Treatment approaches for paraphilias and behavioral addiction management

Paraphila

The ancient philosopher Plato claimed that all immoral behavior was the result of some disorder in the soul (Gert and Culver, 2009, p. 489). Although very few people now hold this view, deviant sexual behavior is often considered symptomatic of a mental disorder. However, not all deviant behaviors fit the clinical definition. For example, if a heterosexual man becomes aroused by dressing in women's clothing, it is considered by most people to be abnormal behavior. However, his behavior may be ego-syntonic, meaning that the man is not troubled by either the impulses or by acting them out. Such an individual would not seek treatment. He is not a danger to himself or to anyone else and unless there were objections on the part of his wife or significant other, there is no compelling reason, in the man's mind, to manage his impulses or behavior. As Bhugra and McMullen (2010, p. 245) point out, dressing in women's clothing may not be considered an illness unless and until it results in criminal behavior (e.g., stealing women's clothing that then leads to an arrest.) The mere act of dressing in women's clothing is not a crime and there is no victim. Pedophilia, on the other hand, is a mental disorder by the same definition. For the perpetrator, it causes "clinically significant distress or impairment in social, occupational, or other important areas of functioning" (Gert and Culver, p. 488). For the young victim, the behavior can be devastating, with lifelong consequences.

Throughout history, there has been a range of perceptions in different cultures as to what constitutes sexual deviance, including degree of consent, location of the sexual behavior, the age of the individuals involved, whether or not any harm or distress occurs, the frequency of the practice, and the degree of distaste felt by others about the particular sexual behavior (Hensley and Tewksbury, 2003, cited in Gordon, 2008, p. 79).

Pedophilia is a clinical diagnosis usually made by a psychologist or psychiatrist (Hall and Hall, 2007, p. 457). "Pedophilia" is neither a criminal or legal term; "forcible sexual offense" is used instead by the justice system. According to the FBI's National Incident-Based Reporting System (NIBRS), forcible sexual offenses are those directed against another individual forcibly and/or against that person's will, or not forcibly or not against the person's will when that person is incapable of giving consent. The diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, defines a pedophile as one who fantasizes about, is sexually aroused by, or experiences sexual urges toward prepubescent children (under the age of 13) for a period of at least six months. Generally, these individuals are at least sixteen years of age and at least five years older than the object(s) of their fantasies.

There has long been debate about whether sexual deviancy, including pedophilia, is a mental condition that might be considered an impulse control disorder or whether it is a learned behavior that has its roots in other factors. Sexual practices are linked with kinship patterns and power structures within a society and influenced by such factors as age, social status, religious practice and educational status (Bhugra and McMullen, 2010, p. 246).

Individuals who were themselves offended as youngsters are at higher risk of becoming pedophiles. Alcohol and drug abuse can exacerbate these tendencies, although individuals who commit offenses against juveniles while intoxicated are not considered pedophiles according to legal and clinical definitions if the offense was not one the individual would normally commit, or even fantasize about, while sober. (Hall and Hall, 2007, p. 457). It is a fine distinction. Individuals with poor social skills, perhaps falling somewhere on the autism spectrum, can also be at risk for desiring sexual contact with children.

Treatment of the paraphilias began in the late nineteenth century, around the time sexual deviance was first thought of as a medical condition. The initial treatment approach was surgical castration (Gordon, 2008, p. 81). Modern treatments use counseling, medication or both. Marshall and Marshall (2006, p. 163) are critical of the "one-size-fits all" treatment programs that are guided by "excessively detailed treatment manuals… research-funding agencies and by the administrators of institutional services that provide treatment in several settings." A number of recent studies by Marshall and others demonstrate that a therapist's demeanor, including empathy, warmth, directiveness, and encouragement "is predictive of the clients' attainment of the goals of sexual offender treatment" (Marshall and Marshall, p. 164). There is a growing body of evidence correlating process issues with sexual offenders' attainment of treatment goals.

Treatment for pedophilia depends to a large extent on the age of the perpetrator. As has been mentioned, an early solution was surgical castration and incarceration. Treatment of adult offenders is usually punitive; offenders may or may not take part in prison-based therapy. Since the mid-1990s, the literature has generally supported inverse correlation between sex offender recidivism and treatment programs (Minnesota Department of Corrections, 2010, p. 1). The goal for adult sex offenders is harm-reduction, and in therapy individuals work on managing their impulses so they can safely return to society. In therapy, individuals will learn to recognize triggers for deviant behaviors and learn what they can do to minimize their risks for repeat offenses. Pornography is the number one trigger, and individuals are counseled to avoid it. Drugs and alcohol can loosen inhibitions and lessen fears about re-incarcertation, so those, too, are to be avoided. Individuals are also charged with avoiding situations that might encourage deviant thoughts, such as deliberately walking past a playground, or visiting a video game arcade where it is known that children will be present. In some cases, individuals may be prescribed drugs to reduce libido but only in very rare instances is this mandated by the courts. In most situations, taking the libido-reducing medication is voluntary and there is always the problem of an individual staying on medication once he is released from prison and/or therapy.