Paraphiliacs differ from other psychiatric patients because they have deviant sexual interest. Currently, there are three psychophysiological assessment methods that can be used to evaluate possible paraphilic interest.
Penile plethysmography involves direct measurement of changes occurring in penile circumference or volume when patients are presented with slides, audiotaped vignettes, or videotaped vignettes depicting paraphilic and non-paraphilic sexual behaviour. Penile plethysmography has the advantage of high face validity because one can conclude that if the patient gets erections to unique or unusual sexual interests during such assessment, he probably has considerable interest in this category. ^l)
When penile plethysmography reveals aberrant interest in the laboratory, patients can be confronted with their deviant responses, regardless of whether they admit to or deny deviant activities and/or interests outside the laboratory. Paraphiliacs frequently admit paraphilic interests that were either previously concealed or denied during such confrontations.
Patients use a variety of tactics to conceal their sexual interest. There are a number of drawbacks to using penile plethysmograpy for the clinical assessment of deviant sexual response. One central issue is whether or not arousal responses seen in the laboratory are equal to similar arousal in the real world. Individuals undergoing psychophysiological assessment often deny any and all deviant sexual interest, and so penile plethysmography frequently involves measuring possible sexual interest that the patient has absolutely denied. This can be problematic when attempting to delineate deviant sexual interests through penile plethysmography. Recently, penile plethysmography has come under greater scrutiny because slides depicting nude children are frequently used to assess paedophilic interest. The use of nude slides is considered unethical and illegal in some countries such as the United States. Another problematic issue is the necessity of obtaining two separate rooms to complete penile plethysmographic assessments, one for the patient and the other for a highly skilled clinician to administer the plethysmographic evaluation. Finally, there have also been frequent concerns expressed by patients undergoing penile plethysmography regarding possible risk of disease transmission from wearing the genital transducer that is utilized to measure arousal.
A second means of assessing deviant behaviour involves the clinical usage of polygraphs. (12> Clinical usage has increasingly included 'full disclosure polygraphs', in which patients are asked a series of pointed questions to specify all of their paraphilic interests and activities. In addition, polygraphy is often used during the maintenance phase of treatment, when it is necessary to ask patients whether they have continued involvement in various paraphilic behaviours.
The advantages of polygraphs are that they can be used to assess a wide variety of paraphilic behaviours and, most importantly, to assess recidivism of paraphilic behaviours post-treatment. Also, polygraphy can be used with males or females. Drawbacks include the extensive training needed to become a certified polygrapher and problems with validity and reliability. In many countries polygraphs are not allowed to be used in the courtroom as evidence of criminal activity.
The newest method of clinical assessment involves testing visual reaction time to quantify the amount of time that an individual attends to various categories of slides as a measure of sexual interest in those categories. (l3i Various methods of measuring visual reaction time have been developed since the early 1940s. The major advantage of this system is that it can be used with males and females, adults and juveniles, without the necessity of showing nude slides. Slides of clothed males and females of various ages are presented to the patient. Patients are confronted when their visual reaction time suggests high sexual interest in a category for which they have previously denied sexual interest.
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