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We describe approaches to treatment of persons with paraphilias, although the majority of treatment programs described in the literature target just sexual offenders. We identify several issues of ongoing disagreement within the field and provide data on long-term treatment outcome.
Key Words: cognitive therapy, relapse prevention, sexual offenders, therapeutic processes, treatment effectiveness.
The paraphilias, as described in the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR, American Psychiatric Association, 2000), embrace rather disparate problems, such as transvestic fetishism, pedophilia, and sexual sadism. These appear to have little in common other than that the DSM implies that all are sexually motivated. In fact, the past 20 years has seen a proliferation of both research and well-defined treatment programs for sexual offenders (some, but certainly not all, of whom meet DSM criteria for a paraphilia); very few investigators have described the nonoffending paraphilias. Nor have any broadly accepted treatment programs for these nonoffending paraphilias been described in the literature. As a result, we will focus on sexual offenders. This choice does not, apparently, do a disservice to the treatment of the other paraphilias because they are typically thought to share enough features with sexual offending to warrant quite similar treatment (see Laws & O'Donohue [1997] for descriptions of treatment approaches for the nonoffending paraphilias). What is needed, however, are more systematic studies of the nonoffending paraphilias so that treatment programs can be designed on more empirical bases.
Focusing this article on sexual offenders avoids a further problem: the poor reliability evident in the DSM diagnoses of paraphilias. In five reviews the clarity of the DSM diagnostic criteria for the paraphilias have been called into question and evidence suggesting that these diagnoses are unreliable has been presented (Marshall, 1997, 2006c; in press-b; Marshall & Kennedy, 2003; O'Donohue, Regev, & Hagstrom, 2000). In particular, the diagnosis of sexual sadism has been shown not to meet satisfactory levels of validity and interdiagnostician reliability in both actual clinical practice (Levenson, 2004; Marshall, Kennedy, & Yates, 2002) and in a quasi-field trial (Marshall, Kennedy, Yates, & Serran, 2002). Furthermore, Levenson (2004) produced data that revealed the specific unreliability of diagnoses for pedophilia and exhibitionism, and even for the more general category of any paraphilia.
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