Critical Reflection 4

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CHAPTER OUTLINE

Introduction, 364 What are Paraphilias?, 364 Types of Paraphilias, 366

Fetishism, 366 Transvestism, 368 Sadomasochism, 371 Voyeurism, 373 Exhibitionism, 375 Pedophilia, 376 Other Paraphilias, 377

Paraphilia Controversies, 381 Treatment of Paraphilic Disorders, 382

Medical Therapies, 382 Psychological Therapies, 383 Social Skills Training, 383 Effectiveness, 383

Variations in Sexual Behavior

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Lehmiller, J. J. (2017). The psychology of human sexuality. ProQuest Ebook Central <a onclick=window.open('http://ebookcentral.proquest.com','_blank') href='http://ebookcentral.proquest.com' target='_blank' style='cursor: pointer;'>http://ebookcentral.proquest.com</a> Created from umuc on 2020-12-05 01:06:22.

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14 Variations in Sexual Behavior364

Introduction

After puberty. . . [my interest in horses] became more sexual. . . One night [when 19 years old] there was a horse standing in a narrow ditch. . . She was a mare, and it suddenly struck me I might be able to straddle the ditch and have sex with her. I had had many sexual encounters with human females so I knew what went where. . . I pressed the head of my penis against her vulva, started thrusting, and suddenly slid in. The sensation is hard to describe, incredibly warm, almost a shock to the senses, culminating in a very strong orgasm.

Male zoophile describing his first sexual encounter (as cited in Williams & Weinberg, 2003, p. 528)

For most people, having sex with a horse probably falls beyond the boundaries of what they would consider “normal” sexual activity. As a result, many of you probably reacted to the above quote with shock, revulsion, or perhaps even anger. While sex with animals is indeed an unu- sual sexual interest, it is just one of many sexual variations documented by psychologists that may evoke such responses. For instance, we know that some people like to expose their genitals to strangers on the subway, others like to asphyxiate themselves just before reaching orgasm, and a few are turned on by the prospect of having sex with a corpse. Thus, when we consider the full range of human sexual expression, we see that it is far broader than was discussed in chapter 9. The purpose of the current chapter is to explore sexual interests and practices that are uncommon and, in some cases, are harmful to the persons involved and/or their partners. Specifically, we will explore paraphilias, or patterns of sexual attraction and behavior that deviate from social and cultural norms. We begin by describing the nature of paraphilias. Fol- lowing that, we will discuss some of the most common types, and finish by considering treat- ment options in cases where it is warranted.

What are Paraphilias?

The word paraphilia is often translated as “beyond typical love” or “abnormal love.” However, this leads to the obvious question of how we define words like “normal” and “typical” when it comes to sexual behavior. There is no clear answer to this question because, as we have discussed previously in this book, judgments of sexual normalcy are culturally relative. For instance, in the Western world, the general consensus of the medical and psychological communities is that homosexuality is not a disorder and that it represents a normal varia- tion in sexual behavior. However, in some parts of Africa and the Middle East, homosexuality continues to be seen as an illness and a “crime against nature.” Likewise, consider that the age of sexual consent in some countries is a low as 12, but as high as 21 in others (Avert, 2012). As you can see from these examples, the same sexual act involving the same people may be viewed in a very different light depending upon where it takes place, which means that the criteria for establishing what constitutes typical and atypical sexual behavior may differ dra- matically across cultures and societies. In other words, the types of behaviors that would be classified as paraphilic can differ depending upon how a given culture views sex (e.g., is sex seen as something that is primarily practiced for pleasure, or is sex inextricably linked to the goal of procreation?).

When discussing paraphilias, it is useful to distinguish between having a paraphilia and hav- ing a paraphilic disorder (Blanchard, 2010a). Historically, psychologists and psychiatrists have viewed virtually all paraphilias as disordered behavior; in the DSM-5, however, a distinction

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hat are araahiliass 365

has been made between unusual sexual interests that are relatively harmless and those that are actively harmful. Thus, we can think of a paraphilia as simply representing an unusual sexual interest that does not necessarily require any type of treatment. In contrast, a paraphilic disorder represents an unusual sexual interest that is personally distressing to the individual (e.g., perhaps it interferes with one’s ability to establish a satisfying sexual or romantic relation- ship) and/or involves victimization of others. In addition, paraphilic disorders represent per- sistent patterns of behavior (according to the DSM-5, the urges or behaviors must last longer than 6 months). The paraphilia/paraphilic disorder distinction makes it clear that it is possible for someone to have sexual interests outside of the mainstream, yet still be psychologically healthy; non-normative sexual interests are only pathological to the extent that some harm results from them. This step toward reducing the stigma associated with paraphilias has had an important social impact because there had been previous cases in which persons with unusual sexual interests (such as sadomasochism, which involves deriving sexual pleasure from either giving or receiving pain) had their sexual desires and practices held against them in divorce proceedings and child custody cases. Having a clearer distinction between paraphilias and paraphilic disorders helps to ensure that adults with unusual sexual desires that are consensual and harmless are not subject to discrimination.

Where do paraphilias come from? Like all other sexual attitudes and behaviors, they have biopsychosocial roots. Biologically speaking, it is theorized that certain hormones (e.g., testosterone) and neurotransmitters (e.g., serotonin) are linked to paraphilic interests (Kafka, 1997). As support for this idea, research has found that by providing medications that alter the balance of these chemicals in the body, it is possible to reduce paraphilic desires (more on this at the end of the chapter). In addition, psychological learning theory (i.e., classical and operant conditioning) has been implicated in the development of sev- eral paraphilias, which explains why so many sex therapists attempt behavioral therapy as a means of treating paraphilic disorders. Many psychologists also believe that certain personality profiles may predispose people to developing paraphilias. The thought here is that when people possess personality traits and characteristics that make it more difficult to establish functional relationships, they appear more likely to gravitate toward unusual forms of sexual gratification. Consistent with this idea, research on the Big Five has found that paraphilias are linked to higher levels of neuroticism (i.e., emotional instability), as well as lower levels of agreeableness and conscientiousness (Fagan et al., 1991). Beyond this personality profile, poor interpersonal skills (e.g., limited conversational ability, dif- ficulty decoding nonverbal cues) are also linked to having paraphilias (Emmers-Sommer et al., 2004). Thus, it seems that the more problems people have interacting with others, the more likely they are to have unusual sexual interests.

Another factor that may play a role in the development of paraphilias is the finding that sexual arousal overrides our disgust impulses. That is, when we are highly aroused, some things that we would normally consider gross do not seem quite as offensive and, instead, may be perceived as pleasurable. As support for this idea, consider a novel study by Borg and Jong (2012) in which heterosexual women were randomly assigned to watch either (1) a sexu- ally arousing film, (2) an arousing but nonsexual film (i.e., people skydiving and rock climb- ing), or (3) a neutral and nonarousing video. Afterward, participants were asked to perform a series of disgusting tasks (e.g., they were asked to place their hand in a bowl of condoms that appeared to have been used and feel each one). The women who were sexually aroused were most willing to attempt the disgusting tasks and felt the least disgusted afterward compared to the other groups of women. In a related study conducted with heterosexual men, partici- pants were asked to rate how sexually attractive they found 20 different stimuli to be, including women’s shoes, a 12-year-old girl, watching a woman urinate, and having sex with an animal

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(Ariely & Loewenstein, 2006). Participants rated each stimulus twice: once while unaroused, and a second time while masturbating. Consistent with the idea that sexual arousal reduces disgust, higher desirability ratings were obtained for 19 out of the 20 stimuli in the masturba- tion condition! These findings may help to explain how some people first come to incorporate seemingly disgusting things into their sex lives. If high levels of arousal alter our perceptions and open the door to trying things we might normally stay away from, that could lay the basis for developing all kinds of unusual interests.

It is worth noting that almost all paraphilias are more common among men than they are among women. This is not a small sex difference either. For example, a national survey from Sweden found that, compared to women, men were about twice as likely to have exposed their genitals to a stranger and about three times as likely to have spied on other people having sex (Långström & Seto, 2006). We do not know exactly why this is the case, but as discussed in chapter 6, it may have something to do with women’s supposedly greater erotic plastic- ity. To the extent that men’s sexuality is indeed more “fixed” and women’s is more “flexible,” it could explain why men are more likely to become oriented on a specific sexual interest and why it is more difficult to treat paraphilic disorders in men. Another possibility suggested by some research is that this sex difference in paraphilias is largely a product of the fact that men are simply more likely than women to have compulsive sexual urges and desires (Dawson, Bannerman, & Lalumière, 2014). In other words, perhaps we see a sex difference in the preva- lence of paraphilias largely because there is an underlying sex difference in the rate of sexual compulsivity.

Types of Paraphilias

Paraphilias are generally grouped into two broad categories: those that are noncoercive and nonvictimizing (i.e., paraphilias that involve only the self or that include consenting adults) and those that are coercive and victimizing (i.e., paraphilias that involve nonconsensual sexual activ- ity with adults or children). Fetishism, transvestism, and sadomasochism as usually lumped into the noncoercive camp, while voyeurism, exhibitionism, telephone scatologia, pedophilia, necrophilia, and zoophilia are usually lumped into the coercive camp. Below, we detail each of these sexual interests. For a brief summary of each paraphilia, see Table 14.1.

Fetishism

Fetishism occurs when a person experiences intense sexual arousal in response to either a nonhuman object, a nongenital body part, or a bodily secretion (Kafka, 2010). You may be wondering whether you have a fetish because you get turned on by certain parts of the body (e.g., nice legs, big biceps) or by seeing other people wearing certain articles of clothing (e.g., skimpy underwear, high heels); however, what distinguishes a “turn-on” from a fetish is that someone with a fetish tends to obsess over the fetish object and focus exclusively on it. The object eventually becomes a sexual necessity, such that the individual may not be able to become aroused and/or reach orgasm without it. People can develop fetishes for nearly anything, but to get a sense of some of the most and least common fetishes, check out Table 14.2.

Fetishism has been described as a “multi-sensory sexual outlet” (Kafka, 2010), meaning that a fetish object may produce arousal because the individual likes the way it looks, tastes, smells, or feels. In addition, it is common for fetishes to occur in clusters (e.g., the same individual may have a fetish for both a body part and an object) and to overlap with other paraphilias,

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Table 14.1 Types of paraphilias.

Paraphilia Source of sexual arousal

Fetishism A nonhuman object, body part, or bodily secretion Transvestism Dressing up as a member of the other sex or seeing oneself as a member of

the other sex Masochism Receiving pain Sadism Giving pain to others Voyeurism Spying on unsuspecting others who are undressing or having sex Exhibitionism Exposing one’s genitals to unsuspecting others Telephone Scatologia

Placing obscene telephone calls

Pedophilia Prepubescent children Necrophilia Corpses or human bones Zoophilia Nonhuman animals

Table 14.2 Prevalence of selected fetishes among members of online fetish communities.

Bodily fetishes

Fetish Percentage of group members with that fetish

Feet and/or toes 47% Bodily fluids (e.g., blood, urine) 9% Hair 7% Muscles 5% Tattoos and piercings 4% Oral area (mouth, lips, and/or teeth) 2% Fingernails or toenails Less than 1% Body odors Less than 1%

Object fetishes

Fetish Percentage of group members with that fetish

Stockings, skirts, and other objects worn on the legs

33%

Footwear 32% Underwear 12% Stethoscopes 1% Diapers Less than 1% Catheters (i.e., tubes inserted into the urethra to draw urine out of the bladder)

Less than 1%

Data Source: Scorolli et al. (2007).

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14 Variations in Sexual Behavior368

particularly transvestism and sadomasochism (Kafka, 2010). For information on how fetishes develop, consult the Digging Deeper 14.1 box.

Many people with fetishes do not meet the criteria for fetishistic disorder because they do not necessarily experience any personal distress or impairment (Scorolli et al., 2007). Fetishists can often develop satisfying sexual and romantic relationships and find partners who enjoy their fetish behavior or do not mind it. Treatment is generally only warranted in cases where the fetish interferes with one’s ability to maintain a relationship, leads the individual to engage in criminal behavior such as burglary (indeed, fetishists sometimes steal the objects of their desire; Kafka, 2010), or causes some other type of distress.

Transvestism

Transvestism is characterized by cross-dressing for purposes of sexual arousal (i.e., dressing up as a member of the other sex because it is a turn-on). Please recall from chapter 5 that trans- vestism is not the same as transsexualism, nor is it the same as performing in drag. Although cross-dressing may occur in all of these cases, it is done for entirely different reasons. Transves- tism used to be viewed as a subtype of fetishism. In fact, in earlier editions of the DSM, it was referred to as transvestic fetishism (in contrast, it is referred to as “transvestic disorder” in the DSM-5). However, this label was inappropriately narrow because while there are indeed some transvestites for whom this behavior is a type of fetish (i.e., they are aroused by the feeling of the other sex’s clothing), there are other transvestites who become aroused by seeing them- selves as a member of the other sex (Blanchard, 2010b).

There is a popular stereotype that most (if not all) transvestites are gay men. However, this could not be further from the truth. For instance, in a survey of over 1,000 male transvestites,

Figure 14.1 Feet and toes are among the most common fetish objects. ©PhotoMediaGroup/Shutterstock.

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Taes oof araahilias 369

Digging Deeper 14.1 Why Do People Have Fetishes?

Given that fetishes can run the gamut from the conventional (e.g., silk panties and leather boots) to the unusual (e.g., dirt and cars), it is perhaps no surprise that the most common question people have about fetishes is how they develop in the first place. There are several schools of thought on this issue, but the explanation that has received the most attention suggests that fetishes develop from learned associations. In other words, we are talking about conditioned behaviors, or cases in which people have learned an association between a certain object and sexual pleasure. To illustrate this point, consider this example reported in a research article of a man describing his first encounter with a fetish object:

I was home alone and saw my uncle’s new penny loafers. I went over and started smelling the fresh new leather scent and kissing and licking them. It turned me on so much that I actually ejaculated my first load into my pants and have been turned on [by them] ever since. (Weinberg, Williams, & Calhan, 1995, p. 22)

In this case, the presentation of a novel object (leather loafers) created arousal in the individual, which he psychologically interpreted as being sexual in nature. It appears that this single event was so powerful that it instilled in him a lifelong sexual association with this object. Of course, not all fetishes develop so quickly. Some people might require repeated pairings of the object with pleasure to develop such an association. However, you get the idea from this example: fetishism is something that we seem to acquire through experience and learning.

Figure 14.2 Rachman (1966) classically conditioned a mild boot fetish in a group of male participants, thereby providing a clear demonstration of the role of learning in the development of paraphilias. ©Karkas 2013. Used under license from Shutterstock.com.

(Continued)

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87% identified as heterosexual and 83% were currently married or had been married before (Doctor & Prince, 1997). It is for this reason that the DSM criteria for transvestic disorder lim- its the diagnosis only to heterosexual men. Transvestism is almost unheard of in women, and when it occurs in gay men it rarely becomes clinically significant. We do not know exactly how transvestism develops, but individuals’ first experience with it tends to occur very early in life (often before age 10; Doctor & Prince, 1997) and it is theorized to have roots similar to fetish- ism (i.e., conditioning and reinforcement).

Some cross-dressers dislike the term “transvestite” and its clinical implications and prefer the label of “cross-dresser” instead. In addition, many within this community find the diagnosis of “transvestic disorder” offensive because they feel that it unnecessarily pathologizes the behav- ior of cross-dressing. Our use of these terms in this textbook is not meant to be hurtful or stigmatizing, but rather to be scientifically accurate and to use the language that you would see in the DSM and in journal articles should you perform additional reading on this topic. That said, it is important to emphasize that cross-dressing does not inherently represent disordered behavior. Indeed, you can be a cross-dresser and be just as psychologically healthy as anyone else. The current view in the mental health community is that the “transvestite” label is simply used to describe a behavior and does not imply any type of disorder. Like all other paraphilias, the DSM only categorizes transvestism as a “disorder” when it causes significant personal dis- tress or impairment.

A related way fetishes can develop is through classical conditioning. To the extent that a spe- cific object repeatedly appears just before we experience sexual arousal, we may eventually come to see that object as a cue for sexual arousal in the future such that every time we see that object, we get turned on. This idea was demonstrated in a fascinating experiment con- ducted in the 1960s in which heterosexual male participants were hooked up to a penile strain gauge to measure their arousal (Rachman, 1966). Participants were then shown images of boots (a nonarousing stimulus to most heterosexual guys), immediately followed by images of sexy naked women (an arousing stimulus to most heterosexual guys). After repeatedly showing boots followed by nudes, the men eventually started showing arousal in response to the boots alone! Thus, the experimenter successfully conditioned a mild boot fetish into the participants. A more recent study replicated this effect using an image of a jar of pennies (something that is not sexual at all) instead of boots, which goes to show that you can develop a fetish for almost anything (Plaud & Martini, 1999).

Animal studies have also provided support for the idea that fetishes are learned. For instance, in one study, researchers took young male rats that had never previously mated and allowed them to mate several times with sexually receptive females (Pfaus, Erikson, & Talianakis, 2013). However, before doing so, half of the male rats were clothed in tiny harness jackets. Later in the study, the researchers took the jackets away from some of the rats that had become accustomed to wearing them and found that this impaired their sexual performance, such that they were less likely to mount, penetrate, and ejaculate compared to the rats that were allowed to keep their jackets on. That’s right—it appears that animals can learn fetishes, too!

Learning theory thus provides a rather simple and intuitive explanation for the origin of fet- ishes. While this is not the only possible theory out there on the origin of fetishism, it has the strongest body of research supporting it and suggests that all fetishes, regardless of how unusual they are, may potentially develop as a result of the same underlying process.

Note: Reprinted with permission from Sex and sTchologT (www.lehmiller.com).

Digging Deeper 14.1 (Continued)

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Taes oof araahilias 371

Sadomasochism

Sadomasochism is the umbrella term used to refer to a class of sexual activities in which sexual arousal is derived from either giving or receiving pain. In popular culture, the acronym BDSM (which stands for bondage, discipline, dominance, submissions, sadism, and masochism) is often used to describe such behaviors. Psychologists generally make a distinction between masochists, who derive sexual gratification from receiving physical or psychological pain (Krueger, 2010a), and sadists, who derive sexual gratification from inflicting physical or psy- chological pain on others (Krueger, 2010b). Individuals who engage in one of these behaviors do not necessarily engage in the other.

There are a number of public misconceptions about BDSM. First, research indicates that BDSM practices are relatively common, with survey studies indicating that 14% of men and 11% of women have had at least some experience with sadomasochistic activities (Janus & Janus, 1993), while far more have had sadomasochistic sexual fantasies (Joyal, Cossette, & Lapierre, 2015). Thus, it is not as rare as people think. Second, although masochists may enjoy the experience of pain during sexual activity, they do not find all forms of pain to be pleasur- able and arousing. For instance, a masochist with a stubbed toe will find the experience to be just as unpleasant as anyone else. Third, most people tend to associate BDSM with very extreme activities and torture devices, perhaps because in media depictions of BDSM, people who are into pain almost invariably have a medieval dungeon in their basement. However, for most BDSM practitioners, the preference is for mild or perhaps even symbolic pain that stays within mutually agreeable limits. In fact, “safe, sane, and consensual” is the mantra of

Figure 14.3 Transvestites dress as members of the other sex because they receive sexual arousal from it, not because they truly want to become members of the other sex. ©joesayhello 2013. Used under license from Shutterstock.com.

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most in the BDSM community. Consistent with that idea, the most commonly reported BDSM activities involve bondage, light flagellation (i.e., whipping or flogging), blindfolds, and gags— activities that are not particularly violent and pose a low risk of danger (Sandnabba, Santtila, Alison, & Nordling, 2002). The more extreme and potentially harmful activities (e.g., cutting, electric shocks) are practiced by a few people, and a small number of deaths have been linked to such behaviors over the years (perhaps most commonly with asphyxiophilia, a behavior that overlaps with masochism and involves receiving sexual arousal from oxygen deprivation; Krueger, 2010a); however, such cases are quite rare.

Fourth, many people assume that BDSM is pathological because sadism and masochism are listed in the DSM and because media depictions of the BDSM community (e.g., Christian Grey, the main character in the popular book and movie Fifty Shades of Grey) promote the stereotype that people who associate pain with sex are victims of childhood abuse who have developed psychological problems as adults. In reality, however, people who practice BDSM are no more likely to be psychologically disturbed than anyone else. In fact, research has found that practicing BDSM is not linked to having been a victim of childhood sexual abuse nor is it associated with higher levels of psychological distress in adulthood (Richters, de Visser, Rissel, Grulich, & Smith, 2008). It is also important to note that sexual masochism disorder is only diagnosed when fantasizing about or receiving pain causes psychological distress (Krue- ger, 2010a) and sexual sadism disorder is only diagnosed when sadistic urges or behaviors cause distress or are inflicted on a nonconsenting person (Krueger, 2010b).

There are many possible explanations for the emergence of sadomasochistic desires. One possibility is that they may stem from a sensation-seeking personality, in which riskier or more thrilling activities are required in order to achieve arousal. As some support for this idea, research has found an association between sensation seeking and sexual sadism (Aluja, 2007). Learning theory and conditioning processes represent another possibility (e.g., children who are

Figure 14.4 Contrary to popular belief, most people who practice BDSM prefer to give or receive only very mild forms of pain. ©Doug Stevens 2013. Used under license from Shutterstock.com.

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Taes oof araahilias 373

punished for masturbating may come to psychologically associate pleasure and pain over time). It has also been proposed that masochism may represent an escape from high self- awareness (Baumeister, 1988). In other words, masochistic activities may allow you to “lose yourself” in the moment because either your focus shifts to the physical sensations you are having, or you start to see yourself as an object rather than a person during the experience. Another way to think about this is that the experience of pain may help to block out anxieties and insecurities that impede sexual pleasure by redirecting your attention away from the self. Finally, one other potential reason some people may be drawn to masochism is because it induces altered states of consciousness that are similar to what one might experience during meditation or hypnosis. In one study, researchers studied participants taking part in an extreme ritual in which they received temporary body piercings with attached weights—an experience that would obviously cause significant pain (Lee et al., 2016). During this event, pierced individuals appeared to enter a state of transient hypofrontality, described by the researchers as including “reductions in pain, living in the here and now, little active decision making, little active logic, and feelings of floating and peacefulness.” This suggests that masochistic practices may be appealing to those who are in search of a spiritual state.

Voyeurism

Voyeurism refers to the act of experiencing sexual arousal from fantasizing about or viewing an unsuspecting person(s) who is naked or having sex (Långström, 2010). This appears to be one of the most common sexual behavior variations, despite the fact that it is illegal in many cultures and can potentially get you in a lot of trouble, resulting in anything from financial pen- alties, to jail time, to mandatory sex offender registration. To give you some idea of prevalence, a nationally representative survey in Sweden revealed that 12% of male adults and 4% of female adults reported having spied on another person having sex at least once and derived sexual arousal from it (Långström & Seto, 2006).

Given the immense popularity of pornography, strip clubs, and reality television shows (some of which go so far as to include cameras in bedrooms and bathrooms), it would appear that at least some degree of voyeurism is socially accepted. However, it is worth noting that people who appear in professionally produced porn, dance at strip clubs, or appear on reality TV fully realize that other people will be watching them, so if you enjoy watching these things, it does not necessarily make you a true voyeur.

Another defining feature of voyeurism is repeating the behavior over time. For exam- ple, one study of men undergoing treatment for voyeurism found that, on average, they reported having spied upon 470 people (Abel & Rouleau, 1990)! It is important to note that this study only looked at voyeurs who had been caught in the act, and was based upon ret- rospective recall of past events, which means there are some concerns about the reliability and validity of the numbers. For voyeurs who are better at concealing their behavior, the number of voyeuristic acts committed over the course of a lifetime may be far higher than anyone ever suspected.

Voyeuristic disorder is only diagnosed to the extent that the individual is distressed by their voyeuristic urges and/or acts upon them with a nonconsenting person (Långström, 2010). People may act upon these urges in a variety of ways and settings. For instance, voyeurism may take place in public, such as in a department store dressing room or a restroom, or it can take place in one’s own home (e.g., by spying on people who are using your bedroom or bathroom to undress or have sex). Voyeurism may or may not include photographing or filming the unsuspecting person(s) with a hidden camera. On a side note, it is important to recognize that filming yourself having sex with another person can get you charged with voyeurism under the law and lead to major criminal consequences if your partner has not

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consented to appearing on film. In other words, you do not have a right to film or photograph sexual activities, even those that take place in your own home, unless you have the consent of everyone involved.

Like many other paraphilias, voyeuristic urges and behaviors often begin at a young age (early teenage years or sooner). Although we do not know where voyeurism comes from, research has found that it is correlated with reports of psychological problems, substance use, as well as having a higher sex drive and higher overall levels of sexual activity (Långström & Seto, 2006). Thus, one potential explanation is that biological factors create a predisposition (e.g., an unu- sually high sex drive or compulsive sexual tendencies) that, combined with certain psychoso- cial factors (e.g., poor social skills and/or a lack of a socially appropriate sexual outlet), may plant the seed for developing voyeuristic tendencies or other unusual sexual interests (e.g., exhibitionism). Operant conditioning may provide another possible explanation in the sense that if spying on others is incredibly rewarding the first time (e.g., if it is accompanied by a particularly powerful orgasm), the behavior is likely to occur again in the future.

Voyeurism can be psychologically harmful to its victims, particularly in cases where some- one is filmed and that video is uploaded to the Internet. Voyeurs will sometimes sell their videos to websites for financial gain. Unfortunately, if it is unknown who filmed the video and/ or the video is hosted on a foreign website, victims may have little recourse. Related to this, it is becoming increasingly common for people who have been dumped to try and get back at their partner by posting their partner’s sex videos or nude pictures on “revenge porn” sites (Chang, 2013). The combined betrayal by a former loved one and the resulting social embar- rassment can be particularly devastating for the victim. However, people who attempt to exact revenge through such means often fail to realize that they may be breaking video voyeurism laws. What this means is that even if your partner originally consented to having those pictures taken, publishing those pictures without your partner’s consent can potentially get you in major legal trouble.

Figure 14.5 As the name “peeping tom” implies, most voyeurs are men who become aroused by watching unsuspecting persons undress or have sex. ©ESB Professional. Used under license from Shutterstock.com.

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Exhibitionism

Revealing one’s genitals in public, often referred to as “indecent exposure,” is illegal in many countries; however, there is wide cross-cultural variability in terms of what type of exposure is considered “indecent.” For instance, throughout most of the United States, it is illegal to expose one’s genitals or a woman’s nipples in public regardless of the reason behind it (with the excep- tion of breastfeeding a child), and such behavior can be subject to jail sentences and/or required sex offender registration. This means you may want to check local laws before streaking across campus as part of a fraternity or sorority stunt! In contrast, in parts of Europe, attitudes toward public nudity are somewhat more relaxed, at least with regard to nudity that does not have a sexual purpose (e.g., sunbathing in the park or on a beach). Such behavior is typically only considered problematic to the extent that an individual uses nudity to harass others.

Although people commonly apply the label of “exhibitionist” to everyone who publicly exposes themselves, psychologists reserve the term only for those persons who expose their genitals (or fantasize about exposing their genitals) to an unsuspecting stranger (Långström, 2010). Thus, the true exhibitionist engages in socially inappropriate nudity. What exhibitionists find arousing is the shocked reaction of others, and it is this reaction that exhibitionists tend to think about when pleasuring themselves or having sex.

Research suggests that exhibitionism is much more common among men than women. For instance, in the aforementioned national survey from Sweden, 4.1% of men and 2.1% of women reported having exposed themselves to a stranger at least once and received arousal from it (Långström & Seto, 2006). However, such behavior is far more likely to be labeled problematic and punished under the law when committed by a man—an example of a reverse

Figure 14.6 What turns the exhibitionist on is the shocked reaction of an unsuspecting stranger. Exposing oneself to willing others is not of particular interest to the true exhibitionist. ©Gemenacom 2013. Used under license from Shutterstock.com.

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double standard. Think about it this way: how would a heterosexual man likely react to a female flasher? How would a heterosexual woman likely react to a male flasher? Would one be more likely to call the police than the other?

Exhibitionistic disorder is only diagnosed when an individual experiences distress or impair- ment resulting from these urges or acts upon these urges with a nonconsenting person (Långström, 2010). The nonconsenting person should rightfully be thought of as a victim in this case because some people find the experience traumatizing and experience concern for their personal safety.

The profile of a typical exhibitionist is similar in many ways to the typical voyeur, with the first experience usually occurring early in life. In addition, both behaviors are associated with psychological problems, substance use, and hypersexuality (Långström & Seto, 2006). Exhibitionists frequently exhibit social skills deficits as well (Emmers-Sommer et al., 2004), a factor that could potentially contribute to the development of this paraphilia due to dif- ficulties establishing healthy sexual and romantic relationships. It is also worth noting that exhibitionism and voyeurism frequently overlap (meaning an individual who has one of these interests often has the other), which is another reason to suspect common roots.

Telephone Scatologia Telephone scatologia, or the practice of making obscene telephone calls to an unsuspecting stranger, is considered a subtype of exhibitionism (Dalby, 1988). The goal is to induce a shocked reaction in the recipient, because that is what the caller finds arousing. Telephone scatologists are often young and share many of the same characteristics as the typical exhibitionist. Repeat calls are often made to the same individual, which can lead to feelings of sexual harassment and concerns about being stalked among victims.

Interestingly, the nature of telephone scatologia may be in the process of changing as a result of broader changes in how we communicate and use our phones. For instance, people today spend less time talking on their phones and more time sending text messages. As texting has become more popular, some scatologists have begun using this medium to send obscene mes- sages and photos. Most commonly, this takes the form of a man sending an unsolicited picture of his penis to a woman. Please note that this is different from sexting because what we are talking about here are cases in which people are sending unwanted sexual messages that are designed to shock—not arouse—the recipient.

Pedophilia

Pedophilia is characterized as a sexual attraction toward prepubescent children and, generally speaking, tends to be the most socially abhorred of all paraphilias. According to the DSM-5, pedophilic disorder is diagnosed when an individual of at least 16 years of age either acts upon the urge to have sex with a prepubescent child (usually age 13 or younger) or experiences psy- chological distress related to such urges. In addition, the individual must be at least 5 years older than the target of their arousal. Despite being subject to much criticism for being vague (e.g., What constitutes “acting on” a pedophilic urge? Is it still pedophilia if the victim is very young but has started puberty?), the diagnostic criteria were not changed during the most recent revision of the DSM. The only change that was made was to rename the diagnosis from pedophilia to pedophilic disorder.

Although it was not always the case, psychologists have increasingly come to recog- nize that not all pedophiles are child molesters and not all child molesters are pedophiles (Blanchard, 2010a). In other words, not all pedophiles will seek out sexual contact with a child, and not everyone who sexually molests a child has a sexual preference for children.

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Thus, although most people use the terms “pedophile” and “child molester” interchangeably, it is useful to distinguish between the two of them by using (1) pedophilia in reference to a pattern of sexual attraction to children and (2) child molestation in reference to specific sexual actions taken against children. Such a distinction avoids implying that all child sexual abuse stems from the same motive (and, indeed, it does not; see chapter 15).

Most pedophiles are heterosexual, married men (de Silva, 1999) and it is estimated that pedophiles make up somewhere around 4% of the population (Cloud, 2003). For years, it was thought that pedophilia had primarily psychological roots and stemmed from past personal experience with childhood sexual victimization. Consistent with this idea, many pedophiles report having been sexually abused themselves as children (de Silva, 1999). However, recent research suggests that there may be a biological or biosocial basis. For instance, pedophiles are three times as likely to be left-handed or ambidextrous relative to the general population, and they typically possess below average IQs (Blanchard et al., 2007). These findings suggest that pedophilia may potentially be traced to prenatal hormone exposure or some developmen- tal variation that either alters brain function or creates a predisposition that is brought out through environmental factors. Further support for a biological origin of pedophilia comes from fMRI studies comparing the brains of pedophilic and nonpedophilic men. This research reveals that pedophiles tend to have less white matter in the temporal and parietal lobes of the brain (Cantor et al., 2008). White matter is composed of nerve fibers and is what connects dif- ferent parts of the brain. One possibility is therefore that pedophiles’ brains are perhaps wired differently, or are “cross-wired” in such a way that, rather than evoking the typical feelings of nurturance, children evoke a sexual response.

On a side note, the term hebephilia is sometimes used to distinguish persons who are sexu- ally attracted to pubescent children from persons who are attracted to prepubescent children. Research employing genital arousal measures suggests that hebephilia is indeed a distinct erotic age preference, such that hebephilic men demonstrate more arousal in response to images of pubescent children than they do to either prepubescent children or to adults (Blanchard et al., 2009). This research also suggests that hebephilia may actually be more common than pedophilia. On the basis of such results, some sex researchers have argued that there should be separate diagnostic categories in the DSM for attraction to pubescent and prepubescent children. However, this has proved controversial and such a distinction was not adopted during creation of the DSM-5.

Child sexual abuse is a serious issue that can have devastating consequences for victims and their families. We will address the prevalence and effects of such abuse in the following chapter.

Other Paraphilias

The paraphilias discussed above are the ones that have received the most research attention and, historically, have been explicitly addressed in the DSM. However, there are a multitude of other, less common sexual variations that have been documented. In this section, we will discuss necrophilia and zoophilia. For a brief sampling of a few other paraphilic interests, visit the Digging Deeper 14.2 box.

Necrophilia Necrophilia is a very rare sexual variation that involves an erotic attraction to dead bodies. When cases of this behavior are discovered, they often make international headlines due to their highly unusual nature. For instance, in 2012, a Swedish woman was arrested for “violating the peace of the dead” after it was discovered that she had a large collection of human bones in her home that she filmed herself using as sex toys (France-Presse, 2012).

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Digging Deeper 14.2 A Closer Look at the World of Paraphilias.

An enormous number of paraphilias have been identified, with one source putting the total at 547 (Aggrawal, 2009)! However, many of these behaviors are exceedingly rare and most of them have not received much in the way of research attention, at least not yet. With that in mind, let us take a look at ten of the most interesting, but lesser known paraphilias.

10) Paraphilic infantilism: Sexual arousal is derived from dressing up like a baby or being treated like one. This may or may not overlap with diaper fetishism, in which a person receives sexual pleasure from wearing or using diapers. Either way, both sexual and nonsexual role-playing typically occur, and there are often themes of dominance and submission.

9) Formicophilia: Sexual arousal is derived from having small creatures (e.g., ants, snails) crawl all over one’s body and/or genitals. Some people enjoy the sensation of insect bites during this activity, which suggests that there may be some overlap with masochism.

8) Troilism: Sexual pleasure is derived from seeing one’s partner engage in sexual activity with another person, or from knowing that one’s partner is having sex with others. Colloquially, this is known as “cuckolding” when a man has this fantasy/desire, and “cuckqueaning” when a woman has it.

7) Abasiophilia: Sexual arousal is derived from either viewing or sexually interacting with a person who has limited mobility, such as an individual wearing a cast or using crutches.

6) Omorashi: Sexual pleasure is derived from either having a full bladder, or watching someone else with a full bladder wet themselves. This is separate from urophilia, in which a person experiences arousal in response to urinating on someone else or being urinated upon.

5) Frotteurism: Sexual arousal is derived from rubbing up against a nonconsenting person in a public place (e.g., on a subway or at a bar), usually with one’s genitals. Compared to the others on this list, frotteurism is somewhat more common and there is actually a specific listing for ofrotteuristic disorder in the DSM-V that is applied to persons who are either distressed by their frotteuristic urges or who act upon them.

4) Bug chasing: Sexual arousal is derived from having sex with (or fantasizing about having sex with) someone who is HIV-positive. Some of these individuals hope to catch the infection in the process. The underlying psychological motivations for this desire are complex, but sometimes include sensation-seeking tendencies.

3) Symphorophilia: Sexual pleasure is derived from watching a disaster occur, such as a car accident or fire. Some go as far as to repeatedly arrange accidents in order to achieve sexual gratification.

2) Sacofricosis: Sexual arousal is derived from cutting a hole inside the pocket of one’s pants in order to masturbate in public without anybody realizing that it is happening.

1) Vorarephilia: Sexual arousal is derived from the thought of eating another person or being eaten by someone else whole and live. Due to the physical impossibility of this desire, most vorarephiles just fantasize about the act; however, some achieve sexual gratification through role-playing with puppets, swallowing live insects, or watch- ing nature videos of animals as they eat other animals (Nothman & Lykins, 2015). Vorarephilia is distinct from sexual cannibalism, which involves deriving sexual arousal from the consumption of human flesh. This is extremely rare, but I read about a case a few years back involving a 43-year-old German man who solicited a younger guy online who wanted to be eaten (literally). I do not know the full extent of their relationship other than that they kissed and dined on the young man’s penis together before he bled to death (Harding, 2003).

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This case received a lot of attention not only because it involved a woman (studies have found that 95% of necrophiles are men; Rosman & Resnick, 1989) but also because the focus was on skeletons (most cases of necrophilia I have read about involve a recently deceased corpse).

You are probably wondering why anyone would want to have sex with a dead body. What the research indicates is that the single most common reason given by necrophiles is a desire for a partner who will not put up resistance or reject one’s advances (Rosman & Resnick, 1989). This suggests that interpersonal difficulties may precede necrophilic behavior in many cases. However, other reported motivations include wanting to “reconnect” sexually with a partner who has passed away and not having a current living partner.

To fulfill their desires, some necrophiles work in morgues so that they can access bodies; alternatively, they may convince a live partner to “play dead.” In contrast, other necrophiles will commit murder so that they can have sex with the body afterward (Rosman & Resnick, 1989). Homicidal necrophiles are those who kill as a means of fulfilling their desire for sex with a corpse. In contrast, pseudonecrophilic killers are those who prefer live partners, but will still have sex with someone they have killed, perhaps because violating their victim in this way further increases their feelings of power and enhances their self-esteem.

Necrophilia is considered an extremely deviant behavior because of its nonconsensual nature and the fact that homicidal tendencies sometimes accompany it. However, it is a difficult behavior to identify and prevent because the victims cannot report it and because research has found that most necrophiles (aside from the murderous ones, of course) do not meet clinical criteria for psychosis and typically lead relatively normal lives in most other ways (Rosman & Resnick, 1989).

Note: Reprinted with permission from Sex and sTchologT (www.lehmiller.com).

Digging Deeper 14.2 (Continued)

Figure 14.7 Frotteurists derive sexual arousal from rubbing up against unsuspecting strangers in crowded places. ©Ahmet Ihsan Ariturk/123RF.COM.

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Zoophilia Although you might be tempted to think the term zoophilia means “love of the zoo,” it most certainly does not; rather, it refers to a true love of animals. And I mean “love” as in the pas- sionate and erotic kind. Zoophilia is generally classified as a coercive and victimizing paraphilia because it is presumed that animals cannot consent to sex with humans. However, zoophiles argue otherwise. In fact, in a study of 114 men who have had sex with animals, most participants expressed concern for the well-being of their animal partners and felt that it was important to obtain consent before having sex with them (Williams & Weinberg, 2003). In the words of some of the participants themselves:

My relationship with animals is a loving one in which sex is an extension of that love as it is with humans, and I do not have sex with a horse unless it consents. (p. 526) Although I do get an erection when interacting sexually with a stallion, my first priority is always the animal’s pleasure, erection, and personal affection toward me. (p. 526)

Most participants in this study made a distinction between zoophiles (i.e., those who are concerned for the animal’s health, safety, and pleasure) and bestialists (i.e., those who care only about their own sexual pleasure), and the majority (93%) identified with the zoophile label. Dogs (63%) and horses (29%) were the most common animal partners reported, but some par- ticipants indicated experience with sheep, cats, cows, dolphins, and chickens. Most of the men (58%) indicated being bisexual with respect to the desired sex of their partner and, on aver- age, participants reported having had eight animal partners, with whom they most commonly engaged in vaginal and oral sex.

The prevalence and origin of zoophilia is not well understood. Kinsey found that about 8% of the men in his research had some previous sexual experience with an animal, and this

Figure 14.8 Necrophiles often work in settings where they can easily access corpses. Homicidal necrophiles may kill in order to have access to a dead body, but such behavior is very rare. ©Fernando Gregory Milan/123RF.

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number was much higher among men who grew up or lived on farms (Kinsey, Pomeroy, & Martin, 1948); however, his numbers are likely an overestimate due to the nonrepresentative nature of his sample. Most zoophiles report starting this behavior at a young age (early teens) and indicate various motivations, including desire for sexual pleasure and affection, lack of interest in human sex, and not being attractive or popular enough to find a human partner (Williams & Weinberg, 2003). As with the other paraphilias discussed above, operant con- ditioning could serve as one viable explanation for zoophilia, such that if the first encounter with an animal is extremely pleasurable (e.g., as described in the chapter-opening quote), the individual will likely seek to repeat it.

What are your thoughts on zoophilia? Check out the arguments raised in the Your Sexuality 1.1 box and weigh in with your perspective.

Paraphilia Controversies

Altogether, hundreds of sexual interests have been labeled paraphilic over the years (Aggrawal, 2009); however, this has been the subject of great controversy. Why? It turns out that many sexual interests have been classified as “unusual” in the absence of evidence indicat- ing that these interests are indeed statistically rare. For instance, in a study in which people were asked to rate the degree to which they had fantasized about 55 different sexual acts, just two emerged as statistically rare (meaning they were endorsed by less than 2.3% of participants): sex with children under the age of 12 and sex with animals (Joyal et al., 2015). By contrast, fantasies about sadistic and masochistic acts, as well as voyeurism were reasonably common in this study. Thus, it does not seem to be the case that all of the behaviors psychologists have labeled as paraphilic are all that unusual.

A related controversy is that, if the diagnostic criteria for a paraphilic disorder require either subjective distress or nonconsensual behavior, then why does the DSM need to identify any specific sexual behaviors as paraphilic in the first place? In other words, instead of having

Your Sexuality 14.1 Perspectives on Zoophilia.

Most people would label someone who has sex with animals a “pervert.” It is usually argued that because animals cannot consent, it is an act of cruelty to have sex with them. As a result, many countries around the world have instituted bans on zoophilia and bestiality. At the same time, however, the countries that ban these practices typically permit and make exceptions for ani- mal husbandry (i.e., breeding of animals for food or other purposes). Animal husbandry takes many forms, but humans often play a very active role in the breeding. For instance, when artifi- cially inseminating a female pig, breeders sometimes sexually stimulate the pig with their hands because that has been found to increase fertility rates (Roach, 2008). In fact, I have even seen an instructional video on how to stimulate a sow for such purposes and, let me tell you, it was a very “hands on” encounter. What is interesting about this is the fact that the issue of consent almost never arises when it comes to the subject of breeding. In response to this, many zoophiles have argued that it is hypocritical to suggest that zoophilia is morally wrong because animals cannot consent to sex, while simultaneously condoning forced sexual stimulation of animals for breed- ing purposes (Spiegel, 2012). Where do you stand on this issue? Can animals consent to sexual contact with humans? Is sexual stimulation of an animal acceptable under certain circumstances, but not others?

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entries such as voyeuristic disorder and masochistic disorder, why not just have a single entry for “Disorders of Sexual Interests” that encompasses any sexual desire or practice that leads to distress or victimization (Joyal, 2014)? A diagnosis like this would be more inclusive and would eliminate the need to make arbitrary judgments about what is normal vs. unusual when it comes to sex.

Treatment of Paraphilic Disorders

It should be clear from the above discussion that not every unusual sexual interest is a prob- lem or disorder that requires treatment. Indeed, therapeutic intervention is only warranted for paraphilic interests that cause subjective distress or impairment to the individual or that cause physical or psychological harm to others. Several therapeutic approaches have been developed, each based on a different theoretical perspective.

Medical Therapies

Some scientists have proposed biological explanations for paraphilias, suggesting that unusual sexual interests stem from variations in hormone and/or neurotransmitter levels. As a result, many treatments have been developed in an attempt to alter the composition of individuals’ body chemicals with the goal of changing unwanted or socially undesirable sexual behaviors. Historically, the primary medical treatment for men with unusual or dangerous sexual interests was surgical castration (i.e., removal of the testes). In the past, not only was castration used on persons with paraphilias like those described in this chapter, but it was also applied to any individuals who expressed sexual behaviors that were considered “deviant” at the time, includ- ing persons who engaged in same-sex activity. Today, however, surgical castration is generally regarded as cruel and unusual punishment and is not forced upon sexual offenders like it once was. However, in some countries, sex offenders have the option of selecting surgical castration in exchange for reduced prison sentences (Sealey, 2012).

In modern times, chemical castration (previously introduced in chapter 4) has become more normative. Chemical castration involves administering drugs such as Depo-Provera in order to block the body’s ability to produce testosterone. Research has found that such drugs can be effective at reducing deviant sexual urges among convicted sex offenders; however, it is difficult to get individuals to continue with these drug programs on a voluntary basis, owing to the fact that people find their paraphilic desires pleasurable and because there are side effects. There is also a high rate of reoffending among those who stop treatment (Miner & Coleman, 2001). Chemical castration is not free from controversy either, given that it is not always effective, and some have argued that it is cruel and unusual.

One other medical approach involves the use of antidepressants, particularly SSRIs like Prozac. Such drugs are potentially useful for two reasons. For one thing, there is the arousal- inhibiting effect of serotonin previously discussed in chapter 4. However, the other reason SSRIs may be helpful is because these drugs have been found to reduce compulsive behavior in obsessive-compulsive disorder (OCD). Some have argued that paraphilic urges are like com- pulsions in many ways and perhaps represent a variant of OCD, which may be why the same drug can be used to treat both disorders. Consistent with this idea, case studies have found that paraphilic urges often decline among patients on SSRIs. However, the use of these drugs on their own is generally only recommended for those seeking treatment for nonviolent para- philias where the risk of reoffending is low (Guay, 2009). When the risk of reoffending is higher, combined treatment consisting of SSRIs and anti-androgen drugs is recommended.

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reattent oof araahilic isorders 383

Psychological Therapies

Medical therapies are effective in treating some paraphilias, but the best outcomes typically occur when drug treatment is combined with a psychological intervention (Guay, 2009). This is especially true in cases where there are multiple victims, sexual violence, and a past history of failed treatments.

Most psychological therapies are cognitive-behavioral in nature. One of the most com- mon is orgasmic reconditioning (Marquis, 1970). In this therapy, the client is instructed to masturbate to a paraphilic fantasy (e.g., spying on a neighbor who is undressing) until the brink of orgasm, at which point the client is asked to think about a more socially appropriate fantasy (e.g., watching a stripper or exotic dancer). After a few attempts, the client will start introducing the new fantasy earlier and earlier into masturbation. This therapy is based upon classical conditioning principles, with the idea being that the pairing of sexual arousal with an appropriate stimulus will ultimately lead the appropriate stimulus to become arousing in and of itself.

An alternative approach is aversive conditioning, where the goal is to psychologically pair the paraphilic desire with something unpleasant or punishing. In an earlier time and place, this may have involved using a truly painful punishment, such as electric shocks. In the modern world, however, it would probably be more likely to involve administration of nausea-inducing drugs, exposure to unpleasant photographs, or offensive odors. There is also a somewhat milder variant of aversive conditioning known as covert sensitization, in which paraphilic desires are paired with unpleasant thoughts, such as being put in jail or socially ridiculed (Maletzky, 1980).

One other variation on aversive conditioning is masturbatory satiation (Abel et al., 1984). In this approach, the client is instructed to masturbate to orgasm (if at all possible) while think- ing of a socially appropriate stimulus. Upon climaxing, however, the client is instructed to start thinking about their paraphilic desire. In men, the continued masturbation is likely to be unpleasant and their refractory period is likely to make a second orgasm difficult. The idea is that such behavior will enhance the pleasure associated with the socially appropriate fantasy and decrease it for the paraphilic urges.

Social Skills Training

One final approach to treating paraphilic disorders involves enhancing the client’s social inter- action skills and abilities (Graves, Openshaw, & Adams, 1992). As mentioned above, social skills deficits are associated with certain paraphilias, including exhibitionism. It may be the case that persons who have difficulty developing and maintaining sexual and romantic rela- tionships gravitate toward unusual forms of sexual fulfillment because they lack a socially appropriate outlet.

Social skills training has many elements and may involve addressing social fears, coping with rejection, developing conversational skills, and learning how to express intimacy appropriately. Sex surrogates (discussed in the previous chapter) are sometimes used in this training and may serve as mock dates for the client. These “dates” may involve going out to dinner and practicing typical dating conversation, and potentially practicing sexual intimacy afterward.

Effectiveness

Although each of the above therapeutic approaches has shown promise, the results have left a bit to be desired. For instance, a meta-analysis of 80 studies revealed a 37% reduction in the re-offense rate for persons with paraphilias who received some treatment versus those

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Discussion Questions: What is Your Perspective on Sex?

● BDSM practices range from mild to wild. Although most people engage in relatively mild activities, should people be permitted to carry out their desires no matter what? Is there a line that can be crossed and, if so, where do you draw that line?

● Do you agree with the perspective that paraphilias are largely learned behaviors and that more appropriate sexual desires can be learned? Why or why not?

● For individuals with paraphilias who are convicted of sex crimes, should they be required to undergo treatment? If so, what type of treatment do you think is most appropriate?

References

Abel, G.G., Becker, J.V., Cunningham-Rathner, J., Rouleau, J.L., Kaplan, M., & Reich, J. (1984). The treatment of child molesters. Atlanta, GA: Behavioral Medicine Institute of Atlanta.

Abel, G.G., & Rouleau, J.L. (1990). The nature and extent of sexual assault. In W. L. Marshall, D. R. Laws, & H. E. Barbaree (Eds.), Handbook of sexual assault: Issues, theories, and treatment of the offender (pp. 9–22). New York: Plenum Press.

Aggrawal, A. (2009). Forensic and medico-legal aspects of sexual crimes and unusual sexual practices. Boca Raton, FL: CRC Press.

Aluja, A., Cuevas, L., García, L.F., & García, O. (2007). Zuckerman’s personality model predicts MCMI-III personality disorders. Personality and Individual Differences, 42, 1311–1321. doi:10.1016/j.paid.2006.10.009

Ariely, D., & Loewenstein, G. (2006). The heat of the moment: The effect of sexual arousal on sexual decision making. Journal of Behavioral Decision Making, 19, 87–98. doi:10.1002/bdm.501

Avert (2012). Worldwide ages of consent. Retrieved from http://www.avert.org/age-of-consent.htm (accessed September 7, 2013).

who received none (Schmucker & Losel, 2008). Although that is a substantial reduction, it is far from perfect. Treatment efficacy also varied considerably across paraphilias, with the meta-analysis revealing better success for exhibitionism and less for pedophilia. Moreover, research has found that treatment tends to be far more successful when it is sought voluntarily than when it is mandated, and the unfortunate reality is that most sex offenders do not spon- taneously seek treatment on their own. These problems, combined with the damaging effects caused by sexual victimization (a topic we will consider in the next chapter), make it clear that the search for effective treatments for paraphilic disorders will remain an urgent area of sexuality research for years to come.

Key Terms

paraphilias fetishism transvestism sadomasochism masochists sadists

voyeurism exhibitionism telephone scatologia pedophilia hebephilia necrophilia

zoophilia orgasmic reconditioning aversive conditioning covert sensitization masturbatory satiation

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