Paraphilia Scales From Kurt Freund’s Erotic Preferences Examination Scheme

Paraphilia Scales From Kurt Freund’s Erotic Preferences Examination Scheme‌

RAY BLANCHARD,Centre for Addiction and Mental Health

Paraphilia Scales From Kurt Freund, MD, DSc (1914–1996), was one of the most influential researchers in the areas of sexual orientation, gender identity, and paraphilias in the latter half of the 20th century. Freund was born into a German-speaking Jewish family in Czechoslovakia, and he conducted his pioneering research on penile plethysmography (phallometry) while living and working in Prague. He fled from Czechoslovakia to Canada in 1968, in the wake of the “Prague Spring,” and accepted a position at the Clarke Institute of Psychiatry (now the Centre for Addiction and Mental Health; CAMH) in Toronto. Shortly after arriving at the Clarke Institute, he began developing the first English-language version of his self-report questionnaire for erotic preferences and gender identity in men.

Freund’s questionnaire sections for pedophilia and hebephilia, voyeurism and exhibitionism, sadism and masochism, fetishism, and transvestism and transsexualism all have date stamps indicating that they were revised for the first time on October 15, 1971. This suggests that his questionnaire development must have been well under way prior to the autumn of 1971.

The last major revision, according to the date stamps, was completed during April 3–9, 1974. This version was referred to in Freund’s laboratory as Questionnaire III (Q-III). This is the only version of the questionnaire for which computerized data still exist; in other words, the laboratory’s electronic database at the CAMH currently includes Freund questionnaire data for subjects going back to 1974.

Major changes to Q-III after 1974 consisted primarily of additions. Freund added a new section on courtship dis- orders (voyeurism, exhibitionism, toucheurism, frotteur- ism, telephone scatologia, and preferential rape) on July 17, 1980—the same week that I began work at the Clarke Institute—and with his encouragement I added a questionnaire section on transvestism and autogynephilia in the next month. In later years, Freund occasionally inserted extra items into various sections, when he became dissatisfied with an existing item or perceived the need for an additional one.

Freund eventually needed a better name than Q-III for the purpose of describing the instrument in publications. I suggested Erotic Preferences Examination Scheme (EPES), which he readily adopted. The EPES has never been published in its entirety, and there would be little purpose in doing so at this point. Many of its multi-item scales

have been published in scholarly journals or book chapters, often in appendices or tables. These include scales intended to assess parent-child relations, childhood gender identity, gynephilia (the erotic preference for physically mature females), androphilia (the erotic preference for physically mature males), and degree of heterosexual experience.

It is not my purpose to collect and review all of the EPES scales here. My purpose in this document is to bring together, in one place, all of the scales corresponding to the specific paraphilias listed in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM). I am doing this partly for historical purposes and partly because the scales’ contents illustrate many of the points an experienced clinician might cover in interviewing a potentially paraphilic patient. These scales have not been copyrighted for commercial purposes, and any clinician or researcher who wishes to use them as they are, or to quote them, or to modify them for his or her own purposes is free to do so.

The first thing to point out is that the EPES is designed for men. Freund never attempted, at least after moving to Canada, to produce a parallel version for women. That is because the majority of Freund’s patients were sex offenders, and the overwhelming majority of sex offenders are men.

Freund made no attempt, in writing these items, to mis- lead or distract the patient from the meaning of the item or its implications. The items were designed on the sole principle of face validity. Of course Freund understood as well as anyone that patients, especially those accused of criminal sexual behavior, are not candid about their erotic interests. Patients’ scores on these scales are influenced both by whether they have a paraphilia and by whether they are willing to admit a paraphilia if they have one. Freund chose to stress the latter source of variance when he called his measures of pedophilia and hebephilia the Pedo Admitter Scale and the Hebe Admitter Scale rather than the Pedo Scale and the Hebe Scale.

Freund was also well aware of the repetitiousness of the items in some of the scales; he commented wryly about that on one occasion I remember. That repetitiousness results, in part, from the fact that paraphilias are essentially mono- symptomatic conditions. He did vary item content when he could. He included, for example, items about love as well as items about lust in his pedophilia and hebephilia measures.

Address correspondence to Ray Blanchard, Centre for Addiction and Mental Health, 250 College Street, Toronto, Ontario M5T 1R8, Canada; e-mail: [email protected]

Freund often went over patients’ questionnaire responses with them and helped them complete the questionnaire if they had difficulty answering the items on their own. He naturally used their responses to key items (along with their sexual offense histories and their phallometric results) in making clinical diagnoses. He did not, to the best of my knowledge, habitually use the computed scale totals for diagnostic purposes. He therefore did not conduct much, if any, research to identify cutting scores for the various scales, so cutting scores for classifying a patient as paraphilic or nonparaphilic are not available. The computed scale totals were primarily for the purposes of research rather than individual diagnosis.‌

It is necessary to know one aspect of Freund’s standard operating procedure in order to understand what psychometric data are and are not available. I have already explained that the EPES was physically divided into sections. Freund did not give every patient every section. In general, he gave patients only those sections that were relevant to their clinical presentations. Thus, a patient who presented with exhibitionism would not get the section on fetishism (unless he also acknowledged fetishism). A patient who presented with fetishism, on the other hand, might also be given the

section on sadism and masochism without his having mentioned those interests spontaneously, because fetishism is commonly found in association with sadism and masochism. Freund did this for a variety of practical reasons, one being that patients who had no interest in a particular para- philia (e.g., transvestism or pedophilia) were sometimes upset and offended to be asked about cross-dressing or sexual feelings toward children. The upshot of this is that it was never feasible to conduct a grand, omnibus factor analysis of all paraphilia measures on all patients. Thus, the available psychometric data are alpha reliability coefficients.

These scales, whatever their psychometric flaws, did yeoman’s service in a large number of studies, which I have not attempted to list comprehensively in this document. They still offer, at the very least, a starting point for the further development of self-report scales that canvass patients’ sexual desires as well as their sexual actions.

A more complete description of these scales as well as the individual scales (with scoring weights in parentheses after each response option), references, and some psychometric data about the scales may be found online at