Psychodynamic Perspectives

Freud’s psychoanalytic understanding of the paraphilias was the dominant psychological perspective throughout the 20th century. He believed that these disorders were perversions representing both biological and psychological factors in early development ^[1]. Perversion is a type of human behavior that deviates from that which is understood to be orthodox or normal. Although the term perversion can refer to a variety of forms of deviation, it is most often used to describe sexual behaviors that are considered particularly abnormal, repulsive, or obsessive. Perversion differs from deviant behavior, in that the latter covers areas of behavior (such as petty crime) for which perversion would be too strong a term. It is often considered derogatory, and, in psychological literature, the term paraphilia has been used as a replacement, though this term is controversial, and deviation is sometimes used in its place.

The majority of the psychological literature on paraphilic disorders focuses on pedophilic disorder. Various psychological theories exist in the literature to explain the behavior of men who commit child sex offenses, including the belief that child sexual abuse (CSA) is a predisposing factor for the transition from victim to the offender. These theories are, however, unable to explain the fact that while most victims of CSA are female, most perpetrators of CSA are male. The sex specificity of CSA in terms of victims and offenders suggests that the experience of CSA and its psychosocial effects may be different for boys compared to girls. And contrary to these theories is the fact that most abuse victims do not go on to abuse or molest children. On the other hand, some people with pedophilic disorder who were abused as children show an age preference that matches their age when they were abused, suggesting that they could be replicating the abuse they experienced as children.

Paraphilic Lovemaps

A lovemap is a person’s emotional, internal blueprint for their ideal erotic, sexual situations. The concept was originated by sexologist John Money in his discussions of how people develop their sexual preferences. Money defined it as “a developmental representation or template in the mind and in the brain depicting the idealized lover and the idealized program of sexual and erotic activity projected in imagery or actually engaged in with that lover.”

Money describes the formation of an individual’s lovemap as similar to the acquisition of a native language, in that it becomes established at an early age and bears the mark of the person’s unique individuality, like an accent in a spoken language. According to Money, lovemaps are not present at birth, but begin to develop shortly thereafter, and manifest in full after puberty. The individual may not discover certain aspects of their lovemap until triggered by a relevant experience (such as pornography use) later in life. Vandalized lovemaps—according to Money—occur when the lovemapping process becomes traumatized, as when a young child is either exposed to, or forced to participate in such inappropriate behaviors as child sexual abuse, incest, or sadomasochism. He states that such a lovemap is typically formed between the ages of five and eight. A vandalized lovemap may be paraphilic or hyposexual.

In paraphilic disorders, lust is attached to fantasies and practices that are socially forbidden, disapproved of, ridiculed, or penalized. According to Money, it can result from lust being displaced from a “vandalized” area of an ordinary lovemap following abuse. Alternatively, Money suggests that a paraphilic lovemap could arise from a non-sexual childhood experience that induced genital arousal in the child.

Sociocultural Perspectives on Sexual Deviations

There is no stereotypical profile of sexually violent persons. Perpetrators may come from various backgrounds and they may be someone known by the victim, like a friend, a family member, an intimate partner, or an acquaintance or they may be a complete stranger. The primary motivators behind sexually violent acts are believed to be power and control, and not, as it is widely perceived, a sexual desire. Sexual violence is rather a violent, aggressive, and hostile act aiming to degrade, dominate, humiliate, terrorize, and control the victim. Some of the reasons for committing sexual violence are that it reassures the offender about their sexual adequacy, it discharges frustration, compensates for feelings of helplessness, and achieves sexual gratification.

Figure 1. This map shows us that sexual violence occurs all over the world and at different rates in different countries.

Data on sexually violent men are somewhat limited and heavily biased towards apprehended rapists, except in the United States, where research has also been conducted on male college students. Despite the limited amount of information on sexually violent men, it appears that sexual violence is found in almost all countries (though with differences in prevalence), in all socioeconomic classes, and in all age groups from childhood onwards. Data on sexually violent men also show that most direct their acts at women whom they already know. Among the factors increasing the risk of a man committing rape are those related to attitudes and beliefs as well as behavior arising from situations and social conditions that provide opportunities and support for abuse.

Developmental and Behavioral Perspectives 

There is evidence to suggest that sexual violence is also a learned behavior in some adults, particularly in regard to child sexual abuse. Studies on sexually abused boys have shown that around one in five continue in later life to molest children themselves.

Childhood environments that are physically violent, emotionally unsupportive, and characterized by competition for scarce resources have been associated with sexual violence. Sexually aggressive behavior in young men, for instance, has been linked to witnessing family violence and having emotionally distant and uncaring fathers. Men raised in families with strongly patriarchal structures are also more likely to become violent, to rape and use sexual coercion against women, and to abuse their intimate partners than men raised in homes that are more egalitarian.

With regard to early childhood environments, research has stressed the importance of encouraging nurturing, with better and more gender-balanced parenting, to prevent sexual violence. A prevention model that adopts a developmental approach, with interventions before birth, during childhood, and in adolescence and young adulthood has been developed and is used by some. In this model, the prenatal element would include discussions of parenting skills, the stereotyping of gender roles, stress, conflict, and violence. In the early years of childhood, health providers would pursue these issues and introduce child sexual abuse and exposure to violence in the media to the list of discussion topics, as well as promoting the use of non-sexist educational materials. In later childhood, health promotion would include modeling behaviors and attitudes that avoid stereotyping, encouraging children to distinguish between good and bad touching, and enhancing their ability and confidence to take control over their own bodies. This intervention would allow room for talking about sexual aggression. During adolescence and young adulthood, discussions would cover myths about rape, how to set boundaries for sexual activity, and breaking the links between sex, violence, and coercion.

Treatment for Sexual Deviations

The treatment and management of paraphilias and paraphilic disorders pose extreme difficulty due to a multitude of factors. Despite the egosyntonic and egodystonic dual nature of paraphilias in general, the overall majority of patients rarely seek treatment voluntarily. Many individuals may feel indignity, culpability, or discomfiture, while others focus on the difficulty and lack of desire to halt efforts of achieving intense sexual pleasure and ultimate satisfaction. Furthermore, many may fear the legal repercussions of coming forward for treatment. Those patients in treatment or seeking treatment are most often either mandated legally or convinced by family, friends, or sexual partners.

Figure 2. Psychotherapy combined with group therapy may be particularly useful for patients with a paraphilic disorder.

The management of paraphilic disorders falls into two main categories, incorporating both psychological and biological constituents. The psychological approach, which includes psychotherapy, but more importantly, CBT, yields an overall positive outcome in terms of efficacy, regardless of the type of diagnosed paraphilic disorder.

Treatments within the psychological perspective seem most effective when combining individual with group therapy. The cognitive-behavioral perspective is particularly useful in helping clients recognize their distortions and denial. At the same time, these clients benefit from training in empathy, so that they can understand how their victims are feeling. Adding to the equation within the psychological perspective, clinicians may also train clients in learning to control their sexual impulses. ^[2] However, due to the patient’s reluctance to seek treatment or the legal obligation to obtain treatment, psychiatrists are often forced to focus efforts on protection against potential victimization and limit focus on the reduction of distress in the patient. The predisposition of committing sexual offenses demonstrates the significance of biological treatments for paraphilic disorders for not only the suffering individual, but also for the greater good of society. However, specialized management, with a comprehensive treatment plan encompassing both psychological and pharmacological components, proves to be the optimal therapeutic option overall.

The three main classifications of pharmacological agents used in the management of paraphilic disorders involve selective serotonin reuptake inhibitors (SSRIs), synthetic steroidal analogs, and antiandrogens. The therapeutic choice is dependent upon previous medical history and medication compliance, along with the intensity of both the sexual fantasy and the risk of sexual violence.

Literature suggests that each of the three drug categories mentioned above help to target diverse physiological pathways and subsequent psychological attributes through their unique mechanism of action. Studies have shown SSRIs to be particularly useful in the adolescent population and milder paraphilias, including exhibitionism, as well as in patients suffering from comorbidities of obsessive-compulsive disorders (OCD) or depression. SSRIs have also been used in the attempted alleviation of hypersexuality, but strong evidence of actual efficacy has yet to be established. Antiandrogens, with emphasis on gonadotropin-releasing hormone (GnRH) analogs, have shown to considerably reduce the frequency and intensity of both deviant sexual arousal and behavior. Gonadotropin-releasing hormone (GnRH) analogs are also considered to be among the most promising pharmacological management for those sex offenders at high risk of particularly violent acts, particularly serial rapists or those individuals with pedophilic disorder. Of note, informed consent is obligatory before initiating antiandrogenic therapy.

Treatment for the Sexually Violent

Sexually violent men have been shown to be more likely to consider victims responsible for the rape and are less knowledgeable about the impact of rape on victims. Such men may misread cues given out by women in social situations and may lack the inhibitions that act to suppress associations between sex and aggression. They may have coercive sexual fantasies and overall are more hostile towards women than are men who are not sexually violent. In addition to these factors, sexually violent men are believed to differ from other men in terms of impulsivity and antisocial tendencies. They also tend to have an exaggerated sense of masculinity.

The research on convicted rapists has found several important motivational factors in the sexual aggression of males. Those motivational factors repeatedly implicated are having anger at women and having the need to control or dominate them. A study by Marshall et al. (2001) found that male rapists had less empathy toward women who had been sexually assaulted by an unknown assailant and more hostility toward women than non-sex-offenders and nonoffender males/females. Meta-analyses indicate that convicted rapists demonstrate greater sexual arousal to scenes of sexual coercion involving force than do non-rapists.

Psychotherapy can also be helpful in treatment, though research is unclear about its effectiveness for long-term prevention.^[3]

Applied criminal psychology

The effect of psychological and social factors on the functioning of our brain is the central question forensic or criminal psychologists deal with due to the fact it is the seed of all our actions. For forensic psychiatry, the main question is, “Which patient becomes an offender?” or “Which offender becomes a patient?” Another main question asked by these psychiatrists is, “What came first, the crime or the mental disorder?” Psychologists also look at environmental factors along with genetics to determine the likeliness (profiling) of a particular person to commit a crime.

Criminal and forensic psychologists may also consider the following questions:

1. Is a mental disorder present now? Was it present during the time of the crime?
2. What is the level of responsibility of the offender for the crime?
3. What is the risk of reoffending and which risk factors are involved?
4. Is treatment possible to reduce the risk of reoffending?

Accordingly, individual psychiatric evaluations are resorted to measuring personality traits by psychological testing that have good validity for the purpose of the court.

Figure 3. Incarceration alone does not guarantee that offenders won’t commit acts of sexual violence again.

Therapists use various methods to assess individual sex offenders’ recidivism risk. Risk assessment tools consider factors that have been empirically linked by research to sexual recidivism risk. Researchers and practitioners consider some factors as static, such as age, the number of prior sex offenses, victim gender, relationship to the victim, and indicators of psychopathy and deviant sexual arousal, and some other factors as dynamic, such as an offender’s compliance with supervision and treatment. By examining both types of factors, a more complete picture of the offender’s risk can emerge, compared with static or dynamic factors used alone.

Recidivism is a major concern, in the treatment of paraphilia, especially in pedophilia. Most people recognize that incarceration alone will not solve sexual violence. Treating the offenders is critical in an approach to preventing sexual violence and reducing victimization.

Behavior modification programs have been shown to reduce recidivism in sex offenders. Often, such programs use principles of applied behavior analysis (ABA), also called behavioral engineering, which is a scientific technique concerned with applying empirical approaches based upon the principles of respondent and operant conditioning to change behavior of social significance. Two such approaches from this line of research have promise. The first uses operant conditioning approaches (which use reward and punishment to train new behavior, such as problem-solving) and the second uses respondent conditioning or classical conditioning procedures, such as aversion therapy (a form of  treatment in which the patient is exposed to a stimulus while simultaneously being subjected to some form of discomfort). Many of the behaviorism programs use covert sensitization (eliminating the unwanted behavior by creating a profound and lasting association between the behavior and a highly disturbing covert, i.e., imagined, stimulus or consequence) and/or odor aversion: both are forms of aversion therapy, which have had ethical challenges. Such programs are effective in lowering recidivism by 15–18%. The use of aversion therapy remains controversial, and is an ethical issue related to the professional practice of behavior analysis. Previous research in the early 1990s has shown covert conditioning to be effective with sex offenders as part of a behavior modification treatment package. Clinical studies continue to find it effective with some generalization from office to natural environment with this population.

Castration as a treatment for men with paraphilic disorder, particularly pedophilic disorder, is intended to destroy the body’s production of testosterone through surgical castration (removal of the testes) or chemical castration, in which the individual receives medications that suppress the production of testosterone. Chemical castration is also used in some countries, including the United States, to treat male sex offenders. Unlike physical castration, it is reversible by stopping the medication. For male sex offenders with severe or extreme paraphilias, physical castration appears to be effective, although more radical. It results in a 20-year re-offense rate of less than 2.3% (versus 80% in the untreated control group), according to a large 1963 study involving a total of 1,036 sex offenders by the German researcher A. Langelüddeke. This rate was much lower than otherwise expected compared with overall sex offender recidivism rates.

Programs for Perpetrators

There are few programs outside of the criminal justice system that target perpetrators of sexual violence. They are generally aimed at men convicted of male-on-female sexual assault, who form a significant portion of criminal cases of sexual violence. A common response of men who commit sexual violence is to deny both that they are responsible and that what they are doing is violent. These programs work with male perpetrators to make them admit responsibility. One way of achieving this admittance is for programs that target male perpetrators of sexual violence to collaborate with support services for victims, but this could potentially be a revictimization of rape victims and be a poor choice of action unless the rape perpetrator is highly apologetic.

In 2007, the Texas State Auditor released a report showing that sex offenders who completed the Texas Sex Offender Treatment Program (SOTP) were 61% less likely to commit a new crime.^[4] Oftentimes psychological treatment programs are mandated in sentences, but unlike the successes shown in this Texas report, their efficacy is contested.^[5]