Professional Documents
Culture Documents
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
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-
Table 3
Percentage of Subjects with Only One Diagnosis and Average Number of Paraphilias per
Subject
*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
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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
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