Noncoercive Paraphilias
Noncoercive Paraphilias
Noncoercive Paraphilias
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1<br />
<strong>Paraphilias</strong><br />
My last sexual partner was very much into golden showers. Having spent a little of my time<br />
watching G. G. Allen movies, I was well acquainted with the existence of watersports, but<br />
somehow it never occurred to me that I would like to partake in them. When my partner revealed<br />
his desire to drink my urine, I was taken off guard. I have been known to try some things I would<br />
deem a little atypical, so I gave it a shot. I was very nervous about the actual part of the<br />
procedure, though. Thoughts such as, “What if he was joking – he would think I’m nuts” and<br />
“What if I completely miss” entered my head. It was nerve-racking and made it especially hard to<br />
pee. Eventually, my anxiety subsided and I was able to participate. His reaction was amazing to<br />
me. He began to masturbate fervishly and lapped up my urine ecstatically. I have never seen him<br />
so turned on. More surprising though was how much I enjoyed it. Although I cannot imagine<br />
being on the other end, it was really an empowering and enjoyable experience. (Author’s files)<br />
This description of a rather unusual sexual experience, may strike our readers as reflecting an abnormal or<br />
perhaps even deviant form of sexual behavior. However, we believe it is more realistic to consider this anecdote to<br />
be an account of uncommon or atypical sexual behavior. One note of caution: Because HIV has been found in the<br />
urine of infected persons, it is prudent to avoid contact with a partner’s urine unless he or she is known to be HIV<br />
negative and not infected with any other STDs. Now let us consider for a moment what constitutes atypical sexual<br />
behavior.<br />
What Constitutes Atypical Sexual Behavior?<br />
In this chapter, we focus on a number of sexual behaviors that have been variously labeled as deviant, perverted,<br />
aberrant, or abnormal. More recently, the less-judgmental term paraphilia (pair-uh-FIL-e-uh) has been used to<br />
describe these somewhat uncommon types of sexual expression. Literally meaning “beyond usual or typical love,”<br />
this term stresses that such behaviors are usually not based on an affectionate or loving relationship, but rather are<br />
expressions of psychosexually disordered behavior in which sexual arousal and/or response depends on some<br />
unusual, extraordinary, or even bizarre activity (American Psychiatric Association, 1994). The term paraphilia is<br />
used in much of the psychological and psychiatric literature. However, in our own experience in dealing with and<br />
discussing variant sexual behaviors, the one common characteristic that stands out is that each behavior in its fully<br />
developed form is not typically expressed by most people in our society. Therefore, we also categorize the behaviors<br />
discussed in this chapter as atypical sexual behaviors.<br />
Several points should be noted about atypical sexual expression in general before we discuss specific behaviors.<br />
First, like many other sexual expressions, the behaviors singled out in this chapter represent extreme points on a<br />
continuum. Atypical sexual behaviors exist in many gradations, ranging from mild, infrequently expressed<br />
tendencies to full-blown, regularly manifested behaviors. Although these are atypical behaviors, many of us may<br />
recognize some degree of such behaviors or feelings within ourselves—perhaps manifest at some point in our lives,<br />
or mostly repressed, or emerging only in very private fantasies.<br />
A second point has to do with the state of our knowledge about these behaviors. In most of the discussions that<br />
follow, the person who manifests the atypical behavior is assumed to be male, and evidence strongly indicates that<br />
in most reported cases of atypical or paraphilic behaviors, the agents of such acts are male (American Psychiatric<br />
Association, 1994; Money, 1988). However, the tendency to assume that males are predominantly involved may be<br />
influenced by the somewhat biased nature of differential reporting and prosecution. Female exhibitionism, for<br />
example, is far less likely to be reported than is similar behavior in a male. John Money (1981) has suggested that<br />
atypical sexual behavior may be decidedly more prevalent among males than females because male erotosexual differentiation<br />
(the development of sexual arousal in response to various kinds of images or stimuli) is more complex<br />
than that of the female and subject to more errors.<br />
A third noteworthy point is that atypical behaviors often occur in clusters. That is, the occurrence of one<br />
paraphilia appears to increase the probability that others will also be manifested, simultaneously or sequentially<br />
(Bradford et al., 1992; Fedora et al., 1992). One hypothesis offered to account for this cluster effect is that engaging<br />
in one atypical behavior, such as exhibitionism, may reduce the participant’s inhibitions to the point where engaging
2<br />
in another paraphilia, such as voyeurism, becomes more likely (Stanley, 1993).<br />
A final consideration is the impact of atypical behaviors both on the person who exhibits them and on others to<br />
whom they may be directed. People who manifest atypical sexual behaviors often depend on these acts for sexual<br />
satisfaction. The behavior is frequently an end in itself. It is also possible that their unconventional behavior will<br />
alienate others. Consequently, these people often find it very difficult to establish satisfying sexual/intimate<br />
relationships with partners. Instead, their sexual expression may assume a solitary, driven, even compulsive quality.<br />
Some of these behaviors do involve other people whose personal space is violated in a coercive, invasive fashion. In<br />
the following section we consider the distinction between coercive and noncoercive paraphilias.<br />
<strong>Noncoercive</strong> versus Coercive <strong>Paraphilias</strong><br />
A key distinguishing characteristic of paraphilias is whether or not they involve an element of coercion. Several<br />
of the paraphilias are strictly solo activities or involve the participation of consensual adults who agree to engage in,<br />
observe, or just put up with the particular variant behavior. Because coercion is not, involved, and a person’s basic<br />
rights are not violated, such so-called noncoercive atypical behaviors are considered by many to be relatively benign<br />
or harmless. Clearly, the chapter opening account falls into this category. However, as we shall see, these<br />
noncoercive behaviors may occasionally engender potentially adverse consequences for people drawn into their<br />
sphere of influence. We will consider seven varieties of noncoercive paraphilias.<br />
Some paraphilias are definitely coercive or invasive in that they involve unwilling recipients of behavior such<br />
as peeping or exhibitionism. Furthermore, research suggests that such coercive acts may have harmful effects on the<br />
targets of such deeds, who may be psychologically traumatized by the experience. They may feel they have been<br />
violated or that they are vulnerable to physical abuse, and they may develop fears that such unpleasant episodes will<br />
recur. This is one reason many of these coercive paraphilias are illegal. On the other hand, many people who<br />
encounter such acts are not adversely affected. Because of this and because many of these coercive behaviors do not<br />
involve physical or sexual contact with another, many authorities view them as minor sex offenses (sometimes<br />
called “nuisance” offenses). However, evidence that some people progress from nuisance offenses to more serious<br />
forms of sexual abuse may lead to a reconsideration of whether these offenses are “minor” (Bradford et al., 1992;<br />
Fedora et al., 1992).<br />
In our discussion of both types of paraphilias, coercive and noncoercive, we examine how each of these<br />
behaviors is expressed, some of the common characteristics of those exhibiting it, and the various factors thought to<br />
contribute to its development.<br />
<strong>Noncoercive</strong> <strong>Paraphilias</strong><br />
In this section we first discuss three fairly common types of noncoercive paraphilias: fetishism, sexual sadism, and<br />
sexual masochism. We will also describe four less common varieties of noncoercive paraphilias.<br />
Fetishism<br />
Fetishism (FET-ish-iz-um) refers to sexual behavior in which an individual becomes sexually aroused by<br />
focusing on an inanimate object or a part of the human body. As with many other atypical behaviors, it is often<br />
difficult to draw the line between normal activities that may have fetishistic overtones and those that are genuinely<br />
paraphilic. Many people are erotically aroused by the sight of undergarments and certain specific body parts, such as<br />
feet, legs, buttocks, thighs, and breasts. Many men and some women may use articles of clothing and other<br />
paraphernalia as an accompaniment to masturbation or sexual activity with, a partner. Only when a person becomes<br />
focused on these objects or body parts to the exclusion of everything else is the term fetishism truly applicable. In<br />
some instances, a person may be unable to experience sexual arousal and orgasm in the absence of the fetish object.<br />
In other situations where the attachment is not so strong, sexual response may occur in the absence of the object but<br />
often with diminished intensity. For some people, fetish objects serve as substitutes for human contact and are dispensed<br />
with if a partner becomes available. Some common fetish objects include women’s lingerie, shoes<br />
(particularly high-heeled), boots (often affiliated with themes of domination), hair, stockings (especially black mesh<br />
hose), and a variety of leather, silk, and rubber goods (American Psychiatric Association, 1994; Davison & Neale,<br />
1993).
3<br />
How does fetishism develop? One way is through incorporating the object or<br />
body part, often through fantasy, in a masturbation sequence where the<br />
reinforcement of orgasm strengthens the fetishistic association. This is a kind of<br />
classical conditioning in which some object or body part becomes associated with<br />
sexual arousal. This pattern of conditioning was demonstrated some years ago by<br />
Rachman (1966), who created a mild fetish among male subjects under laboratory<br />
conditions by repeatedly pairing a photograph of women’s boots with erotic slides<br />
of nude females. The subjects soon began to show sexual response to the boots<br />
alone. This reaction also generalized to other types of women’s shoes. Although<br />
some critics have suggested that Rachman’s experiment was tainted by methodological<br />
problems (O’Donohue & Plaud, 1994), two additional studies provided<br />
further evidence for classical conditioning of fetishism (Langevin & Martin, 1975;<br />
Rachman & Hodgson, 1968).<br />
Another possible explanation looks to childhood in explaining the origins of<br />
some cases of fetishism. Some children may learn to associate sexual arousal with<br />
objects (such as panties or shoes), which belong to an emotionally significant person, like the mother or older sister<br />
(Freund & Blanchard, 1993). The process by which this may occur is sometimes called symbolic transformation.<br />
Here, the object of the fetish becomes endowed with the power or essence of its owner, so that the child (usually a<br />
male) responds to this object as he might react to the actual person (Gebhard et al., 1965). If these patterns become<br />
sufficiently ingrained, the person will engage in little or no sexual interaction with others during the developmental<br />
years, and even as an adult may continue to substitute fetish objects for sexual contact with other humans.<br />
Only rarely does fetishism develop into an offense that might harm someone. Occasionally, an individual may<br />
commit burglary to supply an object fetish, as in the following account:<br />
Some years ago we had a bra stealer loose in the neighborhood. You couldn’t hang your bras<br />
outside on the clothesline without fear of losing it. He also took panties, but bras seemed to be his<br />
major thing. I talked to other women in the neighborhood who were having the same problem.<br />
This guy must have had a roomful. I never heard that he was caught. He must have decided to<br />
move on because the thefts suddenly stopped. (Authors’ files)<br />
Burglary is the most frequent serious offense associated with fetishism. Uncommonly, a person may do<br />
something bizarre such as cut hair from an unwilling person. In extremely rare cases, a man may murder and<br />
mutilate his victim, preserving certain body parts for fantasy-masturbation activities.<br />
Sexual Sadism and Sexual Masochism<br />
Sadism and masochism are often discussed under the common category sadomasochistic (sA-dO-MAs-O-kiz-tic)<br />
behavior (also known as SM) because they are two variations of the same phenomenon, the association of sexual<br />
expression with pain. Furthermore, the dynamics of the two behaviors are similar and overlapping. Thus, in the<br />
discussion that follows, we will often refer to SM behavior or activities. However, a person who engages in one of<br />
these behaviors does not necessarily express the other, and thus sadism and masochism are actually distinct<br />
behavioral entities. The American Psychiatric Association’s DSM-IV (1994) underlines this distinction by listing<br />
separate categories for each of these paraphilias: sexual sadism and sexual masochism.<br />
Labeling behavior as sexual sadism or sexual masochism is complicated because many people enjoy some form<br />
of aggressive interaction during sex play (such as “love bites”) for which the label SM seems inappropriate. Alfred<br />
Kinsey and his colleagues found that 22% of the males and 12% of the females in his sample responded erotically to<br />
stories with SM themes. Furthermore, over 25% of both sexes reported erotic response to receiving love bites during<br />
sexual interaction. Hunt (1974) found that 10% of males and 8% of females in his sample (under age 35) reported
4<br />
obtaining sexual pleasure from SM activities during interaction with a partner. A more recent survey of 975 men<br />
and women found that 25% reported occasionally engaging in a form of SM activity with a partner (Rubin, 1990).<br />
Although sadomasochistic practices have the potential for being physically dangerous, most participants generally<br />
stay within mutually agreed-on limits, often confining their activities to mild or even symbolic SM acts with a<br />
trusted partner. In mild forms of sexual sadism, the pain inflicted may often be more symbolic than real. For<br />
example, a willing partner may be “beaten” with a feather or a soft object designed to resemble a club. Under these<br />
conditions, the receiving partner’s mere feigning of suffering is sufficient to induce sexual arousal in the individual<br />
inflicting the symbolic pain.<br />
People with masochistic inclinations may be aroused by such things as being whipped, cut, pierced with<br />
needles, bound, or spanked. The degree of pain one must experience to achieve sexual arousal varies from symbolic<br />
or very mild to, on rare occasions, severe beatings or mutilations. Sexual masochism is also reflected in individuals<br />
who achieve sexual arousal as a result of “being held in contempt, humiliated, and forced to do menial, filthy, or<br />
degrading service” (Money, 1981, p. 83). The common misconception that any kind of pain, physical or mental, will<br />
sexually arouse a person with masochistic inclinations is not true. The pain must be associated with a staged<br />
encounter whose express purpose is sexual gratification.<br />
In yet another version of masochism, some individuals derive sexual pleasure from being bound, tied up, or<br />
otherwise restricted. This behavior, called bondage, usually takes place with a cooperative partner who binds or<br />
restrains the individual and often administers discipline, such as spankings or whippings. One survey of 975<br />
heterosexual women and men revealed that bondage may be a fairly common practice: One-fourth of respondents<br />
reported engaging in some form of bondage during some of their sexual encounters (Rubin, 1990).<br />
Many individuals who engage in SM activities do not confine their participation to exclusive sadistic or<br />
masochistic behaviors. Some alternate between the two roles, often out of necessity, because it may be difficult to<br />
find a partner who prefers only to inflict or to receive pain. Most of these people seem to prefer one or the other role,<br />
but some may be equally comfortable in either (Moser & Levitt, 1987; Weinberg et al., 1984).<br />
There are some indications that individuals with sexual sadistic tendencies are less common than their<br />
masochistic counterparts (Gebhard et al., 1965). This imbalance may reflect a general social script—certainly it is<br />
more virtuous to be punished than to carry out physical or mental aggression toward another. A person who needs<br />
severe pain as a prerequisite to sexual response may have difficulty finding a cooperative partner. Consequently,<br />
such individuals may resort to causing their own pain by burning, mutilating, or autoerotic asphyxia. Likewise, a<br />
person who needs to inflict intense pain in order to achieve sexual arousal may find it very difficult to find a willing<br />
partner, even for a price. We occasionally read of sadistic assaults against unwilling victims: The classic lust murder<br />
is often of this nature (Money, 1990). In these instances, orgasmic release may be produced by the homicidal<br />
violence itself.<br />
Many people in contemporary Western societies view SM in a highly negative light. This is certainly<br />
understandable, particularly for those who regard sexual sharing as a loving, tender interaction between partners<br />
who wish to exchange pleasure. However, much of this negativity stems from a generalized perception of SM<br />
activities as perverse forms of sexual expression involving severe pain, suffering, and degradation. It is commonly<br />
assumed that individuals caught up in such activities are often victims rather than willing participants.<br />
One group of researchers disputed these assumptions, suggesting that the traditional medical model of SM as a<br />
pathological condition is based on a limited sample of individuals who come to the attention of clinicians as a result<br />
of personality disorders or severe personality problems. As with some other atypical behaviors discussed in this<br />
chapter, these researchers argued that it is misleading to draw conclusions from such a sample. They conducted their<br />
own extensive fieldwork in nonclinical environments, interviewing a variety of SM participants and observing their<br />
behaviors in many different settings. Although some subjects’ behaviors fit traditional perceptions, the researchers<br />
found that, for most participants, SM was simply a form of sexual enhancement involving elements of dominance<br />
and submission, role-playing, and consensuality “which they voluntarily and mutually chose to explore” (Weinberg<br />
et al., 1984, p. 388).<br />
What factors might motivate a person to engage in SM activity?<br />
Many people who engage in SM activities are motivated by a desire to experience dominance and/or submission<br />
rather than pain (Weinberg, 1987). This desire is reflected in the following account recently provided by a student
in a sexuality class:<br />
5<br />
I fantasize about sadomasochism sometimes. I want to have wild animalistic sex under the control<br />
of my husband. I want him to “force” me to do things. Domination and mild pain would seem to<br />
fulfill the moment. I have read books and talked to people about the subject, and I am terrified at<br />
some of the things, but in the bounds of my trusting relationship I would not be afraid. It seems<br />
like a silly game, but it is so damned exciting to think about. Maybe it will happen someday.<br />
(Authors’ files)<br />
Studies of sexual behavior in other species reveal that many nonhuman animals engage in what might be<br />
labeled combative or pain-inflicting behavior before coitus. Some theorists have suggested that such activity has<br />
definite neurophysiological value, heightening accompaniments of sexual arousal such as blood pressure, muscle<br />
tension, and hyperventilation (Gebhard et al., 1965). For a variety of reasons (such as guilt, anxiety, or apathy),<br />
some people may need additional nonsexual stimuli to achieve sufficient arousal. It has also been suggested that<br />
resistance or tension between partners enhances sex and that SM is just a more extreme version of this common<br />
principle (Tripp, 1975).<br />
SM may also provide participants with an escape from the rigidly controlled, restrictive role they must play in<br />
their everyday, public lives. This helps to explain why men who engage in SM activity are much more likely to play<br />
masochistic roles than are women (Baumeister, 1988). John Money describes the scenario in which “men who may<br />
be brokers of immense political, business or industrial power by day [become] submissive masochists begging for<br />
erotic punishment and humiliation at night” (1984, p. 169). Conversely, individuals who are normally meek may<br />
welcome the temporary opportunity to assume a powerful, dominant role within the carefully structured role-playing<br />
of SM. A related theory sees sexual masochism as an attempt to escape from high levels of self-awareness. Similar<br />
to some other behaviors (such as getting drunk) in which a person may attempt to “lose” himself or herself,<br />
masochistic activity blocks out unwanted thoughts and feelings, particularly those that may induce anxiety, guilt, or<br />
feelings of inadequacy or insecurity (Baumeister, 1988).<br />
Clinical case studies of people who engage in SM sometimes reveal early experiences that may have established<br />
a connection between sex and pain. For example, being punished for engaging in sexual activities (such as<br />
masturbation) might result in a child or adolescent associating sex with pain. A child might even experience sexual<br />
arousal while being punished—for example, getting an erection or lubricating when one’s pants are pulled down and<br />
a spanking is administered (spanking is a common SM activity). Paul Gebhard and his colleagues (1965) reported<br />
one unusual case in which a man developed a desire to engage in SM activities following an episode during his<br />
adolescence in which he experienced a great deal of pain while a fractured arm was set without the benefit of<br />
anesthesia. During the ordeal he was comforted by an attractive nurse, who caressed him and held his head against<br />
her breast in a way that created a strong conditioned association between sexual arousal and pain.<br />
Many people, perhaps the majority, who participate in SM do not depend on these activities to achieve sexual<br />
arousal and orgasm. Those who practice it only occasionally may find that at least some of its excitement and erotic<br />
allure stems from the fact that it represents a marked departure from more conventional sexual practices. Other<br />
people who indulge in SM acts may have acquired strong negative feelings about sex, often believing it is sinful and<br />
immoral. For such people, masochistic behavior provides a guilt-relieving mechanism: Either they get their pleasure<br />
simultaneously with punishment, or they first endure the punishment to entitle them to the pleasure. Similarly,<br />
people who indulge in sadism may be punishing partners for engaging in anything so evil. Furthermore, people who<br />
have strong feelings of personal or sexual inadequacy may resort to sadistic acts of domination over their partners to<br />
temporarily alleviate these feelings.<br />
Other <strong>Noncoercive</strong> <strong>Paraphilias</strong><br />
In this section we consider four additional varieties of noncoercive paraphilias that are generally uncommon or even<br />
rare. We begin our discussion by describing autoerotic asphyxia, a very dangerous form of variant sexual behavior.<br />
We then offer a few brief comments about three other uncommon noncoercive paraphilias: klismaphilia, coprophilia,<br />
and urophilia.
6<br />
Autoerotic Asphyxia<br />
Autoerotic asphyxia (also called hypoxyphilia or asphyxiophilia) is an extraordinarily rare and life-threatening<br />
paraphilia in which an individual, almost always a male, seeks to reduce the supply of oxygen to the brain during a<br />
heightened state of sexual arousal (American Psychiatric Association, 1994; Stanley, 1993). The oxygen deprivation<br />
is usually accomplished by applying pressure to the neck with a chain, leather belt, ligature, or rope noose (via<br />
hanging). Occasionally a plastic bag or chest compression may be used as the asphyxiating device. A person may<br />
engage in these oxygen-depriving activities while alone or with a partner.<br />
We can only theorize from limited data what motivational dynamics underlie such bizarre behavior. People who<br />
practice autoerotic asphyxia rarely disclose this activity to relatives, friends, or therapists, let alone discuss why they<br />
engage in such behavior (GarzaLeal & Landron, 1991; Saunders, 1989). For some, the goal seems to be to increase<br />
sexual arousal and to enhance the intensity of orgasm. In this situation, the item used to induce oxygen deprivation<br />
(such as a rope) is typically tightened around the neck to produce heightened arousal during masturbation and then<br />
released at the time of orgasm. Individuals often devise elaborate techniques that enable them to free themselves<br />
from the strangling device prior to losing consciousness.<br />
The enhancement of sexual excitement by pressure-induced oxygen deprivation may bear some relationship to<br />
reports that orgasm may be intensified by inhaling amyl nitrate (“poppers”), a drug used to treat heart pain. This<br />
substance is known to temporarily reduce brain oxygenation through peripheral dilation of the arteries that supply<br />
the brain with blood.<br />
It has also been suggested that autoerotic asphyxia may be a highly unusual variant of sexual masochism in<br />
which participants act out ritualized bondage themes (American Psychiatric Association, 1994; Cosgray et al.,<br />
1991). People who engage in this practice sometimes keep diaries of elaborate bondage fantasies and, in some cases,<br />
describe experiencing fantasies of being asphyxiated or harmed by others as they engage in this rare paraphilia.<br />
One important fact about this seldom-seen paraphilia is quite clear: This is a very dangerous activity that often<br />
results in death (Blanchard & Hucker, 1991; Cosgray et al., 1991). Accidental deaths sometimes occur due to<br />
equipment malfunction or mistakes such as errors in the placement of the noose or ligature. Data from the United<br />
States, England, Australia, and Canada indicate that one to two deaths per million population are caused by<br />
autoerotic asphyxiation each year (American Psychiatric Association, 1994). The Federal Bureau of Investigation<br />
estimates that deaths in the United States resulting from this activity may run as high as 1000 per year.<br />
KlismaphiIia<br />
Klismaphilia (klis-ma-FIL-ë-uh) is a very unusual variant in sexual expression in which an individual obtains<br />
sexual pleasure from receiving enemas. Less commonly, the erotic arousal may be associated with giving enemas.<br />
The case histories of many individuals who express klismaphilia reveal that as infants or young children they were<br />
frequently administered enemas by concerned and affectionate mothers. This association of loving attention with<br />
anal stimulation may eroticize the experience for some people so that as adults they may manifest a need to receive<br />
an enema as a substitute for or necessary prerequisite to genital intercourse.<br />
Coprophilia and Urophilia<br />
Coprophilia (cop-ro-FIL-e-uh) and urophilia (yoo’-ro-FIL-e-uh) refer to activities in which people obtain sexual<br />
arousal from contact with feces and urine, respectively. Individuals who exhibit coprophilia achieve high levels of<br />
sexual excitement from watching someone defecate or by defecating on someone. In rare instances, they may<br />
achieve arousal when someone defecates on them. Urophilia is expressed by urinating on someone or being urinated<br />
on. This activity, reflected in the chapter-opening anecdote, has been referred to as “water sports” and “golden<br />
showers.” There is no consensus opinion as to the origins of these highly unusual paraphilias.
Coercive <strong>Paraphilias</strong><br />
7<br />
In this section we first discuss three very common forms of coercive paraphilic behaviors: exhibitionism, obscene<br />
phone calls, and voyeurism. Three other varieties of coercive paraphilias—frotteurism, necrophilia, and zoophilia—<br />
will also be discussed.<br />
Exhibitionism<br />
Exhibitionism, often called “indecent exposure,” refers to behavior in which an individual (almost always male)<br />
exposes his genitals to an involuntary observer (usually an adult woman or female child) (American Psychiatric<br />
Association, 1994; Marshall et al., 1991). Typically, a man who has exposed himself obtains sexual gratification by<br />
masturbating shortly thereafter, using mental images of the observer’s reaction to increase his arousal (Blair &<br />
Lanyon, 1981). Some men may, while having sex with a willing partner, fantasize about exposing themselves or<br />
replay mental images from previous episodes (Money, 1981). Still others may have orgasm triggered by the very act<br />
of exposure, and a few may masturbate while exhibiting themselves (American Psychiatric Association, 1994;<br />
Freund et al., 1988). The reinforcement of associating sexual arousal and orgasm with the actual act of<br />
exhibitionism, or with mental fantasies of exposing oneself, contributes significantly to the maintenance of<br />
exhibitionistic behavior (Blair & Lanyon, 1981). Exposure may occur in a variety of locations, most of which allow<br />
for easy escape. Subways, relatively deserted streets, parks, and cars with a door left open are common places for<br />
exhibitionism to occur. However, sometimes a private dwelling may be the scene of an exposure, as revealed in the<br />
following account:<br />
One evening I was shocked to open the door of my apartment to a naked man. I looked long<br />
enough to see that he was undressed for the occasion and then slammed the door in his face. He<br />
didn’t come back. I’m sure my look of total horror was what he was after. But it is difficult to<br />
keep your composure when you open your door to a naked man. (Authors’ files)<br />
Certainly, many of us have exhibitionistic tendencies: We may go to nude beaches, parade before admiring<br />
lovers, or wear provocative clothes or scanty swimwear. However, such behavior is considered appropriate by a<br />
society that in many ways exploits and celebrates the erotically portrayed human body. The fact that legally defined<br />
exhibitionistic behavior involves generally unwilling observers sets it apart from these more acceptable variations of<br />
exhibitionism.<br />
Our knowledge of who displays this behavior is based almost exclusively on studies of arrested offenders—a<br />
sample that may be unrepresentative. This sampling problem is common to many forms of atypical behavior that are<br />
defined as criminal. From the available data, however limited, it appears that most people who exhibit themselves<br />
are adult males in their 20s or 30s, and over half are married or have been. They are often very shy, nonassertive<br />
people who feel inadequate and insecure and suffer from problems with intimacy (Arndt, 1991; Marshall et al.,<br />
1991). They may function quite efficiently in their daily lives and be commonly characterized by others as “nice, but<br />
kind of shy.” Their sexual relationships are likely to have been quite unsatisfactory. Many were reared in atmospheres<br />
characterized by puritanical and shame-inducing attitudes toward sexuality.<br />
What influences a person to engage in exhibitionism? What do you think might motivate such behavior?<br />
A number of factors may influence the development of exhibitionistic behavior. Many individuals may have<br />
such powerful feelings of personal inadequacy that they are afraid to reach out to another person out of fear of<br />
rejection (Minor & Dwyer, 1997). Their exhibitionism may thus be a limited attempt to somehow involve others,<br />
however fleetingly, in their sexual expression. Limiting contact to briefly opening a raincoat before dashing off<br />
minimizes the possibility of overt rejection. Some men who expose themselves may be looking for affirmation of
8<br />
their masculinity. Others, feeling isolated and unappreciated, may simply be seeking attention they desperately<br />
crave. A few may feel anger and hostility toward people, particularly women, who have failed to notice them or who<br />
they believe have caused them emotional pain. In these circumstances, exposure may be a form of reprisal, designed<br />
to shock or frighten the people they see as the source of their discomfort. In addition, exhibitionism is not<br />
uncommon in emotionally disturbed, intellectually disabled, or mentally disoriented individuals. In these cases, the<br />
behavior may reflect a limited awareness of what society defines as appropriate actions, a breakdown in personal<br />
ethical controls, or both.<br />
In contrast to the public image of an exhibitionist as one who lurks about in the shadows, ready to grab hapless<br />
victims and drag them off to ravish them, most men who engage in exhibitionism limit this activity to exposing<br />
themselves (American Psychiatric Association, 1994; Davison & Neale, 1993). Yet the word victim is not entirely<br />
inappropriate, in that observers of such exhibitionistic episodes may be emotionally traumatized by the experience<br />
(Cox, 1988; Marshall et al., 1991). Some may feel that they are in danger of being raped or otherwise harmed. A<br />
few, particularly young children, may develop negative feelings about genital anatomy from such an experience.<br />
Investigators have noted that some people who expose themselves, probably a small minority, may actually<br />
physically assault their victims. Furthermore, it also seems probable that some men who engage in exhibitionism<br />
progress from exposing themselves to more serious offenses such as rape and child molesting. In a one-of-a-kind<br />
study, Gene Abel (1981), a Columbia University researcher, conducted an in-depth investigation of the motives and<br />
behavior of 207 men who admitted to a variety of sexual offenses, including child molesting and rape. This research<br />
is unique in that all participants were men outside the legal system who voluntarily sought treatment after being<br />
guaranteed confidentiality. Abel found that 49% of the rapists in his sample had histories of other types of variant<br />
sexual behavior, generally preceding the onset of rape behavior. The most common of these were child molestation,<br />
exhibitionism, voyeurism, incest, and sadism. A more recent study of 274 Canadian sex offenders, all adult males,<br />
revealed that most had engaged in multiple types of variant sexual behavior, including paraphilias and more serious<br />
forms of sexual victimization, such as child molestation and rape. Collectively, these subjects admitted to 7677 total<br />
incidents of sexual offenses, an average of 28 incidents per offender. These findings suggest that “paraphiliacs tend<br />
to have multiple types of sexual aberrations as well as a high frequency of deviant acts per individual” (Bradford et<br />
al., 1992, p. 104). These findings do not imply that people who engage in such activities as exhibitionism and<br />
voyeurism will inevitably develop into child molesters and rapists. However, it seems clear that some people may<br />
progress beyond these relatively minor acts to far more severe patterns of sexual aggression.<br />
Although perhaps all of us would like protection against being sexually used without our consent, it seems<br />
unnecessarily harsh and punitive to imprison people for exhibitionistic behavior, particularly first-time offenders. In<br />
recent years, at least in some locales, there has been some movement toward therapy as an alternative to<br />
incarceration. Later in this chapter, we will discuss a variety of therapeutic techniques used to treat exhibitionism<br />
and other paraphilias.<br />
What is an appropriate response if someone exposes himself to you? It is important to keep in mind that most<br />
people who express exhibitionist behavior want to elicit reactions of shock, fear, disgust, or terror. Although it may<br />
be difficult not to react in any of these ways, a better response is to calmly ignore the exhibitionist act and go about<br />
your business. Of course, it is also important to immediately distance yourself from the offender and to report such<br />
acts to the police or campus security as soon as possible.<br />
Obscene Phone Calls<br />
People who make obscene phone calls share similar characteristics with those who engage in exhibitionism. Thus,<br />
obscene phone calling (sometimes called telephone scatologia) is viewed by some professionals as a subtype of<br />
exhibitionism. People who make obscene phone calls typically experience sexual arousal when their victims react in<br />
a horrified or shocked manner, and many masturbate during or immediately after a “successful” phone exchange. As<br />
one extensive study has indicated, these callers are typically male, and they often suffer from pervasive feelings of<br />
inadequacy and insecurity (Matek, 1988; Nadler, 1968). Obscene phone calls are frequently the only way they can<br />
find to have sexual exchanges. Fortunately, a caller rarely follows up his verbal assault with a physical attack on his<br />
victim.<br />
A recent survey of a nationally representative sample of several hundred women found that 16% had received at<br />
least one obscene phone call during the previous six months. The majority of these calls appeared to not be random
9<br />
but rather targeted in some fashion, often on women less than 65 years of age who were neither married nor<br />
widowed. The study’s author suggests that her findings indicate that obscene phone calls occur in patterns similar to<br />
that of the expression of rage and perhaps can be best explained as “displaced aggression against a vulnerable<br />
population” (Katz, 1994, p. 155).<br />
What is the best way to handle obscene phone calls? Information about how to deal with obscene phone calls is<br />
available from most local phone company offices. Because they are commonly besieged by such queries, you may<br />
need to be persistent in your request. A few tips are worth knowing; they may even make it unnecessary to seek outside<br />
help.<br />
First, quite often the caller has picked your name at random from a phone book or perhaps knows you from<br />
some other source and is just trying you out to see what kind of reaction he can get. Your initial response may be<br />
critical in determining his subsequent actions. He wants you to be horrified, shocked, or disgusted; thus, the best<br />
response is usually not to react overtly. Slamming down the phone may reveal your emotional state and provide<br />
reinforcement to the caller. Simply set it down gently and go about your business. If the phone rings again<br />
immediately, ignore it. Chances are that he will seek out other, more responsive victims.<br />
Other tactics may also be helpful. One, used successfully by a former student, is to feign deafness. “What is that<br />
you said? You must speak up. I’m hard of hearing, you know!” Setting down the phone with the explanation that<br />
you are going to another extension (which you never arrive at) may be another practical solution. Finally, screening<br />
calls via an answering machine may also prove helpful. The caller is likely to hang up in the absence of an<br />
emotionally responding person.<br />
If you are persistently bothered by obscene phone calls, you may need to take additional steps. Your telephone<br />
company should cooperate in changing your number to an unlisted one at no charge. It is probably not a good idea to<br />
heed the common advice to blow in the mouthpiece with a police whistle (which may be quite painful and even<br />
harmful to the caller’s ear) because you may end up receiving the same treatment from your caller.<br />
A relatively new service offered by many telephone companies, called call trace or call tracing, may assist you<br />
in dealing with repetitive obscene or threatening phone calls. After breaking connection with the caller, you enter a<br />
designated code, such as star 57. The telephone company then automatically traces the call. After a certain number<br />
of successful traces to the same number, a warning letter is sent to the offender indicating that he or she has been<br />
identified as engaging in unlawful behavior, which must stop. The offender is warned that police intervention or<br />
civil legal action may be an option if the behavior continues. Call trace is clearly not effective when calls are placed<br />
from a public pay phone, and calls made from cellular phones cannot be traced.<br />
Voyeurism<br />
Voyeurism (voi-YuR-iz-um) refers to deriving sexual pleasure from looking at the naked bodies or sexual<br />
activities of others, usually strangers, without their consent (American Psychiatric Association, 1994). Because a<br />
degree of voyeurism is socially acceptable (witness the popularity of R- and X-rated movies and magazines like<br />
Playboy and Playgirl), it is sometimes difficult to determine when voyeuristic behavior becomes a problem (Arndt,<br />
1991; Forsyth, 1996). To qualify as atypical sexual behavior, voyeurism must be preferred to sexual relations with<br />
another or indulged in with some risk (or both). People who engage in this behavior are often most sexually aroused<br />
when the risk of discovery is high—which may explain why most are not attracted to such places as nudist camps<br />
and nude beaches, where looking is acceptable (Tollison & Adams, 1979).<br />
As the common term peeping Tom implies, this behavior is typically, although not exclusively, expressed by<br />
males (Davison & Neale, 1993). Voyeurism includes peering in bedroom windows, stationing oneself by the<br />
entrance to women’s bathrooms, and boring holes in the walls of public dressing rooms. Some men travel elaborate<br />
routes several nights a week for the occasional reward of a glimpse through a window of bare anatomy or, rarely, a<br />
scene of sexual interaction.<br />
Again, people inclined toward voyeurism often share some characteristics with people who expose themselves<br />
(Arndt, 1991; Langevin et al., 1979). They may have poorly developed sociosexual skills, with strong feelings of<br />
inferiority and inadequacy, particularly as directed toward potential sexual partners. They tend to be very young<br />
men, usually in their early 20s (Davison & Neale, 1993; Dwyer, 1988). They rarely “peep” at someone they know,<br />
preferring strangers instead. Voyeurism is not typically associated with other antisocial behavior. Most individuals<br />
who engage in such activity are content merely to look, keeping their distance. However, in some instances, such
10<br />
individuals go on to more serious offenses such as burglary, arson, assault, and even rape (Abel, 1981; Langevin<br />
et al., 1985; MacNamara & Sagarin, 1977).<br />
It is difficult to isolate specific influences that trigger voyeuristic behavior, particularly because so many of us<br />
demonstrate these tendencies in a somewhat more controlled fashion. The adolescent or young adult male who<br />
displays this behavior often feels great curiosity about sexual activity (as many of us do) but at the same time feels<br />
very inadequate or insecure. Peeping becomes a vicarious fulfillment because he may be unable to consummate<br />
sexual relationships with others without experiencing a great deal of anxiety. In some instances, voyeuristic behavior<br />
may also be reinforced by feelings of power and superiority over those who are secretly observed.<br />
Other Coercive <strong>Paraphilias</strong><br />
We conclude our discussion of coercive paraphilias with a few brief comments about three additional varieties of<br />
these coercive or invasive forms of paraphilias. The first two, frotteurism and zoophilia, are actually fairly common.<br />
The third variant form, necrophilia, is quite rare in addition to being an extremely aberrant form of sexual<br />
expression.<br />
Frotteurism<br />
Frotteurism (fro-TUR-izm) is a fairly common coercive paraphilia that goes largely unnoticed. It involves an<br />
individual, usually a male, who obtains sexual pleasure by pressing or rubbing against a fully clothed female in a<br />
crowded public place, such as an elevator, bus, subway, large sporting events, or an outdoor concert. The most<br />
common form of contact is between the man’s clothed penis and a woman’s buttocks or legs. Less commonly he<br />
may use his hands to touch a woman’s thighs, pubic region, breasts, or buttocks. Often the contact seems to be<br />
inadvertent, and the woman who is touched may not notice or pay little heed to the seemingly casual contact. On the<br />
other hand, she may feel victimized and angry. In rare cases, she may reciprocate (Money, 1984).<br />
The man who engages in frotteurism may achieve arousal and orgasm during the act. More commonly, he<br />
incorporates the mental images of his actions into masturbation fantasies at a later time. Men who engage in this<br />
activity have many of the characteristics manifested by those who practice exhibitionism. They are frequently<br />
plagued with feelings of social and sexual inadequacy. Their brief, furtive contacts with strangers in crowded places<br />
allow them to include others in their sexual expression in a safe, non-threatening manner.<br />
As with other paraphilias, it is difficult to estimate just how common this variety of coercive paraphilias is. One<br />
study of a sample of reportedly typical or normal college men found that 21% of the respondents had engaged in one<br />
or more frotteuristic acts (Ternpleman & Sinnett, 1991).<br />
Zoophilia<br />
Zoophilia (zO-O-FIL-e-uh), sometimes called bestiality, involves sexual contact between humans and animals<br />
(American Psychiatric Association, 1994). You may wonder why we classify this as a coercive paraphilia because<br />
such behavior does not involve coercing other people into acts they would normally avoid. In many instances of<br />
zoophilia, it is reasonable to presume that the involved animals are also unwilling participants, and the performed<br />
acts are often both coercive and invasive. Consequently, assigning this paraphilia to the coercive category seems<br />
quite appropriate.<br />
In Kinsey’s sample populations, 8% of the males and almost 4% of the females reported having had sexual<br />
experience with animals at some point in their lives. The frequency of such behavior among males was highest for<br />
those raised on farms (17% of these men reported experiencing orgasm as a result of animal contact). The animals<br />
most frequently involved in sex with humans are calves, sheep, donkeys, large fowl (ducks and geese), dogs, and<br />
cats. Males are most likely to have contact with farm animals and to engage in penile—vaginal intercourse or to<br />
have their genitals orally stimulated by the animals (Hunt, 1974; Kinsey et al., 1948). Women are more likely to<br />
have contact with household pets, involving the animals licking their genitals or masturbating a male dog. Less<br />
commonly, some adult women have trained a dog to mount them and engage in coitus (Gendel & Bonner, 1988;
11<br />
Kinsey et al., 1953).<br />
Sexual contact with animals is commonly only a transitory experience of young people to whom a human<br />
sexual partner is inaccessible or forbidden (Money, 1981). Most adolescent males and females who experiment with<br />
zoophilia make a transition to adult sexual relations with human partners. Occasionally an adult may engage in such<br />
behavior as a “sexual adventure” (Tollison & Adams, 1979). True or nontransitory zoophilia exists only when<br />
sexual contact with animals is preferred regardless of what other forms of sexual expression are available. Such<br />
behavior, which is quite rare, is generally only expressed by people with deep-rooted psychological problems or<br />
distorted images of the other sex. For example, a man who has a pathological hatred of women may be attempting to<br />
express his contempt for them by choosing animals in preference to women as sexual partners.<br />
Necrophilia<br />
Necrophilia (nek-rO-FIL-e-uh) is an extremely rare sexual variation in which a person obtains sexual gratification<br />
by viewing or having intercourse with a corpse. This paraphilia appears to occur exclusively among males, who may<br />
be driven to remove freshly buried bodies from cemeteries or to seek employment in morgues or funeral homes<br />
(Tollison & Adams, 1979). However, the vast majority of people who work in these settings do not have tendencies<br />
toward necrophilia.<br />
There are a few cases on record of men with necrophilic preferences who kill someone in order to gain access to<br />
a corpse. The notorious Jeffrey Dahmer, the Milwaukee man who murdered and mutilated his victims, is believed by<br />
some experts on criminal pathology to have been motivated by uncontrollable necrophilic urges. More commonly,<br />
the difficulties associated with gaining access to dead bodies lead some men with necrophilic preferences to limit<br />
their deviant behavior to contact with simulated corpses. Some prostitutes cater to this desire by powdering<br />
themselves to produce the pallor of death, dressing in a shroud, and lying very still during intercourse. Any<br />
movement on their part may inhibit their customers’ sexual arousal.<br />
Men who engage in necrophilia almost always manifest severe emotional disorders (Goldman, 1992). They<br />
may see themselves as sexually and socially inept and may both hate and fear women. Consequently, the only “safe”<br />
woman may be one whose lifelessness epitomizes a nonthreatening, totally subjugated sexual partner (Rosrnan &<br />
Resnick, 1989; Stoller, 1977).<br />
Treatment of Coercive <strong>Paraphilias</strong><br />
In most instances noncoercive paraphilias, while clearly atypical, fall within the boundaries of acceptable modes<br />
of sexual expression. Furthermore, since they rarely cause personal anguish or harm to others, treatment is generally<br />
not called for. However, in view of the invasive nature of coercive paraphilias, which often harm others, treatment is<br />
appropriate and often necessary. Unfortunately, getting people who engage in these paraphilias to seek or accept<br />
therapeutic intervention is another matter. People who embrace one or more of the coercive paraphilias usually do<br />
not voluntarily seek treatment, nor do they acknowledge that they are in need of and/or will benefit from treatment.<br />
These individuals are thus more likely to become involved with the mental health system only after either being<br />
arrested and processed by the legal system, or because of pressure from family members who have discovered their<br />
paraphilic behavior(s).<br />
The treatment difficulties attributable to the nonvoluntary nature of client referrals is further compounded by<br />
the fact that paraphilic behaviors are typically a source of immense pleasure. Consequently, most people are highly<br />
motivated to continue rather than give up these acts (Money, 1988; Money & Lamacz, 1990). Therapeutic treatment,<br />
regardless of the specific techniques or strategies employed, is often not very successful with clients who are<br />
resistant to change.<br />
Finally, people who compulsively engage in one or more of the coercive paraphilias often claim they are unable<br />
to control their urges. This perceived lack of control runs counter to a basic tenet of most mental health therapies,<br />
which, simply stated, maintains that before we can constructively change our behavior we first must accept<br />
responsibility for our actions, no matter how driven or uncontrollable they may appear to be. Thus, a first step in a<br />
successful treatment program is to break through a client’s belief that he is powerless to change his behavior.<br />
A number of different approaches have been used in the treatment of coercive paraphilias with varied degrees
12<br />
of success. We will consider four of the more commonly used avenues of treatment: psychotherapy, behavior<br />
therapies, drug treatments, and social skills training.<br />
Psychotherapy<br />
Individual psychotherapy—in which a client talks with a psychologist, psychiatrist, or social worker for an hour<br />
or more each week—has generally not proven very effective in treating coercive paraphilias. It is difficult to<br />
overcome years of conditioning and the resultant powerful urges to continue paraphilic behavior, however<br />
problematic, in one or two hours a week of verbal interaction.<br />
Limited success in treating paraphilias has been reported by psychologists who employ cognitive therapies.<br />
Cognitive therapies are based on the premise that most psychological disorders result from distortions in a person’s<br />
cognitions or thoughts. Psychotherapists who operate within the cognitive framework attempt to demonstrate to their<br />
clients how their distorted or irrational thoughts have contributed to their difficulties, and they use a variety of<br />
techniques to help them change these cognitions to more appropriate ones (Johnston et al., 1997). Thus, although the<br />
goal of therapy is to change a person’s maladaptive paraphilic behavior, the method in cognitive therapies is to first<br />
change what the person thinks.<br />
Unfortunately, it is often very difficult to modify the distorted ideas or cognitions that people use to justify their<br />
paraphilic behaviors. In addition to being highly invested in continuing these intensely pleasurable activities, most<br />
people who engage in coercive paraphilias believe that the problems associated with these acts result from society’s<br />
intolerance of their variant behaviors, and not from the fundamental inappropriateness of such acts. Changing these<br />
distorted cognitions can be a real challenge.<br />
Behavior Therapies<br />
Traditional models of psychotherapy have emphasized the underlying causes of psychological disorders, which<br />
are viewed as distinct from those that mold so-called normal behavior. Behavior therapy departs from this traditional<br />
conception. Its central thesis is that maladaptive behavior has been learned, and that it can be unlearned. Furthermore,<br />
the same principles that govern the learning of normal behavior also determine the acquisition of abnormal or<br />
atypical behaviors. Behavior therapy draws heavily on the extensive body of laboratory research on strategies for<br />
helping people to unlearn maladaptive behavior patterns. Behavior therapy focuses on the person’s current behaviors<br />
that are creating problems. These maladaptive patterns are considered to be the problem, and behavior therapists are<br />
not interested in restructuring personalities or searching for repressed conflicts. To change these inappropriate<br />
behaviors, they enact appropriate changes in the interaction between the client and his or her environment. For<br />
example, a person who responds sexually while exposing himself might be treated through repeated exposures to an<br />
aversive stimulus paired with the situation/stimuli that elicits the inappropriate arousal pattern. This technique,<br />
called aversive conditioning, is one of several behavior therapy techniques outlined as follows.<br />
Aversive Conditioning<br />
The goal of aversive conditioning is to substitute a negative (aversive) response for a positive response to an<br />
inappropriate stimulus situation. For example, an undesired sexual behavior, such as masturbating while replaying<br />
mental images from previous episodes of exhibitionism, is paired repeatedly with an aversive stimulus such as a<br />
painful but not damaging electric shock, a nausea-inducing drug, or a very unpleasant odor. Similarly, an aversive<br />
stimulus may be administered to a person while he views photographs or color slides depicting the paraphilic<br />
behavior.<br />
A recent study reported some success in the use of aversive conditioning to treat exhibitionism. A number of<br />
male offenders were instructed to carry smelling salts (a very unpleasant odor) and told to inhale deeply whenever<br />
they felt compelled to expose themselves. This approach helped some of the offenders to develop some control over<br />
their paraphilic behaviors by virtue of learning to associate the aversive odor with their deviant fantasies/urges<br />
(Marshall et al., 1991).<br />
Aversive conditioning is not a pleasant experience, and you may wonder why anyone would undergo it<br />
voluntarily. The answer is that aversive conditioning as a treatment for coercive paraphilias is most commonly used<br />
with men required by the legal system to undergo treatment. However, in some cases family pressures or a personal
13<br />
dissatisfaction with the complications associated with paraphilic behavior have led some men to voluntarily seek<br />
this therapeutic intervention.<br />
Systematic Desensitization<br />
One of the most widely used behavior therapy techniques is systematic desensitization, a strategy originally<br />
developed by Joseph Wolpe (1958 & 1985) to treat people who are excessively anxious in certain situations. This<br />
behavioral technique is based on the premise that people cannot be both relaxed and anxious at the same time.<br />
Therefore, if individuals can be trained to relax when confronted with anxiety-inducing stimuli, they will be able to<br />
overcome their anxiety.<br />
People who engage in paraphilias frequently depend on these acts for sexual satisfaction, because they often<br />
find it very difficult to establish satisfying sexual relationships with partners, due to strong feelings of personal<br />
inadequacy and poorly developed interpersonal skills. Consequently, helping people to overcome their anxieties<br />
about relating to others by conditioning them to relax in sociosexual situations can help to replace inappropriate<br />
paraphilic behaviors with more healthy expressions of intimacy and sexuality.<br />
The key to successful application of this therapeutic method is to proceed slowly and systematically. The first<br />
step is to construct a hierarchy of situations that trigger anxiety or inappropriate sexual arousal with the most intense<br />
anxiety-inducing or sexually arousing at the top of the list and the least at the bottom. The next phase is to teach the<br />
client to relax selected muscle groups in his body. In the final stage, muscle relaxation is paired repeatedly with each<br />
of a series of progressively more intense images. When the client is able to repeatedly imagine the mildly<br />
threatening or arousing situation at the bottom of the list without experiencing any anxiety or arousal, his attention is<br />
then directed to the next image in the hierarchy. Over the course of several sessions, relaxation gradually replaces<br />
anxiety or sexual arousal to each of the stimulus situations, even the most intense at the top of the hierarchical list.<br />
Note from Dr. Kramer: (Basically, this treatment is used to replace anxiety in social situations with relaxation. If<br />
the man can relax in social/sexual situations, then it is thought he might be more likely to obtain “normal”<br />
social/sexual gratification).<br />
Orgasmic Reconditioning<br />
The goal of this version of behavior therapy is to increase sexual arousal and response to appropriate stimuli by<br />
pairing imagery/fantasies of socially normative or acceptable sexual behavior with the reinforcing pleasure of<br />
orgasm (Laws & Marshall, 1991; Walen & Roth, 1987). In orgasmic reconditioning, the client is instructed to<br />
masturbate to his usual paraphilic images or fantasies. However, when he feels orgasm is imminent, he switches to<br />
more socially appropriate imagery, on which he is told to focus during orgasm. Ideally, after practicing this<br />
technique several times, he will become accustomed to having orgasms in conjunction with more healthy<br />
imagery/fantasies. Once this is achieved, the client is encouraged to move these more appropriate images to a<br />
progressively earlier phase of his masturbation-produced sexual arousal and response. In this fashion he may<br />
gradually become conditioned to experiencing sexual arousal and orgasm in the context of socially acceptable<br />
behaviors.<br />
Satiation Therapy<br />
Another, related technique for treating coercive paraphilias in which masturbation plays a central role is called<br />
satiation therapy. In this approach to treatment the client masturbates to orgasm while fantasizing or imagining<br />
images of appropriate sexual situations. He is instructed to switch to his favorite paraphilic fantasy immediately after<br />
orgasm and to continue masturbating. The premise or theory behind this approach is that the low level of arousal and<br />
response accompanying the postorgasmic masturbation to paraphilic images will eventually result in these<br />
inappropriate stimuli becoming unarousing and perhaps even irritating (Abel et al., 1992; Laws & Marshall, 1991).
14<br />
Drug Treatment<br />
Antiandrogen drugs that drastically lower testosterone levels have been used effectively in some instances to block<br />
the inappropriate sexual arousal patterns underlying coercive paraphilic behavior (Abel Ct al., 1992; Bradford, 1998;<br />
Rosler & Witzturn, 1998). Medroxyprogesterone acetate (MPA, also known by its trade name, Depo-Provera) and<br />
cyproterone acetate (CPA) are two antiandrogen drugs most commonly used to treat sex offenders, including those<br />
whose paraphilic behaviors have brought them into contact with legal authorities.<br />
Drug treatment of coercive paraphilias is most effective when combined with other therapeutic methods such as<br />
psychotherapy or behavior therapy (Abel et al., 1992; Bradford & Pawlak, 1993b). The major advantage of these<br />
drugs as adjuncts to other treatment techniques is that they markedly reduce the driven or compulsive nature of the<br />
paraphilia. This better enables the client to focus his efforts on other therapeutic procedures without being so<br />
strongly distracted by his paraphilic urges.<br />
Social Skills Training<br />
Finally, people who engage in paraphilias often have great difficulty forming sociosexual relationships and thus may<br />
not have access to healthy forms of sexual expression. Consequently, these individuals may benefit from social<br />
skills training designed to teach them the skills necessary to initiate and maintain satisfying relationships with<br />
potential intimate/sexual partners. Such training, often conducted in conjunction with other therapeutic<br />
interventions, may involve practice in initiating social interaction with prospective companions, conversational<br />
skills, how to ask someone out on a date, and how to cope with perceived rejection.<br />
Sexual Addiction: Fact, Fiction, or Misnomer?<br />
In recent years, both the professional literature and the popular media have directed considerable attention to a<br />
condition commonly referred to as sexual addiction. The idea that people may become dominated by insatiable<br />
sexual needs has been around for a long time, exemplified by the terms nymphomania, applied to women, and<br />
satyriasis or Don Juanism, applied to men. Many professionals have traditionally reacted negatively to these labels,<br />
suggesting that they are disparaging terms likely to induce unnecessary guilt in individuals who enjoy an active sex<br />
life. Furthermore, it has been argued that one cannot assign a label implying excessive sexual activity when no clear<br />
criteria establish what constitutes “normal” levels of sexual involvement. The criteria often used to establish alleged<br />
subconditions of hypersexuality— nymphomania and satyriasis—are subjective and value laden. Therefore, these<br />
terms are typically defined moralistically rather than scientifically 1 , a fact that has generated harsh criticism from a<br />
number of professionals (Klein, 1991; Levine & Troiden, 1988). Nevertheless, the concept of compulsive sexuality<br />
achieved a heightened legitimacy with the publication of Patrick Carnes’s book, The Sexual Addiction (1983), later<br />
retitled Out of the Shadows: Understanding Sexual Addiction (1992, 2nd ed.).<br />
According to Carnes, many people who engage in some of the atypical or paraphilic behaviors described in this<br />
chapter (as well as victimization behaviors, such as child molesting) are manifesting the outward symptoms of a<br />
process of psychological addiction in which feelings of depression, anxiety, loneliness, and worthlessness are<br />
temporarily relieved through a sexual high not unlike the high achieved by mood-altering chemicals such as alcohol<br />
or cocaine. Carnes suggested that a typical addiction cycle progresses through four phases. Initially, the sex addict<br />
enters a trancelike state of preoccupation in which obsessive thoughts about a particular sex behavior, such as<br />
exposing oneself, create a consuming need to achieve expression of the behavior. This intense preoccupation<br />
1 Note from Dr. Kramer: Here we see this writer agree with me that we must strive to minimize the influence of our<br />
“values” when doing good science.
15<br />
induces certain ritualistic behaviors, such as running a regular route through a particular neighborhood where<br />
previous incidents of exposing have occurred. Their ritualistic behaviors tend to further intensify the sexual<br />
excitement that was initially aroused during the preoccupation phase. The next phase is the actual expression of the<br />
sexual act, in this case exposing oneself. This is followed by the final phase, one of despair, in which sex addicts are<br />
overwhelmed by feelings of worthlessness, depression, and anxiety. One way to minimize or anesthetize this despair<br />
is to start the cycle again. With each repetitive cycle, the addiction behavior becomes more intense and<br />
unmanageable, “thus confirming the basic feelings of unworthiness that are the core of the addict’s belief system”<br />
(Carnes, 1986, p. 5).<br />
Carnes’s conception of the sexual addict has generated considerable attention within the professional<br />
community. However, many sexologists do not believe that sexual addiction should be a distinct diagnostic<br />
category, because it is both rare and lacking in distinction from other compulsive disorders, such as gambling and<br />
eating disorders, and because this label negates individual responsibility for “uncontrollable” sexual compulsions<br />
that victimize others (Barth & Kinder, 1987; Levine & Troiden, 1988; Peele & Brodsky, 1987). This position is<br />
reflected in a decision not to include a category encompassing hypersexuality in the most recent version of the<br />
Diagnostic and Statistical Manual (DSM-IV) of the American Psychiatric Association (1994) (the most widely<br />
accepted system for classifying psychological disorders).<br />
A number of professionals acknowledge the validity of such arguments against the addiction concept but<br />
nevertheless recognize that some people may become involved in patterns of excessive sexual activity that reflect a<br />
lack of control. Noteworthy in this group is sexologist Eli Coleman (1990 & 1991), who prefers to describe these<br />
behaviors as symptomatic of sexual compulsion rather than addiction. According to Coleman, a person manifesting<br />
excessive sexual behaviors often suffers from feelings of shame, unworthiness, inadequacy, and loneliness. These<br />
negative feelings cause great psychological pain and this pain then causes the person to search for a “fix,” or an<br />
agent that has pain-numbing qualities, such as alcohol, certain foods, gambling, or, in this instance, sex. Indulging<br />
oneself in this fix produces only a brief respite from the psychological pain that returns in full force, thus triggering<br />
a greater need to engage in these behaviors to obtain temporary relief. Unfortunately, these repetitive, compulsive<br />
acts soon tend to be self-defeating in that they compound feelings of shame and lead to intimacy dysfunction by<br />
interrupting the development of normal, healthy interpersonal functioning.<br />
The topic of compulsive sexual behavior has been the subject of growing interest in both the professional<br />
community and the popular media (Black et al., 1997). We can expect that professionals within the field of sexuality<br />
will continue to debate for some time how to diagnose, describe, and explain problems of excessive or uncontrolled<br />
sexuality. Even as this discussion continues, professional treatment programs for compulsive or addictive sexual<br />
behaviors have emerged throughout the nation (over 2000 programs at last count), most modeled after Alcoholics<br />
Anonymous’s twelve-step program. Data pertaining to treatment outcomes for these programs are still too limited to<br />
evaluate therapeutic effectiveness. Besides formal treatment programs, a number of community-based, self-help<br />
organizations have surfaced throughout the United States. Some of these groups are Sex Addicts Anonymous,<br />
Sexaholics Anonymous, Sexual Compulsives Anonymous, and Sex and Love Addicts Anonymous.<br />
From: “Our Sexuality” by Crooks & Baur, 7 th Ed, 1999<br />
From: “Abnormal Psychology”, Sarason & Sarason, 2002