PSCY Essay

Running Head: PARAPHILLIC DISORDERS 1

Paraphilic Disorders Within the Sex Offender Population

Student Name

College Name

PARAPHILLIC DISORDERS 2

Abstract

This paper discusses the diagnostic criteria for the subset of paraphilic disorder known as

courtship disorders, and addresses what is both known and assumed regarding their

prevalence in the general population. A number of treatment methods for paraphilic

disorders among the sex offender population are explored, as well as the current support, or

lack of support, for their success in reducing recidivism. It is noted that treatment is

typically geared towards those who may cause the most harm, such as pedophiles or sexual

sadists. As such, there is a dearth of research specific to managing courtship disorders, or

more specifically; exhibitionism, voyeurism, and frotteurism. The impact of the therapeutic

alliance and counselor characteristics is stressed, as it is shown to be more relevant to the

success of treatment than the specific method used. Finally, this text highlights the

optimism relayed in the literature regarding the use of treatment methods, developed to

reduce recidivism, to help those living with all types of paraphilic disorders manage their

symptoms.

Keywords: paraphilic disorder, sex offender, treatment

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Paraphilic Disorders Within the Sex Offender Population

Paraphilic disorders have two predominant classifications; anomalous activity

preferences and anomalous target preferences. The anomalous activity preferences

classification is further subdivided into courtship disorders, featuring distorted

components of human courtship behavior, and algolagnic disorders, which involve pain

and suffering (APA, 2013). Algolagnic disorders include sexual masochism disorder

and sexual sadism disorder, while the courtship disorders include voyeuristic disorder,

exhibitionistic disorder, and frotteuristic disorder. Courtship disorders will be the focus

of this manuscript. As defined by the DSM-5 (American Psychiatric Association, 2013),

voyeuristic disorder can be defined as “spying on others in private activities,”

exhibitionistic disorder is known as “exposing the genitals,” and frotteuristic disorder

involves “touching or rubbing against a nonconsenting individual” (p.685). It is

important to note that due to the inherent potential harm to others, these behaviors are

classified as criminal offenses. The term paraphilia in and of itself “denotes any intense

and persistent sexual interest other than sexual interest in genital stimulation or

prepatory fondling with phenotypically normal, physically mature, consenting human

partners” (APA, 2013, p.685).

Diagnosis

For a paraphilia to rise to the level of being a diagnosable paraphilic disorder it

must be causing the individual distress or impairment, or entail personal harm, or risk of

harm, to others. It is important to keep in mind that a paraphilia by itself does not

necessarily warrant clinical intervention. In order to be diagnosed with a paraphilic

disorder, an individual must meet diagnostic Criterion A and B. Criterion A specifies

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“the qualitative nature of the paraphilia”, while Criterion B specifies its negative

consequences (APA, 2013, p.686). It is not uncommon for an individual to have a

number of paraphilias, and comorbid diagnoses of individual paraphilic disorders may

be warranted if more than one paraphilia is causing distress to the individual or harm to

others (APA, 2013). Moreover, it is important to consider the likelihood of other co-

occurring disorders. The most prevalent disorders among the sex offender population

are mood and anxiety disorders, as well as ADHD and substance abuse (Kafka &

Hennen, 2002). As such, treatment providers should be on the look-out for signs and

symptoms that suggest comorbidity, and always be open to differential diagnoses.

Prevalence

Of potentially law-breaking sexual behaviors, voyeuristic acts are the most

common (APA, 2013, p.687). Based on voyeuristic sexual acts in nonclinical samples,

the highest possible lifetime prevalence for voyeuristic disorder is approximately 12%

in males and 4% in females. The specific population prevalence of voyeuristic disorder

is unknown. Similarly, the prevalence of exhibitionistic disorder is unknown, though

based on sexual acts in nonclinical or general populations, the highest possible

prevalence is thought to be between 2% and 4% in the male population (APA, 2013,

p.690). The prevalence of exhibitionistic disorder in females is even more uncertain but

is largely assumed to be significantly lower than in males. Finally, about 10%-14% of

adult males seen for paraphilic disorders and hypersexuality in outpatient settings meet

the diagnostic criteria for frotteuristic disorder (APA, 2013, p.692-693). As such, while

the population prevalence of the disorder in the general population is not known, it is

unlikely to exceed the rate found in clinical settings. As with both voyeuristic and

PARAPHILLIC DISORDERS 5

exhibitionistic disorders, the prevalence of frotteuristic disorder in women is unknown

but commonly believed to be notably lower in females. It is important to note that the

vast majority of information quoted in studies of paraphilic disorders is derived from

research done with the sexual offender population. Moreover, given the rate of

comorbidity in paraphilias, there is some overlap in the statistics as well as the

recommendations for treatment (APA, 2013).

Treatment

In the history of sex offender treatment, a number of methods have been

explored; including surgical, hormonal, and chemical castration (Mpofu et al., 2018).

Such methods are more common with high-risk or violent offenders, such as pedophiles

and rapists, and are not considered effective treatment methods for offenders who

engage in less serious criminal sexual behaviors such as exhibitionism, voyeurism, or

frotteurism. Overall, psychosocial interventions are perceived to be more humane and

more promising than medical castration, and with an augmented understanding of an

offender’s criminogenic needs, there is value to tailoring interventions in accordance

with individual offender profiles (Mpofu et al., 2018). A specific treatment method that

has received significant attention in the literature in relation to sexual offending is

Cognitive Behavioral Therapy (CBT). CBT is “a cluster of interventions to address

presumed dysfunctional thought processes that mediate a precipitating event and otherwise

harmful behavioral responses to the event. The aim of CBT is to correct the cognitive

distortions or decisional lapses believed to be behind maladaptive behaviors, including

criminal behavior” (Mpofu et al., 2018, p.172). When working with the sex offender

population, increasing decisional choice when faced with criminogenic impulses can be key

PARAPHILLIC DISORDERS 6

to minimizing the risk of recidivism. As such, the techniques and strategies promoted in

CBT can be a fundamental part of therapy aimed at preventing relapse (Schmucker & Losel,

2015). A number of studies have explored the effectiveness of CBT on recidivism within

this population, with many showing the use of CBT leading to a significant reduction in re-

offending. Examples include an integrative study by Craig, Browne, and Stringer (2003)

which compared a recidivism rate of 8% for CBT studies with 17% for those in

comparative treatments, and a meta-analysis published by Hall (1995) that reported a

median rate of re-offense of 10.5% for those treated with CBT, compared to a rate of

19.96% among those who received other treatments. These studies suggest that CBT is a

promising intervention to reduce the risk of recidivism among sex offenders. However, it is

important to note that when sex offenders do re-offend, it tends not to be sexual or violent

nature (Craig et al., 2003), yet the focus of many studies is on all criminal offending

(sexual, violent, and general), not specifically sexual offending. As such, one should not

generalize and interpret these results to mean that CBT is successful, at the rates mentioned

above, in preventing relapse of disordered sexual behaviors.

Moreover, given the range of harmfulness among paraphilic disorders, it should

not come as a shock that the vast majority of research focuses on those that directly

involve the infliction of harm upon others. As a result, there is more information

available regarding effective treatment methods for those disorders, such as pedophilic

disorder, for example. Interestingly, it has been found that when treatment has been

implemented for paraphilias that receive less attention in the research literature, the

treatment programs were typically based on those developed for the more problematic

disorders (Marshall & Marshall, 2015). Luckily, there does not appear to be

PARAPHILLIC DISORDERS 7

significantly different results as a consequence of treatment when the same treatment is

applied to different types of offenders. A particular challenge in treatment of paraphilic

disorders is that those with sexually deviant interests and behaviors typically have no

motivation for treatment (Prescott, 2014). Accordingly, Motivational Interviewing (MI)

was identified as a tool to build clients’ interest and commitment to treatment. MI

instructs treatment providers to utilize a more therapeutic style (i.e., empathic, genuine,

collaborative) that will create an alliance between clients and their counselors and

positively influence the client’s commitment to treatment (Miller & Rollnick, 2002).

Further, the Good Lives Model proposes that sex offenders (i.e., those with diagnosable

paraphilic disorders) seek to satisfy the same needs as others, but as a result of a deficit

of skills they look to meet these needs in inappropriate ways. As such, treatment should

focus on skill building and instilling attitudes that enable the realization of life-fulfilling

goals, as opposed to focusing solely on the deficits of paraphilics (Ward, 2002). This

model is in line with positive psychology, where the focus is on strengthening a client’s

positive features as a method of surmounting problems. The two approaches discussed

here, MI and GLM are in contrast with the earlier thought that sex offenders ought to be

confronted forcefully about their distorted perceptions and problematic behaviors.

Subsequently, the focus of sex offender treatment has turned to risk assessment.

While risk assessments initially focused on identifying risk of recidivism based on past

behavior, the historical features considered were unchangeable and therefore not useful

targets for treatment. Researches then began to examine features that could be amenable

to change while still being viable predictors of future risk, developing what are now

known as static and dynamic risk factors in the field of sexual offending (Hanson &

PARAPHILLIC DISORDERS 8

Thornton, 1999). Static risk factors that predict reoffending are derived from features of

the offender’s history that are not modifiable, and as such do not come into play in

treatment. Conversely, the dynamic risk factors identified give treatment providers

something to focus on changing, and by reducing these issues and developing strengths

to counter these dangers the risk of re-offense can go down. There are two forms of

dynamic risk factors, those that are stable and reflect lasting issues, and those that are

acute which surface in the life of the offender preceding the onset of offending. While

treatment may target both sets of factors, the priority is addressing stable factors, while

acute factors may become a focus of post-treatment support. Stable factors include

“insecure attachments, lack of intimacy, emotional loneliness, poor self-regulation, sexual

preoccupation, deviant sexual interests, emotional congruence with children, lack of

concern for others, attitudes supportive of sexual offending, and hostility toward women”

(Marshall & Marshall, 2015, p.3). However, it is important to note that these factors are

predominantly relevant to child molesters, rapists, etc., there is a dearth of research on the

dynamic factors specific to those who commit exhibitionism, voyeurism, and frotteurism.

As a result, it is often assumed that the treatment for these disorders are the same as those

relevant to more violent or target-focused offenders, though this assumption is largely

unfounded. This treatment does not have strong evidence in support of its effectiveness.

Rather, it has been found that the way in which treatment is delivered has a greater impact

on reducing recidivism than does the actual implementation of practices (Marshall &

Marshall, 2012).

Consequently, there has been an emphasis on the role of the counselor in

treatment delivery, with three preeminent facets of the research; “features of the

PARAPHILLIC DISORDERS 9

therapist’s style, the therapeutic alliance, and the climate of treatment groups” (Marshall &

Marshall, 2015, p.4). In an extensive review of the literature, Norcross (2002) summed

up the research and revealed that the therapeutic alliance is responsible for somewhere

between 25 and 30% of the positive outcomes of treatment. Sex offenders report gaining

the most from therapists who are empathic, nonjudgmental, warm, and supportive

(Drapeau, 2005). Marshall and his colleagues executed an extensive review of therapist

features that predicted success in treatment programs oriented towards the sex offender

population, and they found that more than 30% of the positive changes were rooted in

the counselors’ characteristics (Marshall, et al., 2013). While treatment providers who

had a confrontational or aggressive style negatively impacted their clients, those who

were warm, empathic, and offered guidance produced positive transformations. One

study examined specifically the group counseling dynamic in a number of sex offender

treatment programs and found that those that were characterized by cohesiveness and

expressiveness were the most effective by far (Beech & Hamilton-Giachritsis, 2005).

Overall, the research seems to support the idea that as long as the appropriate issues,

namely dynamic risk factors, are targeted, and treatment delivery itself is effective, the

theoretical orientation used has minimal influence on treatment effectiveness (Marshall

& Marshall, 2012).

In this vein, it is important to take a step back and acknowledge that, given the

shame and stigma surrounding paraphilias and sexual offending, it is vital to cultivate a

strong therapeutic alliance with the client to increase the likelihood of disclosure of

behaviors at the start of treatment. In a forensic setting a therapist may have access to

official documents with objective information such as police reports, victim statements,

PARAPHILLIC DISORDERS 10

criminal records including prior sexual and nonsexual offenses, etc., however

information provided by the client can be an extremely useful addition, and in non-

forensic settings may be the only way to properly diagnose the client and move forward

with treatment. In working with clients with paraphilic disorders, mental health

practitioners have been found to assess factors such as offense patterns and victim

preferences, frequency of behavior, duration of behavior, compulsivity, and more,

(Morin & Levenson, 2008). This information is used to determine the diagnosis and

develop a treatment plan, and can come only from the offender, which further

emphasizes the importance of the counselor-client relationship and the trust needed to

encourage the client’s self-report.

Conclusion

Overall, research has shown us that regardless of the method used, if a sex offender

treatment program follows established principles, the effects will be overarchingly positive.

The benefits of attending treatment, compared to offender groups who do not receive

treatment, is indisputable. There is a significant reduction in recidivism among those who

have received treatment, irrespective to the treatment type. Though programs that focus on

the effective features delineated earlier, namely targeting dynamic risk factors, using

appropriate techniques to modify these risks, and provide treatment in a warm and empathic

fashion, seem to maximize success. While there is no clear evidence that individuals with

paraphilic disorders in the general population will respond similarly to the treatment

programs currently in place, the results with sex offenders inspires optimism about the

potential to help them manage the symptoms of their disorders and live more fulfilling

lives.

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References

American Psychiatric Association. (2013). Paraphilic Disorders. In Diagnostic and

statistical manual of mental disorders (5th ed.). Arlington, VA: Author.

Beech, A.R., & Hamilton-Giachritsis, C.E. (2005). Relationship between therapeutic

climate and treatment outcome in group-based sexual offender treatment programs.

Sexual Abuse: A Journal of Research and Treatment, 17, 127–140.

Craig, L. A., Browne, K. D., & Stringer, I. (2003). Treatment and sexual offence

recidivism. Trauma, Violence & Abuse, 4, 70-89.

Drapeau, M. (2005). Research on the processes involved in treating sexual offenders.

Sexual Abuse: A Journal of Research and Treatment, 17, 117–125.

Hall, G.C.N. (1995). Sexual offender recidivism revisited. A meta-analysis of recent

treatment studies. Journal of Consulting and Clinical Psychology, 63, 802-809.

Hanson, R.K., & Thornton D. (1999). Static 99: Improving actuarial risk assessments for

sex offenders (User Report 99–02). Ottawa: Department of the Solicitor General of

Canada.

Kafka, M.P., & Hennen, L. (2002). A DSM-IV Axis I comorbidity study of males (n=120)

with paraphilias and paraphilia-related disorders. Sexual Abuse: A Journal of

Research and Treatment, 14(4), 349-366.

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Marshall, W.L., Boer, D., & Marshall, L.E. (2014). Assessing and treating sex offenders.

In: I.B. Weiner & R.K. Otto (Eds.), The handbook of forensic psychology (pp. 839–

866). Hoboken: Wiley.

Marshall, W.L. & Marshall, L.E. (2015). Psychological Treatment of the Paraphilias: A

Review and an Appraisal of Effectiveness. Current Psychiatry Reports, 17(14), 1-6.

doi:10.1007/s11920-015-0580-2.

Marshall, W.L., & Marshall, L.E. (2012). Treatment of sexual offenders: Effective elements

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on evaluating criminal justice and corrections (pp. 71– 94). Bingley: Emerald

Publishing.

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Appendix A

Diagnostic Criteria for Voyeuristic, Exhibitionistic, and Frotteuristic Disorders

Voyeuristic Disorder

A. Over a period of at least 6 months, recurrent and intense sexual arousal from observing

an unsuspecting person who is naked, in the process of disrobing, or engaging in sexual

activity, as manifested by fantasies, urges, or behaviors.

B. The individual has acted on these sexual urges with a nonconsenting person, or the

sexual urges or fantasies cause clinically significant distress or impairment in social,

occupational, or other important areas of functioning.

C. The individual experiencing the arousal and/or acting on the urges is at least 18 years of

age.

Exhibitionistic Disorder

A. Over a period of at least 6 months, recurrent and intense sexual arousal from the

exposure of one’s genitals to an unsuspecting person, as manifested by fantasies, urges, or

behaviors.

B. The individual has acted on these sexual urges with a nonconsenting person, or the

sexual urges or fantasies cause clinically significant distress or impairment in social,

occupational, or other important areas of functioning.

Frotteuristic Disorder

PARAPHILLIC DISORDERS 15

A. Over a period of at least 6 months, recurrent and intense sexual arousal from touching or

rubbing against a nonconsenting person, as manifested by fantasies, urges, or behaviors.

B. The individual has acted on these sexual urges with a nonconsenting person, or the

sexual urges or fantasies cause clinically significant distress or impairment in social,

occupational, or other important areas of functioning.