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A CASE SERIES OF WOMEN EVALUATED FOR PARAPHILIC SEXUAL DISORDERS.

ABSTRACT: The scientific literature on paraphilias has focussed almost exclusively on men. When women whose behaviour might imply paraphilia are discussed, it is mainly in terms of their victimization at the hands of men with paraphilic disorders. The purpose of this report is to review the current literature on female paraphilias and to present the clinical features of 14 women who sought treatment for presumed paraphilic sexual disorders. Social and personal history characteristics of the 14 women were compared to those of 118 men similarly assessed for presumed paraphilic sexual disorders. The 12 women classified as having at least one paraphilia were similarly compared with an age-matched subsample of these men with diagnoses of paraphilia. Cases were drawn from the clinical records of a Forensic Psychiatrist who has conducted outpatient clinics for assessment and treatment of paraphilic disorders in three countries. The three most common paraphilic disorders in the female study group were: pedophilia (36%), sexual sadism (29%), and exhibitionism (29%). Co-morbid psychiatric disorders diagnosed among these women included major depression (36%), generalized anxiety disorder (14%), post traumatic stress disorder (7%) and erotomania (7%). There were no significant differences between women and men in terms of age, number of victims, employment status, sexual orientation, education, history of substance abuse, history of non-sexual criminal behavior, history of personal sexual abuse, frequency of incestuous assaults, or referral source.

Key words: Paraphilia Sexual disorder Female

INTRODUCTION

Since most of the research on paraphilias is derived from studies of convicted sex offenders, and since most convicted sex offenders are male, there is a clear research bias excluding females. Of the reports on females with paraphilias, most have involved selected single case reports of particularly unusual cases (e.g., Richards, 1990; Sass, 1975; Zaviacic, 1994); or studies involving reports by convicted male sex offenders of their childhood experiences allegedly involving female offenders (e.g., Groth & Burgess, 1980). Books that might be expected to deal with the issue of female paraphilias do not address the topic (e.g., Anderson & Struckman-Johnson, 1998; Bjorkquist & Niemela, 1992). When women are discussed, it is mainly in terms of their involvement in paraphilic activities at the behest of men with paraphilic disorders (e.g., Hazelwood, Warren, & Dietz, 1993; Warnes, 1986). This situation suggests a bias against the study of paraphilias in women in terms of both research and diagnosis.

For example, the text of the American Psychiatric Association Diagnostic and Statistical Manual (DSMIV) indicates that:
 Except for Sexual Masochism, where the sex ratio is estimated to be 20
 males for each female, the other paraphilias are almost never diagnosed in
 females, although some cases have been reported (DSM-IV, 1994, p. 524).


Eight specific paraphilias are listed in the manual, together with a ninth category, "paraphilia not otherwise specified" (see Table 1; for diagnostic criteria and definitions pertinent for the present study, see Methods section). Of the nine subcategories of paraphilias listed in Table 1, the DSM describes two of them (exhibitionism and frotteurism) using the masculine pronoun. In addition, the diagnostic criteria for transvestic fetishism require that the individual not only be male, but also heterosexual. The DSM-IV thus reinforces the widespread acceptance in sexology that paraphilias in women are rare to nonexistent. There are, nevertheless, historical case reports of women who appear to meet the criteria for every known paraphilia (see Fedoroff & Fishell, in press), including (with the exception of being female) transvestic fetishism (Stoller, 1982). Evidence of paraphilias in women is also reflected by reports in the non-academic literature (e.g., Antoniou, 1995; Burnside & Cairns, 1995; John, 1993; Palac, 1998).
Table 1 DSM-IV Paraphilic Disorders(*)

DSM-IV Defining
Paraphilic Disorder Characteristic

Exhibitionism Exposure of genitals
Fetishism Use of nonliving objects
Frotteurism Touching and rubbing against a
 nonconsenting person
Pedophilia Focus on prepubescent children
Sexual masochism Receiving humiliation or suffering
Sexual sadism Inflicting humiliation or suffering
Transvestic fetishism Cross-dressing as member of
 the other sex
Voyeurism Observing sexual activity
Paraphilia not All other paraphilias
 otherwise specified


(*) As cited in APA (1994).

This paper presents information on a case series of women who were referred to clinics specializing in the assessment and treatment of paraphilic disorders. It should be emphasized at the outset that this is not a study into the frequency or prevalence of paraphilias in the female population nor can the findings be used to draw such inferences. The design of the study precludes any such inferences. Rather, it is intended to provide information about the phenomenology of paraphilic disorders and their presentation in some females. The Discussion therefore includes analysis of each of the female case examples on which the following quantitative findings are based.

METHOD

The data used in this analysis were obtained from the clinical records of the first author who, over the past fifteen years, has conducted outpatient clinics for the assessment and treatment of individuals referred for suspected paraphilic disorders. Individuals referred to these clinics included both forensic and non-forensic patients. The clinics have been located in different countries (Canada, the United States, and Great Britain) and all have been affiliated with universities. An ethics committee approved the retrospective chart review conducted on the clinic records.

Fourteen female patients referred with a suspected paraphilic disorder were identified. Group demographic variables for these women were compared to a convenience sample consisting of all men referred to the same clinic for suspected paraphilic disorder who had completed the same standardized intake assessment questionnaire (available on request from the corresponding author). In addition, the females who were subsequently diagnosed with paraphilic disorders (n = 12) were compared to an age-matched sub-sample of the male group with diagnosed paraphilic disorders.

The same DSM-IV criteria were used to assign diagnoses for the male and female groups. In every case in which a paraphilic disorder was diagnosed, the individual was found to meet Criterion A of the DSM-IV: "recurrent, intense sexually arousing fantasies, sexual urges, or behaviors generally involving 1) nonhuman objects 2) the suffering or humiliation of oneself or one's partner, or children or other nonconsenting persons that occur over a period of at least 6 months" (DSM-IV, pp. 522-523). Individuals who did not meet this criterion were not assigned a paraphilia diagnosis even if they had been accused or convicted of a sex crime. Conversely, individuals who met DSM-IV criteria for a paraphilia that is not typically associated with criminal activity (e.g., sexual fetish) were assigned the appropriate paraphilia diagnosis even if they had not been accused or convicted of a sex crime.

The questionnaire was administered in an identical fashion to both the males and females. Patients first completed the form in private; each item was then reviewed with the psychiatrist (JPF) to ensure that the patient had understood the form and completed it accurately. A standardized mental status exam and review of the presenting problem was also conducted. Also available were past medical and psychiatric records and police and probation reports. Any inconsistencies between the questionnaire and other reports were carefully reviewed with the patients by the first author at the time of intake.

ENSURING CONFIDENTIALITY

The following measures were taken to ensure the anonymity of case studies reported: (1) identifying demographic variables are reported only as grouped data; (2) the clinic and country in which the cases were assessed is not reported; (3) the year of assessment is not reported; and (4) other details of the case presentation that could be associated with a specific individual have been altered. The above data were available on request to the scientific reviewers of this manuscript under conditions of confidentiality.

STATISTICAL ANALYSIS

The data were analyzed using contingency tables, frequency counts, and unpaired, two tailed t-tests as appropriate.

RESULTS

Out of 132 assessments included in the study, 14 (11%) were women All 14 women had been accused of and/or admitted to activities consistent with a paraphilic disorder. Using strict DSM-IV criteria (including the criterion of at least six months of admitted sexually arousing fantasies and/or behaviour involving a paraphilic activity), eight women could conservatively have been considered as having had at least one paraphilia. Another four could arguably be considered paraphilic and two could not. Within the total female sample, the most common diagnoses were pedophilia (36%), sexual sadism (29%), and exhibitionism (29%). Female paraphilia diagnoses are summarized in Table 2 (see Discussion section for further details about the female cases).
Table 2 Summary of 14 Females Referred for Paraphilic Assessment

Case Presenting Problem(s)

 1 Sexual fondling of boy
 2 Attempted sadistic rape of man
 3 Sex assault of boy and girl
 4 Sexual fondling of boy
 5 Sexual assault of boys
 6 Public masturbation; touching
 Exposing; sex with dogs; children
 8 Torture of male partner
 9 Sex attraction to murderer
 10 Fantasies of sex with children
 (ego-dystonic)
 11 Obligatory group sex with men
 12 Rape of girl; exposing to men
 13 Sadistic murder
 14 Rape of boy

Case Paraphilia(s)

 1 Pedophilia
 2 Sadism; masochism
 3 Pedophilia; sadism
 4 Pedophilia
 5 Pedophilia
 6 Exhibitionism; frotteurism
 Exhibitionism; zoophilia;
 pedophilia; sadism
 8 Sadism
 9 Masochism; hybristophilia
 10 None
 11 Troilism; zoophilia; exhibitionism
 12 Exhibitionism
 13 None
 14 Voyeurism; simulated pedophilia

Case Other Psychiatric Diagnoses

 1 None
 2 Erotomania; bipolar disorder
 3 Generalized anxiety d/o
 4 None
 5 Major depression
 6 Generalized anxiety d/o; erotomania;
 major depression
 Bipolar d/o; inhibited orgasm
 8 Post traumatic stress d/o
 9 Major depression; inhibited orgasm
 10 Major depression
 11 Dysthymic d/o; inhibited orgasm
 12 Major depression; bulimia
 13 None
 14 Malingering


Of the 118 men in this study, 55 met DSM-IV criteria for pedophilia (47%), 34 for transvestic fetishism (29%), 6 for exhibitionism (5%), 4 for sadism (3%), 5 for frotteurism (4%), 5 for paraphilias not otherwise specified (4%), and 4 for voyeurism (3%). In addition, 4 also had gender identity disorders (3%) and one had a sexual foot fetish. Several men and women had more than one paraphilia but the women in this limited sample were more likely to have multiple paraphilic disorders (men: 30 [25%], women: 7 [50%]; [Chi square] = 3.7, df = 1, p = 0.05).

Summary demographic and psychiatric history data for the women and men are presented in Table 3. There was only one demographic characteristic on which men and women in the sample differed statistically (females were more likely to have a family history of alcoholism). This overall lack of statistically significant personal/social differences between men and women was unchanged when the 12 women with probable or possible paraphilia were compared to an age-matched subsample of 12 men drawn from all men in the study sample.

Table 3 Demographic Characteristics of Male and Female Cases
 Women Men
Parameter n (%) (n = 14) (n = 118)

Mean age (S.D.) 344 [+ or -] 15 364 [+ or -] 12
Marital status
 Married 5 (36) 49 (42)
 Single 7 (50) 41 (35)
 Divorced 0 (0) 23 (20)
 Separated 2 (14) 4 (3)
Employed 8 (57) 85 (73)
Finished high school 13 (93) 106 (90)
Has children 6 (43) 55 (47)
Legal referral source 5 (36) 37 (31)
 Family history
 Psychiatric d/o 7 (50) 41 (35)
 Alcoholism 9 (64) 43 (36)(*)
Personal history
 Prior non-sex offence 4 (29) 46 (39)
 Substance abuse 4 (29) 32 (28)
 Alcoholism 4 (29) 46 (39)
Sex history
Incest victim 3 (21) 12 (10)
Sexual orientation
 Heterosexual 12 (86) 91 (84)
 Homosexual 1 (7) 8 (7)
 Bisexual 1 (7) 8 (7)


(*) p = 0.05

DISCUSSION AND CASE DESCRIPTIONS

The major finding of this study was the identification of a small, but clinically significant, sample of women with a wide range of paraphilic interests or activities. Before discussing the findings, it is important to recognize a number of important limitations of the study. First, as stated in the introduction, this study was not designed to answer questions about the population prevalence of paraphilias in women. The women included in this study were all referred to specialized university clinics that focus on the assessment and treatment of paraphilic disorders. Therefore generalizations from these findings to other populations is not warranted.

Second, due to the unequal numbers of men and women, statistical comparisons between the two groups should be viewed as descriptive only. Nevertheless, taken as a whole, the results of this study contrast with the major conclusions of other recent reviews of the literature. Hunter and Mathews (1997) emphasized the prevalence of female juvenile sex offenders (see also Fehrenbach & Monastersky, 1988; Mathews, Hunter, & Vuz, 1997) whereas all but one of the women in the present study were adult. Among juvenile female offenders, a history of childhood sexual abuse is frequently reported (e.g., 93-100% in Knopp & Lackey, 1987). Whereas in this study, only 3 women (21%) reported past sexual victimization compared to 12 of the men (10%). Similarly, while anxiety disorders affected 14% of the women in this study, only one had post-traumatic stress disorder. This contrasts with the emphasis that other researchers have placed on the prevalence of post traumatic stress disorder in juvenile female sex offenders (e.g., Briere, 1992; Hunter, 1993). The reasons for these differences are not known, but likely reflect the different populations studied: forensic adult outpatients versus residential juvenile offenders. The possibility of type II errors is particularly important to acknowledge. Further studies with larger numbers of female paraphilics will be necessary in order to explore questions about whether or not they differ in substantial ways from male paraphilics.

Finally, as in all studies of this nature, since the current diagnostic criteria for paraphilic disorders is dependent upon self-report, caution is needed both in assigning and dismissing paraphilia diagnoses. For this reason, brief descriptions of the presentations and phenomenology of the women involved in this study are presented below. Again, readers should be aware that identifying data has been altered in order to protect the confidentiality of the individuals involved (please see Methods section above for details).

FEMALE CASE DESCRIPTIONS

The cases described below refer sequentially to the individuals listed in Table 2.

Case 1. This heterosexual woman had been convicted of sexual exploitation of an unrelated 9-year-old boy. The offence occurred while she was baby-sitting. She was seen at the request of her lawyer for a pre-sentencing report. She had been accused of touching the boy's penis and asking him to masturbate in front of her while she watched religious programs on television. She maintained her innocence but did admit to being sexually active with older men until she underwent a "religious conversion" at age 19.

Comment: This woman's presentation is similar to that of men who are "pre-sentence" in that she attempted to deny any inappropriate sexual activities or interests in spite of having been convicted. At the time of the assault she did not have a boyfriend and had been on a self-imposed "celibacy program" (total abstention from sex including masturbation) for six years. Like some men with high degrees of sex guilt, she appears to have managed to convince herself that whatever she did with the boy was not sexual "since women don't do that sort of thing" and therefore did not contravene her religious and moral beliefs. The simultaneous "un-doing" of the sex acts by watching religious programs at the same time is also characteristic of paraphilic behaviour (Money, 1986). Although she maintained her innocence, she was willing to accept any punishment since she considered herself guilty for having had sexual thoughts about males of all ages, but said she would prefer to receive "the sentence that God will give me".

Case 2. This bisexual woman was brought to the emergency room by police, but not charged. Police had been called to a man's apartment when she appeared at his door and told him she wanted to have sex with him after she tied him to the bed. Instead of letting her in, the man called the police. When they arrived, she told them she would go with them quietly if they first let her carry out her sexual wishes. She was searched and a rope and large hunting knife were seized. On examination, she was hyper-talkative, grandiose, and irritable. She reported an insatiable sex drive directed toward the man she had intended to rape. She also described a belief that her mother had been attempting to poison her.

Comment: This woman was clearly in the manic phase of a bipolar mood disorder at the time of assessment. During the previous 3 weeks she had also shown symptoms of erotomania. Erotomania is a delusional disorder. It is one example of a psychiatric disorder that can result in behaviour (e.g., stalking) that is sometimes confused with paraphilic behaviour (Menzies, Fedoroff, Green, & Isaacson, 1995). She had become convinced that the man, with whom she had daily but casual contact, had become madly in love with her and seduced her by sending her coded messages to which she had responded.

When asked why she thought the man in question had not opened the door of his apartment to her she said, "I think he is a naive virgin". Although her presentation was coloured mainly by her major mental illness, she did admit to having strong sadistic and masochistic sexual fantasies (including non-consensual activities) which, while not required for sexual arousal, greatly enhanced it.

Case 3. This heterosexual woman was found guilty of two counts of sexual assault on unrelated children (a girl age 4 and a boy age 9). In the case of the girl, she claimed she was unable to remember whether or not she had pushed a crayon up the girl's vagina since she had been depressed at the time. She received 1 year's probation for this offence. Several months later, she assaulted the boy, also while baby-sitting him: "I called him into my bedroom. I took my top off and put my finger up his anus. I remember that one." Asked why site had done it, she replied, "I think I had a lot of depression. I was frustrated that my mother wasn't spending time with me".

For her second offence she received two years probation (concurrent) and her children were placed in care. She denied any paraphilic sexual arousal but said that as a child her mother's boyfriend would tie her up and force her to watch him having sex with her mother, an activity that she recalled as very sexually arousing.

She had become involved with a man who had spent time in prison for sexually assaulting a girl before they met. He confessed his past to her only after she had been arrested. They are not known to have assaulted anyone together.

Comment: This woman admitted being sexually aroused by coercive sexual encounters and although she denied specific arousal from sex with children, had been unable to resist re-offending while on probation. The case is notable for the rather lenient sentence she received (supporting the hypothesis that women may be under-represented in prison surveys because they are dealt with differently by the judicial system).

This woman had married a man with similar sexual interests. Similar alignments of mutually compatible paraphilic interests have been commented upon by other researchers (see Keyes & Money, 1993). However, there is no indication that this woman was somehow coerced into paraphilic behaviour by her partner.

Case 4. This heterosexual woman had been convicted of sexually assaulting her nephew when he was between the ages of 7 to 8. She admitted touching his penis during "wrestling sessions" as well as sexual arousal during these events. She received two years probation for this offence. She had a family history of alcoholism and was herself a polysubstance abuser although she denied any association between drug use and her sex offences.

Comment: Case 4's presentation was similar to most convicted male incest sex offenders seen in the first author's outpatient sex offender clinics. While she admitted committing the offences, she denied any ongoing paraphilic interests and she attempted to argue that the assaults on her nephew were purely opportunistic (he happened to be available at a time when she felt "lonely"). Of particular concern was the fact that she had chosen a profession that would bring her into daily contact with children, a practice common among male pedophiles.

Case 5. This heterosexual woman was referred for assessment by the local Children's Aid Society after she reported to them that she had been performing fellatio on her sons, aged 1 and 3. Although no charges had been laid, she had agreed to a voluntary supervision order. While she admitted to committing the offences, she denied sexual arousal as a motivation saying, "I did it on impulse. I remember my husband was mad at me and I was mad at him so I did it. I had a feeling of insecurity and needed intimacy." She did admit to sexual fantasies that were extremely arousing to her: "humiliation or rape of other women. I would like to be a woman but with a penis. I have fantasies of me doing it to other women. I also have fantasies of being promiscuous with other men. I have fantasies of humiliation of women during sex i.e. rape, degradation, powerlessness, sodomy."

In addition, she described sexual fantasies involving her children and fantasies of having sex with dogs, or of being a prostitute who was forced to do "degrading things". At the time of assessment, she also met DSMIV criteria for Major Depression.

Comment: In this case, there appeared to be a strong association between her episodes of depression and her paraphilic fantasies and behaviours. All her paraphilic interests resolved once her depression was treated but returned one year later when she became depressed again (her male partner discovered that she had begun advertising in "swinger's forums" for men to have "degrading" sex with her without his knowledge).

Case 6. This lesbian woman with moderate development:al disability was referred by the group home where she lived because of concerns about her public sexual activities. Typically, she would "fixate" on a female staff member and follow her around attempting to rub against the staff member. This behaviour would escalate to "flashing" her genitals and breasts at the staff member, followed by masturbation in public. At the time of assessment, she was receiving intramuscular injections of medroxy-progesterone acetate (MPA) (an anti-androgen often used to reduce paraphilic activities in males) (Fedoroff, Wisner-Carlson, Dean, & Berlin, 1992) but there had been no noticeable change in her sexual behaviours.

Comment: This case is characteristic of ones in which disinhibition of sexual urges is secondary to developmental disability resulting from organic factors (in this case, likely fetal alcohol syndrome). She also showed signs of erotomania and major depression. Treatment with an antidepressant medication appeared to decrease her inappropriate sexual behaviours more effectively than MPA, a finding also reported in some male sex offenders (e.g., Fedoroff, 1995).

Case 7. This heterosexual woman was self-referred because of "a tendency to exhibit". She was not currently facing charges. She described a ritual of undressing herself and masturbating with the lights on in front of her apartment window, approximately 5 times a month. While she was aroused by the idea of being seen by male strangers, she denied any wish to engage in sex with anyone who saw her. Unless she was involved in "really bizarre situations," she had primary anorgasmia even when masturbating.

At one point she began driving her truck through unfamiliar neighbourhoods with pet food in an attempt to befriend cats and dogs which she would "abduct". She would coax the cats to lick her genitals by placing honey on her vaginal area. She would perform oral sex on male dogs who she "abducted" in a similar manner. She also described sexual fantasies about having sex with boys and girls between the ages of 8 and 10. On one occasion, she had "punished" an unidentified 8-year-old boy she was baby-sitting by squeezing his penis and "physically smacked him around". She was sexually aroused by this activity and would often masturbate while recalling this episode.

Three years prior to assessment she had become involved in a unique form of prostitution in which she would flag down taxis from her truck and then proceed to talk the cab drivers into taking her for coffee and eventually into paying to have sex with her. She did the same thing with men she met on "phone sex lines". She did this for about a year and then stopped because she said, "It wasn't me". She had been engaged but found she could not have sex with her male partner unless she acted out her paraphilic interests (activities that caused him to leave her).

Comment: This woman's presentation is typical of many self-referred men who are not facing charges in that there are multiple, highly idiosyncratic and obligatory sex "rituals" described. She was "obsessed" with sex, devoting the majority of her waking days to fulfilling her desires. However she also described high levels of sex guilt (a finding also characteristic of male sex offenders). Although she found these activities highly sexually arousing, they were at the same time highly aversive to her, particularly "because she was a Christian". This case is also instructive for the fact that her partner (in this case, a male), was not supportive of her paraphilic activities. This woman found it impossible to forgo her paraphilic activities, even though she knew it spelled the end of the most important romantic relationship she had ever established.

Case 8. This heterosexual woman was self-referred with her male partner because of concerns about their sexual activities. There were no legal issues. She explained that she had been aroused by the idea of "domination" all her life. Her partner was a self-proclaimed masochist who enjoyed being tied up and severely whipped and/or tortured by her. They had a compatible and happy sex life together except that her partner was also interested in public sexual activities in "S/M sex clubs". She, on the other hand, felt that her sexual activities, particularly her sadistic activities with her partner, were "too sexy, too important for me for me to want to do this with other people around. I totally enjoy what we do but it would be like asking a `straight' person how they would feel about masturbating in public".

Comment: This woman had sadistic sexual arousal but no exhibitionist sexual interests. Her partner's arousal pattern was perfectly compatible in terms of his masochistic interests, but he also required an exhibitionistic component, which was the source of this couple's sexual conflict. Treatment involved couple's therapy as well as pharmacologic therapy to reduce her husband's exhibitionistic urges. In this case, no attempt was made to alter the woman's paraphilic interests since neither she nor her husband wished to change them. It should be noted that although the relationship of this couple was consensual, both the woman and her partner were primarily aroused by non-consensual sadomasochism. Therefore, she would meet current DSM-IV criteria for sexual sadism (although the manual is silent about situations in which the "victim" is willing to be "nonconsensual").

Case 9. This heterosexual woman was self-referred because of masochistic interests. Although she was aware of sexual arousal from thoughts of "being tied up" since she was age 8, she had sought help at this time because of a work situation. During the course of her duties she had come to know a man who confessed he had been involved in a murder. She became very aroused by this information, fantasizing about having sex with the confessed murderer. She was considering entering a relationship with him but said, "I'm afraid. Someone described him to me as a sociopath. I find him cold and cruel. Knowing he could hurt me is the fascination."

She said she had never in her life been able to reach orgasm through sexual relations with any man who was "kind" to her and admitted she had sought out activities which brought her into contact with men who were not "kind".

Comment: This case is typical of many sexual masochists who are able to live high functioning lives while secretly harbouring paraphilic interests. Although the phenomenon of women who are romantically attracted to criminals is well known (e.g., Isenberg, 1977) this women described a primary sexual attraction based on her knowledge that the man involved could murder. This pattern of sexual attraction and arousal has previously been described and named (hybristophilia) (Money, 1986)and has been associated in non-scientific literature with other women known to have engaged in sadomasochistic activities (e.g., Williams, 1996).

Like many masochists, she considered herself (and women in general) to be powerful. In the past, a man who had been very close to her had committed suicide at home by shooting himself in the head and she always wondered "whether a woman had killed him".

Case 10. This heterosexual woman was referred by her family doctor because of her fantasies of having sex with boys between the ages of 7 and 14. Age of onset of these fantasies was uncertain but appeared to have been associated with symptoms of major depression which caused her to seek therapy. Although she had never had sex with another person, she was also ormented by the fear that she might have AIDS.

Comment: Although she clearly described thoughts of having sex with boys, all her fantasies were sexually arousing but "ego-dystonic" (aversive). The DSM is unclear about how to rate ego-dystonic, sexually arousing paraphilic fantasies. As her depression improved, her thoughts about sex with minors decreased. It is uncertain whether these thoughts were truly paraphilic or whether they represented obsessional thoughts akin to her obsessions about contracting AIDS. As is typical with many men with non-criminal paraphilias, although she had definite pedophilic fantasies associated with sexual arousal, she had sought treatment because of depression.

Case 11. This heterosexual woman was self-referred because she believed she had been "desensitized to normal orgasms". She explained that she had no problems with her sexual activities and interests until 7 years prior to assessment when she noticed it was becoming increasingly difficult to reach orgasm through intercourse with her male partner, or with masturbation. She then had a series of "extramarital affairs" (with her partner's knowledge and consent).

Each time she started a new "affair" she was able to reach orgasm through sexual intercourse with her new partner easily for about a month before her symptoms of anorgasmia began to return. Eventually she and her partner discovered that if she had sex with a succession of men in the same evening, she was able to reach orgasm consistently and reliably. She also discovered that she was sexually aroused by watching X-rated, zoophilic videos (depictions of animals having sex with women), and by making videos in which she disrobed and masturbated.

She and her partner presented for assessment because of concerns that her interests were not "normal". Her partner was also interviewed and although he tolerated her wishes, he himself was not aroused by her triolism, exhibitionism or zoophilic interests. This couple's sexual activities had been her idea as was her choice of pornographic videos. No sexual problems (either paraphilic or in terms of ability to function sexually) were detected in her regular partner.

Comment: Couple's therapy was initiated but made little progress until it was discovered that she consumed large amounts of L-tryptophan, available in health food stores, to help her sleep. This substance is metabolized into serotonin which is known to cause difficulty reaching orgasm. She was advised to discontinue taking L-tryptophan.

Soon afterward, her ability to reach orgasm through intercourse with her regular partner alone returned, and with it, her paraphilic interest in group sex, exhibitionism, and zoophilia disappeared. The onset of paraphilic interests following the onset of anorgasmia in a woman has previously been described in a woman with Huntington's disease (Fedoroff, Peyzer, Franz, & Folstein, 1994).

Case 12. This heterosexual woman was charged with sexual assault on a 13-year-old female and seen at the request of her lawyer. She explained that she and her ex-male partner (who was also charged with the same offence and who had a past history of sexual assaults on pubescent females) had been with the victim. She said, "He kept forcing me to have sex with her and I kept saying, no, she is only thirteen and she is a girl and I don't like doing it with a girl." Later, when she again objected to having sex with the girl, her partner had threatened to stab her with a knife. There were no other paraphilic activities, aside from her report of becoming sexually aroused by "flashing" her genitals to same aged men in the group home where she lived.

Comment: This is a young woman with mild developmental disability and a childhood history of severe, systematic sexual abuse at the hands of her father and his male friends. She was willing to engage in activities that were aversive to her in exchange for affection, a quality that her paraphilic and opportunistic co-accused used to his advantage. Although she was certainly not pedophilic, she did show symptoms of exhibitionism but it is uncertain whether her "flashing" was motivated more by a need for affection or by true paraphilic sexual desires. Again, the DSM-IV is somewhat unclear about how to rate paraphilic behaviours which are for the purpose of affection rather than for simple sexual arousal.

Case 13. This heterosexual married woman was facing no charges but was seen at the request of her lawyer who was concerned about a police investigation that was launched when her son alleged that she had been involved in sadistic torture and murder of children as part of ongoing satanic rituals. Allegations included torture, dismemberment, and cannibalism of children abducted by the woman and her "coven". These allegations had been made after her adult son had been treated for depression by a psychotherapist who believed that most mental illness is the result of childhood sexual abuse. She denied all the allegations and any symptoms of any paraphilic disorders.

Comment: There was no evidence that any of the allegations were true and this is almost certainly a case of "false memory syndrome" (see Ceci & Bruck, 1995; Loftus & Ketcham, 1994) resulting from the misguided therapy of her son. Although there is little evidence that Case 13 has a paraphilic disorder, she was included in this series since she had presented for evaluation of possible paraphilic interests. Her presentation was identical to that of men facing similar allegations from relatives who are in therapy.

Case 14. This heterosexual woman was assessed at the request of her lawyer, responding to a request from Children's Aid concerning the question of whether she could care for her children. Concerns had arisen after she self-disclosed in a treatment group for women who had themselves been sexually abused, that she herself had once sexually assaulted a "ten-to twelve-year-old boy". She proceeded to report the event to the police and Children's Aid Society. She said she had met the boy in a park, become sexually aroused, and lured him to an abandoned apartment where she had sex with him against his will. She claimed, "although there was no violence, after we finished he started throwing up, I think he thought he had been raped."

No charges were laid since neither the police nor Children's Aid had received any complaints; there was no apartment building in the location she said; and there were inconsistencies in details of the alleged assault such as when it occurred and what exactly had taken place.

The woman's own children were already in the care of Children's Aid since she was known to have physically (but not sexually) abused them.

In the past, she had worked as a prostitute which she claimed was for the purpose of "improving my self esteem" rather than for financial reasons. She had also worked as an "exotic dancer" which she found very sexually arousing. Although she admitted having fantasies of spying on unsuspecting males she had never actually done so. Her presentation was also notable for the fact that she claimed to be taking numerous medications. However, consultation with her physicians indicated these medications had never been prescribed for her. Blood tests also showed no evidence that she was taking any of the medications she named.

Comment: Case 14 is unusual in that the only evidence "against" her was her own testimony. No victim or crime scene was ever found. She admitted she did not particularly want to be reunited with her children, with whom she had had disputes and who were known to have been sexually abused by a previous male partner. Cases of individuals who simulate paraphilias have previously been described (Fedoroff, Hanson, McGuire, Malin, & Berlin, 1992) and this woman's case thus raises the possibility that she may have been reporting events that never happened in order to keep her children in care.

IMPLICATIONS

Given the previously described limitations of the present study, what are the implications of the findings? The first issue involves the question of why so few reports of females with paraphilias have appeared in the literature to date?

One possible explanation is that most paraphilia research is conducted on people who have been convicted of sex crimes (e.g., Gebhard, Gagnon, Pomery, & Christenson, 1965). Men far outnumber women in criminal populations either because women commit fewer crimes, are caught less frequently, and/ or are dealt with differently by the judicial system. If sex crimes are associated with paraphilic sexual disorders and if more men than women are convicted of sex crimes, it would follow that more men than women would appear in the paraphilia literature.

In contradiction of the last two of these premises, the literature suggests that people accused of sex crimes are a heterogeneous group and that not all sex criminals have paraphilic sexual disorders. Some offenders are simply opportunistic criminals, some are suffering front major mental disorders, some act while intoxicated and many are a combination of the foregoing groups. In addition, some reported "sex criminals" are either falsely accused (Fedoroff et al., 1997) or their behaviour simulates paraphilias (Fedoroffet et a1., 1992).

Further, "sex crime" is itself a term which is applicable to a wide range of behaviours. The Criminal Code of Canada lists more than 20 different categories of sex crime. These can be broadly subdivided into those in which there is a non-consensual victim (e.g., sexual assault) and those without (e.g., so-called "victimless crimes", prostitution-related offences). Paradoxically, more men than women are convicted of sex crimes with victims, whereas more women than men are charged and convicted of consensual sex crimes, particularly prostitution-related crimes. Since the majority of academics, physicians, judges, and indeed women themselves do not consider the possibility that females can harbour paraphilic interests, they are highly unlikely to recognize women with paraphilias.

Our lack of knowledge in this area is exacerbated by the fact that the population of paraphilics of most interest to researchers has been individuals who engage in illegal non-consensual sexual activities. While being arrested for sexual assault on a child is neither a necessary nor sufficient criterion for the diagnosis of pedophilia, a major source of information about pedophilia comes from studies of people accused or convicted of child sex abuse.

If some females fit the clinical definition of pedophilia, it would be expected that there should be at least some reports of females who have acted on their paraphilic urges and committed sexual assaults on children. Such reports do exist. For example, Finkelhor and Russell (1984) reviewed the literature on the prevalence of women who sexually assault children. Seventeen studies were identified: American Humane Association (A.H.A.), 1979; Bell & Weinberg, 1981; DeFrancis, 1969; DeJong, Hervada, & Emmett, 1983; Ellerstein & Canavan, 1980; Fedoroff et al., 1992; Finkelhor, 1979; Finkelhor & Hotaling, 1983; Fritz, Stoll, & Wagner, 1981; Fromuth, 1983; Gebhard et al., 1.965; Griffith, Anderson, Bach, & Paperny, 1981; Grob, 1985; Jaffe, Dynneson, & Ten Bensel, 1975; National Center for Child Abuse and Neglect (NCCAN), 1981; Queen's Bench Foundation, 1976; Russell, 1983.

A total of 8,865 sex offenders are described in these studies in which, depending on the study, females account for between 0 and 60% of the child abusers. Finkelhor and Russell (1984) reviewed possible sources of bias which could result in an over or underestimation of the true prevalence of female sex offenders and concluded that by "best estimates", the percent of sexual assaults against children attributed to women is between 14% to 27% for male victims and between 0% to 10% for female victims. Taking these and other literature reviews together, (see Saradjian & Hanks, 1996; Schwartz & Cellini, 1995), it appears that female sex offenders against children do exist. From the perspective of the present study, however, we do not know what proportion of these offences involved a paraphilia.

Araji (1997) recently reviewed an additional eight studies involving a total of 365 juvenile female sex offenders (Araji, Jache, Pfeiffer, & Smith, 1993; Araji, Jache, Tyrell, & Field, 1992; Bonner, Walker, & Berliner [unpublished]; Cantwell, 1988; English & Ray, 1991; Friedrich & Luecke, 1988; Johnson, 1989; Pithers & Gray, 1997). The major finding of these studies, which involved only juvenile offenders who may have different characteristics than adult offenders, was that 100% of the offending females reported a history of sexual abuse.

Since sexually abusing a child does not necessarily mean the offender is a pedophile, the existence of females with pedophilia can not be established through these studies of female offenders. The danger of equating a history of criminal sexual activity with the presence or absence of a specific paraphilia was dramatically demonstrated by Kaplan and Green (1995) who compared 11 incarcerated female sex offenders (only 4 of whom committed their offence[s] without a male accomplice) to 11 incarcerated females without known sex offences. The characteristics of the two groups were found to be similar except that the sex offender group was more likely to report having been physically and sexually abused, particularly by their own family members. In face-to-face interviews, the sex offender group reported fewer paraphilic fantasies than the non-sex offender group (2 vs 5). Only one sex offender admitted to having had sexual fantasies about her victim. However, when given a "self-report sexual interest card sort", the sex offender group gave responses suggestive of pedophilia (2), voyeurism (3), and masochism (1). The non-sex offender group's responses included indications of exhibitionism (5), pedophilia (1), voyeurism (2), fetishes (1), zoophilia (1), urophilia (1) and sadism (2). These data support the findings of the present study which suggest that females can harbour paraphilic interests. It also raises cautions concerning the fact that what researchers find is strongly influenced by what they are looking for and how they go about the search.

Despite the limitations of this study, the findings are consistent with the existent literature which predicts that sexual masochism is one paraphilia that women may have. We also identified a full range of other paraphilic disorders, a finding that should come as no surprise since the history of sex research has often shown that men and women have more similarities than was previously supposed. For example, the literature on sexual fantasies has repeatedly shown that men and women tend to be aroused by the same themes (Leitenberg & Henning, 1995), including unconventional sexual themes (Zimmer, Borchardt, & Fischle, 1983).

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J. Paul Fedoroff
Centre for Addiction and Mental
Health & Department of Psychiatry
University of Toronto,
Toronto, Ontario

Alicja Fishell
Department of Psychiatry
University of Toronto
Toronto, Ontario

Beverley Fedoroff
Whitby Mental Health Centre
Whitby, Ontario
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Author:Fedoroff, J. Paul; Fishell, Alicja; Fedoroff, Beverley
Publication:The Canadian Journal of Human Sexuality
Geographic Code:1CANA
Date:Jun 22, 1999
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