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Multiple Paraphilic Diagnoses

among Sex Offenders


Gene G. Abel, MD; Judith V. Becker, PhD; Jerry Cunningham-Rathner, BA;
Mary Mittelman, DrPH; and Joanne-L. Rouleau, PhD

The psychiatric literature suggests that paraphiliacs can be expected to partic-


ipate in only one type of deviant sexual behavior. Using self-reports gathered with
assured confidentiality from 561 nonincarcerated paraphiliacs, we discovered that
most paraphiliacs have had significant experience with as many as ten different
types of deviant sexual behavior without regard, in many cases, to gender, age,
and familial relationship of the victim. The relevance of these findings to our un-
derstanding of paraphiliacs and their treatment is discussed.

Sex crimes are a major social problem. portant research. If the accelerating in-
Despite changing cultural trends toward cidence of reported sex crimes and the
open discussion of sexual behavior, in- attendant victimizations are to be re-
formation about sex crimes and the in- duced, however, the psychopathology
dividuals who commit them remains of the perpetrators must be examined.
sketchy and inconclusive. Psychiatry, The best source of accurate infor-
psychology, and sociology have tended mation about participation in deviant
to avoid the study of sex offenders, per- sexual behaviors is the paraphiliacs
haps because they are viewed with dis- themselves. However, a major factor
dain by all levels of society. Instead, the inhibiting the collection of accurate in-
focus has been on the victims of sex formation from paraphiliacs is the fear
crimes-certainly worthwhile and im- of negative social and legal repercus-
sions because of the lack of assured
confidentiality. The paraphiliac be-
Dr. Abel is Professor of Psychiatry and Dr. Rouleau lieves that valid reporting of his deviant
is Assistant Professor of Psychology, Department of
Psychiatry, Emory University, Atlanta, GA. Dr. behavior is likely to increase the prob-
Becker is Associate Professor of Psychology, Ms. Cun-
ningham-Rathner is Assistant Instructor of Psychol- ability of arrest for crimes unknown to
ogy, and Dr. Mittelman is Associate Research Scien- others, to prolong his incarceration, or
tist, Department of Psychiatry, College of Physicians
and Surgeons, Columbia University, New York, NY. to jeopardize his probation status. Fur-
Address reprint requests to Dr. Abel, Behavioral Med- thermore, most states have laws that re-
icine Institute, 3193 Howell Mill Rd., Suite 202, At-
lanta, GA 30327. quire the reporting of some sex crimes
This research was supported by the National Institute (e.g., child molestation) to law enforce-
of Mental Health, Grant ROlMH33678, "The Evalu-
ation of Child Molesters," awarded to Dr. Gene G. ment authorities. Therefore, paraphi-
Abel. The authors gratefully acknowledge the editorial liacs are reluctant to discuss the true
assistance of Larry Brown in the preparation of this
manuscript. scope of their deviant behavior with
Bull Am Acad Psychiatry Law, Vol. 16, No. 2, 1988 153
Abel et a/.

others. The key issue, then, to obtain- tained from incarcerated paraphiliacs,
ing valid and reliable information from these studies reported that each had
paraphiliacs in order to facilitate as- participated, on the average, in fewer
sessment and treatment is an assurance than two different types of paraphilia.
of confidentiality. Information gathered under a Certifi-
Information currently available con- cate of C~nfidentiality,',~.~
however, re-
cerning paraphiliacs has come generally vealed that paraphiliacs have often been
from incarcerated offenders who are involved in many more paraphilias than
also unlikely to report accurately their previously suspected. To gain a better
various deviant sexual interests and be- understanding of the number of differ-
haviors. It is well known among incar- ent paraphilias in which the paraphiliac
cerated paraphiliacs that if the nature of may participate and how the various
their crimes becomes known to fellow paraphilic diagnoses interrelate, the fol-
inmates, the risk of violent reprisal will lowing study was undertaken.
be substantially increased. Conse-
Methods
quently, what we know about sex of-
fenders as a population has been lim- Subjects The study population in-
ited. cluded 561 men seeking voluntary eval-
Recent studies,'-3 relying on a Cer- uation andlor treatment for possible
tificate of Confidentiality from the fed- paraphilia at the University of Tennes-
eral government4 that protects the iden- see Center for the Health Sciences,
tity and confidentiality of research Memphis, Tennessee, or at the New
subjects (in this case, self-reports ob- York State Psychiatric Institute, New
tained from paraphiliacs), have re- York City. At the former site, all cate-
vealed a marked discrepancy between gories of paraphilia were evaluated; at
information in the literature regarding the latter, subjects with a diagnosis of
paraphiliacs and information gathered rape and/or child molestation, because
from paraphiliacs with the above assur- of preselection, constituted the largest
ance of confidentiality. The literature segment of the subject population. Ap-
suggests that the average sex offender proximately one third of the subjects
commits fewer than two crimes5-'; were referred through mental health
more recent studies' indicate that a rap- routes, one third from legal or forensic
ist may commit as many as seven rapes, sources, and one third from other
that a pedophile molesting young boys sources.'
may commit an average of 240 such Diagnostic Criteria Interviews were
crimes, and that exhibitionists, frot- conducted over an eight-year period
teurs, and voyeurs commit an average (1977 to 1985), during which time the
of over 500 paraphilic acts each. Diagnostic and Statistical Manual of
Previous studies5**have also under- Mental Disorders of the American Psy-
estimated the number of different types chiatric Association was revised from
of paraphilia in which sex offenders DSM-I1 to DSM-111. Both DSM-I1 and
may participate. With information ob- DSM-I11 describe nearly all of the char-
154 Bull Am Acad Psychiatry Law, Vol. 16, No. 2, 1988
Multiple Paraphilic Diagnoses

acteristics of paraphilias appearing in paraphilia by relying upon the DSM-I1


this study, i.e., unusual or bizarre im- or DSM-I11 criteria, therefore, would
agery or acts that tend to be insistently undermine any investigation into the
and involuntarily repetitive, generally coexistence of multiple paraphilic di-
involving the preference for the use of agnoses in a single subject. Regardless
a nonhuman object for sexual arousal, of what proportion of sexual arousal re-
repetitive activities with humans in- sulted from paraphilic interests or fan-
volving real or simulated suffering or tasies, the victimization and the attend-
humiliation, or repetitive sexual activi- ant consequences still occurred. This
ties with nonconsenting partners. All study describes individuals who, at
subjects reported recurrent, repetitive times, participated in nonparaphilic be-
urges to carry out these deviant sexual haviors without relying on paraphilic
behaviors; subjects were not included thoughts, and, at other times, used par-
simply because they had committed the aphilic thoughts to develop fantasy,
behavior. erection, and/or behaviors. Thus, our
Diagnostic problems arose, however, diagnostic criteria in this one respect
when the criteria for diagnosis using varied with the diagnostic criteria out-
DSM-I1 and DSM-I11 indicated that the lined in DSM-I1 and DSM-111.
subject's predominating sexual activity Based upon the subjects' reported life
must involve paraphilic behavior history, we categorized each paraphilic
(DSM-11), or that sexual excitement is diagnosis by gender and age of target
possible only when the individual fan- (less than 14, 14 to 17, and more than
tasizes or uses paraphilic images or be- 17 years of age) except in paraphilias
haviors to become sexually excited where such divisions were irrelevant
(DSM-111). We discovered that these (e.g., bestiality, coprophilia, some fe-
latter criteria were inconsistent with our tishes). The majority of targets of the
clinical experience with individuals who various paraphilic interests were fe-
repetitively carry out paraphilic acts. male, except in cases of child moles-
The majority of paraphiliacs in our sub- tation involving assaultive behavior.
ject population could become involved Categories were subsequently col-
with adult partners without relying lapsed across genders except in the cat-
upon paraphilic fantasies and behav- egory of child molestation. The familial
iors. Many indicated that they preferred relationship of the perpetrator to the
paraphilic fantasies or behaviors to non- target was also initially categorized but
paraphilic sexual behaviors, but both was subsequently ignored for all diag-
paraphilic and nonparaphilic sexual be- noses except child molestation. The
havior clearly coexisted in most of the number of pedophiles involved in in-
subjects. cestuous activities was quite significant
In most cases, the DSM-I1 or DSM- and appeared to warrant discrimination
I11 definition of paraphilia excludes the from nonincestuous child molestation.
possibility of multiple, concomitant The behaviors characterizing the 21
paraphilias. To determine a diagnosis of categories of paraphilias (see Table 2)
Bull Am Acad Psychiatry Law, Vol. 16, No. 2,
Abel et a/.

are described in DSM-I1 and DSM-111. verse consequences. Subjects were


The public masturbator differed from given the opportunity to discuss their
the exhibitionist in that the former mas- concerns and to ask questions before
turbated in a public setting but made no signing the consent form.
attempt to expose his penis to his target. All subjects underwent a structured
The exhibitionist, by contrast, became clinical interview'~1° focusing on spe-
maximally aroused by exposing his cific demographic characteristics, num-
penis to an unsuspecting target. Uro- bers and types of deviant acts, and num-
lagnia involved sexual gratification as ber of victims. The subjects were again
the perpetrator urinated on his victim reminded of the confidentiality of the
or was urinated upon by others. Two data and the voluntary nature of their
subjects were seen who were aroused participation, and told that they were
by specific odors associated with men free to withdraw at any time for any rea-
or women and appeared to be distinct son. If subjects were easily able to recall
from coprophiliacs in that the odor to and describe the variety and complexity
which they were particularly attracted of their paraphilic interests, the struc-
did not involve feces. tured clinical interview lasted approxi-
Three nonparaphilic categories of mately one hour. If subjects experi-
sexual behavior (rape of adult women, enced difficulty, the interview lasted up
transsexualism, and ego-dystonic ho- to five hours.
mosexuality) were included in the sam- Numerous problems arose during the
ple to investigate whether these cate- clinical interviews. First, it was some-
gories of sexual behavior correlated times difficult for subjects to describe
with any traditional paraphilic behav- the frequency of their involvement with
ior. By including these three nonpara- paraphilias that had developed much
philic categories, it was hoped that fur- earlier in their lives. To assist the sub-
ther scientific data could be gathered to jects with the chronology of their de-
substantiate or refute the inclusion of viant arousal and to improve the valid-
these three categories of behavior in the ity of their reports, interviewers
paraphilia category. attempted to associate important events
Procedure In an effort to minimize in the subjects' lives with the onset and
the subjects' attempts to conceal their frequency of their paraphilias.
deviant behavior, each subject viewed Second, some subjects reported sev-
a one-hour, videotaped presentation eral paraphilias occurring simultane-
that explained the human investigation ously but at different frequencies. Such
aspects of the study, the confidentiality reports tended to indicate that, as one
of the data, and the protection afforded paraphilia rose to become the predom-
to him under the Certificate of Confi- inating deviant behavior, others would
dentiality. Subjects were informed that become less dominant. This wave effect
their participation was strictly volun- continued as another paraphilia rose to
tary and that they were free to withdraw dominance and other deviant interests
from the study at any point without ad- diminished. Special care was taken
156 Bull Am Acad Psychiatry Law, Vol. 16, No. 2, 1988
Multiple Paraphilic Diagnoses

under these circumstances to separate Results


the occurrences and frequencies of the The age range of the study population
various paraphilias. of 561 males was 13 to 76 years, with a
Third, the validity of the frequency mean age of 31.5. Of these, 67 percent
of past deviant behaviors was a major fell into the age range of 20 to 39 years
concern. Verification of the subjects' of age. Approximately half of the study
reported frequency of paraphilic acts population were single and the remain-
with arrest records proved to be inef- ing half either were married, had been
fective because the subjects' reported married, or had formed a significant,
frequencies of deviant behavior were "living with" relationship with an adult
substantially higher than the number of partner. The ethnic distribution was
actual arrests. For example, the ratio of 62.1 percent white, 23.8 percent black,
arrest to reported commission of the vi- and 11.2 percent Hispanic. The major-
olent crimes of rape and child moles- ity of the participants had completed
tation was approximately 1 :30 and the high school and 40 percent had com-
ratio of arrest to reported commission pleted at least one year of college.
of the less violent crimes of exhibition- Nearly two thirds (65%) of the subjects
ism and voyeurism was approximately were fully employed and earned annual
1: 150. When the subject reported a incomes in the range of $7,500 to
range in the frequency of his deviant be- $25,000. Approximately 30 percent
havior (e.g., three to five times a were referred for evaluation through
month), the lowest value was selected legal or judicial sources, and 30 percent
so that the data would reflect minimal were referred by mental health profes-
frequencies of deviant behavior. Only sionals. The remainder were referred by
incidents of deviant behavior as re- other sources, including self-referral.
ported by the subject himself were in- To determine a paraphilic diagnosis,
cluded. For example, if a family mem- the data were analyzed according to the
following four subcategories: (1) gender
ber reported five incidents of deviant
of target, (2) age of target, (3) inces-
behavior but the subject reported only
tuous versus nonincestuous behavior,
two, then the interviewer recorded two
and (4) assaultive versus nonassaultive
acts. Conversely, if the subject reported
behavior. All paraphilic diagnoses were
ten acts of deviant behavior but his ar-
classified by each of these subcatego-
rest record reflected only three, then
ries and the frequency of occurrence of
the interviewer recorded ten acts. each subcategory was determined. It
Fourth, the possibility of overreport- should be noted that, in order to be in-
ing was addressed. In the few instances cluded in a diagnostic category, a sub-
of suspected overreporting, the inter- ject must have reported an overt act in
view was repeated until data were con- that category; deviant arousal alone
sistent. If repeated interviews failed to was not sufficient.
yield consistency, the subject's data Gender of Target In our total popu-
were not included in the study. lation of 561 subjects, we observed that
Bull Am Acad Psychiatry Law, Vol. 16, No. 2, 1988 157
Abel et a/.

Table 1 (8.4%) participated in deviant behavior


Target Age
that was not classifiable according to
No. of % of age of target, e.g., fetishism. Analysis
Subjects Subjects
of these data reveals that 239 subjects
Child, adolescent, (42.3%) targeted victims in at least two
adult
Chiid and age groups.
adolescent Incestuous versus Nonincestuous Be-
Child and adult havior It is commonly thought that
Adolescent and
adult paraphiliacs offend either against their
Child only family members or against nonfamily
Adolescent only
Adult only members, but rarely against both. In
Not applicable our total population of 561 subjects, we
Total observed that 3 15 (56.1%) participated
in nonincestuous deviant behavior only
and 68 (12%) participated in incestuous
377 (67.2%) targeted only females and deviant behavior only. Again, 47 sub-
67 (11.9%) targeted only males. Five jects participated in deviant behavior
subjects participated in deviant behav- that was not classifiable in this subcat-
ior that was not classifiable in this sub- egory, e.g., fetishism. A total of 131
category, e.g., fetishism. A total of 112 (23.3%) subjects offended against both
(20%) subjects offended against both family and nonfamily targets, indicating
male and female targets, indicating that that this subgroup of the study popu-
this subgroup of the study population lation participated in deviant behavior
participated in deviant behavior irres- irrespective of familial relationship.
pective of gender of target. Assaultive versus Nonassaultive Behav-
Age of Target Another important ior Subjects were next categorized by
area of concern was age of the victims, assaultive or nonassaultive paraphilic
i.e., whether a paraphiliac who offends behavior to determine whether para-
against a young child would also com- philiacs who committed assaultive acts
mit acts against an adolescent and/or an (child molestation, rape, frottage) also
adult, and vice versa. Subjects were di- carried out nonassaultive paraphilic be-
vided into three categories of age of tar- haviors (public masturbation, voyeur-
get: children less than 14 years of age, ism, exhibitionism) and vice versa. In
adolescents 14 to 17 years of age, or our total population of 561 subjects, we
adults (more than 17 years of age) observed that 331 (59%) participated in
(Table 1). In our total population of 561 assaultive deviant behavior only and 84
subjects, we observed that 275 subjects (14.9%) participated in nonassaultive
(49%) targeted victims in only one age deviant behavior only. However, 146
group, 176 subjects (3 1.3%) targeted (26%) subjects participated in both as-
victims in two age groups, and 63 sub- saultive and nonassaultive deviant be-
jects (11.2%) targeted victims in all havior indicating that this subgroup of
three age groups. Forty-seven subjects the study population offended against
158 Bull Am Acad Psychiatry Law, Vol. 16, No. 2, 1988
Multiple Paraphilic Diagnoses

targets involving both touching and in which our subjects could have been
nontouching behaviors. involved. (For this and subsequent
The foregoing analyses indicate that analyses, pedophiles targeting children
a significant percentage of paraphiliacs less than 14 years of age and those tar-
cross gender, age, familial, and assaul- geting adolescents aged 14-17 were
tive/nonassaultive behavior boundaries combined into a single category.)
during the commission of paraphilic The percentage of subjects in each of
acts. the 21 diagnostic categories who had
We next examined the interrelation- one or more paraphilic diagnoses ap-
ship between paraphilic diagnoses. The pears in Table 2. Excluding infrequently
full impact of the results of this study seen categories having less than 12 sub-
emerges when the crossings of deviant jects per category (such as obscene
behaviors are combined in order to de- mail, urolagnia, coprophilia, and attrac-
termine multiple paraphilic diagnoses. tion to specific odors), subjects in all
Number of Paraphilic Diagnoses by Di- other diagnostic categories had histo-
agnostic Category Our clinical experi- ries of numerous other separate para-
ence with this population of 561 sub- philic diagnoses. There were at least a
jects indicates that, when multiple few subjects in each category who had
paraphilias exist in the same subject, as many as 10 different paraphilic di-
one paraphilia initially takes domi- agnoses.
nance. A second paraphilia develops Because of preselection, it was as-
and overtakes the first in dominance, sumed that the relative occurrence of
and then continues for a number of paraphiliacs in the sample was unrepre-
months or years, while the first contin- sentative of the general population, ex-
ues at a greatly reduced intensity. On cept for the relative occurrence of the
rare occasions, the initial paraphilia will subcategories of child molesters. To
appear to lose its arousal properties en- avoid skewing of the data by overre-
tirely for the patient and essentially dis- presentation of some groups (e.g., child
appear. Because our role was to deter- molesters) and underrepresentation by
mine the existence of more than one others (e.g., voyeurs) and to obtain a
paraphilia in the same subject, we less biased appraisal of the number of
elected to count all paraphilias that had different paraphilias in the "average
occurred during his lifetime, even paraphiliac," the percentage of each of
though some were no longer actively the 21 paraphilic classifications with
arousing or erection producing. The one or more paraphilias was calculated
temporal relationship among the var- and then averaged across all 21 para-
ious paraphilic diagnoses awaits further philic categories. This averaged inci-
analysis. dence of concomitant or nonconcomi-
Clinical interviews revealed that a tant paraphilic diagnoses is reflected in
number of subjects were involved in dif- Figure 1 . Only 10.4 percent of these
ferent paraphilias during their lives. "average paraphiliacs" had one diag-
There were 21 categories of paraphilia nosis, 19.9 percent had two diagnoses,
Bull Am Acad Psychiatry Law, Vol. 16, No. 2, 1988 159
Abel et a/.

Table 2
Percentage of Paraphiliacs with Multiple Paraphilias

% of Paraphiliacs
Diagnosis
I* 2* 3* 4' 5' 6* 7* 8' 9' 10'
Pedophilia 15.2 23.7 19.2 14.7 9.4 4.5 6.7 3.1 1.3 2.2
(nonincestuous),
female target
Pedophilia 19.0 26.8 19.6 12.4 4.6 3.9 6.5 3.9 .7 2.6
(nonincestuous),
male target
Pedophilia 28.3 25.8 17.0 5.7 8.2 3.8 5.0 1.9 .6 3.8
(incestuous),
female target
Pedophilia 4.5 15.9 20.5 18.2 13.6 6.8 9.1 2.3 .O 9.1
(incestuous),
male target
Rape 27.0 17.5 19.0 12.7 7.1 3.2 7.9 1.6 1.6 2.4
Exhibitionism 7.0 20.4 22.5 15.5 7.0 7.0 9.2 4.9 2.8 3.5
Voyeurism 1.6 9.7 27.4 14.5 12.9 8.1 11.3 8.1 3.2 3.2
Frottage 21.0 16.1 12.9 16.1 11.3 3.2 12.9 3.2 .O 3.2
Obscene mail .O 33.3 66.7 .O .O .O .O .O .O .O
Transsexualism 51.7 31.0 13.8 3.4 .O .O .O .O .O .O
Transvestitism 6.5 29.0 29.0 9.7 .O 6.5 12.9 .O 6.5 .O
Fetishism .O 15.8 21.1 15.8 26.3 5.3 10.5 .O 5.3 .O
Sadism .O 17.9 28.6 14.3 14.3 3.6 3.6 3.6 7.1 7.1
Masochism .O 41.2 11.8 5.9 11.8 5.9 5.9 5.9 5.9 5.9
Homosexuality 25.0 41.7 25.0 4.2 .O .O .O 4.2 .O .O
Obscenephonecalling 5.3 5.3 21.1 21.1 5.3 10.5 15.8 5.3 5.3 5.3
Public masturbation 5.9 17.6 .O 17.6 17.6 17.6 5.9 5.9 5.9 5.9
Bestiality .O 28.6 7.1 14.3 14.3 7.1 14.3 .O 14.3 .O
Urolagnia .O .O .O 25.0 .O 25.0 .O .O 25.0 25.0
Coprophilia .O .O .O .O .O .O .O 50.0 25.0 25.0
Arousal to odors .O .O 50.0 .O .O .O .O 50.0 .O .O
Refers to number of paraphilias.

20.6 percent had three diagnoses, and highest percentage (52%) of individuals
11.5 percent had four diagnoses. The re- with only one paraphilia were those in-
maining 37.6 percent were concomi- volved with transsexualism. In each of
tantly or nonconcomitantly involved in the other 17 categories of paraphilias
five to ten different paraphilic behav- presented, less than 30% of the subjects
iors. confined their deviant behavior to only
The percentage of cases in each di- one paraphilia. In 10 categories of par-
agnostic category with only one para- aphilia, less than 10 percent of subjects
philia is indicated in Table 3. Categories had participated in only one type of par-
containing fewer than 12 subjects were aphilic behavior. It was especially im-
excluded because the number of sub- pressive that no cases of fetishism, sad-
jects was considered too small to rep- ism, masochism, or bestiality were seen
resent such paraphilias reliably. The in which an individual had only one par-

160 Bull Am Acad Psychiatry Law, Vol. 16, No. 2, 1988


Multiple Paraphilic Diagnoses

havior, the likelihood of the possible


presence of other paraphilias relative to
that indicated in column 1 is indicated
in Table 4, a cross-diagnosis table.
(Note: Table 4 should be read from left
to right and not from top to bottom.) To
ensure that the number of paraphiliacs
who had multiple paraphilic diagnoses
indeed reflected more than a simple de-
viant sexual arousal, data reflect the
number of subjects who had reported
actual commission of different para-
philic acts. Table 4, Column 1, includes
the possible paraphilic diagnoses. Col-
umns 2 through 22 represent additional
O 1 l l l l a a t a t l concomitant or nonconcomitant para-
0 1 2 3 4 5 6 7 8 9 1 0
Number of Paraphilias philic behaviors that subjects had com-
Figure 1. Average number of paraphilias. mitted. By reading across row 1, for ex-
ample, one sees in Column 2 that 100
percent (224 subjects) represents the
aphilic diagnosis. These results clearly total subsample of men involved with
indicate that paraphiliacs with only one girls outside the home. Reading further
paraphilia are rare. to the right, 35 percent of these indi-
The average number of different par- viduals were (or had been) also involved
aphilias found in the histories of the 561 in male nonincestuous pedophilia, 35
subjects in our study population is percent in female incestuous pedophi-
shown in Table 3. Except for those with lia, 12 percent in male incestuous pe-
a diagnosis of transsexualism or ego- dophilia, 25 percent in rape, 29 percent
dystonic homosexuality, the average in exhibitionism, 14 percent in voyeur-
number of paraphilias by diagnosis was ism, 11 percent in frottage, and so forth.
in the range of three to five paraphilias Therefore, from the clinical standpoint,
per diagnostic category. Especially re- 35 percent of paraphiliacs involved in
vealing was that multiple paraphilias nonincestuous deviant behavior with
were very common in individuals tra- female targets have a high probability
ditionally considered to have only one of having been involved with noninces-
paraphilia, i.e., female-targeted incest tuous deviant behavior with male tar-
pedophilia and male-targeted incest pe- gets. By examining each row, one can
dophilia. see the frequent history of cross-diag-
To understand which paraphiliacs nostic behavior that exists in paraphi-
have histories of having committed liacs. For those diagnoses with fewer
other specific types of paraphilic be- than 12 subjects per category, i.e., ob-

Bull Am Acad Psychiatry Law, Vol. 16, No. 2, 1988 161


Abel et a/.

Table 3
Percentage of Subjects with Only One Diagnosis and Average Number of Paraphilias per
Subject

No. of % with only Average No. Total


Diagnosis
Subjects' 1 Diagnosis of Paraphilias Paraphilias

Pedophilia (nonincestuous), 806


female target
Pedophilia (nonincestuous), 520
male target
Pedophilia (incestuous), 493
female target
Pedophilia (incestuous), 198
male target
Rape 41 6
Exhibitionism 596
Voyeurism 298
Frottage 236
Transsexualism 49
Transvestitism 118
Fetishism 84
Sadism 129
Masochism 75
Homosexuality 55
Obscene phone calling 97
Public masturbation 87
Bestiality 67
Total 4,324

*A subject is included in each diagnostic category in which he reported a completed act of paraphilic
behavior. Therefore, overlapping of subjects across categories occurs.

scene mail, urolagnia, coprophilia, and jects who reported involvement with fe-
arousal to specific odors, these data male incestuous pedophilia, 49 percent
should be interpreted cautiously. With had histories of also having been in-
the exception of these four categories volved in female nonincestuous pedo-
and transsexualism, all categories of philia, 12 percent in male nonincestuous
paraphilia had large percentages of sub- pedophilia, and 12 percent in male in-
jects who had also participated at one cestuous pedophilia. Of the 44 subjects
time or another in other types of para- who reported involvement with male in-
philic behavior. cestuous pedophilia, 61 percent had his-
Especially impressive were results in tories of also having been involved with
the categories of child molestation. Of female nonincestuous pedophilia, 68
the 153 subjects involved with boys out- percent with male nonincestuous pe-
side the home, 51 percent had histories dophilia, and 43 percent with female in-
of also having been involved with girls cestuous pedophilia. From these data,
outside the home, 12 percent with girls it becomes apparent that child molest-
within the home, and 20 percent with ers have a very high incidence of de-
boys within the home. Of the 159 sub- viant behavior with both family and
162 Bull Am Acad Psychiatry Law, Vol. 16, No. 2, 1988
Multiple Paraphilic Diagnoses

nonfamily targets. Furthermore, these other deviant behaviors in this subsam-


data suggest that, contrary to traditional ple of paraphiliacs.
belief, incestuous child molesters are or Voyeurs, frotteurs, and fetishists all
have been involved very frequently revealed histories of paraphilic interests
with children outside the home. in other major categories of paraphilia.
Rapists also demonstrated a high in- Sadists and masochists also appear to
cidence of concomitant or nonconcom- have or have had experiences with
itant cross diagnosis. Of the 126 sub- other types of paraphilia. Of greatest
jects who had raped an adult woman, concern is that 46 percent of sadists re-
44 percent had also been involved in fe- ported involvement with rape behavior,
male nonincestuous pedophilia, 14 per- the highest percentage of cross-diag-
cent in male nonincestuous pedophilia, nosis into the rape category of any other
and 24 percent in female incestuous pe- category of paraphilia.
dophilia; 28 percent had histories of ex- Ego-dystonic homosexuals, obscene
hibitionism, 18 percent of voyeurism, phone callers, and public masturbators
and the remainder had been involved, all had significant histories of involve-
to a lesser degree, in other types of par- ment with other paraphilias. It is diffi-
aphilia. cult to draw conclusions from infre-
Exhibitionists had a high degree of quently seen paraphiliacs (e.g., senders
other concomitant or nonconcomitant of obscene mail) because these cate-
paraphilic behaviors in addition to ex- gories of paraphilia occurred at a low
hibitionism. Forty-six percent had been frequency in the study population and,
involved in female nonincestuous pe- therefore, these findings need corro-
dophilia, 22 percent in male noninces- boration from studies of larger subject
tuous pedophilia, 22 percent in female populations.
incestuous pedophilia, 25 percent in In summary, examination of Table 4
rape, 28 percent in voyeurism, and 16 suggests that our traditional view of
percent in frottage. Smaller proportions paraphiliacs has been somewhat naive.
of exhibitionists had been involved in With the exception of transsexuals,
the other categories of paraphilia. An there is a significant incidence of cross-
impressive aspect of these findings was ing of deviant sexual behaviors.
that, contrary to some traditional texts, Conclusions
the exhibitionists evaluated frequently The principal conclusion to which
were involved in a large variety of other this study points is that paraphiliacs fre-
paraphilic behaviors at one time or an- quently participate in a variety of dif-
other, some overtly aggressive. Once ferent paraphilias and that the paraphi-
again, these data do not indicate that all liac with a history of only one paraphilia
exhibitionists have also been involved is rare. These assertions are at variance
in other paraphilias, but it certainly sug- with the traditional view of the para-
gests that there is a much higher like- philiac, i.e., as one who becomes fix-
lihood of a history of involvement in ated on one type of paraphilia to the ex-
Bull Am Acad Psychiatry Law, Vol. 16, No. 2, 1988 163
Table 4
Percentage of Cross-Diagnosis by Paraphilia
2
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3 3 (I)
- 0 3
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o a2
Female
nonincestuous
pedophilia
Male nonincestuous
pedophilia
Female incestuous
pedophilia
Male incestuous
pedophilia
Rape

Exhibitionism

Voyeurism
Frottage N 2 4 1 2 1 0 4 1 4 2 3 1 4 6 2 0 0 1 3 7 0 0 4 2 1 0 0 1 ZE
% 3 9 1 9 1 6 7 2 3 3 7 2 3 1 0 0 0 0 2 5 1 1 0 0 7 3 2 0 0 2 5
Obscene mail N 1 0 1 0 1 1 0 0 3 0 0 0 0 0 1 0 0 0 0 0 0 -o_
% 3 3 0 3 3 0 3 3 3 3 0 0 1 0 0 0 0 0 0 0 3 3 0 0 0 0 0 0 "
Transsexualism N 0 0 1 0 0 1 0 0 0 2 9 9 0 0 0 7 0 0 0 0 0 0
% 0 0 4 0 0 4 0 0 0 1 0 0 3 1 0 0 0 2 4 0 0 0 0 0 0 $
Transvestitism N 7 4 7 2 6 1 1 3 1 0 9 3 1 2 3 4 6 3 1 4 2 1 0
% 23 13 23 7 19 36 10 3 0 29 100 7 10 13 19 10 3 13 7 3 0 -.
-
Fetishism N 1 0 6 5 3 5 4 4 3 0 0 2 1 9 1 2 2 0 1 0 1 0 0
% 5 3 3 2 2 6 1 6 2 6 2 1 21 16 0 0 11100 5 11 11 0 5 0 5 0 0 n
&I
Sadism N 1 1 7 9 1 1 3 6 7 7 0 0 3 1 2 8 5 0 4 2 2 2 2 0 5
% 3 9 2 5 3 2 4 4 6 2 1 2 5 2 5 0 0 1 1 410018 0 1 4 7 7 7 7 0 0
Masochism N 6 6 5 1 3 6 1 0 0 0 4 2 5 1 7 2 0 0 1 2 2 0 g
% 35 35 29 6 18 35 6 0 0 0 24 12 2 9 1 0 0 12 0 0 6 12 12 0
Homosexuality N 1 3 1 2 0 3 0 0 1 7 6 2 0 2 2 4 0 0 1 1 0 0
% 4 1 3 4 8 0 1 3 0 0 4 2 9 2 5 8 0 8100 0 0 4 4 0 0
Obscene phone N 8 3 5 0 7 1 2 9 4 0 0 3 0 4 0 0 1 9 2 2 0 1 0
calling % 42 16 26 0 37 63 47 21 0 0 16 0 21 0 0 1 0 0 11 11 0 5 0
Publicmasturbation N 5 2 4 1 4 1 2 5 2 0 0 1 1 2 0 0 2 1 7 1 1 1 0
% 2 9 1 2 2 4 6 2 4 7 1 2 9 1 2 0 0 6 6 1 2 0 012100 6 6 6 0
Bestiality N 1 0 1 6 3 3 5 6 1 0 0 4 0 2 1 1 2 1 1 4 1 1 0
% 71 7 4 3 21 21 3 6 4 3 7 0 0 29 0 14 7 7 14 7100 7 7 0
Urolagnia N 2 1 2 2 0 2 1 0 0 0 2 1 2 2 1 0 1 1 4 2 0
% 50 25 50 50 0 50 25 0 0 0 50 25 50 50 25 0 25 25 100 50 0
Coprophilia N 4 2 3 1 0 3 1 0 0 0 1 0 2 2 0 1 1 1 2 4 0
% 100 50 75 25 0 75 25 0 0 0 25 0 50 50 0 25 25 25 50 100 0
Arousal to odors N 0 0 0 0 1 1 2 1 0 0 0 0 0 0 0 0 0 0 0 0 2
% 0 0 0 0 5 0 5 0 1 0 0 5 0 0 0 0 0 0 0 0 0 0 0 0 0100
Abel et a/.

clusion of other kinds of deviant sexual the scope of the various deviant sexual
behavior. activities of each subject.
Because these results challenge our A third and extremely important fac-
traditional view of the paraphiliac, one tor is the issue of confidentiality. Be-
might question the validity of these cause the majority of prior research on
findings. Why have traditional inter- paraphilias has been conducted within
views failed to reveal a variety of par- the prison setting, where confidentiality
aphilias? One reason might be the is limited, it is not surprising that the
amount of time required to obtain a sub- subjects reported a low incidence of
ject's full history. When histories are multiple paraphilias. Using the various
taken in the rush of forensic evaluation, means of maintaining confidentiality
the interviewer is likely to focus upon described earlier, we found that sub-
behaviors that have come to his or her jects would more honestly report their
attention. The interviews used in this various paraphiliac behaviors if they
study were time consuming (from one felt assured that negative repercussions
to five hours in duration) but provided as a result of such revelations would not
the subject with the opportunity to es- be forthcoming. Where confidentiality
tablish rapport with the examiner and is minimal or nonexistent, concealment
to acquire some degree of comfort with is common, and therefore histories will
the interview. be less valid.
A second factor might be the lack of The finding that histories of multiple
specificity in the questions that inter- paraphilias are common and cross-di-
viewers pose. Our early experience in- agnoses are a frequent occurrence
should be of importance to clinical judg-
dicated that suspected paraphiliacs did
ments regarding paraphilias. For ex-
not volunteer information relative to all
ample, it is customarily believed that
of their deviant sexual activities. Ini-
cases of incest simply result from dis-
tially, interviews focused on the behav-
torted family dynamics and that indi-
ior that had come to our attention. As
viduals involved in incest are unlikely
we gained greater experience and
to be involved in other types of para-
greater knowledge about the frequent philias. This conclusion, however, is in-
occurrence of multiple deviant behav- consistent with the findings described
iors, the interviewers were more aware above. These results and prior psycho-
of the need to ask specific questions physiological investigation of inces-
about other types of paraphilias. As in- tuous and nonincestuous pedophiles2."
terviews became more structured, in- suggest that incest cases frequently in-
terviewers worked from a listing of all volve individuals who participate in
possible paraphilias and asked each nonincestuous activities in addition to
subject about his participation in each. incestuous behaviors. Similarly, indi-
Although the latter technique was viduals involved with children outside
rather routine and nonspontaneous, it the home frequently have concurrent
was critical for an accurate recording of involvement with children within the
166 Bull Am Acad Psychiatry Law, Vol. 16, No. 2, 1988
Multiple Paraphilic Diagnoses

home. Treatment plans and assessment a result of the first deviant act may rein-
strategies must therefore investigate force the rationalization or acceptability
both of these possibilities. The presence of the act for the perpetrator. Thus, he
of more serious paraphilias in individ- may feel less inhibited about acting
uals with "benign" paraphilias should upon other paraphilic fantasies.
also be of concern. Some professionals Regardless of how one might inter-
have considered exhibitionists, voy- pret the theoretical implications of the
eurs, and fetishists as being rather be- results of this study, a number of factors
nign, nuisance paraphiliacs. These re- suggest that these findings are repre-
sults, however, suggest that some (but sentative of paraphiliacs seeking psy-
not all) of the benign paraphilias may chiatric or psychological evaluation and
actually lead to very aggressive behav- treatment. The large subject population
iors and should not be viewed as reli- was collected at two different sites in
ably benign. Further clinical relevance the United States, both offering assess-
of these results is the indication that ment and treatment services for indi-
treatment must be modified to incor- viduals seeking help in controlling their
porate all of the various paraphilias that sexual behavior. Both sites emphasized
an individual might have. If an individ- treatment for assaultive sex offenders
ual involved in incestuous pedophilia is (child molesters and rapists), which is
also involved with children outside of the major treatment emphasis for most
the home, then treatment must focus on sex offender treatment programs
the full scope of the individual's pedo- throughout the country. Furthermore,
philic interests including the possibility the considerable consistency with
of other, unsuspected paraphilias. which paraphiliacs reported involve-
Without a thorough investigation of an ment in multiple paraphilias (regardless
individual's deviant interests and the of an initial category of paraphilia) ap-
formulation of a comprehensive treat- pears to support the validity of these
ment program, recidivism is much more new findings.
likely. Prevention of sexual violence and de-
Finally, the theoretical relevance of viant sexual acts necessitates a better
these findings must be considered. Why appreciation of the perpetrator-who
do paraphiliacs have histories of so he is and what his deviant interests
many different paraphiliac interests and are-so that appropriate services may
behaviors? If a specific conflict ac- be provided to control sexually deviant
counted for one discreet type of para- behavior and to prevent further victim-
philia, how could it explain the exis- ization.
tence of multiple paraphilias in the same
individual? Because paraphilic behav- References
ior is, by and large, a secretive event, Abel GG, Becker J V , Mittelman M, et al:
and because most paraphilic acts re- Self-reported sex crimes of non-incarcer-
ated paraphiliacs. Journal of Interpersonal
main unreported, it may be that failure Violence 2:3-25, 1987
to experience aversive consequences as Abel GG, Mittleman MS, Becker JV: Sexual

Bull Am Acad Psychiatry Law, Vol. 16, No. 2, 1988


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Bull Am Acad Psychiatry Law, Vol. 16, No. 2, 1988

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