Paraphilias are clusters of sexual behaviors in the Diagnostic and Statistical Manual, V (DSM V)that have evolved with the evidence and social norms that for a diagnosis cause distress and impairment, at times to the sufferer, at times to society. As a result, there is controversy regarding what is deviant, illegal, and what is not, as this relates to sexuality. To some degree, the paraphilias are related to cultural views and norms, and as such can be difficult to define. Until 1973, homosexuality was defined as deviant for example, and was classified in the DSM-II as a paraphilia; the research and culture both probably influenced this shift from pathologizing homosexuality, and which has sparked this new controversy in paraphilias overall. People with paraphilias are not mentally ill, necessarily; these are a set of behaviors or interests that are distressing or impairing, and those with paraphilia have a sexual desire or behavior that involves another person’s psychological distress, injury, or death, or a desire for sexual behaviors involving unwilling persons or persons unable to give legal consent. The male to female ratio is roughly 20:1, depending upon the specific behavior. (American Psychiatric Association, 2013). The paraphilias Much of the data for the previous version, the DSM-IV TR and current DSM V were taken from forensics as well as clinical samples, making paraphilias a unique classification. Paraphilias include exhibitionism, which occurs when one exposes one’s genitals to an unsuspecting person or performs sexual acts that can be watched by others; fetishism is the use of inanimate objects to gain sexual excitement, and frotteurism is the touching or rubbing against a non-consenting person. Pedophilia is having a sexual preference for prepubescent children, and voyeurism includes having urges to observe an unsuspecting person who is naked, undressing, or engaging in sexual activities, or in activities deemed to be of a private nature. Transvestic fetishism is becoming aroused from clothing associated with members of the opposite sex; sexual masochism is the desire to be humiliated, beaten, bound, or otherwise made to suffer for sexual pleasure; sexual sadism occurs when the desire for pain or humiliation of a person is sexually pleasing. Paraphilia not otherwise specified includes a variety of behaviors including zoophilia, necrophila, coprophila, and others. (American Psychiatric Association, 2013) Comorbidity and paraphilia Other than pedophilia, which is a legal issue and not a medical one, is the question of is the behavior distressing and impairing because it is culturally taboo, a fear of discovery, or because the behavior is genuinely representative of something that is intrinsically distressing? I don’t have those answers and doubt that anyone does at present, but would warrant that pathologizing or medicalizing sexual behavior is precarious, and is why this classification is controversial in the psychiatric community. One reason that the paraphilia category remains in use is forensics and research rather than for help in the general population; there is currently no way to know what the underlying paraphilia means from the average patients perspective. One study surveyed adult men in an inpatient population for paraphilias to determine the prevalence; the results were that of the population, 8.0% engaged in voyeurism, 5.4% engaged in exhibitionism, and 2.7% in sexual masochism. The patients who engaged in paraphilic behaviors had more psychiatric hospitalizations, were more likely to have attempted suicide, and were significantly more likely to report having been sexually abused than patients without a paraphilia. (Marsh PJ et, al.) Research on in-patient sex offenders in one study from 1996-2001 on comorbid or co-occurring diseases that are frequently present along with paraphilias and childhood sexual abuse is the norm. Common comorbid diagnoses in sex offenders overall include depression, bipolar disorder, impulse control disorder, and antisocial, borderline, and narcissistic personality disorders. Offenders with paraphilia were much more likely than other offenders to have mood, anxiety, and impulse control disorders, and more than half of the subjects had been victims of sexual abuse themselves, while more than a quarter had been victims of incest. (Joan Arehart-Treichel) Treatment of paraphilias and discussion In forensics as far as sex offender populations, thus far proposed treatments have been fairly unsuccessful, with the exception of anti-androgens that have unfortunate side effects such as leg cramps, bone and mineral loss and cardiovascular disease, with a risk/benefit ration being unfavorable for using such drugs. Gonadotropin releasing hormone has shown some promise and efficacy working in a way that is similar to chemical castration. Gonadotropin releasing hormone desensitizes the hormone receptors, reducing luteinizing hormone that ultimately diminishes testosterone release from the testes. Treatment research in paraphilia itself is minimal; the sample sizes are small, there are few follow up studies; there are biases, and there is association with other comorbid conditions in the studies, making the results of treatment inconclusive at best. Treatment of non-criminal paraphilia is negligible. As for non-criminal paraphilia, sexuality is defined by culture, as far as what is deviant and what is not, an idea that varies with time and geography; this is influenced by a multitude of factors, including religion and location, but is not restricted to a single variant. Sexuality and sex behaviors may be sex positive or sex negative. There may be utility in paraphilias with respect to forensic applications and pathologizing sexual behavior in the general public does not appear to add much, if anything, to the characterization of sexuality; perhaps as we learn more on this subject, including cross-cultural phenomenon, we can further shape and change our ideas on paraphilias as a classification.