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Sexual Deviance. Theory, Assessment, and Treatment. Second edition

Richard Balon, MD

Wayne State University, Detroit, MI, USA

Sexual deviations or paraphilias attract considerable attention from the public, the media, and law enforcement, yet are at the periphery of most psychiatrists’ interest. This is unfortunate because like other sexual problems, these disorders—and for that matter, many mental disorders—are at the crossroads of biology, psychology, and social sciences. Maybe because these disorders require a complex therapeutic approach is the reason for the lack of interest among psychiatrists or maybe it is the lack of training and progress in research in this area. It seems that other mental health professionals are more interested and involved in this area, as reflected by the editors and authors of this encyclopedical volume— both editors are psychologists and there are only 4 MDs among the 50 chapter authors.

Edited by D. Richard Laws and William T. O’Donohue; The Guilford Press; New York, New York; 2008; ISBN 13: 978-1-59385-605-2; pp 642; $70.00 (hardcover).

The second, revised edition of this book consists of 32 chapters. The first 3 chapters—“Introduction,” “An integrated theory of sexual offending,” and “Sexual deviance over the lifespan: reductions in deviant sexual behavior in the aging sex offender”—address some general issues. All paraphilias, rape, and online sex offending—including exhibitionism, fetishism, frotteurism, pedophilia, sexual sadism, sexual masochism, transvestic fetishism, voyeurism, rape, paraphilias not otherwise specified, and online sex offending—are covered in 22 following chapters. Each of these paraphilias is addressed in 2 chapters, “Psychopathology and theory” and “Assessment and treatment.” The remaining 7 chapters focus on issues that usually are not addressed in general textbooks (2 chapters on “Sexual deviance in females,” and chapters on “Multiple paraphilias,” “Sexual deviance and the law,” “Neurobiological processes and comorbidity in sexual deviance,” “Medical models and interventions in sexual deviance,” and “The public health approach: a way forward?”).

The Introduction addresses some areas I touched upon at the beginning of this review and provides a thoughtful critique of some issues. It starts by discussing definitional matters and rightfully mentions that the DSM-IV-TR approach is an institutional rather than scientific resolution to the definition problem in this and other areas (as the authors note, “there are no votes by the American Chemical Association to determine whether oxygen or hydrogen is inside or outside this taxonomy” [p 1]). The authors and editors also are critical of development of treatments for sexual deviations. They say “we now have a 50-year history of such treatments, and it is entirely reasonable to ask: What have we got to show for it? The answer, sadly, is very little.” The authors state that we must do better and suggest that we “ought to look at a macro-organizational level and plan strategies (as opposed to letting this remain a laissez-faire process) so that in the coming years more progress will be made.” They propose development of new interventions, such as the self-regulation model, the good-lives model, and desistance (which unfortunately they do not explain very well).

The chapter on integrated theory of sexual offending is the usual fare found in many textbooks and encyclopedias—a lot of theory and no answers. On the other hand, the chapter on sexual deviance across the lifespan offers more interesting arguments. The authors propose that, “although some individual traits and predispositions underlying sexual deviance, such as sexual preferences or antisocial traits, may persist to the end of life, the expression or performance of sexually deviant behavior decreases with age” (p 37). The chapter also contains a solid discussion of the well-known role of testosterone in male sexual behavior.

Chapters on particular sexual deviances provide standard, well-written summaries of each paraphilia, its psychopathology, theory, assessment, and treatment, in many cases with not much to say. I will touch on a few interesting points only. For those not familiar with Kurt Freund’s theories and proposals,1 the discussion of his conceptualization of some deviations as courtship disorders may be interesting. The authors of the chapter on frotteurism summarize Freund’s theory of courtship disorders (p 137) as “aberrations of the behavioral interactions that precede and initiate sexual intercourse: 1) the finding phase, consisting of locating and appraising a potential partner (ie, voyeurism); 2) an affiliative phase, characterized by nonverbal and verbal overtures such as looking at, smiling at, and talking to a potential partner (ie, exhibitionism); 3) a tactile phase, in which physical contact is made (ie, frotteurism); 4) a copulatory phase, in which sexual intercourse occurs (ie, rape).”

Some of the authors seem to assume that the reader knows the definitions and theories and resort to analysis of various issues and procedures without describing them well. An example is Viewing Time, an attractive alternative to measuring penile tumescence in pedophilia. The authors state that this test is easier to administer, but do not explain how to do it—ie, show various pictures to a suspected offender and measure the time spent over various pictures to classify the offender’s interest. The chapter on paraphilias not otherwise specified contains an exhaustive list and discussion of more and less known or sensational sexual deviations, from abasiophilia (lame or crippled condition of partner) to zoophilia. The interesting discussion of online sexual offending includes the COPINE Scale (as usual, COPINE is not defined)—a typology of Internet child pornography images for the COPINE organization ranging from Level 1: Indicative to Level 10: Sadistic/bestiality. The chapter also discusses the legal issue of “pseudoimages,” ie, digitally altered images without a clear-cut identification of the subject. The discussion on treatment of online sex offending is similarly interesting and important. The authors propose a useful typology of cybersex users or “cybersex user categories” (p 471-473), including recreational users (some of them may use cybersex to enhance their current relationship), sexual harassers, discovery users, predisposed users, lifelong sexually compulsive users, and sex offenders.

Chapters on sexual deviations in women are useful and interesting. Most of us might not pay attention to paraphilias in women, as “paraphilias are mostly a male affair.” Interestingly, the majority of sexual assaults perpetrated by women are committed against young people (p 487). The authors discuss various classifications of “female abusers,” such as self-initiated abusers (“predisposed abusers” and “teacher/lovers”) and accompanied abusers (“male-coerced abusers” and “male-accompanied abusers”). The authors also suggest that “rates of reported female sexual offending are likely to rise as practitioners are guided in what to look for, given encouragement and support to recognize and identify sexually inappropriate conduct by females, and given clear guidance on what to do in response” (p 504). The chapter on sexual deviance and the law addresses issues such as the forensic relevance of sexual deviance, standards of practice, diagnosis of sexual deviance in the forensic setting, and assessment of volitional impairment. The chapter on neurobiology, although well and heavily referenced, does not provide much new insight.

This is a solid, worthwhile volume for clinicians interested in paraphilias. It is well organized and contains a wealth of information. It is a useful addition to any mental health clinician’s library or university libraries as a reference book. The text has its weaknesses, such as some overlap among chapters. The biggest weakness, in my opinion, is the lack of practical advice. This is not your practical manual to guide you when managing sexual deviances. Rather it is, as I wrote, a reference book. Maybe the next edition could be more practical if we succeed in getting more information on the macro-organizational level and new strategies. Nevertheless, for anyone interested in this area, the book is worth buying.


  1. Freund K. Courtship disorders. In: Marshall WL, Laws DR, Barbaree HE, eds. Handbook of sexual assault: Issues, theories, and treatment of the offender. New York, NY: Plenum Press; 1990:195-207.