As far as is known, the paraphilias occur predominantly in males, with the exception of sexual masochism, which is also commonly observed in females, although still with less frequency than in males. Exceptions have been reported, including single case reports of female genital exhibitionism and female fetishism (11-13). Two recent reports described, collectively, five cases of accidental autoerotic death in females, with evidence strongly suggesting the presence of the paraphilia asphyxiophilia, in which cerebral hypoxia is induced for the purpose of generating or intensifying sexual arousal (14,15). Gosink reported that autoerotic deaths occur differentially in males and females at a ratio of more than 50:1. It is not known to what extent this figure reflects gender differences in the prevalence of other paraphilias. Another recent report described multiple paraphilias in a female, including fetishistic arousal to men in diapers as well as sexual sadism characterized by extreme preoccupation with sexual torture and a collection of detailed plans to murder young males to whom she was sexually attracted (16). Another report described a female sex offender who displayed elements of hyper-sexuality, sexual sadism, sexual masochism, and pedophilia, including violent sexual fantasies involving children (17).
Pedophilia in females is rare but has been reported. A recent review of records in the authors' clinic revealed, among 149 individuals diagnosed with one or more paraphilias, one female was diagnosed with pedophilia, one with sexual sadism, and five with paraphilia NOS. All other subjects were male. Chow and Choy recently reported on the positive response to treatment with the SSRI sertraline in a female diagnosed with pedophilia (18). True prevalence of pedophilia is difficult to determine from sex offender records, as offenders are not commonly assessed for deviant sexual interests and many studies fail to differentiate between sexually deviant and nondeviant offenders. Therefore, the relative occurrence of pedophilia in male and female sex offenders is not known.
A 1991 review by Wakefield and Underwager revealed that, among female sex offenders who were assessed for sexual deviancy, most were determined to not have pedophilia, suggesting that factors other than sexual gratification often motivate the behavior (19). Some gender differences in clinical characteristics between males and females with pedophilia have been suggested. Most significantly, while history of sexual victimization is reported with some frequency by both males and females with pedophilia, the higher frequency in females suggests that history of sexual abuse may have greater etiological significance in the development of pedophilia in females than in males (F. Berlin, personal communication, 2003) (19).
In summary, while the literature strongly supports the assumption that the paraphilias occur predominantly in males, there are increasing reports of paraphilias in females. The occurrence of paraphilias in females may be a less rare clinical phenomenon than previously assumed.
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