1
Paraphilias
My last sexual partner was very much into golden showers. Having spent a little of my time
watching G. G. Allen movies, I was well acquainted with the existence of watersports, but
somehow it never occurred to me that I would like to partake in them. When my partner revealed
his desire to drink my urine, I was taken off guard. I have been known to try some things I would
deem a little atypical, so I gave it a shot. I was very nervous about the actual part of the
procedure, though. Thoughts such as, “What if he was joking – he would think I’m nuts” and
“What if I completely miss” entered my head. It was nerve-racking and made it especially hard to
pee. Eventually, my anxiety subsided and I was able to participate. His reaction was amazing to
me. He began to masturbate fervishly and lapped up my urine ecstatically. I have never seen him
so turned on. More surprising though was how much I enjoyed it. Although I cannot imagine
being on the other end, it was really an empowering and enjoyable experience. (Author’s files)
This description of a rather unusual sexual experience, may strike our readers as reflecting an abnormal or
perhaps even deviant form of sexual behavior. However, we believe it is more realistic to consider this anecdote to
be an account of uncommon or atypical sexual behavior. One note of caution: Because HIV has been found in the
urine of infected persons, it is prudent to avoid contact with a partner’s urine unless he or she is known to be HIV
negative and not infected with any other STDs. Now let us consider for a moment what constitutes atypical sexual
behavior.
What Constitutes Atypical Sexual Behavior?
In this chapter, we focus on a number of sexual behaviors that have been variously labeled as deviant, perverted,
aberrant, or abnormal. More recently, the less-judgmental term paraphilia (pair-uh-FIL-e-uh) has been used to
describe these somewhat uncommon types of sexual expression. Literally meaning “beyond usual or typical love,”
this term stresses that such behaviors are usually not based on an affectionate or loving relationship, but rather are
expressions of psychosexually disordered behavior in which sexual arousal and/or response depends on some
unusual, extraordinary, or even bizarre activity (American Psychiatric Association, 1994). The term paraphilia is
used in much of the psychological and psychiatric literature. However, in our own experience in dealing with and
discussing variant sexual behaviors, the one common characteristic that stands out is that each behavior in its fully
developed form is not typically expressed by most people in our society. Therefore, we also categorize the behaviors
discussed in this chapter as atypical sexual behaviors.
Several points should be noted about atypical sexual expression in general before we discuss specific behaviors.
First, like many other sexual expressions, the behaviors singled out in this chapter represent extreme points on a
continuum. Atypical sexual behaviors exist in many gradations, ranging from mild, infrequently expressed
tendencies to full-blown, regularly manifested behaviors. Although these are atypical behaviors, many of us may
recognize some degree of such behaviors or feelings within ourselves—perhaps manifest at some point in our lives,
or mostly repressed, or emerging only in very private fantasies.
A second point has to do with the state of our knowledge about these behaviors. In most of the discussions that
follow, the person who manifests the atypical behavior is assumed to be male, and evidence strongly indicates that
in most reported cases of atypical or paraphilic behaviors, the agents of such acts are male (American Psychiatric
Association, 1994; Money, 1988). However, the tendency to assume that males are predominantly involved may be
influenced by the somewhat biased nature of differential reporting and prosecution. Female exhibitionism, for
example, is far less likely to be reported than is similar behavior in a male. John Money (1981) has suggested that
atypical sexual behavior may be decidedly more prevalent among males than females because male erotosexual differentiation (the development of sexual arousal in response to various kinds of images or stimuli) is more complex
than that of the female and subject to more errors.
A third noteworthy point is that atypical behaviors often occur in clusters. That is, the occurrence of one
paraphilia appears to increase the probability that others will also be manifested, simultaneously or sequentially
(Bradford et al., 1992; Fedora et al., 1992). One hypothesis offered to account for this cluster effect is that engaging
in one atypical behavior, such as exhibitionism, may reduce the participant’s inhibitions to the point where engaging
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in another paraphilia, such as voyeurism, becomes more likely (Stanley, 1993).
A final consideration is the impact of atypical behaviors both on the person who exhibits them and on others to
whom they may be directed. People who manifest atypical sexual behaviors often depend on these acts for sexual
satisfaction. The behavior is frequently an end in itself. It is also possible that their unconventional behavior will
alienate others. Consequently, these people often find it very difficult to establish satisfying sexual/intimate
relationships with partners. Instead, their sexual expression may assume a solitary, driven, even compulsive quality.
Some of these behaviors do involve other people whose personal space is violated in a coercive, invasive fashion. In
the following section we consider the distinction between coercive and noncoercive paraphilias.
Noncoercive versus Coercive Paraphilias
A key distinguishing characteristic of paraphilias is whether or not they involve an element of coercion. Several
of the paraphilias are strictly solo activities or involve the participation of consensual adults who agree to engage in,
observe, or just put up with the particular variant behavior. Because coercion is not, involved, and a person’s basic
rights are not violated, such so-called noncoercive atypical behaviors are considered by many to be relatively benign
or harmless. Clearly, the chapter opening account falls into this category. However, as we shall see, these
noncoercive behaviors may occasionally engender potentially adverse consequences for people drawn into their
sphere of influence. We will consider seven varieties of noncoercive paraphilias.
Some paraphilias are definitely coercive or invasive in that they involve unwilling recipients of behavior such
as peeping or exhibitionism. Furthermore, research suggests that such coercive acts may have harmful effects on the
targets of such deeds, who may be psychologically traumatized by the experience. They may feel they have been
violated or that they are vulnerable to physical abuse, and they may develop fears that such unpleasant episodes will
recur. This is one reason many of these coercive paraphilias are illegal. On the other hand, many people who
encounter such acts are not adversely affected. Because of this and because many of these coercive behaviors do not
involve physical or sexual contact with another, many authorities view them as minor sex offenses (sometimes
called “nuisance” offenses). However, evidence that some people progress from nuisance offenses to more serious
forms of sexual abuse may lead to a reconsideration of whether these offenses are “minor” (Bradford et al., 1992;
Fedora et al., 1992).
In our discussion of both types of paraphilias, coercive and noncoercive, we examine how each of these
behaviors is expressed, some of the common characteristics of those exhibiting it, and the various factors thought to
contribute to its development.
Noncoercive Paraphilias
In this section we first discuss three fairly common types of noncoercive paraphilias: fetishism, sexual sadism, and
sexual masochism. We will also describe four less common varieties of noncoercive paraphilias.
Fetishism
Fetishism (FET-ish-iz-um) refers to sexual behavior in which an individual becomes sexually aroused by
focusing on an inanimate object or a part of the human body. As with many other atypical behaviors, it is often
difficult to draw the line between normal activities that may have fetishistic overtones and those that are genuinely
paraphilic. Many people are erotically aroused by the sight of undergarments and certain specific body parts, such as
feet, legs, buttocks, thighs, and breasts. Many men and some women may use articles of clothing and other
paraphernalia as an accompaniment to masturbation or sexual activity with, a partner. Only when a person becomes
focused on these objects or body parts to the exclusion of everything else is the term fetishism truly applicable. In
some instances, a person may be unable to experience sexual arousal and orgasm in the absence of the fetish object.
In other situations where the attachment is not so strong, sexual response may occur in the absence of the object but
often with diminished intensity. For some people, fetish objects serve as substitutes for human contact and are dispensed with if a partner becomes available. Some common fetish objects include women’s lingerie, shoes
(particularly high-heeled), boots (often affiliated with themes of domination), hair, stockings (especially black mesh
hose), and a variety of leather, silk, and rubber goods (American Psychiatric Association, 1994; Davison & Neale,
1993).
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How does fetishism develop? One way is through incorporating the object or
body part, often through fantasy, in a masturbation sequence where the
reinforcement of orgasm strengthens the fetishistic association. This is a kind of
classical conditioning in which some object or body part becomes associated with
sexual arousal. This pattern of conditioning was demonstrated some years ago by
Rachman (1966), who created a mild fetish among male subjects under laboratory
conditions by repeatedly pairing a photograph of women’s boots with erotic slides
of nude females. The subjects soon began to show sexual response to the boots
alone. This reaction also generalized to other types of women’s shoes. Although
some critics have suggested that Rachman’s experiment was tainted by methodological problems (O’Donohue & Plaud, 1994), two additional studies provided
further evidence for classical conditioning of fetishism (Langevin & Martin, 1975;
Rachman & Hodgson, 1968).
Another possible explanation looks to childhood in explaining the origins of
some cases of fetishism. Some children may learn to associate sexual arousal with
objects (such as panties or shoes), which belong to an emotionally significant person, like the mother or older sister
(Freund & Blanchard, 1993). The process by which this may occur is sometimes called symbolic transformation.
Here, the object of the fetish becomes endowed with the power or essence of its owner, so that the child (usually a
male) responds to this object as he might react to the actual person (Gebhard et al., 1965). If these patterns become
sufficiently ingrained, the person will engage in little or no sexual interaction with others during the developmental
years, and even as an adult may continue to substitute fetish objects for sexual contact with other humans.
Only rarely does fetishism develop into an offense that might harm someone. Occasionally, an individual may
commit burglary to supply an object fetish, as in the following account:
Some years ago we had a bra stealer loose in the neighborhood. You couldn’t hang your bras
outside on the clothesline without fear of losing it. He also took panties, but bras seemed to be his
major thing. I talked to other women in the neighborhood who were having the same problem.
This guy must have had a roomful. I never heard that he was caught. He must have decided to
move on because the thefts suddenly stopped. (Authors’ files)
Burglary is the most frequent serious offense associated with fetishism. Uncommonly, a person may do
something bizarre such as cut hair from an unwilling person. In extremely rare cases, a man may murder and
mutilate his victim, preserving certain body parts for fantasy-masturbation activities.
Sexual Sadism and Sexual Masochism
Sadism and masochism are often discussed under the common category sadomasochistic (sA-dO-MAs-O-kiz-tic)
behavior (also known as SM) because they are two variations of the same phenomenon, the association of sexual
expression with pain. Furthermore, the dynamics of the two behaviors are similar and overlapping. Thus, in the
discussion that follows, we will often refer to SM behavior or activities. However, a person who engages in one of
these behaviors does not necessarily express the other, and thus sadism and masochism are actually distinct
behavioral entities. The American Psychiatric Association’s DSM-IV (1994) underlines this distinction by listing
separate categories for each of these paraphilias: sexual sadism and sexual masochism.
Labeling behavior as sexual sadism or sexual masochism is complicated because many people enjoy some form
of aggressive interaction during sex play (such as “love bites”) for which the label SM seems inappropriate. Alfred
Kinsey and his colleagues found that 22% of the males and 12% of the females in his sample responded erotically to
stories with SM themes. Furthermore, over 25% of both sexes reported erotic response to receiving love bites during
sexual interaction. Hunt (1974) found that 10% of males and 8% of females in his sample (under age 35) reported
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obtaining sexual pleasure from SM activities during interaction with a partner. A more recent survey of 975 men
and women found that 25% reported occasionally engaging in a form of SM activity with a partner (Rubin, 1990).
Although sadomasochistic practices have the potential for being physically dangerous, most participants generally
stay within mutually agreed-on limits, often confining their activities to mild or even symbolic SM acts with a
trusted partner. In mild forms of sexual sadism, the pain inflicted may often be more symbolic than real. For
example, a willing partner may be “beaten” with a feather or a soft object designed to resemble a club. Under these
conditions, the receiving partner’s mere feigning of suffering is sufficient to induce sexual arousal in the individual
inflicting the symbolic pain.
People with masochistic inclinations may be aroused by such things as being whipped, cut, pierced with
needles, bound, or spanked. The degree of pain one must experience to achieve sexual arousal varies from symbolic
or very mild to, on rare occasions, severe beatings or mutilations. Sexual masochism is also reflected in individuals
who achieve sexual arousal as a result of “being held in contempt, humiliated, and forced to do menial, filthy, or
degrading service” (Money, 1981, p. 83). The common misconception that any kind of pain, physical or mental, will
sexually arouse a person with masochistic inclinations is not true. The pain must be associated with a staged
encounter whose express purpose is sexual gratification.
In yet another version of masochism, some individuals derive sexual pleasure from being bound, tied up, or
otherwise restricted. This behavior, called bondage, usually takes place with a cooperative partner who binds or
restrains the individual and often administers discipline, such as spankings or whippings. One survey of 975
heterosexual women and men revealed that bondage may be a fairly common practice: One-fourth of respondents
reported engaging in some form of bondage during some of their sexual encounters (Rubin, 1990).
Many individuals who engage in SM activities do not confine their participation to exclusive sadistic or
masochistic behaviors. Some alternate between the two roles, often out of necessity, because it may be difficult to
find a partner who prefers only to inflict or to receive pain. Most of these people seem to prefer one or the other role,
but some may be equally comfortable in either (Moser & Levitt, 1987; Weinberg et al., 1984).
There are some indications that individuals with sexual sadistic tendencies are less common than their
masochistic counterparts (Gebhard et al., 1965). This imbalance may reflect a general social script—certainly it is
more virtuous to be punished than to carry out physical or mental aggression toward another. A person who needs
severe pain as a prerequisite to sexual response may have difficulty finding a cooperative partner. Consequently,
such individuals may resort to causing their own pain by burning, mutilating, or autoerotic asphyxia. Likewise, a
person who needs to inflict intense pain in order to achieve sexual arousal may find it very difficult to find a willing
partner, even for a price. We occasionally read of sadistic assaults against unwilling victims: The classic lust murder
is often of this nature (Money, 1990). In these instances, orgasmic release may be produced by the homicidal
violence itself.
Many people in contemporary Western societies view SM in a highly negative light. This is certainly
understandable, particularly for those who regard sexual sharing as a loving, tender interaction between partners
who wish to exchange pleasure. However, much of this negativity stems from a generalized perception of SM
activities as perverse forms of sexual expression involving severe pain, suffering, and degradation. It is commonly
assumed that individuals caught up in such activities are often victims rather than willing participants.
One group of researchers disputed these assumptions, suggesting that the traditional medical model of SM as a
pathological condition is based on a limited sample of individuals who come to the attention of clinicians as a result
of personality disorders or severe personality problems. As with some other atypical behaviors discussed in this
chapter, these researchers argued that it is misleading to draw conclusions from such a sample. They conducted their
own extensive fieldwork in nonclinical environments, interviewing a variety of SM participants and observing their
behaviors in many different settings. Although some subjects’ behaviors fit traditional perceptions, the researchers
found that, for most participants, SM was simply a form of sexual enhancement involving elements of dominance
and submission, role-playing, and consensuality “which they voluntarily and mutually chose to explore” (Weinberg
et al., 1984, p. 388).
What factors might motivate a person to engage in SM activity?
Many people who engage in SM activities are motivated by a desire to experience dominance and/or submission
rather than pain (Weinberg, 1987). This desire is reflected in the following account recently provided by a student
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in a sexuality class:
I fantasize about sadomasochism sometimes. I want to have wild animalistic sex under the control
of my husband. I want him to “force” me to do things. Domination and mild pain would seem to
fulfill the moment. I have read books and talked to people about the subject, and I am terrified at
some of the things, but in the bounds of my trusting relationship I would not be afraid. It seems
like a silly game, but it is so damned exciting to think about. Maybe it will happen someday.
(Authors’ files)
Studies of sexual behavior in other species reveal that many nonhuman animals engage in what might be
labeled combative or pain-inflicting behavior before coitus. Some theorists have suggested that such activity has
definite neurophysiological value, heightening accompaniments of sexual arousal such as blood pressure, muscle
tension, and hyperventilation (Gebhard et al., 1965). For a variety of reasons (such as guilt, anxiety, or apathy),
some people may need additional nonsexual stimuli to achieve sufficient arousal. It has also been suggested that
resistance or tension between partners enhances sex and that SM is just a more extreme version of this common
principle (Tripp, 1975).
SM may also provide participants with an escape from the rigidly controlled, restrictive role they must play in
their everyday, public lives. This helps to explain why men who engage in SM activity are much more likely to play
masochistic roles than are women (Baumeister, 1988). John Money describes the scenario in which “men who may
be brokers of immense political, business or industrial power by day [become] submissive masochists begging for
erotic punishment and humiliation at night” (1984, p. 169). Conversely, individuals who are normally meek may
welcome the temporary opportunity to assume a powerful, dominant role within the carefully structured role-playing
of SM. A related theory sees sexual masochism as an attempt to escape from high levels of self-awareness. Similar
to some other behaviors (such as getting drunk) in which a person may attempt to “lose” himself or herself,
masochistic activity blocks out unwanted thoughts and feelings, particularly those that may induce anxiety, guilt, or
feelings of inadequacy or insecurity (Baumeister, 1988).
Clinical case studies of people who engage in SM sometimes reveal early experiences that may have established
a connection between sex and pain. For example, being punished for engaging in sexual activities (such as
masturbation) might result in a child or adolescent associating sex with pain. A child might even experience sexual
arousal while being punished—for example, getting an erection or lubricating when one’s pants are pulled down and
a spanking is administered (spanking is a common SM activity). Paul Gebhard and his colleagues (1965) reported
one unusual case in which a man developed a desire to engage in SM activities following an episode during his
adolescence in which he experienced a great deal of pain while a fractured arm was set without the benefit of
anesthesia. During the ordeal he was comforted by an attractive nurse, who caressed him and held his head against
her breast in a way that created a strong conditioned association between sexual arousal and pain.
Many people, perhaps the majority, who participate in SM do not depend on these activities to achieve sexual
arousal and orgasm. Those who practice it only occasionally may find that at least some of its excitement and erotic
allure stems from the fact that it represents a marked departure from more conventional sexual practices. Other
people who indulge in SM acts may have acquired strong negative feelings about sex, often believing it is sinful and
immoral. For such people, masochistic behavior provides a guilt-relieving mechanism: Either they get their pleasure
simultaneously with punishment, or they first endure the punishment to entitle them to the pleasure. Similarly,
people who indulge in sadism may be punishing partners for engaging in anything so evil. Furthermore, people who
have strong feelings of personal or sexual inadequacy may resort to sadistic acts of domination over their partners to
temporarily alleviate these feelings.
Other Noncoercive Paraphilias
In this section we consider four additional varieties of noncoercive paraphilias that are generally uncommon or even
rare. We begin our discussion by describing autoerotic asphyxia, a very dangerous form of variant sexual behavior.
We then offer a few brief comments about three other uncommon noncoercive paraphilias: klismaphilia, coprophilia, and urophilia.
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Autoerotic Asphyxia
Autoerotic asphyxia (also called hypoxyphilia or asphyxiophilia) is an extraordinarily rare and life-threatening
paraphilia in which an individual, almost always a male, seeks to reduce the supply of oxygen to the brain during a
heightened state of sexual arousal (American Psychiatric Association, 1994; Stanley, 1993). The oxygen deprivation
is usually accomplished by applying pressure to the neck with a chain, leather belt, ligature, or rope noose (via
hanging). Occasionally a plastic bag or chest compression may be used as the asphyxiating device. A person may
engage in these oxygen-depriving activities while alone or with a partner.
We can only theorize from limited data what motivational dynamics underlie such bizarre behavior. People who
practice autoerotic asphyxia rarely disclose this activity to relatives, friends, or therapists, let alone discuss why they
engage in such behavior (GarzaLeal & Landron, 1991; Saunders, 1989). For some, the goal seems to be to increase
sexual arousal and to enhance the intensity of orgasm. In this situation, the item used to induce oxygen deprivation
(such as a rope) is typically tightened around the neck to produce heightened arousal during masturbation and then
released at the time of orgasm. Individuals often devise elaborate techniques that enable them to free themselves
from the strangling device prior to losing consciousness.
The enhancement of sexual excitement by pressure-induced oxygen deprivation may bear some relationship to
reports that orgasm may be intensified by inhaling amyl nitrate (“poppers”), a drug used to treat heart pain. This
substance is known to temporarily reduce brain oxygenation through peripheral dilation of the arteries that supply
the brain with blood.
It has also been suggested that autoerotic asphyxia may be a highly unusual variant of sexual masochism in
which participants act out ritualized bondage themes (American Psychiatric Association, 1994; Cosgray et al.,
1991). People who engage in this practice sometimes keep diaries of elaborate bondage fantasies and, in some cases,
describe experiencing fantasies of being asphyxiated or harmed by others as they engage in this rare paraphilia.
One important fact about this seldom-seen paraphilia is quite clear: This is a very dangerous activity that often
results in death (Blanchard & Hucker, 1991; Cosgray et al., 1991). Accidental deaths sometimes occur due to
equipment malfunction or mistakes such as errors in the placement of the noose or ligature. Data from the United
States, England, Australia, and Canada indicate that one to two deaths per million population are caused by
autoerotic asphyxiation each year (American Psychiatric Association, 1994). The Federal Bureau of Investigation
estimates that deaths in the United States resulting from this activity may run as high as 1000 per year.
KlismaphiIia
Klismaphilia (klis-ma-FIL-ë-uh) is a very unusual variant in sexual expression in which an individual obtains
sexual pleasure from receiving enemas. Less commonly, the erotic arousal may be associated with giving enemas.
The case histories of many individuals who express klismaphilia reveal that as infants or young children they were
frequently administered enemas by concerned and affectionate mothers. This association of loving attention with
anal stimulation may eroticize the experience for some people so that as adults they may manifest a need to receive
an enema as a substitute for or necessary prerequisite to genital intercourse.
Coprophilia and Urophilia
Coprophilia (cop-ro-FIL-e-uh) and urophilia (yoo’-ro-FIL-e-uh) refer to activities in which people obtain sexual
arousal from contact with feces and urine, respectively. Individuals who exhibit coprophilia achieve high levels of
sexual excitement from watching someone defecate or by defecating on someone. In rare instances, they may
achieve arousal when someone defecates on them. Urophilia is expressed by urinating on someone or being urinated
on. This activity, reflected in the chapter-opening anecdote, has been referred to as “water sports” and “golden
showers.” There is no consensus opinion as to the origins of these highly unusual paraphilias.
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Coercive Paraphilias
In this section we first discuss three very common forms of coercive paraphilic behaviors: exhibitionism, obscene
phone calls, and voyeurism. Three other varieties of coercive paraphilias—frotteurism, necrophilia, and zoophilia—
will also be discussed.
Exhibitionism
Exhibitionism, often called “indecent exposure,” refers to behavior in which an individual (almost always male)
exposes his genitals to an involuntary observer (usually an adult woman or female child) (American Psychiatric
Association, 1994; Marshall et al., 1991). Typically, a man who has exposed himself obtains sexual gratification by
masturbating shortly thereafter, using mental images of the observer’s reaction to increase his arousal (Blair &
Lanyon, 1981). Some men may, while having sex with a willing partner, fantasize about exposing themselves or
replay mental images from previous episodes (Money, 1981). Still others may have orgasm triggered by the very act
of exposure, and a few may masturbate while exhibiting themselves (American Psychiatric Association, 1994;
Freund et al., 1988). The reinforcement of associating sexual arousal and orgasm with the actual act of
exhibitionism, or with mental fantasies of exposing oneself, contributes significantly to the maintenance of
exhibitionistic behavior (Blair & Lanyon, 1981). Exposure may occur in a variety of locations, most of which allow
for easy escape. Subways, relatively deserted streets, parks, and cars with a door left open are common places for
exhibitionism to occur. However, sometimes a private dwelling may be the scene of an exposure, as revealed in the
following account:
One evening I was shocked to open the door of my apartment to a naked man. I looked long
enough to see that he was undressed for the occasion and then slammed the door in his face. He
didn’t come back. I’m sure my look of total horror was what he was after. But it is difficult to
keep your composure when you open your door to a naked man. (Authors’ files)
Certainly, many of us have exhibitionistic tendencies: We may go to nude beaches, parade before admiring
lovers, or wear provocative clothes or scanty swimwear. However, such behavior is considered appropriate by a
society that in many ways exploits and celebrates the erotically portrayed human body. The fact that legally defined
exhibitionistic behavior involves generally unwilling observers sets it apart from these more acceptable variations of
exhibitionism.
Our knowledge of who displays this behavior is based almost exclusively on studies of arrested offenders—a
sample that may be unrepresentative. This sampling problem is common to many forms of atypical behavior that are
defined as criminal. From the available data, however limited, it appears that most people who exhibit themselves
are adult males in their 20s or 30s, and over half are married or have been. They are often very shy, nonassertive
people who feel inadequate and insecure and suffer from problems with intimacy (Arndt, 1991; Marshall et al.,
1991). They may function quite efficiently in their daily lives and be commonly characterized by others as “nice, but
kind of shy.” Their sexual relationships are likely to have been quite unsatisfactory. Many were reared in atmospheres characterized by puritanical and shame-inducing attitudes toward sexuality.
What influences a person to engage in exhibitionism? What do you think might motivate such behavior?
A number of factors may influence the development of exhibitionistic behavior. Many individuals may have
such powerful feelings of personal inadequacy that they are afraid to reach out to another person out of fear of
rejection (Minor & Dwyer, 1997). Their exhibitionism may thus be a limited attempt to somehow involve others,
however fleetingly, in their sexual expression. Limiting contact to briefly opening a raincoat before dashing off
minimizes the possibility of overt rejection. Some men who expose themselves may be looking for affirmation of
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their masculinity. Others, feeling isolated and unappreciated, may simply be seeking attention they desperately
crave. A few may feel anger and hostility toward people, particularly women, who have failed to notice them or who
they believe have caused them emotional pain. In these circumstances, exposure may be a form of reprisal, designed
to shock or frighten the people they see as the source of their discomfort. In addition, exhibitionism is not
uncommon in emotionally disturbed, intellectually disabled, or mentally disoriented individuals. In these cases, the
behavior may reflect a limited awareness of what society defines as appropriate actions, a breakdown in personal
ethical controls, or both.
In contrast to the public image of an exhibitionist as one who lurks about in the shadows, ready to grab hapless
victims and drag them off to ravish them, most men who engage in exhibitionism limit this activity to exposing
themselves (American Psychiatric Association, 1994; Davison & Neale, 1993). Yet the word victim is not entirely
inappropriate, in that observers of such exhibitionistic episodes may be emotionally traumatized by the experience
(Cox, 1988; Marshall et al., 1991). Some may feel that they are in danger of being raped or otherwise harmed. A
few, particularly young children, may develop negative feelings about genital anatomy from such an experience.
Investigators have noted that some people who expose themselves, probably a small minority, may actually
physically assault their victims. Furthermore, it also seems probable that some men who engage in exhibitionism
progress from exposing themselves to more serious offenses such as rape and child molesting. In a one-of-a-kind
study, Gene Abel (1981), a Columbia University researcher, conducted an in-depth investigation of the motives and
behavior of 207 men who admitted to a variety of sexual offenses, including child molesting and rape. This research
is unique in that all participants were men outside the legal system who voluntarily sought treatment after being
guaranteed confidentiality. Abel found that 49% of the rapists in his sample had histories of other types of variant
sexual behavior, generally preceding the onset of rape behavior. The most common of these were child molestation,
exhibitionism, voyeurism, incest, and sadism. A more recent study of 274 Canadian sex offenders, all adult males,
revealed that most had engaged in multiple types of variant sexual behavior, including paraphilias and more serious
forms of sexual victimization, such as child molestation and rape. Collectively, these subjects admitted to 7677 total
incidents of sexual offenses, an average of 28 incidents per offender. These findings suggest that “paraphiliacs tend
to have multiple types of sexual aberrations as well as a high frequency of deviant acts per individual” (Bradford et
al., 1992, p. 104). These findings do not imply that people who engage in such activities as exhibitionism and
voyeurism will inevitably develop into child molesters and rapists. However, it seems clear that some people may
progress beyond these relatively minor acts to far more severe patterns of sexual aggression.
Although perhaps all of us would like protection against being sexually used without our consent, it seems
unnecessarily harsh and punitive to imprison people for exhibitionistic behavior, particularly first-time offenders. In
recent years, at least in some locales, there has been some movement toward therapy as an alternative to
incarceration. Later in this chapter, we will discuss a variety of therapeutic techniques used to treat exhibitionism
and other paraphilias.
What is an appropriate response if someone exposes himself to you? It is important to keep in mind that most
people who express exhibitionist behavior want to elicit reactions of shock, fear, disgust, or terror. Although it may
be difficult not to react in any of these ways, a better response is to calmly ignore the exhibitionist act and go about
your business. Of course, it is also important to immediately distance yourself from the offender and to report such
acts to the police or campus security as soon as possible.
Obscene Phone Calls
People who make obscene phone calls share similar characteristics with those who engage in exhibitionism. Thus,
obscene phone calling (sometimes called telephone scatologia) is viewed by some professionals as a subtype of
exhibitionism. People who make obscene phone calls typically experience sexual arousal when their victims react in
a horrified or shocked manner, and many masturbate during or immediately after a “successful” phone exchange. As
one extensive study has indicated, these callers are typically male, and they often suffer from pervasive feelings of
inadequacy and insecurity (Matek, 1988; Nadler, 1968). Obscene phone calls are frequently the only way they can
find to have sexual exchanges. Fortunately, a caller rarely follows up his verbal assault with a physical attack on his
victim.
A recent survey of a nationally representative sample of several hundred women found that 16% had received at
least one obscene phone call during the previous six months. The majority of these calls appeared to not be random
9
but rather targeted in some fashion, often on women less than 65 years of age who were neither married nor
widowed. The study’s author suggests that her findings indicate that obscene phone calls occur in patterns similar to
that of the expression of rage and perhaps can be best explained as “displaced aggression against a vulnerable
population” (Katz, 1994, p. 155).
What is the best way to handle obscene phone calls? Information about how to deal with obscene phone calls is
available from most local phone company offices. Because they are commonly besieged by such queries, you may
need to be persistent in your request. A few tips are worth knowing; they may even make it unnecessary to seek outside help.
First, quite often the caller has picked your name at random from a phone book or perhaps knows you from
some other source and is just trying you out to see what kind of reaction he can get. Your initial response may be
critical in determining his subsequent actions. He wants you to be horrified, shocked, or disgusted; thus, the best
response is usually not to react overtly. Slamming down the phone may reveal your emotional state and provide
reinforcement to the caller. Simply set it down gently and go about your business. If the phone rings again
immediately, ignore it. Chances are that he will seek out other, more responsive victims.
Other tactics may also be helpful. One, used successfully by a former student, is to feign deafness. “What is that
you said? You must speak up. I’m hard of hearing, you know!” Setting down the phone with the explanation that
you are going to another extension (which you never arrive at) may be another practical solution. Finally, screening
calls via an answering machine may also prove helpful. The caller is likely to hang up in the absence of an
emotionally responding person.
If you are persistently bothered by obscene phone calls, you may need to take additional steps. Your telephone
company should cooperate in changing your number to an unlisted one at no charge. It is probably not a good idea to
heed the common advice to blow in the mouthpiece with a police whistle (which may be quite painful and even
harmful to the caller’s ear) because you may end up receiving the same treatment from your caller.
A relatively new service offered by many telephone companies, called call trace or call tracing, may assist you
in dealing with repetitive obscene or threatening phone calls. After breaking connection with the caller, you enter a
designated code, such as star 57. The telephone company then automatically traces the call. After a certain number
of successful traces to the same number, a warning letter is sent to the offender indicating that he or she has been
identified as engaging in unlawful behavior, which must stop. The offender is warned that police intervention or
civil legal action may be an option if the behavior continues. Call trace is clearly not effective when calls are placed
from a public pay phone, and calls made from cellular phones cannot be traced.
Voyeurism
Voyeurism (voi-YuR-iz-um) refers to deriving sexual pleasure from looking at the naked bodies or sexual
activities of others, usually strangers, without their consent (American Psychiatric Association, 1994). Because a
degree of voyeurism is socially acceptable (witness the popularity of R- and X-rated movies and magazines like
Playboy and Playgirl), it is sometimes difficult to determine when voyeuristic behavior becomes a problem (Arndt,
1991; Forsyth, 1996). To qualify as atypical sexual behavior, voyeurism must be preferred to sexual relations with
another or indulged in with some risk (or both). People who engage in this behavior are often most sexually aroused
when the risk of discovery is high—which may explain why most are not attracted to such places as nudist camps
and nude beaches, where looking is acceptable (Tollison & Adams, 1979).
As the common term peeping Tom implies, this behavior is typically, although not exclusively, expressed by
males (Davison & Neale, 1993). Voyeurism includes peering in bedroom windows, stationing oneself by the
entrance to women’s bathrooms, and boring holes in the walls of public dressing rooms. Some men travel elaborate
routes several nights a week for the occasional reward of a glimpse through a window of bare anatomy or, rarely, a
scene of sexual interaction.
Again, people inclined toward voyeurism often share some characteristics with people who expose themselves
(Arndt, 1991; Langevin et al., 1979). They may have poorly developed sociosexual skills, with strong feelings of
inferiority and inadequacy, particularly as directed toward potential sexual partners. They tend to be very young
men, usually in their early 20s (Davison & Neale, 1993; Dwyer, 1988). They rarely “peep” at someone they know,
preferring strangers instead. Voyeurism is not typically associated with other antisocial behavior. Most individuals
who engage in such activity are content merely to look, keeping their distance. However, in some instances, such
10
individuals go on to more serious offenses such as burglary, arson, assault, and even rape (Abel, 1981; Langevin
et al., 1985; MacNamara & Sagarin, 1977).
It is difficult to isolate specific influences that trigger voyeuristic behavior, particularly because so many of us
demonstrate these tendencies in a somewhat more controlled fashion. The adolescent or young adult male who
displays this behavior often feels great curiosity about sexual activity (as many of us do) but at the same time feels
very inadequate or insecure. Peeping becomes a vicarious fulfillment because he may be unable to consummate
sexual relationships with others without experiencing a great deal of anxiety. In some instances, voyeuristic behavior
may also be reinforced by feelings of power and superiority over those who are secretly observed.
Other Coercive Paraphilias
We conclude our discussion of coercive paraphilias with a few brief comments about three additional varieties of
these coercive or invasive forms of paraphilias. The first two, frotteurism and zoophilia, are actually fairly common.
The third variant form, necrophilia, is quite rare in addition to being an extremely aberrant form of sexual
expression.
Frotteurism
Frotteurism (fro-TUR-izm) is a fairly common coercive paraphilia that goes largely unnoticed. It involves an
individual, usually a male, who obtains sexual pleasure by pressing or rubbing against a fully clothed female in a
crowded public place, such as an elevator, bus, subway, large sporting events, or an outdoor concert. The most
common form of contact is between the man’s clothed penis and a woman’s buttocks or legs. Less commonly he
may use his hands to touch a woman’s thighs, pubic region, breasts, or buttocks. Often the contact seems to be
inadvertent, and the woman who is touched may not notice or pay little heed to the seemingly casual contact. On the
other hand, she may feel victimized and angry. In rare cases, she may reciprocate (Money, 1984).
The man who engages in frotteurism may achieve arousal and orgasm during the act. More commonly, he
incorporates the mental images of his actions into masturbation fantasies at a later time. Men who engage in this
activity have many of the characteristics manifested by those who practice exhibitionism. They are frequently
plagued with feelings of social and sexual inadequacy. Their brief, furtive contacts with strangers in crowded places
allow them to include others in their sexual expression in a safe, non-threatening manner.
As with other paraphilias, it is difficult to estimate just how common this variety of coercive paraphilias is. One
study of a sample of reportedly typical or normal college men found that 21% of the respondents had engaged in one
or more frotteuristic acts (Ternpleman & Sinnett, 1991).
Zoophilia
Zoophilia (zO-O-FIL-e-uh), sometimes called bestiality, involves sexual contact between humans and animals
(American Psychiatric Association, 1994). You may wonder why we classify this as a coercive paraphilia because
such behavior does not involve coercing other people into acts they would normally avoid. In many instances of
zoophilia, it is reasonable to presume that the involved animals are also unwilling participants, and the performed
acts are often both coercive and invasive. Consequently, assigning this paraphilia to the coercive category seems
quite appropriate.
In Kinsey’s sample populations, 8% of the males and almost 4% of the females reported having had sexual
experience with animals at some point in their lives. The frequency of such behavior among males was highest for
those raised on farms (17% of these men reported experiencing orgasm as a result of animal contact). The animals
most frequently involved in sex with humans are calves, sheep, donkeys, large fowl (ducks and geese), dogs, and
cats. Males are most likely to have contact with farm animals and to engage in penile—vaginal intercourse or to
have their genitals orally stimulated by the animals (Hunt, 1974; Kinsey et al., 1948). Women are more likely to
have contact with household pets, involving the animals licking their genitals or masturbating a male dog. Less
commonly, some adult women have trained a dog to mount them and engage in coitus (Gendel & Bonner, 1988;
11
Kinsey et al., 1953).
Sexual contact with animals is commonly only a transitory experience of young people to whom a human
sexual partner is inaccessible or forbidden (Money, 1981). Most adolescent males and females who experiment with
zoophilia make a transition to adult sexual relations with human partners. Occasionally an adult may engage in such
behavior as a “sexual adventure” (Tollison & Adams, 1979). True or nontransitory zoophilia exists only when
sexual contact with animals is preferred regardless of what other forms of sexual expression are available. Such
behavior, which is quite rare, is generally only expressed by people with deep-rooted psychological problems or
distorted images of the other sex. For example, a man who has a pathological hatred of women may be attempting to
express his contempt for them by choosing animals in preference to women as sexual partners.
Necrophilia
Necrophilia (nek-rO-FIL-e-uh) is an extremely rare sexual variation in which a person obtains sexual gratification
by viewing or having intercourse with a corpse. This paraphilia appears to occur exclusively among males, who may
be driven to remove freshly buried bodies from cemeteries or to seek employment in morgues or funeral homes
(Tollison & Adams, 1979). However, the vast majority of people who work in these settings do not have tendencies
toward necrophilia.
There are a few cases on record of men with necrophilic preferences who kill someone in order to gain access to
a corpse. The notorious Jeffrey Dahmer, the Milwaukee man who murdered and mutilated his victims, is believed by
some experts on criminal pathology to have been motivated by uncontrollable necrophilic urges. More commonly,
the difficulties associated with gaining access to dead bodies lead some men with necrophilic preferences to limit
their deviant behavior to contact with simulated corpses. Some prostitutes cater to this desire by powdering
themselves to produce the pallor of death, dressing in a shroud, and lying very still during intercourse. Any
movement on their part may inhibit their customers’ sexual arousal.
Men who engage in necrophilia almost always manifest severe emotional disorders (Goldman, 1992). They
may see themselves as sexually and socially inept and may both hate and fear women. Consequently, the only “safe”
woman may be one whose lifelessness epitomizes a nonthreatening, totally subjugated sexual partner (Rosrnan &
Resnick, 1989; Stoller, 1977).
Treatment of Coercive Paraphilias
In most instances noncoercive paraphilias, while clearly atypical, fall within the boundaries of acceptable modes
of sexual expression. Furthermore, since they rarely cause personal anguish or harm to others, treatment is generally
not called for. However, in view of the invasive nature of coercive paraphilias, which often harm others, treatment is
appropriate and often necessary. Unfortunately, getting people who engage in these paraphilias to seek or accept
therapeutic intervention is another matter. People who embrace one or more of the coercive paraphilias usually do
not voluntarily seek treatment, nor do they acknowledge that they are in need of and/or will benefit from treatment.
These individuals are thus more likely to become involved with the mental health system only after either being
arrested and processed by the legal system, or because of pressure from family members who have discovered their
paraphilic behavior(s).
The treatment difficulties attributable to the nonvoluntary nature of client referrals is further compounded by
the fact that paraphilic behaviors are typically a source of immense pleasure. Consequently, most people are highly
motivated to continue rather than give up these acts (Money, 1988; Money & Lamacz, 1990). Therapeutic treatment,
regardless of the specific techniques or strategies employed, is often not very successful with clients who are
resistant to change.
Finally, people who compulsively engage in one or more of the coercive paraphilias often claim they are unable
to control their urges. This perceived lack of control runs counter to a basic tenet of most mental health therapies,
which, simply stated, maintains that before we can constructively change our behavior we first must accept
responsibility for our actions, no matter how driven or uncontrollable they may appear to be. Thus, a first step in a
successful treatment program is to break through a client’s belief that he is powerless to change his behavior.
A number of different approaches have been used in the treatment of coercive paraphilias with varied degrees
12
of success. We will consider four of the more commonly used avenues of treatment: psychotherapy, behavior
therapies, drug treatments, and social skills training.
Psychotherapy
Individual psychotherapy—in which a client talks with a psychologist, psychiatrist, or social worker for an hour
or more each week—has generally not proven very effective in treating coercive paraphilias. It is difficult to
overcome years of conditioning and the resultant powerful urges to continue paraphilic behavior, however
problematic, in one or two hours a week of verbal interaction.
Limited success in treating paraphilias has been reported by psychologists who employ cognitive therapies.
Cognitive therapies are based on the premise that most psychological disorders result from distortions in a person’s
cognitions or thoughts. Psychotherapists who operate within the cognitive framework attempt to demonstrate to their
clients how their distorted or irrational thoughts have contributed to their difficulties, and they use a variety of
techniques to help them change these cognitions to more appropriate ones (Johnston et al., 1997). Thus, although the
goal of therapy is to change a person’s maladaptive paraphilic behavior, the method in cognitive therapies is to first
change what the person thinks.
Unfortunately, it is often very difficult to modify the distorted ideas or cognitions that people use to justify their
paraphilic behaviors. In addition to being highly invested in continuing these intensely pleasurable activities, most
people who engage in coercive paraphilias believe that the problems associated with these acts result from society’s
intolerance of their variant behaviors, and not from the fundamental inappropriateness of such acts. Changing these
distorted cognitions can be a real challenge.
Behavior Therapies
Traditional models of psychotherapy have emphasized the underlying causes of psychological disorders, which
are viewed as distinct from those that mold so-called normal behavior. Behavior therapy departs from this traditional
conception. Its central thesis is that maladaptive behavior has been learned, and that it can be unlearned. Furthermore, the same principles that govern the learning of normal behavior also determine the acquisition of abnormal or
atypical behaviors. Behavior therapy draws heavily on the extensive body of laboratory research on strategies for
helping people to unlearn maladaptive behavior patterns. Behavior therapy focuses on the person’s current behaviors
that are creating problems. These maladaptive patterns are considered to be the problem, and behavior therapists are
not interested in restructuring personalities or searching for repressed conflicts. To change these inappropriate
behaviors, they enact appropriate changes in the interaction between the client and his or her environment. For
example, a person who responds sexually while exposing himself might be treated through repeated exposures to an
aversive stimulus paired with the situation/stimuli that elicits the inappropriate arousal pattern. This technique,
called aversive conditioning, is one of several behavior therapy techniques outlined as follows.
Aversive Conditioning
The goal of aversive conditioning is to substitute a negative (aversive) response for a positive response to an
inappropriate stimulus situation. For example, an undesired sexual behavior, such as masturbating while replaying
mental images from previous episodes of exhibitionism, is paired repeatedly with an aversive stimulus such as a
painful but not damaging electric shock, a nausea-inducing drug, or a very unpleasant odor. Similarly, an aversive
stimulus may be administered to a person while he views photographs or color slides depicting the paraphilic
behavior.
A recent study reported some success in the use of aversive conditioning to treat exhibitionism. A number of
male offenders were instructed to carry smelling salts (a very unpleasant odor) and told to inhale deeply whenever
they felt compelled to expose themselves. This approach helped some of the offenders to develop some control over
their paraphilic behaviors by virtue of learning to associate the aversive odor with their deviant fantasies/urges
(Marshall et al., 1991).
Aversive conditioning is not a pleasant experience, and you may wonder why anyone would undergo it
voluntarily. The answer is that aversive conditioning as a treatment for coercive paraphilias is most commonly used
with men required by the legal system to undergo treatment. However, in some cases family pressures or a personal
13
dissatisfaction with the complications associated with paraphilic behavior have led some men to voluntarily seek
this therapeutic intervention.
Systematic Desensitization
One of the most widely used behavior therapy techniques is systematic desensitization, a strategy originally
developed by Joseph Wolpe (1958 & 1985) to treat people who are excessively anxious in certain situations. This
behavioral technique is based on the premise that people cannot be both relaxed and anxious at the same time.
Therefore, if individuals can be trained to relax when confronted with anxiety-inducing stimuli, they will be able to
overcome their anxiety.
People who engage in paraphilias frequently depend on these acts for sexual satisfaction, because they often
find it very difficult to establish satisfying sexual relationships with partners, due to strong feelings of personal
inadequacy and poorly developed interpersonal skills. Consequently, helping people to overcome their anxieties
about relating to others by conditioning them to relax in sociosexual situations can help to replace inappropriate
paraphilic behaviors with more healthy expressions of intimacy and sexuality.
The key to successful application of this therapeutic method is to proceed slowly and systematically. The first
step is to construct a hierarchy of situations that trigger anxiety or inappropriate sexual arousal with the most intense
anxiety-inducing or sexually arousing at the top of the list and the least at the bottom. The next phase is to teach the
client to relax selected muscle groups in his body. In the final stage, muscle relaxation is paired repeatedly with each
of a series of progressively more intense images. When the client is able to repeatedly imagine the mildly
threatening or arousing situation at the bottom of the list without experiencing any anxiety or arousal, his attention is
then directed to the next image in the hierarchy. Over the course of several sessions, relaxation gradually replaces
anxiety or sexual arousal to each of the stimulus situations, even the most intense at the top of the hierarchical list.
Note from Dr. Kramer: (Basically, this treatment is used to replace anxiety in social situations with relaxation. If
the man can relax in social/sexual situations, then it is thought he might be more likely to obtain “normal”
social/sexual gratification).
Orgasmic Reconditioning
The goal of this version of behavior therapy is to increase sexual arousal and response to appropriate stimuli by
pairing imagery/fantasies of socially normative or acceptable sexual behavior with the reinforcing pleasure of
orgasm (Laws & Marshall, 1991; Walen & Roth, 1987). In orgasmic reconditioning, the client is instructed to
masturbate to his usual paraphilic images or fantasies. However, when he feels orgasm is imminent, he switches to
more socially appropriate imagery, on which he is told to focus during orgasm. Ideally, after practicing this
technique several times, he will become accustomed to having orgasms in conjunction with more healthy
imagery/fantasies. Once this is achieved, the client is encouraged to move these more appropriate images to a
progressively earlier phase of his masturbation-produced sexual arousal and response. In this fashion he may
gradually become conditioned to experiencing sexual arousal and orgasm in the context of socially acceptable
behaviors.
Satiation Therapy
Another, related technique for treating coercive paraphilias in which masturbation plays a central role is called
satiation therapy. In this approach to treatment the client masturbates to orgasm while fantasizing or imagining
images of appropriate sexual situations. He is instructed to switch to his favorite paraphilic fantasy immediately after
orgasm and to continue masturbating. The premise or theory behind this approach is that the low level of arousal and
response accompanying the postorgasmic masturbation to paraphilic images will eventually result in these
inappropriate stimuli becoming unarousing and perhaps even irritating (Abel et al., 1992; Laws & Marshall, 1991).
14
Drug Treatment
Antiandrogen drugs that drastically lower testosterone levels have been used effectively in some instances to block
the inappropriate sexual arousal patterns underlying coercive paraphilic behavior (Abel Ct al., 1992; Bradford, 1998;
Rosler & Witzturn, 1998). Medroxyprogesterone acetate (MPA, also known by its trade name, Depo-Provera) and
cyproterone acetate (CPA) are two antiandrogen drugs most commonly used to treat sex offenders, including those
whose paraphilic behaviors have brought them into contact with legal authorities.
Drug treatment of coercive paraphilias is most effective when combined with other therapeutic methods such as
psychotherapy or behavior therapy (Abel et al., 1992; Bradford & Pawlak, 1993b). The major advantage of these
drugs as adjuncts to other treatment techniques is that they markedly reduce the driven or compulsive nature of the
paraphilia. This better enables the client to focus his efforts on other therapeutic procedures without being so
strongly distracted by his paraphilic urges.
Social Skills Training
Finally, people who engage in paraphilias often have great difficulty forming sociosexual relationships and thus may
not have access to healthy forms of sexual expression. Consequently, these individuals may benefit from social
skills training designed to teach them the skills necessary to initiate and maintain satisfying relationships with
potential intimate/sexual partners. Such training, often conducted in conjunction with other therapeutic
interventions, may involve practice in initiating social interaction with prospective companions, conversational
skills, how to ask someone out on a date, and how to cope with perceived rejection.
Sexual Addiction: Fact, Fiction, or Misnomer?
In recent years, both the professional literature and the popular media have directed considerable attention to a
condition commonly referred to as sexual addiction. The idea that people may become dominated by insatiable
sexual needs has been around for a long time, exemplified by the terms nymphomania, applied to women, and
satyriasis or Don Juanism, applied to men. Many professionals have traditionally reacted negatively to these labels,
suggesting that they are disparaging terms likely to induce unnecessary guilt in individuals who enjoy an active sex
life. Furthermore, it has been argued that one cannot assign a label implying excessive sexual activity when no clear
criteria establish what constitutes “normal” levels of sexual involvement. The criteria often used to establish alleged
subconditions of hypersexuality— nymphomania and satyriasis—are subjective and value laden. Therefore, these
terms are typically defined moralistically rather than scientifically1, a fact that has generated harsh criticism from a
number of professionals (Klein, 1991; Levine & Troiden, 1988). Nevertheless, the concept of compulsive sexuality
achieved a heightened legitimacy with the publication of Patrick Carnes’s book, The Sexual Addiction (1983), later
retitled Out of the Shadows: Understanding Sexual Addiction (1992, 2nd ed.).
According to Carnes, many people who engage in some of the atypical or paraphilic behaviors described in this
chapter (as well as victimization behaviors, such as child molesting) are manifesting the outward symptoms of a
process of psychological addiction in which feelings of depression, anxiety, loneliness, and worthlessness are
temporarily relieved through a sexual high not unlike the high achieved by mood-altering chemicals such as alcohol
or cocaine. Carnes suggested that a typical addiction cycle progresses through four phases. Initially, the sex addict
enters a trancelike state of preoccupation in which obsessive thoughts about a particular sex behavior, such as
exposing oneself, create a consuming need to achieve expression of the behavior. This intense preoccupation
1
Note from Dr. Kramer: Here we see this writer agree with me that we must strive to minimize the influence of our
“values” when doing good science.
15
induces certain ritualistic behaviors, such as running a regular route through a particular neighborhood where
previous incidents of exposing have occurred. Their ritualistic behaviors tend to further intensify the sexual
excitement that was initially aroused during the preoccupation phase. The next phase is the actual expression of the
sexual act, in this case exposing oneself. This is followed by the final phase, one of despair, in which sex addicts are
overwhelmed by feelings of worthlessness, depression, and anxiety. One way to minimize or anesthetize this despair
is to start the cycle again. With each repetitive cycle, the addiction behavior becomes more intense and
unmanageable, “thus confirming the basic feelings of unworthiness that are the core of the addict’s belief system”
(Carnes, 1986, p. 5).
Carnes’s conception of the sexual addict has generated considerable attention within the professional
community. However, many sexologists do not believe that sexual addiction should be a distinct diagnostic
category, because it is both rare and lacking in distinction from other compulsive disorders, such as gambling and
eating disorders, and because this label negates individual responsibility for “uncontrollable” sexual compulsions
that victimize others (Barth & Kinder, 1987; Levine & Troiden, 1988; Peele & Brodsky, 1987). This position is
reflected in a decision not to include a category encompassing hypersexuality in the most recent version of the
Diagnostic and Statistical Manual (DSM-IV) of the American Psychiatric Association (1994) (the most widely
accepted system for classifying psychological disorders).
A number of professionals acknowledge the validity of such arguments against the addiction concept but
nevertheless recognize that some people may become involved in patterns of excessive sexual activity that reflect a
lack of control. Noteworthy in this group is sexologist Eli Coleman (1990 & 1991), who prefers to describe these
behaviors as symptomatic of sexual compulsion rather than addiction. According to Coleman, a person manifesting
excessive sexual behaviors often suffers from feelings of shame, unworthiness, inadequacy, and loneliness. These
negative feelings cause great psychological pain and this pain then causes the person to search for a “fix,” or an
agent that has pain-numbing qualities, such as alcohol, certain foods, gambling, or, in this instance, sex. Indulging
oneself in this fix produces only a brief respite from the psychological pain that returns in full force, thus triggering
a greater need to engage in these behaviors to obtain temporary relief. Unfortunately, these repetitive, compulsive
acts soon tend to be self-defeating in that they compound feelings of shame and lead to intimacy dysfunction by
interrupting the development of normal, healthy interpersonal functioning.
The topic of compulsive sexual behavior has been the subject of growing interest in both the professional
community and the popular media (Black et al., 1997). We can expect that professionals within the field of sexuality
will continue to debate for some time how to diagnose, describe, and explain problems of excessive or uncontrolled
sexuality. Even as this discussion continues, professional treatment programs for compulsive or addictive sexual
behaviors have emerged throughout the nation (over 2000 programs at last count), most modeled after Alcoholics
Anonymous’s twelve-step program. Data pertaining to treatment outcomes for these programs are still too limited to
evaluate therapeutic effectiveness. Besides formal treatment programs, a number of community-based, self-help
organizations have surfaced throughout the United States. Some of these groups are Sex Addicts Anonymous,
Sexaholics Anonymous, Sexual Compulsives Anonymous, and Sex and Love Addicts Anonymous.
From: “Our Sexuality” by Crooks & Baur, 7th Ed, 1999
From: “Abnormal Psychology”, Sarason & Sarason, 2002