Most paraphilias emerge during adolescence although there is usually a connection with events or relationships in early childhood. Once established, they tend to be chronic, although some research has indicated that the behaviors will reduce as the individual ages (Barbaree & Blanchard, 2008). Most individuals with paraphilias are men. Although biological factors play a role in some paraphilias, researchers have yet to identify a specific biological or biochemical cause. Instead, psychological factors seem to be central. In most cases, one or more events occurred during childhood that led the individual to associate sexual pleasure with that event (or object) thus resulting in the development of a paraphilia. Thus in therapy it may be helpful to explore early sexual experiences and fantasies (Getzfeld, 2006). Treatment depends on the nature of the paraphilia and may include a biological component (such as medication), a psychological component (such as psychotherapy), and a sociocultural component (such as group or family therapy). The following provides a brief outline of some treatments that have been used with individuals who have a paraphilia.
a) Medications: The use of certain medications may be helpful in decreasing paraphiliac behavior. In fact, reducing the amount of testosterone in the body in effect lowers sex drive. If/when sex drive is lower, sexual behavior is likely to decrease. When sex drive is effectively lowered, the frequency in which an individual engages in sexual behaviors also decreases (Murphy & Page, 2008). While decreasing sex drive by lowering testosterone levels may help, it is important to note that this may not "cure" the paraphilia. Therefore, medication should be combined with some type of cognitive-behavioral treatments as well. These treatments are described below.
b) Victim Identification: Victim identification may be a useful treatment intervention for individuals with exhibitionism, frotterism, pedophilia, sexual sadism, and voyeurism. This type of treatment involves the therapist helping the client to realize that the person they are doing the behavior to (i.e., exposing themselves, exhibiting sadist-type behaviors) is a victim. Additionally, the client may be encouraged to identify the harm they cause to the person they are exposing themselves to. Exercises such as role reversal may be used and the client may be asked how the victim might feel both during and after the victimizing act. The goal of this therapeutic approach is for the client to develop empathy towards their victims (Murphy & Page, 2008). If the client is able to develop sufficient empathy toward their victims, they may reduce or discontinue the behavior because it is less pleasurable. However, it is important to note that many sex offenders may also have a personality disorder called Anti-Social Personality Disorder. This disorder is characterized by a lack of empathy. Thus, treatments which depend upon increasing empathy may have limited effectiveness for certain people.
c) Covert conditioning: Covert conditioning is a behavioral method in which undesirable behavior becomes less desirable and is eventually eliminated. In the case of paraphilias, the client is asked to imagine feeling shame when friends or family members observe him engaging in the behavior associated with the paraphilia. (Morin & Levenson, 2008). This type of intervention can be used with nearly all of the paraphilias and can help the client not engage in the behavior or to find the behavior less pleasurable.
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d) Orgasmic reconditioning: In orgasmic reconditioning the principles of learning are applied and the client is first asked to identify a fantasy that involves the paraphilia in question. Next, they are encouraged to engage in masturbation at home with specific instructions to become aroused by the fantasy associated with their paraphilia, but to complete the masturbation exercise (orgasm) while looking at an appropriate object (i.e., a picture of an adult partner). Finally, the client is instructed not to incorporate the fantasy at all. This type of treatment may be particularly helpful for individuals who have a fetish. The client with a fetish is asked to identify their fetishistic object. They are then sent home with instructions to become aroused with/by the fetishistic object and to masturbate. Prior to reaching orgasm they are encouraged to look at a picture of an adult partner and to orgasm/ejaculate while doing so (Plaud, 2007). The idea behind this treatment is simple: they are redirecting their arousal pattern and providing themselves positive reinforcement (orgasm) while looking at an "appropriate" object.
e) Masturbatory Extinction: Masturbatory Extinction also includes the instruction to masturbate. However, in this treatment the client is encouraged to masturbate and orgasm to an appropriate fantasy. Then after orgasm (i.e., ejaculation) they are encouraged to continue masturbating but to the deviant sexual fantasy. This causes the appropriate fantasy to be reinforced with an orgasm but the inappropriate fantasy to not be reinforced at all (Plaud, 2007).
f) Masturbatory Satiation: In masturbatory satiation, the client is encouraged to masturbate with the deviant fantasy in mind. When the client reaches orgasm they must continue to masturbate to the deviant fantasy for one hour. Since this activity does not end in reinforcing ejaculation, the client may eventually loose interest in such fantasies (Plaud, 2007).
g) Aversive Therapies: Aversive therapies include pairing arousal to the deviant fantasy with either mild electric shock or unpleasant smells (Plaud, 2007). If you have ever experienced food poisoning, you will understand this treatment intervention perfectly. Simply imagine a food that has made you sick. You are quite likely making a scrunched up face as you read this. This is because you have learned to associate being sick with the food that made you sick. The same principle applies here. In this type of treatment the client is encouraged to become aroused by the deviant fantasies and is immediately bombarded with an unpleasant smell or electric shock. The pairing of deviant fantasies with unpleasant sensations is thought to decrease both fantasies and behaviors.
h) Group Therapy: Group therapy may also be useful in the treatment of paraphilias. The focus may be on taking responsibility for actions, victim impact and empathy, establishing family support, building relationship and social skills, and cognitive restructuring (Morin & Levenson, 2008). With at least some of the paraphilias the individual may lack social skills and have difficulty establishing relationships with others. Thus, treatment that focuses on building social skills may be helpful. This may include some of the tactics we have already discussed (i.e., victim identification) and may also help the client to develop a new way of looking at things.