Case Study: Derek

Derek and Camilla met online and hit it off immediately. Derek knew Camilla had a nine-year-old daughter named Maggie, and when Camilla introduced the two of them, they also hit it off. No one was surprised when they decided to marry, even if they had only known each other shortly. Derek and Camilla were visibly in love, and they all seemed to be a happy family. Not too long after his marriage, Derek began developing an inappropriately close relationship with Maggie, now his stepdaughter. Seemingly innocent back rubs turned into extra time to give her bubble baths. He found it harder and harder to control urges he was having when left alone with the child. After only two months of life together under the same roof, Derek’s behavior stepped outside the limits of normal parental physical affection. When Camilla, a nurse, left for work early each morning, Derek invited Maggie to the parental bedroom on the pretext that she could watch cartoons with him on the bed. He  would stroke Maggie’s hair and gradually proceed to massage her body while encouraging her to touch his genitals, saying that it was “OK for her to learn about what daddies are like.” Maggie was confused by his behavior and even a little scared, but she did as she was told. Derek reinforced compliance to this behavior by offering Maggie gifts. He also encouraged her to keep their secret, and stated that even if she told anyone, he would deny it. One day Camilla returned home unexpectedly because she had forgotten something and caught him engaging in this behavior. She later learned that it had been going on for over a year.

Treatment

As evident in Derek’s case, individuals with pedophilic disorder often do not feel distressed as a result of their urges and may never seek treatment. Thus, the first issue to address in psychotherapy would be to help Derek realize the harm he had done to both Maggie and Camilla; in other words, making his disorder ego-dystonic. The hope would be that it would become increasingly difficult for Derek to deny the problems his urges caused and recognize that he would have to work to control his urges throughout the rest of his life. He might eventually accept that his disorder was harmful to others and to his relationship with his wife, and that there could have been legal ramifications. Therapy would focus on controlling his urges and fantasies about children, in combination with the antiandrogen medication to reduce his fantasies and urges to have sex with children. 

Case Study: Anne

For a number of years, Anne and Jodie have mutually enjoyed BDSM (bondage, domination/discipline, sadism/submission, and masochism) sex parties as a part of a community. Lately, Anne has developed a strong interest in maintaining control, both in regard to sex (e.g., tying up her girlfriend, Jodie) and in her life. She has insisted on submitting Jodie to demeaning and abusive sexual behavior. In the early years of their relationship, Jodie’s requests involved relatively innocent pleas that Anne pinch her and bite her while they were sexually intimate. Over time, however, behaviors that involved pain increased and the nature of the pain changed. At present, they engage in what they call “private parties,” during which Anne handcuffs Jodie to the bed and inflicts various forms of torture. Jodie goes along with and likes Anne’s ideas of new ways to inflict pain. Now Anne has a repertoire of behaviors, ranging from burning Jodie’s skin with matches to cutting her with razor blades. Anne and Jodie no longer have an interest in sexual intimacy other than that involving pain.

Controversies in Diagnosing Paraphilias

As mentioned in this module, deciding what is “normal” in the area of sexuality is an issue fraught with difficulty and controversy. Critics of the DSM argue that several of the paraphilic disorders in DSM-5 pathologize nonnormative sexual behavior. These critics maintain that even breaking the law is not a sufficient basis for determining that an individual engaging in a paraphilic behavior has a psychological disorder. This criticism also applies to exhibitionistic, voyeuristic, and frotteuristic disorders, which don’t involve victims in the same sense as do the other paraphilic disorders.^[1]