousal is distorted. The unconventional behaviour is mistaken for arousal.
• The third theory: the sexual addiction model states that fetishism comes from a compulsive behavioural disorder.

What is cross-dressing?

When someone dresses as the opposite gender this is referred to as cross dressing. Many transsexuals have a phase of cross-dressing in the process of becoming their preferred gender. Drag queens are people who dress up as women. Drag kings are women who dress up as men. Female impersonators are men and women who dress like a specific woman for the purpose of entertainment. A transvestic disorder is when the cross-dressing causes sexual arousal -and excitement and the behaviour is maintained for at least six months. It happens almost exclusively with males, this is because female’s clothing is designed for sensual purposes, men’s clothing is mostly designed for comfort.

What is sadism and masochism?

A person who experiences intense and persistent sexual arousal from physiological or physical suffering is called a sexual sadist. A person who gets sexually aroused by humiliation, beatings or bondage is called a sexual masochist. It can be expressed in behaviour, but also in urges and fantasies. When it causes significant distress and lasts for more than six months it is classified as paraphilic disorder. The difference between sadism and masochism is the sexual nature, thus giving or receiving pain. There are two techniques important for sadism-masochism (S-M). The techniques are bondage and discipline (B-D). Sexual interaction is done with physically restraining devices or constraints. These devices or constraints may also enforce obedience without physical pain. Dominance and submission (D-S) refers to the interaction to exchange power to control sex. These behaviours of both B-D and D-S can be atypical or paraphilic.

What is sadomasochistic behaviour?

There are both nonparaphilic and paraphilic forms of sadomasochistic behaviour. There is a spectrum of activities that constitute S-M. Before people enact in S-M they often tried a range of activities of which a few are satisfying. Santtila et al. (2002) found four clusters of S-M behaviour: hypermasculinity, receiving and administering pain, physical restriction and humiliation. The sexual activities within each cluster seem to be scripted, less intense behaviours are more common. Social interaction and play are important in S-M, especially the enactment and creation of scenes.

Causes of sadomasochism are not yet known. There are several theories, which are learning theory, the sexual addiction model and cognitive theory, the same as for fetishes. Baumeister (1988) proposed a theory to explain masochism, not sadism. The theory states that masochism is the motivation to escape self-awareness. This might be because self-awareness can lead to anxiety or pressure. Masochism provides an opportunity to be autonomous and powerful.

What are theories on sexual addictions?

According to the analysis of Carnes in his book “sexual addiction”, sexually addictive behaviour proceeds in a four-step cycle:

1. The first is preoccupation where someone is unable to think about something else than the sexual act of the addiction.
2. Rituals refer to the repetitive motions that become prelude to the addictive act.
3. Compulsive sexual behaviour is the behaviour the person does not have control about.
4. Despair is the feeling of hopelessness that results from the addiction.

The Compulsive sexual behaviour approach to sexual addiction is when a person has no impulse of controlling the behaviour rather than being driven to perform the sexual action.

What is bondage and discipline?

The sexual behaviour of using restraining devices for sexual purposes is called sexual bondage. It is difficult to gather data about this type of sexual expression. People engage in B-D because it is playful, some do it because of the exchange of power. The key to S-M is not pain, it is dominance and submission (D-S). It is often practised according to a strict script where people take roles as master or naughty child. The outcomes of serious risks are rare because social arrangements are made in advance.

What is voyeurism and exhibitionism?

Exhibitionism and voyeurism are quite different. A voyeurist would not be aroused by watching an exhibitionist. A voyeur is defined as someone who experiences sexual arousal from watching a person in the process of engaging in sexual activity. This person is often not suspecting being watched. It becomes a paraphilia, when the behaviour is classified as “peeping”. It is normal for a person to enjoy watching someone get undressed in a strip club. The behaviour becomes problematic when people start watching strangers engage in sexual activity that do not want another person to know what they are doing. Exhibitionism is receiving pleasure from exposing his or her genitals to another person. Generally, when a woman shows her breasts this is seen as arousing, however when a man shows his penis, this is considered offensive. Whether it is a paraphilic depends on the person engaging in exhibitionism. Most people that have an exhibitionistic disorder characterise their youth with inconsistent discipline, but the exact cause is unknown. It might be a bad relationship or marriage with little positive sexual reinforcement. Sexual offenders in general seem to have fewer social skills than others.

What is hypersexuality and asexuality?

Hypersexuality and asexuality are not listed in the DSM, but they might still be paraphilic due to the consequences. The conditions nymphomania (women) and satyriasis (men) are forms of hypersexuality where someone has an extraordinarily high sex drive. The meaning of these terms differs from person to person. One might think sex every day is completely normal whereas in other cultures this might be considered abnormal. Clinical researchers therefore use the term hypersexuality. It leads to compulsive behaviour where negative and inefficient behaviour can intervene with everyday life. This might result in not having orgasms or never being satisfied with sexual activity. The criteria for paraphilia are that there should be about seven or eight orgasms in each weak for at least six months. Additionally, the man should engage in sexual activity for about two hours per day. Unconventional behaviours are masturbation, exhibitionism, voyeurism, pedophilia and promiscuity. There is an ongoing discussion about whether hypersexuality should be considered a disorder or not. Carvalho (2015) described two clusters of hypersexuality. First, when a person experiences a lack of control and various negative outcomes hypersexuality seems problematic. Second, if someone has high desire and frequent activity this behaviour does not have to cause any problems.

Asexuality is the absence of sexual attraction to any sex. Asexuals are more likely to be women and have poorer health and a low socioeconomic status. It does not seem to be a sexual orientation, which is a strong preference for intimate relationships with people of one gender, because asexual people often cohabit, marry and even have children. According to Bogaert (2015) most asexual behaviour can be classified as hypoactive sexual disorder. This is a dysfunction rather than a paraphilia.

What is the use -and abuse of cybersex?

Recently, a new type of sexual -and possibly problematic behaviour is concerning clinicians and therapists. Cybersex can become compulsive, paraphilic and addictive, especially because of the variety and availability of online content. The compulsive and persistent use of cybersex can be classified as hypersexuality if it causes distress and lasts for at least six months. Whether the extensive use of pornography can be classified as compulsive behaviour depends on the problems caused by the behaviour. A pornographic addiction is like another type of addiction and is characterised by the craving for a substance and the inability to control the craving. Also, neurological changes have been reported for people with a pornographic addiction that are similar to other addictions. There seems to be a high prevalence of co-occurrence with depression, alcohol -and drug abuse and sleep disturbances.

What are other sexual variations?

Other sexual variations are uncommon and have not been thoroughly studied. These variations include asphyxiophilia, zoophilia and frotteurism.

• Asphyxiophilia is the wish or desire to get into a state of oxygen deficiency to create sexual arousal, excitement and an orgasm. People with asphyxiophilia believe the lack of oxygen intensifies the orgasm.
• Zoophilia is the pleasure of sexual contact with an animal. Other names are bestiality or sodomy. Zoophiles describe themselves as having consensual sexual intercourse with animals with a concern for the animal welfare. The pleasure can be described by learning theory where sexual rewards from animals are easy, intense and extremely reinforcing.
• Frotteurism is the sexual fantasy, urge or behaviour to rub genitals against the body of someone else in a public space. Frotteurism can result in a frotteuristic disorder when the symptoms cause significant distress.
• Troilism is the sexual encounter by three people. It is also be referred to as voyeurism if there is one person just watching the sexual encounter between the other two. If the third person in troilism is a heterosexual encounter is male, it places the male in a cuckold.
• Saliromania is the desire to soil or damage a woman’s image or clothing for sexual arousal.
• Coprophilia is the sexual desire to use feces for sexual satisfaction and urophilia is the use of urine.
• Necrophhilia is described as having sexual contact with a dead person.
• Sexsomnia or sleep sex is when someone exhibits sexual behaviour during sleep. The person is often unaware of this behaviour. The sexual behaviours range from masturbation to sexual assault.

How can sexual variations be prevented?

The distress or harm caused by sexual disorders calls for prevention methods. The best way would be to prevent the sexual variation from happening in the first place. It is problematic due to the difficulty to diagnose sexual variations. Another option is to analyse components of sexual development. Disturbances in these components might give clues on prevention of sexual variations. The components are the following (Bancroft, 1978):

1. Gender identity
2. Sexual responsiveness
3. Formation of relationships with others

The different components can cause different variations. Childhood sexual abuse is seen as a great risk for paraphilic behaviour. This is done by adults, so they also should be educated and treated.

How can sexual variations be treated?

Treatment options range with the variety of the sexual disorder. Only sexual behaviour in the abnormal part of the continuum need to be treated. Especially for paraphilic disorder classified by the DSM, treatment is necessary. There are four categories of treatment:

• Medical treatments view paraphilia as disorder with a biological cause. Surgical castration used to be common for men with uncontrollable sexual urges. Currently hormonal treatment can be used to reduce sexual desire. The drug MPA binds to androgen receptors to reduce sexual desire but has serious side effects and did not reduce the chance of reoffending. Now CPA is replacing MPA and blocks testosterone uptake. LA is also used and suppresses androgen production and reduces sexual fantasies.
• Psychopharmalogical treatment such as the use of antidepressants seems to work as well. They change the obsessive or compulsive disorder rather than the sexual desire.
• Cognitive behavioural therapy (CBT) can be used to reduce inappropriate sexual behaviour, modify distorted thinking, train social skills and prevent a relapse.
• Skills training is training in forming and maintaining relationships. People with paraphilia often lack the social skills to even maintain a conversation. Some programs use sex surrogates where the surrogate interacts sexually with the client. Some people think of this method as unethical
• AA-type 12-step programs are based upon sex addiction and aims to help control the uncontrollable and inappropriate sexual behaviours.

Do these interventions work?

Some programs are more effective than others, medical treatment is quite successful a reduced sexual recidivism by thirty-seven percent. Also, classic behavioural programs are the least effective and CBT-methods have proven to be the most effective. The chance of re-offending after CBT is only twenty-seven percent, however this depends on the type of paraphilia. The AA-type 12 step programs have not been proven to treat sexual disorders.