Case Studies in Sexual Deviance: Toward Evidence-Based Practice

The concept of sexual deviance necessitates understanding sexual normalcy and pathology, and when there is pathology, how it is competently assessed. Case Studies in Sexual Deviance enriches the reader's knowledge of paraphilic disorders through vivid case studies and thorough assessments by the respective evaluators. The academic background of the authors includes counseling, forensic psychology, and social work, and they originate from the United States, New Zealand, Singapore, and Canada.

The chapter on Multisystem Therapy for Youth Problem Sexual Behavior (MST-PSB) was very informative. MST has clear principles and requires each member of the treatment team to have master's level or higher credentials. It is the only treatment for sex offenders that has undergone randomized clinical trials. Although studies show that MST-PSB is effective in addressing sex offending by juveniles, the authors failed to mention valid limitations to their interpretation, ranging from small sample sizes to whether confounding variables were controlled for and to what extent the results can be generalized across cultures and societies. Readers of the Journal would appreciate the discussion of the challenges of court-ordered treatment, especially when it relates to sexual abuse, the perception that it is coerced, and parental feelings that their delinquent children are not monsters.

Assessments and treatment of a rapist can be daunting to a clinician. Lawrence Ellerby, however, enables readers to master the evaluation through the case scenario and suggests how the evaluator might gather data, including the use of collateral information, psychological testing, and self-report measures. The assessment is enriched with techniques in the art of clinical interviewing, including pacing of topics and strategies to enhance disclosure. This discussion will be invaluable to clinicians who are relatively inexperienced in the field. The segment of evaluation is concluded by how to formulate a case and write a comprehensive report. The chapter concludes with a discussion of treatment planning and the stages of therapeutic engagement.

Rehabilitation of a child sex offender was discussed in conjunction with the Good Lives Model (GLM), which assists offenders in meeting their basic needs in more prosocial ways. Even though the authors were aware of the challenges in using this model, especially in the area of culture, it would have been more educational if they had proposed solid interventions. For example, when an offender stated that sexual intercourse with young female victims is not harmful to them and used cultural excuses to justify unacceptable acts against children, there was no strong rebuttal of this excuse for pathological behavior that could wreak lifelong damage on victims. Even though the diagnosis of sexual masochism may appear straightforward, the authors did not mention that there is poor agreement among clinicians. For example, among 15 known forensic psychiatrists with experience working with sexually sadistic offenders, there was a very low κ statistic for interdiagnostician agreement (κ = 0.14).¹

The chapter on voyeurism differentiates between acceptable voyeuristic activities such as watching reality television shows and those of pathological voyeurism. The role of technology in increasing the complexity of voyeuristic activities and recent statutory changes are important for readers to absorb. The case of Mr. V. was methodically presented and adequately formulated. Factors that affect static and dynamic risks, including recidivism and propensity for sexual interest in children, were dissected. However, given the thoroughness with which the authors approached the subject, I found their ambivalence regarding whether viewing pornographic materials by sex offenders should be prohibited to be a palpable deficiency. Clinicians and administrators working with sex offenders in institutions struggle with this question, especially in the contrast between what clinicians may recommend versus what the clients' human rights advocates dictate. This section would have been enriched by more research into the mechanism of the reward system in voyeurism vis-à-vis neuroplasticity and the dopaminergic circuitry. A theory proposes that the voyeuristic aspect of pornographic materials induces synaptic plasticity, which then enables the formation of new neuronal connections and consequent dopaminergic release, which further perpetuates the urge to repeat the maladaptive behavior.² A case could be made for restricting access to pornography, rather than concluding that exposure to such materials raises more questions than answers and that the best way to raise self-esteem is to lower expectations.

The book also delved into some rarer areas of sexual deviance, such as telephone scatologia, where callers derive sexual gratification through arousal and or masturbation when they lure an unsuspecting listener into explicit and obscene telephone conversations. However, given the ready availability of the Internet to young children, this chapter could have included a section on transmitting sexually explicit material via social media (sexting) and “sextual activities.” Is sexting a pathological social activity or a criminal activity? Should deviance in this area be defined by the nature of what is sexted, by the frequency of sexting, or by the ages of the people involved (e.g., underaged children)? What are the parental dilemmas, and how could clinicians mitigate cases without allowing a young person to be criminalized? This may be a subject for future editions of the book. Overall, it is a well-edited, concise book that would benefit readers of the Journal.

• © 2015 American Academy of Psychiatry and the Law