Atypical Frotteurism Associated with Voyeurism and Obsession in a Six-Year-Old Boy

Paraphilia refers to the achievement of orgasm through aberrant sexual behavior rather than through normal sexual behavior (1). According to the fifth edition of the diagnostic and statistical manual of mental disorders (DSM-5), frotteurism (frotteuristic sexual interest) is a rare paraphilia characterized by at least six months of recurrent, intense, and usually male sexual arousal from touching or rubbing against a non-consenting and usually female body, especially touching or rubbing of private parts in crowded public places (2). Although the majority of frotteurs are male and victims are usually female, female on male, female on female, and male on male frotteurs do exist (3). Crowded places are unique opportunities for two reasons: First, rubbing behavior is easily concealed under the guise of finding a way through the crowd, and second, the non-consenting individuals are easily found. Anonymous victims are suitable because if frotteuristic behavior is a form of sexual assault and may seriously affect the frotteur socially and occupationally if they are caught (4). Depending on cultural beliefs, the type of questionnaire used, the level of complexity of the case, and whether or not childhood behaviors are considered, different prevalence rates of frotteurism have been reported, with an average rate of 15 percent. Considering the legal burden when such paraphilic behavior occurs and the complex background of psychiatric, neurotic, and neuro-psychiatric developmental abnormalities, it is important to consider frotteurism as an important and usually overlooked diagnosis (5). On the other hand, in historically religious countries such as Iran, such behavior is very negatively perceived by the public, and if noticed by the victim it could have severe legal and personal consequences, especially for those frotteurs that have insight, leading to experiences of severe shame and guilt. Here, we present a case of six-year-old boy with frotteurism without depression and with voyeurism and obsession as co-morbidities.

A six-year-old boy was referred to the psychiatrist while accompanied by his mother and grandmother with the complaint of excessively rubbing his genitalia many times a day against his female family members’ bodies, primarily their buttocks. Similar behaviors were first noticed by the child’s mother at the age of 18 months during breastfeeding. His mother said that during breastfeeding, her baby usually rubbed his genitalia against her body. This behavior worsened at the age of four, when he started rubbing his genitalia many times a day against his grandmother’s hand, foot, and back; the grandmother reported this behavior to the mother. Each rubbing instance lasted about five to 20 minutes, and the rubbing occurred at an average frequency of three times per day. After being scolded for his behavior, the child usually secluded himself in the toilet for long periods. The boy did not feel any guilt about the behavior, although he demonstrated good insight and sometimes succeeded in controlling his behavior. At the time the child presented to the psychiatrist, he had been experiencing sleeplessness, decreased appetite, and obsession for two months. He displayed irritability and aggressiveness, but there was no evidence of depression. His mother reported that her son exhibited voyeurism by experiencing sexual arousal while watching pornographic TV channels. However, because the patient is not currently attending school and is not a member of any social group, his sexual behavior in crowds cannot be evaluated.

There were no identifiable triggers for the behavior, although the patient does have a background of decreased maternal support due to his mother’s employment. There was no history of any other psychiatric disorder, developmental abnormalities, chronic physical illness, or drug dependence, and there was no history of child abuse. Although the patient’s mother suffers from major depressive disorder and his parents’ relationship is not healthy, there are no similar sexual disorders in his family history. His parents are very concerned about the disorder’s progression and treatment. Some frotteuristic sexual interest signs exhibited by the patient include sexual pleasure or gratification, sexual fantasy, sexual interest in females, voyeurism, recurrent rubbing, and experience of orgasm. Physical examination included complete blood count (CBC), electroencephalogram (EEG), and brain computed tomography scan (CT-scan), all of which were normal. The child visited many psychiatrists; however, due to his family’s beliefs and lack of immediate and obvious response, no one could follow up with him in the long term. He was medically treated with Risperidone 1mg daily, Imipramine 10 mg daily, and Sertraline 50mg (1/4 of a tablet) daily. Due to poor response to medication, psychotherapy was adopted as the primary approach, and we focused on providing the patient’s parents with good insights and informing the patient about the aggravating effects of emotional stress on his condition.

Scientifically, there is currently no consensus on the etiology of paraphilias, and the etiology of frotteurism is especially unclear (6). Most experts believe that frotteurism occurs due to accidental touching of the genitalia causing sexual excitement, which is reinforced and perpetuated by repetition (1). We believe that exposure to emotional stressors in childhood is the major trigger rather than accidental physical arousal. Although due to paucity of literature the exact prevalence rate of frotteurism is not known, especially in females, according to a systematic review, male frotteurism prevalence varies from 35 percent in the United States to 7.9 percent in Japan (2). The prevalence has not been established in Iran, partly because, due to cultural factors, most people with frotteurism in Iran do not voluntarily seek professional help and rarely present in the majority of clinical settings, and frotteurism is known as a very rare disorder in Iran. As mentioned previously, most frotteurs are male, and the majority of victims are female. Although there is no minimum age for the onset of frotteurism (7). It is believed that frottage behaviors are typically engaged in between the ages of 15 and 25, and after 25 the frequency of such acts usually decreases. However, our patient is only six years old (6).

Frotteurism has been reported in association with bipolar disorder, child abuse, temporal lobe epilepsy, and schizophrenia (8). The differential diagnoses include early onset bipolar disorder, attention deficit hyperactivity disorder (ADHD), and conduct disorder; however, this case meets the criteria of frotteurism more than those for any other condition, especially considering the fact that this patient is experiencing constant sexual thoughts and purposeful related acts leading to orgasm most of the time, which indicates a dominant behavior that is not supposed to be the major feature of other differential diagnoses. This case is atypical because the patient engages in early masturbation, which is defined as a median age at the first incident of about 19.5 months (range, 4 - 36 months) (7). The patient started masturbating when he was only 18 months old, and he is now six. This case is also atypical because frotteurism usually occurs in crowded and public places, but in our case it occurred secretly, although the patient has not yet participated in any social group that would allow his behavior to be investigated in a crowd. Third, there is no co-morbidity-such as major depressive disorder or attention deficit hyperactivity disorder-which is expected to occur after development of frotteurism. Fourth, there were no feelings of guilt associated with the behavior. Fifth, although voyeurism is typically seen after 15 years of age, the patient’s mother also complains of pathological indulgence in looking at some form of nudity. Lastly, the patient is fully resistant to antipsychotics and selective serotonin receptor inhibitors (SSRIs). If such hypersexual behavior occurs as a part of psychosis or drug use, then it is necessary to start treatment with antipsychotics or to stop the use of the offending drug; however, in this case there was no history of psychosis, and the patient did not take any medication (9). This patient’s treatment was based on psychotherapy aimed at uncovering and working through the underlying cause or causes of the behavior (10).

It seems that there are two major points about frotteurism: First, because of the patient’s insight, including being ashamed and feeling guilt, and because of heavy legal burdens, especially in historically religious countries such as Iran, frotteurs are rarely referred to experts. Second, psychiatric associations-such as major depressive disorder, schizophrenia, bipolar disorder, and even child abuse-are seen with frotteurism, and onset cannot be restricted to an certain age range. Given these points, experts are advised to focus on different sexual history dimensions including orientation, behaviors, fantasies, and especially unmanageable masturbatory behaviors that can predict sexual interests in the future so that frotteurism is not overlooked and can be managed with the best approach as soon as possible. Although frotteurism is a rare psychiatric disorder, in this case, atypical presentation in childhood with abnormal sexual behavior carried out in secret and not in a crowd was apparent after ruling out other, more common disorders.