015 - Chapter 13 - Sexual Variants, Abuse, & Dysfun0001

Sexual Variants, Abuse,and Dysfuncti ns

SOCIOCULTURAL INFLUENCES ON SEXUALPRACTICES AND STANDARDSCase 1: Degeneracy and Abstinence TheoryCase 2: Ritualized Homosexuality in MelanesiaCase 3: Homosexuality and American Psychiatry

SEXUAL AND GENDER VARIANTSThe ParaphiliasCausal Factors and Treatments for ParaphiliasGender Identity Disorders

SEXUAL ABUSEChildhood Sexual Abuse

PedophiliaIncestRapeTreatment and Recidivism of Sex Offenders

SEXUAL DYSFUNCTIONSDysfunctions of Sexual DesireDysfunctions of Sexual ArousalOrgasmic DisordersDysfunctions Involving Sexual Pain

UNRESOLVED ISSUES:How Harmful Is Childhood Sexual Abuse?

oving, sexually satisfying relationships contribute a great deal to our happiness, and if weare not in such relationships, we are apt to spend a great deal of time, effort, and emotionalenergy looking for them. Sexuality is a central concern of our lives, influencing with whomwe fall in love and mate, and how happy we are with them and with ourselves.

In this chapter we shall first look at the psychological problems that make sexual fulfillmentespecially difficult for some people-the vast majority of them men-who develop unusual sex-ual interests that are difficult to satisfy in a socially acceptable manner. For example, exhibition-ists are sexually aroused by showing their genitals to strangers, who are likely to be disgusted,frightened, and potentially traumatized. Other sexual or gender variants may be problematicprimarily to the individual: Transsexualism, for example, is a disorder involving discomfort withone's biological sex and a strong desire to be of the opposite sex. Still other variants such asfetishism, in which sexual interest centers on some inanimate object or body part, involvebehaviors that, although bizarre and unusual, do not clearly harm anyone. Perhaps no other areacovered in this book exposes the difficulties in defining boundaries between normality and psy-chopathology as clearly as variant sexuality does.

The second issue we shall consider is sexual abuse, a pattern of pressured, forced, or inap-propriate sexual contact. During the last few decades, there has been a tremendous increase inattention to the problem of sexual abuse of both children and adults. A great deal of researchhas addressed its causes and consequences. As we shall see, some related issues, such as thereality of recovered memories of sexual abuse, are extremely controversial.

The third category of sexual difficulties examined in this chapter is sexual dysfunctions,which include problems that impede satisfactory performance of sexual acts. People who havesexual dysfunctions (or their partners) typically view them as problems. Premature ejaculation,for example, causes men to reach orgasm much earlier than they and their partners find satisfy-ing. And women with orgasmic disorder get sexually aroused and enjoy sexual activity but havea persistent delay, or absence of, orgasm following a normal sexual excitement phase.

Much less is known about sexual deviations, abuse, and dysfunctions than is knownabout many of the other disorders we have considered thus far in this book. There are alsomany fewer sex researchers than researchers formany other disorders, so relatively few articlesrelated to sexual deviations and dysfunctions arepublished. One major reason is the sex taboo.Although sex is an important concern for mostpeople, many have difficulty talking about itopenly-especially when the relevant behaviorsmay be socially stigmatized, as in homosexuality.This makes it hard to obtain knowledge abouteven the most basic facts, such as the frequency ofvarious sexual practices, feelings, and attitudes.

A second reason why sex research has pro-gressed less rapidly is that many issues related tosexuality-including homosexuality, teenage sexual-ity, abortion, and childhood sexual abuse-areamong our most divisive and controversial. In fact,sex research is itself controversial and not wellfunded. Two large-scale sex surveys were haltedbecause of political opposition even after being offi-cially approved and deemed scientifically meritori-

Loving, sexually satisfying relationshipscontribute a great deal to our happiness, butour understanding of them has advancedslowly, largely because they are so difficult forpeople to talk about openly and becausefunding for research is often hard to come by.

ous (Udry, 1993). Senator Jesse Helms and others had argued that sex researchers tended toapprove of premarital sex and homosexuality and that this would be likely to bias the resultsof the surveys. Fortunately, one of these surveys was funded privately, though on a muchsmaller scale, and it is now considered the definitive study for the 1990S (Laumann et aI., 1994;see also Laumann et aI., 1999). Several smaller studies have also been published since 2000(e.g., Bancroft et aI., 2003).

Despite these significant barriers, some progress has been made in the past half-centuryin understanding some important things about sexual and gender variants and dysfunctions.The contemporary era of sex research was first launched by Alfred Kinsey in the early 1950S(Kinsey, Pomeroy, & Martin, 1948; Kinsey, Pomeroy, Martin, & Gebhard, 1953). Kinsey and hispioneering work are portrayed in a fascinating way in the 2004 award-winning movie Kinsey.However, before we discuss this progress, we first examine sociocultural influences on sex-ual behavior and attitudes in general. Doing so will provide some perspective about cross-cultural variability in standards of sexual conduct and remind us that we must exercisespecial caution in classifying sexual practices as "abnormal" or "deviant."

SOCIOCULTURALINFLUENCES ONSEXUAL PRACTICESAND STANDARDSAlthough some aspects of sexuality and mating such asmen's greater emphasis on their partner's attractiveness arecross-culturally universal (Buss, 1989, 1999), others arequite variable. For example, all known cultures have taboosagainst sex between close relatives, but attitudes towardpremarital sex have varied considerably across history andaround the world. Ideas about acceptable sexual behavioralso change over time. Less than 100 years ago, for exam-ple, sexual modesty in Western cultures was such thatwomen's arms and legs were always hidden in public.Although this is by no means the case in Western culturestoday, it remains true in many Muslim countries.

Despite the substantial variability in sexual attitudesand behavior in different times and places, people typicallybehave as though the sexual standards of their time andplace are obviously correct, and they tend to be intolerantof sexual nonconformity. Sexual nonconformists are oftenconsidered evil or sick. We do not mean to suggest thatsuch judgments are always arbitrary. There has probablynever existed a society in which Jeffrey Dahmer, who wassexually aroused by killing men, having sex with them,storing their corpses, and sometimes eating them, wouldbe considered psychologically normal. Nevertheless, it isuseful to be aware of historical and cultural influences onsexuality. When the expression or the acceptance of a cer-tain behavior varies considerably across eras and cultures,we should at least pause to consider the possibility that ourown stance is not the only appropriate one.

Because the influences of time and place are so impor-tant in shaping sexual behavior and attitudes, we begin byexploring three cases that illustrate how opinions about"acceptable" and "normal" sexual behavior may changedramatically over time and may differ dramatically fromone culture to another. In the first case, America during themid-1800s, "degeneracy theory," a set of beliefs about sex-uality, led to highly conservative sexual practices and direwarnings about most kinds of sexual "indulgence." In thesecond case, we look briefly at the Sambia tribe in NewGuinea, in which a set of beliefs about sexuality prescribethat all normal adolescent males go through a stage ofhomosexuality before switching rather abruptly to hetero-sexuality in adulthood. Finally, in the third case, we con-sider changes across time in the status of homosexuality inWestern culture.

Case 1: Degeneracy andAbstinence TheoryDuring the 1750s, Swiss physician Simon Tissot developeddegeneracy theory, the central belief of which was thatsemen is necessary for physical and sexual vigor in menand for masculine characteristics such as beard growth(Money, 1985, 1986). He based this theory on observationsabout human eunuchs and castrated animals. Of course,we now know that loss of the male hormone testosterone,and not of semen, is responsible for the relevant character-istics of eunuchs and castrated animals. On the basis of histheory, however, Tissot asserted that two practices wereespecially harmful: masturbation and patronizing prosti-tutes. Both of these practices wasted the vital fluid, semen,as well as (in his view) overstimulating and exhausting thenervous system. Tissot also recommended that marriedpeople engage solely in procreative sex to avoid the wasteof semen.

A descendant of degeneracy theory, abstinence the-ory, was advocated in America during the 1830s by theReverend Sylvester Graham (Money, 1985, 1986). Thethree cornerstones of his crusade for public health werehealthy food (graham crackers were named for him),physical fitness, and sexual abstinence. In the 1870s Gra-ham's most famous successor, Dr. John Harvey Kellogg,published a paper in which he ardently disapproved ofmasturbation and urged parents to be wary of signs thattheir children were indulging in it. He wrote about the 39signs of "the secret vice," which included weakness, dull-ness of the eyes, sleeplessness, untrustworthiness, bash-fulness, love of solitude, unnatural boldness, mock piety,and round shoulders.

As a physician, Kellogg was professionally admiredand publicly influential, and he earned a fortune publish-ing books discouraging masturbation. His recommendedtreatments for "the secret vice" were quite extreme. Forexample, he advocated that persistent masturbation inboys be treated by sewing the foreskin with silver wire or, asa last resort, by circumcision without anesthesia. Femalemasturbation was to be treated by burning the clitoris withcarbolic acid. Kellogg, like Graham, was also very con-cerned with dietary health-especially with the idea thatconsumption of meat increased sexual desire. Thus, heurged people to eat more cereals and nuts and inventedKellogg's cornflakes "almost literally, as anti-masturbationfood" (Money, 1986, p. 186).

Given the influence of physicians like Kellogg, itshould come as no surprise that many people believed thatmasturbation caused insanity (Hare, 1962). This hypothe-sis had started with the anonymous publication in theearly eighteenth century in London of a book entitledOnania, or the Heinous Sin of Self-Pollution. It asserted thatmasturbation was a common cause of insanity. This ideaprobably arose from observations that many patients inmental asylums masturbated openly (unlike sane people,who are more likely to do it in private) and that the age atwhich masturbation tends to begin (at puberty in adoles-cence) precedes by several years the age when the first signsof insanity often appear (in late adolescence and youngadulthood; Abramson & Seligman, 1977). The idea thatmasturbation may cause insanity appeared in some psy-chiatry textbooks as late as the 1940s.

Although abstinence theory and associated attitudesseem highly puritanical by today's standards, they have hada long-lasting influence on attitudes toward sex in Ameri-can and other Western cultures. It was not until 1972 thatthe American Medical Association declared, "Masturba-tion is a normal part of adolescent sexual development andrequires no medical management" (American MedicalAssociation Committee on Human Sexuality, 1972, p. 40).Around the same time, the Boy Scout Manual dropped itsantimasturbation warnings. Nonetheless, in 1994 JocelynElders was fired as U.S. Surgeon General for suggestingpublicly that sex education courses should include discus-

sion of masturbation. Moreover, the Roman CatholicChurch still holds that masturbation is sinful.

Case 2: Ritualized Homosexualityin MelanesiaMelanesia is a group of islands in the South Pacific that hasbeen intensively studied by anthropologists, who haveuncovered cultural influences on sexuality unlike anyknown in the West. Between 10 and 20 percent of Melane-sian societies practice a form of homosexuality within thecontext of male initiation rituals that all male members ofsociety must experience.

The best-studied society has been the Sambia ofPapua New Guinea (Herdt, 1999; Herdt & Stoller, 1990).Two beliefs reflected in Sambian sexual practices are semenconservation and female pollution. Like Tissot, the Sam-bians believe that semen is important for many thingsincluding physical growth, strength, and spirituality. Fur-thermore, they believe that it takes many inseminations(and much semen) to impregnate a woman. Finally, theybelieve that semen cannot easily be replenished by thebody and so must be conserved or obtained elsewhere. Thefemale pollution doctrine is the belief that the female bodyis unhealthy to males, primarily because of menstrual flu-ids. At menarche, Sambian women are secretly initiated inthe menstrual hut forbidden to all males.

In order to obtain or maintain adequate amounts ofsemen, young Sambian males practice semen exchangewith each other. Beginning as boys, they learn to practicefellatio (oral sex) in order to ingest sperm, but afterpuberty they can also take the penetrative role, inseminat-ing younger boys. Ritualized homosexuality among theSambian men is seen as an exchange of sexual pleasure forvital semen. (It is ironic that although both the Sambiansand the Victorian-era Americans believed in semen con-servation, their solutions to the problem were radically dif-ferent.) When Sambian males are well past puberty, theybegin the transition to heterosexuality. At this time thefemale body is thought to be less dangerous, because themales have ingested protective semen over the previousyears. For a time, they may begin having sex with womenand still participate in fellatio with younger boys, buthomosexual behavior stops after the birth of a man's firstchild. Most of the Sambian men make the transition toexclusive adult heterosexuality without problems andthose who do not are viewed as misfits.

Ritualized homosexuality among the Melanesians is astriking example of the influence of culture on sexual atti-tudes and behavior. A Melanesian adolescent who refusedto practice homosexuality would be viewed as abnormal,and such adolescents are apparently absent or rare. Homo-sexuality among the Sambia is not the same as homosexu-ality in contemporary America, with the possible exceptionof those Sambian men who have difficulty making the tran-sition to heterosexuality.

Case 3: Homosexuality and AmericanPsychiatryDuring the past half-century, the status of homosexualityhas changed enormously both within psychiatry and psy-chology, and for many Western societies in general. In thenot-too-distant past, homosexuality was a taboo topic.Now, movies, talk shows, and television sitcoms and dra-mas address the topic explicitly by including gay men andlesbians in leading roles. As we shall see, developments inpsychiatry and psychology have played an important partin these changes. Homosexuality was officially removedfrom the DSM (where it had previously been classified as asexual deviation) in 1973 and today is no longer regardedas a mental disorder. A brief survey of attitudes towardhomosexuality within the mental health profession itselfagain illustrates how attitudes toward various expressionsof human sexuality may change over time.

HOMOSEXUALITY AS SICKNESS Reading the med-ical and psychological literature on homosexuality writ-ten before 1970 can be a jarring experience, especially ifone subscribes to views prevalent today. Relevant articlesincluded "Effeminate homosexuality: A disease of child-hood" and "On the cure of homosexuality." It is only fairto note, however, that the view that homosexual peopleare mentally ill was relatively tolerant compared withsome earlier views-for example, the idea that homosex-ual people were criminals in need of incarceration(Bayer, 1981). British and American cultures had longtaken punitive approaches to homosexual behavior. Inthe sixteenth century, King Henry VIII of England declared"the detestable and abominable vice of buggery [analsex]" a felony punishable by death, and it was not until1861 that the maximum penalty was reduced to 10 years'imprisonment. Similarly, laws in the United States werevery repressive until recently, with homosexual behaviorcontinuing to be a criminal offense in some states (Pos-ner & Silbaugh, 1996) until the 2003 Supreme Court rul-ing that struck down a Texas state law banning sexualbehavior between two people of the same sex (Lawrence& Garner v. Texas). For the first time, this ruling estab-lished a broad constitutional right to sexual privacy inthe United States.

During the late nineteenth and early twentieth cen-turies, several prominent sexologists such as Havelock Ellisand Magnus Hirschfeld suggested that homosexuality isnatural and consistent with psychological normality.Freud's own attitude toward homosexual people was alsoremarkably progressive for his time and is well expressed inhis touching "Letter to an American Mother" (1935).

Dear Mrs ....I gather from your letter that your son is a homo-

sexual. I am most impressed by the fact that you do notmention this term yourself in your information about

him. May I question you, why you avoid it? Homo-sexuality is assuredly no advantage, but it is nothing tobe ashamed of, no vice, no degradation, it cannot beclassified as an illness.... Many highly respectable indi-viduals of ancient and modern times have been homo-sexuals, several of the greatest men among them (Plato,Michelangelo, Leonardo da Vinci, etc.). It is a greatinjustice to persecute homosexuality as a crime, andcruelty too ....

By asking me if I can help, you mean, I suppose, if Ican abolish homosexuality and make normal heterosex-uality take its place. The answer is, in a general way,wecannot promise to achieve it....

Sincerely yours with kind wishes,Freud

Beginning in the 1940s, however, other psychoana-lysts, led by Sandor Rado, began to take a more pessimisticview of the mental health of homosexual people-and amore optimistic view of the possible success of therapy toinduce heterosexuality. Rado (1962) believed that homo-sexuality develops in people whose heterosexual desireswere too psychologically threatening; thus homosexualitywas an escape from heterosexuality and therefore incom-patible with mental health (see also Bieber et al., 1962). Inthe case of male homosexuality, one argument was thatdomineering, emotionally smothering mothers anddetached, hostile fathers played a causal role. Unfortu-nately, these psychoanalysts based their opinions primarilyon their experiences seeing gay men in therapy, who areobviously more likely than other gay men to be psycholog-ically troubled.

HOMOSEXUALITY AS NON PATHOLOGICAL VARIA-TION Around 1950, the view of homosexuality as sick-ness began to be challenged by both scientists andhomosexual people themselves. Scientific blows to thepathology position included Alfred Kinsey's finding thathomosexual behavior was more common than had beenpreviously believed (Kinsey et al., 1948; Kinsey et al.,1953). Influential studies also demonstrated that trainedpsychologists could not distinguish the psychological testresults of homosexual subjects from those of heterosexualsubjects (e.g., Hooker, 1957).

Gay men and lesbians also began to challenge the psy-chiatric orthodoxy that homosexuality is a mental disor-der. The 1960s saw the birth of the radical gay liberationmovement, which took the more uncompromising stancethat "gay is good." The decade closed with the famousStonewall riot in New York City, sparked by police mis-treatment of gay men, which sent a clear signal that homo-sexual people would no longer tolerate being treated assecond -class citizens. By the 1970s, openly gay psychiatristsand psychologists were working from within the mentalhealth profession to have homosexuality removed fromDSM-II (1968).

In the not-too-distant past, homosexuality was a taboo topic. Today,gay men and lesbian women and their everyday lives are topicsprevalent in all aspects of popular culture. Also, it is more and morecommon for homosexual couples to raise children together.

After acrimonious debate in 1973 and 1974, the Amer-ican Psychiatric Association (APA) voted in 1974 by a voteof 5,854 to 3,810 to remove homosexuality from DSM-II.This episode was both a milestone for gay rights and an

embarrassment for psychiatry. The spectacle of the psychi-atric nomenclature being modified on the basis of a voterather than through the scientific consensus of expertsappeared to confirm what the harshest critics of psychodi-agnosis, such as Thomas Szasz (1974), had been saying-that the label "mental illness" merely reflects the values ofmental health professionals.

We believe the APA made a correct decision here,because the vast majority of evidence shows that homo-sexuality is compatible with psychological normality. Fur-thermore, resolving this issue by vote is not especiallyproblematic. The classification of any behavior as psy-chopathology necessitates a value judgment that thebehavior is undesirable (see Chapter 1). Challenges by gayand lesbian people forced mental health professionals toconfront the values question explicitly, and they made thecorrect determination that homosexuality is not a psycho-logical disorder. (See Developments in Thinking 13.1.)

In ReVIew~ What does each of the three examples of

sociocultural influences on sexual practicesand standards reveal about culturaldifferences and historical changes in whatis considered acceptable and normal sexualbehavior?

~ How has the psychiatric view of homo-sexuality changed over time? Identify a fewkey historical events that propelled thischange.

3.1 Homosexuality as aNormal Sexual Variant

2llthOUgh its current status as a nonpsy-chopathological sexual variant rather thana disorder might suggest that no furthermention of homosexuality is warranted inan abnormal psychology textbook, we

have provided a more extensive discussion, for two rea-sons. First, American attitudes toward homosexualityremain highly ambivalent, and at least part of this ambiva-lence reflects uncertainty about the causes and correlatesof sexual orientation. Thus one goal is to review what isknown about homosexuality to clarify why we believe it isnot pathological. Second, although homosexuality is not

pathological, it is sometimes related to a condition thatremains in DSM-IV-TR: Gender Identity Disorder (seeChapter 11). Thus some findings about homosexuality mayapply to gender identity disorder as well.

How Common Is Homosexuality?Large, carefully selected samples from the United States(Laumann & Michael, 2000), France (ACSF Investigators,1992), and England (Wellings et aI., 1994) suggest that therate of adult homosexual behavior is between 2 and 6 per-cent, with the rate of exclusive male homosexuality esti-

mated at about 2.4 percent (LeVay & Valente, 2006). Theanalogous rates of exclusive female homosexuality is, how-ever, less than 1 percent. The fact that homosexuality is rel-atively rare has no implications for its status as anon pathological sexual variant because, for example,genius too is rare but not pathological. Moreover, approxi-mately 20 percent of men and women may report havinghad at least one instance of sexual attraction to a memberof their own sex after the age of 15 (Sell, Wypij, & Wells,1995). Some people are also bisexual, although this maybe even less common in men than exclusive homosexuality,especially since the onset of the AIDS epidemic in the mid-1980s (Masters, Johnson, & Kolodny, 1992). One intensivestudy of bisexuals found that for many, their homosexualitycame after they had established a heterosexual orientation(Weinberg, Williams, & Pryor, 1994).

What Causes Some People to Be Homosexualand Others Heterosexual?An important study by the Kinsey Institute for Sex Researchexamined the psychoanalytic hypothesis that homosexual-ity is associated with dysfunctional parent-child relation-ships and found only very limited support for it (Bell,Weinberg, & Hammersmith, 1981). For example, gay mendid recall relatively distant relationships with their fathers,but the differences observed were so small that they couldnot account for development of sexual orientation. Themost striking finding concerned childhood behavior. Onaverage, homosexual adults recalled substantially moresex-atypical behavior than heterosexual adults. For exam-ple, gay men were more likely than heterosexual men torecall playing with girls, cross-dressing, shunning sports,and wishing they were girls. Lesbians were more likely thanheterosexual women to recall enjoying sports and wishingthey were boys. (See Table 13.1 on p. 456.) Similar differ-ences have been found in many other studies (Bailey &Zucker, 1995; LeVay & Valente, 2006). Nevertheless itshould also be emphasized that many gay men and les-bians appear to have been sex-typical as children.

Observations that homosexual people have sexualorientations and often other behaviors more typical of theopposite sex are consistent with the most influential cur-rent etiological model of sexual orientation: Homosexualpeople have been subjected to early, possibly prenatal,hormonal influences more typical of the opposite sex. Per-haps the best evidence for this hypothesis comes from therare cases in which normal male infants have been reas-signed as females shortly after birth, and reared asfemales, because of traumatic injury to the penis (Bradley,Oliver, et aI., 1998; Diamond & Sigmundson, 1997). Asadults, these individuals are primarily attracted to females,which is consistent with their prenatal biology rather thantheir postnatal rearing. In addition, a well-known study bySimon LeVay (1991) found gay men to be different from het-erosexual men and similar to heterosexual women in thesize of one region of the hypothalamus that affects sexual

behavior. A later study partially replicated this finding(Byne, Tobet, et aI., 2001).

Genetic factors have also been implicated in bothmale (Bailey & Pillard, 1991; Hamer et al., 1993) and female(Bailey et aI., 1993) sexual orientation. Concordance rateshave varied widely across studies, with recent, more care-ful studies yielding smaller figures (Bailey, Dunne, & Mar-tin, 2000; Kendler, Thornton, Gilman, & Kessler, 2000).Nevertheless, even the most recent evidence is consistentwith a moderate role for heredity. However, because atleast half of the monozygotic twin pairs in the bettergenetic studies were discordant for sexual orientation,environmental factors are clearly also important (Baileyet aI., 2000). The nature of the environmental influences isuncertain; these could include either biological (e.g., pre-natal stress) or social (e.g., parental child-rearing philoso-phy) factors. One erroneous environmental hypothesis isthat homosexual adults seduce and "recruit" younger indi-viduals to homosexuality. There is no scientific evidence forthis belief and much against it. For example, the largemajority of gay men and lesbians had homosexual feelingsat least a year before their first homosexual experience(Bell et aI., 1981).

Is Homosexuality a Sign of Mental Disturbance?Historically, the belief that homosexuality reflects mentaldisturbance has been linked to discomfort with the sexualbehavior of homosexual people. For example, some havepointed to the high number of sexual partners reported bygay men (especially before the AIDS epidemic) as evi-dence that these men are abnormally impulsive andpromiscuous. However, a more parsimonious explanationof this finding is that all men have an elevated desire forcasual sex but that homosexual men have more casualsex opportunities because they interact sexually withother men (Symons, 1979). One study supporting thisidea found that gay men and heterosexual men reportedsimilar levels of interest in casual sex (Bailey, Gaulin,Agyei, & Gladue, 1994).

Several large and careful surveys have examined ratesof mental problems in people with and without homosex-ual feelings or behavior (Fergusson et aI., 1999; Herrell,Goldberg, et aI., 1999; Sandfort, de Graaf, et aI., 2001).Homosexual people do appear to have elevated risk forsome mental problems. For example, compared with het-erosexual men, gay men have higher rates of anxiety disor-ders and depression, and they are more likely tocontemplate suicide. Lesbians also have a higher rate ofsubstance abuse (Sandfort, de Graaf, et aI., 2001).Although it remains unclear why homosexual people havehigher rates of certain problems (Bailey, 1999), one plausi-ble explanation is that such problems result from societalstigmatizing of homosexuality. Regardless, homosexualityis compatible with psychological health-most gay menand lesbians do not have mental disorders.

'j Sex-Typical and.Sex-AtypicalBehavior inChildhood

1. As a child, did you enjoy boys' activitieslike baseball or football (at leastsomewhat)?

Gay menHeterosexual menLesbiansHeterosexual women

32%89%85%57%

2. Did you enjoy girls' activities likehopscotch, playing house, or jacks?

G~mm %%Heterosexual men 12%Lesbians 33%Heterosexual women 82%

3. Did you dress in opposite-sex clothes andpretend to be a child of the opposite sex(other than for Halloween or schoolplays)?

Gay menHeterosexual menLesbiansHeterosexual women

32%10%49%7%

Source: From Sexual Preference: Its Development in Menand Women, a study by the Kinsey Institute, by Alan P.Bell, Martin S. Weinberg, and Sue Kiefer Hammersmith(1981). Reprinted by permission of Martin S. Weinberg.

SEXUAL AND GENDERVARIANTSWe now turn to the problematic sexual variants includedin DSM -IV-TR. There are two general categories: para phil-ias and gender identity disorders.

The ParaphiliasPeople with paraphilias have recurrent, intense sexuallyarousing fantasies, sexual urges, or behaviors that gener-ally involve (1) nonhuman objects, (2) the suffering orhumiliation of oneself or one's partner, or (3) children orother nonconsenting persons. To meet DSM -IV-TR crite-ria, these patterns must last at least 6 months. Accordingto DSM-IV- TR (APA, 2000), five of these conditions can

be diagnosed simply if the person has acted on his fantasies or urges, even if the person does not experience sig-nificant distress or impairment-which is otherwise acriterion for nearly all mental disorders (see also Malet-zky, 2002). This change recognizes that certain paraphiliaslike exhibitionism should be diagnosed even if the indi-vidual is not bothered by them. Although mild forms ofthese conditions probably occur in the lives of many nor-mal people, a paraphilic person is distinguished by theinsistence and relative exclusivity with which his sexualityfocuses on the acts or objects in question-without whichorgasm is often impossible. Paraphilias also frequentlyhave a compulsive quality, and some individuals withparaphilias require orgasmic release as often as four to tentimes per day (Money, 1986; Weiner & Rosen, 1999). Indi-viduals with paraphilias mayor may not have persistentdesires to change their sexual preferences. Because nearlyall such persons are male (a fact whose etiological impli-cations we consider later), we use masculine pronouns torefer to them.

Paraphilias are thought to be quite rare although thereare no good prevalence data, in part because people areoften reluctant to disclose such deviant behavior (Maletzky,2002). The DSM-IV recognizes eight specific paraphilias:(1) fetishism, (2) transvestic fetishism, (3) voyeurism,(4) exhibitionism, (5) sexual sadism, (6) sexual masochism,(7) pedophilia, and (8) frotteurism (rubbing against anonconsenting person). An additional category, Para-philias Not Otherwise Specified, includes several rarerdisorders such as telephone scatologia (obscene phonecalls), necrophilia (sexual desire for corpses), zoophilia(sexual interest in animals; Williams & Weinberg, 2003),apotemnophilia (sexual excitement and desire about hav-ing a limb amputated), and coprophilia (sexual arousal tofeces). Although the different paraphilias very often co-occur, we will discuss each of the paraphilias separately,except for frotteurism, a category that is relatively newand has not yet been satisfactorily researched. Our dis-cussion of pedophilia is postponed, however, until a latersection concerning sexual abuse.

FETISHISM In fetishism, the individual has recurrent,intense sexually arousing fantasies, urges, and behaviorsinvolving the use of some inanimate object to obtain sex-ual gratification (see DSM-IV- TR Criteria for Several Dif-ferent Paraphilias). (DSM-IV-TR states that a fetish isdiagnosed only when the object is inanimate, but most sexresearchers have not traditionally made this distinction.)As is generally true for the paraphilias, reported cases offemale fetishists are extremely rare (Mason, 1997). Therange of fetishistic objects includes hair, ears, hands,underclothing, shoes, perfume, and similar objects associ-ated with the opposite sex. Rarely more unusual fetishesdevelop, as, for example, in men who are sexually fixatedon people who have an amputated limb (LeVay & Valente,

A. FETISHISM

(1) For at least 6 months, recurrent, intense sexually arousing fantasies, urges, or behaviors involving the use of nonlivingobjects (e.g., female undergarments, though not if used for cross-dressing).

(2) The fantasies, urges, or behaviors cause distress or impairment in functioning.

B. TRANSVESTIC FETISHISM

(1) For at least 6 months, in a heterosexual male, recurrent, intense sexually arousing fantasies, urges, or behaviorsinvolving cross-dressing.


C. VOYEURISM

(1) For at least 6 months, recurrent, intense sexually arousing fantasies, urges, or behaviors involving the act of observingan unsuspecting person who is naked, in the process of disrobing, or engaging in sexual activity.

(2) The person has acted on these sexual urges, or, the sexual urges or fantasies cause marked distress or impairment.

D. EXHIBITIONISM

(1) Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, urges, or behaviors involving theexposure of one's genitals to an unsuspecting stranger.


E. SEXUALSADISM

(1) Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, urges, or behaviors involving real actsin which the psychological or physical suffering of the victim is sexually exciting to the person.


F. SEXUALMASOCHISM

(1) Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, urges, or behaviors involving the realact of being humiliated, beaten, bound, or otherwise made to suffer.


G. PEDOPHILIA

(1) Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, urges, or behaviors involving sexualactivity with a prepubescent child or children (generally age 13 or younger).


(3) The person is at least age 16 and at least 5 years older than the child.

2006). The mode of using these objects to achieve sexualexcitation and gratification varies considerably, but it com-monly involves masturbating while kissing, fondling, tast-ing, or smelling the objects. Fetishism does not normallyinterfere with the rights of others, except in an incidentalway such as asking the partner to wear the object duringsexual encounters. Many men have a strong sexual fascina-tion for paraphernalia such as bras, garter belts, hose, andhigh heels, but most do not typically meet diagnostic crite-ria for fetishism because the paraphernalia are not neces-sary or strongly preferred for sexual arousal. Nevertheless,

they do illustrate the relatively high frequency of fetish-likepreferences among men.

To obtain the required object, a person with a fetishmay commit burglary, theft, or even assault. Probably thearticles most commonly stolen by such individuals arewomen's undergarments. In such cases, the excitement andsuspense of the criminal act itself typically reinforce thesexual stimulation and sometimes actually constitute thefetish, the stolen article itself being of little importance.One example of this pattern of fetishism is provided inthe case of a man whose fetish was women's panties:

J Panties

A single, 32-year-old male freelance photographer ...related that although he was somewhat sexually attractedby women, he was far more attracted by "theirpanties." ... [His] sexual excitement began about age 7,when he came upon a pornographic magazine and feltstimulated by pictures of partially nude women wearing"panties." His first ejaculation occurred at 13 via mastur-bation to fantasies of women wearing panties. He mas-turbated into his older sister's panties, which he hadstolen without her knowledge. Subsequently he stolepanties from her friends and from other women he metsocially.... The pattern of masturbating into women'sunderwear had been his preferred method of achievingsexual excitement and orgasm from adolescence until thepresent consultation. (Adapted from Spitzer et aI., 2002,P·247·)

Source: Adapted with permission from the DSM-TR-Casebook:A Learning Companion to the Diagnostic and Statistical Manualof Mental Disorders, Fourth Edition, Text Revision (Copyright2002). American Psychiatric Publishing, Inc.

Many theories of the etiology of fetishism emphasizethe importance of classical conditioning and social learn-ing (e.g., Maletzky, 2002; Mason, 1997). For example, it isnot difficult to imagine how women's underwear mightbecome eroticized via its close association with sex and thefemale body. But only a small number of men developfetishes, so there must be individual differences in condi-tionability of sexual responses (just as there are in the con-ditionability of fear and anxiety responses). Men high insexual condition ability would be prone to developing oneor more fetishes. We will later return to the role of condi-tioning in the development of paraphilias more generally.

TRANSVESTIC FETISHISM According to DSM-IV-TR,heterosexual men who experience recurrent, intense sexu-ally arousing fantasies, urges, or behaviors that involvecross-dressing as a female may be diagnosed withtransvesticfetishism (see DSM-IV- TR Criteria on p. 457).Typically, the onset of transvestism is during adolescenceand involves masturbation while wearing female clothingor undergarments. R. Blanchard (1989, 1992) has termedthe psychological motivation of transvestites autogy-nephilia: paraphilic sexual arousal by the thought or fan-tasy of being a woman (Blanchard, 1991, 1993; Zucker &Blanchard, 1997). The great sexologist Magnus Hirschfeldfirst identified a class of cross-dressing men who are sexu-ally aroused by the image of themselves as women: "Theyfeel attracted not by the women outside them, but by thewoman inside them" (Hirschfeld, 1948, p. 167). Althoughsome gay men dress "in drag" on occasion, they do not typ-

i~"lly~Qthi~fQr~~Aualplea~ure and hen~e are not trans-vestic fetishists.

In 1997 over 1,000 cross-dressing men were surveyed.The vast majority (87 percent) were heterosexual, 83 per-cent had married, and 60 percent were married at the timeof the survey (Docter & Prince, 1997). Many managed tokeep their cross-dressing a secret, at least for a while. How-ever, wives often found out, and had a wide range of reac-tions, from accepting to being extremely disturbed. Thefollowing case illustrates both the typical early onset oftransvestic fetishism and the difficulties the condition mayraise in a marriage.

Mr. A., a 65-year-old security guard, formerly a fishing-boat captain, is distressed about his wife's objections tohis wearing a nightgown at home in the evening, now thathis youngest child has left home. His appearance anddemeanor, except when he is dressing in women'sclothes, are always appropriately masculine, and he isexclusively heterosexual. Occasionally, over the past 5years, he has worn an inconspicuous item of femaleclothing even when dressed as a man, sometimes a pairof panties .... He always carries a photograph of himselfdressed as a woman.

Hisfirst recollection of an interest in female clothingwas putting on his sister's bloomers at age 12, an actaccompanied by sexual excitement. He continued peri-odically to put on women's underpants-an activity thatinvariably resulted in an erection, sometimes a sponta-neous emission, sometimes masturbation .... He wascompetitive and aggressive with other boys and alwaysacted "masculine." During his single years he wasalways attracted to girls....

His involvement with female clothes was of thesame intensity even after his marriage. Beginning at age45, after a chance exposure to a magazine calledTransvestia, he began to increase his cross-dressingactivity. He learned there were other men like himself,and he became more and more preoccupied with femaleclothing in fantasy and progressed to periodically dress-ing completely as a woman. More recently he hasbecome involved in a transvestite network ... occasion-ally attending transvestite parties.

Although still committed to his marriage, sex with hiswife has dwindled over the past 20 years as his wakingthoughts and activities have become increasingly cen-tered on cross-dressing .... He always has an increasedurge to dress as a woman when under stress; it has a tran-quilizing effect. If particular circumstances prevent himfrom cross-dressing, he feels extremely frustrated ....

Because of disruptions in his early life, the patienthas always treasured the steadfastness of his wife and

the order of his home. He told his wife about his cross·dressing practice when they were married, and she wasaccepting so long as he kept it to himself. Nevertheless,he felt guilty ... and periodically he attempted torenounce the practice, throwing out all his female clothesand makeup. His children served as a barrier to his givingfree rein to his impulses. Following his retirement fromfishing, and in the absence of his children, he finds him-self more drawn to cross-dressing, more in conflict withhis wife, and more depressed. (Adapted from Spitzeret aI., 2002, pp. 257-59.)

Source: Reprinted with permission from the DSM-TR-Casebook:A Learning Companion to the Diagnostic and Statistical Manualaf Mental Disorders, Fourth Edition, Text Revision (Copyright2002). American Psychiatric Publishing, Inc.

Like other kinds of fetishism, however, transvesticfetishism causes overt harm to others only when accom-panied by such an illegal act as theft or destruction ofproperty. This is not always the case with the other para-philias, many of which do contain a definite element ofinjury or significant risk of injury-physical or psycho-logical-to one or more of the parties involved in a sexual

Studies have shown that transvestic men often feel sexual arousalwhile cross-dressing, as well as less anxiety and shyness when intheir female roles. Although a transvestic man may therefore enjoyexcursions into the social roles of the other sex, he may also bemarkedly distressed by urges to do so, and, if married, histransvestic fetishism may also cause difficulties for his wife.

encounter. Some of these practices have strong legal sanc-tions against them.

VOYEURISM A person is diagnosed with voyeurismaccording to DSM-IV- TR ifhe has recurrent, intense sexu-ally arousing fantasies, urges, or behaviors involving theobservation of unsuspecting females who are undressingor of couples engaging in sexual activity (see DSM-IV-TRCriteria on p. 457). Frequently, such individuals mastur-bate during their peeping activity. Peeping Toms, as theyare commonly called, commit these offenses primarily asyoung men.

How do some young men develop this pattern? First,viewing the body of an attractive female is sexually stimu-lating for many, if not most, heterosexual men. In addition,the privacy and mystery that have traditionally surroundedsexual activities tend to increase curiosity about them. Sec-ond, if a young man with such curiosity feels shy and inad-equate in his relations with the opposite sex, he may acceptthe substitute of voyeurism, which satisfies his curiosityand to some extent meets his sexual needs without thetrauma of actually approaching a female. He thus avoidsthe rejection and lowered self-status that such an approachmig t bring. In fact, voyeuristic activities often provideimportant compensatory feelings of power and secretdomination over an unsuspecting victim, which may con-tribute to the maintenance of this pattern. If a voyeur man-ages to find a wife in spite of his interpersonal difficulties,as many do, he is rarely well adjusted sexually in his rela-tionship with his wife, as the following case illustrates .

.~~~~lA Peeping Tom

A young married college student had an attic apartmentthat was extremely hot during the summer months. Toenable him to attend school, his wife worked; she camehome at night tired and irritable and not in the mood forsexual relations. In addition, "the damned springs in thebed squeaked." In order "to obtain some sexual gratifi-cation," the youth would peer through his binoculars atthe room next door and occasionally saw the young cou-ple there engaged in erotic activities. This stimulatedhim greatly, and he decided to extend his peeping to asorority house. During his second venture, however, hewas reported and was apprehended by the police. Thisoffender was quite immature for his age, rather puritani-cal in his attitude toward masturbation, and prone toindulge in rich but immature sexual fantasies.

More permIssIve laws concerning "adult" movies,videos, and magazines in recent years have probablyremoved much of the secrecy from sexual behavior andalso have provided an alternative source of gratification

for would-be voyeurs. However) their a~tual effe~t onvoyeurism is a matter of speculation because there neverhave been good epidemiological data on its prevalence(Kaplan & Krueger, 1997; Maletzky, 2002), although it isthought to be one of the most common paraphilias. Formany voyeurs, these movies and magazines probably donot provide an adequate substitute for secretly watchingthe sexual behavior of an unsuspecting couple or the "real-life" nudity of a woman who mistakenly believes she enjoysprivacy.

Although a voyeur may become reckless in his behav-ior and thus may be detected or even apprehended by thepolice, voyeurism does not ordinarily have any other seri-ous criminal or antisocial behaviors associated with it. Infact, many people probably have some voyeuristic inclina-tions, which are checked by practical considerations suchas the possibility of being caught, and by ethical attitudesconcerning the right to privacy.

EXHIBITIONISM Exhibitionism (indecent exposure inlegal terms) is diagnosed in a person with recurrent,intense urges, fantasies, or behaviors that involve exposinghis genitals to others (usually strangers) in inappropriatecircumstances and without their consent (see DSM-IV- TRCriteria on p. 457). The exposure may take place in somesecluded location such as a park or in a more public placesuch as a department store, church, theater, or bus. Incities, an exhibitionist (also known as a flasher) oftendrives by schools or bus stops, exhibits himself while in thecar, and then drives rapidly away. In many instances theexposure is repeated under fairly constant conditions, suchas only in churches or buses, or in the same general vicin-ity and at the same time of day. In one case, a youth exhib-ited himself only at the top of an escalator in a largedepartment store. For a male offender, the typical victim isordinarily a young or middle-aged female who is notknown to the offender, although children and adolescentsmay also be targeted (Murphy, 1997). Exhibitionism,which usually begins in adolescence or young adulthood, isthe most common sexual offense reported to the police inthe United States, Canada, and Europe, accounting forabout one-third of all sexual offenses (McAnulty et aI.,2001; Murphy, 1997). According to some estimates, asmany as 20 percent of women have been the target of eitherexhibitionism or voyeurism (Kaplan & Krueger, 1997;Meyer, 1995).

In some instances, exposure of the genitals is accom-panied by suggestive gestures or masturbation, but moreoften there is only exposure. A significant minority of exhi-bitionists commit aggressive acts, sometimes includingcoercive sex crimes against adults or children, and a subsetof exhibitionists may best be considered as having antiso-cial personality disorder, as described in Chapter 11(Kaplan & Krueger, 1997).

Despite the rarity of aggressive or assaultive behavior inthese cases, an exhibitionistic act nevertheless takes place

Men who engage in exhibitionism often cause emotional distressin the viewers because of the intrusive quality of the act, alongwith its explicit violation of propriety norms.

without the viewer's consent and may be emotionally upset-ting, as is indeed the perpetrator's intent. This intrusivequality of the act, together with its explicit violation of pro-priety norms about "private parts;' ensures condemnation.Thus society considers exhibitionism a criminal offense.

SADISM The term sadism is derived from the name ofthe Marquis de Sade (1740-1814), who for sexual purposesinflicted such cruelty on his victims that he was eventuallycommitted as insane. In DSM -IV-TR, for a diagnosis ofsadism, a person must have recurrent, intense sexuallyarousing fantasies, urges, or behaviors that involve inflict-ing psychological or physical pain on another individual(see DSM-IV- TR Criteria on p. 457). A closely related, butless severe, pattern is the practice of "bondage and disci-pline" (B & D), which may include tying a person up, hit-ting or spanking, and so on, to enhance sexual excitement.

In some cases, sadistic activities lead up to or termi-nate in actual sexual relations; in others, full sexual gratifi-cation is obtained from the sadistic practice alone. A sadist,for example, may slash a woman with a razor or stick her

with a needle, experiencing an orgasm in the process. Thepain inflicted by sadists may come from whipping, biting,cutting, or burning; the act may vary in intensity, from fan-tasy to severe mutilation and even murder. Mild degrees ofsadism (and masochism, discussed below) are involved inthe sexual foreplay customs of many cultures, and somecouples in our own society-both heterosexual and homo-sexual-regularly engage in such practices, which are oftenquite ritualized. It is important to distinguish transient oroccasional interest in sadomasochistic practices fromsadism as a paraphilia. Surveys have found that perhaps 5to 15 percent of men and women enjoy sadistic and/ormasochistic activities voluntarily on occasion (Baumeister& Butler, 1997; Hucker, 1997). Paraphilic sadism andmasochism, in which sadomasochistic activities are thepreferred or exclusive means to sexual gratification, aremuch rarer; not uncommonly they co-occur in the sameindividual (LeVay & Valente, 2006). The situation canrange from full consent of the victim to complete lack ofconsent, although changes to DSM -IV-TR in 2000 requirethat the diagnosis of sadism be reserved for cases in whichthe victim is nonconsenting (LeVay & Valente, 2006).

Extreme sexual sadists may mentally replay their tor-ture scenes later while masturbating. Serial killers, whotend to be sexual sadists, sometimes record or videotapetheir sadistic acts. One study characterized 20 sexuallysadistic serial killers who were responsible for 149 murdersthroughout the United States and Canada (Warren, Dietz,& Hazelwood, 1996). Most were white males in their late-twenties or early thirties. Their murders were remarkablyconsistent over time, reflecting sexual arousal to the pain,fear, and panic of their victims. Choreographed assaults

After a decades·long search for a psychopathic serial killer whowas also a sexual sadist, Wichita, Kansas, police captured DennisRader (the BTK killer) in February 2005. By June 27, 2005, Raderhad confessed to murdering 10 people over the previous threedecades. Many of his victims were found partially unclothed andRader reportedly obtained sexual gratification while torturingthem and watching them die. Rader also sometimes practicedbondage on himself while watching pictures and videos of youngattractive women.

allowed them to carefully control their victims' deaths.Some of the men reported that the God-like sense of beingin control of the life and death of another human beingwas especially exhilarating. Eighty-five percent of the sam-ple reported consistent violent sexual fantasies, and 75 per-cent collected materials with a violent theme includingaudiotapes, videotapes, pictures, or sketches of their sadis-tic acts or sexually sadistic pornography.

Notorious serial killers include Ted Bundy, who wasexecuted in 1989. Bundy confessed to the murder of over30 young women, nearly all of whom fit a targeted type:women with long hair parted in the middle. Bundy admit-ted that he used his victims to re-create the covers of detec-tive magazines or scenes from "slasher movies." JeffreyDahmer was convicted in 1992 of having mutilated andmurdered 15 boys and young men, generally having sexwith them after death. (He was subsequently murdered inprison.) Although many sadists have had chaotic child-hoods, both Bundy and Dahmer came from middle-classfamilies and had loving parents. Unfortunately, we do nothave a good understanding of the causal factors involved inthese extreme cases of sadism.

MASOCHISM The term masochism is derived from thename of the Austrian novelist Leopold V. Sacher-Masoch(1836-1895), whose fictional characters dwelt lovingly onthe sexual pleasure of pain. In sexual masochism, a personexperiences sexual stimulation and gratification from theexperience of pain and degradation in relating to a lover.According to DSM-IV- TR (see DSM-IV- TR Criteria onp. 457), the person must have experienced recurrent,intense sexually arousing fantasies, urges, or behaviorsinvolving the act of being humiliated, beaten, or bound,often in a ritualistic pattern of behavior (Sandnabba et al.,2002). Interpersonal masochistic activities require the par-ticipation of at least two people-one superior "discipli-narian" and one obedient "slave." In a significant minorityof cases, the women who fall into such a pattern with theirpartners were sexually or physically abused as children(Warren & Hazelwood, 2002).

Such arrangements in mild form are not uncommonin either heterosexual or homosexual relationships.Masochists do not usually want, or cooperate with, truesexual sadists, but with individuals willing to hurt orhumiliate them within limits they set. Masochism appearsto be much more common than sadism and occurs in bothmen and women (Baumeister & Butler, 1997; Sandnabbaet al., 2002). Sadomasochistic activities, including bondageand discipline, are often performed communally, within"dungeons" popular in major cities. Such activities mightinvolve men being bound and whipped by women called"dominatrixes;' who wear tight leather or rubber outfitsand are paid to inflict pain and humiliation in a sexuallycharged sense.

One particularly dangerous form of masochism,called autoerotic asphyxia, involves self-strangulation to

Sadomasochistic activities, including bondage and discipline,are often performed communally, within "dungeons" popular inmajor cities.

the point of oxygen deprivation, which appears in theseindividuals to increase the intensity of orgasm by constric-tion of blood flow to the brain during masturbation(LeVay & Valente, 2006). Coroners in most major U.S.cities are familiar with cases in which the deceased is foundhanged next to masochistic pornographic literature orother sexual paraphernalia. Accidental deaths attributableto this practice have been estimated to range between 500and 1,000 per year in the United States (LeVay & Valente,2006). The following is a case of autoerotic asphyxia with atragic ending.

A woman heard a man shouting for help and went to hisapartment door ....

The woman with her two sons ... broke into theapartment. They found the man lying on the floor, hishands tied behind him, his legs bent back, and his anklessecured to his hands. A mop handle had been placedbehind his knees. He was visibly distraught, sweating,and short of breath, and his hands were turning blue. He

had defecated and urinated in his trousers. In his kitchenthe woman found a knife and freed him.

When police officers arrived and questioned the man,he stated that he had returned home that afternoon, fallenasleep on his couch, and awakened an hour later only tofind himself hopelessly bound. The officers noted that theapartment door had been locked when the neighborsbroke in ... [and] when the officers filed their report, theynoted that "this could possibly be a sexual deviation act."Interviewed the next day, the man confessed to bindinghimself in the position in which he was found.

A month later, the police were called back to thesame man's apartment. A building manager had discov-ered him face down on the floor in his apartment. Apaper bag covered his head like a hood. When the policearrived, the man was breathing rapidly with a satin clothstuffed in his mouth. Rope was stretched around hishead and mouth and wrapped his chest and waist. Sev-erallengths ran from his back to his crotch, and ropes athis ankles had left deep marks. A broom handle lockedhis elbows behind his back. Once freed, the man explained,"While doing isometric exercises, I got tangled up in therope." ...

Two years passed and the man moved on to anotherjob. He failed to appear for work one Monday morning. Afellow employee found him dead in his apartment. Duringtheir investigation, police were able to reconstruct theman's final minutes. On the preceding Friday, he hadbound himself in the following manner: sitting on his bedand crossing his ankles, left over right, he had boundthem together with twine. Fastening a tie around hisneck, he then secured the tie to an 86-inch pole behindhis back .... [By a complicated set of maneuvers heapplied] pressure to the pole, still secured to the tiearound his neck, [and] strangled himself. (From Spitzeret aI., 2002, pp. 86-88.)

Source: Reprinted with permission from the DSM-TR-Casebook:A Learning Companion to the Diagnostic and Statistical Manualof Mental Disorders, Fourth Edition, Text Revision (Copyright2002). American Psychiatric Publishing, Inc.

CausaL Factors and Treatments forParaphiLiasMany individuals with paraphilias have explanations fortheir unusual sexual preferences. For example, oneamputee paraphilic (whose preference is a partner with amissing limb) recalled that his fascination with femaleamputees originated during adolescence. He was neglectedemotionally by his cold family but heard a family memberexpress sympathetic feelings for an amputee. He developedthe wish that he would become an amputee and thus earntheir sympathy (see First, 2005, for a discussion of thisparaphilia, known as apotemnophilia). This story raisesmany questions. Emotionally cold families are not uncom-

Men's vulnerability to paraphilias such as fetishism may be aresult of their greater dependence on visual stimuli. This in turnmakes them more likely to form sexual associations to nonsexualstimuli. such as women's legs or high-heeled shoes, quite possiblythrough a process of classical conditioning.

mon, and sympathy for amputees is nearly universal. Cer-tainly not every male in a cold family who detects sympa-thy for amputees develops an amputee paraphilia. Suchstories do not necessarily have any validity because we areoften unaware of the forces that shape us (Nisbett & Wil-son, 1977).

Several facts about paraphilia are likely to be impor-tant in their development. First, as we have already noted,nearly all persons with paraphilias are male; females withparaphilias are so rare that they are found in the literatureonly as case reports (e.g., Fedoroff, Fishell, & Fedoroff,1999). Second, paraphilias usually begin around the timeof puberty or early adolescence. Third, people with para-philias often have more than one (e.g., LeVay & Valente,2006; Maletzky, 1998). For example, the corpses of menwho died accidentally in the course of autoerotic asphyxiawere partially or fully cross-dressed in 25 to 33 percent ofcases (Blanchard & Hucker, 1991). There is no obvious rea-son for the association between sexual masochism andtransvestism. Why should it be so?

Money (1986) and others have suggested that malevulnerability to paraphilias is closely linked to their greaterdependence on visual sexual imagery. Perhaps sexualarousal in men depends on physical stimulus features to a

greater degree than in women, whose arousal may dependmore on emotional context such as being in love with apartner. If so, men may be more vulnerable to forming sex-ual associations to nonsexual stimuli, which may be mostlikely to occur after puberty when the sexual drive is high.Many believe that these associations arise as a result ofclassical and instrumental conditioning and/or sociallearning that occurs through observation and modeling.When observing paraphilic stimuli (e.g., photographs ofmodels in their underwear), or when fantasies about para-philic stimuli occur, boys may masturbate, and the rein-forcement by orgasm-release may serve to condition anintense attraction to paraphilic stimuli (e.g., Kaplan &Krueger, 1997; LeVay & Valente, 2006).

TREATMENTS FOR PARAPH I LIAS The vast majority ofstudies concerning the treatment of paraphilias have beenconducted with sex offenders. The literature concerningtreatment of men with paraphilias who have not commit-ted any offense, or who have victimless paraphilias (e.g.,masochism), consists primarily of case reports becausemost people with paraphilias do not seek treatment forthese conditions. Thus we defer discussion of the treat-ment of paraphilias until we discuss the treatment of sexoffenders, many of whom have paraphilias.

Gender Identity DisordersGender identity refers to one's sense of maleness or female-ness and may be distinguished from gender role, whichrefers to the masculinity and femininity of one's overtbehavior (Money, 1988). Of all behavioral traits, genderidentity may have the strongest correlation with biologicalsex, but the correlation is not perfect. Some rare individu-als feel extreme discomfort and unhappiness with theirbiological sex and strongly desire to change to the oppositesex. Indeed, some adults with gender identity disorders,often called transsexuals, opt for expensive and compli-cated surgery to accomplish just that. In DSM -IV-TR,gender identity disorder is characterized by two compo-nents: (1) a strong and persistent cross-gender identifica-tion-that is, the desire to be, or the insistence that one is,of the opposite sex-and (2) gender dysphoria-persis-tent discomfort about one's biological sex or the sense thatthe gender role of that sex is inappropriate. The disordermay occur in children or adults and in males or females.

GENDER IDENTITY DISORDER OF CHILDHOOD Boyswith gender identity disorder show a marked preoccupa-tion with traditionally feminine activities (Zucker, 2005;Zucker & Bradley, 1995). They may prefer to dress infemale clothing. They enjoy stereotypical girls' activitiessuch as playing dolls and playing house. They usually avoidrough-and-tumble play and often express the desire to be agirl. Boys with gender identity disorder are often ostra-cized as "sissies" by their peers.

DSM-IV-TR

A. A strong and persistent cross-gender identification. Inchildren four of the following must also be present:(1) Repeatedly stated desire to be, or insistence one is,

the other sex.(2) In boys, preference for cross-dressing in female attire;

in girls, insistence on wearing stereotypical masculineclothing.

(3) Strong and persistent preferences for cross-sex roles inmake-believe play or persistent fantasies of being theother sex.

(4) Intense desire to participate in the stereotypical gamesand pastimes of the other sex.

(5) Strong preference for playmates of the other sex.In adolescents and adults, the disturbance is manifestedby symptoms such as stated desire to be the other sex,frequent passing as the other sex, and/or desire to live orbe treated as the other sex.

B. Persistent discomfort with his or her sex or sense ofinappropriateness in the gender role of that sex. In boys,this could be in the form of assertion that his penis ortestes are disgusting or that it would be better not tohave a penis, or rejection of stereotypical male toys,games, and activities. In girls: Rejection of urinating in asitting position, assertion that she will grow a penis, orassertion that she does not want to grow breasts ormenstruate. In adolescents and adults: preoccupation withgetting rid of primary and secondary sex characteristics, orother procedures to physically alter sexual characteristicsto simulate the other sex.

Girls with gender identity disorder typically balk atparents' attempts to dress them in traditional feminineclothes such as dresses, preferring boys' clothing and shorthair. Fantasy heroes typically include powerful male fig-ures like Batman and Superman. They show little interestin dolls, and increased interest in sports. Although meretomboys frequently have many or most of these traits,girls with gender identity disorder are distinguished bytheir desire to be a boy or to grow up as a man. Young girlswith gender identity disorder are treated better by theirpeers than are boys with gender identity disorder, becausecross-gender behavior in girls is better tolerated (Cohen-Kettenis et aI., 2003; Zucker, Sanikhani, & Bradley, 1997).In clinic-referred gender identity disorder, boys outnum-ber girls 5 to 1 (Cohen-Kettenis et aI., 2003). An apprecia-ble percentage of that imbalance may reflect greaterparental concern about femininity in boys than aboutmasculinity in girls.

The ffiQ t CQ 0 adv 0 c m of boy with gen-der identity disorder appears to be homosexuality ratherthan transsexualism (Bradley & Zucker, 1997; Zucker,2005). In Richard Green's (1987) prospective study of 44very feminine boys from the community, only one soughtsex change surgery by age 18. About three-quartersbecame gay or bisexual men who were evidently satisfiedwith their biological sex. However, several later studies ofclinic-referred children have found that 10 to 20 percentof boys with gender identity disorder later were diagnosedas transsexual by age 16 or 18, and about 40 to 60 percentidentified themselves as homosexual or bisexual, a per-centage that may have increased by the time they wereolder (Zucker, 2005). There are several smaller prospectivestudies of girls with gender identity disorder that haveshown that 35 to 45 percent may show persistent genderidentity disorder (leading to a desire for sex reassignmentsurgery in many), and approximately half had a homo-sexual orientation.

Given that many such children typically adjust wellin adulthood, should they be considered to have a mental

Boys with gender identity disorder enjoy dressing up in femaleclothing and make-up, and enjoy stereotypical girls' activities.As a consequence, they are often ostracized as "sissies" bytheir peers.

disorder as children? Some have argued that such chil-dren should not be considered "disordered" because theprimary obstacle to their happiness may be a society thatis intolerant of cross-gender behavior. However, mostresearchers who work with these children maintain thatthe distress and unhappiness these children and adoles-cents have about the discrepancy between their biologicalsex and their psychological gender is consistent with thisbeing called a mental disorder (e.g., Zucker, 2005; Zucker& Spitzer, 2005). Moreover, these children are frequentlymistreated by their peers and have strained relations withtheir parents, even though their cross-gender behaviorharms no one.

Treatment Children with gender identity disorder areoften brought in by their parents for psychotherapy. Spe-cialists attempt both to treat the child's unhappiness withhis or her biological sex and to ease strained relations withparents and peers. Children with gender identity disordersoften have other general behavioral problems such as anx-iety and mood disorders that also need therapeutic atten-tion (Zucker, Owen, et al., 2002). Therapists try to improvepeer and parental relations by teaching such children howto reduce their cross-gender behavior, especially in situa-tions where it might cause interpersonal problems. Genderdysphoria is typically treated psychodynamically-that is,by examining inner conflicts. Controlled studies evaluat-ing such treatment remain to be conducted (Zucker &Bradley, 2003).

TRANSSEXUALISM Transsexuals are adults with gen-der identity disorder who desire to change their sex, andsurgical advances have made this goal partially feasible,although expensive. (Adults who have gender identity dis-order and do not desire to change their sex are usuallyreferred to as transgendered.) Transsexualism is appar-ently a very rare disorder. European studies suggest thatapproximately 1 per 30,000 adult males and 1 per 100,000adult females seek sex reassignment surgery. Until fairlyrecently, most researchers assumed that transsexualismwas the adult version of childhood gender identity disor-der, and indeed this is often the case. That is, many trans-sexuals had gender identity disorder as children (despitethe fact that most children with gender identity ~sorderdo not become transsexual), and their adult behavior isanalogous. This appears to be the case for all female-to-male transsexuals (individuals born female who becomemale). Virtually all such individuals recall being extremelytomboyish, with masculinity persisting unabated intoadulthood. Most, but not all, female-to-male transsexualsare sexually attracted to women. One female-to-maletranssexual had these recollections:

[I have felt different] as far as I can remember. Threeyears old. I remember wanting to be a boy. Wearingboys' clothes and wanting to do all the things boys do. I

remember my mother ... saying, "Areyou ever going tobe a lady?Are you ever going to wear women's cloth-ing?" ... I can remember as I got a little older alwayslooking at women, always wanting a woman .... I feellike a man, and I feel like my loving a woman is perfectlynormal. (Green, 1992,p. 102)

In contrast to female-to-male transsexuals, there aretwo kinds of male-to-female transsexuals, with very dif-ferent causes and developmental courses: homosexualand autogynephilic transsexuals (Blanchard, 1989; LeVay &Valente, 2006). Homosexual transsexual men are generallyvery feminine and have the same sexual orientation as gaymen: They are sexually attracted to biological males (theirpreoperative biological sex). However, because these trans-sexual men experience their gender identity as female, theyoften define their sexual orientation as heterosexual andresent being labelled gay. Thus what is referred to in theresearch literature as a homosexual male-to-female trans-sexual is a genetic male seeking a sex change operation whodescribes himself as a woman trapped in a man's bodyand who is sexually attracted to heterosexual male partners(Bailey, 2003). In contrast, autogynephilic transsexualsappear to have autogynephilia-a paraphilia in whichtheir attraction is to thoughts, images, or fantasies ofthemselves as a woman (Blanchard, 1991, 1993). Thisdiagnostic distinction has not been made in the DSM -IV,although it is briefly mentioned. Although it may not berelevant for treatment purposes (both types of transsexu-als are appropriate candidates for sex reassignmentsurgery), it is fundamental to understanding the diversepsychology of male-to-female transsexualism.

One important finding is that homosexual transsexu-als generally have had gender identity disorder sincechildhood, paralleling what is found in female-to-maletranssexuals as discussed above. However, because mostchildren with gender identity disorder do not becometranssexual adults (but instead become gay or bisexualmen), there must be other important determinants oftranssexualism. One hypothesis is that there are some pre-natal hormonal influences affecting which childrendevelop gender identity disorder and later become trans-sexuals. For example, primate research clearly shows that afemale fetus exposed to high levels of androgens in uterousually develops masculine types of rough-and-tumbleplay (Goy et al., 1988; Whalen, 1996).

Autogynephilic (sometimes called heterosexual)transsexualism almost always occurs in genetic males whousually report a history of transvestic fetishism. However,unlike other transvestites, autogynephilic transsexualsfantasize that they have female genitalia, which can lead toacute gender dysphoria, motivating their desire for sexrea signment surgery. Autogynephilic transsexuals mayreport sexual attraction to women, to both men andwomen, or to neither. Research has shown that these sub-types of autogynephilic transsexuals (varying in sexual

Mianne Bager (a Danish-born Australian resident) is a male-to-female transsexual who has golfed professionally in women'stournaments since 2003_ She is the first known femaleprofessional golfer who was born male. Before she could playwomen's tournaments, rule changes had to be implemented inEurope, Australia, and other countries so that it was no longerrequired that a competitor be female at birth.

orientation) are very similar to each other and differ fromhomosexual transsexuals in other important respects(Bailey, 2003; Blanchard, 1985, 1989, 1991). Unlike homo-sexual transsexuals, autogynephilic transsexuals do notappear to have been especially feminine in childhood oradulthood, and they typically seek sex reassignmentsurgery much later in life than do homosexual transsexuals(R. Blanchard, 1994). The causes of autogynephilic trans-sexualism probably overlap etiologically with the causes ofother paraphilias but are not yet well understood.

Treatment Psychotherapy is usually not effective inhelping adolescents or adults resolve their gender dyspho-ria (Cohen-Kettenis, Dillen, et al., 2000; Zucker & Bradley,1995). The only treatment that has been shown to be effec-tive is surgical sex reassignment. Initially, transsexualsawaiting surgery are given hormone treatment. Biologicalmen are given estrogens to facilitate breast growth, skinsoftening, and shrinking of muscles. Biological women aregiven testosterone, which suppresses menstruation,increases facial and body hair, and deepens the voice.Before they are eligible for surgery, transsexuals typically

must live for many months with hormonal therapy, andthey generally must live for at least a year as the gender theywish to become. If they successfully complete the trialperiod, they undergo surgery and continue to take hor-mones indefinitely. In male-to-female transsexuals, thisentails removal of the penis and testes and the creation ofan artificial vagina. Moreover, such transsexuals mustundergo extensive electrolysis to remove their beards andbody hair. They also have to learn to raise the pitch of theirvoice. Female-to-male transsexuals typically are givenmastectomies and hysterectomies and often have otherplastic surgery to alter various facial features (such as theAdam's apple).

Only a subset of female-to-male transsexuals seek anartificial penis because relevant surgical techniques are stillsomewhat primitive and very expensive. Moreover, theartificial penis is not capable of normal erection, so thosewho have this surgery must rely on artificial supports tohave intercourse anyway. The rest function sexually with-out a penis. As surgical techniques advance, this is verylikely to change. A 1990 review of the outcome literaturefound that 87 percent of 220 male-to-female transsexualshad satisfactory outcomes (meaning that they did notregret their decisions) and that 97 percent of 130 female-to-male transsexuals had successful outcomes (Green &Fleming, 1990). More recent studies have reported similarfindings. Thus the majority of transsexuals are satisfiedwith the outcome of sex reassignment surgery, althoughthere is variability in the degree of satisfaction (Cohen-Kettenis & Gooren, 1999; LeVay & Valente, 2006). In spiteof the reasonably good success record for transsexualpatients who are carefully chosen, such surgery remainscontroversial because some professionals continue tomaintain that it is inappropriate to treat psychological dis-orders through drastic anatomical changes.

In ReVIew~ Define paraphilia, and cite eight paraphilias

recognized in the DSM, along with theirassociated features.

~ What two components characterize genderidentity disorder?

~ Identify the two types of male-to-femaletranssexuals, and describe theirdevelopmental course as well as that offemale-to-male transsexuals.

~ What are the most effective treatments forchildhood gender identity disorder and adulttranssexualism?

SEXUAL ABUSESexual abuse is sexual contact that involves physical orpsychological coercion, or at least one individual who can-not reasonably consent to the contact (e.g., a child). Suchabuse includes pedophilia, rape, and incest, and it concernssociety more than any other sexual problem. It is some-what ironic, then, that of these three forms of abuse, onlypedophilia is included in DSM -IV-TR. This partly reflectsthe seriousness with which society views these offenses andits preference for treating coercive sex offenders as crimi-nals rather than as having a mental disorder (althoughobviously many criminals also have mental disorders).

The past few decades have seen intense concern aboutchildhood sexual abuse, with an accompanying increasein relevant research. There are at least three reasons forthis. First, much evidence suggests that, broadly defined,childhood sexual abuse is more common than once wasassumed. Second, there are possible links between child-hood sexual abuse and some mental disorders, so suchabuse may be important in the etiology of some disorders(see especially Chapters 3, 5, 8, and 11). Third, some dra-matic and well-publicized cases involving allegations ofchildhood sexual abuse have raised very controversialissues such as the validity of children's testimony and theaccuracy of recovered memories of sexual abuse. We shallconsider all three of these issues in turn.

PREVALENCE OF CHILDHOOD SEXUAL ABUSE Theprevalence of childhood sexual abuse depends on its defin-ition, which has varied substantially across studies. Forexample, different studies use different definitions of"childhood,"with the upper age limit ranging from 12 to ashigh as 19 years. Some studies have counted any kind ofsexual interaction, even that which does not include phys-ical contact (e.g., exhibitionism); others have counted onlyphysical contact; others have counted only genital contact;and still others have counted consensual sexual contactwith a minor. Depending on which definition is used,prevalence figures have ranged from less than 5 percent tomore than 30 percent. Even the lowest plausible figures jus-tify concern.

CONSEQUENCES OF CHILDHOOD SEXUAL ABUSEChildhood sexual abuse may have both short-term andlong-term consequences. The most common short-termconsequences are fears, post-traumatic stress disorder, sex-ual inappropriateness (e.g., touching others' genitals ortalking about sexual acts), and poor self-esteem (e.g.,Kendall- Tackett, Williams, & Finkelhor, 1993; McConaghy,1998). Approximately one-third of sexually abused chil-

dren show no symptoms. Thus there is no single "sexualabuse" syndrome.

A number of studies have found associations betweenreports of childhood sexual abuse and adult psychopathol-ogy, including borderline personality disorder (Battle,Shea, et aI., 2004; Fossati, Madeddu, & Maffei, 1999), som-atization disorder with dissociative symptoms (Sar et aI.,2004), dissociative symptoms (Chu & Dill, 1990), and dis-sociative identity disorder (Maldonado et aI., 2002; Ross,1999). A wide variety of sexual symptoms have also beenalleged to result from early sexual abuse (e.g., Leonard &Follette, 2002; Loeb et aI., 2002), ranging, for example,from sexual aversion to sexual promiscuity. However, asdiscussed in Chapters 8 and 11, knowledge about thesehypothesized associations is very limited because of diffi-culties in establishing causal links between early experi-ences and adult behavior (see also Unresolved Issues at theend of this chapter).

CONTROVERSIES CONCERNING CHILDHOOD SEX·UAL ABUSE Several types of high-profile criminal trialshave highlighted the limitations of our knowledge con-cerning questions of great scientific and practical impor-tance. In one type of case, children have accused adultsworking in day-care settings of extensive, often bizarresexual abuse, and controversial issues have been raisedabout the degree to which children's accusations can betrusted. In a second type of case, adults claim to haverepressed and completely forgotten memories of earlysexual abuse and then to have "recovered" the memoriesduring adulthood, typically while seeing a therapist whobelieves that repressed memories of childhood sexualabuse are a very common cause of adult psychopathol-ogy. Many controversial issues have been raised about thevalidity of these "recovered" memories.

Children's Testimony Several cases of alleged sexualabuse in day-care settings shocked the country startingin the 1980s. The most notorious was the McMartinPreschool case in California (Eberle & Eberle, 1993). In1983 Judy Johnson complained to police that her son hadbeen molested by Raymond Buckey, who helped run theMcMartin Preschool, which her son attended. Johnson'scomplaints grew increasingly bizarre. For example, sheaccused Buckey of sodomizing her son while he stuck theboy's head in a toilet and of making him ride naked on ahorse. Johnson was diagnosed with acute paranoid schizo-phrenia, and she died of alcohol-related liver disease in1986. By the time she died, prosecutors no longer neededher. Children at the preschool who were interviewed beganto tell fantastically lurid stories-for example, that chil-dren were forced to dig up dead bodies at cemeteries, jumpout of airplanes, and kill animals with bats. Nevertheless,prosecutors and many McMartin parents believed the chil-dren. Buckey and his mother (who owned the day-care

3.2 The Reliability ofChildren's Reports ofPast Events

5li buse of children is distressingly common,and children's reports of such abuse mustalways be taken seriously. However, asmore and more children have beenbrought forward to testify in court about

alleged physical and sexual abuse by parents or otheradults, researchers have become increasingly concernedabout determining how reliable the testimony of children,especially that of young children, can be expected to be-especially when they have been subjected to repeatedinterviews over many months with highly leading ques-tions, sometimes in a coercive atmosphere. Unfortunately,this continues to be the way in which such children aresometimes treated before the trials in which they testify.

Stephen Ceci and Maggie Bruck, leading develop-mental psychologists studying this problem, have con-ducted a series of experiments that cast grave doubt onyoung children's testimony if they have been exposedrepeatedly to suggestive interviews with leading ques-tions over long intervals of time (Bruck, Ceci, & Hem-brooke, 2002; Ceci, Bruck, & Battin, 2000; London et aI.,2005). For example, Ceci and colleagues summarized evi-dence that preschoolers have greater difficulty than olderchildren or adults in distinguishing between real andimagined acts (such as whether they really touched theirnose or only imagined touching it; Ceci et aI., 2000; Foleyet aI., 1989). In one well-known study, Ceci and colleagueshad an adult interview preschoolers weekly for 10 weeksabout whether certain actual events (such as getting in anaccident that required stitches) and certain fictitiousevents (such as getting their hand caught in a mousetrapand having to go to the hospital to get it removed) hadoccurred. Each week, the children were asked to thinkhard about whether the event had happened and wereprompted to visualize the scene. Later, each child had avideotaped interview with a new adult and was asked torecall what happened, with the adult using probing ques-tions. The results were striking. Over half claimed that atleast one of the fictitious events had actually happened tothem, and one-quarter claimed that nearly all of the ficti-tious events had happened to them. Their narrativesdescribing these fictitious events were often elaborate,embellished, coherent, and emotional, and many children

firmly believed that these events had happened to them,and could not be talked out of their false reports (Ceci,1995). When psychologists who specialize in interviewingchildren were shown these videotapes, their accuracy atdetecting real events from fictitious events was no betterthan chance. Similar results have been obtained forjudges, social workers, and psychiatrists. Ceci's conclu-sion was: "Repeatedly thinking about a fictitious eventcan lead some preschool children to produce vivid,detailed reports that professionals are unable to discernfrom their reports of actual events" (1995, p. 103).

Other research by Ceci and Bruck has shown thatthose who interview young children about possible abuseare actually more likely to obtain accurate information ifthey ask open-ended questions than if they ask many spe-cific questions (London et aI., 2005). And contrary to thewidely held opinion that most children will not discloseabuse they have experienced, recent studies have shownthat most children with substantiated abuse do disclosethe abuse within one or two sessions when questioned informal settings. These findings are contrary to the opinionof many professionals that when children disclose abusereadily, their reports should be considered suspect. Forexample, consider the following interchange cited by Lon-don et al. (2005, p. 196) between a prosecutor and anexpert witness in a 2001 case (People v. Carroll, p. 70):

Q: Doctor, you mentioned earlier that with respect tochild victims, it is not unusual that they would fullydescribe all of the events in your first interview.

A: No.Q: And if they do, is it suspicious to you?A. To me, yes.

On the other hand, many expert witnesses are alsonot inclined to believe children when they deny abuse hashappened:

Indeed Dr. Snow herself admitted that she used interro-gation procedures that were not intended to sift truthfrom error. She forthrightly admitted she was not a neu-tral interviewer; rather she was "an ally for the child,""biased," and not a fact collector like the police ....since she starts an interrogation with the assumption

facility) were tried in a trial that took 2Y2 years and cost$15 million. The jury acquitted Ms. Buckey on all countsand failed to convict Raymond Buckey on any; however, hewas freed only after retrial, after having spent 5 years in jail.The jurors' principal reason for not finding the defendantsguilty was their concern that interviewers had coaxed the

children into telling stories of abuse that were not true byusing the sorts of leading or coercive methods of ques-tioning described in Developments in Research 13.2.Moreover, subsequent research on children with reportedsatanic abuse found no evidence (including physical evi-dence) that such abuse had occurred, and so any such

that abuse occurred, she then proceeds to prove thatpoint. ... "I didn't believe any of those kids when theytold me it didn't happen." (State v. Bullock, 1989, p.175; cited in London et aI., 2005, p. 215.)

In several other important studies, Ceci and col-leagues looked at young children who had been exposedto a staged event and examined the effect of the kinds ofquestions the children received from an interviewer. Forexample, in the Sam Stone Study, Leichtman and Ceci(1995) interviewed preschool children four times over 10weeks for details about a previously staged 2-minute visitto their day-care center by a stranger named Sam Stone.Some of the children were given no prior informationabout Sam Stone before his visit and were never askedsuggestive questions during the four interviews; otherchildren were given a stereotype about Sam Stone (suchas that he was clumsy) before his visit and were also givenleading questions suggesting that Sam Stone had donecertain things consistent with the stereotype. One monthlater (about 14 weeks after Sam Stone's visit), all the chil-dren were interviewed by a new interviewer, who askedabout two events that had not happened during SamStone's visit. For the children who had been given no priorstereotype about Sam Stone and no leading questionsduring the initial four interviews, only 10 percent of theyoungest preschoolers claimed that Sam Stone had doneeither of these two nonevents. (Older preschoolers sel-dom committed such errors.) By contrast, for the youngerpreschoolers who were given a prior stereotype that SamStone was clumsy and who had been asked leading ques-tions during the four interviews, a startling 72 percent ofthe youngest children claimed that Sam Stone had doneeither one or both of the nonevents. When gently chal-lenged, 44 percent continued to claim that they had seenhim do these things.

Videotapes of some of these forensic interviews werelater shown to over 1,000 researchers and clinicians whowork with children, and they were then asked to rate thechildren for the accuracy of their testimony. The majority ofthe professionals were highly inaccurate. Indeed, thevideotape of the child who was least accurate was rated asmost credible, and the videotape of the child who wasmost accurate was rated as least credible. Leichtman andCeci (1995) concluded "the accuracy of children's reports isextremely difficult to discern when children have been sub-jected to repeated erroneous suggestions over long reten·tion intervals, especially when coupled with the induction

reports of satanic abuse are scientifically very doubtful

(London, Bruck, et a!', 2005).

Recovered Memories of Sexual Abuse In 1990, ayoung woman named Eileen Franklin testified in court that

she had seen her father rape and murder an 8-year-old play-

of stereotypes" (p. 20). In a later study, two groups of chil-dren who watched a memorable staged event (an archaeo-logical dig) were later questioned about that event. Onegroup had seen two target events during the archaeologi-cal dig that the second group did not see, and the childrenfrom the two groups were allowed to discuss it with eachother before being interviewed. Results showed that hav-ing personal conversations with peers can also lead tofalse reports of nonexperienced events, even in theabsence of misleading questions (Principe & Ceci, 2002).

Finally, Ceci's and Bruck's work also challenges theuse of anatomically correct dolls (dolls with bodies show-ing the sex organs) to symbolically represent actions, atleast for very young children. Bruck and colleagues (1995)studied 70 three-year-old boys and girls who were visitingtheir pediatrician, 35 of whom were given a genital exam(which involved touching the genital area but no genitalinsertions) and 35 of whom were not given a genital exam.Mothers were present during these exams. Five minuteslater, with the mothers still present, the children wereasked to describe where the doctor had touched them.They were then presented anatomical dolls and asked topoint on the dolls where the doctor had touched them.When interviewed verbally, most of the children who hadnot received a genital exam correctly refrained from statingthat their genitals had been touched. However, when giventhe anatomical doll, nearly 60 percent of those who hadnot received a genital exam claimed that the doctor hadmade genital and/or anal insertions and done other acts tobe concerned about. On the other hand, just over half ofthe children who had been given a genital exam claimedthat their genitals had not been touched, even though theyhad. Thus it seemed that the use of anatomical dolls failedto improve the accuracy of the 3-year-olds' reports of whatdid or did not happen. Bruck et al. (1998) reported verysimilar results with 4-year-olds. Although older childrenmay make fewer errors, no one has yet shown that the useof anatomical dolls improves reporting (Bruck et aI., 1995;Ceci et aI., 2000).

In summary, although young children are capable ofcorrect recall of what has happened to them, they are alsosusceptible to a greater variety of sources of post-eventdistortion than older children and adults. To a lesserdegree, even adults are susceptible to a variety of sourcesof post-event distortion (Ornstein, Ceci, & Loftus, 1998; seealso the Unresolved Issues in Chapter 8). Thus the differ-ences should be seen as a matter of degree rather than ofkind (Ceci et aI., 2000).

mate 20 years earlier. Remarkably, despite her claim to have

witnessed the murder, she had no memory of the event

until she "recovered" the memory by accident in adulthood

(MacLean, 1992). Franklin's father was convicted and given

a life sentence, although in 1995 the conviction was over-

turned because of two serious constitutional errors made

Recent evidence has suggested that the use of anatomicallycorrect dolls to question young children about where they mayhave been touched in alleged incidents of sexual abuse does notimprove the accuracy of their testimony relative to verbalinterviews alone.

during the original trial that might have affected the jury'sverdict. In another case, Patricia Burgus sued her two psy-chiatrists in Chicago for false-memory implantation,claiming the doctors had persuaded her through hypnosisand other therapeutic techniques "to believe that she wasa member of a satanic cult, that she was sexually abused bymultiple men, and that she engaged in cannibalism andabused her own children" (Brown, Goldstein, & Bjork-lund, 2000, p. 3). In 1997 she was awarded $10.6 million(as far as we know, the largest judgment yet in a false-memory lawsuit).

As discussed in some detail in Chapter 8, whethertraumatic experiences can be utterly forgotten and thensomehow recovered intact years later has been heatedlydebated during the past several decades. Some haveargued that repressed memories are common (e.g., Her-man, 1993) and are responsible for a great deal of psy-chopathology. In the controversial but very popular bookThe Courage to Heal, journalists Ellen Bass and LauraDavis asserted, "If you are unable to remember any spe-cific instances [of sexual abuse] ... but still have the feel-ing that something abusive happened to you, it probablydid" (1988, p. 21). Yet as researchers have pointed out,there is absolutely no evidence that this statement is true.Some therapists still routinely give this book to theirclients, and those clients often do report "recovering" suchmemories. Those skeptical about recovery of repressedmemories point out that even normal, unrepressed mem-ories can be highly inaccurate and that false memoriescan be induced experimentally (Loftus et aI., 1995;Thomas & Loftus, 2002). For example, adolescents andadults who have been told to imagine several times hav-ing engaged in bizarre and unusual acts have sometimescome to believe that they actually performed those acts(see Chapter 8).

Th~ Q~b~t~QbQutth~ nl"Q·w of m~moli~~of \thild-hood sexual abuse that arise during therapy remainsextremely heated. Some researchers (the nonbelievers)maintain that the concept of repressed memory is whollyor largely invalid. In their view, virtually all "recoveredmemories" are false (Crews, 1995; Loftus & Ketchum,1994; Thomas & Loftus, 2002). Others (the believers)maintain that false memories rarely occur and that recov-ered memories are typically valid, and they often cite casesin which the accused perpetrator confesses to the sexualabuse he is accused of (e.g., Pope, 1996). Psychologistsequally familiar with the evidence have argued bitterlyabout this issue, and, as discussed in more detail inChapter 8, a task force assembled by the American Psycho-logical Association to study the issue in the mid -1990sfailed to reach a consensus. This lack of consensus contin-ues today. Indeed, this debate concerning recovered mem-ories of sexual abuse is one of the most important andinteresting contemporary controversies in the domains ofpsychopathology and mental health as discussed in theUnresolved Issues section in Chapter 8.

PedophiliaAccording to DSM -IV-TR, pedophilia is diagnosed whenan adult has recurrent, intense sexual urges or fantasiesabout sexual activity with a prepubertal child, althoughacting on these desires is not necessary for the diagnosis(see DSM-IV- TR Criteria on p. 457). Pedophilia frequentlyinvolves fondling or manipulation of the child's genitals,and occasionally penetration. Although penetration andassociated force are often injurious to the child, injuries areusually a by-product rather than the goal they would bewith a sadist (although a minority of men diagnosed withpedophilia are sexual sadists or have antisocial personalitydisorder or psychopathy; Cohen & Galynker, 2002). It isimportant to emphasize that pedophilia is defined by bodymaturity, not the age, of the preferred partner. Thus stud-ies of childhood sexual abuse, which typically define child-hood in terms of an age range that may extend well intoadolescence, do not necessarily concern pedophilia(McAnulty et aI., 2001).

Nearly all pedophiles are male, and about two-thirdsof their victims are girls, typically between the ages of 8and 11 (Cohen & Galynker, 2002). Some pedophiles (espe-cially those who abuse prepubescent children) are rela-tively indifferent to the sex of their victim, but most areheterosexual or homosexual with about 1 in 2 or 3 beinghomosexual. Homosexual pedophiles tend to have morevictims than heterosexual pedophiles (Blanchard, 2000;Cohen & Galynker, 2002).

Studies investigating the sexual responses ofpedophiles have revealed several patterns of results (Bar-baree & Seto, 1997; LeVay & Valente, 2006). Such studiestend to use a penile plethysmograph to measure erectileresponses to sexual stimuli directly rather than relying on

self-report. (A plethysmograph consists of an expandableband placed around the penis that is connected to arecording device.) Some men who have molested nonfa-milial female children show greater sexual arousal thanmatched nonoffenders in response to pictures of nude orpartially clad girls-and greater arousal to such picturesthan to pictures of adult women. But other pedophilesrespond to children as well as to adolescents and/or adults(Seto et aI., 1999).

Child molesters are more likely than nonoffenders tobelieve that children will benefit from sexual contacts withadults and that children often initiate such contact(Cohen & Galynker, 2002; Segal & Stermac, 1990). Moti-vationally, many pedophiles appear to be shy and intro-verted, yet still desire mastery or dominance over anotherindividual; some also idealize aspects of childhood such asinnocence, unconditional love, or simplicity (Cohen &Galynker,2002).

Pedophilia usually begins in ado-lescence and persists over a person'slife. Many engage in work with chil-dren or youth so that they have exten-sive access to children; a subset nevertake advantage but many others do.Several studies show that men withpedophilia were much more likely tohave been sexually abused as childrenthan were rapists (Lee et al., 2002).

For several decades we have seenan increasing number of cases ofpedophilia among a group long con-sidered to be highly trustworthy: theCatholic clergy. Although the major-ity of priests are innocent of sexualwrongdoing, the Catholic Church hasbeen forced to admit that a signifi-cant minority have committed sexualabuse, including pedophilia. At least400 priests were charged with sexualabuse during the 1980s, and $400million was paid in damages between1985 and the early 1990s (Samborn,1994). One very serious scandalinvolved James R. Porter, a 57-year-oldfather of four who is alleged to havesexually abused as many as 100 chil-dren when he was a priest in Massa-chusetts during the 1960s. Porter lateradmitted to his offenses and was con-victed of molesting his children'sbaby-sitter in 1987. The Church set-tled a multimillion-dollar suit with 25 men whom Porterhad abused while a priest.

This scandal erupted anew in 2002, with heightenedpublicity regarding revelations that a substantial numberof priests in many cities had been sexually involved with

children and adolescents-and that a significant numberhad been protected by their superiors. Indeed, this scandalled, after a prolonged public outcry, to the resignation ofCardinal Bernard Law of the Archdiocese of Boston. Overmany years, Law had protected numerous priests who wereguilty of sexual misconduct, allowing them to move fromone parish to another after their sexual misconduct wasdiscovered. Thus he allowed their sexual molestation tocontinue with more and more girls and boys. The Confer-ence of Bishops subsequently adopted a policy of manda-tory removal of any priest from his ministerial duties if heis known to have had sexual contact with a minor. Thisnew policy seems to be working at least to some extent. InSeptember 2005, for example, Cardinal Francis George ofthe Archdiocese of Chicago permanently removed 11priests from public ministerial duties for reasons of sexualmisconduct (Chicago Tribune, September 27, 2005). Similarproblems of priests engaging in abuse have also occurred in

Ireland (LeVay & Valente, 2006).

Culturally prohibited sexual relations(up to and including coitus) betweenfamily members such as a brother andsister or a parent and child are knownas incest. Although a few societieshave sanctioned certain incestuousrelationships-at one time it was theestablished practice for Egyptianpharaohs to marry their sisters to pre-vent the royal blood from being"contaminated"-the incest taboo isvirtually universal among human soci-eties. Incest often produces childrenwith mental and physical problemsbecause close genetic relatives aremuch more likely than nonrelatives toshare the same recessive genes (whichoften have negative biological effects)and hence to have children with twosets of recessive genes. Presumably forthis reason, many nonhuman animalspecies, and all known primates, havean evolved tendency to avoid matingsbetween close relatives. The mecha-nism for human incest avoidanceappears to be lack of sexual interest inpeople to whom one is continuouslyexposed from an early age. For exam-ple, biologically unrelated children

who are raised together in Israeli kibbutzim rarely marryor have affairs with others from their rearing group whenthey become adults (Kenrick & Luce, 2004). Evolutionarily,this makes sense. In most cultures, children reared togetherare biologically related.

Former priest John Geoghan was foundguilty of sexually molesting two boys,and accused of sexually molestingdozens more in several parishes in theBoston area. In January 2002, theBoston Globe published a special reporton the archdiocese's failure to stopGeoghan's cycle of abuse. This reportbecame a catalyst for hundreds ofpeople to come forward and expose thewidespread scandal of sexual abuse andcover-up in the Catholic church.Geoghan was killed in prison in 2003.

In our own society, the actual incidence of incest is dif-ficult to estimate because it usually comes to light only whenreported to law enforcement or other agencies. It is almostcertainly more common than is generally believed, in partbecause many victims are reluctant to report the incest or donot consider themselves victimized. Brother-sister incest isthe most common form of incest, even though it is rarelyreported (LeVay & Valente, 2006). The second most com-mon pattern is father-daughter incest. It seems that girls liv-ing with stepfathers are at especially high risk for incest,perhaps because there is less of an incest taboo amongnonblood relatives (Finkelhor, 1984; Masters et a!', 1992).Mother-son incest is thought to be relatively rare. Fre-quently, incest offenders do not stop with one child in afamily (Wilson, 2004), and some incestuous fathers involveall of their daughters serially as they become pubescent.

Incestuous child molesters tend to have somepedophilic arousal patterns (Barsetti, Earls, et a!', 1998;Seto, Lalumiere, & Kuban, 1999), suggesting that they areat least partly motivated by sexual attraction to children,although they also show arousal to adult women. However,they differ from extrafamilial child molesters in at least tworespects (Quinsey, Lalumiere, et a!., 1995). First, the largemajority of incest offenses are against girls, whereasextrafamilial offenses show a more equal distributionbetween boys and girls. Second, incest offenders are morelikely to offend with only one or a few children in the fam-ily, whereas pedophilic child molesters are likely to havemore victims (LeVay & Valente, 2006).

RapeThe term rape describes sexual activity that occurs underactual or threatened forcible coercion of one person byanother (see Figure 13.1). In most states, legal definitions

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restrict forcible rape to forced intercourse or penetrationof a bodily orifice by a penis or other object. Statutory rapeis sexual activity with a person who is legally defined (bystatute or law) to be under the age of consent (18 in moststates), even if the underage person consents. In the vastmajority of cases, rape is a crime of men against women,although in prison settings it is often committed by menagainst men.

It is important to note that forced sex is not unique tohumans but rather occurs in many species in the animalkingdom, where it has often evolved as a reproductivestrategy by males to produce more offspring. It has alsoexisted in most human societies (including preliterateones) at some time in history (Lalumiere et a!', 2005).Across history, rape is traditionally most frequent duringand following wars, when it sometimes reaches epidemicproportions. This may be because during war, men per-ceive few costs for the offense and it is perceived as a goodway to express antagonism and contempt toward theenemy (Lalumiere et a!., 2005).

PREVALENCE It might seem to be fairly straightfor-ward to estimate the prevalence of rape, but the results ofdifferent studies have varied widely. Figures may vary inboth the precise definition of rape and the way informa-tion is gathered (direct or indirect questions, for exam-ple), and when the estimates are made. For example, theU.S. Department of Justice figures from 1998 estimatedthat 1 in 3 women would experience rape or attemptedrape at some point in their lives, with many of these beingattempted but not completed rapes. But between 1993and 2003 the number of rapes declined dramaticallyaccording to U.S. Department of Justice figures; thus rapefigures for 2003 were only about one-fifth of what theyhad been in 1991 (LeVay & Valente, 2006).

65 andover

FIGURE 13.1Age of Rape and SexualAssault VictimsYoung women are most at risk.(Data from u.s. Department ofjustice, 20000.)

IS RAPE MOTIVATED BY SEX OR AGGRESSION?Traditionally, rape has been classified as a sex crime, andsociety has assumed that the rapist was motivated by lust.However, in the 1970s some feminist scholars began tochallenge this view, arguing that rape is motivated by theneed to dominate, to assert power, and to humiliate a vic-tim rather than by sexual desire for her (e.g., Brownmiller,1975). Certainly from the perspective of the victim, rape-which is among women's greatest fears-is always an act ofviolence and is certainly not a sexually pleasurable experi-ence, whatever the rapist's motivation.

In spite of the fact that feminist writers have arguedthat rape is primarily a violent act, there are many com-pelling reasons why sexual motivation is often, if notalways, a very important factor (e.g., Ellis, 1989; Thorn-hill & Palmer, 2000). For example, although rape victimsinclude females of all ages and degrees of physical attrac-tiveness, the age distribution of rape victims is not at allrandom but includes a very high proportion of women intheir teens and early twenties (see Figure 13.1), support-ing the interpretation that rapists prefer younger (andhence usually considered more attractive) victims. Thisage distribution is quite different from the distributionof other violent crimes, in which the elderly are over-represented because of their vulnerability. Furthermore,rapists usually cite sexual motivation as a very importantcause of their actions. Finally, as we shall see, at least somerapists exhibit features associated with paraphilias andhave multiple paraphilias (Abel & Rouleau, 1990; LeVay& Valente, 2006). Men with paraphilias are typicallyhighly sexually motivated. Thus, there is a great deal ofevidence showing that sexual desire is a factor in motivat-ing many rapists, although not the exclusive motivationalfactor for all.

In the past few decades, several prominent researchersstudying sex offenders have shown that all rapists actuallyhave both aggressive and sexual motives, but to varyingdegrees. For example, Knight and Prentky (1990) identi-fied four subtypes of rapists with two subtypes motivatedprimarily by aggression, and two subtypes motivated pri-marily by distorted sexual motives (see also Knight, Pren-tky, & Cerce, 1994). More recently, McCabe and Wauchope(2005) provided empirical support for a somewhat differ-ent classification system that also has four subtypes ofrapists with differing amounts of sexual and aggressivemotives. One type is largely motivated by undifferentiatedanger and gratuitous aggression rather than sexual moti-vation; the second and third types are each motivated bydisplaying hostility and power over women through rapebecause of their own inadequacies (including sexual; thethird type has a more sensitive, apologetic, and compli-mentary demeanor with his victim than the second); and afourth type is motivated by sexually sadistic fantasies. Atpresent it is not clear which scheme of classification is best,and some rapists cannot readily be characterized (LeVay &Valente, 2006).

RAPE AND ITS AFTERMATH Rape tends to be a repeti-tive activity rather than an isolated act, and most rapes areplanned events. About 80 percent of rapists commit the actin the neighborhoods in which they reside; most rapesoccur in an urban setting at night, in places ranging fromdark, lonely streets to elevators and hallways, and apart-ments or homes. About a third or more of all rapes involvemore than one offender, and often they are accompaniedby beatings. The remainder are single-offender rapes inwhich the victim and the offender are acquainted witheach other (in about two-thirds of rapes); this includeswives (Bennice & Resick, 2003).

In addition to the physical trauma inflicted on a vic-tim, the psychological trauma may be severe, leading in asubstantial number of female victims to what used to becalled rape trauma syndrome (Burgess & Holmstrom,1974). Since 1980 this has been recognized as post-traumatic stress disorder (see Chapter 5), which, whencaused by rape, is often also associated with severe sexualproblems. Other especially unfortunate factors in rape arethe possibility of pregnancy or of contracting a sexuallytransmitted disease. A rape may also have a negativeimpact on a victim's marriage or other intimate relation-ships. Although there has been little systematic study ofmen who have been raped, one recent study of 40 malerape victims revealed that nearly all experienced somelong-term psychological distress following rape includinganxiety, depression, increased feelings of anger, and loss ofself-image (Walker, Archer, & Davies, 2005).

Other relative \3% .•• \

Relationship unknown1%

Most Rapes Are Not Committed by StrangersThe graph shows the relationships of perpetrators of rape andsexual assault to their victims. (Data from u.s. Department ofJustice, 2ooob.)

Which scenario do you think is more likely to lead to rape? It is difficult to guess because date rape is increasingly common, and rapes by casualacquaintances usually occur in dark, lonely places.

Rape, even at its least violent, is a bullying, intrusiveviolation of another person's integrity, selfhood, and per-sonal boundaries that deserves to be viewed with moregravity-and its victims with more compassion and sensi-tivity-than has often been the case. Nevertheless, the con-cept of "victim-precipitated" rape, once a favorite ofdefense attorneys and of some police and court jurisdic-tions, still remains in certain circles, even though it is amyth. According to this view, a victim (especially a repeatvictim), though often bruised both psychologically andphysically, is regarded as the cause of the crime, often onsuch grounds as the alleged provocativeness of her cloth-ing, her past sexual behavior, or her presence in a locationconsidered risky (LeVay & Valente, 2006; Stermac, Segal, &Gillis, 1990). The attacker, on the other hand, is regarded asunable to quell his lust in the face of such irresistible provo-cation-and therefore is not treated as legally responsiblefor the act. Fortunately, rape shield laws began to be intro-duced in the 1970s. These laws protect rape victims by, forexample, preventing the prosecutor from using evidence ofa victim's prior sex history; however, many problems inthese laws still remain (LeVay & Valente, 2006).

RAPISTS AND CAUSAL CONSIDERATIONS Informa-tion gathered by the FBI about arrested and convictedrapists suggests that rape is usually a young man's crime.

According to FBI Uniform Crime Reports, about 60 per-cent of all rapists arrested are under 25 years old, with thegreatest concentration in the 18-to-24 age group. Of therapists who get into police records, about 30 to 50 percentare married and living with their wives at the time of thecrime. As a group, they come from the low end of thesocioeconomic ladder and commonly have a prior crimi-nal record (Ward et al., 1997). They are also quite likely tohave experienced sexual abuse, a violent home environ-ment, and inconsistent caregiving in childhood (Hudson& Ward, 1997).

One subset of rapists, date rapists (a date rapist is anacquaintance who rapes a woman in the context of a dateor other social interaction), have a somewhat differentdemographic profile in that they are often middle- toupper-class young men who rarely have criminal records.However, these men, like incarcerated rapists, are alsocharacterized by promiscuity, hostile masculinity, and anemotionally detached, predatory personality (e.g., Knight,1997; LeVay & Valente, 2003). Their victims are oftenhighly intoxicated (Mohler-Keuo et al., 2004; Testa et al.,2003). What distinguishes them, primarily, is that incarcer-ated rapists show much higher levels of impulsive, antiso-cial behavior than the date rapists.

As suggested earlier, there is evidence that somerapists are afflicted by a paraphilia (Abel & Rouleau, 1990;

Freund & Seto, 1998). For example, rapists often reporthaving recurrent, repetitive, and compulsive urges to rape.They typically try to control these urges, but the urgeseventually become so strong that they act on them. Manyrapists also have other paraphilias. In one study of 126rapists, for example, 28 percent had an interest in exhibi-tionism and 18 percent in voyeurism (Abel & Rouleau,1990). Most important, rapists have a characteristic pat-tern of sexual arousal (Abel & Rouleau, 1990; Lohr, Adams,& Davis, 1997). Most rapists are similar to normal nonof-fending men in being sexually aroused by depictions ofmutually satisfying, consensual intercourse. However, incontrast to normal men and other nonsexual offenders,many rapists are also sexually aroused by depictions of sex-ual assaults involving an unwilling victim (Lalumiere et aI.,2005b). A small minority of rapists are sexual sadists, char-acterized by very violent assaults and aroused more byassault than by sexual stimuli.

In terms of personality, rapists are very often charac-terized by impulsivity, quick loss of temper, lack of person-ally intimate relationships, and insensitivity to social cuesor pressures (Giotakos et aI., 2004). Many rapists also showsome deficits in social and communication skills (Emmers-Sommer et aI., 2004), as well as in their cognitive appraisalsof women's feelings and intentions (Ward et aI., 1997). Forexample, they are particularly deficient in skills involved insuccessful conversation, which is necessary for developingconsenting relationships with women. In addition, theyhave difficulty decoding women's negative cues duringsocial interactions and often interpret friendly behavior asflirtatious or sexually provocative (Emmers-Sommer et aI.,2004). This can lead to inappropriate behaviors thatwomen would experience as sexually intrusive.

Estimates are that only 20 to 28 percent of rapes areever reported, compared to 60 percent of robberies, but thenumber of rapes being reported has increased over the pastseveral decades (Magid et aI., 2004). Among men who arearrested, only about half are convicted; of these, only abouttwo-thirds serve a jail term (LeVay & Valente, 2006). Con-victions often bring light sentences, and a jail term does notdissuade a substantial number of offenders from repeatingtheir crimes. The upshot of all this is that the large major-ity of rapists are not in prison but out among us.

Treatment and Recidivism ofSex OffendersThere is growing intolerance for sex offenders who repeattheir crimes. Soon after his release from prison, convictedsex offender Earl Shriner forced a 7-year-old boy off hisbike in the woods near Tacoma, Washington, and thenraped and stabbed him before cutting off the boy's penis.Just before his release from prison, Shriner had confided toa cellmate that he still had fantasies of molesting and mur-dering children (Popkin, 1994). In a similar case, 7-year-old Megan Kanka was sexually molested and murdered by

1475

a convicted pedophile living in her neighborhood. Casessuch as these have inspired a number of measures to pro-tect society from sexual predators (see The World AroundUs 13.3 on p. 476).

But are such stories representative? Are sex offenderstypically incurable? Should they receive life sentences onthe presumption that they are bound to offend again? Orhave they been unfairly singled out by media sensational-ism when they really are responsive to treatment (Berlin &Malin, 1991)? The efficacy of treatment for sex offenders iscontroversial, and this is the topic to which we now turn(e.g., Hanson, Gordon, et aI., 2002; Maletzky, 2002).

Recidivism rates for some types of offenders arehigher than they are for others (Berner et aI., 2003; Rabi-nowitz et aI., 2004). Specifically, sex offenders with deviantsexual preferences (e.g., exhibitionists, severe sadists, andthose who are most attracted to children) have particularlyhigh rates of sexual recidivism (Dickey et aI., 2002;Langevin et aI., 2004). One recent follow-up study of morethan 300 sex offenders over 25 years found that over halfwere charged with at least one additional sexual offense(Langevin et aI., 2004). The recidivism rate for rapistssteadily decreases with age, but that for child molestersdoes not decline much until after age 50 (Dickey et aI.,2002; Hanson, 2002).

PSYCHOTHERAPIES AND THEIR EFFECTIVENESSTherapies for sex offenders typically have at least one of thefollowing four goals: to modify patterns of sexual arousal,to modify cognitions and social skills to allow more appro-priate sexual interactions with adult partners, to changehabits or behavior that increases the chance of reoffending,or to reduce sexual drive. Attempts to modify sexualarousal patterns usually involve aversion therapy, in whicha paraphilic stimulus such as a slide of a nude prepubes-cent girl for a pedophile is paired with an aversive eventsuch as forced inhalation of noxious odors or a shock tothe arm. An alternative to electric aversion therapy is covertsensitization, in which the patient imagines a highly aver-sive event while viewing or imagining a paraphilic stimu-lus, or assisted covert sensitization, in which a foul odor isintroduced to induce nausea at the point of peak arousal(Maletzky,2002).

Deviant arousal patterns also need to be replaced byarousal to acceptable stimuli (Maletzky, 2002; Quinsey &Earls, 1990). Most often, investigators have attempted topair the pleasurable stimuli of orgasm with sexual fantasiesinvolving sex between consenting adults. For example,patients are asked to masturbate while thinking of deviantfantasies. At the moment of ejaculatory inevitability, thepatient switches his fantasy to a more appropriate theme.Although aversion therapy has been shown to be some-what effective in the laboratory (Maletzky, 1998; Quinsey& Earls, 1990), how well this therapeutic change general-izes to the patient's outside world is uncertain if his moti-vation wanes. Although aversion therapy is still widely

13.3

On July 29, 1994, seven-year-old MeganKanka, from Hamilton Township, New Jersey,was walking home from her friend's housewhen a neighbor invited her to his house tosee his new puppy. The neighbor, Jesse Tim-

mendequas, 33, was a landscaper who had lived across thestreet for about a year. Unknown to Megan, to Megan's par-ents, or to anyone else in the neighborhood, he was also atwice-convicted child molester (who lived with two otherconvicted sex offenders). When Megan followed himinside, he led her to an upstairs bedroom, strangled herunconscious with his belt, raped her, and asphyxiated herwith a plastic bag. Timmendequas then placed Megan'sbody in a toolbox, drove to a soccer field, and dumped itnear a portable toilet. Timmendequas was subsequentlyapprehended, convicted, and sentenced to death.

Megan's murder sparked outrage at the fact that dan-gerous sex offenders could move into a neighborhoodwithout notifying the community of their presence. Inresponse, the New Jersey state legislature passed Megan'sLaw, which mandated that upon release, convicted sexoffenders register with police and that authorities notifyneighbors that convicted sex offenders have moved in bydistributing flyers, alerting local organizations, and can-vassing door-to-door. Similar laws have been passed inmany other states, and it is now possible in several statesto visit a Web site containing pictures and addresses ofconvicted sex offenders subject to that state's Megan'sLaw. Some states require convictions of sex offenses to beindicated on drivers' licenses.

Although Megan's Laws have been enormously popu-lar with state legislators and citizens, they have not beenuncontroversial. Civil libertarians have objected to commu-nity notification requirements, which, they argue, endangerreleased offenders (who have arguably paid their debts tosociety) and also prevent them from integrating success-fully back into society. Although the various Megan's Lawsare intended to protect potential victims rather than toencourage harassment of sex offenders, the latter hasoccurred. For example, in July 1993, the home of convictedchild rapist Joseph Gallardo was burned to the ground aftercitizens in Snohomish County, Washington, learned that hewas about to be paroled. John Becerra, a convicted sex

used for sex offenders, it is not used anymore as a sole form

of treatment (Marshall, 1998)_The remaining psychological treatments are aimed at

reducing the chances of sexual reoffending. Cognitiverestructuring attempts to eliminate sex offenders' cognitive

distortions, because these may playa role in sexual abuse

offender, moved into a two-story home in the New York Cityarea in December 1995, hoping to begin a new life with hiswife and their 9-year-old son. But he and his family foundthemselves the target of a persistent campaign of protestsby their neighbors. Signs around the neighborhoodwarned, "Beware of Sex Offender," their car was vandal-ized, and rallies were held outside their home. In addition,the limited amount of relevant data has brought the effec-tiveness of Megan's Laws into question. A 1995 Washing-ton State study found that in the period before that state'sMegan's Law was passed, 22 percent of sex offenders whohad been arrested committed another sex crime; after thelaw went into effect, the rate was quite similar, 19 percent(Schenk,1998).

Recognition that some sex offenses have high recidi-vism rates-and uncertainty whether treatment helps-has led some states to pass laws that require involuntarycommitment of dangerous offenders to psychiatric facili-ties even after their sentences have been served. LeroyHendricks was convicted five times of molesting childrenand admitted that only his death could guarantee that hewould commit no further offenses. Kansas prosecutorsinvoked state law to prevent his release after he served 10years in prison, but this action was challenged as unconsti-tutional. The primary objection was that holding Hendricksafter his sentence had been served amounted to giving hima second punishment for the same offense. In 1997 theu.s. Supreme Court ruled narrowly (5 to 4) that peoplesuch as Hendricks can be held if they are considered men-tally abnormal and are likely to commit new crimes. Earlysigns are that once committed, few sex offenders will bereleased.

In order to ensure that released sex offenders will notreoffend, some states have passed legislation requiringchemical or surgical castration for certain types of sexoffenders. For example, California now requires that repeatchild molesters undergo chemical castration as a conditionof parole. Michigan has passed a similar law applying torepeat rapists. Civil libertarians, exemplified by the ACLU,have argued that because of potentially severe sideeffects, such requirements violate the Constitution's banon cruel and unusual punishment.

(Maletzky, 2002). For example, an incest offender who

maintained that "If my ten-year-old daughter had said no I

would have stopped" might be challenged about a numberof implied distortions: that a child has the capacity to con-

sent to have sex with an adult, that if a child does not say no

she has consented, and that it is the child's responsibility to

stop sexual contact. In addition, social-skills training aims tohelp sex offenders (especially rapists) learn to process socialinformation from women more effectively and to interactwith them more appropriately (Maletzky, 2002; McFall,1990). For example, some men read positive sexual conno-tations into women's neutral or negative messages, orbelieve that women's refusals of sexual advances reflect"playing hard to get." Training typically involves interactionof patients and female partners, who can give the patientsfeedback on their response to their interactions.

Although some studies in the treatment literaturehave reached positive conclusions (see Maletzsky, 2002, for areview), other studies have found essentially no differencesbetween treated and untreated offenders (Emmelkamp,1994; Quinsey et aI., 1991; Rice et aI., 1991). A recent meta-analysis of 43 studies containing nearly 10,000 sex offend-ers did find that treated offenders were less likely toreoffend than untreated offenders (Hanson, Gordon, et aI.,2002), but the effect was modest: 12.3 percent of treatedoffenders were convicted of another sex offense, comparedwith 16.8 percent of untreated offenders. Current cogni-tive-behavioral techniques appeared to be much moreeffective than older techniques such as aversion therapy.There are also indications in the literature that certainparaphilias respond better to treatment than others (Laws& O'Donohue, 1997). For example, one very long-termfollow-up (5 to 15 years) of over 2,000 sex offenders whohad entered a cognitive-behavior treatment programfound that child molesters and exhibitionists achieved bet-ter overall success rates than pedophiles and rapists(Maletzky & Steinhauser, 2002).

BIOLOGICAL AND SURGICAL TREATMENTS In recentyears antidepressants from the SSRI category have beenfound to be useful in treating a variety of paraphilias byreducing paraphilic desire and behavior; they are not,however, useful in treatment of sexual offenders. The mostcontroversial treatment for sex offenders involves castra-tion-either surgical removal of the testes or the hormonaltreatment sometimes called "chemical castration" (e.g.,Berlin, 2003; Bradford & Greenberg, 1996). Both surgicaland chemical castration lower the testosterone level, whichin turn lowers the sex drive, allowing the offender to resistany inappropriate impulses. Chemical castration has mostoften involved the administration of antiandrogen steroidhormones such as Depo-Provera and Lupron, which canboth have serious side effects. One uncontrolled study ofthe drug Lupron yielded dramatic results: Thirty men withparaphilias reported an average of 48 deviant fantasies perweek prior to therapy, and no such fantasies during treat-ment (Rosier & Witztum, 1998; see also Maletzky & Field,2003). However, relapse rates upon discontinuation of thedrug are very high (Maletzky, 2002). Studies of surgicalcastration of repeat sex offenders with violent tendenciesconducted in Europe and more recently in the UnitedStates had similar results (but without high rates of

relapse); (Weinberger et aI., 2005). These studies have typ-ically included diverse categories of offenders, frompedophiles to rapists of adult women. Follow-up hassometimes exceeded 10 years. Recidivism rates for cas-trated offenders are typically less than 3 percent, comparedwith greater than 50 percent for uncastrated offenders(e.g., Berlin, 1994; Green, 1992; Prentky, 1997). Many feelthat the treatment is brutal, unethical, and dehumanizing(Farkas & Strichman, 2002; Gunn, 1993), although thisassumption has been challenged (Bailey & Greenberg,1998). Interestingly, some recent cases have involved arequest by the sex offender himself to be castrated inexchange for a lighter sentence (LeVay & Valente, 2006),and in some states a repeat offender's eligibility for proba-tion or parole is linked to acceptance of mandated hor-monal therapy (Scott & Holmberg, 2003).

COMBINING PSYCHOLOGICAL AND BIOLOGICALTREATMENTS Not surprisingly, many treatment pro-grams now use a combination of hormone therapy andcognitive-behavioral treatments, the hope being that thehormone treatment can be tapered off after the offenderhas learned techniques for impulse control (Maletzky,2002). However, the single most important defect of nearlyall available studies is the lack of randomly assigned con-trols who were equally motivated for treatment. Some haveargued that denying treatment to sex offenders is unethical(e.g., Marshall et aI., 1991). However, this could be trueonly if the treatment were effective, and it is not clear atthis point whether it is. Research in this area is furthercomplicated by the fact that the outcome variable in moststudies is whether the man is convicted for another sexoffense during the follow-up period. Because most sexoffenses go unpunished (the offender is often never evencaught, let alone convicted), this will exaggerate the appar-ent effectiveness of treatment and underestimate the dan-gerousness of sex offenders. Given the social importance ofdetermining whether sex offenders can be helped and howlikely they are to reoffend, it is crucial that society devotethe resources necessary to answering these questions.

SUMMARY It is possible both to acknowledge that sexoffenders cause immense human suffering and to feel sym-pathy for the plight of many offenders who have been bur-dened with a deviant sexual arousal pattern that has causedthem great personal and legal trouble. Consider the case ofScott Murphy, a convicted pedophile:

He lives alone with a friend, works odd hours, anddoesn't go out of his way to meet neighbors. Ironically,Murphy has never been prouder of his behavior. Headmits he'll never be cured and will always be attractedto young boys. But he says he is now making everyattempt to steer clear of them: "I went from constantlyliving my whole life to molest kids to now living mywhole life to not molest kids." It's a 24-hour-a-day job.

On the highway, Murphy keeps at a distance to guaran-tee he make~ no eye contact with the young pa~~enger~in school buses. When the Sunday paper arrives athome, he immediately throws out the coupon sectionbecause the glossy ads often depict attractive boy mod-els. He refuses to leave the office when kids might bewalking to or from school and got rid of his televisionso the sit-com images of young boys wouldn't distracthim. (Popkin, 1994,p. 67)

Society cannot allow Murphy to act on his sexual pref-erence, nor can his past crimes be forgotten. Nevertheless,in deciding how to treat people like Scott Murphy, it isimportant and humane to remember that many of themhave a tormented inner life.

In ReVIew~ What are the short-term consequences of

childhood sexual abuse, and why are we lesscertain about its long-term consequences?

~ What are the major issues surroundingchildren's testimony about sexual abuse andadults' recovered memories of sexual abuse?

~ Define pedophilia, incest, and rape, andsummarize the major clinical features of theperpetrators of these crimes.

~ Identify the main goals of treatment of sexoffenders, and describe the differenttreatment approaches.

SEXUAL DYSFUNCTIONSThe term sexual dysfunction refers to impairment eitherin the desire for sexual gratification or in the ability toachieve it. The impairment variesmarkedly in degree, but regardless ofwhich partner is alleged to be dysfunc-tional, the enjoyment of sex by bothparties in a relationship is typicallyadversely affected. Sexual dysfunctionsoccur in both heterosexual and homo-sexual couples. In some cases, sexualdysfunctions are caused primarily bypsychological or interpersonal factors.In others, physical factors are mostimportant. In recent years, both expla-nations and treatments of sexual dys-function have become more biological,although some psychological treatments have beenempirically validated and psychosocial factors clearly

playa causal role as well (Heiman, 2002; Heiman &

Meston, 1997, Segraves & Althof, 2002).Today researchers and clinicians typically identify

four different phases of the human sexual response as orig-inally proposed by Masters and Johnson (1966, 1970,1975). According to DSM-IV-TR, disorders can occur inany of the first three phases:

The first phase is the desire phase, which consists offantasies about sexual activity or a sense of desire tohave sexual activity.

The second phase is the excitement phase, charac-terized by both a subjective sense of sexual pleasureand physiological changes that accompany this sub-jective pleasure, including penile erection in themale and vaginal lubrication and clitoral enlarge-ment in the female.

The third phase is orgasm, during which there is arelease of sexual tension and a peaking of sexualpleasure.The final phase is resolution, during which the per-son has a sense of relaxation and well-being.

Although these four phases are described as if theywere distinct, it is important to remember that they areexperienced by an individual as a continuous set of feel-ings, and biological and behavioral reactions. There areother conceivable ways to discuss and organize thesequence that occurs, but we will follow this schemebecause it is the one that DSM has used to categorize dys-functions. We will first describe the most common dys-functions that can occur in the first three phases and thendiscuss causation and treatment.

How common are sexual dysfunctions? It is obviouslydifficult to do large-scale research on such a sensitive topic.Nevertheless, the National Health and Social Life Survey(Laumann, Paik, & Rosen, 1999) assessed sexual problemsduring the previous year in 3,159 randomly selected Amer-icans by asking them if they had experienced the symp-toms of any of the different sexual dysfunctions in the past

12 months. Sexual problems were verycommon, with 43 percent of womenand 31 percent of men reporting havingexperienced at least one of these prob-lems in the previous 12 months. Forwomen, the reported rate of sexualproblems decreased with age; for menit increased. Married men and women,and those with higher educationalattainment, had lower rates of problems.For women, most common complaintswere lack of sexual desire (22 percent)and sexual arousal problems (14 per-cent). For men, climaxing too early

(21 percent), erectile dysfunction (5 percent), and lack ofsexual interest (5 percent) were reported most frequently.

i' . .•Irll •., . •......

empirically validated

Empirically validated treatmentsare treatments that have beendetermined to be helpful based onwell-designed, scientific researchby more than just one group ofresearchers.

This study has been criticized by Bancroft and others(2003), however, who believe that these numbers overesti-mate how many people have true sexual dysfunctions.Although the Laumann et ai. results are often referred to asbeing about sexual dysfunction, in fact the investigatorsnever asked people about whether the problems causedthem distress or impairment in any way; yet these are nec-essary criteria for making a diagnosis in DSM-IV-TR.When Bancroft and colleagues (2003) did a related survey(although just in women), they found very similar per-centages to those found by Laumann et al. However, Ban-croft et al. (2003) found that only about half as manyreported that the problem caused them "severe distress."Nevertheless, this is still a relatively high percentage ofpeople experiencing sexual dysfunction at some point intheir lives. The DSM-IV- TR Criteria box on page 480 sum-marizes each of the dysfunctions covered here.

Dysfunctions of Sexual DesireResearchers have delineated two types of sexual desire dis-orders. The first is hypoactive sexual desire disorder. It is adysfunction in which either a man or a woman shows littleor no sexual drive or interest (see DSM-IV-TR Criteria onp. 480). Research on the degree to which the diminishedsex drive has a biological basis remains controversial, butin many (and perhaps most) cases (and especially inwomen), psychological factors appear to be more impor-tant than biological factors (Weiner &Rosen, 1999). These people usually come tothe attention of clinicians only at therequest of their partners, who typicallycomplain of insufficient sexual interaction.This fact exposes one problem with thediagnosis, because it is known that prefer-ences for frequency of sexual contact varywidely among otherwise normal individu-als. Who is to decide what is "not enough"?DSM -IV-TR explicitly indicates that thisjudgment is left to the clinician, taking intoaccount the person's age and the context ofhis or her life. In extreme cases, sex actuallybecomes psychologically aversive and war-rants a diagnosis of sexual aversion disor-der, the second type of sexual desiredisorder. With this disorder, the personshows extreme aversion to, and avoidanceof, all genital sexual contact with a partner.

Prior or current depression may con-tribute to many cases of sexual desire disor-ders (Weiner & Rosen, 1999). Althoughsexual desire disorders typically occur inthe absence of obvious physical pathology,there is evidence that physical factors maysometimes play a role. Sexual interest, inboth men and women, depends in part on

testosterone (Alexander & Sherwin, 1993; LeVay & Valente,2006). That sexual desire problems increase with age maybe in part attributable to declining levels of testosterone,but testosterone replacement therapy is usually not benefi-cial, except possibly in women whose ovaries have beenremoved (Segraves & Althof, 2002). Although there hasbeen interest since antiquity in the possibility that a drugto increase sexual desire might be found, no effectiveaphrodisiacs yet exist. However, one recent study hasfound that sustained use ofbupropion (an atypical antide-pressant), relative to placebo, improved sexual arousabilityand orgasm frequency in women who were in a committedrelationship and had hypoactive sexual desire disorder(Segraves et al., 2004).

Hypoactive sexual desire disorder appears to be themost common female sexual dysfunction (Laumann et ai.,1994, 1999). Despite this fact, it has inspired far lessresearch into its origins and treatment than male dysfunc-tions, especially erectile disorder and premature ejacula-tion. One main reason for this disparity is doubtless thegreat importance that many men place on their ability toperform sexually. Until recently, there has also been a moregeneral neglect of female sexuality and an implicit (thoughlargely mistaken) societal attitude that women simply donot care much about sex.

Fortunately, this has been changing gradually inrecent years (e.g., Althof et ai., 2005; Basson, 2005). Oneemerging finding is that it is uncommon for women to

Sexual dysfunctions can occur at the desire, excitement, or orgasm phases of thesexual response cycle. Many people, if not most, will experience some sexualdysfunction sometime during their lives. If it becomes chronic or disturbing to one orboth partners, it warrants treatment.

Criteria for Different Sexual Dysfunctions

General Criteria for All Dysfunctions1. The disturbance causes marked distress or interpersonal difficulty.

2. The sexual dysfunction is not better accounted for by another Axis I disorder and is not due to direct effects of a substanceor a general medical condition.

3. Specifiers include: Lifelong vs Acquired Types, and Generalized vs Situational Types.

Specific Criteria for Different DysfunctionsA. Sexual Desire Disorders:

(1) Hypoactive Sexual Desire Disorder:

Persistently or recurrently deficient or absent sexual fantasies and desire for sexual activity. This judgment of deficiencyor absence is made by the clinician taking into account such factors as age and context of a person's life.

(2) Sexual Aversion Disorder:

Persistent or recurrent extreme aversion to, and avoidance of, all (or almost all) genital sexual contact with a sexual partner.

B. Sexual Arousal Disorders:

(1) Female Sexual Arousal Disorder

Persistent or recurrent inability to attain, or to maintain until completion of the sexual activity, an adequate lubrication-swelling response of sexual excitement.

(2) Male Erectile Disorder

Persistent or recurrent inability to attain, or to maintain until completion of the sexual activity, an adequate erection.

C. Orgasmic Disorders:

(1) Female Orgasmic Disorder

Persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase. Diagnosis is madebased on clinician's judgment that the woman's orgasmic capacity is less than would be reasonable for her age,sexual experience, and the adequacy of sexual stimulation she receives.

(2) Male Orgasmic Disorder

Persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase during sexual activitythat the clinician, taking into account the person's age, judges to be adequate in focus, intensity, and duration.

(3) Premature Ejaculation

Persistent or recurrent ejaculation with minimal sexual stimulation before, on, or shortly after penetration and before theperson wishes it. The clinician must take into account factors such as age, novelty of the sexual partner, or situationand recent frequency of sexual activity.

D. Sexual Pain Disorders:

(1) Dyspareunia

Recurrent or persistent genital pain associated with sexual intercourse in either a male or a female.

(2) Vaginismus

Recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina that interferes withsexual intercourse.

cite sexual desire as a reason or incentive for sexual activ-ity. For many women, sexual desire is only experiencedafter sexual stimuli have led to subjective sexual arousal(Basson, Leiblum, et al., 2003), and for others, motivationfor sexual activity may involve a desire for increasing emo-tional intimacy, or increasing one's sense of well-being

and one's self-image as an attractive female (Basson, 2003,2005). Thus, some research suggests that the supposedlylinear sequence of desire leading to arousal, leading toorgasm originally posited for women as well as men byMasters and Johnson (1970) and DSM is not very accuratefor women (e.g., Basson, 2005).

Dysfunctions of Sexual ArousalMALE ERECTILE DISORDER Inability to achieve ormaintain an erection sufficient for successful sexualintercourse was formerly called impotence. It is nowknown as male erectile disorder or erectile insufficiency(see DSM-IV- TR Criteria p. 480). In lifelong erectile disor-der, a man has never been able to sustain an erection longenough to accomplish a satisfactory duration of penetra-tion. In acquired or situational erectile disorder, a man hashad at least one successful experience of sexual activityrequiring erection but is presently unable to produce ormaintain the required level of penile rigidity. Lifelonginsufficiency is a relatively rare disorder, but it has beenestimated that half or more of the male population has hadsome experience of erectile insufficiency on at least a tem-porary basis.

Masters and Johnson (1975; Masters et al., 1992) andKaplan (1975, 1987) hypothesized that erectile dysfunc-tion is primarily a function of anxiety about sexual perfor-mance. In other reviews of the accumulated evidence,however, Barlow and colleagues (Beck & Barlow, 1984;Sbrocco & Barlow, 1996) have played down the role of anx-iety per se-which under some circumstances can actuallyenhance sexual performance in normally functioning menand women (Barlow, Sakheim, & Beck, 1983; Palace &Gorzalka, 1990; see Sbrocco & Barlow, 1996, for a review).In one study, for example, sexually functional male sub-jects in a laboratory experiment were made anxious bybeing told that there was a 60 percent chance of theirreceiving an electric shock while watching an erotic filmunless they had an average-sized erection. These men actu-ally showed more sexual arousal to the film than did menwho were not threatened with shock (Barlow et al., 1983).

Barlow (2002a) emphasizes that it is the cognitive dis-tractions frequently associated with anxiety in dysfunc-tional people that seem to interfere with their sexualarousal. For example, one study found that nondysfunc-tional men who were distracted by material they were lis-tening to on earphones while watching an erotic filmshowed less sexual arousal than men who were not dis-tracted (Abrahamson et al., 1985). Barlow and colleagueshypothesize that sexually dysfunctional men and womenget distracted by negative thoughts about their perfor-mance during a sexual encounter ("I'll never get aroused"or "She'll think I'm inadequate"). Their research suggeststhat this preoccupation with negative thoughts, ratherthan anxiety per se, is responsible for inhibiting sexualarousal (see also Weiner & Rosen, 1999). Moreover, suchself-defeating thoughts not only decrease pleasure but alsocan increase anxiety if the erection does not happen(Malatesta & Adams, 1993), and this in turn can fuel fur-ther negative, self-defeating thoughts (Sbrocco & Barlow,1996). A related finding is that men with erectile dysfunc-tion make more internal and stable causal attributions forhypothetical negative sexual events that do men without

sex al dysfunction, much as depressed people do for moregeneral hypothetical negative events (Scepkowski et al.,2004). Combined with Bancroft et al.'s (2005) findings thatfear of performance failure is a strong predictor of erectiledysfunction in both gay and heterosexual men, one can seehow a vicious cycle develops in which fears of failure aresometimes followed by erectile dysfunction, which is thenattributed to internal and stable causes, thereby perpetuat-ing the problem.

Erectile problems occur in as many as 90 percent ofmen on certain antidepressant medications (especially theSSRIs), and are one of the primary reasons men cite for dis-continuing these medications (Rosen & Marin, 2003).These problems are also a common consequence of aging.Perhaps two-thirds of men over the age of 50 have somedegree of erectile dysfunction (Carbone & Seftel, 2002).However, complete and permanent erectile disorder beforethe age of 60 is relatively rare. Moreover, studies have indi-cated that men and women in their eighties and nineties areoften quite capable of enjoying intercourse (Malatesta &Adams, 1993; Masters et al., 1992). For example, in onestudy of 202 healthy men and women between the ages of80 and 102, it was found that nearly two-thirds of the menand one-third of the women were still having sexual inter-course, although this was not generally their most commonform of sexual activity (Bretschneider & McCoy, 1988).

The most frequent cause of erectile disorder in oldermen is vascular disease, resulting in decreased blood flowto the penis or in diminished ability of the penis to holdblood to maintain an erection. Thus hardening of thearteries, high blood pressure, and other diseases such asdiabetes that cause vascular problems often account forerectile disorder. Smoking, obesity, and alcohol abuse areassociated lifestyle factors (Weiner & Rosen, 1999). Dis-eases that affect the nervous system such as multiple scle-rosis can also cause erectile problems. For young men, onecause of erectile problems is having had priapism-that is,an erection that will not diminish even after a couple ofhours, typically unaccompanied by sexual excitement. Pri-apism can occur as a result of prolonged sexual activity, asa consequence of disease, or as a side effect of certain med-ications. Untreated cases of priapism result in erectile dys-function approximately 50 percent of the time (Starck,Branna, & Tallen, 1994) and thus should be regarded as amedical emergency (LeVay & Valente, 2006).

Treatment A variety of treatments-primarily med-ical-have been employed in recent years, often whencognitive-behavioral treatments have failed. Theseinclude: (1) medications such as yohimbine, (2) injectionsof smooth-muscle-relaxing drugs into the penile erectionchambers (corpora cavernosa), (3) even a vacuum pump(LeVay & Rosen, 2006; Rosen, 1996). In extreme cases,penile implants may be used. These devices can be inflatedto provide erection on demand. They are made of silicone

Sachse, et al., 2001). There is also one study showing thatthe usefulness of these medications may be furtherenhanced in couples who also use a cognitive-behavioraltreatment manual along with a weekly phone call with atherapist (Bach et aI., 2004).

rubber or polyurethane rubber. Such treatments havegenerally shown success in clinical trials, although theyare rather extreme interventions that often evoke bother-some side effects (Rosen & Leiblum, 1995; Segraves &Althof,2002).

In 1999 the revolutionary new drug Viagra (sildenalfil)was introduced on the U.S. market and was received with agreat deal of attention. Viagra works by making nitricoxide, the primary neurotransmitter involved in penileerection, more available. Viagra is taken orally, at least anhour before sexual activity. Unlike some other biologicaltreatments for erectile dysfunction, Viagra promotes erec-tion only if some sexual excitation is present. Thus, con-trary to some myths, Viagra does not improve libido orpromote spontaneous erections (Segraves & Altho£, 2002).

Clinical trials ofViagra have been impressive. In a dou-ble-blind study, over 70 percent of men receiving at least 50mg of Viagra reported that their erections had improved,compared with fewer than 30 percent of men receiving aplacebo (Carlson, 1997; see also Goldstein et aI., 1998). Sideeffects were relatively uncommon and not serious (e.g., themost common side effect, headache, was reported by 11percent of patients), provided that the person had no seri-ous preexisting heart problems (Cheitlin, Hutter, et al.,1999). When heart problems do exist, Viagra should be pre-scribed with caution, because it can interact in dangerousways with heart medications. Viagra has been highly suc-cessful commercially although as many as 40 percent ofmen who fill one prescription never refill it according tothe drug company's own statistics. This is an indication ofboth the high prevalence of sexual dysfunction in men andthe importance that people attach to sexual performance.Two other related medications introduced in 2003 to treaterectile dysfunction were Cialis (tadalafil; Padma-Nathan,McMurray, et al., 2001) and Levitra (vardenafil; Stark,

FEMALE SEXUAL AROUSAL DISORDER Formerly andsomewhat pejoratively referred to as frigidity, female sex-ual arousal disorder-the absence of feelings of sexualarousal and an unresponsiveness to most or all forms oferotic stimulation-is in many ways the female counter-part of erectile disorder (see DSM-IV-TR Criteria onp. 480). Its chief physical manifestation is a failure to pro-duce the characteristic swelling and lubrication of thevulva and vaginal tissues during sexual stimulation-acondition that may make intercourse quite uncomfortable.

Although the causes of this disorder are not wellunderstood, possible reasons for this inhibition of sexualfeelings range from early sexual traumatization; to exces-sive and distorted socialization about the "evils" of sex; todislike of, or disgust with, a current partner's sexuality.One interesting recent study also found that women withsexual arousal disorder show lower tactile sensitivity thanis seen in other women, and the lower the level of tactilesensitivity, the more severe the arousal dysfunction (Frol-ich & Meston, 2005). Whether this lower tactile sensitivityplays a causal role or is merely a symptom of sexual arousaldisorder is not yet clear.

One reason why progress toward understanding thisdisorder is slow is that female sexuality may in some waysbe more complicated than male sexuality. For example, itappears that the correlation between subjective sexualarousal and physiological sexual arousal (genital response)is lower for women than for men (Heiman, 1980; Laan &Everaerd, 1995). That is, it is not uncommon for women to

feel unaroused sexually at a subjective level,but to have some genital response; thereverse can also occur, although less fre-quently. This has led to a suggestion thatfemale sexual arousal disorder be separatedinto two subtypes: genital and subjective(Basson, Leiblum, et aI., 2003).

The once taboo topic of erectile dysfunction now gets plenty of attention through the popularityof the drug Viagra, the most popular treatment for the disorder. Viagra works by making nitricaxide, the primary neurotransmitter involved in penile erection, more available. It is taken orally,about an hour before sexual activity. Unlike some other biological treatments for erectiledysfunction, Viagra only works if sexual desire is present.

Treatment Few controlled treatmentstudies of female arousal disorder havebeen conducted (Heiman, 2002), althoughclinical experience suggests that psy-chotherapy and sex therapy may playimportant roles. The widespread use ofvaginal lubricants may effectively mask andtreat the disorder in many women. In addi-tion, because female genital responsedepends in part on the same neurotrans-mitter systems as male genital response,there has been great interest in the possibil-ity that Viagra, Levitra, and/or Cialis would

have positive effects for women analogous to its positiveeffects for men (Kolata, 1998). Unfortunately, enoughresearch has now been performed to make it clear thatthose drugs are not as useful for women as men (Bassonet aI., 2002; LeVay & Valente, 2006). They do, however,seem useful for a subset of women with sexual arousal dis-order, specifically those for whom the disorder is caused bysustained use of antidepressants (LeVay & Valente, 2006).

Orgasmic DisordersPREMATURE EJACULATION Premature ejaculation isthe persistent and recurrent onset of orgasm and ejacula-tion with minimal sexual stimulation. It may occurbefore, on, or shortly after penetration and before the manwants it to (see DSM-IV- TR Criteria on p. 480). The con-sequences often include failure of the partner to achievesatisfaction and, often, acute embarrassment for the pre-maturely ejaculating man, with disruptive anxiety aboutrecurrence on future occasions. Men who have had thisproblem from their first sexual encounter often try todiminish sexual excitement by avoiding stimulation, byself-distracting, and by "spectatoring:' or psychologicallytaking the role of an observer rather than a participant(Metz, Pryor, et aI., 1997).

An exact definition of prematurity is necessarilysomewhat arbitrary. For example, the age of a client mustbe considered-the alleged "quick trigger" of the youngerman being more than a mere myth (McCarthy, 1989).Indeed, perhaps half of young men complain of early ejac-ulation. Not surprisingly, premature ejaculation is mostlikely after a lengthy abstinence (Malatesta & Adams,1993). DSM-IV- TR acknowledges these many factors thatmay affect time to ejaculation by noting that the diagnosisis made only if ejaculation occurs before, on, or shortlyafter penetration and before the man wants it to. Prema-ture ejaculation is the most common male sexual dysfunc-tion at least up to age 59 (LeVay & Valente, 2006; Segraves& Althof, 2002).

In sexually normal men, the ejaculatory reflex is, to aconsiderable extent, under voluntary control. They moni-tor their sensations during sexual stimulation and aresomehow able, perhaps by judicious use of distraction, toforestall the point of ejaculatory inevitability until theydecide to "let go" (Kaplan, 1987). Premature ejaculators arefor some reason unable to use this technique effectively.Explanations have ranged from psychological factors suchas increased anxiety (Kaplan, 1987) to physiological factorssuch as increased penile sensitivity (Gospodinoff, 1989)and inflammation of the prostate gland (LeVay & Valente,2006). Presently, however, no explanation has receivedmuch empirical support (LeVay & Valente, 2006).

Treatment For many years, most sex therapists consid-ered premature ejaculation to be psychogenically causedand highly treatable via behavioral therapy such as the

pause-and-squeeze technique developed by Masters andJohnson (1970). This technique requires the man to mon-itor is sexual arousal during sexual activity. When arousalis intense enough that the man feels that ejaculation mightoccur soon, he pauses, and he or his partner squeezes thehead of the penis for a few moments, until the feeling ofpending ejaculation passes. Initial reports suggested thatthis technique was approximately 60 to 90 percent effec-tive; however, more recent studies have reported a muchlower overall success rate (Rosen & Leiblum, 1995; Seg-raves & Althof, 2002). In recent years, with men for whombehavioral treatments have not worked, there has beenincreasing interest in possible use of pharmacologicalinterventions. Antidepressants such as paroxetine (Paxil)and sertraline (Zoloft) that block serotonin reuptake havebeen found to prolong significantly ejaculatory latency inmen with premature ejaculation (LeVay & Valente, 2006;Rowland & Slob, 1997); some antidepressants can be takenabout 6 hours before anticipated intercourse, and othersmust be taken every day. Evidence suggests that the med-ications work only as long as they are being taken (Segraves& Althof, 2002).

MALE ORGASMIC DISORDER Sometimes calledretarded ejaculation or inhibited male orgasm, maleorgasmic disorder refers to the persistent inability to ejac-ulate during intercourse (see DSM-IV- TR Criteria onp. 480). Men who are completely unable to ejaculate arerare. About 85 percent of men who have difficulty ejaculat-ing during intercourse can nevertheless achieve orgasm byother means of stimulation, notably through solitary mas-turbation (Masters et aI., 1992). In milder cases a man canejaculate in the presence of a partner, but only by means ofmanual or oral stimulation. Psychological treatmentsemphasize the reduction of performance anxiety in addi-tion to increasing genital stimulation (Rosen & Leiblum,1995; Segraves & Althof, 2002).

In other cases, retarded ejaculation can be related tospecific physical problems such as multiple sclerosis or tothe use of certain medications. For example, we noted thatantidepressants that block serotonin reuptake appear to bean effective treatment for premature ejaculation. However,in other men, these same medications-especially theSSRIs-sometimes delay or prevent orgasm to an unpleas-ant extent (Ashton, Hamer, & Rosen, 1997; LeVay &Valente, 2006). These side effects are common but canoften be treated pharmacologically with medications likeViagra (Ashton et aI., 1997; LeVay & Valente, 2006).

FEMALE ORGASMIC DISORDER The diagnosis oforgasmic dysfunction in women is complicated by the factthat the subjective quality of orgasm varies widely amongwomen, within the same woman from time to time, anddepending on mode of stimulation. Nevertheless, accord-ing to DSM -IV-TR, female orgasmic disorder (formerlyinhibited female orgasm) can be diagnosed in women who

are readily sexually excitable and who otherwise enjoy sex-ual activity but who show persistent or recurrent delay inor absence of orgasm following a normal sexual excite-ment phase (see DSM-IV- TR Criteria on p. 480). Of thesewomen, many do not routinely experience orgasm duringsexual intercourse without direct supplemental stimula-tion of the clitoris; indeed this pattern is so common that itis not generally considered dysfunctional. A small percent-age of women are able to achieve orgasm only throughdirect mechanical stimulation of the clitoris, as in vigorousdigital manipulation, oral stimulation, or the use of anelectric vibrator. Even fewer are unable to have the experi-ence under any known conditions of stimulation; thiscondition, which is called lifelong orgasmic dysfunction, isanalogous to lifelong erectile insufficiency in males. Onestudy estimated that 10 to 15 percent of women in theUnited States have never experienced an orgasm (Althof &Schreiner-Engel,2000).

What causes female orgasmic disorder is not wellunderstood, but a multitude of contributory factors havebeen hypothesized. For example, some women feel fearfuland inadequate in sexual relations. A woman may beuncertain whether her partner finds her sexually attractive,and this may lead to anxiety and tension that interfere withher sexual enjoyment. Or she may feel inadequate becauseshe is unable to have an orgasm or does so infrequently.Sometimes a nonorgasmic woman will pretend to haveorgasms to make her sexual partner feel fully adequate.The longer a woman maintains such a pretense, however,the more likely she is to become confused and frustrated;in addition, she is likely to resent her partner for beinginsensitive to her real feelings and needs. This in turn onlyadds to her sexual difficulties.

Treatment One important issue regarding treatment iswhether women should seek it or not. Most cliniciansagree that a woman with lifelong orgasmic disorder needstreatment if she is to become orgasmic. However, in themiddle range of orgasmic responsiveness, our own view isthat this question is best left to a woman herself to answer.If she is dissatisfied about her responsiveness, then sheshould seek treatment.

For those who do seek treatment, it is important todistinguish between lifelong and situational female orgas-mic dysfunction. Treatment of the former, which typicallybegins with instruction and guided practice in masturbat-ing to orgasm, has a high likelihood of success (Andersen,1983; Segraves & Althof, 2002). "Situational" anorgasmia(where a woman may experience orgasm in some situa-tions, with certain kinds of stimulation, or with certainpartners, but not under the precise conditions she desires)often proves more difficult to treat, perhaps in partbecause it is often associated with relationship problemsthat may also be hard to treat (Althof & Schreiner-Engel,2000; LeVay & Valente, 2006).

Dysfunctions Involving Sexual PainVAGINISMUS According to DSM-IV-TR, vaginismusinvolves an involuntary spasm of the muscles at theentrance to, and outer third of, the vagina (not due to aphysical disorder) that prevents penetration and sexualintercourse (see DSM-IV-TR Criteria on p. 480). However,researchers have recently raised important questions aboutthis diagnostic criterion. They have noted that most diag-nosticians do not require a physical exam to make the diag-nosis in order to confirm the presence of involuntarymuscle spasm. Moreover, there are serious doubts aboutthe reliability of involuntary spasm as the primary diag-nostic criterion for vaginismus. For example, Reissing,Binik, et al. (2004) found that only about a quarter ofwomen with diagnosed vaginismus reported experiencingspasm with attempted intercourse, and less than a thirdexperienced spasm during a gynecological exam. However,muscle tension (not spasm) in the vaginal and pelvic mus-cles was common. Moreover, they did find that womendiagnosed with vaginismus frequently experienced painupon examination, and the researchers suggested that painupon penetration (as well as fear and avoidance of pene-tration) is perhaps a more reliable diagnostic criterionthan involuntary spasm.

In some cases, women who suffer from vaginismusalso have sexual arousal disorder, possibly as a result ofconditioned fears associated with earlier traumatic sexualexperiences (e.g., Reissing, Binik, et al., 2003). In manycases, however, they show normal sexual arousal but arestill afflicted with this disorder (Masters et al., 1992). Thisform of sexual dysfunction is relatively rare, but when itoccurs, it is likely to be extremely distressing for both anaffected woman and her partner and may sometimes leadto erectile or ejaculatory dysfunction in the partner (Seg-raves & Althof, 2002). Treatment of vaginismus typicallyinvolves a combination of banning intercourse, training ofthe vaginal muscles, and graduated self-insertion of vagi-nal dilators of increasing size. This treatment generallyappears to be effective (Rosen & Leiblum, 1995; Segraves &Althof, 2002).

DYSPAREUNIA Painful coitus, or dyspareunia, involvespersistent or recurrent genital pain associated with sexualintercourse (see DSM-IV- TR Criteria on p. 480). It canoccur in men but is far more common in women-espe-cially young women (LeVay & Valente, 2006). This is theform of sexual dysfunction most likely to have an obviousphysical basis. Some examples of physical causes include:acute or chronic infections or inflammations of the vaginaor internal reproductive organs, vaginal atrophy thatoccurs with aging, scars from vaginal tearing, or insuffi-ciency of sexual arousal. Understandably, dyspareunia isoften associated with vaginismus. Treatment of this prob-lem usually requires addressing the specific physical prob-

lems that contribute to it, but often there may also be aconditioned psychological response that needs psycholog-ical intervention as well (Segraves & Althof, 2002).

Recently, some prominent researchers have arguedagainst classifying dyspareunia as a "sexual disorder" ratherthan as a "pain disorder" (e.g., Binik, 2005). For example,Binik and colleagues argue that the pain in "sexual paindisorders" is qualitatively similar to the pain in other, non-sexual areas of the body and that the causes of "sexual paindisorder" are more similar to the causes of other pain dis-orders (e.g., low back pain) than to those of other sexualdysfunctions. They have recommended that dyspareuniabe reclassified as a "pelvic pain disorder." It is also interest-ing to note in this regard that the pain of dyspareuniasometimes precedes any sexual experiences-as for exam-ple, in some adolescent girls trying to use a tampon.

In ReVIew~ Compare and contrast the symptoms of the

dysfunctions of sexual desire, arousal, andorgasm in men and women.Why have common female sexualdysfunctions been studied less than malesexual dysfunctions?

~ What are the most effective treatments formale erectile disorder and prematureejaculation and for female orgasmicdisorder?

ost contemporary Americans believe thatchildhood sexual abuse (CSA)is veryharmful. This is reflected both in theirconcern for the victims of CSAand in theiroutrage at its perpetrators. The assump-

tion of harmfulness is so deeply ingrained that many peoplefind it shocking even to consider the alternative possibilitythat, at least sometimes, CSAis not very harmful. Surely,though, the issue of harm is answerable by empirical means.What do the results show?

In 1998 psychologist Bruce Rind ofTemple Universityand two colleagues published, in the prestigious journalPsychological Bulletin, an article reviewing 49 previous studiesthat had asked college students about their sexual experiencesduring childhood (Rind, Tromovitch, & Bauserman, 1998). Fur-thermore, the studies assessed the students' current adjust-ment, enabling Rind and colleagues to examine the associationbetween early sexual experiences and mental health in youngadulthood. Here are some conclusions of this study:

~ Correlations between childhood sexual abuse and laterproblems were of surprisingly small magnitude, sug-gesting that such experiences are not typically veryharmful.

~ After general family problems had been statistically con-trolled for, the small association between CSAand adultproblems was reduced to essentially zero, suggesting

that the negative family environment in which child sex-ual abuse often occurs might explain much of the linkbetween CSAand later problems, rather than the sexualabuse per se.

~ Incest (sex with relatives) and forced sex were bothassociated with more problems than sex between nomi-nally consenting nonrelated individuals.

~ Age at which CSAwas experienced was unrelated toadult outcome.

At first, the study's provocative conclusions attracted lit-tle attention. However, after the conservative radio personal-ity Dr. Laura Schlessinger learned of the study, she incited afirestorm of controversy. Both Dr. Laura and other criticsaccused Rind and his co-authors of giving comfort to childmolesters and being insensitive to victims of CSA.The contro-versy culminated in 1999 with a resolution by the U.S. Houseof Representatives that condemned the study (Lilienfeld,2002; Rind, Bauserman, & Tromovitch, 2000).

Rind's study was attacked on two general grounds: First,some argued that it is socially dangerous to make the kindsof claims that the authors made in their article (Ondersma,Chaffin, et aI., 2001). Second, some argued the study was notstrong enough, scientifically, to justify such risky conclusions.Let us examine both criticisms.

Clearly, it would be wrong to understate the harm ofCSA.Victims of CSAwould suffer from having their pain

(continued)

unappreciated, and we may well invest too little in solvingproblems related to CSA. But overstating the harm of CSAmay also entail significant costs. For example, people who areled to believe that they have been gravely and permanentlyharmed by CSA may suffer unnecessarily if CSA does notinvariably have grave and permanent consequences. If CSA isoften not very harmful, we need to know that.

Assessing the validity of Rind's study is a scientific mat-ter. Psychological Bulletin published a lengthy scientific cri-tique of Rind's study (Dallam, Gleaves, et aI., 2001) along witha reply by Rind and his co-authors (2001). One criticism of theoriginal study was that it relied on college students, who maybe unrepresentative. Perhaps they were able to attend col-lege despite CSA because they were especially resilient. How-ever, in another study, Rind analyzed data from communitysamples (samples not selected on the basis of educationalattainment) and got virtually identical results (Rind & Tro-movitch, 1997). Some of Rind's statistical decisions andanalyses have also been criticized, but he has shown that hisresults do not change much when he analyzes the data the

way his critics would. Although the question "How harmful isCSA?" has not been definitively answered by Rind's study,future research must contend with his findings.

Recently Rind (2003,2004) has extended his discussionto the issue of how harmful adult-adolescent sexual relation-ships are (see also LeVay & Valente, 2006). The current Ameri-can view, which has spread throughout the Western world, isthat such relations are by definition also "childhood sexualabuse" even though marriages involving young teenagerswere common in previous centuries. He reviews evidenceshowing that current views on this topic are driven by ideol-ogy and moral panic rather than by any empirical researchshowing these experiences to be harmful-especially thosebetween adolescent boys and adult females, where consider-able evidence suggests that many teenage boys see per-ceived benefits from such relationships regarding their sexualconfidence and self-acceptance (see also LeVay & Valente,2006). These are obviously controversial issues that deservemore careful research in the future.

~ Defining boundaries between normality andpsychopathology in the area of variant sexuality isvery difficult, in part because sociocultural influenceson what have been viewed as normal or aberrantsexual practices abound.

~ Degeneracy theory and abstinence theory werevery influential for long periods of time in theUnited States and many other Western culturesand led to very conservative views onheterosexual sexuality.

~ In contrast to Western cultures, in the Sambia

tribe in Melanesia, homosexuality is practiced byall adolescent males in the context of male sexualinitiation rites; these males transition toheterosexuality in young adulthood.

~ Until rather recently, in many Western cultureshomosexuality was viewed either as criminalbehavior or as a form of mental illness. However,since 1974 homosexuality has been consideredby mental health professionals to be a normalsexual variant.

~ Sexual deviations in the form of paraphilias involvepersistent and recurrent patterns of sexual behaviorand arousal, lasting at least 6 months, in whichunusual objects, rituals, or situations are required forfull sexual satisfaction. Their occurrence is nearlyalways in males. The paraphilias include fetishes,

transvestic fetishism, voyeurism, exhibitionism,

sadism, masochism, pedophilia, and frotteurism.

~ Gender identity disorders occur in children andadults. Childhood gender identity disorder occurs inchildren who have cross-gender identification andgender dysphoria. Most boys who have this disordergrow up to have a homosexual orientation; a fewbecome transsexuals. Prospective studies of girlswho have this disorder have not yet been reported.

~ Transsexualism is a very rare disorder in whichthe person believes that he or she is trapped inthe body of the wrong sex. It is now recognizedthat there are two distinct types of transsexuals:homosexual transsexuals and autogynephilictranssexuals, each with different characteristicsand developmental antecedents.

~ The only known effective treatment fortranssexuals is a sex change operation. Althoughits use remains highly controversial, it does appearto have fairly high success rates when the peopleare carefully diagnosed as being true transsexuals.

~ There are three overlapping categories of sexualabuse: pedophilia, incest, and rape. All three kinds ofabuse occur at alarming rates today.

~ Active debate persists about several issuesrelated to sexual abuse and identification of itsperpetrators. These include controversies about

the accuracy of children's testimony and theaccuracy of recovered memories of sexual abusethat often occur in psychotherapy.

~ All sexual abuse can sometimes have seriousshort-term and long-term consequences for itsvictims. What leads people to engage in sexualabuse is poorly understood at this time.

~ Treatment of sex offenders has not as yet provedhighly effective in most cases, although promisingresearch in this area is being conducted.

~ Sexual dysfunction involves impairment either in thedesire for sexual gratification or in the ability toachieve it. Dysfunction can occur in the first three ofthe four phases of the human sexual response: thedesire phase, the excitement phase, and orgasm.

~ Both men and women can experience hypoactivesexual desire disorder, in which they have little or

no interest in sex. In more extreme cases, theymay develop sexual aversion disorder, whichinvolves a strong disinclination to sexual activity.

~ Dysfunctions of the arousal phase include maleerectile disorder and female arousal disorder.

~ Dysfunctions of orgasm for men includepremature ejaculation and male orgasmicdisorder (retarded ejaculation), and for womeninclude female orgasmic disorder.

~ There are also two sexual pain disorders:vaginismus, which occurs in women, anddyspareunia (painful coitus), which can occur inwomen and occasionally in men.

~ In the past 35 years, remarkable progress hasbeen made in the treatment of sexualdysfunctions.

autogynephilia (P. 465)

cross-gender identification (P. 463)

desire phase (P. 478)

dyspareunia (P. 484)

excitement phase (P. 478)

exhibitionism (P. 460)

female orgasmic disorder (P. 483)

female sexual arousal disorder(p.482)

fetishism (P. 456)

gender dysphoria (P. 463)

gender identity disorder (P. 463)

hypoactive sexual desire disorder(p.479)

incest (P. 471)

male erectile disorder (P. 481)

male orgasmic disorder (P. 483)

masochism (P. 461)

orgasm (P. 478)

paraphilias (P. 456)

pedophilia (P. 470)

premature ejaculation (P. 483)

rape (P. 472)

resolution (P. 478)

sadism (p.460)

sexual abuse (P. 467)

sexual aversion disorder (P. 479)

sexual dysfunction (P. 478)

transsexualism (P. 465)

transvestic fetishism (p.458)

vaginismus (P. 484)

voyeurism (P. 459)

015 - Chapter 13 - Sexual Variants, Abuse, & Dysfun0001

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