Sexual Deviance: Theory, Assessment and Treatment.

Sexual Deviance: Theory, Assessment and Treatment. Edited by D. Richard Laws and William O'Donohue. New York: Guilford Press, 1997, 514 pages. Hardcover, $60.00.

Reviewed by Michael H. Miner, Ph.D., University of Minnesota, Program in Human Sexuality, 1300 South Second Street, Suite 180, Minneapolis, MN 55454; e-mail: [e-mail]

Drs. Laws and O'Donohue take on the very ambitious project of informing the professional community on the myriad of theories, assessment procedures and treatment techniques that have been applied, and continue to be applied to individuals who exhibit sexual behaviors that are either unusual or socially proscribed. This edited volume contains the contributions of many noted authorities and, with certain exceptions, provides the reader with very thorough and challenging reviews of what is known about the paraphilias listed in the Fourth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). Therein lies both this book's strengths and weaknesses.

Sexual Deviance: Theory, Assessment and Treatment is the first book I am aware of that attempts to treat all of the behaviors that are characterized as paraphilias in one volume. There have been a number of very good books in recent years that have reviewed the literature and discussed theories of etiology and treatment of sexual abuse or sexual aggression, and there are some volumes that address such issues as fetishes, transsexualism, and sadomasochism, but this is the only inclusive resource for all of the behaviors that make up the paraphilias as defined by DSM-IV.

In general, the book is aimed at the practicing clinician who may have occasion to treat individuals with psychosexual disorders. While researchers may find some of the chapters on psychopathology and theory useful, such reviews have, for the most part, been published elsewhere.

In the introduction to the volume, Drs. Laws and O'Donohue spend a great deal of space discussing the weaknesses of the DSM categorization of paraphilic behavior. They convincingly point out that much is missed and much is convoluted by the DSM topological system; however, they then organize this book by DSM diagnostic categories. Specifically, the book is organized so that for each DSM category there is first a chapter that discusses psychopathology and theory and then a chapter that discusses assessment and treatment.

The psychopathology and theory chapters provide a description of the ways that particular behaviors have been described and categorized to form a particular disorder, discuss the epidemiological data available for a particular constellation of behaviors, and discuss co-factors and associated problems. Additionally, the initial chapter on each disorder provides a critical review of the literature addressing theories of etiology, as well as an assessment of the need for future research and the directions of such research. The second chapter in each set provides information on treatment and assessment. The expressed purpose of these chapters is to provide an overview of the issues of assessment, the types of assessment procedures that have been used, and the strengths and weaknesses of assessment instruments and procedures. A critical review of the treatment literature is also a salient part of the assessment and treatment chapters, although the quality of this review varies across chapters. The assessment and treatment chapters then provide practical suggestions for treatment procedures and address the future research needs in the assessment and/or treatment of each constellation of behaviors. Forensic issues are addressed in the chapters on psychopathology and treatment, as well as in the assessment and treatment chapters. This leads to some redundancy.

The choice of the DSM framework for organizing this volume results in some strange chapter content. For instance, Chapter 6, the psychopathology and theory chapter on Frotteurism, is a very readable and inclusive description of the Courtship Disorder theory, including the report of a study designed to test this theory. However, it tells us little specific to Frotteurism. In fact, most of the research described in the chapter involves people who have been involved in exhibitionism, voyeurism and preferential rape, not Frotteurism. Another odd result of the organization of this book is Chapter 13, which describes assessment and treatment of masochism in sex offenders, rather than focusing on masochism per se. This chapter obviously took the strategy of addressing the masochistic tendencies of sex offenders, because the preceding chapter by Baumeister and Butler emphasizes that masochism is not a particularly pathological set of behaviors, nor do masochists tend to have significant psychiatric and/or behavioral co-factors. Thus, most masochists do not come to the attention of treatment providers.

The editors do stray from their general organization by including chapters on rape, which is not a DSM disorder, and chapters on medical models of deviance, medical interventions in sexual deviance, and female sexual deviance. The review of the literature presented in the psychopathology and theory chapter on rape was particularly good and inclusive. Also, a very useful aspect to the chapter on assessment and treatment of rape was a section that reviews many of the standardized instruments used for assessment of sex offenders. This review, while not complete in terms of the range of possible instruments in each area of assessment, did cover the most widely used instruments.

Chapter 22 is entitled "Medical Models of Sexual Deviance" but focuses almost exclusively on sex offending, failing to provide any insight into the non-offending behaviors covered in this volume. The most unfortunate aspect of this chapter is its tone, which was demeaning to mental health professionals who are not psychiatrists. The chapter appears aimed at psychiatrists and is quite hostile toward those of us who are not physicians. Even looking past the chapter's tone, it does not appear to accomplish what one would think was its objective; that is, there is no medical model of sexual deviance or sex offending presented.

The chapter on sexual deviance in women also suffers from the same narrow focus as the medical aspects and medical treatment chapters. The chapter by John Hunter and Ruth Mathews provides an interesting review of what is known about the female sex offender, which the authors acknowledge is limited. However, there is no discussion of the non-illegal forms of paraphilia.

As mentioned earlier, the editors have assembled an impressive group of contributors for this volume. Each chapter is a state-of-the-science review of its particular topic and, as such, provides the reader with important theoretical and practical information for conducting research or providing treatment to individuals who exhibit sexually aberrant behavior. The notable exception to this is the chapter on assessment and treatment of fetishes. This chapter focuses exclusively on learning theory explanations of fetishes and limits its discussion to interventions based on classical conditioning. This is disappointing, because it is in stark contrast to similar chapters that provide even handed and inclusive reviews of the available knowledge and options.

The book's major failing is the lack of a unifying theme, other than the concern about the definition of a mental disorder and the fit of the various sexual behaviors within such a concept. The chapters that make up this volume appear to be written to stand alone. As such, there is considerable redundancy between chapters. This is particularly the case for those that address behavior that is illegal and has fallen under the rubric of sex offender research and treatment. In general, the chapters on exhibitionism, pedophilia, voyeurism, and rape are redundant in that they cite the same body of research and make many of the same points. This is not to say that these chapters are not useful references for anyone interested in working with these populations or conducting research; in fact, the chapters on pedophilia and rape are particularly well done reviews of what is known, what is not known, and what needs to be addressed.

Unfortunately, when reading the entire book, I began to find the same issues discussed and the same points made across the chapters. Much of this is not the fault of the authors: it is just the current state of the research. Where there is little specific research on certain offending behaviors, one must generalize from studies that do not discriminate between different offending behaviors, or from behaviors that are thought to have similar etiologies.

The chapters that do not suffer from the above redundancy are those on fetishes, transvestic fetishism, and masochism. This is likely because these behaviors are viewed differently from the others addressed in this book and from each other. It is also true that these three chapters suffer from a lack of empirical data, which the authors explain is the nature of the field.

The unifying construct in this book appears to be the authors' discomfort with the DSM categorization system and the definition of "sexual deviance" as mental disorder. Interestingly, while this is discussed in many of the chapters, it is not presented in any systematic way, nor does one get the idea that the editors intended this to be the common ground for the various contributions. It does, however, raise some interesting and at times disturbing issues for the clinician working within the current health care system. The DSM-IV consistently defines sexual behavior as a mental disorder if the behavior results in significant distress or impairment in social, occupational, or other important areas of functioning (APA, 1994, p. 523). It is an open question as to whether a behavior that results in criminal adjudication and possible incarceration meets such a definition of disorder if the individual is not distressed by the behavior, but by the consequences of that behavior.

I came away from this book with the impression that there is more that we do not know about deviant sexual behavior than there is that we do know. In fact, the very term "deviance" appears problematic, in that it implies not only infrequent but aberrant as well. The behaviors included in this volume vary in terms of the degree to which there are negative consequences to either the person performing the behaviors or to the targets of those behaviors. Certainly the sex offending behaviors have serious consequences for the victims; however, the same cannot be said for the practitioners of masochism or fetishes. In general, these are behaviors that take place in privacy and/or between consenting adults. To what extent are they "deviant" or meeting the DSM criteria for mental disorder? This question is raised in a number of chapters of this book, and generally, the issue is resolved without empirical data but with clinical observations and personal rhetoric.

A final comment on the content of this volume relates to the focus of the discussions of psychological testing. Authors writing about the use of tests such as the Minnesota Multiphasic Personality Inventory in its two versions, or the various versions of the Millon Clinical Multiaxial Inventory correctly point out that these instruments do not identify individuals with particular sexual disorders, nor have consistent subclasses of individuals been identified within disorders using either the MMPI or MCMI. This, I believe, misses the point. The purpose of using one of the versions of the MMPI or MCMI is not to assess directly the presence or absence of a paraphilia; it is to understand the psychological and personality make up of the individual presenting with paraphilic disorders. Standardized personality instruments are a useful part of a comprehensive psychological assessment, in that they provide data that helps in determining the presence of Axis I and Axis II disorders, as well as providing information important to assessing dangerousness and amenability to treatment, and for making decisions about alternate forms of treatment.

In conclusion, this book is a compilation of the work of some of the most noted individuals studying sexual behavior. As such, most of the chapters provide useful information to the clinician intending to provide assessment and treatment services to individuals with paraphilic behavior. The practical suggestions provided in the assessment and treatment chapters were, for the most part, well grounded in theory and supported by what research existed for a given constellation of behaviors. The authors were very clear when suggestions were not based on empirical findings, and also presented a very evenhanded discussion of the strengths and weaknesses of the research available. Unfortunately, the book as a whole is difficult to read because of the overlap and redundancy across chapters.

REFERENCES

American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition (DSM-IV). Washington, D.C.: Author.

Michael R. Steveson, Ph.D.

Department of Psychological Sciences Ball State University Muncie, IN 47306, USA