Sexual Sadism and Sexual Masochism

20 May

Sexual Sadism and Sexual Masochism

Sexual sadism denotes sexual arousal and excitement in response to the psycho- logical or physical suffering of another, whereas sexual masochism denotes a pre- ferred fantasy of selfsuffering. The term sexual sadism derives from the name of the 18th century French aristocrat and pornographic author, Marquis de Sade, who reportedly lived a disreputable adult life abusing young prostitutes. The term sexual masochism was coined by the 19th century psychiatrist Richard von Krafft-Ebing, who derived the term from the name of the well-known German novelist Leopold von Sacher-Masoch, who was reported to have high interest in images of brutality, and in fantasies of being enslaved by a beautiful and torturing  woman.  Freud  was  the  first to  combine  both  terms—sadism and masochism—into the expression sadomasochism.

The term sadomasochism suggests a fundamental link between sexual sadism  and  sexual  masochism.  Although  not  all  masochists  also  practice sadism and vice versa, factors distinguishing sadism from masochism in any one individual may be subtle and paradoxes may be inherent to both the maso- chist’s and the sadist’s positions. The supposedly submissive masochist holds control and defines the limits of activity, whereas the sadist suffers a dependence on control (34). For example, the man who erotically enjoys being beaten appears at first glance to be a masochist. Thorough assessment, however, may reveal that he is most aroused by the sadistic experience of controlling his partner by pushing her as far as he can, against her will, to inflict pain on him. The more she resists, the more aroused he is. Only a keen understanding of these subtleties and a detailed investigation of the partners’ overt behaviors and internal experiences elucidate an accurate diagnostic formulation.

The incidence of either sexual sadism or sexual masochism is unknown but both appear to be more common in individuals of middle and upper socioeco- nomic groups. Some utilize prostitutes to act out their fantasies (37). Baumeister estimates that between 5% and 10% of the population engage in some form of recreational sadomasochistic activity, where light discomfort, but not severe pain or injury, is commonly inflicted (38). Far fewer have engaged in sex play where sadomasochistic fantasies are acted out on a regular and preferred basis. Nevertheless,  the  prevalence  of  sadomasochistic  social  clubs  suggests  that these preferences are not rare. Surveys of sadomasochistic magazine readers and club members suggest that masochistic interests are more common than sadistic interests.

The actual behaviors, as well as their intensity, associated with sadomaso- chistic preferences vary greatly (39). Spanking or being spanked is common, often using implements such as whips, canes, or hairbrushes. Also common are tying, blindfolding, or handcuffing, or the masochistic reciprocal of being tied, blindfolded, or handcuffed. More rarely, acute pain is inflicted, such as by apply- ing burning candles to bare skin or piercing the skin with sharp objects. Although it is commonly asserted that sadomasochistic partners maintain tightly controlled parameters to avoid serious injury, activities can get out of control and occasion- ally do lead to injury. In S&M clubs, individuals may be suspended from ceilings or confined in cages. Such behaviors underscore, in the eyes of some theorists, both  control  and  hostility  as  core  elements  in  sadomasochism. Among the most dangerous of activities  are  those that  involve  choking and strangling. Even  the  most liberal  advocates of recreational  S&M warn against  “breath control play” or asphyxiophilia, asserting that no amount of care can reliably prevent death (40).

Fetishism and Transvestic  Fetishism

Fetishism

Fetishism was first described in 1886 by Richard von Krafft-Ebing and in 1887 by French psychologist Alfred Binet (41 – 43). The essential feature is the necessity for an inanimate object to achieve or maintain sexual arousal, either in fantasy or in actual behavior. The fetish is often preferred or required for arousal, egosyn- tonic, and rarely the cause of personal distress. Individuals may experience sexual dysfunction when engaging sexually without use of the fetishistic object or fantasy.

Fetishism is demarcated from paraphilia not otherwise specified by the exclusion of body parts from the definition of fetishism. Fetishism is definition- ally limited to the use of nonliving objects and often features masturbation while holding, rubbing, or smelling the object, whereas fetish-like preferences related to the human body or other living creatures are generally coded as paraphilia not otherwise specified (5). These categorical distinctions and their rationale are unclear and are also the source of professional debate (44). According to DSM-IV-TR nosology, for example, what is commonly referred to as “foot fetishism” is a form of partialism and is coded, therefore, as paraphilia NOS (302.9). Many clinicians and researchers, however, conceptualize fetishism as not limited to nonliving objects but, rather, including arousal to part objects (body parts) as well. In this conceptualization, foot fetishism and other part object paraphilias are coded as fetishes (302.81) (20,45).

There is very limited data about fetishistic individuals, since they rarely seek treatment. Many studies are in the form of single case reports. A review by Chalkley and Powell examined the clinical characteristics of 48 fetishists (9). The sample was predominantly male; 22% were homosexual; the majority described preferences for multiple fetishistic objects; and soft textured fabrics were more arousing than hard textures such as rubber.

In his study of Internet chat groups, Junginger found feminine underwear, rubber objects, and body parts such as feet, toes, legs, hair, and ears to be among the most common, although it also appears quite common to fetishize the form or texture of an object, such as silk or rubber. Discussion groups related to diapers and enemas were also found to be common (46). An interesting phenomenon is the shifting of fetish trends over time. Mason has pointed out that a century ago objects made of velvet and silk were preferred, whereas today rubber and leather appear to be more common (44).

A brief Internet search dispels any doubt regarding the high prevalence and diversity of fetishistic curiosity in modern culture. A search, during the summer of 2003, of the word “fetish” drew a list of 359 possible sites and 1192 possible pages, offering both the curious and the desperate virtual buffet of fetishistic opportunities.

Transvestic Fetishism

In transvestic fetishism, cross-dressing in feminine apparel is fetishistically used, or the fantasy of such via autogynephilic—meaning love of self—imagery. The term transvestism was coined by the German sexologist Magnus Hirschfeld (47). DSM-IV-TR criteria require that a heterosexual male experience “recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving cross- dressing” (5,48). The fantasies and behaviors must cause distress or impairment in psychosocial or occupational functioning. The diagnosis is subcategorized to specify whether gender dysphoria, or discomfort with one’s biologic sexual des- ignation, is or is not present. This dimension varies greatly among the cross- dressing population. Some transvestites develop  marked distress about their biologic designation and seek sexual reassignment, whereas others express no such  wish.  Blanchard  used  the  term  transvestic  autogynephilia,  literally meaning “love of oneself as a woman,” to refer to the core feature of sexual exci- tement in response to cross-gender behaviors or fantasies, which include but are not limited to cross-dressing, in the transvestic fetishist (49).

Cross-dressing itself is not diagnostic of transvestic fetishism. Early inves- tigators found cross-dressers to report a wide range of behaviors. The nuclear transvestite  clearly  and  exclusively  fulfills  DSM  diagnostic  criteria.  Other cross-dressers engage in some bisexual or homosexual experiences, although their basic orientation is heterosexual (50). Still others are effeminate homo- sexuals whose cross-dressing is in no way fetishistic.

Many transvestic individuals do not seek psychiatric evaluation or do so only if discovered by a spouse or family member or if they become gender dys- phoric. Thus, knowledge is extremely limited regarding the phenomenological features of fetishistic cross-dressers who do not seek psychiatric assistance. When fetishistic  cross-dressers seek  evaluation  for  gender dysphoria or  for sexual reassignment surgery, they often minimize their arousal patterns when cross-dressed. Resources such as local transsexual support groups and Internet sites may counsel individuals to minimize disclosures that might jeopardize their hopes for surgical or hormonal reassignment. Thus, patients are increasingly savvy about what is expected during psychiatric assessment. The clinician must be aware of these phenomena and that fetishistic arousal is often denied.

A survey of subscribers to a magazine for transvestites offers a broader picture of men reporting themselves to be cross-dressers (51). The vast majority were heterosexual, although almost one-third had some homosexual experiences. Cross-dressing was reported to begin before the age of 10 in two-thirds and the majority noted that cross-dressing allowed them to express a different and pre- ferred side of their personality. The respondents, 57% of whom were above the age of 40, reported that they experienced sexual excitement and orgasm while cross-dressed only occasionally. In total, 75% had experienced  the  need  to purge cross-dressing by throwing out all of their feminine clothes and attempting to renounce the need to cross-dress; 83% reported that their wives were aware of the cross-dressing but only 28% experienced their wives as accepting of it. A dis- tinct minority felt themselves to be a woman trapped inside a man’s body, while three-quarters felt that they were men with a feminine side. The majority felt that they were equally masculine and feminine and almost one-half were interested in utilizing female hormones. Only 17% would have sexual reassignment, if poss- ible, and 45% had at some time consulted a psychologist or psychiatrist. Two- thirds of those who had sought therapy reported it as helpful. When compared with a similar survey 25 years earlier, this figure reflected a dramatic difference in those endorsing help by psychotherapy, perhaps suggesting greater under- standing of the disorder by the mental health profession (52). The majority of cross-dressers in both surveys were primarily heterosexual. Some males, collo- quially designated as “drag queens,” cross-dress to mimic feminine behavior satirically rather than fetishistically. Such individuals do not meet criteria for the diagnosis of transvestic fetishism (53).

Transvestic fetishists report a spectrum of behaviors and cognitions. It is important to note that for some, the need for erotic arousal abates over time. As  the  erotic  cross-dresser  ages,  his  cross-dressing  may  be  used  more  to reduce anxiety than to produce sexual arousal (54).

The content of transvestic fantasy varies. It may be of the self with female genitals and breasts, partially or entirely nude; dressed in female attire; as a preg- nant woman; engaged in nonsexual feminine activities such as house cleaning; or engaged in sexual activity, in the role of a woman, with a partner (55).

The personality profiles of fetishistic cross-dressers who present as patients reveal elevated rates of neuroticism as well as lower rates of agreeableness. This may suggest a vulnerability for affective distress and the propensity for disagree- ableness, which may foster marital discord (56). In a nonclinical cohort of cross- dressers attending a weekend seminar, personality characteristics were found to be no different than normal controls, with the exception of higher reported levels of openness to fantasy (57). These data suggest that the cross-dresser who seeks treatment may be significantly different from the nonpatient transvestite. If so, data from clinical cohorts may not be generalized to all cross-dressers.

Studies indicate that    50% of applicants for surgical sex reassignment have histories of transvestic fetishism (58). The gender dysphoric transvestite may make a dramatic presentation with acute gender dysphoria and the wish for sexual reassignment. Therefore, thorough understanding of these disorders is critical for clinicians (58,59). It must be considered that gender dysphoria is a transient “state phenomenon” related to loss, trauma, or comorbid state (29). Such cases demand consideration of aggressive antidepressant treatment and restraint from supporting sex reassignment as a first line solution. For some trans- vestites, an initial optimism about reassignment is replaced by depression when issues of loss emerge or if illusions about the financial feasibility of reassignment are shattered. Clinicians are advised to avoid simplistic short-term solutions and to remain cognizant of the possibility of emergent deeper levels of dysphoria and self-destructive thoughts. Not uncommonly, complex underlying themes and comorbid conditions become more apparent as treatment progresses, suggesting the pursuit of a long-term treatment approach combining psychotherapy and medication.

Pedophilia

Pedophilia, which literally  means “love  of  children,”  is  a  complicated  and distressing disorder encompassing both psychiatric and forensic spheres. It is a paraphilic syndrome characterizing individuals who experience recurrent and intense erotic fantasies, urges, or behaviors involving a prepubescent (13 years of age or younger) child.  To meet DSM-IV-TR criteria, the  individual  has either acted upon such urges, or the urges cause significant distress or interperso- nal difficulty. Also, to be diagnosed with pedophilia, an individual must be at least 16 years of age and at least 5 years older than the victim. Excluded from this  category  are  older  adolescents  who  are  involved  sexually with  12-  or

13-year-olds. Specifiers denote whether the individual is sexually attracted to males, females, or both; whether the behavior is limited to incestual relationships; and whether the  attraction  to children  is exclusive  or non-exclusive. These specifiers are  best  viewed  as  descriptive  as  opposed  to  reflecting  discreet categories (10).

Sexual behaviors with children, unfortunately, are not uncommon. In a general population survey, 12% of men and 17% of women reported that as a child they were sexually touched by an adult (60). The perpetrators of this beha- vior were often parents or other caretakers. Not all child abuse is motivated by a preferred attraction to younger individuals. Some individuals sexually abuse chil- dren in an opportunistic manner, when intoxicated, or secondary to dementia or mental retardation. Still others are indiscriminate in their partner choice due to excessive drive and loss of impulse control. These individuals may have sex with any available or exploitable person, regardless of age, but are not motivated by a nonnormative age attraction.

Therefore, it is critical for clinicians to note that not all child sexual

offenses are pedophilic. The essential feature of pedophilia is a primary erotic attachment to children, not criminal-mindedness. Many individuals with pedo- philia suffer from fantasies and urges but never engage sexually with a child. Many pedophilic individuals describe romantic love and affection for the children to whom they are also sexually attracted and may fantasize about being in a committed, loving relationship with the child. As abhorrent as this may be to others, an individual with pedophilia is also a sex offender only if he engages in the illegal act of sexual behavior with a child. In and of itself, pedophilia is an unfortunate psychosexual affliction, but not criminal. Most indi- viduals with pedophilia would be grateful to experience more normative sexual attractions.

Approximately 90% of sexual abuse offenses with children are perpetrated by males  (61). Consistent with that  figure, it  appears  that  individuals with pedophilia are predominantly but not exclusively male (62).

Behavioral manifestations of pedophilia vary widely. Some individuals endorse primary erotic fantasies of children but never act upon such urges, including by the use of pornography. Others limit their behavior to viewing child pornography. For some, use of child pornography appears to fuel the under- lying pedophilic urges and increases the risk of escalation from urge to action. However, while clinical observation suggests such as association, only objective research will clarify the correlation, if there is one at all, between exposure to pornography and behavioral manifestation of any paraphilia.

The growth of the Internet and electronic access to child pornography has led to recent legal quagmires regarding exploitation of real vs. virtual children. Possession of child pornography, including in a downloaded format on one’s per- sonal computer, is a criminal felony. However, a recent supreme court decision reversed some aspects of the Child Pornography Prevention Act by ruling that there is no evidence that computer-generated images of children are linked to harm to real children and that regulation of such images is an infringement of pro- tected free speech (63). Similarly, in a recent case involving a patient of one of the authors, in the course of soliciting sex with a supposed minor via the Internet, the individual was entrapped by a federal agent posing as the minor. The charges were later dismissed on grounds of their being no real victim and that prosecution could not be justified on the basis of a “virtual” victim.

Paraphilia  Not Otherwise Specified

When the defining characteristics of a nonnormative pattern of erotic interest meet the DSM-IV-TR general criteria for paraphilia but fall outside the diagnostic cri- teria for the eight listed paraphilias, the interest is categorized as a paraphilia not otherwise specified. Presumably because the number of possible paraphilias and fetishes is virtually limitless, the DSM-IV-TR lists as specific paraphilias those most commonly observed and reported in clinical and forensic practice. The para- philia NOS category includes the many other nonstandard sexual interests, and lists seven as examples: telephone scatologia (obscene phone calls), necrophilia (corpses), partialism (exclusive focus on part of the body), zoophilia (animals), coprophilia (feces), klismaphilia (enemas), and urophilia (urine).

Definitional problems regarding the paraphilias become particularly appar- ent in the NOS category. There are dozens of paraphilias described in the litera- ture, including some listed in the DSM-IV-TR as examples of paraphilia NOS, that fail to meet any of the three subtype criteria for paraphilia: erotic focus on nonhuman objects, suffering or humiliation of self or partner, or children or other nonconsenting persons (64). Partialism, coprophilia, urophilia, and numer- ous other atypical interests described in the literature involve a human focus and do not inherently involve suffering, humiliation, or nonconsenting persons.

Kafka proposed that some problematic sexual behaviors, while they meet DSM-IV-TR criteria for paraphilia NOS, are more accurately conceptualized as a distinct disorder, for which he proposed the category “paraphilia-related disorders” (65,66). Paraphilia-related disorders involve fantasies, urges, or beha- viors that do not meet DSM-IV-TR criterion A for paraphilia because they are normative in content by societal standards but occur with pathological frequency or intensity.

Like the paraphilias, they are repetitive, intrusive, and persist for at least 6 months. Kafka’s suggested paraphilia-related disorders include egodystonic com- pulsive masturbation, protracted promiscuity, and dependence on pornography. This conceptualization has not met with consensus and it remains unclear how such categorical distinctions improve the current classification system. Hope- fully, future iterations of the DSM will resolve some of the nosological confusion.

ETIOLOGY OF  THE PARAPHILIAS

The etiology of the paraphilias remains largely unknown at this time. Studies have identified broad areas of influence as well as some specific risk factors, but precise underlying mechanisms and comprehensive theories of causality await elucidation. What follows are the dominant explanatory theories and ident- ified risk factors. The most current thinking assumes that etiology is based in a complex multifactorial equation reflecting both biology and environment.

Psychoanalytic Models of Etiology

Psychoanalytic writers posit that early life experiences are fundamentally related to the development of the paraphilias. Stoller asserted that vengeful hostility, in response to the young child’s ambivalent struggle to separate from his mother, is the core of all perversion (67). Many variations of this theme have been proposed.

Psychoanalytic View of Fetishism

Psychoanalytic theory suggests that fetishism is due to unconscious fears and a sense of inadequacy related to early childhood experience (68,69). Freud pro- posed that fetishism originates in the phallic phase of psychosexual development as a male child experiences anxiety about his mother’s missing penis, for which he finds a symbolic object, thus resolving his fear and restoring an erotic attach- ment to his mother (70). The memory of sexual pleasure as a mechanism to cope with stress becomes fixated and eventually transmutes into repetitive behavior.

Psychoanalytic View of Transvestic Fetishism

In the orthodox psychoanalytic view, cross-dressing is a defense against cas- tration  anxiety.  Some proposed that  transvestism represents an  unconscious wish  for  the  father’s  attention  by  identification  with  the  mother  (71,72).

Greenacre described transvestism as an effort at reparation of a flawed body image in early life (73). Stoller described transvestism as a “hostile mastery” of early trauma and humiliation by the mother (74). In contrast, Oversey and Person  suggested  anxiety  as  the  central  theme  in  transvestism,  caused  by flawed maternal bonding and consequent incomplete sense of self (75).

Psychoanalytic View of Exhibitionism

To the psychoanalyst, exhibitionism is associated with childhood experiences with a dominant, seductive mother and a distant father (69,76). The assault on the male child’s developing sense of masculinity and adequacy is resolved in the feelings of gratification and power when a female reacts to his genital displays.

Psychoanalytic View of Sadomasochism

Stoller described sexual masochism as the neurotic eroticization of maternal hatred, a narcissistic solution to early life trauma (74), although in later writings, after observing many higher functioning individuals and couples who engaged in recreational S&M practices, he questioned his earlier assumptions (77,78). Kernberg suggested that masochists experience narcissistic gratification in the grandiose view of the self associated with high tolerance for pain (79). Waska described the masochist as alternating between compulsion toward servitude and rage at the internalized possessive, rejecting, or neglectful maternal object (80). The masochist suffers a  core  incapacity  to  self-soothe and, therefore, deep cravings to be soothed by others. The cravings, and accompanying rage, explain the masochist’s inherently ambivalent position, in which self-suffering disguises feelings of anger and yearning for maternal soothing. Ultimately, his compensatory style is one of the expecting to be hurt by those from whom he needs love, and one of the confusing pain and humiliation with longed-for love. He tolerates pain and suffering in order to remain attached to the needed but pain-causing mother, a stance that is preferable to no attachment at all. In Lebe’s  formulation,  the  masochist  is  sensitive  to  others  but  cannot  be  to himself because as a child he was unable to differentiate between self and the punishing or rejecting mother (81). A more recent formulation proposed that sexual desire itself is a driving force in masochism, and that sadomasochistic aggression is, paradoxically, an attempt to find safety under the primitive lure of sexual feelings and preoedipal yearnings (82).

Psychoanalytic interpretations assist the clinician in formulating a sense of the early life experiences of individuals seeking treatment and in understanding their developmental vicissitudes. Most clinicians who treat individuals with para- philias can provide testimony to the life stories that offer convincing anecdotal evidence  for  the  relevance  of  psychoanalytic  constructs  to  our  efforts  to explain unusual erotic interests.

Family Dysfunction Models of Etiology

Other etiological theories, while not based specifically in psychoanalytic thought, view paraphilias as developing out of adverse early life experience and dysfunc- tional  family  processes. Studies  have  found  varying  degrees  of  association between the childhood experiences such as emotional and sexual abuse, family dysfunction, behavior problems, and the paraphilias. In a recent study, childhood sexual abuse was determined to be a specific developmental risk factor for ped- ophilia, whereas emotional abuse and other adverse experiences were found to be general risk factors for the paraphilias (83). Other studies have contradicted this finding (84 – 86). However, most have concluded that, at the least, adverse child- hood experiences increase the risk of developing pedophilia (83,87 – 91). In par- ticular, based on the higher rates of sexual abuse in the life histories of many, although not all, individuals with pedophilia, sexual abuse is now widely recog- nized as a risk factor in the development of pedophilia (89,92,93). Berlin has observed that of the females diagnosed with pedophilia in his clinic over the past 15 years, all reported histories of childhood sexual abuse, leading him to conclude  that  childhood  sexual  abuse  may  play  a  particularly  significant role in the development of pedophilia in females (F. Berlin, personal commun- ication, 2003).

A recent study of the perceptions of sexual offenders found a significant positive association between child sex offending and offender self-reports of childhood neglect and abuse, including sexual abuse and early  exposure to sexually deviant behavior (94). As in many studies, the sample population was described  in  nonspecific  categorical  language  such  as  “child  molesters,” leaving ambiguity regarding how many of the offenders were pedophilic. Nevertheless, the results are consistent with the hypothesis that negative early interpersonal experiences may play a contributing role in the development of problematic adult sexuality, including pedophilia.

A study of five adolescent males who practiced autoerotic asphyxia revealed early histories of physical abuse, sexual abuse, and, more specifically, choking in each of the five boys. The investigators hypothesized that choking had become paired with sexual arousal and that the pairing, along with the abusive early experiences, were etiologically relevant to the development of a paraphilia in four of the five boys (95).

Behavioral  Models of Etiology

Conditioning  Theories of Paraphilia

Theorists of classical conditioning have proposed that some forms of fetishism can be explained by early learned associations between sexual stimulation and common objects of infancy such as diapers, bottles, and pacifiers (22). One early study using aversion techniques with sexual offenders provided modest support  for  conditioning  theories,  in  that  frequency  of  masturbation  to exhibitionist fantasies, implying stronger conditioning, was associated with treatment failure (96). However, etiological explanations based on responses to treatment have limited validity.

Clinical work in the Internet era provides observational support for the role of conditioning in the paraphilias. Exposure to Internet-based sexually explicit material and accompanying high levels of sexual arousal appear to, in some indi- viduals, profoundly influence the development of conditioned sexual fantasy and arousal responses. However, there is a wide range of responses to comparable levels of exposure. Therefore, caution must be exercised in drawing conclusions about any direct causative effects of exposure—Internet or otherwise—on the development or latensification of psychosexual pathology. Fisher and Barak have presented eloquent reviews on the effects of exposure to pornography, concluding that it is difficult to distinguish between the effects of exposure and the effects of pre-existing underlying personality factors in individuals who seek such exposure (97).

In contrast to classic conditioning is the theory of imprinting, which pro- poses that early childhood is a critical period in which animals instinctually grow attached to a primary object. Species such as precocial birds are thought to become “imprinted,” or physiologically programed to follow whatever crea- ture or object they see shortly after hatching (98). Binet hypothesized pathologi- cal imprinting in humans as a possible explanation for the development of fetishes (41). Owing to events in sensitive developmental periods, an association between arousal and a particular object or experience becomes imprinted. Study of nonhuman species suggests that behavior learned through imprinting is extre- mely difficult, if not impossible, to unlearn, whereas in classic conditioning models deconditioning and reconditioning are, theoretically, possible. Overall, empirical attempts to validate conditioning theories in the etiology of paraphilias have produced mixed results.

Junginger pointed out the possible relevance of the two-process learning theory, which has earned acceptance as an explanation of avoidance behavior in obsessive-compulsive disorder, to the development of fetishism (46). In this conceptualization, a formerly neutral object, when paired with sexual stimu- lation, acquires the power to elicit sexual arousal, leading to an operant response of stimulation and approach, rather than fear and avoidance as in OCD. The rewards inherent in sexual arousal and orgasm then serve as positive reinforcement.

Deviant Arousal Theory of Paraphilia

Some behaviorists have examined the role of deviant arousal—arousal in response to deviant or nonnormative stimuli—in the etiology of sexual offending behaviors. Some have found evidence of deviant arousal in pedophilia and others have found deviant arousal in exhibitionism, although with concurrent higher arousal to normative stimuli (99 – 101). Still other studies have failed to find deviant arousal in exhibitionism. The inconsistent findings suggest that deviant arousal is present in some men with paraphilia and less so or not at all in others (102). Why that is the case is unknown and there is no current explanation for the presence or development of the deviant arousal.

Courtship  Disorder  Theory of the Paraphilias

Courtship Disorder theory has been proposed as an etiological explanation for three frequently co-occurring paraphilias—voyeurism, exhibitionism, and frot- teurism—and preferential rape, defined as preferred arousal to coercive sex, based on the  assumption that  they  are  fundamentally related  (103). In this theory, normal sexual interaction has four sequential phases: (1) finding a part- ner; (2) non-physical interaction; (3) physical nongenital contact; and (4) sexual intercourse. Voyeurism is viewed as  a  disturbance in  the  first phase, exhi- bitionism as a disturbance of the second, frotteurism of the third, and preferential rape as a disturbance of the fourth phase. Although this theory has logical appeal, it is not clear from the research whether specific paraphilias tend to co-occur with statistical consistency, or whether, as has been asserted, individuals with one paraphilia suffer from an underlying deficit that predisposes them to the development of others (104).

Personality  Theories of the Paraphilias

Efforts to identify associations between personality and variant sexual behavior have been inconsistently fruitful. Some studies, but not all, have found exhibi- tionists to be unassertive (88). One of the authors’ own studies compared person- ality profiles of men diagnosed with a paraphilia with those of men with sexual dysfunction and with a normative sample (105). Profiles of men diagnosed with a paraphilia showed a distinctive group profile marked by higher neuroticism, lower agreeableness, and lower conscientiousness than those of sexually dysfunc- tional men, whose profiles were comparable with the normative group. Detailed analysis of the facet scores demonstrated that the paraphilic men were signifi- cantly higher than sexually dysfunctional or normals in depression, hostility, impulsiveness, excitement-seeking, and openness to fantasy, while significantly lower in warmth. These findings are consistent with earlier suggestions that men with paraphilias have difficulty with attachment and intimacy, and are commonly  self-centered,  antagonistic,  and  autonomically  prone  to  distress (106 – 109). Consistent with the finding by Fagan and colleagues that the para- philia group was higher in openness to fantasy, others have observed that men with paraphilias often experience fantasy as a central aspect of their sexuality (110,111).

A  recent  study  of  pedophilic  sex  offenders  found  that  60%  of  the sample met criteria for a personality disorder (25). However, contrary to the com- monly asserted hypothesis that antisocial personality disorder is etiologically fundamental to pedophilia, ,23% of the sample met criteria in this study. Others have also found limited evidence to support such hypotheses (112).

Biological Theories of the Paraphilias

Understanding of  the  neurobiology of  sexual  functioning,  both  normal  and deviant, is incomplete. Nevertheless, it is clear that sexual interest and function derive from both the central nervous system and endocrine factors. In normal sexual arousal, central nervous system involvement includes a cascade of con- nections from the neocortex to the limbic system and the hypothalamus, particu- larly the preoptic area and the brainstem (113). Sexual arousal begins via either sensory input, such as tactile, visual or olfactory stimulation, or via fantasy in the neocortex. This cortical arousal propagates through the limbic system and hypo- thalamus to enable a progression of physiologic events that promote sexual beha- viors and orgasm. Subcortical brain areas are important for sexual functioning and include the limbic system and the preoptic nuclei in the hypothalamus. Both  peptides,  such  as  beta  endorphin and  oxytocin,  and  LHRH  modulate sexual behavior in animals.

The role of monoamines is also important in normal sexuality. Dopamine appears to enhance sexual arousal with particular activity in the mesolimbic system, whereas serotonin diminishes sexual drive and arousal (114,115). Prolac- tin inhibits dopamine, resulting in diminished libidinal drive. Lowering prolactin levels via bromocriptine in women with pituitary adenomas has been shown to increase libidinal drive.

Endocrine factors are also relevant to libidinal drive. The role of estrogen in normal sexuality is not fully elucidated but it is evident that estrogen affects ser- otonin receptors as well as regulates beta endorphin, a peptide that has reduced sexual drive in animal studies (116). Progesterone may also lower sexual drive.

Regarding understanding paraphilic dysregulation from a biological per- spective, the most compelling data is found in studies with androgens. It is known that testosterone levels strongly correlate with sexual drive in women, and aggressive sexual offenders often are found to have higher androgen levels than  controls (117,118). Among the  most robust data  supporting biological factors  underlying  sexually  deviant  behavior  is  the  elevation  of  androgen levels found in convicted rapists (119). However, the implications of these find- ings for the paraphilias are unclear at this time.

Early biological hypotheses regarding the paraphilias included Epstein’s theory of phylogenetic preparedness of fetishism (120). He observed that a rubber boot, but not leather, evoked penile erection and ejaculation in a chimpan- zee, suggesting that the fetishistic attraction to an unusal object is not limited to humans. Epstein speculated that the wet surface of the boot bore a relationship to the female chimpanzee’s genitalia during rear mount sexual behavior.

There have been reports of elevated plasma epinephrine and norepi- nephrine  levels  in  individuals  with  pedophilia  (121,122).  Whether  such abnormalities are related to underlying anxiety disorders rather than specific to pedophilia has not been discerned.

A recent well-designed large-scale study comparing the brain functioning of men with pedophilia to men with other atypical sexual interests or beha- viors  found  significant  correlation   between  pedophilia  and   poorer  than average brain functioning, as measured by Full-Scale IQ and verbal and visuospatial  memory  (123).  The  study  also  found  a  significant association between  pedophilia  and  lower  rates  of  right-handedness,  consistent  with earlier  reports  of  decreased  right-handedness  in  child  sex  offenders  (124). The study’s findings suggest that early (prebirth) neurodevelopmental pertur- bations of the developing brain may account for some cases of pedophilia. Future studies may clarify what parts of the brain are affected, whether such perturbations  reflect an  independent  pathological  process  or  a  general  risk factor,  and  whether  such  findings  have  relevance  to  the  development  of other paraphilias.

In another recent study, an association was identified between pedophilia and retrospectively recalled childhood accidents resulting in unconsciousness (125,126). Twice as many pedophiles as nonpedophiles reported head injuries with unconsciousness before the age of 6, suggesting that neurodevelopmental perturbations occurring in a window of time after birth may also increase the risk of pedophilia. The authors of these studies cautiously point out that more data  are  needed  before  the  findings  can  be  interpreted  with  confidence. Whether head injury causes a neurodevelopmental abnormality that increases the risk of pedophilia or whether a pre-existing neurodevelopmental problem increases the risk of both head injury and pedophilia is unknown.

Although most studies regarding possible etiological associations between childhood head injury and the paraphilias have focused on pedophilia, some single case studies have been cited suggesting that some fetishistic behavior may also be related to childhood head injury (127).

A study of 477 adult  males  with traumatic  brain  injury identified 27 men,  or  almost  6%  of  the  sample,  who,  with  no  prior  histories of  sexual offending,  committed  sexual  offenses  following  their  head  injuries  (128). Some but not all of the offending behaviors were paraphilic in nature. The authors  concluded  that  traumatic  brain  injury  was  a  significant etiological factor underlying the offending behaviors. Such studies support the hypothesis that head injury is related to the development of some adult onset cases of paraphilia.

Left temporal lobe lesions have been known to result in sexual disinhibition and compulsivity in some individuals. Similarly, is evidence that temporal lobe epilepsy may cause some cases of fetishism and other paraphilias, most commonly exhibitionism (104,129). However, the majority of individuals with temporal lobe epilepsy do not have a paraphilia and, in fact, many are hyposex- ual. Future studies may explain the occurrence of paraphilia in a small subgroup of these individuals.

Although there is little evidence currently of a genetic link in the develop- ment of paraphilias, studies have found an association between pedophilia and Klinefelter’s syndrome, a rare chromosomal variant in men (130 – 132).

Kafka has suggested that  serotonergic factors may  provide a  biologic explanation for all paraphilias, but there is limited data to confirm this (133). There are also reports of fetishistic cross-dressing across generations in families (134,135). Whether such behaviors indicate biologic or social modeling under- pinnings remains to be demonstrated.

TREATMENT  OF  THE PARAPHILIAS

Treatment of the paraphilias may be biological or psychological. Although there are case reports of success based solely on one, state-of-the-art treatment today is most often a thoughtful integration of both. This section of the chapter reviews the research on pharmacological interventions followed by a discussion of critical variables in the assessment of the paraphilias. The chapter concludes with an overview of the principles of psychotherapeutic treatment. A core assumption of the  authors is that  paraphilias are  most often  chronic and incurable  but highly manageable. Treatment is a process of determining and implementing those interventions that offer the patient maximal opportunity to control behavior, manage affect and impulses, and reduce distress.

Pharmacological Treatment of the Paraphilias

There is no data to suggest that pharmacological intervention cans specifically target or ameliorate underlying paraphilic mechanisms. Rather, pharmacological interventions are either symptom focused or directed toward ameliorating or managing comorbid conditions. For example, where hypersexuality is a factor, pharmacological  treatments  are  commonly  implemented  to  lower  libidinal drive; where concurrent mania fosters hypersexuality, mood stabilizing agents are  indicated;  where comorbid depression or  anxiety  exacerbates paraphilic urges and behaviors, pharmacological intervention to lower affective distress may be a crucial early treatment; where paraphilic behavior is driven by under- lying  psychotic  or  delusional  processes,  the  obvious  first line  treatment  is pharmacological management of the psychotic state. As exemplified in these scenarios, pharmacological interventions for the paraphilias fall into three primary categories: antidepressants, antiandrogens, and neuroleptics and other agents.

Antidepressants

Some  individuals  with  a  paraphilia  experience  distressingly high  drive  and hyperarousability. Pharmacological interventions to lower libidinal urges are not only sometimes useful, but frequently essential, particularly the offending disorders such as pedophilia (136). The side-effect of diminished sexual desire, arousability, and behavior has been well documented in the specific serotonin reuptake inhibitors (SSRIs). Although the precise mechanism of action is unknown, it is thought that the SSRIs lower drive by increasing levels of seroto- nin (10,137,138). The SSRIs are often utilized in cases where high biological drive is a significant contributing factor (139). They are, of course, also helpful in reducing comorbid depressive and anxiety symptoms as well as intrusive sexual preoccupation. The clinical evidence for serotonin agonists include numerous reports of treatment success using fluoxetine, sertraline, and paroxetine for fetishism, voyeurism, exhibitionism, and pedophilia (18,137,140 – 146).

It has been hypothesized that for a subset of individuals, paraphilias may be secondary to obsessive-compulsive related disorders, for which the SSRIs have been found to be effective. A study comparing the effectiveness of the SSRI flu- voxamine to the heterocyclic desipramine in the treatment of exhibitionism found that fluvoxamine effectively reduced the paraphilic urges and behavior, whereas desipramine was associated with relapse (147). A study comparing the effective- ness of fluvoxamine, fluoxetine, and sertraline in paraphilics found all three effective in reducing the severity of fantasies and no significant differences in overall efficacy (138). Kafka and Hennen reported on the successful use of psy- chostimulants in combination with SSRIs in the treatment of individuals with paraphilias and comorbid adult symptoms of ADHD (148).

Although most studies regarding the use of antidepressants in the treatment of the paraphilias have focused on the SSRIs, there have been case reports of the effective use of other antidepressants. The tricyclic clomipramine, which has sig- nificant serotonin reuptake inhibition, has been reported to be effective in treating exhibitionism (149 – 151). Another case report described the remission of exhibi- tionism with trazodone, although the precise mechanism of action in this agent is not fully understood (152).

The number of studies regarding antidepressants in the treatment of the paraphilias remains small and more studies are needed in order to clarify the effects  of  SSRIs compared with other  psychopharmacological interventions. Further, it is unclear whether the SSRIs are selectively useful in individuals with a clear obsessive-compulsive disorder component, comorbid anxiety, or depressive disorder underlying the paraphilia or, rather, they have a more gener- alized usefulness for the paraphilias.

Antiandrogens

In paraphilias where elevated sexual drive does not remit to other treatments, the use of antiandrogens is indicated. In contrast to the SSRIs and other antidepress- ants, where the effects on libido are indirect, the antiandrogens have a direct suppressing effect on testosterone levels. Most of the current knowledge regard- ing the use of antiandrogens stems from research with sex offending populations, although the  use of  testosterone reducing agents has also been  reported in transvestic individuals who cannot control cross-dressing behaviors (153). Use of antiandrogenic medications in the treatment of paraphilias usually must be long-term. Relapse is common upon cessation of the medication. Treatment with antiandrogens may result in erectile dysfunction, although many individuals maintain adequate sexual functioning. As with the SSRIs, the goal of antiandro- gen medications is to augment the individual’s ability to achieve behavioral control (10).

Methoxyprogesterone acetate (MPA) is the most commonly used hormonal agent for the reduction of sex drive in the United States (140,146,154,155). It does not compete with androgens at the receptor level but blocks levels of testos- terone by inducing hepatic testosterone reductase. The goal of this strategy is to reduce baseline testosterone to 50% of initial values. Common dosages are 50 – 300 mg orally or 300 – 400 weekly via intramuscular injections with reduc- tion  to  100 mg  weekly  for  a  maintenance  program.  Depot  preparations  of methoxyprogesterone are also available. Side-effects include weight gain, hyper- glycemia due to an exaggerated insulin response to a glucose load, headaches and increased risk of deep vain thromboses.

Cyproterone acetate (CPA) is also frequently used to suppress sex drive in individuals with paraphilias. CPA blocks androgen receptors, directly decreasing the biological effects of testosterone. It is not available in the United States and most of the research regarding this agent derives from Germany (156). CPA can be given orally 100 mg daily or 200 mg every other week via intramuscular injec- tion. Reports clearly demonstrate that CPA reduces sexual drive and erectile ability. Possible side effects include weight gain, depression and feminization (157,158).

Some researchers argue that long-acting gonadotropin-releasing hormone (GnRH) agonist analoges are the most potent antiandrogens, have the fewest side-effects, and therefore are the most promising pharmacological treatment for the future (159). Either leuprolide or triptorelin is given intramuscularly in doses of 3.75 or 7.5 monthly. These agents suppress testosterone via decreasing the number of pituitary GnRH receptors and testicular LH receptors, thereby desensitizing the testes to LH. It more completely suppresses androgen than MPA or CPA. In an open trial of 30 sex offenders, triptorelin administered on a monthly basis (3.75 mg per dose) diminished paraphilic fantasies and drives according to self-report at 8-months follow-up. In another report, triptorelin treat- ment resulted in complete cessation of paraphilic behavior and significant decreases in paraphilic fantasies in five of six subjects (160). Termination of the treatment resulted in relapse to paraphilic fantasies in some subjects and in behavioral relapse in others. When a GnRH agonist is initially given, a “flare” phenomenon may result in that there is a transient rise in testosterone levels before receptor down regulation (161). To manage this, nonsteroidal antiandro- gens such as flutamide may be helpful.

Neuroleptics and Other Agents

Neuroleptic agents have been reported to diminish paraphilic behaviors and fan- tasies. One early report described the successful treatment of a case of familial exhibitionism in Tourette’s syndrome with haloperidol (162). Additionally, there have been case reports of other pharmacological interventions for the paraphilias. A report described success in eliminating pedophilic cognitions and behaviors with a combination of the anticonvulsant carbamazepine and the benzodiazepine clonazepam (163). These were selected to specifically target the patient’s mixed depression and anxiety as well as his sexual impulsivity. Lithium has also been reported to be effective in reducing inappropriate sexual behaviors. However, the diagnostic classification of subjects in many studies has been vague and the use of mood stabilizers may reflect a comorbid mania or other psychotic state as the actual target of intervention (164,165).

Although more research is needed, the current knowledge base regarding reduction of sexual drive and sexual preoccupation through pharmacological means is compelling. Further, due to the high comorbidity between the paraphi- lias and other psychiatric disorders, the need for pharmacological support in the treatment of the paraphilias is significant. In sum, pharmacological interventions are today a critical component of state-of-the-art treatment of paraphilias, especially the offending paraphilias. Most often, these medications are coupled with, and signifiantly enhance the effects of, concomitant psychological treat- ment, to be discussed in the following section.

Psychological  Treatment of the Paraphilias

As earlier research has demonstrated, medication may modify target symptoms such as anxiety, depression, obsessionality, or hypersexual drive, but cannot “cure” the paraphilia or interpersonal problems (166). Psychotherapy is essential to foster compliance with medication, ameliorate attitudinal problems, and to develop  cognitive  skills  in  resisting and  managing  paraphilic  fantasies  and urges. Because concurrent treatment modalities may demand the involvement of multiple clincians, issues of communication, transference and countertransfer- ence, legal risks, and ethical challenges should be familiar to clinicians before embarking on the multimodal treatment of paraphilias (167).

The empirical evidence regarding outcomes of psychological treatment of the  paraphilias is limited.  To date, most studies have  been  conducted with heterogeneous sex offender populations that include but are not limited to para- philic offenders. The extent to which paraphilic offenders, nonparaphilic offen- ders, and non-offending paraphilics are the same or different in terms of etiological factors or treatment needs is unknown. Further, while there are no studies convincingly demonstrating the superiority of one psychotherapeutic methodology to another, there is growing evidence that cognitive-behavioral and relapse prevention models are effective in reducing recidivism of sexual offending behaviors (168). These models, with their focus on behavior, related cognitions, and development of self-regulatory skills, demonstrate the greatest promise for the psychological treatment of the paraphilias.

From a cognitive-behavioral perspective, the paraphilias are primary and chronic. Although fundamentally altering a sexual interest is not viewed as poss- ible, managing the interest is. Therefore, treatment does not focus on cure, but on management of associated thoughts, fantasies, and urges, reduction of associated distress, and conscious choices about behavior. In this framework, exploration of underlying life history themes takes place after  behavioral goals have been achieved and relapse prevention strategies learned, and is conceptualized as of secondary importance relative to the need for behavioral control.

The current classification system, the multitude of etiological theories and their inferred treatment approaches, and the tendency for outcome studies to focus on specific paraphilias imply that specific paraphilias require specific treat- ments. To the contrary, a general rule of thumb is that the paraphilias are more alike  than  different  and,  regardless  of  the  specific  manifestation,  reflect common underlying mechanisms, such as disordered capacity to regulate affect and impulses, that become the target of treatment.

Psychiatric Assessment of Paraphilias

Assessment informs the clinician regarding necessary intensity of treatment and which psychotherapeutic modalities—individual, group, or conjoint couple—are called for. It is beyond the scope of this chapter to detail the components of the full psychiatric-psychosexual evaluation. Rather, those assessment components uniquely related to the paraphilias are highlighted.

Defining the impairment:       Because psychological treatment focuses on those aspects of the disorder most related to functional impairment, identification of the specific nature of impairment is essential. The following impairment- related variables, summarized in Figure 12.2, are crucial aspects of assessment.

Cognitive impairment.   Sexual thoughts may be as or more distressing than urges or cravings. An individual can have low or average biological drive and still experience frequent distressing and intrusive sexual cognitions. He may be distressed by the content of the fantasies and/or  by their intrusive effects, including, for example, guilt, despair, or distraction during efforts at part- nered sexual activity. Distorted cognitions that promote denial or minimization or blame others for the problematic behavior contribute to impaired judgment and increase  the  risk  of  behavior,  particularly  in  the  offending  paraphilias.  As along as distortions are present, internal motivation to control behavior is minimal and the risk of paraphilic behavior remains significant.

Drive impairment.   High biological drive may fuel sexual urges or crav- ings that are preoccupying, distressing, and difficult to control, increasing the risk of behavioral escalation. Drive assessment inquires about an individual’s ability to control his urges, his subjective experience of his drive, frequency of masturbation, and amount of time spent feeling sexually preoccupied. The presence of high drive and/or preoccupying urges and cravings demands consideration  of  a  pharmacological  intervention  early  in  treatment.  In  the

authors’ clinic, excessively high drive has been identified as a significant com- ponent of the disorder in 10% of patients diagnosed with a paraphilia or nonpar- aphilic problematic sexuality. Although most patients describe themselves as sexually obsessed and preoccupied, and most endorse impairment in controlling their urges, only a fraction experiences difficulty in the form of high drive or genital  hyperarousability.  This  highlights  the  importance  of  assessing  the nature and intensity of sexual cravings from a psychological as well as biological perspective.

Behavioral impairment.   In some individuals, the problem is limited to urges and fantasies. In others, the urges and fantasies have escalated to paraphilic behavior. Problematic behaviors may include frequent masturbation, masturba- tion in inappropriate contexts, excessive use of or preoccupation with paraphilic pornography, placing undue sexual demands on a partner, seeking inappropriate partners with whom to act out a paraphilic interest, unsafe sexual practices, and deceitfulness. As a paraphilia escalates behaviorally, partnered sex may become impaired. Some individuals suffer extreme financial consequences due to purchasing online sexual services, phone sex activities, or hiring sex workers. Most significantly, some paraphilias  lead  to  severe legal  consequences and harm to others.

Exclusivity vs.  nonexclusivity.    Exclusivity  is  associated  with  poorer treatment outcomes. The more exclusive the paraphilia, the more likely it pre- cludes sexual intimacy with an appropriate partner. Treatment then focuses on management of urges and fantasies, behavioral control, minimizing the risk of harm to others, acceptance of one’s sexual differences and grieving related losses rather than return to a previous level of nonparaphilic functioning. Although  the  DSM-IV-TR  includes  a  specifier  for  exclusive/nonexclusive types only for pedophilia, identifying how this variable contributes to impairment is important in any paraphilia.

Egodystonic  vs.  egosyntonic  attitude.     Some  individuals  seek  help because  they  have  been  discovered  engaging  in  paraphilic  behavior  by  a spouse, partner, or employer. This individual may have an egosyntonic relation- ship to the paraphilia, in that he experienced no apparent distress other than that associated with being discovered. Although this may reflect an underlying anti- social or narcissistic personality component that will contribute to poor treatment outcome, this conclusion should be resisted until objective evidence is presented. Distorted cognitions that enable an egosyntonic attitude are common in paraphi- lias that have been enacted secretly over time and may resolve with successful treatment. However, the real presence of underlying sociopathy results in a rigidly egosyntonic attitude and carries significant negative implications for treat- ment outcome. Without rigorous assessment, the degree to which personality factors are contributing to disordered attitude will remain unclear.

Level of risk.   Paraphilic expression may be limited to fantasies, with little immediate risk of behavioral escalation. On the other hand, there may be an immediate danger, as in the offending paraphilias, autoerotic asphyxiation, and some cases of  sexual sadism or  masochism. Danger may  be  symbolic and benign or real and potentially lethal, as in cases reflecting loss of control or confusion regarding the boundary between consent and coercion. Assessment of  self-mutilating  behaviors  is  particularly  critical  in  transvestic  fetishism, where gender dysphoric transvestites may report attempts at auto-castration.

In pedophilia, the number and variety of prior offenses, relationship to victim, age, and gender of victim have been shown to be strong predictors of reoffense (169). Therefore, these variables comprise a critical aspect of risk assessment in pedophilia. Hanson and colleagues, in their excellent reviews, have pointed out that structured assessment of these specific risk factors is more effective than unstructured clinical assessment.

Comorbidity.   Comorbid multiple paraphilias, depressive, anxiety, and sub- stance abuse disorders are common. Although there is no empirical evidence that paraphilias are commonly associated with particular personality disorders, person- ality disorders may co-occur. Comorbidity assessment clarifies the nature and extent of functional impairment, identifies potential obstacles to treatment success, and informs pharmacological decisions and decisions about initial treatment focus.

Cognitive-Behavioral Treatment

Cognitive-behavioral treatment integrates cognitive and behavioral interventions to assist individuals in gaining control of the paraphilic cognitions, urges, and behaviors. Group psychotherapy is often the modality of choice, particularly in severe or offending paraphilias. Although individual treatment can target para- philia related impairments, the potency of group therapy to do so, through both therapeutic support and therapeutic confrontation, is greater. Recent outcome studies, using rates of recidivism, suggest that treatment outcomes in pedophilia are relatively positive (169 – 171). This is contrary to common myth that sexual offenders are untreatable and has positive implications for the application of similar treatments to other paraphilias (172).

The  development  of  insight is  not  central  to  the  cognitive-behavioral model, but insight oriented strategies may be integrated in order to achieve par- ticular goals. Because the paraphilias represent a heterogeneous group, treatment must be individualized and the basic framework adjusted in order to accommo- date individual presentations. It is beyond the scope of this chapter to detail cognitive-behavioral treatment protocols. Rather, a skeleton of treatment guide- lines is presented. Overall treatment objectives include the following.

Control and management of problematic thoughts, affects, urges, impulses, and behaviors

Modification of paraphilic arousal

Amelioration or management of comorbid conditions

Resolution of other life issues

Relapse prevention

Strategies commonly used to promote the development of self-control in thoughts, feelings, urges, and behavior include thought substitution, redirection, distraction, affect and urge tolerance, behavioral rehearsal,  behavioral absti- nence, and positive conditioning. Treatment addresses the cognitions, feelings, urges, and behaviors that are related to the cycle of paraphilic regression. Any factor that increases the odds of paraphilic behavior occurring is conceptualized as a “trigger” or high risk association. The identification of triggers, an under- standing of  the  relative  risk  associated with each,  and  the  development  of concrete strategies to manage them are central components of early treatment. Making decisions about complete or partial avoidance of triggers is a critical aspect of treatment and, later, relapse prevention.

Cognitive distortions provide justification for inappropriate behavior and allow  the  individual  to  minimize  or  deny  the  negative  effects  on  self  and others. Facilitated by cognitive interventions such as thought substitution, redir- ection, and distraction, the individual learns to replace problematic cognitions with rational thought and to redirect his thinking in alternative directions. Similarly, after identifying those feeling states and sexual urges that serve as triggers, the individual learns to use redirection,  distraction,  and affect and urge tolerance. This includes the skill of tolerating feelings without acting on them, and learning to trust that feelings, including sexual feelings, pass if not enacted. Whether particularly high or not, sexual drive must be managed in the treatment of paraphilias. Treatment promotes concrete strategies for mediating sexual feelings and for learning behavioral alternatives to indulgence in paraphi- lic behaviors.

Modifying  paraphilic sexual  arousal:        As noted in the discussion on etiology, treatment regarding paraphilic arousal generally emphasizes behavioral control as opposed to unlearning or relearning. There is considerable disagree- ment about the effectiveness and ethical basis of such techniques, and little empirical evidence that deconditioning strategies are effective in modifying a core paraphilic pattern. However, many individuals enter treatment in the hope that such a possibility exists. Behavior modification strategies are used to chal- lenge the paraphilic fixedness or rigidity. Behavioral  rehearsal  uses mental imagery of paraphilic scenes reported by the patient, but with alternative, nonpar- aphilic outcomes. Positive conditioning is the use of nonparaphilic sexual fantasy during masturbation. The more exclusive the paraphilic arousal, the more difficult is modification. However, if used as one among many strategies, and if neither the patient nor the clinician holds unrealistic expectations, it may have benefits in controlling, not eradicating, sexual arousal.

Relapse prevention:     The risk of relapse in chronic behavioral disorders is high. The core of relapse prevention is the use of cognitive-behavioral strat- egies learned in treatment to manage triggers and high risk situations with com- petence. An individual is ready for this stage of treatment when he has achieved behavioral control, demonstrated capacity to function without cognitive distor- tions,  demonstrated  capacity  to  manage  his  own  affect  and  impulses,  and shown consistent motivation to maintain abstinence from paraphilic behaviors. He has become exquisitely familiar with the repeating sequences of thoughts, urges, and behaviors associated with his own paraphilic regressive cycle. In relapse prevention, he develops a clear personal plan for self-management and for management of high risk situations.

CONCLUSION

The human capacity to eroticize is vast and the boundary between normal and abnormal diffuses. When sexual interests are conceptualized on a continuum rather than as rigid categories, many sexually healthy adults recognize nonpro- blematic but “beyond the usual” aspects of their own erotic preferences. Diagnos- tis is uncomplicated toward the far end of the continuum, where sexual interests are exclusive, or nearly so, and where either others are harmed or suffering is apparent as a result of the interest. Complexity and ambiguity characterize clini- cal scenarios where the interest is nonexclusive, no one has been harmed, and where, while suffering may be present, it has profound contextual or relational dimensions that make distinctions between the pathological and the incompatible less clear. The accessibility, via the world wide web, of sexual stimuli ranging from the traditional and acceptable to the bizarre and abhorrent, has, in one short decade, brought human sexuality into a spotlight that illuminates, embarrassingly, the lack of empirically based knowledge regarding the nature and causes of human sexual interest and behavior. The implications of this cultural phenomenon for the para- philias are profound. Never before has the mandate been greater to conduct rigor- ous scientific inquiry to define the line between sexual recreation and sexual pathology, to develop an empirically based and clinically useful taxonomy, to identify specific etiological mechanisms, and to identify those treatments, both biological and psychological, that offer the most efficacious results.

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