In the book The Paraphilias: Changing Suits in the Evolution of Sexual Interest Paradigms, Dr. J. Paul Fedoroff reviews information about the evaluation and management of the paraphilic disorders specified in the Diagnostic and Statistical Manual, Fifth Edition (DSM-5). In addition, he seeks to alter the widely held view of paraphilic disorders as incurable. Relying on the accumulated experience of 30 years assessing and managing individuals with paraphilic disorders, Dr. Fedoroff presents a viewpoint of problematic sexual behavior that challenges conventional societal and academic wisdom. Even for those with clinical or forensic experience in evaluating sexual offenders or individuals with paraphilic disorders, Dr. Fedoroff's text may be a worthwhile read for his unique perspective on fundamental topics in the field.
Dr. Fedoroff serves as the sole author of this text. He highlights this fact in the dedication of the text, in which he notes that his wife encouraged him to accept sole authorship of such a book because of his unique and often divergent opinions. Dr. Fedoroff has considerable experience in the evaluation and treatment of problematic sexual behaviors. He has worked at the Sexual Behaviours Clinic (SBC) at the Royal Ottawa Mental Health Centre for the last 18 years and serves as its Director. He is a full professor of psychiatry, criminology, and law and the head of the division of forensic psychiatry at the University of Ottawa. Dr. Fedoroff has also served as a President of the Canadian Academy of Psychiatry and the Law and the International Academy of Sex Research. In his role at the SBC, he oversees a robust academic clinical research program that has led to the publication of more than 100 research papers and book chapters.
The first two chapters of The Paraphilias establish the guiding framework and perspective for the remainder of the text. The first chapter describes the different vantage points from which investigators and theoreticians have examined problematic sexual behaviors over the years, including the “disease perspective” or medical model, the “behavioral perspective” based on learning models, the “dimensional perspective,” and the “life story perspective” or psychoanalytic model. Dr. Fedoroff then introduces his own framework for evaluating human sexuality based on five independent characteristics. He indicates that these five characteristics differ in terms of their mutability, such that some might be worthwhile targets of intervention, while others are not. Starting from least mutable, the characteristics are sexual genetics (one's sex chromosomes), gender identity (self-concept) and gender role (public presentation), orientation, drive, and sexual interest. Dr. Fedoroff takes care to distinguish sexual interest, the basis of paraphilic disorders, from sexual orientation, noting that one may be aroused by activities or objects that have nothing to do with the gender for whom one has affection. It is the failure for others to make such a distinction, he argues, that may lead them to believe that sexual interests cannot change.
The second chapter of the text outlines the various assessment and treatment modalities for problematic sexual behaviors and interests that the SBC offers. Integral to the SBC's approach is the voluntary nature of clients' participation and the emphasis on enhancing healthy sex as a substitute for dangerous or problematic sex acts. He also introduces the expectation that clients “stop all problematic paraphilic acts immediately” as “the first step to getting better,” (p 30) a concept that he reiterates throughout the later chapters.
Most of the book reviews the various specified paraphilic disorders in the DSM-5, including exhibitionistic disorder, fetishistic disorder, frotteuristic disorder, pedophilic disorder, sexual masochism and sexual sadism disorder, transvestic disorder, voyeuristic disorder, and the other specified paraphilic disorders. Each chapter starts with an introduction to the diagnosis and its definitions from the DSM-5 and the International Classification of Disease, 11th Revision, before discussing information pertaining to the variations, hypothesized etiologies, prevalence, recidivism rates (where relevant), assessment and treatment recommendations, and prognosis of each diagnosis. Each chapter's review of the literature is very useful as it provides references for those interested in learning more about the various aspects of the disorder. Dr. Fedoroff closes the book with a chapter that summarizes his views on the roles of context, mutability, self-identity, and consent in understanding sexual behavior and sexual interests.
For those interested in furthering their understanding of problematic sexual behaviors or evaluating sex offenders, The Paraphilias offers some truly memorable discussions. As mentioned previously, one of Dr. Fedoroff's primary theses is that sexual interests are highly mutable, provided the treatment approach is adequate and appropriate. He most directly addresses this topic in the chapter on pedophilic disorder. He starts by describing a 2014 retrospective penile plethysmography (PPG) study that demonstrated a change in arousal in 20 men who previously had PPG results consistent with pedophilic interest. He notes that this research generated considerable controversy and argues that its critics discount other sources of information regarding the mutability of pedophilic interests, including those men who self-report a change in their pedophilic interests and behaviors, as well as the reports of their adult sexual partners. Unfortunately, he does not cite any studies to support his claims for the reader to review.
Another memorable discussion occurs in the chapter on sexual masochism and sexual sadism disorder. Dr. Fedoroff discusses the elements of BDSM (bondage/discipline, dominance/submission, and sadism/masochism) and their relationship to problematic sexual behaviors. He notes that sadism and masochism, commonly thought to be opposite sexual interests, exist on a continuum and that individuals who identify as sadists or masochists may have a mix of sadistic and masochistic intentions for their behavior. Further, instead of viewing sadism and masochism as categorically abnormal, he suggests that they exist along a continuum from extreme sadism and masochism to so-called “vanilla” sex. Finally, he indicates that there may be nothing pathological about those who engage in acts of BDSM, unless they force others to participate in nonconsensual sexual acts.
The greatest contribution of the book to the fields of forensic psychiatry and sexology is its unique perspective of sexual interest as a highly mutable characteristic of human sexuality. It is clear from Dr. Fedoroff's writing that this belief undergirds the treatment paradigm at the SBC and that it reinforces the principles of collaboration and voluntariness and the expectation that its clients immediately stop criminal sexual behavior that the SBC advocates. In addition to providing a review of paraphilic disorders specified in the DSM-5, The Paraphilias raises important questions about human sexual behavior about which we have yet to find satisfactory answers. Dr. Fedoroff's views may inspire some controversy, but one hopes they will also promote further study to guide assessment and treatment paradigms for paraphilic disorders in years to come.
Footnotes
Disclosures of financial or other potential conflicts of interest: None.
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