Running head: CBT AND TREATMENT OF SPECIFIC PARAPHILIC DISORDERS 1

Significance of Cognitive Behavioral Therapy and Sexual Fantasy Thoughts Among Specific

Paraphilic Disorders

Sarah M. (Willey) Furtado

Bridgewater State University

CBT AND TREATMENT OF SPECIFIC PARAPHILIC DISORDERS 2

Abstract

The purpose of this mock literature review is to demonstrate the counselor-in-training

understands the core competency of research and development evaluation. Understanding

literature reviews allow counselors to know how to critique research and select the best

evidence-based treatment for their practice.

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Significance of Cognitive Behavioral Therapy and Sexual Fantasy Thoughts Among Specific

Paraphilic Disorders

Paraphilic disorder is an obsessive mental disorder that causes distress and significant

impairments that follows the occurrence of sexual behaviors or fantasies that impact self and

others. Of several paraphilic disorders in the Diagnostic and Statistical Manual of Mental

Disorders, 5th Edition (DSM-5), voyeuristic disorder, pedophilic disorder,

and frotteuristic disorder transpire most often against another individual’s consent (Ripper,

2017). By definition, voyeuristic disorder, also known as “Peeping Tom,” is the act of watching

someone without consent undress, be naked, or engage in sexual activity lasting at least six

months or more (Balon, 2016). People expect privacy when they engage in certain activities and

to uncover intimate details without knowledge is offensive. Another paraphilic disorder

is pedophilic disorder which is the intense sexual focus, urge, or behaviors that involve sexual

activity with prepubescent individuals (Blanchard, 2009). Pedophilic disorder is an obsession

with the body of a child. The distorted thoughts develop into a strong infatuation that pleasure

can only be achieved by the engagement of sexual activity with a child. Paraphilic disorders,

such as voyeuristic disorder and pedophilic disorder, are understudied and need to be researched

due to the uncertainty that sex offenders receive the proper treatment. The last paraphilic

disorder is frotteuristic disorder or the act of rubbing or touching body parts against an

unsuspecting person because of intense sexual urges or fantasies which ultimately results in

significant affliction and the inability to function in society or to perform daily duties (Krueger,

2008). Each disorder, in comparison to another, can be categorized as the victimization of non-

consenting individuals that includes adults to children (First, 2014).   

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Importance

Individuals that experience paraphilic disorders gravely inflict suffering on victims.

Psychological suffering for the victims includes but is not limited to post traumatic stress

disorder, depression, anxiety, significant cognitive distortions, suicidal thoughts and attempts,

eating disorders or substance use disorders. In a survey by the Center for Disease Prevention and

Control (2011), 35% of females that were sexually victimized as minors were also sexually

victimized as adults, as opposed to 14% of women with no prior sexually traumatic experiences.

Predators target more vulnerable victims creating a deeper level of physical, psychological, and

emotional turmoil. The influence of sexual deviance not only impacts society as a whole but

national funding for mental health treatments are spent elsewhere due to the high rate of

recidivism of sex crimes. This is due to that lack of empirical based evidence and the practical

significance. This also suggests that without studies supporting or discouraging mental health

treatment, effective treatment is not identified (Ripper, 2017). Ultimately, the possible legal

consequences permanently impinge an offender’s life. Individuals diagnosed with paraphilic

disorders require treatment to minimize detrimental outcomes such as reoffending and the

likelihood of potential victimization (Yates, 2004). It is difficult to diagnose a paraphilic

disorders because individuals do not believe their sexual “preferences” are a problem and

therefore, disregard mental health treatment.   

Treatment

In order to consider the best evidence-based practice, certain criteria have to be fulfilled.

For each paraphilic disorder mentioned, two highly reliable and valid studies have to be

conducted by two independent researchers, and at least three small experiments that report data

from at least nine participants must be published (Chambless and Hollon, 1998). Due to the lack
CBT AND TREATMENT OF SPECIFIC PARAPHILIC DISORDERS 5

of research and evidence, voyeuristic disorder, pedophilic disorder, and frotteuristic disorder are

not specifically studied in relation to the outcome of the best practice cognitive behavioral

therapy (CBT). Individuals that experience certain paraphilic disorder do not voluntarily seek

treatment thus pointing research towards known convicted sex offenders. It is a challenge to

determine if CBT reduces recidivism because of methodological problems, reluctance to report

sex crimes, quality of sample participants, differences in the CBT approach, and variation in data

analysis (Krueger & Kaplan 2008). Ultimately, if an individual stops treatment then there is an

increased rate of recidivism. Under the circumstances, according to the Association for the

Treatment of Sexual Abusers (ATSA, 2001), the most effective treatment is cognitive behavioral

therapy (CBT). CBT is more cost effective because it is a short-term treatment and an evidence-

based practice. Mental health treatment, like cognitive behavioral therapy, maximizes the

effectiveness of rehabilitation by assessments and individual treatment plans designed to target

the level of risk, low to high, and the intensity of treatment needs (Yates, 2003).   

There is no specific study for the treatment of frotteuristic disorder. When paraphilic

disorders have been studied, frotteuristic disorder is included with other paraphilic disorders. The

studies result in numerous meta-analyses that positively showed effects of CBT, but no actual

specific components of CBT (Krueger & Kaplan, 2008). Like all paraphilic disorders,

voyeuristic disorder has potential to recover from acting out as long as the individual makes a

decision to change. Voyeuristic disorder follows suit with frotteuristic disorder because it is

lumped together with other paraphilic disorders. CBT is a therapy that teaches techniques such as

cognitive restructuring, coping skills, impulse control, and learning appropriately acceptable

means of sexual gratification. Pedophilic disorder is similar to voyeuristic

and frotteuristic disorder when the CBT approach is put into practice. For example, sex offenders
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have intense cognitive distortions where they misinterpret the victim’s actions, cues, or

behaviors. The distorted thoughts influence an individual’s mood and behavior (Beck, 1995).

CBT interventions can be used to initially change one’s belief which will reduce recidivism

(Murphy, 1990).  

Overall, research has not been done to show if CBT leads to significant behavior changes

of specific paraphilic disorders. The behaviors are abnormal sexual desires that result in extreme

or dangerous activities which ultimately can place an individual in the criminal justice system. If

there are significant differences between each paraphilic disorder and frequency of sexual

fantasy thoughts then the rate of recovery and recidivism can be monitored and manipulated to

achieve realistic goals. The study suggests whether or not there are significant differences

between voyeuristic disorder, frotteuristic disorder, and pedophilic disorder on sexual fantasy

thoughts treated with CBT.    

Research Question: Does CBT change sexual fantasy

thoughtsof pediphilic disorder, voyeristic disorder frotterism disorder?

Null Hypothesis: There are no significant differences between voyeuristic

disorder, frotteuristic disorder, and pedophilic disorder on sexual thoughts after treatment

with CBT.

H o: μ 1=μ 2=μ 3
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Alternative Hypothesis: There are significant differences between voyeuristic

disorder, frotteuristic disorder, and pedophilic disorder on sexual thoughts after treatment with

CBT. 

H A : μ 1≠ μ 2

μ 1≠ μ 3

μ 2≠ μ 3

Method

Participants

 Male adult sex offenders diagnosed either with voyeuristic disorder, frotturistic disorder,

or pedophilic disorder

 Certified Cognitive Behavioral Therapist, Licensed Mental Health Counselor (CCBT,

LMHC)

 Bridgewater Correctional Complex

 Forensic Psychologist, Forensic Health Services (sex offender treatment)

 CBT individual treatment (26 weeks/ 26, 45-50 minute sessions)

 Primary Records Access (RAO), Department of Corrections (DOC) Public Record

Request

 Institutional Reentry Committee, Massachusetts DOC Reentry and Program Services

 Probation and parole officers

The population of study is selected by convenience sampling which consists of 36 male adult

sex offenders that were previously or presently incarcerated. A team of five forensic

psychologists randomly selected individuals that met criteria from DSM-5 paraphilic disorders

by reviewing case loads. The population is broken down into three groups: ten have pedophilic
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disorder; thirteen diagnosed with voyeuristic disorder; and thirteen have frottuestic disorder.

Participants were informed that CBT is mandatory condition of probation or parole while

incarcerated and upon release. Ten CCBT were randomly selected by pulling names out of a hat

and names were chosen from a referral list at Massachusetts DOC Reentry and Program Services

and were invited to participate in research study by a written letter and informed consent. They

all volunteered to participate.

Measures

The Lorena Bobbit Sexual Fantasy Likert Scale (LBSFLS) was administered by CCBT

and was given to all participants at the start date of CBT treatment, termination date of CBT

treatment and a year after the termination date of CBT treatment. The purpose of the five-point

LBSFLS is to measure the frequency of sexual fantasy thoughts with thirteen questions that have

scores ranging from one to five. The participant answered one of five linear options on the

questionnaire: never=one; rarely=two, occasionally=three, frequently=four, and very

frequently=five. Frequency is determined by the calculating the mean which is used as

quantitative data.

Researchers critically acclaimed LBSFLS to be logically valid in the course of over 500

studies that used the LBSFLS to assess sexual fantasy thoughts (Clinton, 2001). The LBSFLS

was chosen as a tool to understand human thought and behavior. The data collection is a range of

values of have been replicated many times to result in a confidence level of 95%.

Results

 A one-way analysis of variance was performed to find overall difference from each

groups’ results of LBSFLS. The result was statistically significant at p < .05 and the null

hypothesis was rejected.

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 The rejection of the null hypothesis was supported:

F STAT =28.77 > F CRITICAL=3.32

 In order to confirm where the statistically significant differences were between and

within the different means, a post hoc test was performed. The post hoc test confirmed:

that pedophilic disorder (M= 7.4), frotteruistic disorder (M=5.15), and voyeuristic

disorder (M=3.23). The results of the post hoc indicate that voyeuristic disorder benefited

the most from CBT treatment and pedophilic disorder benefited the least from CBT

treatment.

Discussion

 The study is the first evaluation of the proposed three evaluations; marked at the

beginning of CBT treatment. The next two studies will report more substantial

consistencies or inconsistencies in correlation with the hypothesis.

 Sample biases may have occurred by selecting the option occasionally. Occasionally is a

neutral answer and is considered undecided. This answer could have been selected to

avoid thinking about the answer, thus being the easiest answer.

 Due to sensitive nature of the study, convenience sampling best fit to select the

participants and all sample biases have to be taken into consideration.

 Pedophilic disorder was most statistically significant group from the study which means

the group showed the most frequency of sexual fantasy thoughts.

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References

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