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2 Research Report Paraphilias: Incidence and Co-occurrence in Normative and Sex Offender Samples Ce rapport est également disponible en français. Pour en obtenir un exemplaire, veuillez vous adresser à la Direction de la recherche, Service correctionnel du Canada, 340, avenue Laurier Ouest, Ottawa (Ontario) K1A 0P9. This report is also available in French. Should additional copies be required, they can be obtained from the Research Branch, Correctional Service of Canada, 340 Laurier Ave. West, Ottawa, Ontario K1A 0P Nº R-235

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4 Paraphilias: Incidence and Co-occurrence in Normative and Sex Offender Samples Andrew J. R. Harris, Ph.D., C. Psych. Research Branch Correctional Service of Canada January 2011

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6 Acknowledgements I would like to thank Lynn Stewart for thoughtful and helpful comments on earlier drafts of this paper and Steven Varrette for his assistance. ii

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8 Executive Summary Key words: paraphilia, paraphilias, paraphiliac sexual offenders, incidence, co-occurrence Paraphilias are aberrant or unusual sexual interests and behaviours that are generally not helpful in achieving mutually consensual sexual relations. The presence of paraphilias has been related to elevated risk of recidivism in sexual offenders and as such is of concern to all correctional jurisdictions. This paper gathers data from the literature on the incidence and co-occurrence of these disorders in non-clinical samples and samples of sexual offenders. To date, information on the occurrence of paraphilias in normative and sexual offender samples has not been compiled. This paper gives forensic clinicians an estimate of the average number of additional paraphilias that might be admitted to or detected in various types of sexual offenders utilizing various assessment methods. iii

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10 Table of Contents Acknowledgements... ii Executive Summary... iii Table of Contents... iv List of Tables...v List of Figures... vi List of Appendices... vii Introduction...1 Theories of Paraphilias...1 The DSM-IV-TR Definition of Paraphilias...3 Hypersexuality and the presence of paraphilias...4 Paraphilias are related to the risk of re-offence...4 Method...7 Results...8 Normative samples...8 Normative sample 1 (N1)...8 Normative sample 1a (N1a)...8 Normative sample 2 (N2) Deviant Samples Deviant sample 1 (Ds1) Deviant sample 2 (Ds2) Deviant sample 3 (Ds3) Deviant sample 4 (Ds4) Deviant sample 5 (Ds5) Deviant sample 6 (Ds6) Deviant sample 7 (Ds7) Deviant sample 8 (Ds8) Deviant sample 9 (Ds9) Deviant sample 11 {Sexual Murderers} (Ds11) Discussion Hypersexuality Risk Assessment Methodological Problems References Appendices iv

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12 List of Tables Table 1 The nine paraphilic diagnoses found in the DSM-IV-TR...5 Table 2 Summary table of paraphilic behaviour in normative samples Table 3 Summary table of deviant samples Table 4 Summary table of sexual murderers Table 5 Summary table by presenting problem in deviant samples v

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14 List of Figures Figure 1. Freund s concept of Courtship Disorder: Stages of approximation to genital union and their related paraphilias.3 vi

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16 List of Appendices Appendix A: Sample N1: Average number of paraphilic behaviours admitted to in a non-clinical sample: From Långström and Hanson (2006) Appendix B: Sample N1a: Average number of additional paraphilic fantasies admitted to, broken down by admitted behaviour in a non-clinical sample: From Långström & Seto (2006) Appendix C: Sample N2: Paraphilias (phallometrically determined) in three subject groups: From Fedora, Reddon, Morrison, Fedora, Pascoe, & Yeudell (1992) Appendix D: Sample N2: Number of paraphilias by group (phallometrically determined): From Fedora Reddon, Morrison, Fedora, Pascoe, & Yeudall (1992) Appendix E: Sample Ds1: Average number of additional paraphilias admitted to after a presenting problem of sexual interest in females aged 13 to 16 and adult females: From Freund, Scher, and Hucker (1983) Appendix F: Sample Ds2: Average number of additional paraphilias endorsed subsequent to a presenting problem of sexually anomalous preference: From Langevin, Paitich, and Russon (1985) Appendix G: Sample Ds4: Average number of additional paraphilias by presenting problem: From Abel & Rouleau (1990) Appendix H: Sample Ds6: Average number of additional paraphilias by presenting problem: From Freund and Watson (1990) Appendix I: Sample Ds7: Average number of additional paraphilias by presenting problem: From Marshall, Barbaree, & Eccles (1991) Appendix J: Sample Ds8: Average number of additional paraphilias by presenting problem: From Bradford, Boulet, and Pawlak (1992) Appendix K: Sample Ds9: Additional paraphilias in a sample of sexual offenders with paraphilias : From Dunsieth et al., (2004) Appendix L: Sample Ds10: Additional paraphilias in a sample of intra and extra familial child molesters: From Eher and Ross (2006) Appendices Appendix M: Sample Ds12: Average number of additional paraphilias detected from a sample of 25 multiple sexual murderers and a sample of 17 single sexual murderers: From Prentky, Burgess, Rokous, Lee, Hartman, Ressler, & Douglas (1989) vii

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18 Introduction Sexual offenders, sexual offence recidivism, and the re-integration of eligible sexual offenders into the community are of great concern to the Correctional Service of Canada (CSC) and all other correctional jurisdictions. The release of eligible sexual offenders into the community often causes significant public concern. Research has shown, however, that unguided, non-actuarial assessments estimates of the risks posed to a community by the release of sexual offenders over-estimate the risk to the community (Gardner, 2008; Roberts & Hough, 2005). Recidivism rates for sexual offenders are lower than most people would believe (Harris & Hanson, 2004; Helmus, Hanson & Babchishin, in press), and have been declining over the past decade (Finkelhore & Jones, 2006; Helmus, 2009: Jones & Finkelhore, 2002). However, for those who work with, treat, and supervise sexual offenders it is well known that the presence of paraphilias indicate a higher risk of sexual recidivism (Prentky, Knight, & Lee, 1997). Hanson and Harris (1998, 2000a, 2000b), upon reviewing dynamic predictors of sexual recidivism, found that offenders who exhibited greater numbers of paraphilias were significantly more likely to sexually recidivate than offenders with fewer paraphilias. Epperson, Kaul, and Huot s (1995) meta-analysis found that the presence of multiple paraphilias predicted sexual offence recidivism. A 2004 meta-analytic review by Hanson and Morton-Bourgon found that in four studies the presence of paraphilias significantly predicted sexual recidivism. Theories of Paraphilias There is no generally accepted etiological theory for paraphilias and theories range from the psychodynamic (Bergler, 1944, 1945; Freud, 1962; see also Smith, 1976, for a brief review) to the strictly behavioural, so called one trial learning. Psychodynamic theory suggests that paraphilias are the result of malformed attempts to deal with primal needs while strictly behavioural theories suggest the paring of a possibly accidental sexual experience with a nonconditioned stimulus (Maguire, Carlisle, & Young, 1965). Other theories include the neurochemical deficiency hypothesis of Kafka (2003a) who notes that a number of studies have found that the use of Selective Serotonin Reuptake Inhibitors (SSRI s) have been observed to reduce such paraphilic behaviours as deviant fantasies, abnormal sexual behaviours, obsessions, and compulsions toward aberrant sexual behaviour (Bradford, 2008). 1

19 Additionally, others have hypothesized that certain paraphilias have survival value and have evolved into the human behavioural repertoire. Humans exhibiting some paraphilic behaviours (voyeurism, exhibitionism, frottage, toucherism, rape) could have a sociobiological advantage (Alcock, 2001; Wilson, 2004) as the opportunistic nature and high frequency of these behaviours might result in an overall increased frequency of sexual intercourse resulting in a greater likelihood that the individual s genetic material will be passed on. More support is found in the scientific literature for theories based upon general Social Learning Theory (SLT) (Bandura, 1965, 1969; Laws & Marshall, 1990). SLT states that the development of paraphilias relies heavily upon the concept of modelling, either by direct observation (participant modelling) or through symbolic means such as observing pornography or reading printed descriptions of paraphilic situations (vicarious modelling), in which the individuals learn by observing and do not necessarily have to perform the overt behaviour themselves. SLT also conforms to what is observed in clinical practice as it allows for variation and the escalation of paraphilic attraction by relying on the mechanism of behavioural extinction. SLT hypothesizes that paraphilic acts and fantasies would continually have to be varied and made more exciting to elicit the same sexual response over repeated trials. A more specific and recent theory and one that is generally congruent with clinical practice is Freund s (1990; Freund, Scher, & Hucker, 1983) concept of Courtship Disorder. Freund posits that voyeurism can be understood as a locating behaviour and exhibitionism can be seen as an initial attempt at contact or an offer to a potential mating partner. Toucherism and frottage, in this model, represent the initiation of pre-coital tactile interaction and the preferential rape typology, the final step, in a goal directed mission to achieve genital union. In Freund s concept of Courtship Disorder, the paraphilias represent disorders in the progression from locating a potential mate in an environment to achieving genital union. When the natural process of mate location and initial offer is repeatedly thwarted or disrupted, Freund s theory suggests that paraphilias arise as a warped approximation to the natural mating progression. Figure 1 demonstrates Freund s hypothesized relationship between the normative courting process and Courtship Disorder. Paraphilias are of particular concern to those working in corrections as they often lead to criminal behaviours (Hanson & Morton-Bourgon, 2004). As can be seen in Table 1, about half (7 out of 15) of the paraphilic behaviours noted in the DSM-IV-TR (American Psychiatric 2

20 Association, 2000), the diagnostic manual for mental disorders most commonly used in North America, are always illegal in Canada and the United States if acted upon. Paraphilias are also of concern as they tend to block the reasonable expression of healthy, reciprocal, affectionate sexual activity. Given the presently accepted theories of paraphilic escalation; there is concern that the paraphiliac, when blocked from normative sexual outlets, is more likely to act out sexually. Figure 1. Freund s concept of Courtship Disorder: Stages of Approximation to Genital Union and their Related Paraphilias Location of a potential partner Voyeurism Pre-tactile interaction Exhibitionism, Obscene telephone calling Tactile interaction Toucherism, Frottage Genital union Preferential rape pattern The DSM-IV-TR Definition of Paraphilias As defined in the DSM-IV-TR (American Psychiatric Association, 2000) a clinical paraphilia involves recurrent, intense sexually arousing fantasies, sexual urges, or behaviours generally involving 1) nonhuman objects, 2) the suffering or humiliation of oneself or one s partner, or 3) children or other non-consenting persons, that occur over a period of at least 6 months (p. 566). With regard to the incidence and prevalence of paraphilias, the DSM-IV-TR provides very little information. The DSM-IV-TR states only that the diagnosis of sexual masochism has a gender ratio of 20 males diagnosed for every female diagnosed and that other paraphilias are rarely diagnosed in females. This text continues, given the large commercial market for paraphilic pornography and other paraphernalia the incidence [of paraphilias] in the 3

21 general population is thought to be higher (p. 568). Indeed, so scarce are actual data on the prevalence of paraphilias that the DSM-IV-TR does not provide any data or references on the incidence of these disorders. The DSM-IV-TR states that paraphilic fantasies and behaviours may begin in childhood or early adolescence and that these behaviours tend to be chronic, recurrent, lifelong, and may increase in response to psychological stress (see also Ferreira, 2000). We have reason to believe that paraphilias become more intrusive over time as the individual seeks ever-greater levels of sexual stimulation through fantasy or ritual. It is generally believed that paraphilic fantasies and rituals mutate over time to become more arousing and to ward off satiation and extinction. The nine paraphilic diagnoses outlined in the DSM-IV-TR are show in Table 1. Hypersexuality 1 and the presence of paraphilias Paraphilias are related to the risk of re-offence There is a high co-occurrence between hypersexuality or sexual pre-occupations (Hanson & Harris, 2000a) and the presence of paraphilias. Hanson and Harris (2000b) and Hanson, Harris, Scott, and Helmus (2007) found sexual pre-occupation to be predictive of sexual reoffending. Långström and Hanson (2006) reviewed data from a sample of 1,279 Swedish men and 1,171 Swedish women (ages 18 to 60) from a self-report study of paraphilias as part of the Swedish Sexuality and Health Project (Lewin, Fugl-Meyer, Helmus, Lalos, & Månsson, 1998). Measures of impersonal sex included the presence of excessive masturbation, pornography use, the number of sexual partners in the last year and three paraphilias, voyeurism, exhibitionism, and sadism/masochism. In this sample of self-subscribed male and female adults the level of hypersexuality was strongly related to the presence of paraphilias. One of the interesting findings from the above Swedish national study (Långström & Seto, 2006) was that being a paraphiliac was associated with behaviours that could be seen as risky and as demonstrating sensation seeking behaviour (Zuckerman, 2007). 1 Kafka (1997) recommended minimum diagnostic criteria for hypersexuality disorder - daily orgasm for six consecutive months along with sexual pre-occupation and adverse psychosocial consequences. 4

22 Table 1 The nine paraphilic diagnoses found in the DSM-IV-TR Diagnosis Main behavioural manifestation Behaviour illegal at all times Exhibitionism Exposure of one s genitals to a stranger Yes Fetishism Use of nonliving objects for sexual arousal (panties, shoes) No Frotteurism Touching or rubbing up against a non-consenting person Yes Pedophilia Sexual Masochism Sexual Sadism Transvestic Fetishism Voyeurism Paraphilias Not Otherwise Specified (Paraphilias NOS) Sexual activity with or attraction to prepubescent children (generally 13 years or younger) Being humiliated, beaten, bound, or otherwise made to suffer Deriving sexual excitement from the psychological or physical suffering of others Cross-dressing by a male in women s attire sexual arousal is produced by thoughts or images of that person as a female Observing unsuspecting individuals, usually strangers, in the process of disrobing, or engaging in sexual activity This open-ended category typically includes telephone scatologia (obscene phone calls) [Yes]; necrophilia (corpses) [Yes]; partialism (exclusive focus on a part of the body) [No]; zoophilia; (animals) [Yes]; coprophilia (feces) [No]; klismaphilia (enemas) [No]; urophilia (urine) [No] and like paraphilias. Activity - Yes No No No Yes [as noted to left] High rates of sensation seeking are associated with recidivism in first-time juvenile offenders (Kelber, 2005). Risky behaviours include having used illegal drugs, having a higher number of sexual partners per sexually active year, having paid for sex, being more likely to have contracted a sexually transmitted disease, having had a same sex partner, having a higher 5

23 frequency of masturbation, pornography use in the past year, and feeling that they are more easily sexually aroused than others. With these findings in mind it is reasonable to assume that engaging in the behaviours noted above might increase a given offender s relative criminogenic risk. In direct contrast to these findings, the presence of conditions that directly oppose paraphilic and impersonal sexual behaviour have been generally associated with positive life outcomes. Långström and Hanson (2006) found that high rates of intercourse were mostly associated with positive outcomes. High rates of intercourse were associated with increased satisfaction with sexual life, life in general, physical and psychological health, while high rates of masturbation were associated with decreased satisfaction with sexual life and life in general. This pattern was observed for both men and women. These findings are congruent with the findings of Laumann, Gagnon, Michael, and Michaels (1994) who found measures of happiness to be positively associated with frequency of intercourse while high frequencies of masturbation were associated with decreased levels of happiness. When a psychologist, psychiatrist or sexologist looks across the desk at a person who has been referred for psychosexual evaluation (generally due to concerns relating to child molesting, rape, or other sexual aggression) the clinician generally has little indication of how many other problematic sexual behaviours this person might be engaging in. This paper summarizes the available data on the incidence and prevalence of paraphilias in such a way that clinicians can take into account while conducting their assessment, an estimate what is known about the odds of there being additional paraphilias within a given offence profile. 6

24 Method The psychology literature was searched using electronic databases such as PsychLit, and EBBSCO using the key words paraphilia (s), paraphiliac (s), sexual offenders, fetishes, voyeurism, exhibitionism, frottage, rape, sexual assault, toucherism, and terms of this nature. Papers without data on either normative or sexual offender samples were not included in the analysis but were used to inform the Introduction and Discussion sections of this paper. Research that contained data on the incidence or prevalence of paraphilias in either normative or sex offender populations was retained and reviewed to determine if data were presented on the relative occurrence of different paraphilias. In cases where several papers had been published using the same database, the paper with the most complete information about paraphilias was chosen to represent the dataset. Papers that contained such data in sufficient detail to allow differential calculation of the number of paraphilias given a presenting problem of a paraphilia were abstracted to tables in the Appendices and summary tables are presented in the body of this text. Of special note is that where groups are identified as having a particular diagnosis or presenting problem, i.e., pedophilia, these primary diagnoses or presenting problems are not counted in the tallies of how many additional paraphilias were detected. As a result, the numbers in the tables represent additional paraphilias in addition to the primary paraphilic diagnosis or presenting problem. Given this summary of the data, a clinician perusing the tables would be able to infer that given the presence of condition X one would expect there to be additional paraphilias Y percent of the time. 7

25 Results Normative samples Normative sample 1 (N1) Långström and Hanson s (2006) sample included 1,279 Swedish men and 1,171 Swedish women (ages 18 to 60) using a self-report methodology as part of the Swedish Sexuality and Health Project (Lewin, Fugl-Meyer, Helmus, Lalos, & Månsson, 1998). In their sample 4.1% of males (n = 1,244) positively endorsed the following question Have you ever exposed your genitals to a stranger and become sexually aroused by this? (exhibitionism) (p. 41), 11.6% of this sample positively endorsed the voyeurism question, Have you ever spied on what other people are doing sexually and become sexually aroused by this? (voyeurism) (p. 41), and 2.6% of the sample positively endorsed the question, Have you ever deliberately used physical pain and become sexually aroused by this? (masochism or sadism) (p. 41). In the associated sample of 1,142 women 2.1% of women endorsed the exhibitionism question noted above, 3.9% endorsed the voyeurism question and, 1.8% endorsed the masochism or sadism question. As shown in Appendix A, based upon Swedish normative data, it appears that when assessing males without a sexual presenting problem, one of the three paraphilias sampled in this study would be expected to be endorsed in just under one-in-five men assessed (18%) and that when assessing women without a sexual presenting problem, one of the three paraphilias sampled in this study would be expected to be endorsed in one-in-twelve and a half (8%) women. Normative sample 1a (N1a) Using the same sample (Lewin, et al., 1998), Långström and Seto (2006) looked at exhibitionistic and voyeuristic behaviours and fantasies in a non-clinical, non-forensic, nationally representative sample of men and women in Sweden. In the total sample of men and women, 3.1% (n = 76) reported at least one incident of being sexually aroused by exposing their genitals to a stranger and 7.8% (n = 191) reported at least one incident of being sexually aroused by spying on others having sex. The strength of this study is that it is a large, nationally representative sample; however, the analysis did not provide a breakdown by gender. In the paragraph above, data are reported on people who positively endorsed questionnaire items indicating that they had actually performed exhibitionistic or voyeuristic 8

26 activity. Of those 76 individuals having engaged in exhibitionistic behaviour, 35.5% (n = 27) positively endorsed an item asking about voyeuristic fantasy, and 23.7% (n = 18) positively endorsed an item asking about exhibitionistic fantasy. Of those 191 having engaged in voyeuristic behaviour, 53% (n = 102) positively endorsed voyeuristic sexual fantasies and 10.5% (n = 20) positively endorsed exhibitionistic sexual fantasies. However, a significant proportion of those who had never actually committed exhibitionistic or voyeuristic behaviour also endorsed the following question, I can consider myself becoming sexually aroused by exposing my genitals or spying on what other people are doing sexually (p. 431). Of those participants who answered the exhibitionistic behaviour question (n = 2,433) 49.6%, or 1,207 people, endorsed the item that they had engaged in sexual fantasy involving voyeuristic behaviour and 27.5%, or 669 people, endorsed the item that they had engaged in sexual fantasy involving exhibitionistic behaviour. Of those participants who answered the voyeuristic behaviour question (n = 2,434), 65.0%, or 1,582 people, endorsed the item that they had engaged in sexual fantasy involving voyeuristic behaviour and 14.4%, or 350 people, endorsed the item that they had engaged in sexual fantasy involving exhibitionistic behaviour. The most interesting outcome of this analysis, regardless of the overlap between the 49.6% of the sample that endorsed voyeuristic sexual fantasy and the 65% of the sample that endorsed exhibitionistic fantasy, is that at least half the population is engaging in sexual fantasies of a paraphilic nature, and that they will admit it to researchers. Respondents to the survey who indicated that they had engaged in at least one paraphilic behaviour were also more likely to report having fantasies of other paraphilic behaviours and were more likely to engage in other paraphilic behaviours such as sadomasochistic sex and crossdressing. This study found a lifetime prevalence of exhibitionistic behaviour in 4.1% of men and 2.1% of women and a lifetime prevalence of voyeurism in 11.6% of men and 3.9% of women. Both voyeurs and exhibitionists showed equal elevations in life problems over non-paraphiliacs, both having more psychological problems and a lower satisfaction with life in general. If the presenting problem is Transvestic Fetishism, clinicians are likely (66%) to uncover another paraphilic fantasy should they choose to enquire. If voyeurism is the presenting problem, the clinician may only encounter an additional paraphilia in one out of five patients (21%). However, where a person who does not have a clinical presenting problem has admitted to at least one of these paraphilic behaviours, simply as a heuristic, the clinician would expect to find 9

27 another paraphilic fantasy in about one out of every two patients (44%) (see Appendix B). These figures certainly represent an underestimate, as there are many more paraphilias than the four asked about in this study and one would assume that many people would not have been comfortable endorsing these items to a researcher for a study. Nevertheless, these numbers are helpful in that they provide the clinician some limited ability to estimate, based upon a large normative sample, how often a person who does not have a clinical presenting problem engage in some paraphilic behaviours and fantasies. Normative sample 2 (N2) Fedora, Reddon, Morrison, Fedora, Pascoe, & Yeudall (1992) gathered a sub-sample of 60 paid control-sample males recruited from within a large Canadian psychiatric teaching hospital and from the community with an average age of 31.0 years. This sample was then compared to data from 167 non-aggressive sexual offenders and 60 aggressive sexual offenders who had been referred to the facility for sexual preference testing. The Fedora et al., data differ from other data presented in this paper in that these data were not based on self-report, but upon phallometric assessment of deviant sexual interests. The assessors used a standardized commercially available stimulus set to assess each of the paraphilic categories. For example, the sadism slides contained simulated scenes of males committing violent acts (choking, strangling, threatening with a gun or knife) upon fully clothed females whose expressions were fear, disgust, or pain (p. 5-6). These violent acts were described as non-sexual. The transvestic/fetishistic slides showed scenes of male cross-dressing and the pedophilia slides showed a single prepubescent actor (p. 5). The courtship disorder slides are described as sensitive to exhibitionism, voyeurism, toucherism, frotteurism, and telephone scatologia (obscene telephone calls). Sex offenders were categorized as sexually aggressive if they used physical force or the threat of physical harm, with or without a weapon, on a non-compliant victim (p. 7). In this data set (Fedora et al., 1992), pedophilia was the most common paraphilia and the least likely to be associated with any other paraphilia. The groups differed in the average number of paraphilias displayed under phallometric assessment. Appendix C presents the different incidences of the various assessed paraphilias by subject group. Of particular interest is that when the sub-sample of 60 non-sexual offenders were phallometrically assessed, the data revealed 19 men with paraphilias in this sub-sample. 10

28 When phallometrically assessed, 28% or 17 out of 60 non-sexual offenders responded in a clinically significant manner to at least one of the paraphilia stimulus categories. Rates of paraphilias were twice that level in sexually aggressive (65%) and non-aggressive sexual offenders (60%), (See Appendix D). Table 2 presents results and averages for the five identified samples of non-sexual offenders. In the final rows of the table weighted averages are used due to the very large discrepancies in sample sizes between the Swedish survey results and the more clinical, and much smaller, research samples. Additionally, the weighted average does not include females as the low levels of paraphilias in the female survey data would skew the male data. The result of this analysis is that based on published data, one would expect about one-in-five males admitting to a paraphilia. Deviant Samples Deviant sample 1 (Ds1) Freund, Scher, & Hucker (1983) reviewed data from a sample of 138 men referred to a forensic psychiatric clinic in Toronto, Ontario, for having directed their unwanted sexual behaviours toward females age 13 and over. This sample had an average age of 26 years and most had more than a grade 8 education but less than a grade 12 education. More than half of this sample admitted to having additional paraphilic interests. As this research was developed to further explore Freund s concept of Courtship Disorder it only assesses the relative occurrence of the four Courtship Disorder problems, as can be seen in Appendix E. Freund s data suggest that when assessing men with sexual interests in females aged 13 to 16 and adult females it would be reasonable to expect an additional paraphilia may be present in 50% of offenders. Deviant sample 2 (Ds2) Langevin, Paitich, & Russon (1985) present data from a group of 422 sexually anomalous men who presented at a forensic clinic in Toronto, Ontario, over a six year period. Langevin et al. define a sexual anomaly as an inordinate interest such that total sexual energy (orgasm) is invested in the act and is preferred over sexual intercourse (p. 78). From this group, a subsample of 45 were chosen who had behavioural indicators of voyeuristic interest and a sex 11

29 Table 2 Summary table of paraphilic behaviour in normative samples Sample Identifier N1 N1 N2 Sample Composition Adult non-clinical Swedish males paraphilic behaviour Adult non-clinical Swedish Women paraphilic behaviour Paid community controls recruited specifically for study Data Acquisition Method (n) Average number of paraphilias in this sample National Survey 1, National Survey 1, Phallometrics Ds2 Normal control group Self-report Ds3 Criminals = Non-sexual offenders Clarke Sexual History Questionnaire and Personal History Questionnaire Weighted average males and females 2, Weighted average males only 1, offender control group was also chosen from men who had anomalous sexual behaviours other than voyeuristic behaviours (n = 52). In addition, data from a normal control group (n = 52) were reviewed. This same sample was presented in Paitich, Langevin, Freeman, Mann, & Handy (1977). The average age of the voyeuristic group was 30.4 years with an average of 9.7 years of education. The average age of the normal non-patient control group was 24.3 years with and average of 14.9 years of education. The average age of the sexually anomalous group was 29.8 years with and average of 11.1 years of education. As can be seen in Appendix F, the nonpatient controls showed one paraphilic interest in every three controls. The sexually anomalous group had one sexual anomaly other than voyeurism in their files and one in three of these offenders showed an additional paraphilia. The voyeuristic group exhibited an average of

30 additional paraphilias in addition to their diagnosis of voyeurism. Deviant sample 3 (Ds3) Lang, Langevin, Checkley, & Pugh (1987) report on a sample of persistent exhibitionists (n = 34) and a sample of criminal but non sex offending controls (n = 20) referred to the Alberta Hospital Edmonton Forensic Services Unit or the Edmonton Forensic Assessment and Community Services (outpatient) clinic. The average age of the exhibitionistic group was 26.6 and the average age of the criminal controls was 25.3 years. In both of these groups most men had more than a grade 8 education but less than a grade 12 education. These men were assessed for paraphiliac interests using a personal history questionnaire and the Clarke Sex History Questionnaire (Langevin, Handy, Paitich, & Russon, (1985). The exhibitionistic group showed high levels of paraphilic interest with an average of 2.7 additional paraphilias, in addition to the presenting problem of exhibitionism. Forty percent (40%) of criminal controls showed the presence of one or more paraphilias. Given Lang et al. s findings, when assessing persistent exhibitionists, the clinician should expect to uncover more than two paraphlias in each patient and when assessing non-sex offending criminals the clinician can expect to encounter additional paraphilias in two out of every five offenders. Deviant sample 4 (Ds4) Able and Becker (1988) reported on a sample of community-based sexual assaulters (n = 561) with an average age of 31.5 years, having a moderate level of educational attainment (40% had one year of college). This sample was recruited through informal discussions with health care professionals, and justice meetings and through ads taken out in local newspapers. This sample is unusual in that it was given legal protection such that if the participants admitted to past sexual behaviours or crimes these admissions were protected from police investigation. The authors suggest that this gave the participants a comfort level allowing them to be more open with investigators. The authors claim this protection improved the validity of the reporting and subsequent estimates derived from this sample. In this sample, 63% of voyeurs also reported exhibitionistic behaviours. This sample showed a high percentage of pedophilia as this was generally the presenting problem in this sample. Most of the offenders in this sample have multiple paraphilias, the average for the sample being 2.02 paraphilias per subject (Abel, Becker, 13

31 Mittleman, Cunningham-Rathner, Rouleau, & Murphy, 1987). A recalculation of data from their subsequent article, using the same sample, (Abel & Rouleau, 1990, N = 561) shows a high degree of overlap of paraphilic interests. Taking into account that pedophilia or attraction to prepubescent children was the main presenting problem in this sample, their data show an average of 3.08 additional paraphilias beyond the presenting problem (See Appendix G). Deviant sample 5 (Ds5) Freund (1990) describes a clinical sample of 440 men who had attended an out-patient behavioural sexology clinic in Toronto. Most had been referred for having been caught exhibiting paraphilic behaviours. This sample had an average age of 28.1 years and most had more than a grade 8 education but less than a grade 12 education. It is important to note that these data do not include all possible paraphilias as the author was looking only for those paraphilias related to his concept of Courtship Disorder. In this sample 81.9% of those presenting with voyeurism also presented with exhibitionism and 61.3% of those that presented with toucherism/frottage also presented with exhibitionism. A re-calculation of Freund s data produces average paraphilia counts for this sample of just under 2.1 paraphilias per offender. There were variations in the sample based upon presenting problem with those who presented with voyeurism having the highest number of additional paraphilias on average (2.53 per offender), those who presented with toucherism/frottage having 2.3 additional paraphilias, those who presented with exhibitionism having an average of 1.9 additional paraphilias, and those that presented with rape having 1.6 per additional paraphilias. It is important to note that this sample includes the sample notated as Ds1 (Freund, Scher, & Hucker, 1983) and, in turn, is a subsample of Freund and Watson (1990) which follows. As a result, only data from the largest sample (Freund & Watson, 1990) are included in the summary table calculations. Deviant sample 6 (Ds6) Freund and Watson (1990) present data from a sample of 1,572 heterosexual adult males seen in an out-patient sexology department of a major psychiatric teaching hospital. The average age was 32.7 years and most men had greater than a grade 8 education but less than a grade 12 education. These data are interesting in that each subject in this piece of research admitted in 14

32 interview to having practiced the paraphilia at least once in their lifetime. As presented in Appendix H, Freund and Watson divided this large sample by presenting problem, including Voyeurism, Exhibitionism, Toucherism, other Courtship Disorders, Rape-no sadism, Sadism, Masochism-no sadism, offences against children, and Transvestism. Taking into account missing data and rounding error, these data provide an estimate of the relative occurrence of the various paraphilias in a large community-based group. This data set showed that when divided by presenting problem each man endorsed an average of 1.72 additional paraphilias. Deviant sample 7 (Ds7) Marshall, Barbaree and Eccles (1991) found lower rates of expressed paraphilias in a sample of community-based men (N = 129) who had attended a clinic for child molesters. This sample had an average age of 31.8 years and an average IQ of Of the 57 non-familial, girl target child molesters, only 14% reported one or more additional paraphilias; of 34 non-familial boy target child molesters, only 11.8% reported one or more additional paraphilias, and of 38 incest offenders, only 7.9% reported one or more additional paraphilias. A recalculation of Marshall et al. s (1991) data shows 57 non-familial, girl target child molesters admitting to 17 additional paraphilias and 34 non-familial boy target child molesters admitting to an additional 10 paraphilias. The data are quite different for the 38 incest offenders, only 3 of whom admitted to an additional paraphilia (See Appendix I). Rates produced from these data are considerably lower than those reported by Able and Rouleau (1990). Marshall, Barbaree, and Eccles s data suggest that, when assessing child molesters, you would find an additional paraphilia in every third child molester. Deviant sample 8 (Ds8) Bradford, Boulet, and Pawlak (1992) reviewed data from a sample of 443 adult males who were consecutive admissions to the Sexual Behaviours Clinic of the Royal Ottawa Hospital. This sample had an average age of 33.9 years and full scale WAIS-R scores were found to be in the average range. The sample was assessed using the Male Sexual History Questionnaire which had been developed at the Clarke Institute of Psychiatry (1979) and revised in This sample has a higher likelihood of underestimating the level of paraphilias present as most of those who admitted to sexually deviant behaviour were in the pre-trial phase of a judicial 15

33 proceeding and, in most cases, the assessments had been ordered by the court. Bradford, Boulet, and Pawlak present data for eleven different paraphilias showing an average number of additional paraphilias by presenting problem of 2.18 (see Appendix J). Deviant sample 9 (Ds9) Dunsieth et al. (2004) reported on a sample of male sexual offenders (N = 113), consecutive referrals from prison, jail, or probation to an 18 month residential treatment program designed to treat their sexual offending. These authors divided their sample into 84 men with paraphilias and 26 men without paraphilias. The without paraphilia group, while having been convicted of a sexual offence, did not meet DSM-IV diagnostic criteria for paraphilias. In this study an actual psychiatric diagnosis was performed using the Structured Clinical Interview for DSM-IV (First et al., 1996) to determine the presence of a DSM-IV paraphilia. As a result, there were more men in the without paraphilias group that were more likely to offend against adults exclusively. This categorization put most of the rapists into the without paraphilias group. It could be said that this is appropriate as there is no rape paraphilia in the DSM-IV or DSM-IV-TR and so rape is not actually a paraphilia. Data in Appendix K show that a clinician interviewing a sexual offender with one identified paraphilia would anticipate finding an additional paraphilia in 9 out of 10 offenders. Deviant sample 10 (Ds10) Eher & Ross (2006) looked at relative risk for reoffending in a sample of intrafamilial child molesters (n = 157) and a sample extrafamilial child molesters (n = 131). This sample consisted of men who were consecutive assessments at the Federal Documentation Centre for Sexual Offenders for the Austrian prison system with intakes between 2002 and All were adults and all had been convicted of a hands-on offence against at least one child, aged under 14 years. Criteria for the presence of a paraphilia were strict as the authors used the diagnostic criteria from the DSM-IV (APA, 1994). As shown in Appendix L, there is more than a threefold difference between the number of paraphilias admitted to in a sample of incest offenders (11.5%) and a sample of extra-familial child molesters (38.2%). Caution must be taken in the interpretation of these data as sufficient data are not provided to know the number of paraphilias admitted to by any one man. It is possible that one man could have admitted to all seven of the 16

34 paraphilias examined. However, the paper does report that 10 or 6.4% of the incest offenders admitted to more than one paraphilia and that 26 or 19.9% of the extra-familial group admitted to more than one paraphilia. Table 3 shows a non-weighted average for 11 samples of sexual offenders. The result of this analysis of published data suggests that when assessing a sexual offender the clinician would expect there to be, on average, 1.4 paraphilias present in addition to the presenting problem. Table 4 shows the average number of paraphilias reported in the two samples of sexual murderers. These samples are intriguing in and of themselves and it is interesting to note that the rate of admitted paraphilias in single victim sexual murderers is actually below the level reported in 11 samples of non-murdering sexual offenders, while the rate of paraphilias reported by multiple victim sexual murderers is twice that level. On average, as seen in Table 5, where it could be calculated, it appears that where certain paraphilias are the presenting problem the likely number of paraphilias present is greater than the overall average presented in Table 3. Deviant sample 11 {Sexual Murderers} (Ds11) Prentky, Burgess, Rokous, Lee, Hartman, Ressler, & Douglas (1989) reviewed data from two groups of sexual murderers. This sample contains all of the men reported on in Ressler, Burgess, Hartman, Douglas, & McCormack (1986). The first was a sub-sample of serial sexual murderers (n = 25) with three or more known victims and the second, a sub-sample of sexual murderers with single victims (n = 17). One of the operating hypotheses of this study was that the multiple sexual murderers would demonstrate more paraphilias than the single sexual murderers. These authors assert that the drive mechanism for repeated acts of sexual homicide, among others, is an intrusive fantasy life manifested in higher prevalences of paraphilias (p. 887). The results confirmed their hypothesis; multiple sexual murderers had significantly more paraphilias than single murderers. It should be noted that there is a potential confound in this study as the presence of paraphilias and other information in the multiple sexual murderers was assessed through file review and interviews by FBI special agents while the data on the single sexual murderers were obtained through archival file review alone. A very real possibility exists that more paraphilias came to light in the context of a personal interview than through file review alone. In addition, the authors, in an attempt at rigour, state that paraphilias were only coded as 17

35 Table 3 Summary table of deviant samples Sample Identifier Sample Composition N2 Psychiatric teaching hospital Sexual aggressives Data Acquisition Method (n) Average number of additional paraphilias in this sample Phallometrics Ds2 Forensic psychiatric outpatients Voyeurs = 45 Sexually anomalous = 52 Ds3 Forensic outpatient clinic Persistent Exhibitionists Self-report Clarke Sex History Questionnaire Ds4 Community-based sex assaulters Self-report Ds6 Behavioural sexology clinic Self-report 1, Ds7 Ds8 Ds9 Community-based forensic clinic child molesters Sexual behaviours clinic at a major urban hospital Residential sexual offender treatment program Ds10 Austrian Prison System Intra-familial child molesters n = 157 Extra-familial child molesters n = 131 Self-report Male Sexual History Questionnaire Structured clinical interview DSM-IV Diagnostic Criteria DSM-IV n = n = Average for 11 samples

36 Table 4 Summary table of sexual murderer samples Sample Identifier Ds11 Sample Composition Two samples of sexually oriented murderers prison samples Data Acquisition Method File review alone (n) Single victim murderers n = 17 Average number of additional paraphilias in this sample 1.18 File review plus interview Multiple Victim Murderers n = present when there was clear, unambiguous evidence in the archives and that the paraphilias where defined in concrete behavioural terms and examples were provided (p. 889). These are very stringent criteria for file review as the diagnostic criteria for paraphilias is elusive at the best of times. These data suggest that when interviewing a single sexual murderer the clinician might anticipate at least one additional paraphilia (1.18 average), but when interviewing a multiple sexual murderer the interviewer might expect to detect three additional paraphilias (2.92 average) per offender (see Appendix M). 19

37 Table 5 Summary table by presenting problem in deviant samples Sample Data Acquisition Method (n) Number of additional paraphilias beyond presenting problem Voyeurism Ds2 Self-report Ds4 Self-report Ds6 Self-report Ds8 Ds9 Male Sexual History Questionnaire Structured clinical interview for the DSM-IV Ds10 DSM-IV criteria Weighted Average Exhibitionism Ds1 Self-report Ds2 Self-report Ds3 Clarke Sex History Questionnaire Ds4 Self-report Ds6 Self-report Ds8 Male Sexual History Questionnaire Ds9 Structured clinical interview for the DSM-IV Ds10 DSM-IV criteria Weighted Average Boy Victim Child Molesters Ds2 Self-report Ds4 Self-report Ds7 Self-report Ds8 Male Sexual History Questionnaire Weighted Average

38 Discussion This paper is a simple re-evaluation of existing published data. That said, it does provide some baseline guidance to the clinician as to how many paraphilias might be present given an offender s presenting problem at time of assessment. What demographic and selection data are provided in the body of the text (average ages, education levels, characteristics of subject selection) are offered so the clinician can judge whether the clients they are assessing have similar characteristics to those in the samples. The estimates likely to be the most accurate are those from the sample of sexual offenders that best represents the characteristics of the individual being assessed. Estimates from these data may not apply to men who are grossly unlike the men sampled in these studies (quite young/very old or those who, in the past, would have been unlikely to be referred to correctional/mental health/forensic system for assessment). One of the expected results, based upon this assembled data, is that a voyeur is highly likely to be an exhibitionist and vice versa. It must be remembered that the type of paraphilia itself and the behavioural manifestations of that paraphilia affect the rate of reporting. For example, it is far more likely for an exhibitionist to be caught than a voyeur due to the nature of the behaviour itself, with the voyeur typically being furtive and concealing while the exhibitionist is, by definition, not. In publicly funded institutions and in the justice system paraphilias are seldom examined. With the exception of pedophilia (child molesting) other paraphilias are rarely the presenting problem, and as a result are, if detected, seen as secondary in nature to more pressing problems. In spite of being repeatedly implicated in risk of recidivism, institutions chronically short of professional staff rarely have the time to assess paraphilias and almost never treat them. Paraphilias are a concern not only because they often lead to criminal behaviours but also because their presence blocks the reasonable expression of age and situation appropriate, reciprocal, affectionate sexual activity. Hypersexuality Researchers and clinicians who, at assessment, wish to comment upon whether the client engages in excessive sexual expression may wish to consider such potential indicators as sexual rumination, difficulty in sexual self-regulation, sex as coping (Hanson & Harris, 2001, 2000: 21