There are three components of human sexuality that may be disordered in individuals with paraphilia: sexual urge (the physiological motivation or sex drive), sexual fantasy (recurrent mental imagery), and sexual behavior (which is often the product of the first two). These components function in an interrelated feedback loop, and thus disorder in any area can affect the others. The basic disorder in paraphilia is that any or all of these three components operate in an excitable state that the affected individual has difficulty regulating. Thus paraphilias may be better thought of as hyperphilias, i.e., an abnormally high degree of sexual responsiveness (in contrast to the hypophilias, which are considered sexual dysfunctions).

This conceptualization allows us to identify the aspects of paraphilia that cause distress or impairment for patients and so become the focus of treatment. Sexual urges can be preoccupying and difficult to control (hypersexuality), causing the individual to feel frustration and distress. Sexual urges can energize and intensify both sexual fantasies and behavioral enactment. Sexual fantasies may be so frequent or intrusive that they make it difficult for the individual to concentrate, in a way similar to the interference of other types of obsessional thinking. The content of sexual fantasies may be upsetting to individuals when the content is not congruent with their self-concept or is incompatible with the types of sexual activity available for them. Cognitive distortions and justifications of paraphilic sexual fantasies may develop in an attempt to reconcile paraphilic fantasies with self-concept. Incompatible sexual fantasies can be associated with difficulties in sexual performance (sexual dysfunction) or interfere with intimacy or pair bonding with an available partner. A high frequency or intensity of sexual fantasies may fuel uncomfortably high levels of sexual urges or behavior.

Sexual behavior may be associated with the most intense distress and the greatest social consequences for an individual with a paraphilia. Sexual behavior problems include high frequencies of masturbation, long periods of time spent in masturbation rituals, intense preoccupying search for a sexual outlet, or engaging in sexual activity in situations that ultimately are associated with harm to the self or others. Uncomfortably high levels of autonomic arousal and dissociative or fugue-like states may be part of paraphilic behavioral enactment. Sexual behavior can be so focused and ritualistic that it causes difficulties in developing mutually satisfying sexual relations with a partner. Because of the overdetermined nature of paraphilic sexual interests and associated behavior, the presence of a paraphilic disorder can introduce distortions in development and lifestyle. For example, persons with pedophilia may become excessively involved in activities that appeal to children, while neglecting the development of more adult-oriented interests.

Considerable time and money can be spent in behavior associated with the paraphilia, such as collecting paraphernalia, viewing or acquiring or producing materials associated with the content of the paraphilia, going on to the Internet in the workplace or library to view paraphilia-related sites, as well participating in paid sexual activities. Participation in sexual behavior temporarily assuages sexual fantasies and urges, but in the long run may ultimately fuel and increase them. Behavior can lead to physical, emotional, and financial risk to the self and others. Some paraphilic sexual behaviors are illegal and may result in arrest and incarceration.

Research-practitioners have often discussed and documented treatment outcomes according to the specific paraphilic diagnosis (Langevin, 1983; Laws and O'Donohue, 1997). Although there are differing theories of etiology and some different approaches to treatment related to the specific content of the paraphilias, in general there is a great overlap in treatment methodologies across all of the paraphilias. The trend is toward looking at treatment approaches that can be used with any type of sexual behavioral problem, rather than treatments targeted toward a specific paraphilia (Lehne et al., 2000; Carich and Mussack, 2001). The effectiveness of treatments may vary in different studies based upon the paraphilia and the type of treatment (Greenberg, 1998; Hanson and Bussiere, 1998; Alexander, 1999; Grossman et al., 1999). Review studies have generally suggested that treatment of paraphilias can be effective, although results have varied among studies. Most treatment programs incorporate several treatment modalities (Weiss, 1989). We are not yet able to document that any one specific type of psychological treatment is uniquely effective for any paraphilia or for all types of paraphilia, although cognitive-behavioral group therapy seems to have the greatest acceptance in the published outcome studies.

Thus the current state of the art for treatment of the paraphilias is that there are a variety of distinctly different focuses and goals of treatment. While some of these can be combined in one treatment setting, others are fundamentally incompatible. Different techniques vary in their utility in different settings, such as voluntary compared with involuntary treatment settings.

In the conceptualization of the treatment of paraphilia, we recommend distinctions among the constructs of content, form, and function of the activity. The content is the what of the paraphilia: what is seen, done, or imagined by the person; for example, a man peeking in a bedroom window of an unsuspecting woman. The form is the quality of the behavior, particularly encompassing aspects of volition and range: Is the voyeurism a driven behavior or it is one with a significant degree of voluntary agency? Is it thought about during the day and then acted upon or does it appear to happen spontaneously? Is it restricted to mental life or is it acted upon? Can the man be sexually aroused in other situations or is voyeurism the obligatory means of sexual arousal? The function is the purpose the paraphilia may have in the individual's life or the meanings that are attributed to it. For example, the voyeur fears physical contact with his sexual object and so the behavior is a compromise solution that allows sexual arousal while avoiding personal contact. Content and function have typically been the constructs that were the focus of treatment efforts, especially those that were psychoanalytically informed. We suggest that it may be time to give due attention to the form of paraphilia in designing treatment interventions (Fagan, 2003).

Others have suggested a parallel between paraphilia and anxiety disorders, more specifically with the forms of phobias or obsessive-compulsive disorders (McConaghy, 1993; Bradford, 1999). Early evaluation and treatment of phobias was preoccupied with the many specific types of phobias of individuals. But eventually the content of any phobia was recognized as less important than the extent to which it causes distress or impairment for the individual. In general, the treatment of all phobias follows a similar process, although there may sometimes be specific adjustments based upon the content of the phobia(s) being treated. In the treatment of paraphilia, especially in the treatments that are not psychodynamic, more attention might be paid to the form of the paraphilia than the content and function. Especially as individuals present with multiple concurrent paraphilia or a sequence of paraphilia over years, one thinks, as with phobia, that the form should be given more salience than it has been in the past when determining treatment.

The psychotherapeutic treatment of an individual with a paraphilia raises other issues unique to the disorder that the potential psychotherapist should consider prior to entering into, or remaining in, the psychotherapeutic relationship. As we shall discuss in this chapter, a paraphilia may be associated with the commission of a sexual offense, opening the question of the relationship of the psychotherapy to forensic and legal systems.

Regarding therapist factors, the paraphilic behaviors may represent actions that are personally challenging to the psychotherapist, or behavior that the therapist has never encountered in therapy before. In instances such as these, the therapist should be either well trained in issues of transference and countertransference or be competently supervised in the course of the therapy. ‘First do no harm’ applies not only to the individual patient, but as we shall suggest, to those whose lives are affected by the patient's paraphilic behaviors.

With these caveats and before entering into a course of therapy with an individual who has a paraphilia, there are two sets of pretreatment questions that both patient and therapist should have reached agreement on. The first set should involve questions such as: Do you want to treat the paraphilia? Is the paraphilia the central focus of treatment? Answering such questions is necessary for all therapeutic modalities. Even in a psychoanalytically informed therapy in which presumably all intrapsychic conflicts are potential material for the therapy hour, the therapist should be clear about the extent to which the expectation of therapy is the control or elimination of the paraphilia. A person with an egosyntonic paraphilia that is not illegal, e.g., transvestitic fetishism, may wish to address other matters in therapy, such as life situations that are causing him to be reactively depressed or anxious. The therapist must decide if treatment can begin with the paraphilia itself excluded from treatment goals.

Given a positive response to the first set of questions, the second set revolves around the question: What is the purpose of the therapy regarding the paraphilic behavior or fantasies? This may range from accepting the status quo by assisting the patient to accept the paraphilia as an integral part of his sexuality to making rigorous interventions to help the patient resist any behavioral expression of the paraphilia. While it may be necessary to meet with the patient several times to explore these questions in a ‘pre-therapy’ period, mutual resolution is foundational for the therapeutic alliance. Similarly it is the right of the patient to give informed consent about the risks and goals of therapy, and consent can be meaningful only when the therapist and patient have similar responses to these two sorts of pretreatment questions.

The purpose of this chapter, then, is to describe psychotherapeutic modalities used to treat—usually to control—paraphilic behaviors. When at all possible we shall report treatment effectiveness, though in this area, as in most areas involving psychotherapy efficacy, studies according to specific treatment modality are few. Lastly, we shall employ the male pronoun because it is the male gender that is far more at risk for paraphilic disorders.

When the origin of the paraphilia is the focus of treatment, the goal of treatment is usually the elimination or cure of the paraphilia. There are two main therapeutic approaches that attempt to identify an etiological cause in history of the patient: psychodynamic and trauma theories. Our focus here is on psychodynamic, although many of the psychodynamic formulations and interventions are applicable to trauma theories. According to psychodynamic theories, the origin of the paraphilia is to be found in the failure to resolve successfully early life developmental issues. The therapeutic treatment is long-term individual psychotherapy to assist the individual in resolving these issues through the therapeutic relationship.

Trauma theory holds that paraphilia may result from being psychologically stuck in the content of an unresolved, and usually sexual, trauma, which generally occurred before the age of 8. Treatment involves reprocessing and working through the trauma through the use of short-term, intensive techniques such as actual or imagined desensitization or implosion of the traumatic content.

According to the psychodynamic view, the paraphilic internal script and sexual behavior are manifestations of an underlying pathological state that derives from developmental failures. Etiological formulations have shifted somewhat across the history of psychodynamic theories, moving from internal drive formulations to object relation formulations, from failure to resolve conflicts of the pre-oedipal and oedipal stages to failure of internal object representations in the separation/individuation phase. In general, the paraphilia is seen as an instance of personality pathology (in contrast to their classification as a DSM-IV-TR Axis I disorder). The recommended treatment is nonspecific in the sense that it would be appropriate to any symptomatic pattern of a character disorder, of which deviant sexual behavior is only one of many possible symptom sets.

The etiology of deviant sexuality has been described by Freud (1905), first as the residue of unresolved infantile polymorphous perversity, in which there is a failure to suppress and channel the wide range of sexual desires that characterize infantile sexuality. Freud postulates a continuum from perversion (which is evident in both childhood sexuality and in the unconscious mental life of ‘ordinary neurotics’) through neurotics to normal adult sexuality. In this view, the neurotic symptom is seen as a better solution to the universal problem of sexual and aggressive drives than is the more disturbed symptom of deviant sexuality. Freud later (1919) revised this formulation to describe paraphilia as a defense against castration anxiety.

Classical psychodynamic case formulation was based on hypotheses regarding the individual's internal state, which were drawn from interpretation of symbolic matter, such as dreams, and from theoretically based assumptions regarding internal drives and structures. Character pathology-typically narcissistic or borderline—was invoked to describe the individual's deficits (for example, Kahn, 1969 and Joseph, 1971).

Subsequent formulations by Stoller (1975), Kernberg (1991), and McDougall (1995), among others, have stressed the self in relation to objects, both internal and external. The individual's sexual symptoms are secondary to the failure to establish adequately internal object representations, which results in an inability to tolerate the otherness of the external object (Parsons, 2000). Here the intrapsychic problem to be solved may include as well the failure of the external world, particularly parental figures, and may range from actual abuse of the developing child to interactions that interfere more subtly with the child's ability to make sense of his experience. The deviant sexual behavior is now seen as a defense against object relations, that is, against the experience of the other as real, as complex, and as different from the self. It is also seen as a way of maintaining the self in face of distressing psychological states. In Stoller's formulation, the perverse behavior transforms an earlier traumatic experience into one of mastery; while in McDougall's the ‘neo-sexuality’ permits a sexual experience in the context of a threatening psychological environment.

At this point we do not know specific developmental causes of paraphilia that can be addressed in a psychoanalytic or psychodynamic modality. The most we can assert is that childhood sexual abuse is a risk factor for the development of pedophilia. Emotional abuse and family of origin dysfunction resulting in lack of emotional attachment may also be risk factors in pedophilia, exhibitionism, rape, and multiple paraphilia (Hanson and Slater, 1988; Freund and Kuban, 1994; Dhawan and Marshall, 1996; Lee et al., 2002). Such risk factors are obviously more than minor vicissitudes of growing up. Why some individuals who experience them have paraphilic sexual behaviors as adults, and why others develop sexually without paraphilia remains to be understood.

As this brief summary makes clear, psychodynamic treatment of paraphilia focuses on constructs such as self, integrity, and object relations. Behavior is decidedly secondary and of interest only as symbolic of internal states. Therapy is verbally mediated, reliant on insight, and employs the relationship with the therapist, real and transferential, as central. Change is sought at the internal level (some would say inferential level) of the unconscious drives and object relations. Not only are the paraphilias regarded as simply one possible symptom of an underlying pathology, the similarities between paraphilias are regarded as more significant than the differences, although gradations in object relatedness are acknowledged (Meyer, 1995). Thus, treatment proceeds similarly regardless of the specific deviant behavior. Treatment, as with any character disorder, must be long-term. For those with a paraphilia who are deemed to have sufficient ego strength, psychoanalysis would be recommended. For those who are unable to tolerate, afford, or benefit from analysis, psychodynamically informed therapy would be recommended. Given the psychological limitations of many of these patients, the value of 12-step concurrent support groups is not ruled out (McDougall, 1995).

As with other psychodynamic treatment models, there are no large-scale empirical studies of treatment outcome of psychodynamic treatment of paraphilias. The constructs of psychodynamic theory are difficult to operationalize and the course of therapy is extended and difficult to predict. Published work in support of the model is in the form of case histories, usually of individual cases, sometimes of groups (Carigan, 1999; Lothstein, 2001). Case histories are formulated around a careful reading of the individual's past, inferences regarding the individual's internal state, and interpretations of the individual's relationship with the therapist. The sexual behavior is regarded as a symptomatic solution to an intrapsychic or interpersonal problem, which must be reformulated and reworked in the therapy. One aspect of this model, which is embodied in the rich narrative form of the case history, is its emphasis on the complexity of the individual in the context of a particular life. This representation of personhood can be a useful corrective to the current tendency to demonize people who engage in deviant sexual behaviors. In summary, psychodynamic theories have proposed elaborate formulations regarding the etiology of deviant sexual behavior, but they have not generated a therapeutic strategy specific to the treatment of paraphilias.

Glenmullen (1993) published a case study that exemplifies many of the psychoanalytic techniques, although it relies less on formulations regarding drives and dream analysis than did earlier works (Kahn, 1969; Joseph, 1971). Glenmullen's case is too long to reproduce here, representing months (perhaps years) of therapy, so we shall summarize.

The patient was a young man who presented with a pervasive ‘numbness.’ He had also withdrawn sexually from his female partner. In the early phase of therapy, the patient revealed that his father had abandoned the family when the patient was in his early teens, leaving the family destitute. The father was discovered dead several months later, under suspicious circumstances. After this revelation, the therapist began to ‘articulate the repressed emotions’ of the patient, but the patient pulled back into a narrow focus of repetitive and detailed description of his ‘numbness.’ This withdrawal had a deadening effect on the sessions, and the therapist had to attend to his own internal response (countertransference) and manage it in order to avoid subverting the therapy. This stalemate was eventually infused with the patient's discontent with progress, which created a heightened emotional tone in the sessions.

At this point, the patient referred to his habit of taking late-night walks, which he described as both urgent and dangerous. The therapist guessed that the walks led to the acquisition of pornography for masturbation, and the patient, relieved, described a long-term pattern of compulsive use of pornography. This use was marked by, first, the intensity of the pursuit (‘pounding the pavement’ for hours) and, second, by the patient's awareness of interactions with other men (fellow customers, who may have just leafed through the same magazine, or the clerk, who must be handed money). The patient declared that he could masturbate to orgasm only with the use of pornography, and he denied that he had any sexual fantasies of his own or any sexual dreams.

Although he initially denied being drawn to any particular scene, he subsequently acknowledged that he was particularly aroused by ‘threesomes,’ in which he imagined the two male figures were friends. The therapist, having formulated that these ‘purchased fantasies’ functioned as a defense against the patient's inner life, asked the patient to resist his impulse to use pornography, a request the patient found difficult to fulfill. However, the patient ultimately achieved ‘sobriety’ and, in this state, his response to his experience became more emotional. In particular, he burst into tears after being corrected by an older man at work, whom he admired.

At one point, the therapist inquired regarding his earliest experience of pornography, and the patient described finding a stash of pornography in his father's study. The patient's first masturbatory experiences employed the same images his father was using. The stash disappeared when his father abandoned the family. In the months after the father's disappearance, the patient started riding his bike for miles along rural highways. During the rides he would find abandoned pornographic magazines along the roadside. With the therapist's formulation that pornography represented a connection with other men and, ultimately, with the lost father, the patient displayed a strong affective response. The therapy then turned to working on his unresolved grief for his father. ‘Stripped of its purpose, [the] pornography addiction gradually fell away’ (Glenmullen, 1993, p. 29).

Clinical practice targeting the cognitive control of behavior utilizes individual and group treatment to assist patients in controlling thoughts and behavior so they can minimize the impact of the paraphilia upon themselves or others. While the patient generally assumes that the paraphilic behavior is solely the result of his heightened sex drive, cognitive-behavioral therapy identifies the cognitive assumptions and rationalizations that facilitate the sexual behaviors. Once identified, the therapeutic task is to replace the facilitative assumptions with cognitive formulations that recognize both the motivating and stimulating antecedents as well as the personal and relational consequences of the paraphilic behaviors.

Group therapy comprised of members with sexual disorders (not dysfunctions) is a highly recommended modality for cognitive-behavioral interventions in the treatment of paraphilic disorders. For the treatment of those individuals whose paraphilia are sexual offenses or are coercive, the group therapy modality serves to use the social force of peers and therapist to confront the cognitive distortions and offer more appropriate assumptions to group members about their sexual relationships and behaviors.

The most widely accepted treatments for paraphilia involve helping patients better control and manage their sexualized thinking and behavior. These individual and group therapies work to help the motivated patient achieve better cognitive control of sexual behavior. The practice principles described here are similar to those used in the treatment of different addictions, and reflect the underlying assumption that the paraphilia cannot be eliminated but can be controlled. Individual therapies utilize cognitive-behavioral techniques, while group training and management techniques are also prevalent.

Many current treatment protocols of paraphilia have as a major modality those interventions that have been developed out of the cognitive-behavioral therapy tradition. What follows are brief descriptions of various interventions that should be viewed as complementary components in a cognitive-behavioral treatment plan. Their principal contribution to treatment is to control the cognitions, including sexual fantasies, which lead to paraphilic behaviors or to the affects that trigger them.

Tom was a 32-year-old attorney whose marriage had recently been jeopardized by his wife, Joan, after finding several inexplicable charges to their credit cards totaling $480. She confronted him with the bills. At first he said that there must be some mistake and that someone must be using his credit card number. But his wife persisted and eventually Tom admitted that he had been visiting the website ‘http://www.babe-in-arms.com’ and also a local massage parlor for the past 6 months and using them for sexual gratification. It did not help that during these 6 months Joan was caring for their newborn daughter, their first child. Tears flowed from both.

Upon his wife's insistence, but with agreement from him in order to save the marriage, Tom began both individual and group therapy. Tom acknowledged in treatment that the name of the website was double entendre: the men could either imagine the grown female ‘babes’ in their arms, or they could be the infantile babes in the arms of the women. Tom admitted that he longed to be treated like a baby by his sexual partners and had in fact visited massage parlors that catered to this desire. He found it very arousing to imagine being cleaned and diapered by a woman. His experience in vivo was limited to being in diapers: being verbally scolded for soiling them, and then engaging in noncoital cuddling. Apparently the scene of his wife changing the diapers of their daughter brought back sexual fantasies that had long lay dormant. The admission of this paraphilic arousal pattern was very embarrassing to Tom, but he also admitted relief that his secret was now shared with others who he had found on the Internet. The group responded with support and, to the best of their abilities, understanding.

The methods used in both Tom's individual and group therapies were cognitive-behavioral. Especially helpful was his recognition of the envy he felt at the attention his wife gave to their newborn. He replaced thoughts of sibling envy with the correct thought that this was his daughter and she was entirely dependent upon him. Behaviorally, he countered this envy by helping his wife care for their daughter. What Tom was surprised to learn was that the more he cared for his daughter, including changing her diapers, the more he felt love for his daughter and a grateful love from his wife for sharing the child-care.

With treatment and the threat of divorce, the behaviors of utilizing the website and going to the massage parlors ceased immediately. After 9 months of treatment, even the infantilism fantasies had decreased in frequency and intensity. For 6 months he had not masturbated to the thought of his being cared for like a baby. Tom considered his problem a sexual addiction, and in addition to therapy, attended group meetings of Sex and Love Addicts Anonymous (SLAA). He felt that when therapy was concluded, he would continue to attend the 12-step group for the support and program it gave to his ‘sobriety’.

Tom recognized that it was important for him to establish a RPP to employ for the posttherapy future. In therapy Tom had described his pattern of behavior, his behavioral chain, and alternative thoughts and behaviors that he could use to maintain control of his desire to use the Internet and massage parlors to gratify his sexual desires. In his individual psychotherapy he worked to develop his RPP, using many of the techniques described in publications available from the Safer Society Foundation (http://www.safersociety.org; for example, Steen, 2001).

This is the RPP that Tom and his therapist developed:

• Identify risk states before sexually acting out: negative emotions, like being ignored by my wife; being criticized by partners or clients at work; feeling ineffective or lonely; being bored. Feeling that I deserve a reward and to be cared for.

  • (a) What can I do instead: use the David Burns (Feeling Good Handbook, 1999) Daily Mood Log and Cognitive Distortions Checklist. Do something positive and fun for myself—rent a DVD, buy a CD, take my wife out to dinner; get more involved in caring for and playing with my daughter. Don't be a PIG (Problem of Immediate Gratification)!

• Recognize Seemingly Unimportant Decisions (SUDS) that place in HRS: carrying extra cash beyond what I would need; driving by areas where there are massage parlors; leaving work early for ‘unaccounted for’ time; being in a private area at home with the computer.

  • (a) What can I do instead: never carry more than 15 dollars. Do not carry an ATM card; carry only one credit card, which wife pays the bill for each month. Post picture of wife and child in prominent place on car dashboard. Work out on map alternative routes so that never have to drive by high-risk areas. Call wife before leave to establish time record if feeling tempted to drive by risky areas. Look at relapse prevention card (carry in wallet). Move the computer to a room into which privacy is not a given and face the screen toward the entrance door of the room.

• Avoid lapse in thoughts or behavior: thinking about past experiences with massage parlor women or images and chats on the Internet. Masturbating. Driving near areas where massage parlors are located. Reading the ads for sexual services in the newspaper.

  • (a) What can I do instead: talk to SLAA sponsor, attend extra meetings. Call therapist to discuss. Substitute a positive activity such as a regular exercise program.

• Relapse: surf on Internet for sexual sites. Go to massage parlor.

  • (a) What can I do: remember that it is not the end of the world. I can be sober. Don't give up hope!! Go to SLAA meetings and therapy sessions.

Two years following treatment, Tom continues to employ the RPP that he developed. He and his wife were in marital therapy for 6 months, which helped to clarify the expectations each had of the other in areas such as domestic chores, sex and affection, and leisure activities together. He had one ‘relapse’ within the first 3 months of ending therapy in which he went into a massage parlor. He immediately felt guilty and remorseful and left without having sexual contact. Tom called his SLAA sponsor and reported the incident. They agreed he would increase the frequency of meetings to three times a week. Tom also had a consultation with his therapist. The therapist helped Tom to recognize how he had allowed risk states and SUDS to creep back into his life. They agreed that he would return every 6 months for a ‘check-up’ consultation.

Paraphilias by definition incorporate patterns of physiological sexual arousal that are different in content from mainstream sexuality. Some behaviorists believe that the atypical association between the sexual content and arousal was acquired through a conditioning process, and can be alleviated by reconditioning. Sexual arousal modification focuses treatment on changing the physiological pattern of sexual arousal through the use of behavioral techniques, most commonly by modifying masturbation or physiological arousal in the presence of real or imagined paraphilic content.

Men who seek treatment for paraphilia almost always report a history of being sexually aroused and masturbating to fantasies that embody paraphilic imagery. Disordered sexual arousal is the key diagnostic criterion for the diagnosis of paraphilia, and is the factor most associated with repeated sexual misconduct or sex offending (Murphy and Barbaree, 1994; Hanson and Bussiere, 1998).

According to behavioral theories, paraphilic arousal has been conditioned by the association of paraphilic practices with reinforcement (typically pleasurable sexual arousal or orgasm, or anxiety reduction). Behavioral treatment attempts to modify this pattern by linking paraphilic arousal with aversive stimuli, or not having paraphilic arousal associated with positive stimuli. In some cases alternative patterns of arousal and behavior are conditioned.

Behavioral techniques were developed to modify the pattern of sexual arousal, and were the prevalent treatment approach for paraphilia from the 1960s to the early 1990s (Quinsey and Earls, 1990; Knopp et al., 1992). There has been little research on the effectiveness of these techniques in the past 20 years, but they have a seemingly common sense validity that appeals to therapists and patients. Thus, these techniques continue to be incorporated into treatment programs of varying theoretical orientations (McGrath, 2001) and are strongly recommended by some expert practitioners specializing in the treatment of exhibitionism (Maletzky, 1997) and fetishism (Junginger, 1997).

Sexual arousal modification as a practice principle typically uses behavioral conditioning techniques to try to modify the pattern of physical sexual arousal. Treatment starts with the assessment of the patient's arousal pattern, and the effectiveness of treatment is confirmed when the patient does not show (typically penile) arousal to the previously arousing stimuli. There are three different behavioral approaches to sexual arousal modification—aversive conditioning, covert sensitization, and positive conditioning—as well as mixed models of reconditioning techniques.

This case example illustrates treatment of a man with exhibitionism employing Alternative Behavioral Completion according to McConaghy's protocol (McConaghy, 1993). The patient was a 26-year-old, never-married male with a history since age 16 of exposing to adult women in public parks and woods. First he was trained in progressive muscular relaxation, tensing and then releasing muscle groups starting with his feet and progressing to his head. He had written down a number of his typical exposing scenarios, which had been carefully constructed with the help of the therapist. The scenarios were composed in first-person present tense and were broken down into discrete segments. One example is:

• I am feeling the urge to expose, I can't get the idea out of my head.

• I go to Indian Creek Park and stand next to a tree like I am going to urinate.

• I see an attractive woman jogging on the path.

• I have an urge to unzip my fly and expose my penis.

  (The Alternative Behavioral Completion sequence begins.)

• Then I realize the urge is not so strong.

• I can control it.

• I notice how nice the park is, the beauty of the trees, the smell of the outdoors, the sounds of the birds.

• The woman jogs by while I stand there enjoying the park.

• I leave the park feeling good about myself.

Treatment sessions consisted of progressive muscle relaxation, then the patient imagining the paraphilic scenario. The therapist led him through each segment (numbers 1–9) of the scenario. The patient signaled with his finger when he had successfully imagined each segment, and then he proceeded to imagine the next segment. Each of the different scenarios had first been practiced in sessions with the therapist. After the initial training sessions, the patient could audiotape the scenarios and practice them at home.

After treatment with Alternative Behavioral Completion, this patient continued to have times when he felt the urge to expose, usually on nice days in the summer. Before treatment, he reported that he felt so uncomfortable and stressed out that he would go to the park to expose to get relief. After treatment, he was able to imagine going to the park and felt more relaxed. He reported that he did not have difficulty controlling his urges to expose. Consistent with his general relapse prevention treatment, however, he also did not allow himself to get in his car and drive to the park. Instead he would take his dog for a walk around the block where he lived, a situation where he was unlikely to encounter a situation conducive to exposing and where he had never exposed in the past.

The biological treatment of paraphilia involves the direct reduction of the sex drive, and is usually adjunctive to one of the ‘talking’ therapies. It typically involves pharmacological treatment, and rarely surgical, to reduce the intensity and frequency of sexual urges, thus reducing sexual fantasies, preoccupation, and the pressure to engage in the paraphilic behavior. Sex-drive reduction takes a direct physiological approach to the modification of sexual arousal. The sex drive, mental sexual arousal, and genital arousal are parts of a psychobiological process that frequently cause a state of uncomfortably high arousability for some individuals with paraphilia.

A large body of scientific data in both animals and men documents the association between lowered testosterone and a significant diminution in the frequency of sexually motivated behaviors. In addition, data show low rates of criminal recidivism among paraphilic patients who have undergone therapeutic sex-drive reduction (Freund, 1980). For example, in one study of surgical castration involving more than 900 sex-offending men followed for periods as long as 30 years, the sexual recidivism rate was less than 3% (Sturup, 1968). Although in the past surgical removal of the testes had been the primary means of testosterone reduction, today that same result can be accomplished via the administration of a variety of medications. Those most commonly used are Cyproterone Acetate, Depo-Provera, Depo-Lupron, or Triptorelin (Berlin et al., 1995; Rosler and Witztum, 1998). In adequate dosages, each is capable of significantly lowering testosterone levels.

Some psychotropic medications, such as selective serotonin reducing inhibitors (SSRIs) also have a side-effect of reducing the sex drive or performance, although they do not necessarily reduce testosterone levels (Greenberg and Bradford, 1997). For some individuals with paraphilia, these treatments effectively reduce paraphilic arousal so long as they are being taken, but do not provide a permanent cure for the disorder.

In the past, some theorists have minimized the role of sexual drive per se in attempting to understand a variety of interpersonal sexual behaviors, particularly those that involved either adult–child interactions or were coercive in nature. Often the root of such conduct was thought to be motivated more by a need for power and control than either by lust or by a desire for sexual intimacy. However, reportedly even Freud had once observed that sometimes a cigar is just a cigar. Often behaviors that appear to be sexually motivated are indeed so motivated, albeit in some instances by pathological rather than healthy sexual needs.

Not enough is known presently about qualitative biological differences in sexual makeup to cure a paraphilic disorder. For example, there is no currently known medical or surgical procedure that can erase a pedophilic sexual orientation that is directed exclusively towards children, replacing it instead with an orientation that is directed exclusively towards adults. On the other hand, much is known about the quantitative, intensity dimension of sexual desire, especially in males. Thus, for example, if one is, in effect, hungering sexually for children, the intensity of that hunger can be significantly reduced by interventions that lower testosterone, the hormone that energizes sexual drive (Berlin and Krout, 1986). Although not a cure or a replacement for psychotherapy, such an intervention can represent a useful adjunct to other modalities of treatment.

A metaphor helps to explain to the patient the rationale for biological treatment as part of therapy. Many patients understandably worry that lowering their sexual drive, although helpful in decreasing paraphilic urges, will also interfere with their capacity to engage in acceptable and healthy sexual interactions. Thus, it may be important to explain to them that when the appetite of a would-be dieter is pharmacologically suppressed, it makes it easier for him to diet but not impossible for him to eat. Similarly, lowering the sexual drive is intended to enable the patient to maintain proper self-control, but it is not intended to make sexual performance impossible or inordinately difficult in the context of a healthy and loving adult relationship. In instances where lowering the sexual drive has nonetheless interfered with the ability to perform sexually, such performance can be enhanced without at the same time increasing the intensity of the patient's sexual cravings, by prescribing an oral medication for arousal such as sildenafil (Viagra™).

When engaging in psychotherapy with patients receiving such medications, it is essential to evaluate the intensity and frequency of their paraphilic urges and fantasies in an ongoing fashion. It is also important to assess for any medication side-effects. Even though the sexual drive has been lowered through the use of the antiandrogen medication, it is still important to discuss with the patient strategies for minimizing exposure to unacceptable temptations, the development of a positive social support system, and to confront any denial and rationalizations that may still be present. Given the stigma associated with many of the paraphilias, it is also often important to try to provide ancillary emotional support and comfort. All of these psychological interventions are offered within the context of treatment designed to stop any paraphilic acts that could represent a threat to the well being of either the patient himself or others.

Roger was a 28-year-old man who had been in treatment for exhibitionism for 4 years. He was handsome, with good social skills. As a young teenager, he would masturbate from a window inside his house, watching women walking or driving by. Then he progressed to masturbating in his car while driving around, spending hours some days driving around before he was seen by a woman and finally ejaculated. He also waited in mall parking lots, positioning himself by his car door so that a woman might see his penis. This led to his first legal charge at age 16, which was eventually dropped. His parents wanted him to see a therapist, but he persuaded them that he did not do anything, his penis just slipped out of his shorts as he was getting out of his car. He continued to spend hours planning and engaging in exposing, and more hours recalling the looks on women's faces during masturbation. He could masturbate to orgasm more than four times a day.

He then started exposing himself in stores in malls, leading him to be excluded from some stores and malls and also resulting in a number of legal charges that usually did not progress to conviction because he was a juvenile with an otherwise exemplary life. Finally he was convicted as an adult, placed on probation, and participated in some general psychotherapy with a therapist who did not specialize in sexual disorders. He got involved in a relationship, with satisfying and frequent sexual intercourse. He thought his problem was over. He was discharged from therapy and completed probation without additional charges.

Despite no difficulty finding girlfriends and satisfactory sexual relations, he found himself returning to exhibitionistic practices. On some weekends, he would have sex with his girlfriend in the morning, and then spend the afternoon exposing himself in malls. He usually targeted women in their twenties or thirties. He never approached the women or even attempted to talk with them. He said that he was looking for an expression on their faces of shock and interest. Although he believed that women found him attractive and were interested in seeing his penis, no woman ever approached him when he exposed. He accumulated three adult convictions for exposing, but he was never incarcerated. Then he exposed to a female who turned out to be 15, and her family was adamant in seeking incarceration. This led him to be evaluated by a program specializing in the treatment of sexual disorders, and he enrolled in treatment. He was 24 years old, involved in a relationship for 6 months, and employed in a very good sales job.

The results of the evaluation showed that he clearly met DSM-IV diagnostic criteria for exhibitionism and apparently did not suffer from any other psychological problems. He did not give any evidence suggestive of mood or personality disorder. He did have a history of drinking alcohol at times to excess, with some binge drinking, but consumption of alcohol was not associated with his exposing. His testosterone levels were in the high end of the typical male range, and he did not have any medical problems. He was hypersexual, continuing to masturbate several times a day in addition to sexual intercourse with his girlfriend. His masturbation imagery was based upon his past episodes of exposing himself. Despite his arrests, he had never been able to go more than several months without exposing.

He participated in weekly group psychotherapy. The therapy focused on getting him to acknowledge the problem, challenging his denial and rationalization. He was able to learn from the examples of other men with similar problems. But he still found that he could not totally stop himself from exposing. In group he saw the example of other men who received weekly injections of Depo-Provera to help them control their sexual behavior by reducing their paraphilic sex drive. Upon the recommendation of his doctors, he agreed to a trial of treatment with Depo-Provera. He was started on a dose of 350 mg per week. His testosterone level dropped from 550 ng/ml to 70 ng/ml. He experienced an increase in appetite, and gained 15 pounds in the first 6 months of treatment. He was able to engage in sexual relations with his girlfriend, without sexual dysfunction, although he had a lower sex drive and lower frequency of intercourse. He reported that his sexual relationship with his girlfriend was actually more satisfying than before.

While on Depo-Provera, he had occasional thoughts of exposing. However, he was able to use the techniques he learned in the group therapy to control his behavior. He felt good about himself and his life. He kept pressing his psychiatrist to cut back on the Provera, or go off it. Near the end of his first year of treatment, he was scheduled to take a 2-week vacation, and he missed the Depo-Provera injection before this vacation as well as the medication during his vacation. While on vacation with his girlfriend, he exposed himself several times. On his return, he resumed weekly injections without further problems.

After the second year of treatment, he attended group therapy every other week, and received Depo-Provera injections biweekly. He continued to do well. During the third year, he cut back on group therapy to monthly visits and continued to receive Depo-Provera every other week. He also went to Sexaholics Anonymous meeting several times a month. In the fourth year of therapy, he continued monthly sessions of group therapy, and discontinued Depo-Provera. He married his girlfriend and seemed to settle down. When his probation was completed, he dropped out of treatment citing problems of cost and difficulty attending the sessions regularly because of his work responsibilities, which increasingly took him out of the area.

He knows that he can re-enter treatment should his problems return. We know that exhibitionism has a tendency to decrease in intensity as the individual gets older, in many cases going into remission in the late thirties or forties. However, this patient is much younger. While we cannot compel him to continue in treatment, we do not consider that he poses a great risk to the public.

Paraphilias are diagnosed and treated mostly in adolescent and adult males. Few prepubescent children or females present for evaluation or treatment of paraphilia, so there is little information available regarding these populations. Evaluation and treatment of adolescents with paraphilia is very similar to that with adults, although there are some differences. Adolescents tend to have had less sexual experience, so diagnosis can be difficult. Adolescents may also have fewer opportunities for corrective, positive sexual experiences. Therapists may be uncomfortable or have ethical objections to using treatment tasks involving masturbation or sexually explicit media with adolescents, and they are less likely to recommend medication, including testosterone-lowering antiandrogens, because of the increased possibility of harmful side-effects with long-term usage.