Voyeurism Exhibitionism and Frotteurism

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Voyeurism, exhibitionism, and frotteurism have also been found to frequently co-occur. It has been proposed that they may be fundamentally related through shared underlying mechanisms (32). Voyeurism and exhibitionism involve visual processing of sexual stimuli from a distance, without direct physical contact with a partner, whereas in frotteurism physical contact is made. The voyeur "looks" in order to "receive" an alluring sexual image, the exhibitionist "shows" in order to "transmit" a sexual invitation, and the frotteur touches in order to "feel" intimate (33).

Voyeurism

The paraphilic focus in voyeurism is sexual fantasies, urges, or behaviors involving observing unsuspecting persons, usually unclothed and/or engaged in sexual activity. Federoff has described the "requirement" aspect of voyeurism and the other paraphilias as the central feature distinguishing them from nonpar-aphilic equivalents (34). It is not simply the act of watching a women naked, undressing, or engaging in sex that arouses the paraphilic voyeur; the victim's lack of suspicion that she is being observed and the risk of being discovered are central to the voyeur's arousal. Like the exhibitionist, the voyeur rarely makes contact with his victim. His ritual often is accompanied by masturbation during or after the voyeuristic episode.

Money has described variants of voyeurism (33). They include pictophilia, or dependence on viewing pornography for arousal, and troilism, or dependence for arousal on observing one's partner "on hire or loan" to a third party while engaged in sexual activity. The internet provides increasing opportunities for such paraphilia variants to thrive.

A paraphilia involves, over at least a 6-month period, recurrent, intense sexually arousing fantasies, sexual urges or behaviors. The targets of the fantasies, urges or behavior reflect three subtypes ofparaphilia:

1) non-living objects

2) suffering or humiliation of self or partner

3) children or other nonconsenting persons

A paraphilia involves, over at least a 6-month period, recurrent, intense sexually arousing fantasies, sexual urges or behaviors. The targets of the fantasies, urges or behavior reflect three subtypes ofparaphilia:

1) non-living objects

2) suffering or humiliation of self or partner

3) children or other nonconsenting persons

Paraphilia

Subtype

Criterion A Focal content of fantasies, urges, behaviors

Criterion B Action on urges or distress or impairment

Criterion C Other criterion

Fetishism

1) Nonliving objects

Arousal involving use ofnonliving objects

Resultant distress or impairment

Type of Object Criterion: Objects not limited to female attire or devices used for tactile genital stimulation, e.g. vibrator

Transvestic Fetishism

1) Nonliving objects

Arousal involving cross-dressing

Resulting distress or impairment

No age criteria

Sexual sadism

2) Suffering or humiliation of partner or

3) Children or other nonconsenting persons

Arousal involving psychological or physical suffering of others

Action on urges with unconsenting person or resulting distress

None

Sexual masochism

2) Suffering or humilation ofself

Arousal involving being made to psychologically or physically suffer

Resulting distress or impairment

None

Exhibitionism

3) Other unconsenting persons

Arousal involving exposing one's genitals

Action on urges or resulting distress

None

Voyeurism

3) Other unconsenting persons

Arousal involving observing others naked, disrobing or engaging in sexual activity

Action on urges or resulting distress

None

Frotteurism

3) Other unconsenting persons

Arousal involving touching or rubbing against others

Action on urges or resulting distress

None

Pedophilia

3) Children

Arousal involving prebuscent child

Action on urges or resulting distress

Age criterion: Individual is at least 16 years old and at least 5 years older than the child

Paraphilia NOS

1), 2) or3) Any category of focus

Any focal content not already described in a listed paraphilia

Resulting distress of impairment*

No age criteria

*While the DSM-IV-TR does not list any Criterion B requirements, the authors assume the intent ofconsistency with the 8 listed paraphilias

*While the DSM-IV-TR does not list any Criterion B requirements, the authors assume the intent ofconsistency with the 8 listed paraphilias

Figure 12.1 Summary of DSM-IV-TR criteria for paraphilia. Exhibitionism

In exhibitionism, the individual displays his genitals to an unsuspecting person. The exhibitionist ordinarily becomes aroused in response to the shocked response of a stranger or to the fantasy that the stranger becomes aroused in response to his display. A response of indifference may fuel a conpulsion to repeat the behavior until the craving is satisfied.

Exhibitionism must be distinguished from "nudist" interests, such as enjoyment of vacationing at nude beaches and resorts, and from prank behaviors, such as flashing and mooning. While sometimes offensive or illegal, these do not involve sexual arousal. Fedoroff has stated that exhibitionists have no interest in experiences such as nude beaches, where social norms are intolerant of overt expressions of sexual arousal (34). However, in the authors' research, a small number of diagnosed exhibitionists have reported such overlapping interests and behaviors. A exhibitionistic variant that reflects this overlap is the seeking of approval or validation, such as in the form of applause, as the exhibitionist perceives his victims more as an audience, as does the flasher, than as individuals upon whom he perpetrates harm.

Most exhibitionists and voyeurs are heterosexual men who seek out female victims. Some seek audiences of particular age ranges, such as children or adolescents. In these cases, it is critical to assess for a primary or co-occurring diagnosis of pedophilia. Some seek only adult victims and others are indiscriminate regarding age of their audience.

Frotteurism

Frotteurism is a paraphilic preference for rubbing one's genitals against an unsuspecting person. This paraphilia most often occurs in crowded public places where the frotteur disguises his behavior as an accidental result of crowd or vehicle motion. The frotteur tries to escape after accomplishing contact, to avoid confrontation or arrest. He may fantasize about an intimate, exclusive relationship with his victim (35). He may also fondle his victim's genitals or breasts, a variant of frotteurism known as toucherism (33). Sexual arousal in response to watching other men engage in frotteurism is described as another variant (36).

Like other sexual offenders, exhibitionists, voyeurs, and frotteurs may use cogtive distortions to rationalize, justify, and minimize the negative impact of their behaviors. The voyeur may blame the victim for leaving a window open to outside view, claiming that she wants to be seen; the exhibitionist may believe that others find his display funny rather than offensive; voyeurs and exhibitionists may perceive a harmlessness to their acts because no one is physically touched; the frotteur, who denies intentionality, believes that no harm is done because no one is "meant" to be touched.

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