How do paraphilias differ from sexual orientations?

Sexuality is the most intimate form of communication between sexual partners. At the same time, it is subject to social regulations, which is one of the reasons that most sexual disorders have a psychosomatic cause. An overview of the spectrum of human sexual disorders.


Human sexuality is not only used for procreation - this is only the case with four percent of couples - but, above all, it plays a major role as the most intimate form of communication within couple relationships. This communicative or social dimension is subject to social regulations. The question is: who is allowed to have sex with whom and when and how? This may also be one of the reasons why well over 90 percent of sexual disorders in humans are psychosomatic.

Disorders of sexual functions

The problems subsumed here include disorders of sexual appetite (“too much”, “too little sex”) as well as the classic, mostly psychosomatic sexual disorders of women (dyspareunia, vaginismus) and men (erectile dysfunction, premature orgasm). All of these disorders are not diagnoses, just symptoms. The exact exploration of the causes is the task of the doctor and takes a lot of time, but it is also the basic requirement for a successful therapy.

Sexual development disorder

Sexual identity describes self-worth in one's own gender. Whenever a man or a woman feels himself to be too unattractive for sexuality and his / her sexuality is impaired as a result, it is a question of a disorder of sexual identity. Their symptoms range from withdrawal from sexuality to unnatural measures to improve sexual attraction. This includes most of the cosmetic surgeries, mammoplasties, penis extensions, etc.

Experience shows that such interventions cannot or only temporarily solve the patient's problems; the correct therapy would be sex therapy - sexuality-centered psychotherapy.

Another disorder of sexual development involves sexual orientation. This describes the sexual preference for a certain gender. Men and women can be oriented towards men (androphilia) or women (gynaphilia) - whereby the two sexes differ significantly in their sexual orientation: While 90 percent of women and only ten percent of men are androphilic, 90 percent of men are and only ten percent of women are gynafile.

A disorder occurs when the sexual orientation - regardless of whether it is aimed at the same or the opposite sex - cannot or does not want to be lived. Social barriers usually play a role here.

Source: Ahlers Ch. J., Schaefer G. A., Beier K. M. (2005): The spectrum of sexual disorders and their classifiability in DSM-IV and ICD-10. Sexology 12 (3/4), pp. 120-152.

Gender identity disorder

Gender identity is defined as the persistent experience of one's own individuality as male or female. Gender identity disorder (GIS) is commonly known as transsexuality, but it's not that simple. The treatment of GIS sometimes leads to irreversible changes in the body in the direction of the biological opposite sex, which is why the diagnosis requires special care.

In principle, the diagnosis of a transsexual GIS can only be made after sexual maturation is complete, i.e. at the earliest after puberty. Unfortunately, this was only realized after a series of serious misdiagnoses and treatments, which in retrospect turned out to be disastrous for those affected. In addition to the “real” transsexuality, there is also the non-transsexual GIS and transvestite fetishism.

Sexual reproductive disorders

A disturbed personality development leads to a disturbance of sexuality in the sexual dimension favored by the respective gender. This is how men “repair” their deficient personality in the area of ​​the pleasure dimension, women in the area of ​​the reproductive dimension. Reproversion (Beier) is the female counterpart to the predominantly male perversion. So if - for whatever reasons - a woman's self-system shows deficiencies, the defense strategy is to force reproductive impulses.

Sexual reproductive disorders (see box) cover a wide range from the unfulfilled desire to have children to infanticide. The most common causes for problematic processing of special features arising from reproduction are abortions, miscarriages, unfulfilled desire to have children and imagined or unperceived pregnancy. 42.6 percent of women state that they have had their own traumatic experiences in these areas.

Abuse of a child for self-stabilization or as a self-object deserves special attention. The disorder of sexuality directed against the child consists in the fact that the child is forced to develop and not allowed to develop; This undermines the child's autonomy.

Sexual preference disorder (paraphilias)

Paraphilias ("adversarial love") are a deeply masculine issue, just as sexual reproductive disorders are feminine. Theoretically, one can assume that women could also be paraphilic, but practically no paraphilia has a measurable size in women, with the exception of masochism in a ratio of men to women of 20: 1.

Paraphilias can focus on non-human objects and body parts (fetishism, sodomy), on suffering or humiliation or pain or humiliation of his partner or himself (masochism, sadism) or on children (pedophilia) or non-consenting or incapable of consenting . Paraphilias are not able to reach a majority in public and hardly reach a consensus in the relationship.

Men with paraphilic arousal patterns usually frighten their sexual partners and meet with rejection in public. Only from such a traumatization (the experience of rejection) does the sexual disorder arise. Most paraphilias are primarily not to be classified as deviant at all, but rather a widespread variety of male pleasure. According to the Berlin study of men, the sexual fantasies of almost 60 percent of all men contain paraphilic content.

Paraphilia is the disorder of sexual preference; it does not have to be a criminal offense per se. If this turns into a criminal act, it is called dissexuality.

Transvestite fetishism

When a man wears the clothes of the opposite sex, he imagines himself to be both the male subject and the female object. The transvestite fetishism is a frequent topic in the consultation hours of the sex medicine. Those seeking advice are usually not the patients themselves, but their partners, who sometimes recognize their partner's inclinations by chance, sometimes on the basis of deliberately placed evidence.


Fetishisms are directed at non-human objects (underwear, boots, shoes, etc.), smells or body parts (feet). As harmless as fetishisms are often, it seems difficult to live them within a relationship. Sex partners of fetishistic men are usually overwhelmed with the fulfillment of the wishes and often turn away from their partners.


In sexual masochism, the real (not virtual) act of humiliation or submission, often being beaten or tied up, is perceived as sexually stimulating. Partnerless masochists tend to do violence to themselves, prick needles, or inflict electrical shocks in the genital area. Masochists in a partnership play staging of bondage and punishments or allow themselves to be forced to crawl like a dog because of mock insubordination. Asphyxiophilia is an extreme variety, in which breath control (and the resulting hypercapnia) is intended to achieve a special orgiastic experience.


Real (not virtual) actions that cause another suffering (shackles, whipping, gagging, inflicting burns, attaching clothespins, etc. up to death) are perceived as sexually arousing. The psychoanalytic motive for sadism is a narcissistic wound caused by a lack of maternal love. It leads to anger and aggression towards the failing mother. This sadistic component is sexualized during puberty and thus transferred to the innocent sexual partner.


The voyeur goes to great lengths and overcomes great obstacles in order to observe couples in intimate situations. Most of the time he satisfies himself. This is the essence of his sexuality. To be voyeur does not mean to take a fundamental pleasure in the representation of sexuality. Visual eroticism is an integral part of predominantly male sexuality.


This is genital presentation as a sexual end. The exhibitionist believes he can recognize recognition for his genital equipment from the panicked reaction of a surprised woman. The psychoanalytic explanation for such practices is castration fears. Exhibitionism is not the presentation of physical stimuli for the purpose of initiating sexuality; the criterion of the end purpose is not met here.


Terrycloths rub themselves or their genitals on random or carefully selected victims. They use overcrowded public transport or other public places with crowds of people.

Touchurism ("grabbing")

Someone who touches someone else without their consent is a toucheur. Touchurism is usually found under the influence of alcohol.


This is understood to mean sexual arousal patterns on childlike, i.e. prepubertal, bodies. When a child shows the first signs of sexual development, by definition, pedophilia ends. It is arguably the most sensitive topic in sex medicine, and many sex medicine professionals shy away from commenting on it. The reason for this may be the fact that children are involved, who in their weakness and vulnerability rightly enjoy the special protection of society.

Assaulting a child destroys his personality and impairs his sexual development. That is why pedophilia is prohibited as a sexual practice and has penal consequences.

However, none of this should be used as an opportunity to make an objective view of things impossible: The right strategy towards pedophile men is not their exclusion (which is not possible at all, because according to the Berlin study of men, over ten percent of men have bodies directed at children Arousal patterns), but treating them before they become delinquent.

Pedophilia is an innocently acquired sexual preference that takes place in masturbation fantasies and daydreams. This can neither be criminalized nor punished, as it is a voluntary and therapeutically unchangeable preference.

The treatment aims at complete behavioral abstinence, which can be achieved the sooner the treatment is started. In any case, therapy must be started before a child is victimized.

Men with the corresponding tendencies must therefore be encouraged to seek therapy in good time.

Multiple disorders of sexual preference (polyparaphilia)

Men whose arousal patterns involve multiple paraphilic preferences.


In dissexuality, the disorder of sexual preference (paraphilia) becomes a disorder of sexual behavior. Using the example of pedophilia: as long as arousal patterns on children's bodies play a role in the imagination, this is paraphilic. If a pedophile man becomes delinquent, paraphilia turns into dissexuality and a criminal offense.

Dr. Georg Pfau
General practitioner, sexologist, Linz

© MMA, Clinicum Urologie 4/2013