This work was presented at the Second Argentine Conference on Anxiety Disorders, at the Paseo la Plaza, in Buenos Aires, on 14 August 1998. Its purpose is to review the components of human behaviour as defined by psychiatry in the DSM-III-R and the DSM-IV, by sexology according to John Money, and by pharmacology according to Moizeszowicz and Eli Coleman.

As a systemic therapist, I have wanted to articulate these approaches on the basis of the distressed demand of the paraphilic patient, who does not know how to make their malaise disappear and who, very often, dreams of death as a way of resolving their problem.

That is why we do not work only on the suffering and the anxiety produced in them by what their behaviour has that is inexplicable to themselves (in the case of paraphilias without harm to others): we integrate anguish into it, so that they may discover the harm involved in antisocial paraphilic offending behaviours, through which they injure other people.

Introduction

The law, forensic psychiatry and psychoanalysis call “perversion” what one of the greatest representatives of twentieth-century sexology, John Money, described under the name of “paraphilia”.

Paraphilia appears in the DSM-III-R (Diagnostic Manual of Mental Disorders) among the sexual disorders.

In the last decades of this century, therapists and researchers in the field of paraphilia have observed that many of their paraphilic patients might present a depressive background. Others have reported that an intense anxiety preceded these patients’ behaviours, classified by professionals as compulsive because they occurred without voluntary control on the part of the subjects.

Therapists have noticed that the people who proceeded in this way adhered to an object, a sexual one, with an obsessive, exclusive and specific fixity. Other researchers have compared the anxiety that preceded the compulsive behaviour to the aura of temporal lobe epilepsy. There is as yet insufficient experimental work to corroborate this correlation.

Patients report that the behaviour experts call obsessive-compulsive brings them brief relief from the rise of their anxiety, but that this anxiety reappears cyclically. Their sexual life unfolds between one peak of anxiety and the next, so that gratification is relative and tension-bound. Prescribers say that sexual discharge acts as a short-acting anxiolytic (Eli Coleman).

All these clinical experiences led the authors of the DSM-IV not only to place paraphilia among the sexual disorders, but to consider it from then on as a behaviour belonging to the “impulse-control disorders”, and to coin a new concept, that of “compulsive sexual behaviour”.

If a person’s sexual desire mobilises an anxiety that causes malaise, they act compulsively in order to relieve themselves.

Society disapproves of their behaviour for reasons of moral habit, values or custom. This generates new tensions in them which they will need to discharge compulsively. Thus arises a maintaining circuit, producing new anxieties and new compulsive sexual behaviours, which will perpetuate themselves if we do not intervene therapeutically, with or without medication, according to the needs of the case.

The function of anxiety in paraphilic behaviour

The experience of anxiety announces to the person whose behaviour is paraphilic that their feared and desired object is close. A feared object, because its proximity brings punishment. A desired object, because it alone awakens their desire. But it also reveals that “the content of the person’s paraphilic obsession is alien to them, out of control, and does not fit the kind of thoughts they would expect to have” (DSM-IV).

If, through medication and through therapeutic work, we instrument anxiety, the person may come to experience the satisfaction of controlling their anxious behaviour.

Controlled anxiety enlightens us as to the initial moments of the patient’s current problem, mobilises the subject for change and demonstrates to them that they can conduct themselves.

To this end, a simple instrument consists in drawing up an anxiety meter, in which the patient meticulously records their daily degrees of anxiety, the episodes which, they believe, triggered them, the hour, the day and the circumstance in which the anxiety occurred, as well as their reaction at the moment it was triggered.

This instrument represents a self-reflective process and an active behaviour, which allows the person concerned to discuss in therapy the correction, the assessment and the anticipation of their paraphilic behaviours.

Charting, reflecting on and speaking about what has been felt through the vicissitudes of one’s anxiety produces a learning such that, once integrated into one’s subjective world, the change is carried over into one’s external behaviour.

The anxiety meter allows us to implement the following therapeutic steps.

Starting from the systemic unit patient-therapist, they will carry out these actions:

1. Reading the anxiety meter, from session to session, will detect anxiogenic situations in their multiple expressions, the characters involved, the stimulus or triggering factor and the way it occurs.
2. In each situation, the patient will assess the intensity of the anxiety.
3. The therapeutic system will reconstruct the possible origin of the anxiogenic situation, as Richard Green says in “Impresiones de la memoria. La reconstrucción del recuerdo” (XII World Congress of Sexology, Yokohama, 1995).
4. The therapeutic system will look for the meaning the patient has attributed to the remembered episode.
5. Patient and therapist will work at modifying the crystallised narrative, replacing it with another, a living one, charged with affect, in which sorrow, compassion and non-persecutory guilt find a place, and in which anxiety, now controlled, announces changes of behaviour.
6. The patient will train themselves to graduate the intensity of their anxiety in the face of the stimulus that typically triggers it.
7. The patient will generalise the learning of the control of their anxiety to other feared or undesirable affective situations.
8. If the anxiety revives and becomes unmanageable, patient and therapist will consider the need for medication.

Clarifications

The DSM-III-R says, following the New Zealand sexologist John Money:

The DSM-III-R defined eight of the most common paraphilias: paedophilia, exhibitionism, voyeurism, sexual masochism, transvestic fetishism, sexual sadism, fetishism and frotteurism.

Traumatic bodily experiences undergone at early stages, crucial in the formation of personality, acquire a meaning that creates and amplifies an underlying anxiety disorder (Coleman, “Paraphilias and related disorders”).

Subsequently, this primary anxiety disorder is experienced as a secondary dysthymia.

Paraphilia according to the DSM-IV

The DSM-IV, under “Impulse-control disorders not elsewhere classified”, places paraphilia among the unspecified impulse-control disorders, alongside substance dependence (as symptoms linked to impulse control) (302.70).

“The essential feature of paraphilia is the presence of recurrent, intense sexual fantasies of an arousing kind, sexual urges or behaviours generally involving: 1) non-human objects; 2) the suffering or humiliation of oneself or of one’s partner; or 3) children or other non-consenting persons, and which occur over a period of at least six months” (criterion A).

For some individuals, paraphilic fantasies or stimuli are obligatory in order to obtain arousal, and are invariably included in sexual activity.

In other cases, paraphilic preferences occur only episodically (for example during periods of stress), while at other times the individual is able to function sexually without fantasies or stimuli of that kind.

“The behaviour, sexual urges or fantasies cause clinically significant distress or impairment in social, occupational or other important areas of the individual’s functioning” (criterion B).

Dysthymic disorder: it is a mood disorder. Its essential feature is a chronically depressed mood, present most days. Subjects describe their mood as “sad” or “down” (DSM-IV).

Forms of anxiety

Anxiety: Moizeszowicz describes it as a psychic disquiet. He reserves for anguish a predominantly psychosomatic plane.

A person in the grip of anguish or anxiety hesitates to specify the object that provokes it.

On the psychological plane, symptoms appear in the person because she has lived through emotionally charged situations, and they express symbolically the underlying conflict.

The author states that it is difficult to maintain the exclusively somatic origin of anxiety, since anguish appears to be seated on the mesodiencephalic structures. The anxious person presents a state of disproportionate hyperactivation, which may occasion an anguish abnormal for a given social group.

Anxiolytics reduce her level of anxiety, but when she detects the appearance of the physiological components of anxiety, the activation revives.

Moizeszowicz indicates therapy, since even if medication blocks the somatic components of the illness, psychic anguish persists; and he recommends treatment with benzodiazepines, because it produces a muscle-relaxant action, an anxiolytic action and a disinhibiting action on stressful behaviours.

The DSM-IV, in the chapter “Obsessive-compulsive disorders”, defines as follows the:

Obsessions: ideas, thoughts, impulses or images of a persistent character, which the individual considers intrusive or inappropriate and which provoke anxiety or significant malaise.

This quality of being intrusive or inappropriate is called “ego-dystonic”.

“The individual who has obsessions seeks to neutralise them with other ideas or other activities.”

Compulsions: they are defined as behaviours or mental acts whose purpose is to prevent or relieve anxiety, but which bring neither pleasure nor gratification.

Compulsive sexual behaviour: (or csb) the DSM-IV gives it as an example of a “psychosexual disorder not yet classified”.

Csb is characterised by the will to reduce the anxiety generated by a sexual desire.

Non-paraphilic compulsive behaviours

We have already classified paraphilic sexual behaviours. There are non-paraphilic compulsive sexual behaviours. We group them (Coleman) into five subtypes:

When she is lavished with endless sexual expressions of affection, the relief of anxiety is temporary. Shortly afterwards, she will express her intense possessiveness, her jealousy and her anger.

How to recognise compulsive sexual behaviours

In each person, we must look for the symptoms associated with anxiety disorders, depression and dependence on drugs and alcohol. People presenting csb may experience:

• Motor tension — tremors, shivering, headaches, muscle pain, restlessness, inability to relax, fatigue.
• Autonomic hyperactivity — breathlessness, tachycardia, sweating, dry mouth, dizziness, nausea, diarrhoea, frequent urination, difficulty swallowing.
• Hypervigilance — feeling of being “on edge”, easy startle, difficulty concentrating, insomnia, irritability.

Anxiety is exhausting and demoralising.

Many patients presenting csb experience acute and chronic anxiety, or depression, in response to the csb.

In the sexual act, they feel fixed to their anxiety and their depression. They can come out of this anxiety only for a short time. That is why, when they become depressed, some of them go on to take their own lives.

A few additional questions serve to diagnose symptoms or states of illness. It is advisable to inquire, in each patient, in order to detect:

• Anxiety
• Depression
• Alcohol abuse or drug dependence
• Sexually transmitted infections
• Unwanted pregnancies
• Somatic problems
• Relational discord
• Sexual dysfunction
• Abuse in childhood

These are not compulsive behaviours

An intense involvement in sexual activity, experienced without anxiety and with pleasure.

The increase in sexual relations or in masturbatory relations during adolescence, during the honeymoon or at any stage of life, alone (self-stimulation) or in a relationship with a responsive and satisfying partner.

Problematic sexual behaviours

These are the ones the individual does not accept, because of their religious upbringing or of the social norm opposed to their performance.

With adequate and sufficient information and guidance, people can overcome the problem.

“But other individuals store, in the erotosexual engrams of their brain, the representation of a self-defeating behaviour, perhaps because of the dysfunction of neurotransmitters and of the information that follows from it.

“This csb is pathological, because the brain generates anxiety and the pattern of sexual behaviour acts as a short-range anxiolytic, similar to other obsessive and compulsive behaviours. This sexual behaviour is harmful in its obsessive and compulsive aspect.

Whereas problematic sexual behaviours yield to simple therapies, this is not the case with csb. In that case, medication is necessary” (Eli Coleman).

Pharmacotherapy

The prescriber must assess the severity of the patient’s obsessions, their compulsions and the existence of other physical and psychiatric disorders.

Some physicians prefer serotonergic antidepressants, because they have no potential side effects and because they have anxiolytic, antilibidinal and antidepressant properties, which allows the patient to take part in talking therapy with their full capacity for concentration.

Specialists have observed that fluoxetine is effective in csb, while antiandrogens are used in resistant paraphilic cases (Androcur, Depo-Provera).

Moreover, if the physician judges it so (that the patient is acting out a csb), the patient will be treated with antidepressants, antiepileptics, antipsychotics or other relevant medication.

Psychotherapy and anxiety

Systemic psychotherapeutic treatment helps to resolve the source of the psychiatric problems and of the psychosexual disorder.

It is also useful for improving the management of anxiety and the way of achieving a good intimacy.

Systemic family therapy is essential, because many of these behaviours began in the family environment.

The techniques of therapeutic approach will have to be clear, simple, graduated, creative and diversified, in keeping with the moment the therapy is going through.

I list a few of the resources I habitually use in therapy, where compulsion, obsession and the patient’s anxiety reign, as well as the interaction of the members of their family among themselves and with them.

• Use of the anxiety meter throughout the therapy.
• Relaxation techniques at the beginning of the first sessions, and when anxiety revives.
• Use of a questionnaire inspired by John Money, to detect the circumstances that preceded the construction of the paraphilia, as well as the cognitive elements that weighed on its early family formation and on its present maintenance.
• Information about what is happening to them.
• Bibliographical recommendation (The Situation Is Hopeless, But Not Serious, by Watzlawick, has helped several patients with obsessive ideas a great deal).
• Proposals for learning new relational patterns (learning courtship, for example).
• Setting realistic limits, so as not to be hyper-restrictive and so that the patient can keep to them. For example, to an exhibitionist I indicated, in a first part of the therapy, that he masturbate inside his car with the door progressively more closed, until he managed to close it.

The sample

Eighteen patients presented obsessive-compulsive behaviours, with or without paraphilic content, and anxiety of variable intensity.

The purpose of selecting this group was to study the results of therapy with and without medication, as well as to identify the clinical pictures most resistant to change, in order to clarify the causes of therapeutic failure.

Reason for consulting: not all the patients came for paraphilic problems.

Some of them were concerned about their obsessions, about the discomfort of their uncontrolled behaviour, about their unease in social situations more or less identified by themselves, but whose explanation they did not know.

Many overestimated the scope of their csb, even when it was not harmful to others (example: a patient who stimulated himself with handkerchiefs, another by tearing or having paper torn during the sexual act).

Not knowing what was happening to them increased the anxiety.

It was heightened in those individuals who acted out behaviours condemned by society:

• Touching children sexually
• Touching women’s buttocks in crowds, without their consent
• Saying obscenities on the telephone
• Spying on female nudity or spying on other people’s sexual scenes
• Raping people
• Cross-dressing

Comments on the sample

Of the eighteen people followed, on average for six months at one session a week, six had committed occasional or systematic sexual abuse.

The two patients I was unable to help overcome their kleptophilic compulsion (pleasure in stealing) made me feel that I had failed with them, or that they had failed with me. I was unable to set up a family therapy. They had a history of maltreatment and parental abandonment.

In the other patients, the therapeutic system produced results ranging from successes and modifications in numerous and fundamental aspects of their lives, to a better control of their anxiety, a better management of the obsessions and a more pleasurable sexuality.

Five people received Rivotril and fluoxetine. In all of them, the therapeutic course was favourable. Two people in whom I detected panic attacks benefited from the medication, although they were reluctant for reasons of “allergy” to allopathic drugs; the medical examination therefore preceded the administration of the products by the practitioner, once the patients accepted being treated.

My greatest successes I have had with transvestic fetishists, exhibitionists and homophobes.

A successful case

A young man of twenty-four comes to consult, depressed because he ejaculates prematurely. In adolescence he did not dare court any girl. He was sexually initiated with a prostitute, ejaculated quickly and gave up having sexual relations. When he saw that all his friends had a girlfriend, he consulted a sexologist to control his ejaculation, but did not succeed.

He came to see me at a time when his anxiety was intense. He was on the verge of tears. He was prescribed fluoxetine and, with the therapy, he controlled his ejaculation, spoke about the way he was living his sexuality and about his difficulties in finding a partner. He began to see someone and they had sexual relations with pleasure, after coming as a couple to sex therapy.

They decided to marry, and he had a panic attack. His homophobia appeared. In therapy we worked intensely on the anxiety marriage caused him, on his fear of finding himself among men, on his social and sexual phobia, in individual and couple sessions. Once again on medication and in therapy, they married and were happy.

After some time (three years), a panic attack occurred when she proposed having a child. They came together to the sessions, then he came alone. Finally, he accepted the idea of a possible fatherhood. But they then discovered that she had blocked Fallopian tubes and that his sperm were few in number and of poor quality.

Fertility treatment inhibited, at times, the sexual desire of one or the other.

After becoming very depressed, and after he had struggled with the ghosts of homosexuality and with the frustration of not being able to fulfil his dream of being a father, at the end of a series of sessions they accepted the idea that they might perhaps adopt if they did not manage to conceive a biological child. This caused her intense moral pain, which she gradually overcame through body therapies.

He then came to therapy individually and, despite unfavourable professional circumstances and a demanding fertility treatment, each day his love for his partner overtook him: he took decisions until then unthinkable (organising a trip to Europe for the two of them), tried new forms of approach in dialogue, proposed alternative activities and set himself the goal of a greater sexual closeness. He broke an intense and obscure bond with his family of origin, where men did not count, while at the same time reversing an undifferentiated relationship with her.

If the obsessive ideas arose that men appealed to him, he was able to remain serene, controlling his emotions, in the face of someone’s affective approach, and even to enjoy male friendships.

Towards the end of the therapy he brought me a souvenir from the Vatican: a small box reproducing Michelangelo’s scene of the creation, in which God brings his hand close to Adam to give him life.

The anxiety of therapists

As a member of IATSO, the International Association for the Treatment of Sexual Offenders, I am open to suggestions and to clinical and scientific exchanges that would improve the behavioural health of people presenting pcsb (paraphilic compulsive sexual behaviours).

We need to come together in order to delimit the scope of our action and to correct the social imaginary that identifies therapists with agents of socialisation or with representatives of authority, who would be expected to direct patients, set limits for them and produce changes in them from the outside, automatically.

Money says that working with sexual offenders generates, in many colleagues who do not deal with the question, indifference, rejection or attack towards the specialist.

Since society itself evades the problem rather than helping, since all it advocates is to discipline and punish, many therapists perceive themselves as idealists or as defeated. On the reasons for working with sexual offenders in spite of everything and on the place held there by the work on resilience in family therapy, I have explained myself elsewhere.

Other specialist sexologists propose the following, so that we do not succumb to anxiety or to depression when we deal with the theme of antisocial paraphilias (Eli Coleman):

• Let us obtain the support of our partner: a rich personal affective life counterbalances the difficulties of our profession.
• Let us diversify our themes of work. It is very arduous to work solely on antisocial paraphilias.
• Let us set ourselves realistic objectives and, even so, not expect too much of them.
• Let us ask our colleagues for logistical support, until we form an environment of shared interests.

For my part, I open the doors of the Isabel Boschi Foundation to all the questions that may arise concerning the experiences studied here.