The Nonviolent Serial Offender: Exhibitionism, Frotteurism, and Telephone Scatologia

By Richard B. Krueger and Meg S. Kaplan
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Sexual violence is a serious and widespread problem in our society and has been recognized as such by the public, the criminal justice system, and, more recently, the psychiatric community. Within the class of psychiatric disorders called paraphilias are the “hands-off’ offenses, which include exhibitionism, frotteurism, and telephone scatologia. Because of the attention to and consequences of the more severe paraphilias, which include child victimization, for instance, these “nuisance” paraphilias have generally not been the focus of much attention or study and usually do not result in the severity of sentences that other sexual crimes do. Nevertheless, they are usually repetitive crimes with compulsive overtones, they can cause considerable trauma to innocent victims, and they can result in significant punishments if offenders continue their repetitive behavior.

This chapter examines the above-mentioned disorders of exhibitionism, frotteurism, and telephone scatologia and includes a discussion of the epidemiology, etiology, and current empirical findings (which are quite limited) regarding the treatment of these disorders. Information about these specific disorders is oftentimes generalized from what is known about the assessment and treatment of other paraphilias, as they, too, involve a deviation of sexual interest and repetitive behavior, and many of them coexist in the same individual, often becoming an additional focus of treatment.

The Oxford English Dictionary (Burchfield, 1972; Murray, 1969) defines exhibitionism as the “indecent exposure of the sexual organs, esp. as a manifestation of sexual perversion” and indicates that it is based on the Latin stems ex- Cout”) and habere (to hold); thus, to “hold out.” The Diagnostic and Statistical Manual of Mental Disorders (4th edition, American Psychiatric Association, p. 526; or DSMIV) lists the diagnostic criteria for exhibitionism as being

A. Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving the exposure of one’s genitals to an unsuspecting stranger.
B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impainnent in social, occupational, or other important areas of functioning.

Frotteurism, or frottage, derives from the French word frottage meaning “rubbing” or “friction.” The Oxford English Dictionary notes that, “The special perversion of frottage … consists in a desire to bring the clothed body, and usually though not exclusively the genital region, into close contact with the clothed body of a woman.” The DSM-IV lists the following diagnostic criteria (p. 527):

A. Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving touching and rubbing against a non-consenting person.
B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impainnent in social, occupational, or other important areas of functioning.

Telephone scatologia derives from a Greek stem meaning “dung.” It is not listed as a separate paraphilia in the DSM-IV; however, it is mentioned in the DSM-IV (p. 532) as falling within a category entitled “paraphilia not otherwise specified” and is identified as meaning “obscene phone calls.” Coding for this category does not require any specific duration nor does it specify clinically significant distress or impainnent in social, occupational, or other important areas of functioning, although, presumably, one of these aspects would be present in order for someone to seek out a therapist.

Douglas et al. (1992) authored the Crime Classification Manual, which presents a standardized system for the investigation and classification of violent crimes. The main classifications of violent crimes are homicide, arson, and rape and sexual assault, with many categories of rape and sexual assault. All of the disorders to which our chapter is devoted would presumably fall within the category of “311, Nuisance Offenses” in the Crime Classification Manual (pp. 203-204). These are offenses that occur for purposes of sexual gratification. While the text in the Crime Classification Manual suggests that there is no physical contact between the victim and the offender, there is the notation that these offenses also relate to the paraphilias. Exhibitionism is mentioned specifically in the text, but frotteurism, which does involve physical contact through clothing, and telephone scatologia (which is referred to in an example, but not specifically labeled as such) are not, but it would seem appropriate to place both within this classification, as they are considered nuisance paraphilias.

The category of nuisance offenses noted above is divided into the following categories:

1. 311.01 Isolated/Opportunistic Offense – consists of incidents in which individuals take an opportunity to engage in deviant sexual activity when one is presented, such as dialing the wrong number and blurting out an obscenity or, while intoxicated and urinating in a public place, exposing themselves to a woman who might walk by.
2. 311.02 Preferential Offense – consists of the paraphilias.
3. 311.03 Transition Offense – an individual is experimenting with his behavior, and arousal patterns and his interest might not be fixed.
4. 311.04 Preliminary Offense – a non-contact offense might be a prelude to other serious sex offenses, such as when a rapist might be engaged in voyeuristic activity prior to raping an individual.

The manual notes that there is often a pattern of long-term compulsive behavior, with oftentimes rigid and ritualistic patterns of behavior, such as an offender exposing himself in a certain way, returning again and again to the same location, or an offender repeatedly making obscene phone calls. This is certainly true in our clinical experience.

Although these crimes often have a highly distinctive pattern of behavior, and with appropriate resources are potentially quite solvable, the authors note that contact sex offenses frequently assume a higher priority and command more resources than do these lesser, non-contact offenses (Douglas et aI., 1992, p. 204). The authors also express concern that investigators and interviewers establish whether or not there is a pattern of escalation and whether or not any such nuisance offense is a “preliminary offense” and thus could possibly lead to more serious offenses. Thus, these paraphilias, although not considered to be as dangerous as other paraphilias, should be taken seriously because of their high frequency and because of the concern that they may be precursors to other, more serious offenses.

EPIDEMIOLOGY

Limited epidemiological data are available on the paraphilias. To our knowledge, no items or questions regarding such behavior have been included in any of the national surveys of sexual behavior in the U.S. (Hite, 1976; Kinsey et al., 1953a,b; Laumann et aI., 1994) or in the national surveys of mental disorder conducted by the National Institute of Mental Health (Robins and Regier, 1991). Barriers to such surveys include: (1) the illegality of such behavior and possible consequences in the criminal justice system, (2) a lack of knowledge or interest regarding such behaviors on the part of researchers, and (3) the reluctance and embarrassment of individuals to discuss their sexuality and sexual practices.

In perhaps the most complete and detailed survey of incarcerated sex offenders available, using interviewing techniques developed and tested with the Kinsey reports, Gebhard et al. (1965) interviewed 1356 white males convicted of one or more sex offenses and subsequently incarcerated. They compared this group with 888 white males who had never been convicted for a sex offense and with 477 white males never convicted of anything beyond traffic violations. Of the males convicted of sex offenses, 135, or 10%, were exhibitionists. Only six individuals acknowledged making obscene telephone calls, while 16 others were convicted on the basis of obscene notes, pictures, gestures, or speech but not phone caIIs.

Limited data are available from smaIIer studies. Crepault and Coulture (1980) interviewed 94 men, ages 20 to 45 years, regarding sexual fantasies they had during intercourse. These subjects were volunteers recruited through posters in public places and through advertising in a major French-language newspaper and so were a highly selected sample, but they still were not as selected as individuals who had been arrested and referred for an evaluation or had been incarcerated and interviewed in prison. Of these men, 61.7% reported fantasies of sexually initiating a young girl; 33.0% reported fantasies of raping adult women; 11.7% had fantasies of being humiliated; 5.3% had fantasies of sexual activity with an animal; 5.3% had fantasies of being beaten up; and 3.2% had fantasies of sexuaIIy initiating a young boy. It is important to note that this study involved interviews of males who had not been arrested or accused of sexual crimes and who simply reported on only their fantasies, not their behavior. Also, it is not clear what exactly the advertisement in the newspaper specified.

Templemann and Stinnett (1991) studied 60 undergraduate men who volunteered for college credit to participate in a study of their sexual arousal patterns. The Clarke Sexual History Questionnaire (Paitich et aI., 1977) was used to identify anomalous sexual interest patterns. Overall, 65% reported having actually engaged in some form of sexual misconduct; 42% reported having engaged in voyeurism, 8% in obscene phone calls, 35% in frottage, and 2% in exhibitionism. Subjects were asked if they had ever been arrested for sexual offenses, and two of the 60 men studied reported that they had; two others reported that they had been in trouble with parents, school, or an employer for their sexual behavior.

Abel et al. (1988) reported on 561 non-incarcerated individuals who identified themselves as sex offenders and who were recruited via newspaper advertisements and interviewed under the protection of a certificate of confidentiality, which offered the assurance that information obtained from such individuals could not be subpoenaed by legal authorities. Additional protection was afforded by keeping a key that matched offenders’ names with their record numbers outside of the U.S. Of these 561 men, 62 (12%) engaged in frottage, 142 (25%) engaged in exhibitionism, and 19 (3%) engaged in obscene phone calling.

In another report, Abel et aL (1987) described an aggregate analysis of 291,000 paraphilic acts committed against more than 195,000 victims. Of all the victims, 37.3% were victims of exhibitionism; 28.6%, frottage; and 1%, obscene telephone calIs.

The American Psychiatric Association’s Task Force Report, Dangerous Sexual Offenders (APA, 1999), included data (in the form of a personal communication) regarding the sexual behavior of 2129 sex offenders who were evaluated by Abel. Of these offenders, 13.8% reported exhibitionism, 11.2% frottage, and 6.3% obscene phone calls.

Bradford et al. (1992), assessing 443 adult males who had been consecutively admitted to the Sexual Behaviours Clinic at the Royal Ottawa Hospital for a forensic psychiatric assessment reported that, of the 274 individuals retained in the final analysis, 37 (14%) admitted to scatologia, 58 (21 %) admitted to frotteurism, and 60 (22%) admitted to exhibitionism.

In a more recent study, Kafka and Hennen (1999) reported on a sample of 206 males, consecutively evaluated, who were seeking help for what they referred to as sexual impUlsivity disorders consisting of either paraphilia-related disorders (such as compulsive masturbation, protracted heterosexual or homosexual promiscuity, or telephone sex dependence) or paraphilias. They found that 24% of this total sample complained of telephone-sex dependence. Kafka and Prentky (1992) distinguished the entity “telephone sex dependence” from paraphilic behavior because of its requirement for mutual consent rather than involving coercive victimization, a characteristic of the paraphilias. In a study by Kafka and Hennan (1999) among the group who had paraphilias (n = 143), the prevalence of specific paraphilias, in descending order, was exhibitionism, 37%; voyeurism, 24%; pedophilia, 22%; fetishistic transvestitism, 17%; sexual masochism, 17%; telephone scatologia, 14%; fetishism, 12%; sexual sadism, 9%; frotteurism, 8%; rape, 7.5%; and paraphilia not otherwise specified, 9%. Telephone sex dependence was statistically significantly more common in the paraphilia-related disorder group than in the paraphilia group.

From the above studies of normals and sex offenders, it would appear that exhibitionism, frotteurism, and telephone scatologia are all relatively prevalent fantasies and/or paraphilias.

ETIOLOGY

Little is known of the etiology of paraphilias. Theories of etiology have been hypothesized based on learning theory, psychoanalytic theory, biological observations, or other explanations. Numerous researchers have cited social learning theory and conditioning experiences as contributory causes of paraphilias. McGuire et al. (1965) wrote that the theoretical basis for behavior therapy is that the symptom or behavior to be treated had been learned at some point in the past and that it could be changed by learning new patterns of behavior.

The data in the study by Gebhard et al. (1965) cited above, which found that about one third of exhibitionists with a compulsive and repetitive pattern of behavior had problems with impotence (p. 397), lends some support to the analytic theory that genital inadequacy is characteristic of the exhibitionist (Apfelberg et aI., 1944). Psychoanalysts have postulated that paraphilias are due to unresolved problems of childhood development and intrapsychic conflict. Stoller (1986) suggested that perversion is the erotic form of hatred: “The hostility … takes form in a fantasy of revenge hidden in the actions that make up the perversion and serves to convert childhood trauma to adult triumph” (p. 4). Stoller (1976) also posited that perversion arises as a way of coping with threats to one’s sense of masculinity or gender identity, and that it contains elements of risk, revenge, and triumph. “In the case of the exhibitionist, the risk is that the woman will find one unmanly …. The fact that one may be arrested becomes proof that one really has a penis that detonates other’s fear” (p. 907).

Pearson (1990) suggested that paraphilias may be related to obsessive-compulsive disorder, not only because of the compulsive and repetitive nature of these disorders, but also because of the occurrence of concurrent diagnoses of paraphilias in individuals with obsessive-compulsive disorder and because of the importance of serotonin in impulse control. Additionally, serotonin is involved in sexual responsiveness, and there is a substantial occurrence of sexual side-effects related to the selective serotonin reuptake inhibitors (Rothschild, 1995), again suggesting that serotonin is important in these disorders.

Freund et al. (1983) have suggested that voyeurism, exhibitionism, toucherism, frotteurism, and obscene telephone calling are all based on the same disturbance, which is a distortion of a hypothesized normal sequence of human sexual interactions. Freund and Kolarsky (1965) set forth such a four-phase sequence:

1. Finding phase, consisting of locating and appraising a potential partner

2. Affiliative phase, characterized by nonverbal and verbal overtures, such as looking, smiling, and talking to a potential partner

3. Tactile phase, in which physical contact is made

4. Copulatory phase, in which sexual intercourse occurs

Freund and Kolarsky (1965) suggest that a paraphilia involves the omission or distortion of one of these phases and that a particular paraphilia would reflect the preference of the patient for a virtually instant conversion of sexual arousal into orgasm during this phase. Thus, exhibitionism and telephone scatologia would constitute an exacerbation of the affiliative phase, and frotteurism an exacerbation of the tactile phase. Much remains to be clarified, however, about the origin and development of the paraphilias.

MULTIPLE PARAPHILIC DIAGNOSES AMONG SEX OFFENDERS

Several researchers have reported that multiple paraphilic diagnoses frequently exist in the same offender. Abel et al. (1988), in the sample previously described, reported that many of the subjects had more than one paraphilic diagnosis. Of those subjects who were diagnosed as exhibitionists, only 7% had this as a sole paraphilic diagnosis; the remaining exhibitionists had an average number of paraphilias of 4.2. Of frotteurs, 21 % had frotteurism as a sole diagnosis, while the other frotteurs had an average of 3.8 paraphilic diagnoses. Only 5.5% of those individuals who made obscene phone calls had this as a sole diagnosis; the remaining obscene phone callers had an average of 5.1 paraphilias.

In another report, Abel et al. (1987) reported high means (or average numbers of acts) and high medians (or that number of acts that divides the group into equal halves) for the paraphiles that they studied; 142 exhibitionists had a mean number of 504.9 acts per subject and a median of 50.5; 62 frotteurs had a mean number of 849.5 acts and a median of 19.5; and 19 subjects who made obscene phone calls had a mean of 135.7 acts and a median of 30.0, suggesting that these are highfrequency behaviors. Individuals engaging in these paraphilias also had a high number of victims. In the above described sample, exhibitionists had a mean or average number of 513.9 victims; frotteurs, an average of901.4 victims; and obscene phone callers, an average of lO2.9 victims. In their sample, this would compare, for instance, with a mean of 7.0 victims per rapist; for female targets of incest pedophilia, 1.8; or for male targets of incest pedophilia, 1.7.

Bradford et al. (1992), in their analysis of 274 male sex offenders who were evaluated, reported quite substantially lower incidents and mean number of incidents for subjects engaging in these behaviors. Sixty individuals admitting exhibitionism reported 1055 total incidents, with a mean of 17.58 incidents per offender; for frotteurism, 58 subjects reported 173 incidents with a mean of 2.08 incidents per frotteur; and for scatologia, 37 individuals reported 681 incidents, with a mean of 18.41 incidents per subject. The difference in the results of these two studies may be due to the different populations (outpatient and not compelled for referral vs. inpatient), the degree of confidentiality afforded those in Abel’s study vs. Bradford’s, or the difference in interviewing questionnaires, with Abel et al. relying on DSMIII criteria and Bradford et al. utilizing an instrument called the Male Sexual History questionnaire (Paitich et al., 1977).

Abel et al. (1988) reported that, for the three categories of exhibitionism, frotteurism, and telephone scatologia, there was a co-occurrence of additional paraphilias in many of these individuals. For the exhibitionists studied, 46% had also engaged in female nonincestuous pedophilia; 22%, in male nonincestuous pedophilia; 22%, in female incestuous pedophilia; 5%, in male incestuous pedophilia; 25%, in rape; 28%, in voyeurism; 16%, in frottage; and 9%, in obscene phone calling. Offrotteurs, 39% engaged in female nonincestuous pedophilia; 19%, in male nonincestuous pedophilia; 16%, in female incestuous pedophilia; 7%, in male incestuous pedophilia; 23%, in rape; 37%, in exhibitionism; 23%, in voyeurism; and 7%, in obscene phone calls. For obscene phone callers, 42% engaged in female nonincestuous pedophilia; 16%, in male nonincestuous pedophilia; 26%, in female incestuous pedophilia; 0%, in male incestuous pedophilia; 37%, in rape; 63%, in exhibitionism; and 47%, in frottage. At least 5% of paraphiliacs reported six or more paraphilias, some as many as ten.

Bradford et al. (1992) obtained similar data in their research. They computed a proportional index of multiple deviation, which was obtained by tabulating the frequency of each admitted sexually deviant behavior, adding all positive responses for each paraphilic category, and calculating the proportion of subjects within each of these divisions who also responded affirmatively to questions diagnosing other paraphilias. Thus, of those diagnosed with frotteurism, 24% met criteria for heterosexual pedophilia; 35%, for heterosexual hebephilia; 21%, for homosexual pedophilia; 66%, for voyeurism; 29%, for scatologia; 31%, for attempted rape; 16%, for rape; and 31%, for exhibitionism. For those involved with scatologia, 27% met criteria for heterosexual pedophilia; 24%, for heterosexual hebephilia; 24%, for homosexual pedophilia; 8%, for homosexual hebephilia; 62%, for voyeurism; 46%, for frotteurism; 24%, for attempted rape; 14%, for rape; and 35%, for exhibitionism. For exhibitionism, 20% engaged in heterosexual pedophilia; 20%, in heterosexual hebephilia; 10%, in homosexual pedophilia; 8%, in homosexual hebephilia; 52%, in voyeurism; 22%, in scatologia; 30%, in frotteurism; 13%, in attempted rape; and 7%, in rape.

ADOLESCENT ISSUES

Some data and studies on adolescents and the occurrence of deviant sexual interest and behavior in adolescence are available. Data from a research project by Abel et al. (1985) indicated that, of 411 adult sex offenders who presented for evaluation voluntarily at an outpatient clinic, 58.4% reported that the onset of their deviant sexual arousal occurred before they were 18. Longo and Groth (1983), interviewing 231 institutionalized sexual offenders, found that for a “significant number” of offenders their sexually inappropriate behaviors manifested themselves from early adolescence on.

Becker et al. (1986) reported on 67 male adolescent sexual offenders (ages 13 to 19) who had been accused or convicted of committing a sexual crime and who were referred for treatment. Although the majority (89.2%) had been arrested for a sexual crime only once or not at all, they had committed many more sex offenses and many had begun to cross paraphilias. For example, one adolescent referred to as an incest offender self-reported that he had previously engaged in six acts of frottage against six victims; another adolescent incest offender had made 78 obscene phone calls to 39 victims (Becker and Kaplan, 1992).

Fehrenbach et al. (1986), reporting on 305 juveniles treated at an adolescent clinic between 1976 and 1981, found that the most frequently occurring referral offense for male offenders was “indecent liberties” (59%), followed by rape (23%), exposure (11%), and other hands-off offenses, including peeping, stealing women’s underwear, making obscene calls, or sending obscene letters (7%).

Saunders et al. (1986) studied 63 adolescent sexual offenders who were divided up according to (1) those who had engaged in exhibitionism, toucherism (referring to the brief touching of a woman’s breasts or genitalia), and making obscene phone calls; (2) those who had engaged in sexual assaults; and (3) those convicted of pedophilia. Initial findings revealed that the first group, when compared with the other two groups, came from a less disorganized family background, were better adjusted in school and in the community, and were seen by clinicians as being less seriously disturbed than members of the other two groups. However, upon further examination of the 19 members of this group, it was found that the majority were maladjusted, had committed numerous sexual offenses, and came from multi-problem families.

OFFENDER AND VICTIM CHARACTERISTICS

Gittleson et al. (1978), in an early British study, examined victims of indecent exposure and reported on 100 female nurses who worked at a psychiatric hospital who were interviewed to obtain information regarding the overall frequency of indecent exposure and to ascertain how it was experienced by the victim. Of these nurses, 45 had been the subjects of indecent exposure; one third of them had been a victim on two or more occasions. Histories of 67 separate exposures obtained from members of this group disclosed that 51% of them occurred to these females before their 15th birthday.

The majority of victims (58%) were alone at the time of being exposed to; the rest were in the company of children or other females. Of the exposures, 39% occurred in a park or Woodland, 45% occurred in the street, and 16% occurred in other places such as public buildings or vehicles; 34% occurred after dark. The exhibitionist’s age was estimated by the victims as being under 40 in 42% of the incidents, between 40 and 60 in 49%, and over 60 in 6%. Three percent of the victims could not remember the age of the offender or reported that they did not know. The victims knew the offender in 15% of cases. The study reported that the exposer stood still in 66% of the incidents, walked toward the victim in 21%, walked behind the victim in 4%, sprang out in 7%, and opened a car door in 1% of the incidents.

In the study by Gebhard et al. (1965, pp. 380-399), cited above, the average exhibitionist was nearly 3D at the time of his first conviction for exhibition. A large number (31%) of exhibitionists were married at the time of the offense, 40% had never married, and 29% were separated, divorced, or widowed. Having a sexual partner did not seriously lessen their tendency to expose themselves; 92% chose strangers as objects, 5% acquaintances, 2% girlfriends, and 1% relatives. They also found that about one quarter of all exhibitionists had suffered from impotence, chiefly erectile impotence, and slightly more than a third of those with an extensive pattern of this behavior also had this sexual dysfunction. They found that half of the exhibitionists were “patterned” exhibitionists who repeated this behavior again and again in a compulsive fashion; one eighth of these began exposing themselves when they were 10 or younger, nearly one fifth began between the ages of 16 and 20, and another fifth between 21 and 25. The authors found that one fifth of exhibitionists had problems with alcohol, that the great majority of exhibitionists had or achieved an erection while exposing their genitalia, and that a small percentage reached orgasm through self-masturbation while exposing themselves.

Gebhard et al. (pp. 406-409) also found that five of the six individuals who made obscene phone calls had quite adequate heterosexual coital activity, and that their overall sexual outlet was well above average, with three of the six for some years in their lives averaging more than an orgasm a day. In addition, three of the six had no convictions other than for obscene communication; the other three had numerous other criminal histories and histories of sex offenses.

Forgac et al. (1984) reported on a study using the Minnesota Multiphasic Personality Inventory (MMPI) to assess the degree of psychopathology in male exhibitionists. An increase in psychopathology as measured by the MMPI was not found to be associated with an increase in chronicity of exhibitionist activity.

Marshall et al. (1991 b) studied the sexual preferences of exhibitionists and matched non-offenders using audiotapes and plethysmography. They found that only a small proportion of exhibitionists displayed deviant arousal and suggested that this indicated that a sexual motivation was not a primary one in exhibitionistic behavior.

Smukler and Schiebel (1975) evaluated, retrospectively, the charts of all patients admitted with a major presenting problem of exhibitionism as part of a 5-year ongoing research and treatment project of exhibitionists and voyeurs; 41 were examined clinically and 34 psychometrically with the MMPI and the Cornrey Personality Scale. They found no data to support any definitive character type or evidence of severe psychopathology.

Kafka and Prentky (1994) surveyed 60 consecutively evaluated outpatient males, 21 to 53 years old, who were seeking treatment for paraphilias (n = 34) and/or paraphilia-related disorders (n = 26). Those individuals with paraphilias included 13 exhibitionists, three frotteurs, and three with scatologia. Both groups of males were diagnosed with an elevated lifetime prevalence of mood disorders (76.7%), especially early onset dysthymia (53.3%); psychoactive substance abuse (46.7%), including especially alcohol abuse (40.0%); and anxiety disorders (46.7%), including especially social phobia (31.6%).

In another study (Kafka & Prentky, 1998) reported on a group of 42 males with a paraphilia and 18 with a paraphilia-related disorder; the sample with paraphilias included six individuals with frotteurism, six with telephone scatologia, and 15 with exhibitionism. While both samples had mood disorders (71.7%), anxiety disorders (43.3%), and psychoactive substance abuse disorders (45.0%), the only diagnosis which had statistical significance in separating these two groups was childhood attention-deficit hyperactivity disorder, which was identified in 50.0% of individuals with paraphilic disorders and only 16.7% of individuals with paraphilia-related disorders.

POSSIBLE PROGRESSION OF PARAPHILIC INTEREST AND ACTIONS AND ASSOCIATION OF HAND’S OFF DISORDERS WITH VIOLENCE

Is there any evidence to suggest that lesser paraphilias progress to more serious ones? In his book on sex crimes, Holmes (1991, p. 9) noted that Ted Bundy, a serial killer and rapist, reported that he began his sex crimes as a voyeur at the age of 9. Abel et al. (1988) suggested that when multiple paraphilias existed in the same individual one paraphilia initially takes dominance, then a second paraphilia develops and overtakes the first in dominance. The second paraphilia continues for a number of years, while the first continues at a greatly reduced intensity. In an unstructured series of case histories, Johnson and Becker (1997) reported on nine male teenagers who had fantasies of committing serial killings. None had actually done so, and most were referred for a forensic evaluation after having committed a legal offense; three of these at some point had frotteuristic fantasies or behavior, and one of these three additionally had had exhibitionistic fantasies.

Rooth (1973) reported on a study by Grassberger (1964), who examined criminal records for 220 exposers in Austria convicted over a 25-year period. Of these individuals, 12% were subsequently convicted of serious sexual offenses, particularly sexual assaults. Twenty-five percent of them were convicted of nonsexual offenses involving violence. Rooth (1973) reported on information from 30 exhibitionists.

He noted the several hundred sexual offenses for which these men were convicted, but only five consisted of indecent assault. Interestingly, of this series, 12 individuals described at least one episode of frottage and eight had had extensive experience with this paraphilia.

Gebhard et al. (1965, pp. 393, 399) noted that one in ten of the convicted exposers in his study had attempted or seriously contemplated rape, while about one fifth had engaged in sexual offenses involving the use of force on unwilling females.

Longo and Groth (1983) reported on a sample of 231 sexual offenders drawn from a maximum security prison and a forensic state hospital. Of this sample, 24% had sexually exposed themselves repetitively as juveniles.

Dietz et al. (1990) reported on 30 sexually sadistic male criminals, all of whom tortured their victims in order to arouse themselves. Of this sample, 20% had a history of peeping, obscene telephone calls, or indecent exposure.

Firestone et al. (1998) compared 17 extrafamilial homicidal child molesters with 35 extrafamilial child molesters who had not murdered or attempted to murder their victims – 11.8% of the homicidal child molesters and 2.9% of the nonhomicidal child molesters had had a diagnosis of fetishism, voyeurism, exhibitionism, frotteurism, and/or transvestic fetishism; however, this was not a statistically significant difference between these two groups.

In summary, while there is some occurrence of the lesser paraphilias in the histories of more aggressive sexual criminals, there is no clear evidence that minor paraphilias lead to more aggressive ones, or that they, in fact, are even associated with sexual aggression or other violent crimes. The problem with studying the relationship of the hands-off paraphilias with more aggressive paraphilias or with sexual or other violence is that, while a substantial proportion of individuals convicted of more violent crimes may have engaged in lesser paraphilias, the proportion of individuals involved in lesser paraphilias who progress to violent crimes is not known. Further research is required to examine this issue as well as other variables that may affect the development and progression of paraphilias.

TREATMENT

There is a paucity of literature regarding the treatment of these three paraphilias specifically. Most descriptions of such treatment are included within aggregate analyses of groups of individuals who have a large variety of paraphilias, including pedophilia and other paraphilias.

Freeman-Longo et al. (1994) surveyed 1784 treatment programs and treatment providers for juvenile and adult sex offenders in the U.S. and found that the treatment modalities of victim empathy, anger/aggression management, social skills, sex education, communication, personal victimization/trauma, cognitive distortions, assertiveness training, and frustration tolerance/impulse control comprised the top 10 categories of the 55 categories listed in their questionnaire (p. 14). Regarding medication treatment, fiuoxetine was used by 25.8% of the entities queried; lithium, by 19.5 %; Anafranil®, by 15.3%; BuSpar®, by 15.3%; and Depo-Provera® (hormonal), by 1l.3% (p. 14).

Blair and Lanyon (1981) reviewed the literature regarding the etiology and treatment of exhibitionism and concluded that all of the methodologically adequate treatment studies that had been published involved behavioral treatments. These studies showed that the behavioral technique of covert sensitization reduced the frequency of overt exhibiting acts and that treatment effects persisted at followup for 3 to 12 months.

Marshall et al. (1991a,b) described two studies comparing treatment of exhibitionists which aimed at either modifying deviant sexual preferences or changing cognitions, enhancing relationships and interpersonal skills, and improving awareness with relapse prevention. The first study was comprised of 44 men; the second, 17. The results suggested that a focus on changing cognitions, enhancing relationships and interpersonal skills, and relapse prevention was more effective than behavioral techniques aimed at modifying deviant sexual preferences.

Moergen et al. (1990) described a case study in which covert sensitization and social skills training were used successfully to treat an obscene telephone caller on a behaviorally oriented inpatient psychiatric unit. This treatment included assessment with penile tumescence. A rapid decrease in deviant arousal was associated with the above treatments and maintained at one-year followup.

Alford et al. (1980) reported on the use of covert aversion therapy to treat obscene phone calling and exhibitionism in the same individual; using plethysmographic assessment, they found that treatment of one deviancy resulted in lowering of arousal to both deviancies and that treatment gains were sustained over a 10-month followup period.

Goldberg and Wise (1985) described the successful psychodynamic psychotherapy of a male who had the paraphilia of telephone scatologia. Myers (1991) also described the use of such therapy to successfully treat a man who made obscene telephone calls and who practiced frotteurism.

Gijs and Gooren (1996) reviewed the hormonal and psychopharmacological treatment of the paraphilias; both antiandrogens and antidepressants have been found to be useful, although there is a paucity of well-controlled and well-designed studies.

Kafka and Prentky (1992) reported on 20 men: 10 with non-paraphilic sexual addictions, and 10 with paraphilias. Of the 20 men, 19 met DSM-III-R criteria for dysthymia, and 11 met criteria for current major depression. This group included two individuals with the diagnosis of exhibitionism, one with frotteurism, and two with telephone scatologia. Sixteen individuals completed an open trial of fluoxetine pharmacotherapy. Significant effects were found in both groups over time for all variables related to depression and for both paraphilic and non-paraphilic sexual behaviors as measured by self-report; a response was evident by week four and conventional sexual behavior was not affected adversely by pharmacotherapy.

In a later study, Kafka (1994) reported on the treatment of 24 men with paraphilias and paraphilia-related disorders, including three individuals with a diagnosis of exhibitionism and two with telephone scatologia. Sertraline was used initially, with a mean dose of 100 mg per day; the mean duration of sertraline treatment was 17.4 weeks (±18.6 weeks). Sertraline resulted in a significant reduction in the unconventional total sexual outlet score and in the average time per day spent in unconventional sexual activity. Significant improvement was found in approximately one half of those men who received at least 4 weeks of sertraline therapy. Nine men who failed to respond to sertraline were then given fluoxetine, which produced a clinically significant effect in six additional men.

Zohar et al. (1994) described a single-case study in which an exhibitionist was treated under partial single-blind conditions with fluvoxamine, desipramine, and a placebo that looked like fluvoxamine. They found that fluvoxamine eliminated the undesired impulse and behavior without affecting sexual desire, but desipramine and single-blind fluvoxamine-placebo treatment were both associated with relapses.

Krueger and Kaplan (1997, 1999) reviewed the existing literature relevant to the treatment of frotteurism and suggested a number of stepwise treatment strategies from less to more restrictive, depending on the responsiveness of the individual to any particular treatment.

CONCLUSIONS

Overall, it may be said that exhibitionism, frotteurism, and telephone scatologia are well-described disorders, and they constitute a significant number of the paraphilias that one is apt to encounter in both outpatient and inpatient populations. These paraphilias are often associated with each other in the same individual and with other paraphilias in the same individuals. Oftentimes, these paraphilias begin in adolescence. Alcohol abuse, affective disorder (including dysthymia and depression), and anxiety disorders (including primarily social phobias) are also coexistent in this population. Many individuals who engage in this paraphilic behavior are in satisfactory sexual relationships, while many are not. There is concern that individuals with these disorders may go on to more violent sexual crimes, and some studies of individuals who have committed violent crimes do show a greater association of these paraphilias, but this has not been demonstrated to be statistically significant. The importance of a thorough evaluation must be stressed in order to make correct diagnoses. Effective treatment exists, according to case reports of dynamic therapy, cognitive-behavioral therapy, and pharmacotherapy, with more extensive behavioral and pharmacological studies showing efficacy for these therapies used to treat this population. There is a lack, however, of solid epidemiological studies and of welldesigned and controlled pharmacological studies with this population. While auditing a recent lecture given to second-year medical students at Columbia University, College of Physicians and Surgeons, one author learned that in the past 15 years over 17 double-blind placebo controlled studies have been published studying the treatment of what is now called bulimia-nervosa, yet we have been unable to find even one such study that has targeted the three disorders discussed in this chapter. This would certainly seem to be an area which is in need of further exploration and research.