Keywords

1 Introduction

Civilizations throughout history have developed conceptualizations of norm-appropriate sexual behaviors. Sexual beliefs, practices, values, dispositions, and opinions of normalcy often differ considerably from culture to culture [1]. “Variation” is probably the broadest term used when speaking of paraphilic behaviors, implying some degree of divergence (or “deviancy”) from “normal” as defined socioculturally. Thus, variations in sexuality and loving behaviors are not always consistent with standard Western descriptions and terminologies [2]. This understandably becomes problematic when Westerners who speak English attempt to apply descriptors, inclusions, and exclusions to non-Westerners who speak other languages.

Humans are sexual from birth until death, with dynamic changes occurring throughout the lifespan. While each individual’s experience of sexuality is unique, common patterns and trends in all human beings’ collective experience of sexuality become apparent. The ability to interpret and understand these patterns and trends provides a more in-depth and historically accurate understanding of the human experience of sexuality in general [3,4,5]. Sexuality, including its many disorders and dysfunctions, is a global phenomenon and not something of exclusive interest to Europeans, Americans, and other Westerners [6,7,8,9,10,11]. For example, sex researchers have found premature ejaculation to be prevalent among men in Turkey [11], as well as female sexual dysfunction to be prevalent in Iran [12].

Many sexual behaviors, dispositions, and variations—some controversial—exist across cultures and societies [13, 14]. That which is considered acceptable to one group may not be to another. Examining sexuality in all of its expressions from a cross-cultural perspective highlights the relative nature of standards and customs of behavior within a system or community. Remaining alert to transcultural differences and avoiding ethnocentrism increases opportunities to decrease suspicion of others’ norms and values while also challenging sexual stereotypes, or beliefs within a society as to how members should appear and behave sexually [15].

Many mistakenly use such phrases as “Western culture,” “White culture,” “American culture,” “European culture,” “Asian culture,” “African culture,” and so forth—as if such huge, standardized, and homogenous groupings truly exist in today’s world. Potentially, this is a failure to acknowledge the presence of large-scale cultural diversity. In reality, many different cultural groups with their own norms comprise many different societies cross-nationally.

Because of a severe lack of controlled research studies into paraphilias worldwide, this chapter briefly explores and highlights alternate sexual interests and disorders from a more generalized point of view, particularly within a context of culturally bound and socio-demographic expectations and considerations whenever possible.

2 Perspectives in Human Sexuality

The vast majority of humans belong to one or more sociocultural systems. Of interest to sexual medicine specialists is how these different social systems interact and influence individuals, couples, and households with respect to various expressions of sexuality. The most common of these systems are family, community, work, educational, religious, and technological ones.

Children might receive conflicting or unhealthy messages about sexuality from their parents, school, and/or pornography [16]. As another potent influencer, organized religion’s teachings, morals, tenets, and values can play a powerful role for life for people raised in a religious environment—be it helpful or harmful [17, 18]. One might be scolded for having “perverted thoughts” that “violate God’s laws,” even when the desires and behaviors are harmless, such as the case of an occasional cross-dresser or a couple who mutually agree to an alternative approach to intercourse.

Knowing which system provides what sexual message is helpful for understanding and, if necessary, challenging irrational notions. Furthermore, identifying and analyzing the role of particular cultural and social systems is basic to understanding sexual behaviors—and in the case of this chapter: paraphilias and paraphilic disorders in the context of a more comprehensive, global perspective.

3 Culture, Society, and Roles in Human Sexuality

Culture as a concept refers to beliefs, rules, products, and other characteristics shared (“cultural bonding”) by members of a social group. Society as a concept refers to the people who interact within a common culture. Through culture and society, entities define themselves, conform to agreed-upon values, and contribute to the larger whole. Common cultural and societal institutions include family, education, work, healthcare, and organized religion—all of which claim a stake in deciding normality versus abnormality.

Sexual roles are the parts humans play in their sexual engagements within cultural and societal contexts. What is proper? What is improper? How much sexual freedom is allowed? Do sexual rubrics apply to every member of a society? Sexual roles affect every aspect of life, forming an interconnection between sexual identity, attitudes, and expressions. These are both personal and cultural, defining how persons behave sexually within the parameters of society. Sexual roles determine how sexual events will occur, and if they are culturally characterized as suitable or not.

Regarding paraphilias, sexual roles involve both imaginal and behavioral alternatives that have been acquired through whatever means. Yet enforced sexual roles can prove deleterious to self-expression. Conforming to restrictive, long-standing stereotypes leaves little room for sexual creativity or experimentation.

How are these sexual roles acquired? Learning is the foremost vehicle, especially during childhood and adolescence. Young people receive parental approval by conforming to expectations and adopting culturally accepted, conventional sexual scripts—all of which are repetitively reinforced via other socializing agents, such as social media and television. The learning of sexual roles almost always occurs within social and cultural contexts.

In other words, learning is crucial in forming and shaping sexual roles, beginning with early attractions and desires [19, 20]. Humans exhibit sexual schemas, which are deeply entrenched cognitive frameworks about personal sexuality. People make quick judgments concerning these qualities in others, often based on observations of such inconsequential items as hairstyle, clothing, and spoken cues. Added to what people perceive is what they expect to perceive, based on assumptions about approved sexual preferences. Sexual schemas are taught and reinforced throughout the life cycle via numerous socializing agents—parents, teachers, friends, colleagues, media, and religious leaders—and exert a tremendous effect, especially on young children. Expectations are then passed along to successive generations.

Humans are expected to live out culturally defined roles. Yet fallacy can prevail here. Simply because society defines what behaviors, perceptions, and emotions are normal and abnormal does not mean these labels are necessarily correct or desirable. In the case of paraphilias, ongoing controversy and inconsistencies exist with respect to definitions of deviant/abnormal versus non-deviant/normal given dependency on sociocultural definitions, expectations, approvals, and prohibitions [13].

The consequences of culturally bound sexual behaviors are real—economically, physically, psychologically, spiritually, and clinically. Performance anxieties, dysfunctions, and other concerns about sexual expression are assessed and managed based on generally recognized social norms. The aim of current thinking in sexual medicine is arriving at understandings that ultimately benefit both individuals and societies, and determine whether the majority’s standards related to approved sexual desires and behaviors should be imposed upon all group members.

4 Identity and Orientation in Human Sexuality

Whereas uncertainty concerning exactly how sexual predilections form remains, virtual unanimity exists on at least one point—sexual identity and orientation develop very early in life, and become increasingly irreversible as accumulating sexual experiences continuously reinforce sexual inclinations.

Biological, psychological, and social (“biopsychosocial”) aspects regarding the formation of sexual interests are unmistakably evident—variant or not. Genetics, pre- and post-natal hormones, differences in neurological and reproductive structures, and unique socialization and conditioning patterns all likely contribute to the development of sexual attractions and behaviors, including paraphilias.

Meaning, identity, and rigid expectations would seem to interfere with sexual fulfillment, looming large in creating sexual dysfunctions, as seen, for example, in some Malay women [21]. In many cases people define their unique sexual roles in life through fantasies and behaviors. With men across the globe raised to be dominant/powerful and superior/initiating, and women raised to be passive/weak and inferior/yielding—in other words, heterosexual in a traditional sense—no wonder the penis becomes a symbol of control and power, and the vagina becomes a symbol of submission and vulnerability. Thoughts, emotions, and behaviors outside of this sexual reality, however, are immediately suspect, with those not fitting into neatly defined heterosexual packages automatically shunned and stigmatized [22].

How can societies free persons with unconventional attractions from unfair categorizing in order to lead sexually fulfilling lives? One method is to challenge traditionally defined stereotypes, roles, and expectations, including the objective of applying less Western diagnostic weight to non-Western value systems. This has been a social justice theme of modern sexologists for many years.

5 Deviance in Human Sexuality

Deviance—criminal or non-criminal—refers to behavior that violates social customs and norms, usually of sufficient severity to merit disapproval from a majority of society’s members. As a concept deviance is complex, given that norms can vary considerably across groups, systems, times, and places [14, 23]. What one group might consider acceptable, another might consider deviant. For instance, in some regions of Africa, women are circumcised—termed infibulation or clitoridectomy. This procedure involves surgically removing a young girl’s clitoris and then sewing shut her labia. In the West boys undergoing male circumcision is a conventional practice based on Judeo-Christian norms, but girls undergoing female circumcision, or female genital mutilation as it is sometimes referred to in mainstream America, is an unthinkable practice.

As another example, adults who are sexually attracted to children are known as pederasts or pedophiles. Pedophilia is form of child abuse when perpetrators act upon their urges, force children into sexual activity, purchase pornography that supports mistreatment of minors, and photograph or video children in sexually explicit contexts. Child sexual abuse is culturally forbidden in most parts of the globe, and is illegal everywhere in the USA.

Child sexual abuse becomes incest when the abuser is a relative, irrespective of blood relations. Stepparents can be arrested for incestuously molesting stepchildren. Not all societies have laws forbidding sexual activity among varying degrees of cousins.

The point here: multiple definitions and perspectives in human sexuality are possible. Not all are widely accepted or even legal depending on locale. What is considered tolerable or intolerable to one group or subgroup might not be so to another [24].

6 Sexual Paraphilias

Sexual fulfillment is sometimes found through imaginal and behavioral variations that depart from what are considered to be conventional and acceptable sexual outlets. Paraphilias (from the Greek παρά (para) + φιλία (philia), meaning “beyond love”) are alternative—perhaps even dangerous and illegal—sexual fantasies and/or practices that individuals need for sexual excitement and release. That is, paraphiles rely on peculiar fantasies and/or practices for sexual gratification. Some paraphilias, like cross-dressing in private, are potentially harmless. Others like, molesting children or exposing one’s genitals in public, are not.

Paraphilias occur globally, though just how prevalent these variations are remains elusive, given people’s reluctance to report unusual sexual inclinations and acts [1, 13]. In a comparative study, East Asian sexual offenders (e.g., Korean, Japanese, Chinese) in British Columbia resembled their non-Asian Canadian counterparts in terms of sexual offenses, but did describe more paraphilic behaviors [25]. Multiple paraphilias are defined as three or more paraphilias—a more frequent occurrence than previously thought—that can also include concomitant substance abuse, as noted by Iranian researchers [26]. As well, 13% of male subjects in a study of paraphilic cases in Turkey were found to have more than one paraphilia [27]. Overall, more men than women report being paraphiles [28].

Sex-positive cultural paradigms tend to construe sex acts as pleasure-focused, whereas sex-negative cultural paradigms tend to construe sex acts as procreation-focused [29]. Egocentric/individualistic (“I-focus”) paradigms tend to emphasize personal sexual goals and pursuits, whereas sociocentric/collective (“us-focus”) paradigms tend to emphasize community sexual goals and pursuits. Put another way, sexually permissive societies are maximal with respect to sex (“permissive-maximal”), while sexually repressive societies are minimal with respect to sex (“repressive-minimal”). More liberally tolerant societies may have greater leniency toward sexual alternatives than more conservatively intolerant ones.

Paraphilias, therefore, pose unique challenges to historians, researchers, legislators, technicians, and clinicians as cultures and societies ultimately determine what sexual practices are acceptable versus unacceptable. Collecting epidemiological and comparative data on paraphilias is consequently problematic. Reports of paraphilias across the globe are likely limited depending on cultural norms, privacy concerns, and personal worries about legalities. Whether non-Western individuals are hesitant to report sexual aberrations or simply lack awareness remains to be determined. Generally, disordered paraphilias come to the attention of clinicians and social researchers via legal systems.

6.1 Redefinitions

Hesitancy to social change seems to be a constant in today’s world. In the midst of regular technological developments and breakthroughs, certain entities fear personal loss through social change, leading to vested interests (financial, moral, or otherwise) in preserving the status quo. Many people express concerns of uncertainty when attempting to adapt to ever-changing social tides.

Cultural factors can play an essential role in resisting social changes. Cultural lag is the delay in time that a society requires to “catch up” to cultural evolution. As one example, various organized religions (e.g., Catholic Christianity) encourage large families and regard non-procreative sexual activities that ultimately limit family size as sinful. As another example, certain groups like the Taliban of Afghanistan (in endorsing Sharia law) might even impose the death penalty on those who deviate from established religious traditions. Put another way, cultural factors as well as lag can exist between non-material culture (religious dogmas) and material culture (sexual innovations). Non-material culture inevitably must respond to innovations in material culture.

Social movements, by their very nature, question culturally established norms. In the USA today, both feminist and LGTBT (lesbian-gay-transgender-bisexual-transsexual) rights movements challenge definitions and idealizations of the “natural order” of phallocentric, patriarchal dominance—that females must acquiesce to males, that traditional, procreative heterosexuality is the only acceptable sexual standard, and that any other sexual expressions are irregular and therefore disordered. Continued resistance to sexual social movements remains predictably steadfast.

As one example of a social movement within the Western healthcare industry, the American Psychiatric Association’s (APA) 2013 Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) revisited the notion of all paraphilias being abnormal, and instead distinguished between non-normative sexual interests and sexual disorders per se [28]. Proposed ICD-11 changes are promised to be similar [30]. In other words, from a clinical perspective sexual interests are not inevitably sexual disorders.

Yet such progressive thinking regarding sex has not always been the case. The history of the DSM from its first release in the 1950s (more psychodynamic and biased in approach) to the latest release in 2013 (more psychometric and neutral in approach) has been fraught with controversies, disagreements, discrepancies, and changes in sexual classifications and definitions, exemplifying how clinical and healthcare norms and values can change considerably over time given new research data, values, and laws. Earlier versions of the DSM categorically described all sexual behaviors outside of customary Western conceptualizations of sex, including homosexuality, as abnormal and therefore disordered. With growing scientific evidence to the contrary, relaxing social mores, and humanitarian goals, the APA eventually reversed its position on homosexuality, and has continued to modify its stance on other sexual matters to improve both diagnosis and treatment, with more and more emphasis on the qualifying elements of personal distress, relationship dissatisfaction, and social dysfunction as criteria for diagnosing sexual disorders.

Western sexologists have traditionally differentiated between paraphilias that involve: (1) non-consenting partners, (2) non-human objects, and (3) suffering or humiliation. Lawyers have tended to differentiate between: (1) public indecency, (2) public lewdness, and (3) public nuisance. Criminologists have tended to differentiate between (1) consenting sex, (2) non-consenting sex, and (3) threatened sex. With so many differing perspectives and approaches to paraphilias, correlations and causations remain undetermined. For instance, having a fetish does not inevitably make one a serial rapist, although many criminals might have fetishes. Much remains to be learned in order to understand and define paraphilias within cultural contexts and their relationship to other psychosocial processes.

6.2 Current Classifications

The general consensus among sexologists today is that paraphilic attractions differ from paraphilic disorders, in that paraphilic disorders, to be defined as such, must create impairments in normal daily living, generate distress, prove potentially harmful to self or others, and/or be illegal.

Paraphiles often describe their sexual urges as “irresistable,” “overpowering,” and “overwhelming.” Egosyntonic (consonant) paraphilic urges are those that the individual finds acceptable. Egodystonic (dissonant) paraphilic urges are those that the individual finds unacceptable, and these urges range from mild (being distressed to a slight degree by the urges) to severe (being distressed to a great degree by the urges, and repeatedly acting on them regardless of consequences).

Paraphilias can also have counterparts within the normal range of sexual events. As an example, it is perfectly acceptable for a couple to play with consensual bondage, or for a spouse to enjoy his or her partner wearing sexy undergarments. It is unacceptable for one member of a couple to demand his or her partner submit to unwelcome activities, or for a spouse to require his or her partner’s undergarments to be present to become sexually aroused, or even worse for someone to become solely interested in bondage accouterments or undergarments instead of the partner. When sexual patterns are ongoing and disturbing, interfere significantly with one or more relationships, and/or cause legal or other problems is the person perhaps considered to be sexually disordered [24].

The aforementioned advancements in Western conceptualizations of paraphilic interests versus disorders will hopefully lead to larger societal depathologizing and destigmatizing of consensual, non-normative sexual interests and behaviors across cultures [31, 32]. Winters and colleagues [33] further argue for care in applying diagnostic categories of “unspecified paraphilic disorder” (UPD) and “other specified paraphilic disorder” (OSPD), mainly to avoid unethical labeling of exotic attractions, behaviors, and syndromes.

For reference, next are very brief descriptions of the most commonly encountered sexual paraphilias ([28]; see Table 15.1), with sample non-Western references noted where appropriate.

Table 15.1 Sexual paraphilias
Full size table

6.3 Exhibitionism

Exhibitionists intentionally expose their genitals, buttocks, or breasts (“flashing”) to unsuspecting and unconsenting individuals, emotionally traumatizing victims and leaving them feeling sexually violated and exploited [34]. In a study of Hong Kong undergraduates, no statistical differences were found when compared to a USA sample in terms of the incidence and nature of exhibitionism [35]. Exhibitionism no longer relies on in-person perpetration with the advent of websites and webcams.

6.4 Fetishism

Fetishism involves sexual attraction to inanimate objects, usually non-sexual in nature but related in some way to the human body and culture in question. While any object can be a fetish, clothes (such as bras, panties, and stockings) and accessories (such as gloves, shoes, and purses) are the most predominant. Associated with body image and fashion, uniforms are another common object fetish [36]. As well, fetish in Africa [37] and traditional foot binding in China claim long histories [38]. The typical fetishist is a male who exerts control over the fetishistic object or symbol.

6.5 Frotteurism

Frotteurism typically involves, for the purposes of sexual arousal, a clothed male rubbing his genitals against a clothed female in a crowded setting. Indian researcher Kalra [39] commented on a case of compulsive sexual behavior with frottage, though with depressive disorder as the perpetrator’s primary complaint.

6.6 Pedophilia

Pedophilia is defined as sexual attraction to prepubescent children. A subcategory of pedophilia is hebephilia, which involves attraction to pubescent children. Sea and Beauregard [40] studied a sample of males in Korea, and found hebephilia to be a unique mix of pedophilia and teleiophilia (sexual attraction to adults). From pederasty in Ancient Greece [41] to ritualistic homosexual behavior among younger and older males in Sambia [42, 43], early homoerotic contact is not always predictive of later attractions and behaviors. Heterosexual relations eventually take over in many cases.

Typical pedophiles are males, though there exist reports of female teachers having sexual relations with younger male students [44]. Increasing numbers of pedophiles are seducing youth through online social media [45]. As well, pedophilia appears to be a global phenomenon, including non-Western offenders [46,47,48]. For instance, in Japan “JK business” promotes sexual exploitation and assault of minors [49], and child sexual abuse is stated as an increasingly prevalent problem in India [50, 51].

6.7 Sexual Masochism and Sexual Sadism

Sexual masochism involves sexual gratification from receiving humiliating, restraining, beating, or torturing behaviors, while sexual sadism involves perpetrating these activities [52,53,54]. Although separate diagnostic categories, these two paraphilias frequently occur together—known as sadomasochism (“S/M” or “BDSM” [bondage-discipline sadomasochism], [55, 56]). McCormick [55] reported on flourishing BDSM communities in South Africa. Authors Langdridge of the UK and Parchev of Israel [57] have advocated for BDSM groups to push for social and legal acceptance. Wright [32] and Cardoso [15] have also called for wider acceptance of consensual BDSM.

6.8 Transvestism

Transvestism is sexual gratification from dressing in clothing customarily reserved for the other gender. Reports of transvestites exist across cultures. Bristow, for example, has written about his travels across China with a transvestite from Beijing [58]. Cross-dressing in Taiwanese dramas is also well-known and considered cultural performance [59]. Transvestic disorder can progress to gender dysphoria [60].

6.9 Voyeurism

Voyeurism involves sexual arousal and gratification from watching or recording unsuspecting individuals who are undressing, naked, or engaging in sexual activity. The current availability of inexpensive hidden cameras has increased opportunities for voyeuristic opportunities in locations where privacy is expected, such as public showers and locker rooms, restrooms, motel rooms, hostels, and rental units. Voyeurism is not uncommon worldwide, for example, being the most common paraphilic behavior reported in a study of English-speaking adults in a small town in South India [10]. In another study of paraphilias among young adult undergraduates at a Nigerian University, voyeurism was the most frequent paraphilia [61].

6.10 Other Paraphilias

A literal myriad of additional, unusual paraphilias are cited in both professional and popular literatures (see Table 15.2 for examples). Three of the more frequently of these include necrophilia (deceased persons), telephone scatologia (lewd telephone calls), and zoophilia (animals). Pareek [62] wrote about two notoriously famous necrophiles from modern-day India: Surendra Singh Koli and Moninder Singh Pandher. Perpetration of victims via telephone scatologia in India, Saudi Arabia, and various Arab countries can lead to multi-year imprisonment [63]. Bestiality has been a concern of modern mental health professionals for years [64]. Chandradasa and Champika [65] presented a case report on zoophilia in a high-functioning autistic male from Sri Lanka. The reasons for zoophilia can vary across cultures, but lack of access to human partners is one possible explanation [66, 67].

Table 15.2 Other paraphilias
Full size table

7 Dispositions and Causes of Sexual Paraphilias

Sexologists are unsure of the exact dispositions and causes responsible for paraphilias, which are presumed to arise from combinations of factors that come into play in particular ways for particular persons in particular settings. These combinations, some more prevalent at times than others, result in the different avenues of sexual expression described in this chapter. Similarities of sexual dispositions across varying groups are assumed as well, though conclusions are far from absolute given a scarcity of hard data regarding non-Western peoples.

Various biological etiologies have been offered to explain paraphilias across cultures. Certain people may be disposed, even hardwired, for paraphilias either through genetics or brain pathology [56, 68]. Research employing magnetic resonance imagery (MRI) suggests the presence of differences in brain connectivity [69], including cortical and subcortical abnormalities [70]. Neuroimaging and neuropsychological studies demonstrate structural issues in cortical circuits of the brain’s right hemisphere [71]. And some men apparently have a stronger sex drive perhaps due to increased amounts of and/or sensitivity to testosterone [72, 73]; they might look for additional sexual outlets when more traditional channels are not readily available, and increased sexual reactivity might also enhance their disposition toward paraphilic interests and activities. Research from Poland and the USA does not show statistical differences between paraphilic sexual offenders and controls with respect to the interplay between neurotransmitters and genetics [74]. Medical conditions like Klinefelter syndrome and autism are sometimes associated with gender dysphoria, hypersexuality, and paraphilic disorders, as noted by researchers in Italy [75].

Male dominance in various social arenas is not without negative consequences when sexual disorders manifest. Psychologically, the disordered paraphile is often socially awkward, shy, withdrawn, repressed, confused, anxious, and angry about intimate adult relationships. Regarding the latter, hostility might play a greater role in paraphilias than other sexual interests, perhaps explaining why so much paraphilic behavior across cultures is forced on unsuspecting or unwilling victims in the form of symbolic or literal actions of sexual aggression, humiliation, power, and submission [76]. Victimization of women in Bosnia and Herzegovina through sexual assault that includes paraphilic behaviors is one of many tragic examples [77].

Conditioning likely plays a part in learning and maintaining paraphilic desires and behaviors. Repeatedly masturbating to orgasm in the context of paraphilic fantasies reinforces sexual desires and behaviors, in turn making it more difficult to interrupt patterns over time. Internet access to paraphilic and other pornographic images becomes all the more noteworthy [78]. For example, online communities of zoophiles exist for support of mutual interests as well as the promotion of this paraphilia as their sexual orientation [67].

One classic multidimensional approach to conceptualizing paraphilias is John Money’s theory of “lovemaps.” Money [79] stressed that sexual attractions arise from biological dispositions in combination with sources of early childhood erotic arousal that are later activated by psychosocial factors. Variations in sexuality, then, can occur at any point during development or remain latent indefinitely. “Lovemaps” as a model explains why people from similar backgrounds do not necessarily develop similar sexual patterns; everyone develops a unique sexual map. The question of who develops what sexual interests and behaviors in which cultural substructure depends largely on distinct combinations of positive and negative events present in a given situation for a given person with a given biological disposition. This and similar paradigms, heavily reliant on concepts of reward versus distress, leave open the possibility of people from dissimilar cultural backgrounds developing predilections for the same sexual outlets. Nonetheless, how reward versus distress is communicated to larger groups is inherently dependent on cultural influence, with reward sometimes being at odds with societal dissonance.

8 Treatment of Sexual Paraphilic Disorders

Because paraphilic disorders are deeply and powerfully embedded in the psyche, treatment is difficult at best. One traditional goal in Western clinics is to replace undesirable patterns with desirable ones, always in the context of exploring the patient’s thoughts, emotions, motivations, and social influences. Like other psychiatric conditions, paraphilic disorders are complex with an abundance of variables to be evaluated—the nature, severity, and history of the patient’s chief complaint, personality traits and family system, motivation for treatment, relationship discord, and so forth. How such treatment and patient-practitioner interactions might play out in non-Western clinics remains to be determined.

An example of one fairly standard Western therapy for paraphilic disorders is orgasmic reconditioning, in which non-paraphilic objects, urges, or practices eventually replace paraphilic ones. This technique involves patients masturbating to desired paraphilic fantasies. When orgasm is inevitable during masturbation, patients switch their internal focus to non-paraphilic objects or fantasies. Orgasm occurs while thinking about non-paraphilic objects, thus reinforcing anticipated expression. Patients repeat this procedure each time during masturbation. They ultimately find non-paraphilic objects more arousing than paraphilic ones, losing interest in and abandoning dysfunctions in favor of more suitable interests [63]. How orgasmic reconditioning therapy might play out in non-Western cultures that forbid masturbation and pornography is unknown at this time due to a lack of controlled data.

9 Sexual Offenders

Paraphiles and others who enter the realm of sexual offense by acting on their desires have available a number of behavioral and psychiatric techniques for managing their disordered behaviors [80]. Regrettably, the long-term prognosis for perpetrators’ recovery is poor, irrespective of methods used [81, 82], though not all agree with this premise [83]. Penile plethysmography, or phallometric testing, is a principal means of diagnosing and assessing treatment progress, as self-reporting by offenders is not always reliable [84, 85].

One method of dealing with sex offenders is incarceration, with or without the benefits of individual and/or group counseling [86]. This is perhaps the most-used approach worldwide. Another method is castration, involving chemical destruction (chemical castration) or surgical removal (surgical castration) of the testes. Castration is no assurance perpetrators will not sexually offend in the future, as mentioned in literature from the Republic of Macedonia [87]. Interestingly, the professional literature describes men who are sexually intrigued by the thought of being castrated [88].

Pharmaceutical treatments for disordered paraphiles often center on blocking agents and hormones to dampen perpetrators’ sex drive [89, 90]. Anti-androgen agents such as medroxyprogesterone acetate (MPS) and cyproterone acetate (CPA) are commonly used, as is leuprolide acetate (LPA) [91]. Fluoxetine, a serotonin reuptake inhibitor, has also shown promise for paraphiles with concurrent symptoms of depression and anxiety [63].

Therapy of sex offenders ranges from supportive to aversive approaches. In cognitive-behavioral therapy (CBT), therapists challenge perpetrators’ dysfunctional beliefs and behaviors, and formulate strategies for managing unwelcome sexual impulses. Perpetrators’ early childhood development and impasses are also explored. Behavioral aversion therapy might include electrically shocking perpetrators when sexually aroused by inappropriate stimuli, such as photos of naked children. Images of consensual adult sex acts to recondition offenders follow. Participants also benefit from social skills training, couple’s therapy, group therapy, and cognitive-based Rational Emotive Behavior Therapy (REBT, developed by Albert Ellis, Ph.D.) to confront irrational thinking patterns that manifest as distorted actions [92].

10 Cross-Cultural Influence

The problem of superimposing Western understandings of mental disorders onto non-Western cultures continues to generate controversy and disagreement [93], originating in part from earlier American and European expansionism and colonialism with consequent Western-centric labeling. Even though the DSM-5 prides itself on remaining culture- and bias-free [28], the reality of the matter is, all interpretations of mental, emotional, and behavioral phenomena are unavoidably filtered through the lens of immediate experience and sociocultural paradigms. As such, critiques of the APA and DSM-5’s cultural-free claims continue [93].

A premise of this chapter is that many sexual phenomena, including paraphilias, are likely universal, at least in the sense of Western definitions. As noted above, authors in different parts of the globe have published articles looking at Western-defined paraphilias in non-Western locales. At the same time, however, some sexual phenomena seem to be culturally specific and molded. One example, though not a paraphilia per se, is dhat—the Indian concept of semen-loss anxiety, with resultant sexual and mental dysfunction, from cultural attitudes and expectations of masculine virility and procreative sex roles, dating back to ancient Indian Ayurvedic texts [14, 92]. Another non-paraphilic example is African “brain fag,” referring to a culturally bound syndrome of cognitive, emotive, and somatic complaints [94]. Furthermore, Hinduism allows, under certain specified circumstances, a tradition of cross-dressing: males displaying feminine traits and females displaying masculine traits to foster understanding of the unique merits of both genders [23]. How are sexologists to reconcile? Unfortunately, the controlled scientific literature is sparse with respect to answering this particular question. Paraphilic or non-paraphilic, a one-size-fits-all approach likely benefits no one.

The concepts of cultural boundedness and influence are worth noting here, as features of mental health and other social events occur inside of cultural frameworks [94]. For example, dispositions and causes of paraphilias might be interpreted as either universal or culturally specific depending on people’s access to the Internet, various social media platforms (e.g. Twitter, Facebook), and pornographic sites—all of these being results of growing globalization, immigration, and sexual liberation having a significant impact on actual as well as reported frequencies of the occurrence of paraphilias. The issue of changing economics, rapid industrialization, social progression, and rural versus urban development also needs to be recognized, with lower socioeconomics and rural areas perhaps preserving more folk and even superstitious models of illness and treatment [95].

Logically, cultural influence then determines how various sexual problems are handled by legal authorities and healthcare providers in different places—be it through the courts, psychotherapy, medical intervention, social stigmatization, supportive networks, and so forth. In the USA, for instance, policies related to sexual perpetration typically result in punitive actions, sexual offender registration, and social ostracization. What is not clearly known is if the same occurs in non-Western countries, given differences in degrees of sexual transgressions (e.g., voyeurism as youthful sexual curiosity versus pedophilia as sexual abuse), potentially leading to differing degrees of social interventions. Exercising caution in making blanket extrapolations is advised. What is known is Western treatments are more generally applied worldwide in cultures that both access and embrace Western information. In the absence of these formulations and values, Western terminologies, approaches, and therapies do not necessarily come to mind.

From a cross-cultural perspective, ramifications of the impact of cultural influence on patient/client–provider interactions become relative. For example, if a patient were to disclose that a physical injury resulted from a non-consensual BDSM event with his or her partner, management of this would hopefully be the same in any standard medical setting regardless of the patient’s cultural identity: LGTBT, Middle Eastern, African, Asian, and so forth. In contrast, if a victim were to disclose intentional infliction of harm resulting from a consensual BDSM event, outcomes might vary widely based on cultural distinctions.

11 Sexual Modernity

Communal identity has long been identified as an essential influence on behavior, with a multitude of aspects of culture affecting the needs of its members through the majority’s approval or disapproval.

Sexologists regularly assess a society’s level of sexual awareness and proneness to approval in terms of sexual modernity—a measure of the readiness of organizations and institutions to offer maximal guidance for its members with respect to sex. Although cultures usually transcend national boundaries, social conditions vary substantially within countries when it comes to media access, mobility, income, employment, and other socioeconomic variables that influence sexual mores and behaviors. As knowledge and understanding of broader human sexual experiences increase, so does consumer willingness to tolerate behaviors that satisfy alternative sensory and symbolic needs. When modernity conditions are higher, functional strategies to increase awareness of sexual variants will carry the most appeal; when modernity conditions are lower, functional strategies to increase awareness of sexual variants will carry the least appeal. Measures of exposure to Western values and flexibility provide an accurate description of a nation’s level of sexual modernity.

Another aspect of sexual modernity that influences behavior is exposure to assorted sexual images, products, and services, such as pornography, sexual toys, and prostitution. The extent to which non-Western consumers are exposed to Western, sexually oriented cultural norms could potentially influence attraction to specific sexual images, products, and services.

When cultures describe low levels of sexual modernity, members may not be familiar with the visible aspects of sexual culture or with the ability of products and services to satisfy sensory and symbolic needs. But as cultures express more modernity, exposure to expanded concepts of sexuality increases, motivating members to desire the sexual acceptance and embrace the sexual norms that they see and associate with other cultures and societies. Sexual images and products that promote group connectedness, including values of sexual self-awareness and erotic self-fulfillment, will have greater appeal in higher modernity regions. The information that members access through various media will ultimately shape their needs and attitudes regarding images and the consumption of sexual products and services.

When cultures are high in sexual uncertainty avoidance, risk aversion is amplified, and members become less open to novel behaviors and sexual variety, such as paraphilias. In contrast, when cultures are low in sexual uncertainty avoidance, risk aversion is lessened, and members become more open to novel behaviors and sexual variety. That is, in low uncertainty avoidance cultures, sexual imageries and actions focusing on variability, novelty, and sensory gratification are heightened.

Given powerful social effects on modernity, regional culture would be expected to have moderating effects on sexual images, products, and services. Unfortunately, cultural data concerning sexual divergences are not widely available outside of North America and Europe. Research examining the effects of modernity and subculture on alternative sexual expression should prove enlightening.

12 Sexual Distance and Individualism

Two additional aspects of culture potentially have a significant impact on socio-sexual strategies concerning paraphilias—sexual distance and sexual individualism. Sexual distance is the extent to which a culture advances sexual inequality and discrimination. Cultures high in sexual distance tend to emphasize the role of traditionally defined morals in shaping vertical relationships and boundaries across sexual categories (i.e., paraphile versus non-paraphile, heterosexual versus homosexual, pornography consumer versus non-consumer). Persons in high sexual distance/high sexual uncertainty cultures tend to be avoidant, resistant to change and variety seeking, disinclined to risk, and intolerant of ambiguity.

Put another way, cultures with high sexual distance and low sexual individualism, where people are customarily focused on sexually exclusive roles and group affiliations, often define the social, symbolic, sensory, and experiential aspects of sexual variants as unacceptable. Cultures with low sexual distance and high sexual individualism, where people are not customarily focused on sexually exclusive roles and group affiliations, often define the social, symbolic, sensory, and experiential aspects of sexual variants as acceptable.

13 Awareness to Acceptance

Today’s sexologists strive to bring deeper awareness to and acceptance of the global vastness of human sexual expression. Cultural sensitivity to others’ norms, values, mores, attitudes, customs, practices, taboos, folklore, and folkways requires knowledge of others’ cultural influences and social structures. Of course, researchers continue to elucidate cultural universals—elements common to all cultures—to heighten sensitivity. Languages, dialects, foods, laws, and religious institutions all represent typical geo-demographic and geo-psychographic features. But these are general rather than specific area-based targets. For example, all people drink fluids of one type or another. But some drink alcohol, while others do not. What is accepted as “normal” may vary considerably from within and without; that is, normalcy is difficult to identify, define, and integrate. This leaves much room for misunderstandings, discrimination, and rejection—all too common outcomes when it comes to diverse modes of sexual expression.

Conventional efforts to eliminate intolerance are often too simplistic for such complex phenomena as paraphilias. To promote acceptance of human sexuality in the fullest sense—avant-garde or not, experts should focus energy on producing integrative methods that reduce ethnocentrism and transcultural judgments. Cultural relativism, or the view that one group should be evaluated according to its own standards and not those of another group, is helpful when considering sexual phenomena. Sexologists point out that there really are no good or bad cultures—just different cultures in terms of the specifics. This leads to an improved understanding of others’ standards because one’s own standards are not automatically assumed to be somehow better.

14 Opportunities and Directions

Sexuality in all of its forms is both subtle and complex. All societies obviously have sexual norms, even if not agreeable to all members. Most people desire authoritative guidance, at least to some extent, when it comes to sexual matters. In today’s world this translates into sexual laws and mores, with issues of individual privacy versus the common good determining specifics. Depending on the interpretations of these issues and laws, approval or disapproval of sexual behaviors will be more or less prohibitive.

Cultures clearly have a stake in determining the correctness or incorrectness of various sexual activities. Coercing or forcing individuals into sexual behaviors in which they do not want to engage, or for which they cannot make informed decisions due to incapacity or age, is certainly criminal. Tempting or seducing individuals into sexual behaviors, for which there is hesitancy but consent, is a gray area in which the need for social standards is less defined.

Only when members of societies organize collectively to enact change does lasting social communication and transformation occur. Sociocultural movements can dramatically shape the direction of shared thought. When activists and visionaries transcend conventional confines, they bring about momentous shifts in policies and structures.

As societies inevitably define what is lawful/desirable versus unlawful/undesirable, and because reporting of variant behaviors is directly affected by cultural directives, the collection of reliable data into the prevalence, disposition, and treatment of paraphilias, even under the most sexually liberal of situations, remains problematic and ambiguous. The subsequent virtual dearth of valid and generalizable scientific information about paraphilic desires and disorders is an invitation to sexologists worldwide to advance research in this important clinical area.