Frotteurism: Assessment and Treatment
Richard B. Krueger
Meg S. Kaplan
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Sexual crimes are commanding more media attention in our society. Whether there is an increase in crime or an increase in reporting has not been empirically established. However, the focus on sexually “deviant” interests has led to increased public interest in the paraphilias. More specifically, the lesser paraphilias, traditionally described as “nuisance” behaviors, have become more prominent in the public eye. The public is fearful that these “nuisance” acts might lead to more violent sexual acts, and women upon whom these nuisance acts are usually perpetrated are more apt to speak out against them and to prosecute their perpetrators. Therefore individuals with these behaviors seem to he coming to treatment now more frequently than in the past. This chapter will concern itself with the assessment and treatment of one of theses paraphilias, frotteurism.
Frotteurism is a paraphilia that involves the touching, usually in a crowd or place from which the perpetrator could easily escape if detected, of an unsuspecting person. According to the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994, p. 527), the diagnostic criteria for frotteurism consist of “A. Over a period of a least 6 months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving touching and rubbing against a nonconsenting person,” and “B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.”
Although there is literature on the paraphilias, the available literature on frotteurism is minimal. For example, a computer search by the reference department of the New York State Psychiatric Institute library, using the search title “frotteurism” in Psychlit from 1974 to March 1997, and in Medline from 1966 May 1997, resulted in only 17 sources. Accordingly, many of recommendations regarding the assessment and treatment of frotteurism derive from the clinical experiences of ourselves and our colleague’s in evaluating and treating individuals with multiple paraphilias. Furthermore, although sex offenses are committed by both males and females, there are no published accounts which we know of involving female frotteurs; therefore we will refer to a frotteur as “he.”
As with all psychiatric disorders, diagnostic assessment must begin with a comprehensive initial history and mental status examination. Sexual offenders are notorious for being poor historians, and often they have great incentives to deliberately minimize or deny any history of offenses that they might have. Furthermore, individuals may have cognitive distortions or rationalizations which come into play due to shame, guilt, or fear of consequences. Accordingly, it is very important at the onset of an evaluation to arrange for collateral sources of information to supplement a patient’s history and account of events.
For instance, if an attorney refers an individual for assessment and/or treatment, all relevant court documents, including arrest reports, victims’ statements, and prior psychiatric evaluations should be available, if at all possible, to the examining clinician by the time of the initial interview, so that he or she can question the patient on the basis of sources of information other than self-report. Often this involves reading verbatim from various records and challenging a patient’s own version of events. Any sources of information that exist should be used to develop the history as fully as possible. If possible, interview family members regarding their observations and knowledge of the patient. For instance, in the case of a frotteur, ask them how often does he ride the subway or bus? Are there periods in his schedule during the day that are unaccounted for and that may allow him time or opportunity for frotteuristic activity? In addition, ask the frotteur if he has disclosed his activity to significant others or to family members. The degree of disclosure to family members becomes important later in treatment in the creation of a monitoring network, consisting of family or friends or significant others who agree to observe the patient for signs or evidence of relapse and to report their observations to the treating clinician.
Regarding interviewing technique, it is our practice to conduct an ordered, comprehensive evaluation. In addition to recording the identifying data, source and purpose of referral, and/or the chief complaint, a thorough history of the paraphilic behavior and criminal history is important, focusing on the most recent events but then obtaining information on all prior aspects of the patient’s paraphilic and cnminal histories. We take a thorough history probing for prior psychiatric/psychological therapy, prior psychiatric hospitalizations or incarcerations, and any symptoms suggestive of major psychiatric syndromes. We obtain a thorough sexual history, including both deviant and nondeviant behavior and any history of sexual dysfunction that might be present. Ask about every paraphilia regardless of self-report.
Abel (1989} cites a number of factors affecting prognosis and treatment considerations which are important to include in the initial history and assessnent. These include the age of onset of the paraphilic interest and behavior (earlier onset correlates with greater ingraining of the paraphilia); age of the paraphilic patient (paraphilic behaviors tend to decrease spontaneously with age); frequency of the paraphilia (greater frequency usually is associated with greater recidivism); anxiety or guilt related to the paraphilic behavior (guilt is crucial to gaining insight and motivating the offender); concomitant drug and/or alcohol diagnosis (which should be treated); environmental surveillance (significant others who can help monitor the individual); and the presence or absence of concomitant appropriate sexual arousal.
Obtain a medical history with a focus on any endocrinological or neurological abnormalities, including any history of head injury.
Finally, describe and perform a full mental status examination with special attention to any stigmata of psychosis, major affective disorder, or cognitive abnormalities.
Psychometric Considerations in Diagnostic Assessment
There are numerous tools, including structured interviews and other psychometric tests, that clinicians can use to obtain information on both deviant and nondeviant behavior. Conte (1983) reviewed numerous scales developed to assess sexual functioning, most of which were intended to focus on nondeviant sexual behavior. She describes two instruments, the Clarke Sexual History Questionnaire tor Males (Clarke SHQ: Paitich, Langevin, Freeman, Mann, & Handy, 1977) and the Derogatis Sexual Functioning Inventory (Derogatis 1980; Derogatis & Melisaratos, 1979). She concluded that the Clarke SHQ appeared to be clinically useful for the assessment of deviant sexual behaviors and preferences in males, and that it could be used to assess sex offenders and sexually anomalous individuals. It is a 190-item sexual history questionnaire which inquires about the frequency and age of occurrence of a wide range of sexual behaviors, including paraphilias. This questionnaire has been used effectively in studies and surveys to identify paraphiliacs. In a recent survey, Bradford, Boulet, and Pawlak (1992) used this instrument to study 443 adult males consecutively admitted to the Sexual Behaviours Clinic at the Royal Ottawa Hospital for a forensic psychiatric assessment. A large portion of the sample was excluded from the final analysis, but the 274 subjects retained for analysis admitted to a combined total of 7,677 sexually deviant incidents. The authors noted that, whereas the agreement between actual and self-reported activity is always suspect, this instrument could be used to estimate the overall level of paraphilic activity.
In another recent study of 60 college-aged men, Templeman and Stinnett (1991) used the Clarke SHQ and the Farrenkopf Arousal Portfolio and Cardsort (Farrenkopf, 1986) to better evaluate the role of sexual arousal in individuals usually used as controls in sex research. They found, strikingly, that 65% had engaged in some form of sexual misconduct in the past, although only 2 subjects reported an arrest history. Interestingly, 35% of this sample of 60 had engaged in frottage.
We have found the Clark SHQ to be clinically useful. It can be used in conjunction with a clinical history to look tor inconsistencies between the written and oral histories and to further question the individual, or to pick up details which may have been omitted in the verbal history. There is also a computerized, self-administered version available.
The Derogatis Sexual Functioning Inventory focuses more on current and nondeviant functioning (Derogatis, 1980; Derogatis & Melisaratos, 1979). It is 258-item, self-administered instrument which reflects sexual functioning in 10 areas: information, experience, drive, attitudes, psychological symptoms, affects, gender role definition, fantasy, body image, and satisfaction. Scores are derived from each of the subtests and an overall score of sexual functioning is then computed. A major disadvantage is its length and complexity.
Another instrument, the Abel Screen, was developed by Dr. Gene Abel (Abel, 1994). It is a computer-driven, self-report instrument which initially presents slides of various sexual stimuli and then prompts the patient to endorse in a graded way his or her preference for the stimuli presented. The client then completes questionnaire which, in a very comprehensive fashion, queries about his or her sexual and paraphilic history. Dr. Abel is in the process of validating this instrument, and presented at the 1995 annual meeting of the Association for the Treatment of Sexual Abusers (ATSA) IAbel, 1995) some preliminary reliability and validity data concerning it, but as yet there are no published articles that describe it.
The Adult Cognition Scale was developed by the group at the New York State Psychiatric Institute (Abel et al., 1984). This is a 29-item self-report questionnaire, in which adults endorse statements according to a 5-point Likert-type scale ranging from “strongly agree” to “strongly disagree.” These statements describe various false cognitions that child molesters have. Abel et al. (1989) reported that child molesters endorsed significantly more distorted thoughts about molesting children than did other non-child-molesting paraphiliacs or community controls.
A second instrument developed by Abel (1984) and his colleagues is called the Adult Sexual Interest Cardsort. It consists of 75 items which are statements describing various forms of sexual activity, such as “A 25-year-old man and I are lying side by side naked touching each other all over.” Individuals are asked to endorse one of 7 items about the statement ranging from -3, “extremely sexually repulsive,” to 0, “neutral,” to +3, “extremely sexually arousing.” The items cover a wide range of sexual activities and preferences, This is used routinely by clinicians in the field, but its utility is weakened by the lack of published standardizations or validation.
The use of self-report techniques for assessment has raised the issue of whether some sexual behaviors and fantasies are under- or overreported during interviews or on questionnaires. In recent years researchers have developed objective physiological measures of sexual arousal (Abel, Blanchard, & Barlow 1981: Pithers & Laws, 1988). Although The ATSA Practitioner’s Handbook (Association for the Treatment of Sexual Abusers, 1993. p. 5) states that “plethysmography cannot be used to prove an individual did or did not, or will or will not commit a sexual offense,” it is useful as an aid for diagnosis, for pre- and post-treatment, and for assessment. A research study by Abel, Cunningham-Rathner, Becker, and McHugh(1983) examined the validity of traditional clinical interviews by confronting paraphiliacs with the results of subsequent evaluations. These confrontation revealed that 50 subjects (55.5%) admitted to an additional 92 paraphilic diagnoses. The results demonstrated that at least 55.5% of traditional clinical interviews with paraphiliacs are invalid, as various confrontation procedures (cardsort, 18.9%; reinterview, 20.0%: erection measures. 62.9%)can lead subjects to reveal a large number of new additional acts.
Although the research evidence supports penile erection measures as the most systematic and reliable measure of male sexual arousal, one criticism is the ability of some individuals to suppress penile erections. Some studies have indicated that subjects can intentionally influence their penile responses to visual stimuli in varying degrees (Freund, Watson, & Rienzo. 1988: Laws & Holman. 1978). Nevertheless, although there are difficulties, the objective measurement of sexual arousal is an important assessment technique with this population.
Some clinicians have used lie detector tests as an aid to help the individual admit to paraphilic acts. Lie detectors have been used in the assessment and treatment of pedophiles (Abrams & Abrams. 1993). Lie detector tests are not, for the most part, admissible in a court of law and their predictive value has been demonstrated to be poor (Brett, Phillips, & Beary, 1986). However, they are very intimidating and, not infrequently, they can induce individuals into admitting wrongdoing; some clinicians use them with this strategy in mind. In this regard, it is helpful to meet with the individual being tested before any such test and review his history in such a way that the individual is clearly confronted with a situation of lying or not. Often, his story might change and/or new details might emerge. and whenconfronted with this an individual may admit to deviant acts.
ASSESSMENT FOR TREATMENT
Abel et al. (1987) reported from their assessments of nonincarcerated paraphiliacs that frottage was a common paraphilic act. The rnean number of acts of the 62 adult males they found ‘with a primary diagnosis of frottage was 849.5. Accordingly, to fully quantify an individual’s frotteuristic and paraphilic histories, it is important to ascertain the frequency and number of occurrences. Clinicians should elicit further details which will be particularly relevant in subsequent treatment, such as the frotteur’s usual location for committing his acts (a train, a subway, a crowded street?). What is his usual modus operandi? Does he engage in his activity on his way to or from work or school? Does he engage in such an act impulsively or with planning? What is the frequency of the act? Which sex is his target? Are they old or young? Is there a particular appearance or body type that arouses him? Are their antecedents, for example, alcohol or drug ingestion, stress at work, or disappointment, to the frotteur’s offenses?
Incarcerated offenders also report a high occurrence of nonsexual crimes. Weinrott and Saylor (1991) obtained self-reports from 99 incarcerated sexual offenders and found that this sample reported that they committed nearly 20,000 nonsexual crimes in the year prior to incarceration. Accordingly, it is important to ask not only for a paraphilic history, but also for an overall criminal history. This also can have an obvious hearing on assessment and treatment.
In an early study Rooth (1973) reported that of 30 exhibitionists whom he examined, 12 had engaged in frottage. Abel, Becker, Cunningham-Rathner, Mittelman, and Rouleau (1988) demonstrated that individuals rarely have only one paraphilia. Interviewing 561 nonincarcerated paraphiliacs who were seeking voluntary evaluation and/or treatment for possible paraphilia under the protection of a certificate of confidentiality, they found that only 21% of frotteurs had frotteurism as a sole diagnosis and that on average, individuals with frotteurism had 4.8 paraphilias. Freund, Scher, and Hooker (1983) likewise reported on self report data of a sample of patients referred for evaluation of paraphilia of the 22 patients referred for touch or is some touching breasts or genital area of a female stranger without her consent five reported voyeuristic activity five exhibitionist activity to obscene calls and none rape likewise Bradford et. al. (1992) using the Clarke SHQ (Paitich et al., 1977) to study 443 adult males consecutively admitted to the Sexual Behaviors Clinic at the Royal Ottawa Hospital for a forensic psychiatric assessment found a high occurrence of multiple paraphilias in the same individual. They found that of the individuals who reported frotteurism as a paraphilia, 24% also admitted heterosexual pedophilic activity, 35% heterosexual hebephilic activity, 21% homosexual pedophilic activity, 17% homosexual hebephilic activity, 17% cross-dressing, 66% voyeurism, 29% scatologia, 31% attempted rape,16% rape, and 31% exhibitionism.
Other authors (Freund, 1988, 1990; Freund & Blanchard, 1996) have hypothesized that voyeurism, exhibitionism, toucheurism-frotteurism, and preferential rape patterns are all part of the same disorder, namely courtship disorder. In a more recent publication, Freund and Watson (1990) demonstrated that the preferential rape pattern co-occurred with voyeurism, exhibitionism, and toucheurism-frotteurism to a higher degree than did other paraphilic patterns.
Abel and Rouleau (1990) on the basis of their earlier work, recommended that sex offenders who present with one paraphilia should be evaluated with the possibility in mind that the individual may have multiple paraphilias, as clearly suggested by the other studies mentioned above. The occurrence of multiple or even one additional paraphilia(s) in the same individual is a finding which has not been replicated by Marshall and Eccles (1991), and they take issue with Abel and Rouleau’s (1990) recommendations for the comprehensive evaluation of individuals with one paraphilia for other paraphilias, saying that it could be too time consuming. In our experience, we frequently come across individuals with the coexistence of multiple paraphilias and we recommend asking specifically about additional paraphilias.
Additionally, the concomitant occurrence of a history of physical and/or sexual abuse (Hanson & Slater, 1988), conduct and attention deficit disorder in adolescent sex offenders (Kavoussi, Kaplan, & Becker, 1988), and depressive symptoms (Becker, Kaplan, Tenke & Tartaglini, 1991; Grossman & Cavanaugh, 1990; Kafka & Prentky, 1994) have been documented and clinicians should ask about these in any evaluation.
Psychometric Considerations in Assessment for Treatment
Once the clinician has obtained a clinical history with details as noted above, then he or she can obtain additional information from psychometric assessment to supplement the self-report.
Testing specific to the paraphilias can aid in treatment recommendations by revealing information which unstructured self-reports cannot provide. The Clarke SHQ (Paitich et. al., 1977), mentioned earlier, provides an excellent instrument to probe for multiple paraphilias. The Derogatis Sexual Functioning Inventory (Derogatis, 1980; Derogatis & Melisaratos, 1979, surveys the individual’s sexual functioning.
Penile plethysmography for an individual who admits to his deviant behavior can be a valuable instrument to assess the individual’s arousal to deviant and nondeviant sexual stimuli. Plethysmography was introduced into the study of sexual deviance by Freund (1963, 1965, 1967). Zuckerman (1971) reviewed various physiological and possible biochemical measures of sexual arousal in humans and concluded that the most specific measure of sexual arousal in the male involves penile plethysmography. Simon and Schouten (1991) recently reviewed the use of plethysmography in assessment and treatment of sexual deviance and concluded that its validity and clinical utility remain to he demonstrated. There are numerous problems with the use of plethysmography in treatment, including lack of a standardized stimulus set, lack of standardized protocols in terms of order of presentation or stimuli and length of exposure to stimuli, the possibility of test-retest learning, and the possibility of faking or suppressing responses. Nevertheless, we find this assessment useful. For instance, for frotteurs the presentation of various verbal scenarios and establishment of high arousal to frotteuristic stimuli seems to be good corroborative evidence that this activity is arousing to them. One could then administer behavioral or other treatmenta and reassess after a period of time to determine if there has been an objective decrease in arousal as measured by the plethysmograph. However, plethysmography is time consuming and should be used discriminately; caution in the use of plethysmographic assessment seems warranted. One can contrast the above psychometric tests, which more specifically probe for paraphilic psychopathology, with more general instruments, which may yield other psychiatric diagnoses.
There are well-accepted standard diagnostic instruments that probe for major mental illness, such as the Schedule for Affective Disorders and Schizophrenia (Endicott & Spitzer, 1978) or the National lnstitute of Mental Health Diagnostic lnterview Schedule (Robins, Helzer, Croughan, & Ratcliff, 1981), which could be used if aspects of the history require a more careful examination and confirmation of the diagnoses of major mental disorder.
The Personal Diagnostic Questionnaire (Hyler, 1995) is a self-report questionnaire To assess an individual and generate appropriate personality disorders from the 10 available in DSM-IV. Various versions of this have been described and validated (Hyler et al., 1990; Hyler, Skodol, Kellman, Oldham, & Rosnick, 1990; Trull & Larson, 1994). See the utility of this instrument as well psychological testing and an aid in confirming diagnosis or as a screen which can suggest further areas to explore.
Fagan et al. (1991) reported on the use of an instrument called the and personality inventory (NEO-PI; Costa & McCrae, 1985, 1989), comparing personality profiles generated from 51 men with sexual dysfunction with those of 51 age-matched men with a primary diagnosis of paraphilia. Men from the sexual dysfunction group had an average personality profile comparable to a normative sample whereas the paraphilias men had a distinctive personality profile characterized by high scores in the neuroticism domain and low scores on the agreeableness and conscientiousness domains. A second study by Wise, Fagan, Schmidt, Ponticas, and Costa (1991) examined 24 men diagnosed with transvestic fetishism utilizing DSM-III-R (American Psychiatric Association, 1987) criteria and found this group to be similar on most dimensions of the NEO-PI to the group of paraphiliacs studied earlier.
Erickson, Luxenberg, Walbek, and Seely (1987) reported on a study of 568 convicted sex offenders who had been referred for a presentence evaluation and who were given the Minnesota Multiphasic Personality Inventory (MMPI; Dahlstrom, Welsh, & Dahlstrom, 1972). They concluded that their findings did not support descriptions of any MMPI profile as typical of any sort of sex offender, and they condemned any attempts to identify individuals as likely sex offenders on the basis of their MMPI profiles. They posited that the MMPI could be better used to monitor long-term treatment progress. Hall, Graham, and Shepherd (1991) applied the MMPI to a sample of 261 sexual offenders in a state hospital and found that the offenders comprised a very heterogeneous population. In a broad review of the literature of personality correlates of pedophilia, Okami and Goldberg (1992), reviewing studies using the MMPI and other tests to examine numerous clinical contentions about pedophiles, concluded that “relatively little may be stated about the personality or phenomenology of pedophiles and sex offenders against minors” (p. 320).
Eysenck (1971) administered a personality inventory measuring psychoticism, extroversion, and neuroticism and a 19-question sexual questionaire to approximately 800 male and female students and found that personality scores were correlated with some of the sexual sexual attitude factors. Wilson and Cox (1983) administered the Eysenck Personality Questionnaire (Eysenck & Eysenck, 1975) to 77 members of a self-help club for pedophiles and found that, compared with control males, the pedophiles were more significantly introverted and higher on the psychoticism and neuroticism scales.
The Rorschach (Exner, 1974) has been used in individuals with paraphilias. For examples, Meloy and Gacono (1992) presented a case assault. They used these responses to develop a dynamic portrait which to them suggested a psychotic level of organization and great dangerousness.
The Hare Psychopathy Checklist — Revised (Hare, 1991) has been used to obtain a broad survey of an individual’s sociopathy. This is a 20-item rating scale for assessing psychopathy in male forensic populations. Scores on the Psychopathy Checklist were predictive of voilent recidivism in a maximum security psychiatric setting (Harris, Rice, & Cormier, 1989) and in a sample of adult rapists (Rice, Quinsey, & Harris, 1991). The Buss-Durkee Hostility Inventory (BDHI; Buss & Durkee, 1957) is a widely accepted instrument that can be used to assess impulsivity and aggression. Hall (1989) used this instrument to examine a sample of 239 sexual offenders and found that BDHI scores were higher in sexual offenders against adolescents and adults compared with those of sexual offenders against children. However, Overholser and Beck (1986), comparing incarcerated child molesters, rapists, and three control groups found that the BDHI and other instrument used to assess hostility were not useful in distinguishing child molesters and rapists from the three control groups.
Hucker et al. (1986) reported on the neuropsychological assessment of 41 pedophiles, which included the Reitan neuropsychological test battery (Reitan, 1979), the Luria-Nebraska Neuropsychological Battery (Golden, Hammeke, & Purisch, 1981), the WAIS-R (Wechsler, 1981), and the Michigan Alcohol Screening Test (Selzer, 1971). They found that pedophiles tended to have lower IQs than controls and were significantly more impaired on all measures. Scott, Cole, McKay, Golden, and Liggett (1984) compared sexually anomalous men with normal controls using the Luria- Nebraska Neuropsychological Battery and found that 36% of pedophiles shows impairment. O’Carroll (1989), however, using different neuropsychological tests and a group of only 11 sexually deviant subjects, did not find differences compared with control groups of anxious patients or normal subjects. These studies suggest that there may well be neuropsychological abnormalities in some paraphiliacs. Although we do not routinely do neuropsychological testing, it there is a reason to suspect brain injury or damage from the clinical history, then we use the mini-mental status examination, with modifications (Folstein, Folstein, & McHugh, 1975; Dick et al., 1984), to screen and decide if further evaluation is indicated. It has been used mainly in the study of dementias.
Still another instrument which has been used by some clinicians is the MicroCog (Power et al.1993), is a computer administer method of assessing adults with mild to moderate levels of cognitive impairment. It is a self-administered instrument assesses functioning in nine areas of brain functioning and which can be used as a screen to determine if further neurological Nero psychiatric assessment as warranted. Head injury or neurological illness can be associated with decreased Control and individuals with paraphilias, and a clinical history and the above instruments can screen for these.
Substance abuse is an important area to assess. Erickson et al. (1987) reported that over 50% of the subjects of their sample of 568 convicted sex offenders were chemically dependent. Bradford and McLean (1984) found that the high violence subgroup in their survey of 50 male sex offenders was significantly associated with a history of serious alcohol abuse and dependence. Hucker et al. (1986), in a survey of pedophiles completing the Michigan Alcoholism Screening Test, found that 38% of pedophiles were alcoholics. The Short Michigan Alcoholism Screening Test (Selzer, 1971; Selzer, Vinokur, & Van Rooijan, 1975) is an excellent self administered instrument which can screen for problems with alcohol.
Finally, the Beck Depression Inventory (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961) is a self-administered, brief screen for depression.
The Multiphasic Sex Inventory (MSI; Nichols & Molinder, 1984, 1992) is another instrument that has been administered to sexual offenders. It contains scales of sexual knowledge, sexual deviance, validity, and sexual dysfunction. Data have been published on the utility of the MSI in predicting treatment progress and therapy outcome (Simpkins, Ward, Bowman, & Rinck, 1990).
The Million Clinical Multiaxial Inventory – III (Millon, 1983) is another instrument that has been used with pedophiles; however. there are no published studies involving its use with frotteurs.
Medical Aspects of Assessment for Treatment
Some clinicians incorporate as a usual part of their treatment a physical examination, screening laboratory tests (including a complete blood count with differential), a complete chemistry screen, an electrocardiogram, a urinalysis, and endocrinological measures including testosterone level, follicle stimulating hormone level, and luteinizing hormone level. Although we do not routinely do this, we will refer the patient for a medical or neurological workup if specific aspects of a patient’s history suggest its utility. For example, a history of a head injury antedating paraphilic behavior suggests a possible relationship between the two, and we would refer an individual to a neuropsychologist and/or a neurologist for a more detailed assessment. The development of frotteurism abruptly in a man in his 50s or 60s with headaches might suggest a brain tumor, and that individual should be referred to a neurologist. If an individual is to be placed on tricyclic antidepressants, a treatment which has been used for some frotteurs, then a careful history regarding an individuals cardiovascular health, any family history of cardiovascular disease, and a baseline electrocardiogram to rule out conduction defects in the hearts electric system (which can be exacerbated by tricyclics) is indicated. We usually referred a patient to an internist or to his family doctor for this.
Rada, Laws, and Kellner (1976) that plasma testosterone was significantly higher in sadistic compared with non-sadistic rapists, but failed to replicate this (Rada et al., 1983). Gaffney and Berlin (1984) studied hypogonadal-pituitary function in seven pedophiles, five non-pedophilic paraphiles, and five controls and found a significant difference between the pedophilic group and the other two groups in the luteinizing hormone response to luteinizing hormone releasing hormone, with the pedophiles responding with a marked elevation of luteinizing hormone to luteinizing hormone releasing hormone compared with the two other groups. However, Bradford and McLean (1984), examining morning testosterone levels of 50 consecutive male sexual offenders presenting for an evaluation, found no relation between violent sexual offenders and plasma testosterone levels. Accordingly, it is not our usual practice to perform gonadotropin or endocrinological assessments of individuals unless so guided by other data.
THEORIES OF THERAPY WITH REVIEW OF OUTCOME AND PROCESS RESEARCH
Again, we must emphasize that, aside from a few case reports, therapy suggestions have been developed from a heterogeneous group of paraphiliacs in general and not derived specifically from the treatment of frotteurs, as far as the published literature is concerned. Furthermore, as we have pointed out, frotteurism often occurs along with other paraphilias in the same individual, in therapy must be designed to target multiple paraphilias. Additionally, because the patient may have personality, medical, and other individual factors that require attention and create a unique situation, therapy must be individualized to the needs of the specific frotteur.
That said, major current treatment therapies for frotteurs can be divided into cognitive-behavioral, biological, and relapse prevention modalities.
Cognitive-behavioral therapy has been widely used in the treatment of the paraphilas, and well described in several reviews (Abel, Osborn, Anthony, & Gardos, 1992; Abel, Rouleau, & Cummingham-Rathner. 1983; Hawton, 1985). This treatment views sexual fantasy as an independent variable (Abel & Blanchard, 1974) that can be altered by behavioral interventions, including techniques of covert sensitization that link deviant urges with negative consequences by having the patient mentally and verbally pair the two (Abel et al., 1984), olfactory aversion (pairing the smell of ammonia with paraphilic images and urges; Laws, Meyers, & Holmen, 1978; Laws & Osborn, 1983), masturbatory satiation wherein a patient masturbates in a certain prescribed way designed to decrease his arousal to the deviant stimuli (Laws & Marshall, 1991; Abel et al., 1984), and cognitive restructuring (encountering a paraphile’s rationalizations and cognitive distortions; Abel et al., 1984; Murphy, 1990). It is very practically oriented, focusing most on the here and now and on improving an individual’s control of his deviant impulses and decreasing his arousal.
An earlier review by Kilmann, Sabalis, Bukstell, and Scovern (1982) examined outcome research on the treatment of patients with paraphilias; they noted that there was a reliance upon verbal self-reports in the evaluation of outcome and concluded that the literature tentatively supported on multiple behavioral package specifically tailored to the patient’s sexual arousal pattern. Marshall, Jones, Ward, and Johnston (1991) published a more recent review which concluded that comprehensive cognitive behavioral programs in combined hormonal and psychological treatments we’re effective in treating child molesters and exhibitionists, but not rapists. Quinsey, Harris, Rice, and Lalumiere (1993) challenged this review, expressing the opinion that the effectiveness of treatment in reducing sexual offender recidivism had not yet been scientifically demonstrated and that more well controlled outcomes research was necessary. Marshall (1993) responded to their criticism regarding outcome data. Marshall and Barbaree (1990) reviewed outcomes of comprehensive cognitive behavioral treatment programs and concluded that these approaches had a positive future, but that indices for treatment effectiveness needed to be developed. Laws and Marshall (1991) reviewed the literature on employing various sorts of masturbatory satiation. They reviewed four methods masturbatory reconditioning and noted there were a few controlled studies and no group comparison studies. They indicated that directed masturbation and satiation might be most effective and suggested that more careful, larger studies would be required to develop a solid empirical basis for these techniques.
Many programs identified and described in the survey of treatment programs and models of the Safer Society Program (Freeman-Longo, Bird, Stevenson, & Fiske, 1994) employee a cognitive behavioral approach. This treatment approach utilizes techniques such as masturbatory satiation, covert sensitization, cognitive restructuring, sexual education, social skills training, and assertiveness training. These are administered primarily in a group therapy setting, with augmentation as needed with individual or couple sessions, and with medications. Relapse prevention is also an important component of these programs.
In recent years there has been a great deal of controversy over whether to treat men who deny a sexual behavior problem (Maletzky, 1996). Several approaches have shown positive results in working with offenders who deny (Hoke, Sykes, & Winn, 1989; Maletzky, 1996; O’Donohue & Letourneau, 1993; Schlank & Shaw, 1996; Winn, 1996).
Biological Therapies specific for the paraphilias by and large consisted of antiandrogen therapy and antidepressant therapy. There are several reviews of antiandrogen therapy (Berlin & Meinecke, 1981; Bradford, 1985; Cooper, 1986). These have focused on the use in United States of Depot or oral Provera, which lowers testosterone and in Canada the use of cyproterone acctate, which acts through competitive inhibition androgen receptors, blocking the actions of testosterone and dihydrotestosterone. Cyproterone acetate is not approved for use in the United States. Bradford and Pawlak (1993) reported on double blind, placebo-controlled, crossover study involving 19 paraphilic men referred for a pretreatment assessment, one of whom had the exclusive diagnosis of frotteurism. Results showed a significant reduction of testosterone and follicle stimulating hormone (FSH) along with a reduction in sexual arousal, activity, and fantasy, compared with placebo. Meyer, Cole, and Emory (1992) reported on a serious of 40 men with heterogeneous diagnoses who were treated weekly with intramuscular medroxyprogesterone acetate (MPA) in durations lasting from 6 months to 12 years ( usually more than 2 years): the follow-up period lasted from 2 to 12 years. Whereas the control group was not randomized and it consisted of individuals who had refused the therapy, 18% reoffended while receiving MPA therapy, compared with 58% of control patients. Main side effects included Weight gain, malaise, migraine headaches, leg cramps, elevated blood pressure, gastrointestinal complaints, gallbladder stones, and diabetes mellitus. Gottesman and Schubert (1993) described the use of low dose oral MPA in doses of 60 mg per day in seven men who were outpatients with heterogeneous diagnoses, none of which included frotteurism. All patients reported significant fewer paraphilic fantasies, and none reported engaging in paraphilic incidents during MPA treatment.
Recently there have been several reports on the use of long acting gonadotropic hormone releasing hormone agonists (e.g. Lupton) to treat paraphilias, with excellent results (Dickey, 1992; Thibaut, Cordier, & Kuhm, 1993; Rousseau, Couture, Dupont, Labrie, & Couture, 1990). These agonists result in the continued stimulation of the gonadotrope cells in the anterior pituitary, which secrete luteinizing hormone (LH) and FSH, desensitizing these cells and leading, after a week or two, to suppression of the secretion of LH and FSH; this intern leads to a decrease in gonadal testosterone secretion. They are unrelated to steroid hormones and adverse effects such as gynecomastia, thromboembolism, edema, and liver and gallbladder problems are less common than with other antiandrogen agents (American Medical Association, 1995, Tolis, Mehta, Comaru-Schally, & Schally, 1981). They are also available in depot form, which can be given as a monthly injection.
Possible relationship between paraphilias and obsessive-compulsive disorder (OCD) has been suggested (Cryan, Gutcher & Webb, 1992, Jenike, 1989; Stein et al., 1992), and accordingly, it has been further suggested that agents used to treat OCD might be useful in treatment of paraphilias. Furthermore, Mark side effects on sexual functioning exist for the agents used to treat OCD, including both clomipramine, a tricyclic (Monteiro, Noshirvaru, Marks, & Lelliott, 1987), and other serotonergic medications such as fluoxetine, patoxitine, and sertraline (American Medical Association, 1995). Kruesi, Fine, Valladares, Phillips, and Rapoport (1992) reported on a double-blind, crossover comparison of clomipramine versus desipramine in 15 patients with paraphilias; this sample included three individuals with frotteurism. Four subjects were placebo responders and was dropped from study and three subjects failed to complete the study. Both drugs decreased the severity of paraphilic symptoms relative to placebo and there was no difference between the two drugs. Side effects noted during this five week trial were greater with clomiprmine than with desipramine and included delayed ejaculation, erectile dysfunction, and pain on ejaculation. The authors noted no apparent relation between these side effects and improvement in paraphilia while on the antidepressant; they reported that sexual functioning often improved without return of the paraphilic behavior. Selective serotonin reuptake inhibitors have also been tried successfully. Kafka (1991a) reported that 9 of 10 men with either nonparaphilic secual addiction or paraphilia improved while taking fluoxetine, imipramine or lithium. She also reported on the successful treatment of a rape assailant with fluoxetime (Kafka, 1991b), Perilstein, Lipper, and Friedman (1991) reported on the apparently successful treatment of three individuals, including one with voyeurism/frotteurism, with fluoxetine, Bradford and Gratzer (1995) offered a case report of the successful use of sertraline in a patient diagnosed with pedophilia, major depression, and trichotillomania. The monoamine oxidase inhibitor phenclzine has also been reported to influence sexual behavior (Golwyn & Sevlie, 1993; Warnecke, 1994).
Relapse Prevention Therapies
Relapse prevention strategies have been described and employed recently with paraphiliacs (Freeman-Longo & Pithers, 1992, Laws, 1989, Pithers, 1990; Pithers, Kashima, Cumming, & Beal, 1988). This therapeutic modality emphasizes helping individuals to identify the chain of antecedent thoughts, situations, any behaviors that lead to a relapse and offers strategies to an individual to avoid lapses. These strategies include interrupting the chain of events leading to lapses, avoiding precipitating stimuli, avoiding or escaping from situations of risk, enhancing interpersonal skills, and anger and stress management.
RECOMMENDED TREATMENT STRATEGIES
As with any patient with a psychiatric disorder effective treatment must be based on a thorough assessment and diagnosis. Often this will include a report to the patient’s lawyer and/or to the court. Although a patient’s legal situation can remain on certain for a long period of time, we attempt to help them resolve it with a clear-cut recommendation the court or from parole or probation agencies specifying that individuals continue in therapy.
Given the often very poor motivation of paraphiles, it is imperative to, if possible, get the legal system and/or significant others involved to insist on therapy. It is also important to have the individual acknowledge guilt and accept responsibility. This is sometimes accomplished by the time the individual enters treatment, by admitting his wrongdoing or having pled guilty in court. Many offenders deny at the beginning of treatment but admit responsibility during the course of treatment, some continue to deny. Some clinicians will work with individuals who deny, but only for limited periods of time in which the principal goal of helping them to admit. Recently, conditions have been successful in this area (Maletzky, 1996).
With respect to treatment modality, unless the patient is dangerously out-of-control, the first treatment attempt would involve verbal in cognitive behavioral methods because please avoid the side effects of medication. If an individual has another Axis 1 disorder, such as alcohol or substance-abuse or dependence, bipolar disorder, for depression, then it is important to treat the Axis 1 disorder in the conventional fashion initially, initiating appropriate medications and recommending Alcoholics Anonymous or Narcotics Anonymous, family member participation, toxic screens of blood and/or urine, and hospitalization if indicated.
If an an individual is unable to achieve control of his deviant urges, then the clinician might consider medication using one of serotonin-reuptake inhibitors, which might diminish and give the individual for control over his frotteuristic urges. If these interventions are not successful, then antiandrogen agents might be indicated. Where as either oral or depot Provera could be used, we have found that depot Lupron given at monthly intervals is superior; it is better tolerated, requiring monthly as opposed to weekly injections, and causes markedly fewer side effects than does Provera. Initiating the course of depot Lupron, treatment with flutamide, a nonsteroidal antiandrogen, to commence on the day of Lupron injection and to continue for 2 weeks is indicated to counteract any surge in testosterone which may occur with the onset of Lupron. The antiandrogens are, in our experience, markedly effective in suppressing his sexual urges. Problem with them is that they significantly truncate an individual’s sexual life and sooner or later an individual wishes to stop them. Prior to this happening, and while someone is on a course of Lupron therapy, we initiate and continue cognitive behavioral treatment as well.
Following completion of an acute group of weekly sessions which generally lasts from 1.5 to 2 years, if ready, patients are referred to an ongoing relapse prevention group for indefinite continuation. When family members have been educated regarding the individual’s problem, conditions and join them to help monitor the patient and report any worrisome activity to the therapist. For instance, if an individual’s frotteurism has been associated in the past with alcohol intoxication and his wife sees him intoxicated, and she is to notify his treating clinician. Periodically, the therapist will have individual meetings with the family member or individual patient.
Individuals with paraphilias most of the time do not enter treatment of their own volition, and this is also true of frotteurs. Their paraphilic behavior is pleasureful and reinforcing and patients do not like to relinquish it; often arrest and involvement of the legal system are required to bring the individual to treatment. Frotteurism it’s often viewed as a “nuisance” crime; furthermore, cases are frequently very difficult to prove because a frotteur’s contact me be ambiguous and there need to be many complaints to successfully prosecute a case. Accordingly, any pleas or sentencing may involve a reduction to a misdemeanor (frotteurism is in some states a felony), with sentencing to outpatient therapy and with no jail time. Indeed, it is extremely unlikely that frotteurs will be incarcerated for their frotteuristic activity.
Referral sources often include legal entities with numerous interests, such as defense attorneys, who may wish to have a forensic defense prepared, if possible, or who may wish to have their client assessed and involved with treatment before sentencing or as an aid in sentencing. Some prosecutors may wish to have a second opinion regarding diagnosis and treatment from a psychiatrist or psychologist other than those, you should be hired by the patient’s defense lawyer, you may have already assessed the patient. Judges may wish to have an independent evaluation as an aid in adjudicating the case. Less often, a significant other (spouse or girlfriend) will discover the behavior and insist that individual come to evaluation. Occasionally other entities, such as medical boards, hospital administrations, for corporations will become aware of complaints from patients or employees and refer the individual for therapy.
Accordingly, given the numerous sources of referral and reasons for an evaluation, it is paramount to inform individual, even before the clinician sees him or her, of concerns regarding confidentiality and duty. Usually, because frotteurs do not have an identifiable target here is predictably at risk, there is no duty to report any activity or crimes to the authorities. If an individual is referred from a prosecutor or lawyer, then one should additionally say to the individual just who has ordered the assessment and for what reason. We collection patients that the usual patient-physician confidentiality does not apply, in that whatever they might say could be included in a report to the referring entity. Furthermore, evaluation sessions could be potential used to incriminate them, and we advise individuals of this. If they clinician interviews family members such as a husband, wife, or child, then we give them the same warning. Where ever there is the possibility legal or criminal involvement (which is most of the time), we always ask individuals if they have an attorney, and we advised him to get one if they do not have one already. Clearly, there are numerous purposes for evaluations and confidentiality is not at all assured; we tell the perpetrator involved about the ground rules. Laws and practices regarding confidentiality very from state to state and between different countries, and the clinician should check with his or her professional organization or lawyer for applicable guidelines.
The lack of confidentiality clearly can have a dramatic effect on the extent and truthfulness of industry. Kaplan, Abel, Rathner, and Mittelman (1990) studied offenders who were interviewed about their paraphilic histories, first by their parole officer in a correctional setting, and then at a setting within the mental health system with elaborate safeguards to their confidentiality. Offenders reported only 5% of the sexual offenses in the criminal justice setting that they did in the mental health settings. However, Weinrott and Saylor (1991) on his studies which used computer-administered interviews to examine self-reports of criminal behavior from 99 institutionalized sex offenders, we’re told that their responses would be “confidential but not anonymous.” They found that the offenders disclosed an enormous number of offenses, both sexual and nonsexual, and argued that self-report instruments were a valid method of collecting data. It is never possible to completely ascertained truthfulness. However, it is our experience that individuals range in admissions that they make from complete denial to a seemingly extensive acknowledgment of acts committed under the circumstances of warning.
At the onset of treatment, when the legal system is involved the clinician should have the patient sign a release of information which will allow the clinician to speak with his parole officer, probation officer, or other supervising entity at any point regarding attendance, motivation, or dangerousness. We tell individuals when they sign such a release that by and large we will not reveal details of their treatment or verbalizations, but rather we will tell the supervising official only of the attendance rate, the degree of motivation in sessions, and the reported degree of control over sexual impulses. For individuals who have a probation officer, we often develop a sheet, which the patient is instructed to carry with him at all times, which includes a record of the date and time of the sessions scheduled, the time the patient arrived, the degree of motivation he manifested, any other comments, and the date and time of the next session. The treating clinician initials each completed section. In our initial contact with parole or probation officers we inform them of the existence of such a sheet. This then allows the official to check with the patient at any time regarding their attendance without necessitating frequent written reports from the therapist. This also allows the parole or probation officer to make spot checks or home visits and have immediately available documentation of attended sessions.
Regarding the use of plethysmography, the Association of the Treatment of Sexual Abusers (ATSA) has published standards and guidelines (Association for the Treatment of Sexual Abusers, 1993). According to these guidelines the use of plethysmography as a vehicle for determining the guilt or innocence of an individual is unethical. The determination of guilt or innocence should be left to the judicial system.
Regarding risk assessment, clinicians are frequently ask to make predictions. However, according to Monahan (1981, 1984), the track record of clinicians’ use of intuitive judgments in predicting violence is quite poor. There are no knows empirically validated instruments that we know of which are predictive. There is no “profile” that can be constructed reliably with standard psychometric tests that will predict dangerousness. Clinicians must rely on their experience, and factors or relevance inclue the coexistence of multiple paraphilias, the existence of other diagnoses, the amount of violence involved, the number of victims involved, and the severity of the offense.
With respect to informed consent, the issue of freedom of choice is a significant one, particularly if antiandrogen agents are given. Generally speaking, if an individual does not come to treatment, it could have repercussions for him should his probation or parole officer become aware of this. Accordingly, there exists a subtle or not-so-subtle coercion for the individual to come to therapy, or, as an alternative, to be incarcerated.
We recommend that clinicians have an individual sign an informed consent which lists the risks and benefits of any specific assessment and the risks and benefits of specific treatment modalities. Principally, the main risks of both evaluation and treatment are sexual dysfunction and mild symptoms of anxiety and/or depression. Obviously, medications have their own specific effects; side effects and risks and benefits and should be dealt with separately.
The problem of nonconsenting sexual behavior is widespread in our society. Although the literature on frotteurism is sparse, there is a great deal of research on paraphilias in general. What is known is that men who engage in frotteurism have large numbers of victims, are not often arrested, and, when apprehended, do not serve long sentences. Although frottage is usually considered merely a “nuisance,” future research needs to ascertain what percentage and which of these individuals are at risk to commit more violent sexual offenses. Further research also needs to address the early onset of this behavior.
There are numerous assessment and treatment modalities which have worked with other paraphilias and should work as well with frotteurs. Research needs to address specific area of treatment needs with frotteurs, and what treatments frotteurs respond to.
Psychophysiological assessment is a valuable method of eliciting information which may not be available in other self-report assessments. Because this method of assessment is time consuming and expensive, the development of reliable and valid alternative assessments of sexual interest would be a valuable contribution to the field.
The evidence presented on medication seems especially promising; medications will have an important role to play in conjunction with other treatments. Any case reports or small studies of successful treatment with frotteurs would be an important contribution to the field.