context: Paraphilias are abnormal sexual behaviors or impulses characterized by intense sexual fantasies and urges that keep coming back. The urges and behaviors may involve unusual objects, activities, or situations that are not usually considered sexually arousing by others. Often, a paraphilia may be necessary for the person who has it to function sexually, despite the fact it may also be a source of significant distress. Paraphilias can lead to personal, social, and career problems, and a person with a paraphilia may be called "kinky" or "perverted." The associated behaviors may also have serious social and legal consequences. Exhibitionism (" Flashing") Exhibitionism involves someone exposing his or her genitals to an unsuspecting stranger. The individual with this problem, sometimes called a "flasher," feels a need to surprise, shock, or impress his or her victims. The condition is usually limited to the exposure with no other harmful advances being made. Nevertheless, "indecent exposure" is illegal. Actual sexual contact with the victim is rare. However, the person may masturbate while exposing himself or while fantasizing about exposing himself. Fetishism People with fetishes have sexual urges associated with non-living objects. The person becomes sexually aroused by wearing or touching the object. For example, the object of a fetish could be an article of clothing, such as underwear, rubber clothing, women's shoes, women's underwear, or lingerie. The fetish may replace sexual activity with a partner or may be integrated into sexual activity with a willing partner. When the fetish becomes the sole object of sexual desire, sexual relationships often are avoided. A related disorder, called partialism, involves becoming sexually aroused by a body part, such as the feet, breasts, or buttocks. Frotteurism With this problem, the focus of the person's sexual urges is on touching or rubbing his or her genitals against the body of a non-consenting, unfamiliar person. In most cases of frotteurism, a male rubs his genital area against a female, often in a crowded public location. The contact made with the other person is illegal. Pedophilia People with pedophilia have fantasies, urges, or behaviors that involve illegal sexual activity with a child or children. The children involved are generally 13 years of age or younger. The behavior includes undressing the child, encouraging the child to watch the abuser masturbate, touching or fondling the child's genitals, and forcefully performing sexual acts on the child. Some pedophiles, known as exclusive pedophiles, are sexually attracted only to children and are not attracted to adults. Some limit their activity to incest, involving only their own children or close relatives. Others victimize other children. Predatory pedophiles may use force or threaten their victims with what will happen if they disclose the abuse. Health care providers are legally bound to report such abuse of minors. Pedophile activity constitutes rape and is a felony offense punishable by imprisonment. Sexual Masochism Individuals with this disorder use the act -- real, not simulated -- of being humiliated, beaten, or otherwise made to suffer in order to achieve sexual excitement and climax. These acts may be limited to verbal humiliation, or they may involve being beaten, bound, or otherwise abused. Masochists may act out their fantasies on themselves by such acts as cutting or piercing their skin or burning themselves. Or they may seek out a partner who enjoys inflicting pain or humiliation on others. Activities with a partner include bondage, spanking, and simulated rape. Sadomasochistic fantasies and activities are not uncommon among consenting adults. In most of these cases, however, the humiliation and abuse are acted out in fantasy. The participants are aware that the behavior is a "game" and actual pain and injury is avoided. A potentially dangerous, sometimes fatal, masochistic activity is autoerotic partial asphyxiation. With this activity, a person uses ropes, nooses, or plastic bags to induce a state of asphyxia (interruption of breathing) at the point of orgasm. This is done to enhance orgasm, but accidental deaths sometimes occur. Sexual Sadism Individuals with this disorder have persistent fantasies in which sexual excitement results from inflicting psychological or physical suffering (including humiliation and terror) on a sexual partner. This disorder is different from minor acts of aggression in normal sexual activity -- for example, rough sex. In some cases, sexual sadists are able to find willing partners to participate in the sadistic activities. At its most extreme, sexual sadism involves illegal activities such as rape, torture, and even murder, in which case the death of the victim produces sexual excitement. It should be noted that while rape may be an expression of sexual sadism, the infliction of suffering is not the motive for most rapists, and the victim's pain generally does not increase the rapist's sexual excitement. Rather, rape involves a combination of sex and gaining power over the victim. These individuals need intensive psychiatric treatment and may be jailed for these activities. Transvestitism Transvestitism, or transvestic fetishism, refers to the practice by heterosexual males of dressing in female clothes to produce or enhance sexual arousal. The sexual arousal usually does not involve a real partner but includes the fantasy that the individual is the female partner as well. Some men wear only one special piece of female clothing, such as underwear, while others fully dress as female, including hair style and make-up. Cross-dressing as a transvestite is not a problem unless it is necessary for the individual to become sexually aroused or experience sexual climax. Voyeurism (" Peeping Tom") This disorder involves achieving sexual arousal by observing an unsuspecting and non-consenting person who is undressing or unclothed or engaged in sexual activity. This behavior may conclude with masturbation by the voyeur. The voyeur does not seek sexual contact with the person he or she is observing. Other names for this behavior are "peeping" or "peeping Tom." Most paraphilias are rare and are about 20 times more common among males than among females. However, the reason for this disparity is not clearly understood. While several of these disorders are associated with aggressive behavior, others are not aggressive or harmful. Some paraphilias -- such as pedophilia, exhibitionism, voyeurism, sadism, and frotteurism -- are criminal offenses. Having paraphilic fantasies or behavior, however, does not always mean the person has a mental illness. The fantasies and behaviors can exist in less severe forms that are not dysfunctional in any way, do not impede the development of healthy relationships, do not harm the individual or others, and do not entail criminal offenses. They may be limited to fantasy during masturbation or intercourse with a partner. It is not clear what causes paraphilia. Some experts believe it is caused by a childhood trauma, such as sexual abuse. Others suggest that objects or situations can become sexually arousing if they are frequently and repeatedly associated with a pleasurable sexual activity. In most cases, the individual with a paraphilia has difficulty developing personal and sexual relationships with others. Many paraphilias begin during adolescence and continue into adulthood. The intensity and occurrence of the fantasies associated with paraphilia vary with the individual, but they usually decrease as the person ages. Most cases of paraphilia are treated with counseling and therapy to help the person modify his or her behavior. Medications may help to decrease the compulsiveness associated with paraphilia and reduce the number of deviant sexual fantasies and behaviors. In some cases, hormones are prescribed for individuals who experience frequent occurrences of abnormal or dangerous sexual behavior. Many of these medications work by reducing the individual's sex drive. To be most effective, treatment for paraphilia must be provided on a long-term basis. Unwillingness to comply with treatment can hinder its success. It is imperative that people with paraphilias of an illegal nature receive professional help before they harm others or create legal problems for themselves.