The Paraphilias – Organized Overview (Without Summary):

Definition and Core Characteristics

●​ Recurrent, intense sexually arousing:​

○​ Fantasies​

○​ Sexual urges​

○​ Behaviors​

●​ Typically involve:​

○​ Nonhuman objects​

○​ Suffering/humiliation of self or partner​

○​ Children or nonconsenting persons​

Diagnostic Challenges in DSM

●​ Challenge 1: Harm Without Distress​

○​ E.g., pedophilia, exhibitionism, frotteurism​

○​ Individuals may not feel guilt/distress​

○​ Still considered pathological due to nonconsensual nature​

●​ Challenge 2: Distress Without Harm​

○​ E.g., foot fetishists may be content or distressed​

○​ Both may share the same sexual interest​

●​ DSM-5 Distinction:​
 ○​ Paraphilias = Unusual sexual interests​

○​ Paraphilic Disorders = Cause harm to self/others or significant distress​

Key Features of Paraphilic Behavior

●​ Insistent and sometimes exclusive sexual focus on particular acts/objects​

●​ Orgasm may be impossible without focus on the specific paraphilic object/act​

●​ Often includes:​

○​ Compulsive qualities​

○​ High frequency of orgasmic release (up to 4–10 times per day)​

●​ Variable desire to change preferences​

●​ Majority of cases involve males​

Prevalence

●​ Unknown due to:​

○​ Reluctance in self-disclosure​

○​ Lack of reliable prevalence data​

DSM-5 Recognized Paraphilias

1.​ Fetishism​

2.​ Transvestic Fetishism​

3.​ Voyeurism​
 4.​ Exhibitionism​

5.​ Sexual Sadism​

6.​ Sexual Masochism​

7.​ Pedophilia (discussed also in context of sexual abuse)​

8.​ Frotteurism (rubbing genitals against a nonconsenting person)​

Paraphilias Not Otherwise Specified

●​ Telephone scatologia – obscene phone calls​

●​ Necrophilia – sexual attraction to corpses​

●​ Zoophilia – sexual interest in animals​

●​ Apotemnophilia – arousal from idea of limb amputation​

●​ Coprophilia – arousal from feces​

Comorbidity

●​ Certain paraphilias may co-occur​

●​ Each paraphilia to be discussed individually in further detail​

1.​ FETISHISTIC DISORDER

Core Characteristics
●​ Recurrent, intense sexually arousing:​

○​ Fantasies​
 ○​ Urges​

○​ Behaviors​

●​ Focus involves:​

○​ Inanimate objects (e.g., shoes, underwear)​

○​ Body parts not typically erotic (e.g., feet)​

Gender Differences
●​ Predominantly male​

●​ Female fetishists are extremely rare (Mason, 1997)​

Diagnostic Threshold
●​ Object must be:​

○​ Required or strongly preferred for sexual arousal or activity​

●​ Many men have fetish-like interests (e.g., lingerie), but do not meet criteria​

Behavioral Expression
●​ Common practices:​

○​ Masturbation while engaging with the object (kissing, tasting, smelling)​

●​ Often occurs in context of sadomasochism​

●​ Rare among sexual offenders (Kafka, 2010)​

Relationship and Social Implications

●​ In consensual relationships:​
 ○​ May not interfere with others' rights​

●​ Possible relational strain:​

○​ Non-fetishistic partners may object​

○​ Fetishist may experience shame and reluctance to disclose​

○​ Example: Chemical castration chosen over disclosure (Bergner, 2009)​

Criminal Behavior Association

●​ In some cases:​

○​ Burglary, theft, or assault used to obtain fetish objects​

○​ Commonly stolen: Women’s undergarments​

○​ Excitement of the act may become part of the fetish​

Etiological Hypothesis
●​ Classical conditioning and social learning:​

○​ E.g., Underwear paired with sexual arousal leads to fetish​

●​ Individual differences in sexual conditionability:​

○​ Some men more prone due to high conditionability​

○​ Similar to differences in fear/anxiety conditionability (Chapter 6)​

2.​ TRANSVESTIC DISORDER

Definition and Diagnostic Criteria (DSM-5)

●​ Recurrent, intense sexually arousing:​

○​ Fantasies​
 ○​ Urges​

○​ Behaviors​

●​ Involves cross-dressing as a female​

●​ Diagnosis only if significant distress or impairment is present​

Distinction from Other Behaviors

●​ Heterosexual men primarily affected​

●​ Gay men who dress in drag:​

○​ Typically do not do it for sexual gratification​

○​ Not diagnosed with transvestic disorder​

Typical Onset and Behavioral Pattern

●​ Onset: Adolescence​

●​ Involves:​

○​ Masturbation while wearing female clothing/undergarments​

Autogynephilia Hypothesis (Blanchard, 1989, 2010)

●​ Defined as sexual arousal by the thought/fantasy of being a woman​

●​ Two subgroups among transvestic fetishists:​

○​ With autogynephilia: Stronger link to gender dysphoria and desire for sex
reassignment​

○​ Without autogynephilia: Focus on specific female garments, similar to typical

fetishism​
Historical Context

●​ First identified by Magnus Hirschfeld:​

○​ "Attracted not by the women outside them, but by the woman inside them"​

Social and Legal Impact

●​ Generally harmless behavior​

●​ May cause harm only if associated with:​

○​ Illegal acts such as theft or property destruction (rare occurrences)​

Prevalence and Demographics

●​ Sweden study (Langstrom & Zucker, 2005):​

○​ 3% of men and 0.4% of women reported at least one erotic cross-dressing episode​

○​ Actual prevalence of the disorder is likely much lower​

Associated Factors (from Swedish study)

●​ Men who cross-dressed:​

○​ Reported more childhood sexual abuse​

○​ Had higher sexual arousal and masturbation frequency​

○​ Used pornography more​

○​ More likely to have other paraphilias​

Earlier Survey Findings (Docter & Prince, 1997)

●​ Surveyed over 1,000 frequent cross-dressers:​

○​ 87% were heterosexual​

○​ 83% had married​

○​ 60% were married at the time​

○​ Many kept it secret, but spouses often discovered it​

○​ Reactions varied: from acceptance to severe distress​

Case Illustration

●​ Example highlights:​

○​ Early onset of transvestic fetishism​

○​ Marriage-related difficulties stemming from the condition

3. VOYEURISTIC DISORDER
Definition and Diagnostic Criteria (DSM-5)

●​ Recurrent, intense sexually arousing:​

○​ Fantasies​

○​ Urges​

○​ Behaviors​

●​ Involves observing:​

○​ Unsuspecting females undressing​

○​ Couples engaging in sexual activity​

●​ Often accompanied by masturbation during the act​

Common Terminology and Demographics

●​ Known colloquially as “Peeping Toms”​

●​ Offenses primarily committed by young men​

Co-Occurring Behaviors and Disorders

●​ Frequently co-occurs with:​

○​ Exhibitionism​

○​ Sadomasochism​

○​ Cross-dressing (Transvestism)​

Developmental and Psychological Factors

●​ Sexual stimulation from viewing attractive females​

●​ Curiosity increased by privacy/mystery around sex​

●​ Shyness and social inadequacy can lead to voyeurism as a substitute for relationships​

●​ Voyeurism may provide:​

○​ Compensatory feelings of power and dominance​

○​ A way to avoid rejection and self-esteem loss​

●​ Even when married, voyeurs are often sexually maladjusted​

Impact of Adult Media

●​ Adult movies, videos, magazines offer an alternative source of stimulation​

 ●​ These do not fully substitute the “real-life” voyeuristic experience​

●​ The actual impact of adult media on voyeurism remains speculative​

Prevalence and Epidemiological Data

●​ Lack of solid prevalence data, but considered one of the most common paraphilias​

●​ Swedish survey (Langstrom & Seto, 2006):​

○​ 11.5% of men and 3.0% of women had engaged in voyeurism​

○​ Those who engaged reported:​

■​ More psychological problems​

■​ Lower life satisfaction​

■​ Higher masturbation frequency​

■​ Increased pornography use​

■​ Greater sexual arousability​

Legal and Ethical Aspects

●​ Voyeurs may be caught and apprehended by police​

●​ Rarely associated with broader criminal or antisocial behaviors​

●​ Many people have voyeuristic tendencies, checked by:​

○​ Fear of getting caught​

○​ Ethical concerns about privacy rights

4. EXHIBITIONISTIC DISORDER

Definition and Diagnostic Criteria (DSM-5)

●​ Recurrent, intense urges, fantasies, or behaviors​

●​ Involves exposing genitals to others (usually strangers)​

●​ Occurs in inappropriate circumstances and without consent​

●​ Arousal often comes from the shock or surprise of the victim​

Terminology and Context

●​ Legal term: Indecent exposure​

●​ Colloquial term: Flasher​

Common Locations and Patterns

●​ Secluded or public places:​

○​ Parks, department stores, churches, theaters, buses​

●​ Urban behaviors:​

○​ Driving by schools or bus stops, exposing while in the car, and speeding off​

●​ Often repeated in consistent settings:​

○​ Same location (e.g., churches)​

○​ Same time of day or vicinity​

●​ Unique case examples:​

○​ Youth exposing only at the top of a department store escalator​

Victim Profile

●​ Typically:​

○​ Young or middle-aged females​

○​ Strangers to the offender​

●​ Sometimes:​

○​ Children or adolescents​

Epidemiology and Prevalence

●​ Onset: Typically adolescence or young adulthood​

●​ Most common sexual offense reported to police in:​

○​ United States, Canada, Europe​

●​ Accounts for about one-third of all sexual offenses​

●​ Up to 20% of women may have been targeted by exhibitionism or voyeurism​

●​ Swedish survey (Langstrom & Seto, 2006):​

○​ 4.1% of men and 2.1% of women reported at least one episode​

Comorbidities and Associations

●​ Commonly co-occurs with:​

○​ Voyeurism​

○​ Sadomasochistic interests​

○​ Cross-dressing​
 ●​ Associated psychological features:​

○​ Greater psychological problems​

○​ Lower life satisfaction​

○​ More frequent pornography use​

○​ Higher masturbation frequency​

Behavioral Characteristics

●​ Sometimes involves:​

○​ Suggestive gestures​

○​ Masturbation​

●​ More commonly:​

○​ Only exposure​

●​ A minority may escalate to:​

○​ Aggressive or coercive sexual acts​

○​ May indicate antisocial personality disorder rather than a paraphilia​

Legal and Social Implications

●​ Acts occur without consent​

●​ Often emotionally upsetting to victims​

●​ Violation of norms of decency and privacy​

●​ Considered a criminal offense​

●​ Intrusive and offensive nature ensures social condemnation

5. FROTTEURISTIC DISORDER
Definition

●​ Sexual arousal or excitement from:​

○​ Rubbing one’s genitals against​

○​ Touching the body of a nonconsenting person​

Diagnostic Basis

●​ Diagnosed as frotteuristic disorder when:​

○​ Acts occur, regardless of whether the individual is distressed by the urges​

Contextual Elements

●​ Behavior is a nonconsensual form of physical contact​

●​ Occurs in public settings (e.g., crowded buses or subway trains)​

●​ Often reflects a misuse of behaviors that are normally consensually enjoyed​

Comorbidities and Associations

●​ Frequently co-occurs with:​

○​ Voyeurism​

○​ Exhibitionism​

●​ Part of a broader pattern of paraphilic interests (Langstrom, 2010)​

Prevalence and Risk Considerations

 ●​ Victim experiences are common in public transit environments​

●​ Concern:​

○​ Potential risk for more serious sexual offenses​

○​ Current research: No conclusive evidence to support escalation risk (Langstrom,

2010)​

Legal and Ethical Implications

●​ Involves unwilling participation of others​

●​ Considered a violation of personal autonomy​

●​ Categorized as a criminal behavior due to its nonconsensual nature​

6. SEXUAL SADISM DISORDER

Origin and Definition

●​ Term derived from Marquis de Sade (1740–1814), known for extreme cruelty​

●​ DSM-5 diagnosis requires:​

○​ Recurrent, intense sexually arousing fantasies, urges, or behaviors​

○​ Involving inflicting psychological or physical pain on another individual​

(See “DSM-5 Criteria” on p. 410)​

Nature of Sadistic Fantasies

●​ Themes of dominance, control, and humiliation (Kirsh & Becker, 2007)​

●​ Related but less severe pattern: Bondage and Discipline (B & D)​

○​ Includes tying up, hitting, spanking to enhance sexual excitement​

 ●​ Most sadistic acts occur consensually within sexual relationships without harm​

●​ BDSM subculture includes mild sadism, masochism, bondage, discipline​

●​ Important to distinguish transient/occasional interest from paraphilic sadism​

Prevalence

●​ Surveys: 5–15% of men and women enjoy sadistic/masochistic activities voluntarily

(Baumeister & Butler, 1997; Hucker, 1997)​

Severe and Non Consensual Sadism

●​ Small minority engage in nonconsensual, serious, sometimes fatal sadistic acts (Chang
& Heide, 2009; Dietz et al., 1990; Krueger, 2010)​

●​ Sadistic acts can lead up to or replace sexual intercourse​

●​ Examples of inflicted pain: whipping, biting, cutting, burning; from fantasy to mutilation
and murder​

●​ Sadism and masochism may co-occur in the same individual (Kirsh & Becker, 2007)​

●​ DSM-5 diagnosis requires:​

○​ Victim is nonconsenting, or​

○​ Sadistic behavior causes distress or interpersonal difficulties​

Comorbidity

●​ Common comorbid personality disorders:​

○​ Narcissistic​

○​ Schizoid​
 ○​ Antisocial (Kirsh & Becker, 2007)​

●​ Personality disorder sufferers may be especially non-empathic and prone to acting on

urges​

Extreme Sexual Sadism and Serial Killers

●​ Extreme sadists may mentally replay torture scenes during masturbation​

●​ Some sexually sadistic serial killers record or videotape acts​

●​ Study of 20 sexually sadistic serial killers responsible for 149 murders in US & Canada
(Warren et al., 1996):​

○​ Most: white males, late 20s to early 30s​

○​ Murders were consistent, reflecting sexual arousal from pain, fear, panic​

○​ Control over victim’s life and death produced a “God-like” sense of exhilaration​

○​ 85% reported violent sexual fantasies​

○​ 75% collected violent themed materials: audiotapes, videotapes, pictures,

sketches, pornography​

Notorious Cases

●​ Ted Bundy (executed 1989):​

○​ Murdered 30+ women, targeted type: women with long hair parted in the middle​

○​ Used victims to recreate detective magazine/slasher movie scenes​

●​ Jeffrey Dahmer (convicted 1992):​

○​ Mutilated and murdered 15 boys/young men​

○​ Engaged in sex acts postmortem​

○​ Murdered in prison later​

 ●​ Dennis Rader (BTK Killer):​

○​ 10 murders over 30 years​

○​ Childhood animal torture and fantasized torturing children​

○​ Stalked victims for weeks before attack​

○​ Tied victims, strangled, masturbated after death​

○​ Kept victims’ clothing, sometimes wore them​

○​ Practiced bondage privately for erotic pleasure​

Causation and Understanding

●​ Causes of extreme sexual sadism poorly understood​

●​ Some extreme sadists come from apparently stable, loving families​

Clinical and Forensic Importance

●​ Sexual sadism is a key concern for criminology, law enforcement, forensic mental health​

●​ Diagnosis reliability and validity issues:​

○​ Unwillingness of sadists to disclose violent fantasies (Marshall & Hucker, 2006;

Kingston et al., 2010; Nietschke et al., 2012)​

●​ Importance of distinguishing dangerous vs. non-dangerous sexual sadists​

●​ Proposed improvements:​

○​ Dimensional approach to diagnosis (Krueger, 2010; Marshall & Hucker, 2006)​

○​ Focus on behavioral indicators of sadism (Nietschke et al., 2012)​

7. SEXUAL MASOCHISM
Origin and Definition

●​ Term derived from Leopold V. Sacher-Masoch (1836–1895), Austrian novelist​

●​ Known for fictional characters who found sexual pleasure in pain​

●​ DSM-5 diagnosis requires:​

○​ Recurrent, intense sexually arousing fantasies, urges, or behaviors​

○​ Involving being humiliated, beaten, bound, or otherwise made to suffer​

(See “DSM-5 Criteria” on p. 410)​

Nature of Masochistic Relationships

●​ Consensual sadomasochistic relationships often involve:​

○​ A dominant, sadistic “master”​

○​ A submissive, masochistic “slave”​

●​ Found in both heterosexual and homosexual relationships​

●​ Masochists usually:​

○​ Do not want or cooperate with true sexual sadists​

○​ Prefer partners willing to hurt or humiliate within preset limits​

●​ Masochism is more common than sadism​

●​ Occurs in both men and women (Baumeister & Butler, 1997; Sandnabba et al., 2002)​

Sadomasochistic Community

●​ Includes activities like bondage and discipline​

●​ Often communal in “dungeons” in major cities​

●​ Example:​
 ○​ Men bound and whipped by women called “dominatrixes”​

○​ Dominatrixes wear leather or rubber outfits, paid to inflict pain and humiliation
sexually​

●​ Most members are high functioning and do not appear to suffer from their sexual
interests​

Problematic and Rare Forms of Masochism

●​ Autoerotic asphyxia:​

○​ Involves self-strangulation​

○​ Some speculate oxygen loss intensifies orgasm, but little evidence supports this​

○​ Studies show sexual fantasies of practitioners are strongly masochistic (Hucker,

2011)​

●​ Coroners in major U.S. cities find many deceased cases with masochistic pornography
or sexual paraphernalia​

●​ Estimated accidental deaths in the U.S. per year: 500 to 1,000 (LeVay & Baldwin, 2012)​

●​ More common in men but also occurs in women​

●​ Occurred historically across many cultures for hundreds of years​

●​ Sometimes occurs in consensual or non consensual sadomasochistic acts between two

or more people (McGrath & Turvey, 2008)​

8. PEDOPHILIA
Definition and Diagnosis

●​ DSM-5 diagnosis requires:​

○​ Adult with recurrent, intense sexual urges or fantasies about sexual activity with a
prepubertal child​
 ○​ Acting on desires is not necessary if urges cause distress (see “DSM-5 Criteria”
on p. 410)​

●​ Child defined as “generally age 13 or younger” (DSM-IV-TR wording retained)​

●​ DSM-5 rejected two proposals:​

○​ Diagnosis based on child’s physical maturity (Tanner scores)​

○​ Including men with hebephilia (attraction to pubescent children)​

●​ Debate over these rejected proposals was heated and interesting​

Nature of Sexual Interaction

●​ Sexual interaction often involves:​

○​ Manual or oral contact with child's genitals​

○​ Penetrative anal or vaginal sex is rarer​

●​ Penetration and force often injurious but usually a byproduct, not goal (unlike sadists)​

●​ Minority of pedophilic men are also sexual sadists (Cohen & Galynker, 2002)​

Demographics and Preferences

●​ Nearly all individuals with pedophilia are male​

●​ About two-thirds of victims are girls, typically ages 8–11 (Cohen & Galynker, 2002)​

●​ Majority prefer girls; about 25% prefer boys​

●​ Rate of homosexuality among pedophiles higher than in general population (Seto, 2008)​

●​ Homosexual pedophilia is distinct from normal male homosexuality (Herek, 2009)​

●​ Homosexual pedophilic offenders tend to have more victims than heterosexual pedophilic
offenders (Blanchard et al., 2000; Cohen & Galynker, 2002)​
 ●​ Majority of pedophiles have used childhood pornography (Seto, 2004)​

Research on Sexual Response

●​ Penile plethysmograph studies show:​

○​ Pedophilic men show greater arousal to pictures of nude or partially clad girls
than matched nonoffenders​

○​ Greater arousal to such pictures than to pictures of adult women​

○​ Some respond equally to children, adolescents, and/or adults (Seto, 2004; Seto et
al., 1999)​

Psychological Characteristics

●​ Child molesters more likely to hold self-justifying cognitive distortions, e.g.:​

○​ Belief children benefit from sexual contact​

○​ Belief children initiate contact (Marziano et al., 2006)​

●​ Many pedophilic molesters are shy, introverted, but desire mastery or dominance​

●​ Some idealize childhood traits such as innocence, unconditional love, simplicity (Cohen
& Galynker, 2002)​

Course and Behavior

●​ Pedophilia usually recognized in adolescence and persists lifelong​

●​ Many pedophiles work with children/youth to gain access​

●​ Some never act on preferences; many do​

●​ Difficult to estimate how many remain child-celibate​

 ●​ Higher rates of childhood sexual or physical abuse among pedophiles than adult rapists
(Daversa & Knight, 2007; Lee & Katzman, 2002)​

●​ Meaning of association unclear​

Neurobiological Findings

●​ Compared with non-pedophilic offenders, pedophiles have:​

○​ Lower IQs (Cantor, Blanchard et al., 2005; Seto, 2004)​

○​ Threefold higher rates of non-right-handedness (Cantor, Klassen et al., 2005;

Seto, 2004)​

○​ Higher rates of head injuries with loss of consciousness​

○​ Brain structure differences on imaging, some critical for sexual development

(Cantor et al., 2008; Schiltz et al., 2007)​

●​ Suggests neurodevelopmental perturbations create vulnerability​

Clergy Abuse Scandal

●​ Increasing child molestation cases among Catholic clergy:​

○​ Majority of priests innocent, but significant minority abused children​

○​ 81% of complainants male; 40% involved children ≤12 at abuse start (John Jay
College, 2004)​

○​ At least 400 priests charged in 1980s; $400 million in damages by early 1990s
(Samborn, 1994)​

○​ Example: James R. Porter admitted abusing up to 100 children as priest​

○​ Church scandal in 2002 revealed cover-ups by superiors (e.g., Cardinal Bernard

Law)​

○​ Mandatory removal policies adopted for priests known to have had sexual contact
with minors​
 ○​ 2005: Cardinal Francis George removed 11 priests for sexual misconduct​

○​ Similar scandals in Ireland (LeVay & Baldwin, 2012)​

Behavioral Variability and Support Organizations

●​ Not all pedophiles molest children​

●​ German study: 30% of men seeking help never had sexual contact with children; most
had viewed child pornography (Neutze et al., 2011)​

●​ B4UAct supports law-abiding pedophiles and raises awareness of their existence

(Clarke-Flory, 2012)​

●​ Virtuous Pedophiles works to reduce stigma toward law-abiding pedophiles

(Clarke-Flory, 2012)​

​
​
CAUSAL FACTORS AND TREATMENTS FOR PARAPHILIAS
Individual Explanations and Anecdotes

●​ Example case: Man with apotemnophilia (sexual preference for amputees)​

○​ Originated during adolescence​

○​ Emotionally cold family; relative expressed sympathy for amputees​

○​ Developed desire to become amputee to receive affection/sympathy​

○​ Raises questions:​

■​ Emotional neglect is common​

■​ Sympathy for amputees is widespread​

■​ Paraphilic development not universal in such contexts​

●​ Skepticism of personal explanations:​

 ○​ Individuals often unaware of true psychological influences (Nisbett & Wilson,
1977)​

General Characteristics and Observations

1.​ Gender Disparity:​

○​ Nearly all with paraphilias are male​

○​ Female cases extremely rare (only in case reports or small series)​

○​ Example citation: Fedoroff et al. (1999)​

2.​ Onset and Development:​

○​ Typically begin around puberty or early adolescence​

3.​ Sex Drive Intensity:​

○​ Strong sex drive common​

○​ Frequent masturbation (sometimes multiple times daily)​

4.​ Comorbidity of Paraphilias:​

○​ Individuals often have more than one paraphilia​

○​ Example: Autoerotic asphyxia and cross-dressing​

■​ 25–33% of accidental deaths involved cross-dressing (Blanchard &

Hucker, 1991)​

○​ No clear explanation for paraphilia overlap (e.g., sexual masochism +

transvestism)​

Theoretical Explanations

●​ Visual Sexual Imagery and Male Vulnerability (Money, 1986):​

○​ Males more visually dependent for arousal​

 ○​ Females' arousal possibly more tied to emotional context (e.g., love)​

○​ Greater male vulnerability to sexual associations with nonsexual stimuli​

●​ Conditioning and Learning Theories:​

○​ Classical Conditioning:​

■​ Sexual arousal becomes associated with nonsexual stimuli​

○​ Instrumental Conditioning:​

■​ Orgasm through masturbation reinforces association with stimulus​

○​ Social Learning:​

■​ Modeling or observation may contribute to development​

○​ Example: Masturbation to underwear ads/photos may reinforce fetish (Kaplan &

Krueger, 1997; LeVay & Baldwin, 2012)​

○​ Limitation: Fails to explain why only a minority develop fetishes despite common
exposure​

Treatments for Paraphilias

●​ Majority of treatment studies focus on sex offenders​

●​ Non-offending individuals or those with victimless paraphilias (e.g., masochism):​

○​ Rarely seek treatment​

○​ Existing literature is mostly case reports​

●​ Treatment discussion deferred to section on sex offender treatment, as most relevant

research is in that context​