Voyeurism: Psychopathology and Theory

Voyeurism
Psychopathology and Theory

Meg S. Kaplan
Richard B. Krueger

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DESCRIPTION OF THE DISORDER

“Voyeurism” is viewing some form of nudity or sexual activity, accompanied by sexual arousal. To be classified as a sexual disorder, or a paraphilia, voyeurism must be characterized by observing unsuspecting individuals, usually strangers, who are naked or engaging in sexual activity, for the purpose of seeking sexual excitement (American Psychiatric Association, 1994). Usually, the voyeur weeks no contact with the observed individual or individuals. “Orgasm, usually produced by masturbation, may occur during the activity or later in  response to the memory of what the person has witnessed. Often these individuals have the fantasy of having a sexual experience with the observed person, but in reality this rarely occurs” (American Psychiatric Association, 1994, p. 332.).

According to the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994, p. 532), the diagnostic criteria for voyeurism are “A. Recurrent, intense sexual arousing fantasies, sexual urges or behaviors involving voyeuristic activity, “ and “B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important area of functioning.”

For some individuals, voyeurism is the exclusive form of sexual activity. For others, these fantasies are preferred but not obligatory for sexual arousal. In a third group of individuals these fantasies and urges become more intense only during periods of stress, and they are episodic. Many individuals include voyeuristic fantasy or behavior in a repertoire of sexual fantasies (American Psychiatric Association, 1994, p. 532). It is only when these fantasies become a focus for an extended period of time (6 months or more) and cause distress or impairment in one’s life that this owuld be diagnosable as a paraphilia.

John Money (1996, p. 373) defined voyeurism as “a paraphilia of the solicitational allurative type in which sexualerotic arousal and facilitation or attainment of orgasm are responsive to, and dependent upon, the risk of being discovered while covertly watching a stranger disrobing or engaging in sexual activity.” Other clinicians have used terms other than voyeurism. For example, “peepers” (Gebhard, Gagnon, Pomeroy, & Christianson, 1965), “inspectionalism.” (Coleman, 1964) and “mixoscopia” (Money, 1996) have all been used. In addition, there are related terms and/or sexual disorders which include voyeurism, or wherein gratification may be received from looking instead of participating. These include the following:

1. Scoptolagnia: Sexuoerotic gratification produced by watching people engaging in sexual activity (Money, 1996, p. 270).

2. Scopophilia: The sexual need to watch others undress.

3. Scoptophilia: Excessive interest in looking at genitals or sex acts as a sexual stimulus (Karpman, 1954) and, according to Money (1996) sexual gratification which depends upon watching others engaging in sexual activity.

4. Troilism (or triolism): A paraphilias wherein there is a dependence on “observing one’s partner on hire or loan to a third person while engaging in sexual activities, including intercourse, with that person. A threesome or group sex does not, per se, constitute a paraphilia” (Money, 1996, p. 272) Troilism differs from voyeurism that the person being observed in not a stranger.

5. Pictophilia:Dependence upon viewing onscene or pornographic pictures or video tapes (Money, 1996, p. 268).

Money (1996), in discussing scoptophilia and pictophilia, speaks of both as pertaining to being turned on by “being and invited guest at someone else’s erotic performance, either in pictures, on film, or live, which is far more likely to be an occasional pastime that a paraphilia. Observing qualities as scoptophilia or pictophilia only if it is an imperative on which one’s own arousal and orgasm depend. Unlike voyeurism, scoptophilias is with the consent of the participant: (pp. 82-83).

AGE OF ONSET AND COURSE

According to DSM-IV (American Psychiatric Association, 1994), the onset of voyeuristic behavior is usually before age 15. The course tends to be chronic and lasts a lifetime.

Able and Rouleau (1990) conducted an 8-year longitudinal study of 561 male sexual assaulters who sought voluntary assessment and/or treatment for their paraphilic disorders at the University of Tennessee Center for the Health Sciences in Memphis, and at the New York State Psychiatric Institute in New York City. At the former site, all categories of paraphiliacs were included, whereas at the latter site, because of preselection only subjects whose inappropriate sexual behavior involved children were evaluated. In their study, 50% of voyeurs had interest in that deviant behavior prior to age 15.

EPIDEMIOLOGY

The extent to which voyeurism exists in the general population is unknown because most individuals who have the problem are secretive and fearful of arrest, so they are unlikely to report it even if specifically asked. The legal system collects arrest and conviction data; however, these data are not representative because many voyeurs are not arrested and many acts are committed against an unknowing victim.

Of those who are arrested, the charges are usually nonsexual, such as loitering or disorderly conduct. Data from victim sources may not be representative and do not single out noncontact offenses such as voyeurism apart from other noncontact offenses such as exhibitionism. According to Meyer (1995) as many as 20% of women may have been the target of exhibitionism and voyeurism. Another source of information regarding the incidence of voyeurism is clinics that treat paraphiliacs. These data do not reflect all individuals with voyeurism, as most paraphiliacs are not motivated to seek treatment and they do so only when apprehended.

Oh those paraphiliacs who sought outpatient treatment in a clinic in Atlanta, 13.9% of the adolescents were voyeurs and 12.9% of the adults were voyeurs. The median number of reported voyeuristic acts per patient for voyeurs was 17 (Abel, 1989).

GENDER ISSUES

The exact incidence of sexual crimes committed by women is unknown. However, the reported incidence is low compared with reports of male sexual offenders. According to Finkelhor (1986) 90% of reported cases are male. The cases of female offenders least frequently reported are those where there is no physical contact involved, such as voyeurism. In the few studies available, female sexual offenders have been described as having severe psychiatric impairment (McCarty, 1986; Mayer, 1983, O’Conner, 1987) and prior sexual victimization (McCarty, 1986, Mathews, Mathews, & Speltz, 1989; Travin, Cullen, & Protter, 1990). None of these studies included voyeurism per se.

In a recent study by Kaplan and Green (1995), 11 incarcerated female sexual offenders against children were matched with a comparison group of 11 female offenders incarcerated for nonsexual histories. Both groups of offenders were given a self-report sexual interest card sort in which they rated various sexual scenes on a 3-point scale with the following responses: “I don’t think this” (1), “neutral” (2), “I like this” (3), Three of the female sexual offenders against children endorsed sexual scenes of voyeurism, whereas only one of the comparison offenders endorsed such scenes.

According to Meyer (1995), perversion in females is expressed in a more subtle form. He states, “The old saw that ‘if a man stops by a window to watch a woman undress, he is arrested for peeping, and if a woman stops by a window to watch a man undress, he is arrested for exposure’ reflects both the subtlety of and the cultural tolerance for what in some women is the female equivalent of paraphilic activities” (p. 1346). Due to the fact that female sex offenders are an understudied group, and that there is a paucity of data on voyeurism per se among female sex offenders, future studies will need to include larger samples comparing contact and noncontact sexual offenses among female sex offenders.

ASSOCIATED FEATURES

Paraphiliacs tend to have multiple paraphilias as well as a high frequency of deviant acts per individual (Bradford, Boulet, & Pawlak, 1992). In a study by Abel, Mittelman, and Becker (1985), 411 paraphiliacs admitted to committing 218,900 sex offenses against 138,137 victims.  In this group, 13% (62 men) were diagnosed with voyeurism, and they self-reported 52,669 voyeuristic acts against 55,887 victims (Abel & Rouleau, 1990). In this study, the men diagnosed as voyeurs all revealed histories of additional paraphilic behaviors in addition to voyeurism. Thirty-seven percent had been involved in rape, 52% in female, nonincestuous pedophilia, 63% in exhibitionism, and 11% in sadism. The results of this study suggest that paraphiliacs, including voyeurs, frequently participate in a variety of different paraphilias, some overtly aggressive.

Abel, Mittleman, and Becker (1985) reported on intial paraphilic behavior of adult child molesters and rapists. The first paraphilic behavior was voyeurism for 9% of the voyeurs and 3% of the child molesters. In addition, of the child molesters, 14% were involved in voyeurism. Of the rapists, 20% were involved in voyeurism. In another study, Bradford et al. (1992) studied multiple paraphilias in a group of 274 paraphiliacs in a forensic setting. They found that 115 voyeurs had committed 1,160 incidents of voyeurism (mean=10). They also found that voyeurism was commonplace among those who had committed rape. These results emphasize the diverse nature of the paraphilias, voyeurism included.

Few studies have researched characterists of voyeurs exclusively. Symptoms of depression are common in adults with paraphilias (Grossman & Cavanaugh, 1990; Kafka & Prentky, 1994), as well as juvenile sexual offenders (Becker, Kaplan, Tenke, & Tartaglini, 1991). A history of maltreatment during childhood, including physical and/or sexual abuse, is common in the background of both adult and adolescent sexual offenders (Becker, Cunningham-Rathner, & Kaplan, 1986; Rogers & Terry, 1984). Other characteristics common among voyeurs are social skills and assertiveness skills deficits, deficits of sexual knowledge, sexual dysfunction (Able, Rouleau & Cunningham-Rathner, 1986; Marshall & Eccles, 1991), hypothesized deficits in empathy (Finkelhor, 1984), and problems with intimacy (Marshall, 1989).

Offenders often justify their behavior with rationalizations or cognitive distortions (Able et al., 1984; Hunter, Becker, Kaplan, & Goodwin, 1991). These distortions, or thinking errors, allow the voyeur to continue his behavior without feeling guilty or shameful. Examples of distortions that adult voyeurs use are: “Many people leave their shades up because they want to be seen undressing or having sex,” “There is nothing wrong with looking in the girl’s locker room while they are changing clothes or showering,” “Lots of women walk around their house naked hoping someone will look in,” or “Watching a woman thought a window while she takes a shower will not cause her any harm.”

Gebhard and his colleagues (1965) studied characteristics of sex offenders and divided the voyeurs, or “peepers,” into a separate category. According to their  findings, peepers almost never watch females who are known to them. Forty-five percent of the peepers were married; they had a lower percentage of extramarital coitus than did other sex offenders. Twenty-nine percent had juvenile court convictions, but only 11% of these were sex offenses. Other offenses were minor, only 20% involving any force. These findings cannot be generalized, as these offenders were incarcerated and had been convicted.

Although some voyeurs do not commit more serious paraphilic acts, there are some suggestions in the literature that serial rapists and murderers began with histories of voyeurism (Rosenfeld, 1985). For example, Holmes (1991) notes that Ted Bundy, a serial killer and serial rapist, self-reported that he started his sex crimes as a voyeur at age 9. Other authors (Freund, 1990, Freund & Blanchard, 1986; Freund, Scher, & Hucker, 1984) hypothesized that voyeurism, exhibitionism, toucheurism-frotteurism, and preferential rape patterns are all part of the same syndrome, namely courtship disorder (see Freund, Seto, & Kuban, Chapter 6, this volume). Freund and Watson (1990) demonstrated that the preferential rape pattern co-occurred with voyeurism, exhibitionism, and toucheurism-frotteurism to a higher degree than other paraphilic patterns did.

ASSOCIATED JUVENILE ISSUES

Although it the exact incidence of sexual offenses committed by adolescents is unknown, the problem is serious. A number of studies identified the onset of sexual misconduct in adolescence (Awad, Saunders, & Levene, 1979; Becker, Cunningham-Rathner, et al., 1986). Abel, Osborn, and Twigg (1993) documented the age of onset of paraphilic interest in a group of adult men with paraphilias. The average age of onset for 133 adult male voyeurs was 18. The percentage of voyeurs who is demonstrated paraphilic interest by age 17 was 65%.

Adolescents commit a wide variety of paraphilic acts (Deisher et al. 1982 Fehrenback, Smith, Monastersky, & Deisher, 1986). “Hands off” offenses, such as voyeurism, are common in the histories of adolescent  rapists rapists and child molesters (Becker, Cunningham-Rathner, & Kaplan, 1986; Fehrenbach et al. 1986).

Becker, Cunningham-Rathner, & Kaplan (1986) conducted a study to provide data regarding the characteristics of adolescence you had been identified as sexual offenders and had been permitted to remain in community under supervision rather than being incarcerated. Participating in the study were 67 adolescent males between ages of 13 and 19 (mean 15.47 years), the majority of whom had been charged with or convicted of a sexual crime. Of the subjects, 10% reported never having been arrested for a sexual crime, 79% reported being arrested once, 8% twice; and 3% three times or more. Those juvenile offenders who is looked at other people (usually through windows) for the express purpose of obtaining sexual excitement were labeled as voyeurs. (These were also subdivided b age and sex of the victim). Two of these adolescents self-reported that they had engaged in voyeurism. One boy he had completed 20 acts of voyeurism against five adult women and the other boy had completed 30 acts of voyeurism against five teenaged girls. In another study by Becker, Kaplan, Cunningham-Rathner, and Kavoussi (1986), of 22 adolescent incest perpetrators between the ages of 13 and 18, 41% had also engaged in nonincest paraphilic behaviors unknown to the referral sources. Of these, two boys reported that they committed 50 acts of voyeurism against 10 victims. One boy, who had 30 adolescent female victims, began this activity when he was 10, the other, who targeted adult females, started when he was 16.

To date, there is not an empirically validated model to explain the Development of a paraphilia in adolescents. Becker and Kaplan (1989) proposed a model for the development of atypical sexual behavior in adolescents. This model incorporates individual characteristics, family variables, and social and environmental variables as possible precursors to the commission of adolescents’ first inappropriate sexual act. Following the first sexual offense, they believe that there are three main paths an adolescent might follow:

1. The dead end path, in which in adolescent never commit any further deviant sexual behavior. These adolescents are likely to be the one to suffer the most negative consequences for their behavior for him the behavior may have been exploratory, lacking in violence, related to the lack of a peer partner, or as modeling.

2. The  delinquency path, in which an adolescent commits deviant sexual acts as part of a general antisocial personality pattern.

3. The sexual interest pattern path, in which an adolescent commits further sexual crimes and develops a paraphilic arousal pattern. These adolescents are likely to be those who (a) sound behavior to be very pleasurable, (b) experienced minimal or no consequences in relation to commission of the sexual crime, (c) experienced reinforcement of deviant sexual behavior  through masturbation activity and fantasies, and (d) are deficient in their ability to relate to age appropriate peers.

It is important for the clinician to distinguish between sexually exploratory behavior, innocent sex play, and an atypical sexual interest pattern. For example, teenage boys may “peep” into the girls’ locker room at school and be caught. A clinician assessing such an adolescent should determine if a boy is at risk to develop a paraphilic pattern. Guidelines would be sexual arousal associated with the act, frequency, recurrent voyeuristic fantasy and urges, and impairment in functioning (i.e. cutting classes to peep).

In working with adolescents, it is also imperative that information, when available, be obtained from outside sources such as parents, School, victim reports, court reports, and referral sources, so that other risk factors of an environmental or familial nature can be evaluated. Family risk factors may include intrafamily violence, poor parental management techniques, and criminal behavior by family members. Social and environmental risk factors may include bonding with delinquent peers and inappropriate role models.

THORIES OF ETIOLOGY

Psychoanalytic Theory

The psychoanalytic the views perversion as symptomatic of underlying psychopathology which originates in unresolved conflicts during psychosexual development (Freud, 1969). Freud emphasized that perversion maybe a regression to an earlier level of development and that perversions can’t themselves be extensive formations to prevent more threatening impulses from entering consciousness (cited in Smith, 1976, p. 594).

According to Meyer (1995), leader observations by Freud reemphasize the complexity of the perverse formations in terms of the conscious and unconscious components, the role of guilt and conscience, the contributions of aggression and libidinal interests, the symbolic representation of developmental missteps, and the adaptive functions. “the preferential object is selected because of attributes wish facilitate her substitution for mother in reenacting the struggle over separation and castration. The voyeur a woman to note the true nature of her genitals and identifies with her. However, he reassures himself through masturbation that his penis it Is intact and that he is superior” (Meyer, 1995, p 1342).

In a critique of psychodynamic theory as etiology of paraphilias, Abel and Rouleau (1990) posited that if specific emotional conflicts produced specific sexual offenses, why then would paraphiliacs perpetrate such varied sex crimes? Instead of assuming that many sex offenders have multiple, specific emotional conflicts, one would assume more parsimoniously that a general deficit of control over deviant behavior is at fault in many sex offenders.

Stoller (1991) wrote extensively on the perversions and there psychodynamic origins. She defines perversion as “a habitual, preferred aberration necessary for one’s full satisfaction, primarily motivated by hostility. The hostility in perversion takes form in a fantasy of revenge hidden in the actions tht make p the perversion and serves to convert childhood trauma to adult triumph. To create the greatest excitement, the perversion must also betrayed itself as an act of risk-taking” (Stoller 1975, 1985, 1991, p. 37). According to Stoller, the excitement comes from an awareness—conscious or unconscious—that one is harming and that the harm done is an act of humiliation and revenge for one’s having been humiliated.

Stoller that one of the dynamics that energizes erotic pleasure is “symbiosis anxiety” or “merging anxiety.” By this he means:

Little boys must perform an act of separation from their mothers not required of little girls; they must establish within themselves a barrier against the earliest stage of wanting to stay as the one with their mothers, of not being individuals separate from their mothers, and therefore of not being sure they are fully male: fear of becoming female. Much of masculinity in all cultures is made up of manifestations of this conflict: emphasis on the phallus, fear of intimacy with women, fear of being humiliated by women, need to humiliate women (such as insulting, locker room vocabulary), fetishizing women. (Stoller, 1991, p. 47)

He posited that voyeurism in males is due to their needing to preserve a distance between their bodies/selves and their mothers. Hey could then close this distance by the less intimate technique of looking.

Social Learning Theory

Ford and Beach (1951) stated that human sexuality is affected by experience in two ways. First, the kind of stimulation and the types of situations that become capable of evoking sexual excitement are determined in a large measure by learning, Second, these overt behavior through which this excitement is expressed it depends largely upon the individual’s previous experience. Kinsey and colleagues also concluded that “the sexual capacities which an individual inherits birth appear to be nothing more than the necessary anatomy and the physiologic capacity to respond to a sufficient physical psychological stimulus… but apart from these few inherent capacities, most other aspects of human sexual behavior appear to be the product of learning and conditioning” (Kinsey, Pomeroy, Martin, & Gebhard, 1953, p. 644).

Numerous other researchers also cite social learning approaches as important contributing factors to the development and maintenance of paraphilias. Laws and Marshall’s (1990) model suggested that deviant sexual behaviors are learned in the same manner by which other persons learn sexual behavior and expression. Laws and Marshall hypothesized that sexual arousal patterns are acquired and established through Pavlovian and operant conditioning, Learned from observation and modeling, and shaved through differential reinforcement. Masturbatory fantasy and orgasm increases higher order conditioning and reinforces the behavior so that it becomes more powerful and refined.

Sociobiological Theory

Symons (1979) and other authors (Ford & Beach, 1951) Bring an evolutionary perspective to sexual arousal and interest in visual stimuli in relation to the selection process. Symons (1979) stated that “anthropological discussions of sex differences in dress and posture emphasize the likelihood of male sexual arousal at the sight of the female genitals” (p. 177). Ford and Beach (1951) wrote: “there are no peoples in our sample to generally allow women to expose their genitals under any but the most restricted circumstances. The wearing of clothing by women appears to have as one important function the prevention of accidental exposure under conditions that might provoke sexual advances by men.”

Symons went on to state that “The male’s desire to look at female genitals, especially genitals he has not seen before, and to seek out opportunities to do so, is part of the motivational process that maximizes male reproductive opportunities” (p. 181). Keith explains this in terms of ultimate causation; natural selection favors male abilities to assess reproductive values largely through visual cues. “because email can potentially impregnate a female at almost no cost to himself in terms of time and energy, selection favored the basic male tendency to become sexually aroused by the sight of females” (p. 180).

Other Theories

John Money (1996) stated:

“A paraphilia is a mental template or “love map” that, in response to the neglect, suppression or traumatization of its normophilic (in conformity with the legal or social standard) formation, has developed with distortions, namely, omissions, displacements, and in inclusions that would otherwise have no place in it. A paraphilia permits sexuoerotic arousal, genital performance, and orgasm to take place, but only under the aegis, in fantasy or live performance, of the special substitute imagery of the paraphilia” (p. 39).

According to Money (1984), voyeurism is a displacement paraphilia, one that “involves a segment of the preparatory phase of an erotic and sexual activity before genital intercourse begins” (p. 174). Thus, he hypothesized that a displacement paraphilia is a “love map that goes awry…by the displacement of original elements” (p. 178).

According to Money, voyeurism is one of the showing and looking “allurative” paraphilias. He has coined the term “phylism” which refers to an aspect of behavior or unit of response which is shared by all members of the human race. She theorized the following: “in the genesis of a paraphilia, a phylism that is not ordinarily program med into sexuoerotic functioning becomes disengaged from its regular context to become enlisted in the service of sexual eroticism, and enchained to it” (1996, p. 86). He been went on to speak about voyeurism:

In the solicitational and allurative paraphilias, the phylisms that to become attached to sexuoeroticism are actually reattached, but out of sequence. They belong originally in the preparatory or proceptive phase of the sexuoerotic sequence. Their reattachment is to be accepive phase, test phase that leads to the climax of orgasm. There are three subgroups of solicitational and conversely, to looking, being touched, and listening to or reading.  (p. 98)

Freund and Blanchard (1986) described four phases of erotic interaction: 1. location and first appraisal of a suitable partner 2. pretactile interaction (looking, smiling, talking) to a prospective partner, 3. Tactile interaction, and 4. effecting genital union. According to Freund (1990), voyeurism would be an exaggeration and distortion of the first phase of normal sexual interaction. Freund chose the term “courtship disorder” for this disturbance (Freund, Scher, & Hucker, 1983). The courtship disorder hypothesizes that a particular class of erotic anomalies are distorted counterparts of the four normal phases, with voyeurism involving the first phase (location of the partner); exhibitionism and obscene phone calling, the second phase (pretactile interaction); frotteurism, the third phase (tactile interaction); and a preferential rape pattern, the fourth phase (effecting genital union).

Biological Factors

Recently, biological factors have been postulated as playing a role in the development of paraphilias. Several researchers have investigated the role of androgens, principally testosterone, the hormone most responsible for male sexual behavior (Bancroft, Tennet, Loveas, & Cass. 1974; Bradford & McLean, 1984). Other researchers used medroxyprogesteroneacetate (MPA) to study the male sexual drive (Money, 1970) and antiandrogenic medication in the treatment of sex offenders (Berlin & Meinecke, 1981). Schiavi and his colleagues (Schavi, Theilgaard, Owen, & White, 1984) investigated sex chromosome anomalies in sex offenders. No consistent conclusions can yet be drawn from any of the above studies. Hor-Henry (1987) postulated that neuropsychological deficits mate account for the development of a paraphilia. Although the studies on possible biological factors as etiological in the paraphilias are minimal, further research should be conducted in this area. Several promising studies have investigated selective serotonin reuptake inhibitors in the treatment of paraphilias, including voyeurism (Bradford et al., 1992).

TREATMENT AND TREATMENT RECOMMENDATIONS

The literature on treatment specifically for voyeurism is sparse. There are several early case reports of successful treatment using behavior modification techniques (cited in Smith, 1976, p. 603). More recently, there have been case reports a favorable response to fluoxetine, which is reported to be effective for the treatment of obsessive-compulsive disorder (Emmanuel, Lydiard, & Ballenger, 1991). Treatment recommendations, therefore, have been developed from research with a heterogeneous group of paraphiliacs, many of whom have multiple paraphilias, including voyeurism. Major current treatment strategies are based on various theoretical orientations. Traditionally, cycle analysis was used in the treatment of the paraphilias; in general, this has yielded disappointing results (Cook & Howells, 1981).

Cognitive-behavioral therapy is well established in the treatment of the paraphilias and involves at the outset a thorough assessment to obtain a psychiatric diagnosis, identify sexual arousal patterns, and determine specific treatment needs (Becker & Kaplan, 1990; Laws & Osborn, 1983). Cognitive-behavioral therapy’s Lucas is on helping individuals control their sexual impulses. This treatment is well described in several reviews (Abel, Osborn, Anthony, & Gardos, 1992; Abel et al., 1986). Abel and his colleagues (1984) described a nulticomponent treatment for sex offenders. This program included (1) satiation, in which the offender learned how to use his deviant fantasies postorgasm in a repetitive manner to the point of satiating himself with the very stimuli use to become aroused; (2) covert sensitization, a technique utilized to improve awareness of the antecedents to the offender actually coming into contact with a victim; (3) cognitive restructuring, which confronted the sex offender’s distorted belief system about the appropriateness of his behaviors, (4) social and assertiveness skills training, in which offenders learn to relate to peers in a socially appropriate manner, and (5) sexual knowledge to relate to peers and that they obtained treatment for any sexual dysfunctions that may have been present (Abel et al., 1984). Marshall, Jones, Ward, Johnston, and Barbaree (1991) also published a review, as did Laws and Marshall (1991).

Adherents to a biological treatments have  utilized medications to block for decrease the level of circulatory androgens. In Europe, castration was used with incarcerated sex offenders (Heim, 1981). There are several reviews of antiandrogen therapy (Berlin & Meinecke; 1981; Bradford, 1985, Cooper, 1986). These have focused on the use of Depoor oral provera, which lowers testosterone, in the United States, and cyproterone acetate, which acts through competitive inhibition of androgen receptors, blocking the action of testosterone and dihydrorestosterone, in Canada. Selective serotonin reuptake inhibitors have also been tried successfully (Kafka, 1991). Perilstein, Lipper, and Friedman (1991) reported on the apparently successful treatment of three individuals, including one with voyeurism/frotteurism, with fluoxetine.

Prevention strategies have been described and employed recently with paraphiliacs (Freeman-Longo & Pithers, 1992; Laws, 1989). This therapeutic modality emphasizes helping individuals to identify the chain of antecedent thoughts, situations, and behaviors that lead to a relapse and offers strategies to an individual to avoid relapses.

Because paraphiliacs are a heterogeneous group with multiple problems, and often with multiple paraphilias existing in the same individual, treatment must be comprehensive as well as individualized. Dwyer (1988) listed 16 goals to conducting an effective treatment with paraphiliacs, including voyeurs. Smith (1976, p. 605) stated regarding treatment of voyeurism that “the therapist should not lose sight of the fact that sexual enjoyment from looking is a natural instinct and a normal part of sexual behavior.” He emphasized treatment that controls voyeuristic impulses and attempts to satisfy those impulses through socially acceptable means.

FORENSIC ISSUES

In our culture, voyeurism is considered to be a nuisance crime rather than a crime against society (Holmes 1991; Smith, 1976). These nuisance acts are sexual acts that cause no obvious physical harm to the victim. Voyeurism is one such act, in that there are usually infrequent consequences for engaging in this behavior.

Voyeurism is often committed against a victim who is unaware of what is happening and, as a result, does no lead to apprehension. Voyeurs as a rule cruise specific areas and look for opportunities to peep where they may not be seen. When an individual is caught for peeping, punishment depends on whether the victim files a complaint. According to Smith (1976), voyeurism is not a criminal act in and of itself, as looking is not a crime; however, most voyeurs Break the law by trespassing or illegal entry. Other common charges from a sampling of the prosecutors reveals that voyeurism or illegal entry. Other common charges from a sampling of prosecutors reveals that voyeurism is generally considered a minor crime. In New York and New Jersey, for example, voyeurism is not in a penal code as a sex offense. Historically it has not been a municipal ordinance violation under the term itself, in that the actual criminal charges are other nonsexual offenses such as loitering, vagrancy, or disorderly conduct.

Because individuals with paraphilias are usually not motivated to enter treatment without a mandate to do so from the criminal justice system, in sentences are usually short, this poses a problem for a long term treatment once a client has been evaluated.

Every state has sex abuse reporting laws. Therefore, it is important that clients be informed before any interview being conducted that if the specifics of past sexual offenses which involved minors are disclosed, then the therapist is obliged to report this information. However, to treat the voyeur, therapists must have truthful information from the client asked to the extent of paraphilic behavior. Protection of confidentiality is of the utmost important in obtaining valid self-reports from clients (Kaplan, Abel, Rathner, & Mittelman, 1990).

A thorough evaluation is important to determine risk assessment and to make treatment recommendations. We recommend that all patients signed informed consent before assessment and/or treatment and release of information to the criminal justice system or To the individual who is supervising the case.

FUTURE DIRECTIONS

Although there is a large body of literature on the paraphilias in general, there is little that concentrates on voyeurism. Throughout the literature it is emphasized that “looking” for sexual pleasure is normative. It is only when the looking is nonconsensual and preferred that it is considered a paraphilia. Voyeurism, like any form of sexual behavior, is culturally determined determined to be acceptable or not acceptable. In several reviews of cross-cultural sexual attitudes and behavior, voyeurism was not mentioned (Broude & Greene, 1976; Grubin, 1992). Because voyeurism in and of itself is not a criminal act, punishment is generally mild, and consequently, without a mandate for treatment. Therefor, even when individuals start treatment, many do not remain. However harmless it is considered to be, voyeurism does have victims, in that it is not a consensual act and can range from being a nuisance to a coercive harassing behavior, which can have great psychological consequences for the victim.

There needs to be early interventions to assess the needs of adolescents who engage in voyeurism and other paraphilic acts to prevent further victimization and to help individuals who have the problem satisfy their impulses through socially acceptable means, such as viewing legally sanctioned pornography.

Future research should look at samples from different populations including including the general population to get a better understanding of voyeurism, how it develops, and its prevalence. A study of voyeurs needs to be undertaken to determine risk assessments for this population. Case histories and reports of drug or other behavioral interventions would be most useful to clinicians in the field.