Sexual Deviance
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Sexual Deviance

Understanding and Managing Deviant Sexual Interests and Paraphilic Disorders

Leam A. Craig, Ross M. Bartels, Leam A. Craig, Ross M. Bartels

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eBook - ePub

Sexual Deviance

Understanding and Managing Deviant Sexual Interests and Paraphilic Disorders

Leam A. Craig, Ross M. Bartels, Leam A. Craig, Ross M. Bartels

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About This Book


The essential text for understanding and managing deviant sexual interest and paraphilic disorders

Sexual Deviance is an authoritative text that provides an understanding to the assessment, management, and treatment of sexual deviance and paraphilic disorders. The international panel of contributors—noted experts on the topic—illuminate the emerging theories that help to explain the developmental influences and pathways of sexual deviance and its connection to offending behaviour. The text considers various developmental influences such as neurobiological pathways as well as the effects of pornography.

The contributors highlight the assessment and diagnosis of sexual deviance and explore the links to offending behavior such as rape fantasy, algolagnic paraphilia, online viewing of indecent images of children, and sexual sadism. The book examines the effectiveness of a variety of current treatments including behavioral, pharmacological, cognitive behavioral therapy, and systemic treatment. This important text:

  • Offers contributions from an international panel of experts
  • Examines the causes of deviant sexual interests
  • Presents techniques for managing deviant sexual interests
  • Includes information on co-morbid disorders and sexual offending

Written for students and professionals in psychology, criminology, psychiatry, forensic nursing, and social work, Sexual Deviance explores deviant sexual interests in sexual offenders and reviews the techniques designed to manage behavior.

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Part I
Sexual Deviance and Paraphilic Disorders

1 An Overview of Sexual Deviance and Paraphilic Disorders

Leam A. Craig1 and Ross M. Bartels2


Paraphilias (parəˈfiliə from Greek philos, loving) are difficult to define, contentious as a basis for legal processes, and their classification is prone to criticism. In the purist sense of the word, para—going beside or beyond, amiss; philia—attachment, is typically defined as a condition characterized by abnormal sexual desires, typically involving extreme or dangerous activities (Collins English Dictionary, 2018). According to the Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5: APA, 2013), a sexual fantasy (SF) is paraphilic if it concerns activities outside the realm of “genital stimulation or preparatory fondling with phenotypically normal, physically mature, consenting human partners” (normophilic). Intensity of the paraphilic SF is also “greater than or equal to normophilic interests.”
In the DSM-5, paraphilias are distinct from paraphilic disorders. A paraphilic disorder denotes a paraphilia that is accompanied by distress or impairment in functioning. This indicates that paraphilias are necessary but not sufficient for determining the presence of a paraphilic disorder. According to the DSM-5, a sexual interest is anomalous if its intensity is equal or superior to that of a “normophilic” sexual interest. Eight paraphilias are specifically listed in the DSM-5: pedophilia (prepubescent children), exhibitionism (exposing the genitals to an unsuspecting stranger), voyeurism (spying on unsuspecting strangers in normally private activities), sexual sadism (inflicting humiliation, bondage, or suffering), sexual masochism (experiencing humiliation, bondage, or suffering real or not, physical or not), frotteurism (touching/rubbing against an non-consenting person), fetishism (non-sexual object), and transvestism (cross- dressing). While each paraphilic disorder in this list has its own specific diagnostic criteria, there is an acknowledgment by the American Psychiatric Association (2013) that the list is not exhaustive.
Prevalence rates for paraphilias are difficult to obtain due to changes in criterion over time (Joyal, 2021, chap. 6 in this book) and between cultures (Bhugra et al., 2010). In a sample of 1,915 German men aged between 40 and 79, Ahlers et al. (2011) reported that 62.4% reported at least one paraphilia-associated sexual arousal pattern, and that this caused distress in only 1.7% of cases (Ahlers et al., 2011).
A general interest in paraphilia is not uncommon within non-offending populations. For example, Joyal and Carpenter (2017) found that nearly 50% of non-offending adults expressed an interest in at least one paraphilic category, with approximately one-third having experience with such a practice at least once. Makanjuola et al. (2008) found that between 22% and 44% of men and women admitted to at least one paraphilic interest, while Bártová et al. (2020) found that 31.3% of men and 13.6% of women reported at least one paraphilic interest. Paraphilic sexual fantasies are also common among college students (Leitenberg & Henning, 1995). For example, Williams et al. (2009) found that 95% of their male college sample reported at least one paraphilic or offense-related sexual fantasy. Within non-offending samples, an interest in voyeurism, fetishism, frotteurism, sadism and masochism are most common (Ahlers et al., 2011; Bártová et al., 2020; Joyal & Carpenter, 2017; Leitenberg & Henning, 1995; Williams et al., 2009).
Survey results from Långström and Seto (2006) sample of Swedish adults (N = 2433) revealed a lifetime prevalence of 3.1% for exhibitionistic behavior (4.1% for males and 2.1% for females), broadly consistent with the DSM-5’s prevalence estimate of exhibitionistic disorder, which range between 2 and 4% in the general population (APA, 2013). Also, 8% of their Swedish sample admitted to being sexually aroused by spying on others having sex (Långström & Seto, 2006). While exhibitionistic and voyeuristic acts have been identified as sexually deviant behaviors for centuries, the research on these disorders is scarce. Kaylor and Jeglic (2021, chap. 11 in this book) note that exhibitionistic and voyeuristic behaviors frequently occur together, as well as with other mental health issues, such as depression, substance use, anxiety, hypersexuality, bipolar disorder, attention-deficit/hyperactivity disorder, and antisocial personality disorder. A number of theories have been posited to explain paraphilic interests, including Courtship Disorder Hypothesis, Psychoanalytic Theory, Evolutionary Theory, Behavioral and Social Learning Theory, as well as increased availability with developments in technology. Of these various theories, Kaylor and Jeglic note that the Courtship Disorder model is favored in the field as it explains the high comorbidity rates amongst sexual paraphilias, as well as the escalation toward more serious sexual offending behavior. This hypothesis posits that deviant sexual behavior follows the template of normal dating behaviors, such as visually selecting a partner (voyeuristic behavior), nonphysical interactions (exhibitionistic behavior), physical touching (toucherism/frottuerism), and intercourse (rape).
Fantasies involving masochistic or sadistic content are more atypical, in that they are reported to be experienced by fewer people, although not so infrequently that they may be called rare (16–19% and 9–22% respectively). In fact, the prevalence rates of men who self-identify as BDSM practitioners vary between 2.2% and 7.6% (De Neef et al., 2019). Most people with atypical sexual interests do not have a mental disorder, and thus a paraphilic disorder, where a mental disorder is defined by DSM-5 as:
A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotional regulation, or behaviour that reflects a dysfunction in the psychological, biological or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational or other important activities. An expectable or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder, socially deviant behaviour (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual as described above. (p. 20)
To be diagnosed with a paraphilic disorder, DSM-5 requires that people with these interests: feel personal distress about their interest, not merely distress resulting from society’s disapproval; or have a sexual desire or behavior that involves another person’s psychological distress, injury, or death, or a desire for sexual behaviors involving unwilling persons or persons unable to give legal consent. However, critics have argued that the current criteria for paraphilia are too inclusive, with the crucial difference being the intensity of a sexual fantasy, which must be greater or equal than that of “normophilia.”
Miner and Munn (2021, chap. 17 in this book) highlight that compulsive sexual behavior (CSB) presents even more definitional problems. Indeed, it has been described as “sexual addiction” (Carnes, 1983), “compulsive sexual behavior” (Coleman, 1991), “paraphilia related disorder” (Kafka & Hennen, 1999), “hypersexual disorder” (Kafka, 2010), and “out of control sexual behavior” (Braun-Harvey & Vigorito, 2015). Common across these various descriptors is hypersexual behavior, which has been linked to sexual recidivism (Thornton, 2021, chap. 16 in this book).
If a person denies distress in the form of guilt, shame, or anxiety about their paraphilic impulses; are not impaired in important areas of their functioning due to this interest; and their urges are not acted upon, then they would not meet criteria for a paraphilic disorder (APA, 2013). Diagnostic systems in determining the presence of a paraphilic disorder are not without controversy and the DSM-5, in particular, has been criticized for lacking specificity. This includes an unclear definitional strategy for each paraphilia, whether paraphilias should be construed as categorical or dimensional, whether each paraphilia is properly subtyped, and whether the paraphilias are natural kinds or social constructions. These are but four of the 25 critical points regarding the DSM-5 diagnostic criteria (O’Donohue, 2016). This is demonstrated in a study by Joyal (2015). Using a general community sample (N = 1,501), Joyal (2015) found that the most intense “normophilic” sexual fantasy (receiving oral sex) is statistically more intense, on average, than the most intense “paraphilic” sexual fantasy. However, in four participant subgroups (combined n = 851), the most intense paraphilic sexual fantasy was statistically as intense as the most intense “normophilic” sexual fantasy. In other words, 57% of the study sample had met the DSM-5 definition of paraphilia (not paraphilic disorder). Joyal (2021, chap. 6 in this book) discusses the problems with psychiatric diagnoses of paraphilia in more depth, offering a number of possible solutions, including a more global diagnostic term (e.g., “sexual interest disorder” or a harmful dysfunction definition) and the need to consider different dimensions when diagnosing paraphilias.
Like Joyal (2020), D’Orazio and Flinton (2021, chap. 7 in this book) also highlight the diagnostic limitations of a categorical system when considering the diagnosis of paraphilic disorder and argue that salient aspects of sexual preferences are more accurately understood as occurring on continuums rather than as discrete categorical entities. This means there is a progression in values from one end to the other, and that adjacent points on the continuum are very similar whereas distant points are distinct. They argue that an agonistic continuum model acknowledges that what is commonly referred to as sexual sadism occurs along a continuum much like any other disorder. Sexual scripts and other diagnostic indicators, such as information from self-repo...

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