CHAPTER 26

Paraphilic Disorders

Judith V. Becker, Ph.D.

Bradley R. Johnson, M.D.

Andrew Perkins, M.A.

Because the area of assessing, diagnosing, and treating paraphilic disorders has become a specialty in the field of psychiatry, most psychiatrists will have little exposure to patients with paraphilic disorders in the course of their training and career. Psychiatrists should, of course, as part of a standard diagnostic interview, ask questions regarding sexual functioning, such as "Are you having difficulty with sexual functioning?" or "Do you have any sexual behavior you have engaged in that is of concern?" Because paraphilic disorders are most frequently associated with sexual offenses, these disorders may be more commonly seen by psychiatrists practicing in the forensic arena. However, paraphilic disorders are not always associated with sexual offenses. In fact, many people commit sexual offenses that do not meet the criteria for a paraphilic disorder; likewise, some people diagnosed with a paraphilic disorder never commit a sex crime.

The paraphilic disorders (Table 26-1) are characterized by experiencing, over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors generally involving nonhuman objects or nonconsenting partners. In diagnosing any of the paraphilic disorders, the clinician should also consider whether the person has acted on the urges or is markedly distressed by them. Although an individual may have engaged in a behavior that may be sexually inappropriate or even illegal, he or she may only have the urges or fantasies associated with the paraphilic disorder, and never act on them. Many of the paraphilic disorders have specifiers unique to that particular disorder, and most have to do with the target of the fantasy, urge, or behavior. Additionally, DSM-5 (American Psychiatric Association 2013) has added the following two specifiers to the paraphilic disorders in general: 1) "in a controlled environment," which applies to individuals living in institutional or other settings that limit their opportunities to engage in the behavior, and 2) "in remission," which indicates a lack of distress, impairment, or recurrence of the behavior with a nonconsenting partner for 5 years in an uncontrolled environment. "In remission" does not necessarily mean the interest no longer exists; rather, it indicates that the behavior is not currently problematic.

Paraphilic disorders

Voyeuristic Disorder

Voyeuristic disorder (Box 26-1) is commonly viewed as the act of becoming sexually aroused by fantasy or the actual viewing of unsuspecting and nonconsenting people who are naked, disrobing, or engaging in sexual activity when they do not realize they are being watched or have not given permission (Långström 2010). The behavior may lead to sexual excitement, but generally there is no sexual activity between the voyeur and the victim, although the voyeur may masturbate at the time or later to memory of the event. This type of behavior often has an onset in adolescence and can become persistent (American Psychiatric Association 2013); however, according to DSM-5, the diagnosis cannot be made until an individual is at least age 18 years. The desire to view naked individuals is not necessarily unusual, but in the case of this diagnosis, the professional should be looking for qualitative and quantitative differences from normal behavior, fantasy, or urges. This information either can be freely offered by the individual or can be inferred in some cases by a pattern of recurrent behavior (based on significant objective evidence), even in individuals who do not admit a sexual interest in voyeuristic behavior.

NOTICE. Criteria set above contains only the diagnostic criteria and specifiers; refer to DSM-5 for the full criteria set, including specifier descriptions and coding and reporting procedures.

Exhibitionistic Disorder

Exhibitionistic disorder, known in DSM-IV-TR (American Psychiatric Association 2000) as exhibitionism, is identified as either the exposure of one's genitals to an unsuspecting person or the manifestation of urges to do so in the form of fantasy. When the behavior does occur, it may involve masturbation during the exposure, and in some cases the individual tries to surprise or shock the observer. The exhibitionistic individual may hope or desire that the observer will become sexually aroused or join in sexual activity. Exhibitionistic disorder is generally thought to be a disorder of males, sometimes has an early onset (before age 18 years), and is directed primarily at females (Murphy and Page 2008). Victims can be adults, children, or adolescents (Gittleson et al. 1978; MacDonald and Rickies 1973; Rior-dan 1999). The DSM-5 criteria (Box 26-2) provide specifications for exposing to prepubertal or early pubertal children, to physically mature individuals, or to both. As with many types of paraphilic disorders, there are no good personality profiles for those with exhibitionistic disorder (Blair and Lanyon 1981). Långström and Seto (2006) found that individuals who admitted to having engaged in exhibitionistic behavior also tended to have higher levels of sexual activity in general, replicating results from Långström and Hanson (2006).

NOTICE. Criteria set above contains only the diagnostic criteria and specifiers; refer to DSM-5 for the full criteria set, including specifier descriptions and coding and reporting procedures.

DSM-5 provides for the diagnosis of exhibitionistic disorder both in situations where an individual freely admits to the sexual fantasy urge, or behavior and in situations where an individual may deny such attraction, as long as there is substantial objective evidence that the individual has engaged in the behavior.

Frotteuristic Disorder

Frotteuristic disorder (Box 26-3) involves touching or rubbing against a nonconsenting person, or fantasies about or urges to do so (Långström 2010). When the behavior does occur, it frequently takes place in crowded areas, such as a bus, subway, hall, or sidewalk. Although there are many different ways in which a person can engage in frotteuristic activity, one of the more common is for a male to rub his genitals against the unsuspecting victim; however, the behavior may include touching or rubbing the genitals or sexual organs of the victim without the victim knowing that he or she has been intentionally offended against. Freund et al. (1997) found that this disorder is quite comorbid with other paraphilic behaviors, most typically the other "courtship disorders" (so called because they resemble distorted components of human courtship behavior), which include voyeuristic disorder and exhibitionistic disorder. Frotteuristic disorder is similar to exhibitionistic disorder in that it can be diagnosed in situations where an individual denies sexual attraction to touching or rubbing against nonconsenting persons, but where there is strong objective evidence that the individual has engaged in this behavior in the past. Before diagnosing this disorder in an individual who has a history of frotteuristic behavior but who denies persistent sexual interest (in the form of fantasies or urges), the clinician needs to assess for a recurrent pattern of frotteuristic behavior. That is to say, a single act of frotteurism may not be sufficient to diagnose frotteuristic disorder in a nonadmitter.

NOTICE. Criteria set above contains only the diagnostic criteria and specifiers; refer to DSM-5 for the full criteria set, including specifier descriptions and coding and reporting procedures.

Sexual Masochism Disorder

The DSM-5 diagnostic criteria for sexual masochism disorder require intense sexually arousing fantasies, urges, or behaviors involving the act of being humiliated, beaten, bound, or otherwise made to suffer (Box 26-4). Such acts may include restraint, blindfolding, paddling, spanking, whipping, beating, electrical shocks, cutting, piercing, and being urinated or defecated on (Krueger 2010a). It is important to recall in the context of these paraphilic disorders, which do not necessarily involve nonconsenting partners, that an individual can meet criteria for a diagnosis only if he or she indicates distress or impairment. Behaviors associated with sexual masochism disorder are typically practiced in a consenting, nondistressing, nonpathological way (Baumeister and Butler 1997). For this reason, sexual masochism disorder should only be diagnosed in individuals who freely admit to the behavior and express clinically significant distress or psychosocial role impairment from the behavior. In extreme instances, associated behaviors can be dangerous or even life threatening. Therefore, a new specifier has been added to indicate whether these behaviors or fantasies occur with asphyxiophilia (sexual arousal by asphyxiation). This is an especially important specification to make, considering that asphyxiation, whether with a partner or alone, can be particularly dangerous and even life threatening (Hucker 2011).

NOTICE. Criteria set above contains only the diagnostic criteria and specifiers; refer to DSM-5 for the full criteria set, including specifier descriptions and coding and reporting procedures.

Sexual Sadism Disorder

According to DSM-5 (Box 26-5), sexual sadism involves real acts (not simulated) in which sexual arousal is achieved from the psychological or physical suffering of another individual. Like sexual masochism disorder, this behavior can occur between consenting individuals who are neither distressed nor impaired by the behavior, and who practice it in a safe manner; these individuals may be considered to have sadistic sexual interest but not a disorder (Krueger 2010b). Sexual sadism disorder is more likely to be seen in a mental health context when it involves a nonconsenting person. As with the other paraphilic disorders that involve nonconsenting individuals, sexual sadism disorder can be diagnosed in the face of nonadmission about the fantasy, urge, or behavior if there is substantial objective evidence from the person's psychosocial or legal history that he or she has engaged in this behavior on a recurrent basis. The sadistic acts may involve such things as controlling or dominating the person but may also include, for example, restraint, blindfolding, paddling, spanking, whipping, pinching, beating, burning, electrical shocks, rape (simulated or actual), cutting, stabbing, strangulation, torture, mutilation, or even killing. In individuals with sexual sadism disorder, such fantasies may have begun in childhood but are usually present by early adulthood. Hucker (1997) discussed that sexual sadism may have a number of subcategories, including necrophilia (sexual attraction or behavior with a corpse), sadistic and lust murders (sexual arousal from killing), and sadistic rape.

NOTICE. Criteria set above contains only the diagnostic criteria and specifiers; refer to DSM-5 for the full criteria set, including specifier descriptions and coding and reporting procedures.

A paraphilic disorder for preferential rapists (paraphilic coercive disorder) was proposed for inclusion in DSM-5; however, this issue was controversial due to the legal implication of the term rape versus use of the term from a psychiatric or psychological perspective. The proposed diagnosis of paraphilic coercive disorder was rejected on both legal and scientific grounds (Knight 2010; Thornton 2010).

Pedophilic Disorder

Despite considerable debate, pedophilic disorder, known in DSM-TV-TR as pedophilia, has not changed substantially in DSM-5 (Blanchard 2010a; Blanchard et al. 2009). Pedophilic disorder is defined as intense, recurrent, sexually arousing fantasies, urges, or behaviors involving a prepubescent child or children (generally age 13 or younger) over a period of at least 6 months (Box 26-6). A diagnosis is suggested if an individual has acted on these urges, or if the urges or fantasies caused marked distress. To receive a diagnosis of pedophilic disorder, the individual must have been at least age 16 years and at least 5 years older than the child. The criteria also provide specifiers for an exclusive type (only attracted to children) versus a nonexclusive type (attracted to both adults and children), as well as a specifier for the gender of the child (male, female, or both) and a specifier indicating whether the diagnosis is limited to incest.

NOTICE. Criteria set above contains only the diagnostic criteria and specifiers; refer to DSM-5 for the full criteria set, including specifier descriptions and coding and reporting procedures.

A large spectrum of inappropriate sexual activity can occur between adults and children and be indicative of a pedophilic disorder, ranging from undressing and looking at the child to penetration of different forms and even torture. There have been cases in which pedophilic disorder started during adolescence, and other cases in which the disorder did not seem to begin until mid-adulthood (Seto 2008). Notably, however, a subset of individuals who have this desire do not act on their urges and may seek treatment without having committed a sex offense. Additionally, the Internet has created a new problem in the form of child pornography. Some research suggests that viewing child pornography is a good indicator of pedophilic disorder (Seto et al. 2006). Although this disorder is most often seen in males, and most of the available information is based on the study of males, there are females who meet criteria for this disorder (Grayston and De Luca 1999). As with exhibitionistic and frotteuristic disorders, a pattern of recurrent sexual behaviors involving children may be sufficient for a diagnosis despite an individual not admitting to any sexual interest, fantasy, or urges involving children.

Fetishistic Disorder

Fetishistic disorder (Box 26-7) is sexual arousal that often involves the use of nonliving objects, such as women's underpants, bras, stockings, shoes, boots, or other apparel, but may also include a highly specific focus on nongenital body parts (Kafka 2010). The inclusion of nongenital body parts is new in DSM-5, and a specifier is now included so that a clinician can indicate on which body part(s) or nonliving object(s) a specific individual focuses. In this disorder, the individual might masturbate while holding, rubbing, or smelling an item. Objects used exclusively for the purpose of crossdressing or objects designed for genital stimulation (e.g., vibrators) are not included in this diagnosis. In general, the person may have difficulty in becoming sexually aroused in the absence of the item. One of the most important features of this diagnosis is that the individual must experience clinically significant distress or impairment. If an individual experiences strong fantasies, urges, and behaviors involving the use of nonliving objects but experiences no distress or psychosocial role impairment, then a diagnosis would not be appropriate.

NOTICE. Criteria set above contains only the diagnostic criteria and specifiers; refer to DSM-5 for the full criteria set, including specifier descriptions and coding and reporting procedures.

Despite a paucity of research on fetish-istic disorder, some trends do emerge. Fe-tishistic disorder, like many of the paraphilic disorders, is primarily found in males, and the most common foci are feet and their associated objects (footwear, socks, etc.) and female undergarments (Chalkley and Powell 1983; Scorolli et al. 2007; Weinberg et al. 1994). Regarding the etiology of this class of paraphilic disorder, a number of theories—biological, conditioning, social learning, and psychoanalytical—have been proposed, but they are nearly impossible to test empirically given how rare this disorder appears to be (Darcangelo 2008).

Transvestic Disorder

Identified separately from fetishistic disorder and gender dysphoria, transvestic disorder involves cross-dressing, in most cases producing sexual arousal (American Psychiatric Association 2013). In the DSM-5 criteria (Box 26-8), several specifiers have been added and others removed. The "with gender dysphoria" specifier has been removed to decrease the overlap between this diagnosis and that of gender dysphoria. The specifier "with fetishism" has been added to identify individuals who experience arousal in response to the garments, materials, or fabrics, and the specifier "with autogynephilia" has been added to indicate when the cross-dressing is accompanied by sexually arousing thoughts or images of the self as female (Blanchard 2010b). Although the diagnosis is no longer restricted to heterosexual males, it has most typically been described in heterosexual males, and the clinician needs to perform a differential diagnosis between transvestic disorder and gender dysphoria (see Chapter 21 in this volume, "Gender Dysphoria," by Becker and Perkins). Transvestic disorder may begin in childhood or adulthood, may be temporary or chronic, and may lead to gender dysphoria in some cases (it is often at this point that the individual seeks treatment). Transvestic disorder should be diagnosed only in the presence of clinically significant distress or impairment on the part of the individual. One sign of impairment may be a cycle of acquiring and then disposing of and then reacquiring garments associated with transvestic behavior in an attempt to control the urges or behavior.

NOTICE. Criteria set above contains only the diagnostic criteria and specifiers; refer to DSM-5 for the full criteria set, including specifier descriptions and coding and reporting procedures.

Other Specified and Unspecified Paraphilic Disorders

The other specified and unspecified diagnoses represent a change that has been applied throughout DSM-5. The other specified and unspecified diagnostic categories replace the not otherwise specified (NOS) category as a method for recording presentations in which symptoms do not meet criteria for any specific paraphilic disorder or there is insufficient information to make a specific diagnosis. The diagnosis other specified paraphilic disorder (Box 26-9) is used in cases where the clinician can specify the reason that full criteria are not met. Presentations for which the "other specified" designation would be appropriate include—but are not limited to—recurrent and intense sexual arousal involving telephone scatologia (obscene phone calls), necrophilia (corpses), zoophilia (animals), coprophilia (feces), klismaphilia (enemas), or urophilia (urine). Unspecified paraphilic disorder (Box 26-10) is used in situations where a paraphilic disorder appears to be present but does not meet full criteria for any of the listed disorders and either the clinician chooses not to specify why the disorder does not meet full criteria or there is not enough information to make a more specific diagnosis.

Epidemiology

Because paraphilic behaviors do not typically cause personal distress, scant data are available on the prevalence or course of many of these disorders. Historically, information on those paraphilic disorders involving victims (pedophilic disorder, exhibitionistic disorder) has been obtained from studies of incarcerated sex offenders. However, these data are limited in that many sex offenders are not arrested, and those who are tend to underreport their deviant behavior for fear of further prosecution. For example, two large studies of incarcerated sex offenders found that the offenders had committed only a small number of sexually deviant acts (Frisbie and Dondis 1965; Gebhardt et al. 1965).

In contrast, existing studies of non-incarcerated pedophiles have been enlightening. In a study including 561 men with paraphilic disorders, Abel et al. (1987) gathered data regarding demographic characteristics, frequency and variety of deviant sexual acts, and numbers and characteristics of victims. They found that the average numbers of crimes and victims were substantially higher than had been realized before, and reported that their subjects molested young boys five times more often than young girls.

Långström and his colleagues conducted a series of studies examining sexual behaviors in a sample from the general population. Questions were included on hypersexuality, exhibitionism, voyeurism, and transvestic fetishism. The studies included 2,450 randomly selected adults ages 18-60 from the general population in Sweden. Because the study only examined paraphilia-like behaviors, the results likely overestimate the number of individuals who would be diagnosed with a paraphilic disorder. Långström and Seto (2006) reported that 3.1% of respondents admitted to at least one incident of exhibitionistic behavior and 7.7% to at least one incident of voyeuristic behavior. Långström and Zucker (2005) found that 2.5% of men and 0.4% of women reported at least one episode of transvestic behavior.

Abel et al. (1988) discovered that most individuals diagnosed with a paraphilic disorder have had significant experience with as many as 10 different types of deviant sexual behavior (paraphilic disorders). Similar high rates have also been found by Freund and Watson (1990). Marshall (2007) wrote an excellent review of the research that has been done on multiple paraphilic disorders, noting that there are some drawbacks to the literature. As cited in Marshall (2007), Eher et al. (2001) found in a sample of child molesters that only between 5.6% and 11% met criteria for other paraphilic disorders, which is also in line with findings from Marshall et al. (1991).

The vast majority of individuals with paraphilic disorders are men. For example, among reported cases of sexual abuse, more than 90% of offenders were men (Browne and Finkelhor 1986). Across studies, the rate of identified female perpetrators has varied from 5% to 44% depending on the specific study and the sex of the victim (Bunting 2005; Faller 1995; Peter 2009). However, the low rates of female offenders could in part be due to bias on the part of professionals and the public; sociocultural norms leave little room for women to be diagnosed with paraphilic disorders.

Paraphilic Disorders and Comorbid Psychiatric Diagnosis

The study of comorbidity in regard to paraphilic disorders suffers from the same drawbacks as more general epidemiological research. However, the research does suggest that comorbid psychiatric disorders are likely to be present in those with paraphilic disorders and should be addressed. Kafka and Hennen (2002), in a study of 120 males with paraphilic disorders or paraphilia-related disorders, reported that the most common comorbid Axis I disorders were mood disorders (71.6%), substance abuse (40.8%), anxiety disorders (38.3%), and attention-deficit/hyperactivity disorder (35.8%). Långström et al. (2004) studied psychiatric disorders and adult sex offenders in a much larger study sample (N=1,215) and concluded that alcohol abuse was the most frequent diagnosis, followed by drug abuse, personality disorder, and psychosis.

Dunsieth et al. (2004) published results regarding psychiatric features of 113 men convicted of sexual offenses; the authors found high lifetime rates of Axis I disorders: substance abuse (85%); paraphilic disorders (74%); mood disorders, most commonly bipolar disorder and depression (58%); impulse-control disorders (38%); anxiety disorders (23%); and eating disorders (9%). They also reported that 56% of their sample could be diagnosed with an antisocial personality disorder. These percentages are much higher than the lifetime prevalence of these disorders seen in the general population (Kessler et al. 2007).

Långström and Seto (2006) found that exhibitionistic behavior and voyeuristic behavior in the general population were associated with general measures of psychological problems, lower life satisfaction, greater alcohol and drug use, and higher levels of sexual activity in general. In contrast, Långström and Zucker (2005) found that transvestic fetishism in the same population was not associated significantly with psychological problems.

Etiology

Various theories have been put forth to explain the development of paraphilic disorders. Most of the theories center on those paraphilic disorders that involve victims and are considered criminal behaviors. Some of these theories are specific to the development of paraphilic disorders in general, but most are applied to the development of paraphilic interest and subsequent illegal behavior. Although we discuss some of these theories, a more thorough review is available in Sex Offending: Causal Theories to Inform Research, Prevention, and Treatment (Stinson et al. 2008b).

Some biological factors have been postulated. Destruction of parts of the limbic system in animals causes hypersexual behavior (Klüver-Bucy syndrome), and temporal lobe diseases such as psychomotor seizures or temporal lobe tumors have been implicated in some persons with paraphilic disorders. It also has been suggested that abnormal levels of androgens may contribute to inappropriate sexual arousal. Most studies, however, have dealt only with violent sex offenders and have yielded inconclusive results (Bradford and McLean 1984).

According to learning theory, sexual arousal develops when a person engages in a sexual behavior that is subsequently reinforced through sexual fantasies and masturbation. It is thought that there are certain vulnerable periods (e.g., puberty) when the development of paraphilic sexual arousal can occur. For example, if an adolescent boy is sexual with a 7-year-old boy and there are no negative consequences, the adolescent may continue to fantasize about having sex with the boy and masturbate to those fantasies, developing arousal to young boys (i.e., pedophilia).

Cognitive distortions are often referenced to explain the maintenance of paraphilic behaviors that cause harm to others. Distortions in thinking, or thinking errors, provide a way for an individual to give himself or herself permission to engage in inappropriate or deviant sexual behaviors (Abel et al. 1984).

Several theories have been developed to explain the behavior of individuals who sexually abuse children. Finkelhor (1984) hypothesized that the following four underlying factors are involved in child molestation: emotional congruence with children, sexual attraction to children, inability to meet needs in acceptable ways, and a disinhibition that allows them to behave contrary to social norms. Hall and Hirschman (1992) proposed a similar quadripartite model of child molestation. The four components were physiological sexual arousal, cognitive distortions that justify sex with children, personality problems, and affective dyscontrol. Marshall and Barbaree (1990) proposed that individuals who engage in sexual activity with children during their own childhood experience developmentally adverse events, and therefore develop problematic sexual scripts.

Some theories attempt to provide comprehensive models of sex offending. Ward and Beech (2006) presented an integrated theory that examines factors that affect the developing brain, including genetic variations, neurobiology, and evolution, as well as ecological factors, including personal circumstances and physical environment, and discussed how all of these factors affect neuropsychological functioning. Stinson et al. (2008a) presented their multimodal self-regulation model. This model incorporates biological and temperamental precursors, early experiences and socialization, reinforcement, cognitive worldview, and personality to explain self-regulation and self-regulatory deficits—specifically emotional, cognitive, interpersonal, and behavioral dysregulation.

Recent studies suggest that pedophilia specifically may arise from neuropsychological differences. Men with pedophilia have been identified as displaying a variety of factors, including handedness, IQ, head injuries, and placement in special education programs, that are suggestive of early-occurring brain differences (Blanchard et al. 2003; Cantor et al. 2004, 2005a, 2005b). Additionally, Cantor et al. (2008) and Cantor and Blanchard (2012) found evidence using robust methods that pedophiles have lower volumes of white matter in the temporal lobes bilaterally and parietal lobes bilaterally.

Ln the future, it might be beneficial in the study of paraphilic disorders to move away from focusing solely on sex offending behavior and to look more at the development of sexual behaviors in general, both paraphilic and nonparaphilic. While theory and model development continues, it is important that developing theories continue to be comprehensive and include evolutionary, neuroendocrine, and social learning factors.

Diagnosis

It is important to distinguish between paraphilic disorders such as fetishistic disorder and transvestic disorder and normal variations of sexual behavior. Some couples occasionally augment their usual sexual activities with, for example, bondage or cross-dressing (as exemplified in popular erotic fiction such as Fifty Shades of Grey by E.L. James [2012]). Diagnoses of paraphilic disorders are typically made only when 1) these activities are the exclusive or preferred means of achieving sexual excitement and orgasm, and this behavior is distressing, or 2) the sexual behavior is not consensual. In some cases, the identified client may not be distressed, but his or her partner may be. In such cases, it is important to tread carefully and not make diagnostic conclusions before a thorough evaluation can be conducted. Additionally, depending on the situation—forensic, pretreatment, risk, inpatient, outpatient, and so forth—the clinician may need to obtain collateral data before making a diagnosis.

Obviously, nonconsensual sexual activities, such as sexual contact with children or exhibitionism, can never be appropriate; children never can give consent for sexual activity with an adult. Notably, the DSM-5 criteria give considerably more leeway in diagnosing a paraphilic disorder in situations where an individual is denying interest in the behavior. This latitude is no doubt useful, but evaluators should also use caution and ensure that any diagnosis is based on a solid foundation of objective data.

Inappropriate sexual behavior is not always the result of a paraphilia. A psychotic patient may cross-dress because of a delusional belief that God wishes him or her to hide his or her true sex. A manic patient may expose himself to women because of his hypersexuality and belief that he will be able to "pick them up." A patient with dementia can behave in a sexually inappropriate manner (e.g., masturbate in a room full of people) because of cognitive impairment. An individual with intellectual developmental disorder may engage in a sexually inappropriate behavior because of cognitive impairment, poor impulse control, and lack of sexual knowledge. Some individuals with antisocial personality disorder also commit deviant sexual acts; such behaviors usually are part of the individuals' overall disregard for societal norms and sanctions, and are not necessarily indicative of a deviant sexual interest.

Evaluation and Assessment

Clinical Evaluation

In evaluating an individual for paraphilic behavior, the clinician must perform a careful psychiatric evaluation to exclude other possible causes of this behavior (see previous section, "Diagnosis"). The clinician should take a detailed sexual history, noting the onset and course of paraphilic and appropriate sexual fantasies and behavior and the present degree of control over the deviant behavior. (For a discussion of how to take a comprehensive sexual history, see Taking a Sex History by Pomeroy [1982], but bear in mind that the book is somewhat dated.) In addition, the individual should be evaluated for faulty beliefs (i.e., cognitive distortions) about his or her sexual behavior, social and assertive skills with appropriate adult partners, sexual dysfunctions, and sexual knowledge. Table 26-2 lists information that is important to collect during a clinical psychosexual interview; the information may then be confirmed with collateral sources. Table 26-3 lists specific details that may be covered in the sexual history portion of the evaluation. As discussed in "Diagnosis" above, it is important to consider the purpose of the evaluation and possibly obtain collateral data before making a diagnosis.

Physiological Assessment

Phallometric assessments (i.e., measurements of penile erection) have been used to objectively assess the sexual arousal of individuals who have engaged in paraphilic behavior. This finding is important because persons with paraphilic disorders, especially those in trouble with the law, are reluctant to disclose the full extent of their deviant behavior and fantasies. A transducer (either a thin metal ring or mercury-in-rubber strain gauge) is placed around the penis, and the degree of erection is recorded while the individual is exposed to various sexual stimuli (audiotapes, slides, videotapes) depicting paraphilic and appropriate sexual scenes. This information is then recorded on a polygraph or computer, and the degree of arousal to deviant sexual scenes is compared with arousal to non-paraphilic scenes.

Phallometric assessments of sexual age and gender preferences have excellent discriminant validity with extrafamilial child molesters (Freund and Blanchard 1989). However, exclusively incestuous offenders are less likely than extrafamilial child molesters to show inappropriate sexual age preferences in phallometric assessment (Barbaree and Marshall 1989). Although phallometric assessments attempt to measure the degree of sexual preference among stimulus categories, they do not detail whether someone has engaged in paraphilic behavior or has committed a sexual offense. Furthermore, some individuals are able to influence their responses to appear to have nonparaphilic preferences (Freund et al. 1988). Further research is indicated to standardize this form of assessment and to establish the psychometric properties.

As with the interpretation of most physiological procedures, caution is necessary in interpreting results from plethysmography because the setting in which the data are obtained is quite different from the real world. Also, because variation can occur within subjects over time, the interpretation must take into account the context of the offender's history, available records, and psychological characteristics (Dougher 1995).

Visual Reaction Time

Some instruments have been developed based on the assumption that the length of viewing time of stimuli may correlate to the measure of sexual interest. The Abel Assessment for Sexual Interest is used to measure the subject's viewing time of specially designed photographs of clothed models. Although this seems like a less invasive and simple method compared with the plethysmograph, the procedure and its reliability, sensitivity, and specificity must be corroborated (Krueger et al. 1998). Abel et al. (2001) reported, however, that data support the use of their instrument. The Affinity Program is similar to the Abel Assessment in that it utilizes covert viewing time measurements to determine sexual interest. A study from Mokros et al. (2013) suggests that although the Affinity Program may have some validity, improving its sensitivity and specificity requires additional work. Other cognitive measures are also being developed, including the Implicit Association Test and the Stroop test. Cognitive Approaches to the Assessment of Sexual Interest in Sex Offenders (Thornton and Laws 2009) provides a good review of this area of assessment. Notably, measuring sexual interest may not be the same as measuring sexual arousal; therefore, plethysmography and measures such as the Abel Assessment for Sexual Interest and the Affinity Program may have separate uses.

Self-Report Measures and Other Sources of Data

Other assessments and data sources are used at times to gain additional information. A useful reference is Assessing Sexual Abuse: A Resource Guide for Practitioners (Prentky and Edmunds 1997). Table 26-4 lists self-report assessments. In addition to administering sex-specific self-report instruments, the clinician would be wise to administer measures of personality, trauma, and other areas of psychopathology. The clinician should be careful to correlate assessment results to the clinical evaluation, and not depend on them for diagnosis. Collateral sources of information may be quite helpful to corroborate claims from the person if an offense has been committed. This task may require reviewing such items as police reports, victim statements, prior mental health records, jail or prison records, sex offender treatment records, and school records. In some cases, the clinician may also consider interviewing family members, friends, or even victims to obtain additional information.

Risk Assessment of Sex Offenders

Paraphilic disorders typically come to clinical attention in the context of illegal sexual activity. A mental health professional may be asked not only to determine an appropriate diagnosis but also to address whether or not the individual is at risk to reoffend. This determination is especially important in states with sexually violent predator legislation where individuals may potentially be petitioned for civil commitment. Twenty states currently have statutes that allow for the civil commitment of individuals who have committed sexual offenses and are considered to remain a risk to society. Although the wording of the statutes may vary from state to state, in general the commitment criteria pertain to an individual who has been convicted or adjudicated guilty of a sexually violent offense and has been determined to have a mental disorder—typically a paraphilic disorder or personality disorder—that predisposes him or her to commit dangerous sexual acts. Taken together, these factors identify the individual as a danger to the health and safety of others.

Historically, clinical judgment has been used in determining whether a person poses a risk of either violent or sexually violent behavior. Doren (2002) discussed different methods that have been used to conduct risk assessments. They include unguided clinical judgment, guided clinical judgment, clinical judgment based on an amnestic approach, research-guided clinical judgment, a clinically adjusted actuarial approach, and a purely actuarial approach (p. 104). In the field of risk assessment, a number of actuarial risk assessment instruments are available for use. Doren (2002) noted that in making a determination as to what instrument to use, the following issues need to be addressed: statistical demonstration of reliability and validity; degree of concordance between what the instrument was designed to measure and the legally defined risk; availability of information required to employ the instrument; and availability of interpretive information (p. 115). Actuarial assessment instruments include the Static-99R (Harris et al. 2003), Static-2002R (Phenix et al. 2009), Sex Offender Risk Appraisal Guide (Quinsey et al. 1998), Violence Risk Appraisal Guide (Quinsey et al. 1998), Rapid Risk Assessment for Sex Offense Recidivism (Hanson 1997), Minnesota Sex Offender Screening Tool—Revised (Epperson et al. 2003), and Risk for Sexual Violence Protocol (Hart et al. 2003). A comprehensive risk assessment should include a review of official court documents and interviews with the offender; in addition, a static risk assessment instrument as well as dynamic risk assessments, such as the Stable-2007 and Acute-2007 (Hanson et al. 2007), should be utilized. See Doren (2002) for information regarding risk assessment instruments as well as information on report writing and court testimony.

Hanson and Morton-Bourgon (2005) conducted a meta-analysis assessing the characteristics of persistent sexual offenders. The meta-analysis consisted of 82 recidivism studies involving 29,450 sexual offenders. Results indicated that on average the recidivism rate for sexual offenders was 13.7%; both the violent recidivism rate and the violent nonsexual recidivism rate were 14.3%. The overall recidivism rate—that is, the commission of any crime—was 36.2%. The average follow-up time for these offenders was between 5 and 6 years. The authors noted that because not all sex offenses are detected, the recidivism figure should be considered an underestimate. Results indicated that the strongest predictors of sexual recidivism were sexual deviancy and antisocial orientation.

Hanson and Morton-Bourgon (2009) conducted a meta-analysis examining the accuracy of risk assessment instruments in predicting recidivism. This study was conducted on 118 distinct samples and 45,398 sex offenders. They found that actuarial measures were significantly more accurate in predicting recidivism than was unstructured professional judgment, with structured professional judgment falling somewhere in between. The authors suggested that their findings indicate that empirically derived actuarial measures are most accurate at predicting recidivism, although more research is needed, particularly in the area of integrating multiple measures.

Treatment

Therapeutic Treatment of Paraphilic Disorders

Historically, psychoanalysis and psychodynamic therapy have been used in treating paraphilic disorders, although there is general consensus in the field that this approach alone is not effective in treating deviant sexual arousal (Crawford 1981). Currently, most sex offender treatment programs—the most common context for paraphilic disorder treatment—identify as having a cognitive-behavioral focus (McGrath et al. 2010). Cognitive-behavioral treatments typically involve skills training and cognitive restructuring to change an individual's maladaptive beliefs that lead to sex offenses. Empathy and social skills training are also often components in these types of treatment programs. Some treatments also use behavior therapies that focus on aversive conditioning to deviant fantasy as well as changes to masturbatory behavior (Marshall and Barbaree 1978).

Marques et al. (2005) conducted the only large-scale randomly controlled outcome study to date with incarcerated sex offenders, utilizing a cognitive-behavioral program within a relapse prevention framework. A follow-up period of 8 years led to results that indicated little to no significant difference between treated and untreated groups. Partially in response to this study, Kirsch and Becker (2006) commented on the flaws in the relationship between etiological theories of sex offending and most treatment programs designed for sex offenders, noting that the empirical literature on risk factors, criminogenic needs, and the development of sexual deviance was being ignored when it came to treatment.

Despite these criticisms, in a metaanalysis involving 69 studies and a total of 22,181 offenders, Lösel and Schmucker (2005) found that treated offenders reoffended 37% less than untreated offenders. Hanson and Morton-Bourgon (2009) also conducted a meta-analysis examining 23 recidivism outcome studies and similarly found that treatment had an overall effect in decreasing recidivism in sex offenders. In addition, they found that those programs that utilize risk, needs, and re-sponsivity (RNR) principles showed the largest effect in decreasing recidivism. All authors agree that more high-quality treatment studies are needed to further assess the effectiveness of treatment.

Newer models are seeking to integrate etiological research on the maintenance of sex offending behavior; knowledge about the general therapeutic factors that contribute to change; and the risk, needs, and responsivity principles shown to be effective with antisocial populations (Andrews and Dowden 2007; Andrews et al. 1990). Many of these newer models are more focused on motivation, goals, self-regulation, and criminogenic needs than on sexual deviance per se. One example is the good lives model, which focuses on shared goals, values, and characteristics, as well as on positive principles toward living more productive lives (Stinson and Becker 2012). Another is the multimodal self-regulation model, which refocuses the goals of treatment on self-regulatory deficits and takes a more ecological approach to reducing risk for recommitting illegal sexual acts (Stinson et al. 2008a).

Scientific evaluation is ongoing in the development of these new approaches to therapy with sex offenders, and further empirical research is certainly needed. Such an approach needs to focus on dynamic risk factors, as well as other factors that are known to produce reductions in sexual recidivism. We conclude that sex offender theory and treatment should be guided by empirical evidence and that targeted research in the field will help in developing more optimal treatment programs.

Biological Treatments of Paraphilic Disorders

Biological treatments traditionally have been reserved for individuals with pedophilic, sexual sadism, or exhibitionistic disorder, although occasionally individuals with other paraphilic disorders receive treatment with medications (Bradford and Kaye 1999). Medication treatments are often reserved for more severe cases, especially for individuals who are at high risk to reoffend and do not respond adequately to other interventions. The general consensus is that medication treatments should not generally be used as the sole form of treatment for sex offenders (Association for the Treatment of Sexual Abusers 2005, p. 46).

Rice and Harris (2011) reported that more than half of men who voluntarily either undergo surgical castration or take hormonal medication to lower their testosterone levels appreciate a sense of control over sexual urges and appetites. With that said, no medications on the market in the United States have been approved by the U.S. Food and Drug Administration (FDA) for treating paraphilic disorders or for reducing paraphilic fantasy and behavior. However, the use off-label medications is not unusual in the treatment of psychiatric disorders, and it is accepted in the field that the use of off-label medications that have been shown in the literature to be successful in some cases may be appropriate and is considered a current standard of care for some individuals with paraphilic disorders who do not adequately respond to first-line cognitive-behavioral therapies (Ali and Ajmal 2012).

The main target of hormonal treatment has been testosterone. Both Markianos et al. (2003) and Studer et al. (2005) demonstrated a relationship between high testosterone and sexual violence. These results suggest that there may be cases in which medical lowering of testosterone levels may be helpful in decreasing the risk of recidivism in men with paraphilic disorders (Saleh and Guidry 2003). Of course, one has to keep in mind that even if sexual desire is decreased pharmacologically, this does not necessarily change the patients' sexual interest or their behavior, and an unwilling patient can easily reverse the situation through testosterone replacement (Berlin 2003; Weinberger et al. 2005).

Surgical castration has been widely used in Europe as a method for reducing testosterone with incarcerated sex offenders. However, some have suggested that the results from this procedure are variable, unpredictable, and irreversible, and furthermore many view it not only as highly intrusive but also as cruel and unusual punishment (Heim 1981; Wille and Beier 1989). Weinberger et al. (2005) reviewed the relationship of surgical castration and sexual recidivism in a sexually violent predator/sexually dangerous person population, concluding that surgically castrated sex offenders had a very low incidence of sexual recidivism. However, these authors also pointed out that although orchiectomy can reduce sexual desire, it does not completely eliminate the ability to obtain an erection in response to sexually stimulating material, and the effects can be reversed by testosterone replacement. Berlin (2005) responded by saying that from a treatment standpoint, although lowing testosterone can provide a decrease in sexual appetite in this population, there seems to be little reason to use surgical castration because the same effects can be achieved with testosteronelowering medications.

As early as the 1940s, estrogens were used to treat sex offenders, but this treatment was discontinued by the 1960s due to serious side effects (Neumann and Kalmus 1991). Next, cyproterone acetate (CPA), a progestin derivate, was introduced in Europe and Canada, but it has never been made available in the United States. Medroxyprogesterone acetate (MPA) is available in the United States, and now gonadotropin-releasing hormone (GnRH) agonists, including leuprolide acetate, are being used. Each of these medications works because of its effect on sexual libido by ultimately, although by different mechanisms, lowering testosterone levels. Both MPA and CPA may be given orally or via long-acting intramuscular depot injection (to improve compliance). Importantly, they do not appear to influence the direction of sexual drive toward appropriate adult partners; rather, they act to decrease libido. MPA and CPA thus work best in those persons with paraphilia who have a high sexual drive and less well in those with a low sexual drive or an antisocial personality (Cooper 1986).

Although some clinicians feel that use of these types of biological interventions are useful in treating sex offenders (Berlin 2005; Kafka 1995; Kravitz et al. 1995), there are still relatively few treatment studies examining the use of the medications in this population, particularly those who are resistant to such a treatment. Rice and Harris (2011) argue that although many clinicians who treat sex offenders endorse the use of antiandrogens, it is likely that they do so based primarily on experience with sex offenders who freely request and are compliant with such treatment, and who are therefore likely to be a lower risk group for reoffense in the first place.

Maletzky et al. (2006) studied the outcome of released sex offenders in Oregon who, under state law, were evaluated prior to release to determine whether medical treatment with MPA was indicated to help reduce risk of reoffense. The researchers studied three different groups, including men determined to need MPA who actually received it, men determined to need MPA who did not receive it, and men determined to not need MPA. They measured sexual recidivism data, parole violations, and reincarcerations. The men who received the MPA committed no new sexual offenses, unlike men in the nontreatment groups. In the group that was determined to need MPA but did not receive it, nearly one-third committed new offenses, of which nearly 60% were sexual in nature.

A few researchers (Cooper et al. 1992; Hill et al. 2003; Hucker et al. 1988) demonstrated that many sex offenders are reluctant to use hormonal treatment and that these medications can be the cause of numerous side effects, some of which are serious (Krueger et al. 2006). Hormonal treatment should not be viewed as a guarantee against recidivism, and therefore these medications should never be the sole form of treatment (Briken et al. 2004).

The most significant long-term side effects of hormonal treatment are weight gain, increased blood pressure, impaired glucose tolerance, and gallbladder disease (Meyer et al. 1985). Some clinicians (Reilly et al. 2000) also warn that clinicians should be aware of medical contraindications to the use of hormonal treatments; such contraindications include preexisting pituitary disease, liver disease, and thromboembolic disorders. Hormonal treatments have also been associated with cardiac complications. Osteoporosis has also been associated with each of the hormonal medications and has also been seen in surgically castrated individuals. Clinicians are advised to consult with an endocrinologist and/or internist before and during hormonal treatment.

Treatment protocols often include monitoring of blood pressure, weight, testosterone level, follicle-stimulating hormone, luteinizing hormone, liver function, electrolytes, glucose, and complete blood count, with laboratory tests being repeated every 2-3 months until the patient is stable, and then every 6 months thereafter. Bone scans of pelvis and long bones should be repeated annually, and the patient should be monitored with a physical examination yearly. One could consider also performing baseline and follow-up electrocardiographic monitoring.

The use of antiandrogen medications is often referred to as chemical castration, although we do not think this is necessarily a very helpful terminology to use. Rice and Harris (2011) reported that nine U.S. states and several countries have laws regarding chemical or surgical castration of sexual offenders. Such laws in the United States have withstood legal challenge thus far, but many experts in the field have written about the ethics of such treatments with sex offenders, although it is accepted that some sex offenders can be offered medical treatments ethically (Association for the Treatment of Sexual Abusers 2005; Harrison and Rainey 2009; Stinneford 2006).

Other Pharmacological Treatments

Another promising focus of research has been on the use of other forms of pharmacological treatment for paraphilic disorders. Although a number of case reports and open-label studies have been done using the selective serotonin reuptake inhibitors (SSRIs) in treating paraphilic disorders (Beech and Mitchell 2005), this area of study seems to have stalled, and we are not aware of any new studies in the last few years. One pathway through which SSRIs have been proposed to be effective is by decreasing the libido due to a side effect, thus making paraphilic urges more manageable. One has to keep in mind, however, that there may be multiple reasons for their possible effectiveness. SSRIs have been helpful in treating depression, generalized anxiety disorder, panic disorder, and obsessive-compulsive disorder. Studies also have shown their benefit in such off-label uses as aggression, self-injurious behavior, and impulsivity (Goedhard et al. 2006). It is possible that the combined effects of serotonergic agents on helping to improve mood, decrease impulsivity, decrease sexual obsessions, and lead to sexual dysfunction might increase the ability of these individuals to control their paraphilic behaviors (Rothschild 2000).

To our knowledge, there have been no double-blind placebo-controlled studies to test the efficacy of SSRIs in treating paraphilic disorders. However, case reports and open-label studies dating back to as early as 1990 have concluded that SSRIs can be helpful in treating paraphilic disorder and related disorders (Greenberg and Bradford 1997). Fluoxetine (Bianchi 1990; Coleman et al. 1992; Emmanuel et al. 1991; Kafka 1991a, 1991b; Kafka and Prentky 1992; Lorefice 1991; Perilstein et al. 1991) and sertraline (Bradford 1995; Greenberg et al. 1996) have been the most studied. Other serotonergic agents such as fluvoxamine and clomipramine have also been studied (Clayton 1993; Greenberg et al. 1996; Zohar et al. 1994), as have nefazodone (Coleman et al. 2000) and buspirone (Fedoroff 1988).

Treatment using SSRIs may be applicable to different types of sexually inappropriate behaviors. For example, fluoxetine has been used successfully in the treatment of patients with voyeurism (Emmanuel et al. 1991), exhibitionism, pedophilia (Bourgeois and Klein 1996), and frotteurism (Perilstein et al. 1991) and in persons who have committed rape (Kafka 1991b).

Kafka (2000) noted that men with paraphilic disorders and men with nonparaphilic hypersexuality both benefited from SSRI treatment, and speculated that the enhancement of central serotonin neurotransmission by the SSRI may ameliorate symptoms of mood disorder, heightened sexual desire, compulsivity, and impulsivity associated with these disorders. There was suspicion in a case report, however, that an SSRI may have caused sexual obsessions in a previously nonobsessed individual (Balon 1994); therefore, individuals treated with these agents should be monitored in regard to their outcome.

Kafka (2000) summarized data regarding the current knowledge of using SSRIs in the treatment of both paraphilic disorders and paraphilia-related disorders. The SSRIs can be prescribed in the typical antidepressant dosages, although in our experience, higher dosages, as are often required in the treatment of obsessions, are sometimes necessary. It is important to realize, however, that more research is needed regarding the use of SSRIs for this purpose because the current knowledge is still based mostly on case reports and open clinical trials.

Kafka and Hennen (2000) described an open trial of psychostimulants added to SSRIs when treating paraphilic disorders in men. They concluded that sustained-release methylphenidate can be cautiously and effectively combined with SSRIs in ameliorating paraphilic disorders in some selected cases. However, there are no known follow-up studies to this initial investigation.

Although neuroleptic medications can reduce sexual drive (Olfson et al. 2005), they have not proven successful in treating paraphilic disorders. Additionally, there have been case reports of their use with mood stabilizers in treating single cases of paraphilia (Cesnik and Coleman 1989; Goldberg and Buon-giorno 1983), but no larger studies have shown their overall effectiveness as yet.

Other Pharmacotherapy Issues

Hill et al. (2003) proposed an algorithm for the use of differential pharmacotherapy of paraphilic disorders in sex offenders, but we urge that there has simply not been enough research to conclude that a specific certain pathway of treatment should be pursued in those cases where it is felt that medical interventions may be appropriate. With that said, many clinicians begin with the use of SSRI medications, and only if the SSRIs fail to help the patient do the clinicians use hormonal treatments, which have more serious side effects. Krueger and Kaplan (2001) proposed that the newer GnRH agonists are as effective as MPA or CPA, but with fewer side effects, and they may be the class of choice for hormonal treatment. In addition to having more side effects than SSRIs, hormonal treatments in general often result in lower patient compliance and require substantially more follow-up laboratory and other measures.

Because adolescents are estimated to commit up to 20% of rapes and 50% of child molestations (Hunter 2000), some have proposed using medication treatments in this younger population. Notably, however, the majority of adolescents who commit sex-related crimes would not typically be diagnosed with a paraphilic disorder, so decreasing sexual arousal may not be the primary issues of concern in most situations. However, some clinicians do feel that biological treatments may be called for in severe cases. The use of SSRIs in the adolescent population is quite limited (Galli et al. 1998) but may be considered with informed consent from parents or guardians. The use of hormonal agents in the adolescent population is not without controversy because they can suppress androgen levels that affect physiological changes that occur in puberty, including growth. It is recommended that if a hormonal agent trial is deemed necessary in an adolescent, the treatment should be prescribed for only short periods of time and only for adolescents whose sexual aggression has not responded to any other treatments (Saleh and Grasswick 2005).

Finally, the opioid receptor antagonist naltrexone was used in a small open-ended prospective study (Ryback 2004). Decreased fantasies and masturbation were reported in adjudicated adolescent sexual offenders. However, more research is necessary to conclude if this treatment will actually turn out to be helpful in those adolescents who struggle with paraphilic disorders.

Conclusion

Although significant advances have been made in the risk assessment and treatment of the paraphilic disorders, many questions remain to be answered. Only through rigorous research designs will researchers ultimately be able to answer some of the questions raised by Kirsch and Becker (2006). By successfully treating those individuals who have paraphilic disorders that involve the victimization of children, adolescents, and adults, clinicians will make society safer.

Key Clinical Points

• The paraphilic disorders are characterized as experiencing, over a period of at least 6 months, recurrent and intense sexually arousing fantasies, sexual urges, or behaviors, generally involving nonhuman objects or nonconsenting partners.
• If paraphilic behaviors involve only consenting partners, the diagnosis of a disorder should only be made in the presence of significant distress or psychosocial role impairment.
• If paraphilic behaviors involve nonconsenting partners, the diagnosis of a disorder may be made in the presence of objective evidence of recurrent behaviors, even when an individual denies a sexual interest in the behavior.
• It is important to keep in mind the purpose of the assessment, whether it is forensic or strictly clinical, because this may impact the methods used.
• Assessment of paraphilic disorders should be comprehensive and utilize not only self-report but also, when possible, standardized assessment instruments, physiological assessment tools, and sources of collateral information.
• A variety of behavioral therapies, hormonal treatments, and psychopharmacological treatments have been used to manage paraphilic disorders.
• In the treatment of paraphilic disorders that involve nonconsenting partners and illegal behavior, the clinician should conduct a thorough risk assessment and tailor the intensity of the intervention to the risk level.
• Treatment should focus not only on deviant sexual arousal but also on comorbid psychiatric disorders, criminogenic needs, self-regulatory deficits, and prosocial goals that lead to stability in the community.

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Suggested Readings

Archives of Sexual Behavior Volume 39, Issue 2, 2010

Association for the Treatment of Sexual Abusers (ATSA) Professional Issues Committee: Practice Standards and Guidelines for the Evaluation, Treatment, and Management of Adult Male Sexual Abusers. Beaverton, OR, ATSA, 2005

Laws DR, O'Donohue WT (eds): Sexual Deviance: Theory, Assessment, and Treatment, 2nd Edition. New York, Guilford, 2008

Stinson JD, Sales BD, Becker JV: Sex Offending: Causal Theories to Inform Research, Treatment, and Prevention. Washington, DC, American Psychological Association, 2008