Coprophilia and Coprophagia: A Literature Review

Abstract

BACKGROUND:

Coprophilia and coprophagia are distinct paraphilias that fall under the category of other specified paraphilic disorders in the current edition of the Diagnostic and Statistical Manual of Mental Disorders. Coprophilia refers to sexual excitement from viewing, smelling, or handling feces, as well as fantasizing about another person engaging in these activities. Coprophagia, or eating one’s own or another person’s excrement, has also been observed in some patients with coprophilia.

AIMS:

The purposes of this review are to examine the current literature on the etiology, symptoms, interviewing techniques, pharmacotherapy, and psychotherapy used for each disorder and to elicit best practice guidelines in the treatment of patients with coprophila and coprophagia.

METHODS:

Electronic and hand searches were initiated using CINAHL, EBSCOhost, SAGEpub, and MEDLINE databases between 1990 and 2022 using the terms “coprophilia,” “coprophagia,” “paraphilia NOS,” and “other specified paraphilic disorder” restricted to English.

RESULTS:

Individual case reports and limited studies were found in this literature. Reported treatment protocols included individual and tandem use of pharmacotherapy and psychotherapy, with mixed outcomes. Future studies are needed to explore the factors that mitigate the paraphilias, therapeutic management, and treatment outcomes, to produce evidence-based practice treatment guidelines.

CONCLUSIONS:

Understanding the psychological and biological factors that may contribute to these disorders’ manifestations may portend a greater understanding and insight into the genesis of the paraphilias. Having specific evidence-based treatment protocols will afford the psychiatric nurse practitioner to render patient-centered, safe, and culturally competent care and effect better patient outcomes among this understudied population.

Some adults find sexual satisfaction through variations that depart from what society considers traditional and acceptable sexual outlets. First appearing in the psychiatric literature in 1934 (Money & Lamacz, 1989), paraphilias (from Greek, meaning “love beyond the usual”) are unusual—sometimes even bizarre and dangerous—sexual fantasies or practices that an individual finds necessary for sexual excitement and release (O’Donohue et al., 2017; Rathus et al., 2000). A paraphilia is considered a disorder when it produces angst or threatens to harm another person (Craig & Bartels, 2021). Paraphilias can be centered around a particular object or behavior but are typically characterized by preoccupation with excessive dependency on the object or behavior for sexual satisfaction (Money, 1986, 1999).

In the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association [APA], 2013, p. 685), the term paraphilia is defined as “any intense and persistent sexual interest other than sexual interest in genital stimulation or preparatory fondling with phenotypically normal, physiologically mature, consenting human partners.” Paraphilias, however, may not necessarily classify as “intense and persistent” but rather preferential sexual interests or sexual interests that are greater than nonparaphilic sexual interests. The addition of the word “disorder” to the classification of paraphilias is new to DSM-5 and continues with the Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev.; DSM-5-TR; APA, 2022). The term “disorder” was explicitly added to DSM-5 to indicate a paraphilia that is causing distress or impairment to the individual or a paraphilia whereby satisfaction entailed personal harm, or risk of harm, to others. This distinction was made to identify those sexual behaviors and interests of clinical significance. The DSM-5-TR further states that “a paraphilia is a necessary but not a sufficient condition for having a paraphilic disorder, and a paraphilia by itself does not necessarily justify or require clinical intervention” (APA, 2022, p. 780).

Paraphilic disorders are defined in the 11th edition of the World Health Organization’s (WHO) International Classification of Diseases (ICD-11; WHO, 2019, p.177) as follows:

Paraphilic disorders are characterised [sic] by persistent and intense patterns of atypical sexual arousal, manifested by sexual thoughts, fantasies, urges, or behaviours [sic], the focus of which involves others whose age or status renders them unwilling or unable to consent and on which the person has acted or by which he or she is markedly distressed. Paraphilic disorders may include arousal patterns involving solitary behaviours [sic] or consenting individuals only when these are associated with marked distress that is not simply a result of rejection or feared rejection of the arousal pattern by others or with significant risk of injury or death.

More than 500 different types of paraphilias have been documented (Aggrawal, 2009; Money, 1986, 1999) However, the eight most common of these are exhibitionism (i.e., exposing oneself to unsuspecting strangers), voyeurism (secretly observing others undressing or engaging in sexual activity), fetishism (sex involving nonhuman objects), transvestism (cross-dressing), frotteurism (rubbing against an unsuspecting stranger), sexual sadism (inflicting pain on a sexual partner), sexual masochism (enjoying pain received from a sexual partner), and pedophilia (sex with children). Several less common types include telephone scatologia (obscene phone calls), partialism (attraction to body parts), necrophilia (sex with corpses), and zoophilia (or bestiality, sex with animals).

For most of the 20th century, it was believed that paraphilias were rare (Moser, 1992; Moser & Kleinplatz, 2020), and most of the research on individuals diagnosed with paraphilias appeared in clinical (Arieti, 1944; Begg & McDonald, 1989; Ghaziuddin & McDonald, 1985; Karpman, 1948; Kellogg, 1897; Marsh et al., 2010) and forensic settings (Aggrawal, 2009; Briken et al., 2006; DeLisi et al., 2018; Dobbert, 2004; Eher et al., 2019; Krueger, 2010; Lee et al., 2020). However, recent research on nonclinical populations suggests paraphilias may be underreported, given people’s general hesitancy to report unusual sexual practices. For example, Bártová et al. (2021) found that 31% of men and 14% of women admitted to at least one paraphilic preference. Ahlers et al. (2011) reported that 44% of males engage in at least one paraphilic behavior. Similar findings have been reported worldwide (Baur et al., 2016; Chan, 2022; Dawson et al., 2016; Joyal & Carpentier, 2017; Makanjuola et al., 2008). Overall, far more men than women appear to have paraphilias (APA, 2013, 2022; Chan, 2022; Craig & Bartels, 2021; Dawson et al., 2016; Money, 1986), and it is not uncommon for an individual to manifest two or more paraphilias (APA, 2022).

Coprophilia and Coprophagia: Defined

Coprophilia and coprophagia are a subset of paraphilias and are classified in the DSM-5 as paraphilias not otherwise specified (APA, 2013) and in the DSM-5-TR as other specified paraphilic disorder (APA, 2022). To make this diagnosis, the personal distress experienced by the individual must have been acted upon for at least 6 months and does not meet the criteria for any other paraphilic disorders (APA, 2013, 2022).

Coprophilia (from the Greek, kopros, meaning “dung”) has as its definite focus in excrement (Rathus et al., 2000). While some experts have conceptualized coprophilia as only involving elimination (e.g., McCary, 1967), others have expanded this definition to include the consumption of feces, known as coprophagia (e.g., Allen, 1969). First described by Austrian psychiatrists among asylum inmates in the 1870s (Moore, 2018), coprophagia is often considered a form of pica (Leung & Hon, 2019). Complications of coprophagia include poor oral hygiene, chronic gingival infection, oral and salivary gland infections (Friedin & Johnson, 1979), chronic lesions on the mucosa of the vestibule secondary to the retention of feces (Dura et al., 1988), and even death (Byard, 2001; Erickson et al., 2017).

Coprophilia refers to sexual excitement from viewing, smelling, or handling feces, as well as fantasizing about another person engaging in these activities (Adams & McAnulty, 1993; Aggrawal, 2009; Dobbert, 2004). A coprophile might also become aroused by watching his partner defecate (Skinner & Becker, 1985). As with other types of paraphilias, coprophilia is often comorbid with other paraphilia—all with a focus on a particular individual or object (Aggrawal, 2009; Dobbert, 2004). Excessive desire and actual performance of the act has demonstrated in some patients showing intense guilt and remorse after completion, denoting a form of self-retribution for past wrongdoing (Azizi et al., 2018).

Further complicating matters of definition, some researchers have recorded patients’ interest in excreting on their sexual partner or playing with the excrement (Krafft-Ebing, 1903/1999). Janus and Janus (1993) use the term coprolagnia in describing “brown showers,” those who “achieve orgasm by being defecated on” (p. 112). Individuals who are involved in coprophilic activities do not actually engage in putting feces into their mouths (even though a very small percentage do) (Krafft-Ebing, 1903/1999; Smith, 1976). Instead, the preferred activities most often involve defecating on one’s “loved one” or being defecated upon (Carroll, 2007; Krafft-Ebing, 1903/1999).

Earlier research suggested that, as a whole, this group of paraphilias (i.e., as exclusive sexual outlets) appears to be quite rare (Adams & McAnulty, 1993; Kafka, 2010; Karpman, 1948; Xavier, 1955). In fact, Janus and Janus (1993) reported a prevalence rate of only 1% for coprophilia and 6% for urophilia (a sexual fetish with a focus on urine and urination) among men in their sample. Women reported a prevalence rate of 4% for urophilia (none reported engaging in coprophilia). However, coprophilia might be related to sadomasochism in that the person who enjoys this activity is often involved in a sadomasochistic act with domination/submission and hostile release (Sandnabba et al., 1999, 2002). For example, Sandnabba and colleagues surveyed 164 male sadomasochists in Finland and found that 18.2% of participants reported engaging in coprophilic behavior. Similarly, in an exploratory-descriptive study of a sadomasochistically oriented sample, Moser and Levitt (1987) reported a prevalence rate of 12.5% for coprophilic behavior. Ressler et al. (1986) noted 7% of sexual homicide offenders admitted to engaging in coprophilic behavior during their offenses. In his international survey of 1,580 women from the “kink” community, Rehor (2015) found the following percentages of feces play: (brown showers/scat/excrement/enemas): 3.35% had done them to others, 3.99% had the action done to them, 10.57% had watched the activity, and 13.73% had engaged in any form of the activity. In addition, a perusal of websites suggests that these paraphilias are not as uncommon as once believed.

The purpose for doing a review of the literature on this topic arose from the lack of studies found within the current psychiatric nursing literature. While current prevalence rates for coprophilia and coprophagia vary, what is known is that the paraphilias exist. Additional studies are warranted to assess current prevalence rates and to create best practice guidelines, while adding to nursing’s scientific base.

Coprophilia and Coprophagia in the Literature: Case Reports

Both paraphilias have been seen in patients with varying psychiatric and neurologic disorders, including dementia (Ata et al., 2010; Byard, 2001; Fonseca & Morgado, 2017; Josephs et al., 2016; Sharma et al., 2011; Tsoucalas et al., 2016), seizures (Arieti, 1944; Azizi et al., 2018; Josephs et al., 2016), brain tumor (Josephs et al., 2016; Stewart, 1995), autism (Baker et al., 2005; Hergüner & Hergüner, 2016; Ing et al., 2011; Kılıç & Kültür, 2019; Pardini et al., 2010), Tourette’s syndrome (Shapiro et al., 1988), schizophrenia (Chaturvedi, 1988; Harada et al., 2006; Lingeswaran et al., 2009; Lyketsos et al., 1985; Razali, 1998), schizoaffective disorder (Josephs et al., 2016), catatonia (Varadarajulu & Mahgoub, 2021), antibodies to N-methyl-d-aspartate (NMDA) receptors (Chong et al., 2009), steroid psychosis (Josephs et al., 2016), Kluver–Bucy syndrome (Marlowe et al., 1975; Mendhekar & Duggal, 2005), sialadenitis (Donnellan & Playfer, 1999), borderline personality disorder (Blasco-Fontecilla et al., 2015), obsessive–compulsive disorder (Zeitlin & Polivy, 1995), depression and hypothyroidism (Nicholls & Ananthanarayanan, 1998), depression and alcoholism (Wise & Goldberg, 1995), affective disorder (Azizi et al., 2018; Nissen & Haggag, 1987), cognitive impairment (Sharma, 2012), intellectual developmental disorder (Beck & Frohberg, 2005; Bugle & Rubin, 1993; Erickson et al., 2017; Hingsburger, 1989; Josephs et al., 2016), and malingering (Jaffe & Sharma, 1998).

Azizi et al. (2018) reported on two separate cases involving coprophagia. The report aimed to investigate the disorder’s pathophysiology, management, and outcomes, as there is limited empirical evidence in the literature that answers those queries. Findings showed a commonality of thought content disorder between both patients, but no other similarities were noted.

In earlier literature, the characteristics of coprophagia in adults in psychiatric hospitals have been described (Ghaziuddin & McDonald, 1985). In a study of 14 coprophagic patients with a mean age of 71 years, nine had dementia, two had epilepsy, two had alcoholism, two had depression, and one had depression with cerebral atrophy; three of the patients with coprophagia had no obvious signs of cognitive deficiency.

A study of scatolia, or the smearing of feces, in a long-term geropsychiatric facility identified 14 patients with this problem. All were incontinent of urine and feces. Constipation was a common factor, leading to attempted digital evacuation by the patients. When patients were treated with laxatives, their bowel frequencies returned to normal, and smearing ceased (Begg & McDonald, 1989). However, coprophagia was not seen in the cases of scatolia.

In children, Bacewicz and Martin (2017) reported a case of coprophagia in an 8-year-old boy hospitalized with feculent emesis. Friedin and Johnson (1979) rearranged the shower routine of a 7-year-old boy with intellectual developmental disorder to eliminate his low-frequency feces smearing and coprophagic behavior. Mendhekar and Duggal (2005) and Ing et al. (2011) describe the case of a 6-year-old girl diagnosed with autism who was referred to an outpatient clinic for coprophagia, fecal smearing, and disruptive and self-injurious behavior. The patient was successfully treated with noncontingent access to alternative stimuli.

Psychological and Biological Factors

Experts have not arrived at a consensus regarding the psychological dynamics underlying coprophilia. Smith (1976) offered an analytic interpretation of coprophilia—mainly that the excrement symbolically represents the penis and the presence of the fecal matter acts as a defense against castration anxiety. According to Gardner (1996), coprophilia is a product of childhood perversity in which a young child must learn that touching their fecal eliminations and then placing their fingers (or feces) in the mouth is viewed by society as a disgusting practice. If sexual stimulation becomes associated with the child’s focus on playing with the feces, this could increase the likelihood that the individual might later turn to the practice of coprophilia during adulthood. Karpman (1948) points out that feces [sic] are one of the child’s first toys.

Researchers are uncertain about the exact causes of paraphilias in general and coprophilia in particular, although these disorders probably develop from a combination of factors that come into play in specific ways for particular persons. One biological explanation holds that some people are simply “wired” to have paraphilias (Moser, 1992). Another holds that some men have stronger and more pervasive sex drives, possibly due to increased amounts of or sensitivity to the male sex hormone testosterone. As a result, such men are more prone to seek out other sexual outlets when more traditional outlets are not readily available. Their increased sexual reactivity may also facilitate learning a paraphilia like coprophilia (Lang et al., 1989).

Psychologically, the typical coprophile is perhaps repressed, fearful of adult intimate relationships, confused, and even hostile—eating excrement can be viewed as a desire for a lost love object (Karpman, 1948). Anger might play a more significant role in generating this paraphilic behavior than sexual interest. In some cases, the coprophile might symbolize or act out feelings of hostility and aggression by handling feces and defecating on sexual partners (Krafft-Ebing, 1903/1999; London & Caprio, 1950).

An example of a multidimensional approach to understanding coprophilia and other paraphilias is that of Money (1986), particularly his theory of lovemaps. Money has stressed that sexual variations like coprophilia develop from early childhood sources of erotic arousal that are later activated by particular combinations of psychosocial factors. Sexual deviations can occur at any time along the psychosexual developmental path or remain latent indefinitely. That is why persons from similar backgrounds do not necessarily develop similar sexual patterns. The question of who develops what disorder greatly depends upon the unique combinations of events present in any given situation for a given individual. Specifically, on the topic of coprophilia, Money (1986) explained the following:

Paraphilic fixation on excrement . . . stems from the anatomical proximity of the perineal organs of excretion to those of reproduction and genitoeroticism. In childhood, those organs and their functions are equated with dirtiness and the forbidden. Prohibition of what is dirty in the perineum, therefore, does not differentiate playing with the sex organs from playing with the organs and products of excretion. According to the opponent process principle . . . doing the dirty and forbidden is triumphal defiance over humiliating obedience. It is simultaneously a triumph over the equated dirtiness of the genitoerotic and the excremental functions. The equation signifies that the excremental and the genitoerotic are one. (p. 47)

Gardner (1992) developed his own theory concerning the evolutionary benefits of the paraphilias, including coprophilia. Gardner proposes that many different types of human sexual behavior (e.g., pedophilia, sadomasochism, necrophilia, zoophilia, coprophilia, klismaphilia, and urophilia) can be conceptualized as having species survival value and thus do “not warrant being excluded from the list of the ‘so-called natural forms of human sexual behavior’” (p. 20). Therefore, paraphilias like coprophilia might help fulfill nature’s purposes by enhancing general levels of sexual excitation in society, thereby increasing the chances that people will have sex and assuring the species’ survival.

From Gardner’s (1992, 1996) perspective, many of the paraphilias develop in an attempt to avoid intimacy, as is the case in fetishism, partialism, telephone scatologia, bestiality, and necrophilia. Others engender the release of anger, which might prove more important than the sexual act in serving as a mechanism for sexual gratification, such as coprophilia, urophilia, klismaphilia, and sexual sadism. Others develop to compensate for severe feelings of inadequacy, such as exhibitionism, voyeurism, pedophilia, and sexual masochism.

Interviewing Techniques

The interview should be patient-centered, culturally sensitive, and provide a safe and trusting environment (Wheeler, 2020). Use of therapeutic communication strategies such as active listening, using open-ended questions, accepting, offering self, clarifying, restating, and reflecting are beneficial to foster trust between patient and provider in establishing a therapeutic relationship (Townsend & Morgan, 2018; Wheeler, 2020). Motivational interviewing techniques have shown to be efficacious when utilized for this cohort to facilitate the patient to become empowered and think about and be an active participant in changing their behavior over time (Yakeley and Wood, 2018). The authors suggest providing an environment that endorses empathic understanding, acceptance, and mutual trust, engenders active participation rather than the patients sense the treatment is imposed on them (Yakeley and Wood, 2018). Furthermore, depending upon the patient’s mental status and comorbid psychiatric disorder noted upon presentation, information may be obtained from other informants in addition to the patient (Wheeler, 2020).

Psychotherapy

Because coprophilia, like other paraphilias, appears to be powerfully and deeply embedded in the personality, treatment is probably difficult at best (Laws, 1989; O’Donohue et al., 2017). Earlier forms of therapy included orgasmic reconditioning, the idea of substituting a noncoprophilic object, urge, or practice for the coprophilic one (Laws, 1989). This technique involves having the client masturbate to his usual coprophilic fantasies. Then during masturbation, when orgasm is inevitable, the patient switches his focus to a noncoprophilic object or fantasy (e.g., a photo of a nude woman). Orgasm occurs while the client looks at or thinks about the noncoprophilic object, reinforcing nondeviant sexual expression. The client repeats this procedure each time he masturbates, except that he switches his focus to the noncoprophilic object earlier and earlier. In time, he should find the noncoprophilic object more arousing than the coprophilic one. He ultimately loses interest in and abandons coprophilia in favor of another form of sexual expression.

The most usual approach today is cognitive behavioral therapy (CBT) to try to modify undesirable behavioral patterns (e.g., handling feces) and replace them with desirable patterns, all at the same time exploring the coprophile’s cognitions, emotions, reasons for engaging in coprophilic behavior, and social history (Zeitlin & Polivy, 1995). Azizi et al. (2018) state the time frame for resolution of coprophagia has been reported to occur within 6 to 22 weeks of treatment with pharmacotherapy and CBT.

Pharmacologic Intervention and Rationale

There is little information on the treatment of coprophilia and coprophagia. Strategies typically include treating any underlying nutritional deficiencies (thiamine) and psychiatric disorders, CBT, relief of pruritus ani and constipation, and continuing proper oral hygiene (Stewart, 1995). Carbamazepine has been known to terminate the behavior (Hooshmand et al., 1974; Stewart, 1995), which might have implications for the drug therapy of choice for coprophilia. Other medications that have successfully ameliorated symptoms include selective serotonin reuptake inhibitors (SSRIs), a handful of second-generation antipsychotics, and mood stabilizers (Azizi et al., 2018). There is no definitive rationale for why some medications have more efficacious results in a shorter time. Still, it is hypothesized that once the psychiatric symptoms of the comorbid condition are treated with CBT therapy, the patient is better able to change the behavior (Azizi et al., 2018).

Conclusion

In light of the dearth of studies in the extant literature, future studies need to be designed that explore the factors that mitigate the paraphilia, therapeutic management, and outcomes to produce evidence-based guidelines for treatment. While incidence and prevalence rates vary, what is known is that these paraphilias do exist. Further research is warranted to elicit current incidence and prevalence rates, especially within the forensic population. For the psychiatric nurse practitioner, additional research will not only increase knowledge of the psychological and biological factors that may contribute to these disorders’ manifestations but also may portend a greater understanding and insight into the genesis of the paraphilias. Having specific evidence-based protocols for treatment will afford the psychiatric nurse practitioner to render patient-centered, safe, and culturally competent care while affecting better patient outcomes among this understudied population.