Sexual Disorders chapter 12, Neurocognitive Disorders in DSM 5 chapter 14

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12 sexual variants, abuse, and dysfunctions

learning objectives 12

· 12.1 Why is it difficult to define boundaries between normality and psychopathology in the area of variant sexuality?

· 12.2 What do we mean by sexual and gender variants?

· 12.3 What are the three primary types of sexual abuse?

· 12.4 What is a sexual dysfunction?

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

In this chapter we shall first look at the psychological problems that make sexual fulfillment especially difficult for some people—the vast majority of them men—who develop unusual sexual interests that are difficult to satisfy in a socially acceptable manner. For example, exhibitionists 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 problematic primarily to the individual: Transsexualism, for example, is a disorder involving discomfort with one’s biological sex and a strong desire to be of the opposite sex. Still other variants such as fetishism, in which sexual interest centers on some inanimate object or body part, involve behaviors that, although bizarre and unusual, do not clearly harm anyone. Perhaps no other area covered in this book exposes the difficulties in defining boundaries between normality and psychopathology as clearly as variant sexuality does.

The second issue we shall consider is sexual abuse, a pattern of pressured, forced, or inappropriate sexual contact. During the last few decades, there has been a tremendous increase in attention to the problem of sexual abuse of both children and adults. A great deal of research has addressed its causes and consequences. As we shall see, some related issues, such as the reality 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 have sexual 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 satisfying. And women with orgasmic disorder get sexually aroused and enjoy sexual activity but have a persistent delay, or absence, of orgasm following a normal sexual excitement or arousal phase .

Much less is known about sexual deviations, abuse, and dysfunctions than is known about many of the other disorders we have considered thus far in this book. There are also fewer sex researchers than researchers for many other disorders, so fewer articles related to research on sexual deviations and dysfunctions are published compared with the number of articles on anxiety and mood disorders or schizophrenia. One major reason is the sex taboo. Although sex is an important concern for most people, many have difficulty talking about it openly—especially when the relevant behavior is socially stigmatized, as homosexuality has often been historically. This makes it hard to obtain knowledge about even the most basic facts, such as the frequency of various sexual practices, feelings, and attitudes.

A second reason why sex research has progressed less rapidly is that many issues related to sexuality—including homosexuality, teenage sexuality, abortion, and childhood sexual abuse—are among our most divisive and controversial. In fact, sex research is itself controversial and not well funded. In the 1990s, two large-scale sex surveys were halted because of political opposition even after the surveys had been officially approved and deemed scientifically meritorious (Udry, 1993 ). Conservative former senator Jesse Helms and others had argued that sex researchers tended to approve of premarital sex and homosexuality and that this would likely bias the results of the surveys. Fortunately, one of these surveys was funded privately, though on a much smaller scale, and it is still considered definitive even though it was conducted in the 1990s (Laumann et al., 1994 , 1999 ). Another attack led by social conservatives occurred in 2003, when several federal grants were criticized because they focused on sex (Kempner, 2008). A legislative attempt to defund five of the grants barely failed.

Despite these significant barriers, significant progress has been made in the past half-century in 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 et al., 1948 , 1953 ). Kinsey and his pioneering 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 sexual behavior and attitudes in general. We do so to provide some perspective about cross-cultural variability in standards of sexual conduct and how these perspectives have changed over time. Such examples will remind us that we must exercise special caution in classifying sexual practices as “abnormal” or “deviant.”

Loving, sexually satisfying relationships contribute a great deal to our happiness, but our understanding of them has advanced slowly, largely because they are so difficult for people to talk about openly and because funding for research is often hard to come by.

Sociocultural Influences On Sexual Practices and Standards

Although some aspects of sexuality and mating, such as men’s greater emphasis on their partner’s attractiveness, are cross-culturally universal (Buss, 1989 , 2012), others are quite variable. For example, all known cultures have taboos against sex between close relatives, but attitudes toward premarital sex have varied considerably across history and around the world. Ideas about acceptable sexual behavior also change over time. Less than 100 years ago, for example, sexual modesty in Western cultures was such that women’s arms and legs were always hidden in public. Although this is by no means the case in Western cultures today, it remains true in many Muslim countries.

Despite the substantial variability in sexual attitudes and behavior in different times and places, people typically behave as though the sexual standards of their own time and place are obviously correct, and they tend to be intolerant of sexual nonconformity. Sexual nonconformists are often considered evil or sick. We do not mean to suggest that such judgments are always arbitrary. There has probably never existed a society in which Jeffrey Dahmer, who was sexually aroused by killing men, having sex with them, storing their corpses, and sometimes eating them, would be considered psychologically normal. Nevertheless, it is useful to be aware of historical and cultural influences on sexuality. When the expression or the acceptance of a certain behavior varies considerably across eras and cultures, we should at least pause to consider the possibility that our own stance is not the only appropriate one.

Because the influences of time and place are so important in shaping sexual behavior and attitudes, we begin by exploring three cases that illustrate how opinions about “acceptable” and “normal” sexual behavior may change dramatically over time and may differ dramatically from one culture to another. In the first case, America during the mid-1800s, “degeneracy theory”—a set of beliefs about sexuality—led to highly conservative sexual practices and dire warnings about most kinds of sexual “indulgence.” In the second case, we look briefly at the Sambia tribe in New Guinea, in which a set of beliefs about sexuality prescribe that all normal adolescent males go through a stage of homosexuality before switching rather abruptly to heterosexuality in adulthood. Finally, in the third case, we consider changes across time in the status of homosexuality in Western culture.

Case 1: Degeneracy and Abstinence Theory

During the 1750s, Swiss physician Simon Tissot developed degeneracy theory, the central belief of which was that semen is necessary for physical and sexual vigor in men and for masculine characteristics such as beard growth (Money, 1985 , 1986 ). He based this theory on observations about human eunuchs and castrated animals. We now know, of course, that loss of the male hormone testosterone, and not of semen, is responsible for the relevant characteristics of eunuchs and castrated animals. On the basis of his theory, however, Tissot asserted that two practices were especially harmful: masturbation and patronizing prostitutes. Both of these practices wasted the vital fluid, semen, as well as (in his view) overstimulating and exhausting the nervous system. Tissot also recommended that married people engage solely in procreative sex to avoid the waste of semen.

A descendant of degeneracy theory, abstinence theory was advocated in America during the 1830s by the Reverend Sylvester Graham (Money, 1985 , 1986 ). The three cornerstones of his crusade for public health were healthy food (graham crackers were named for him), physical fitness, and sexual abstinence. In the 1870s Graham’s most famous successor, Dr. John Harvey Kellogg, published a paper in which he ardently disapproved of masturbation and urged parents to be wary of signs that their children were indulging in it. He wrote about the 39 signs of “the secret vice,” which included weakness, dullness of the eyes, sleeplessness, untrustworthiness, bashfulness, love of solitude, unnatural boldness, mock piety, and round shoulders.

As a physician, Kellogg was professionally admired and publicly influential, and he earned a fortune publishing books discouraging masturbation. His recommended treatments for “the secret vice” were quite extreme. For example, he advocated that persistent masturbation in boys be treated by sewing the foreskin with silver wire or, as a last resort, by circumcision without anesthesia. Female masturbation was to be treated by burning the clitoris with carbolic acid. Kellogg, like Graham, was also very concerned with dietary health—especially with the idea that consumption of meat increased sexual desire. Thus, he urged people to eat more cereals and nuts and invented Kellogg’s cornflakes “almost literally, as anti-masturbation food” (1986, p. 186).

Given the influence of physicians like Kellogg, it should come as no surprise that many people believed that masturbation caused insanity (Hare, 1962 ). This hypothesis had started with the anonymous publication in the early eighteenth century in London of a book entitled Onania, or the Heinous Sin of Self-Pollution. It asserted that masturbation was a common cause of insanity. This idea probably arose from observations that many patients in mental asylums masturbated openly (unlike sane people, who are more likely to do it in private) and that the age at which masturbation tends to begin (at puberty in adolescence) precedes by several years the age when the first signs of insanity often appear (in late adolescence and young adulthood) (Abramson & Seligman, 1977 ). The idea that masturbation may cause insanity appeared in some psychiatry textbooks as late as the 1940s.

Although abstinence theory and associated attitudes seem highly puritanical by today’s standards, they have had a long-lasting influence on attitudes toward sex in American and other Western cultures. It was not until 1972 that the American Medical Association declared, “Masturbation is a normal part of adolescent sexual development and requires no medical management” (American Medical Association Committee on Human Sexuality, 1972 , p. 40). Around the same time, the Boy Scout Manual dropped its antimasturbation warnings. Nonetheless, in 1994 Jocelyn Elders was fired as U.S. Surgeon General for suggesting publicly that sex education courses should include discussion of masturbation. Moreover, the Roman Catholic Church still holds that masturbation is sinful.

Case 2: Ritualized Homosexuality in Melanesia

Melanesia is a group of islands in the South Pacific that has been intensively studied by anthropologists, who have uncovered cultural influences on sexuality unlike any known in the West. Between 10 and 20 percent of Melanesian societies practice a form of homosexuality within the context of male initiation rituals, which all male members of society must experience.

The best-studied society has been the Sambia of Papua New Guinea (Herdt, 2000 ; Herdt & Stoller, 1990 ). Two beliefs reflected in Sambian sexual practices are semen conservation and female pollution. Like Tissot, the Sambians believe that semen is important for many things including physical growth, strength, and spirituality. Furthermore, they believe that it takes many inseminations (and much semen) to impregnate a woman. Finally, they believe that semen cannot easily be replenished by the body and so must be conserved or obtained elsewhere. The female pollution doctrine is the belief that the female body is unhealthy to males, primarily because of menstrual fluids. At menarche, Sambian women are secretly initiated in the menstrual hut forbidden to all males.

In order to obtain or maintain adequate amounts of semen, young Sambian males practice semen exchange with each other. Beginning as boys, they learn to practice fellatio (oral sex) in order to ingest sperm, but after puberty they can also take the penetrative role, inseminating younger boys. Ritualized homosexuality among the young Sambian men is seen as an exchange of sexual pleasure for vital semen. (It is ironic that although both the Sambians and the Victorian-era Americans believed in semen conservation, their solutions to the problem were radically different.) When Sambian males are well past puberty, they begin the transition to heterosexuality. At this time the female body is thought to be less dangerous because the males have ingested protective semen over the previous years. For a time, they may begin having sex with women and still participate in fellatio with younger boys, but homosexual behavior stops after the birth of a man’s first child. Most of the Sambian men make the transition to exclusive adult heterosexuality without problems, and those who do not are viewed as misfits.

Ritualized homosexuality among the Melanesians is a striking example of the influence of culture on sexual attitudes and behavior. A Melanesian adolescent who refuses to practice homosexuality would be viewed as abnormal, and such adolescents are apparently absent or rare. In the United States ritualized homosexuality of this type would be stigmatized as homosexual pedophilia, but Melanesian boys who practice it appear neither to have strong objections nor to be derailed from eventual heterosexuality. Obviously, homosexuality in Sambia is not the same as homosexuality in contemporary America, with the possible exception of those Sambian men who have difficulty making the transition to heterosexuality.

Case 3: Homosexuality and American Psychiatry

During the past half-century, the status of homosexuality has changed enormously, both within psychiatry and psychology and for many Western societies in general. In the not-too-distant past, homosexuality was a taboo topic. Now, movies, talk shows, and television sitcoms and dramas address the topic explicitly by including gay men and lesbians in leading roles. As we shall see, developments in psychiatry and psychology have played an important part in these changes. Homosexuality was officially removed from the DSM (where it had previously been classified as a sexual deviation) in 1973 and today is no longer regarded as a mental disorder. A brief survey of attitudes toward homosexuality within the mental health profession itself will again illustrate how attitudes toward various expressions of human sexuality may change over time.

HOMOSEXUALITY AS SICKNESS

Reading the medical and psychological literature on homosexuality written before 1970 can be a jarring experience, especially if one subscribes to views prevalent today. Relevant articles included “Effeminate homosexuality: A disease of childhood” and “On the cure of homosexuality.” It is only fair to note, however, that the view that homosexual people are mentally ill was relatively tolerant compared with some earlier views—for example, the idea that homosexual people are criminals in need of incarceration (Bayer, 1981 ). British and American cultures had long taken punitive approaches to homosexual behavior. In the sixteenth century, King Henry VIII of England declared “the detestable and abominable vice of buggery [anal sex]” a felony punishable by death, and it was not until 1861 that the maximum penalty was reduced to 10 years’ imprisonment. Similarly, laws in the United States were very repressive until recently, with homosexual behavior continuing to be a criminal offense in some states (Eskridge, 2008) until the 2003 Supreme Court ruling that struck down a Texas state law banning sexual behavior between two people of the same sex (Lawrence & Garner v. Texas). For the first time, this ruling established a broad constitutional right to sexual privacy in the United States.

During the late nineteenth and early twentieth centuries, several prominent sexologists such as Havelock Ellis and Magnus Hirschfeld suggested that homosexuality is natural and consistent with psychological normality. Freud’s own attitude toward homosexual people was also remarkably progressive for his time and is well expressed in his touching “Letter to an American Mother” ( 1935 ).

· Dear Mrs….

· I gather from your letter that your son is a homosexual.

· I am most impressed by the fact that you do not mention this term yourself in your information about him. May I question you, why you avoid it? Homosexuality is assuredly no advantage, but it is nothing to be ashamed of, no vice, no degradation, it cannot be classified as an illness…. Many highly respectable individuals of ancient and modern times have been homosexuals, several of the greatest men among them (Plato, Michelangelo, Leonardo da Vinci, etc.). It is a great injustice to persecute homosexuality as a crime, and cruelty too….

· By asking me if I can help, you mean, I suppose, if I can abolish homosexuality and make normal heterosexuality take its place. The answer is, in a general way, we cannot promise to achieve it….

· Sincerely yours with kind wishes,

· Freud

Beginning in the 1940s, however, other psychoanalysts, led by Sandor Rado, began to take a more pessimistic view of the mental health of homosexual people—and a more optimistic view of the possible success of therapy to induce heterosexuality (Herek, 2010). Rado ( 1962 ) believed that homosexuality develops in people whose heterosexual desires are too psychologically threatening; thus, in this view, homosexuality is an escape from heterosexuality and therefore incompatible with mental health (see also Bieber et al., 1962 ). In the case of male homosexuality, one argument was that domineering, emotionally smothering mothers and detached, hostile fathers played a causal role. Unfortunately, these psychoanalysts based their opinions primarily on their experiences seeing gay men in therapy, who are obviously more likely than other gay men to be psychologically troubled (Herek, 2010).

HOMOSEXUALITY AS NONPATHOLOGICAL VARIATION

Around 1950, the view of homosexuality as sickness began to be challenged by both scientists and homosexual people themselves (e.g., Herek, 2010). Scientific blows to the pathology position included Alfred Kinsey’s finding that homosexual behavior was more common than had been previously believed (Kinsey et al., 1948 , 1953 ). Influential studies also demonstrated that trained psychologists could not distinguish the psychological test results of homosexual subjects from those of heterosexual subjects (e.g., Hooker, 1957 ).

Gay men and lesbians also began to challenge the psychiatric orthodoxy that homosexuality is a mental disorder. The 1960s saw the birth of the radical gay liberation movement, which took the more uncompromising stance that “gay is good.” The decade closed with the famous Stonewall riot in New York City, sparked by police mistreatment of gay men, which sent a clear signal that homosexual people would no longer tolerate being treated as second-class citizens. By the 1970s, openly gay psychiatrists and psychologists were working from within the mental health profession to have homosexuality removed from DSM-II (American Psychiatric Association, 1968 ).

After acrimonious debate in 1973 and 1974, the American Psychiatric Association (APA) voted in 1974 by a vote of 5,854 to 3,810 to remove homosexuality from DSM-II. This episode was a milestone for gay rights. We believe the APA made a correct decision here because the vast majority of evidence shows that homosexuality is compatible with psychological health (e.g., Herek, 2010). Challenges by gay and lesbian people forced mental health professionals to confront the issue explicitly, and these professionals made the correct determination that homosexuality is not a psychological disorder.

After mental health professionals stopped merely assuming that homosexuality was pathological, research began systematically to address mental health concerns of gay men and lesbians. Several large and careful surveys have examined rates of mental problems in people with and without homosexual feelings or behavior (Chakraborty et al., 2011 ; Sandfort et al., 2001 ; see Herek & Garnets, 2007 , for a review). Homosexual people do appear to have elevated risk for some mental problems. For example, compared with heterosexual men and women, gay-identified men and lesbian-identified have higher rates of anxiety disorders and depression (Bostwick et al., 2010 ). Whether gay and lesbian people are at increased risk for suicide remains controversial (Savin-Williams, 2006 ), with a recent population study finding no increased risk for gay men (Cochran & Mays, 2011 ). Lesbians also have a higher rate of substance abuse (Herek & Garnets, 2007 ; Sandfort et al., 2001 ). Although it remains unclear why homosexual people have higher rates of certain problems (Bailey, 1999 ; Cochran, 2012 ), one plausible explanation is that such problems result from stressful life events related to societal stigmatizing of homosexuality (Herek & Garnets, 2007 ). Regardless, homosexuality is compatible with psychological health—most gay men and lesbians do not have mental disorders.

During the past 50 years gay men and lesbians have made momentous progress toward legal rights and social acceptance in much of the developed world. For example, in 2010 for the first time a majority of Americans viewed homosexual relations between adults as morally acceptable (Gallup, 2010). A plurality of Americans now support marriage for same-sex couples (Smith, 2011 ), and in many nations and in several U.S. states, gay men and lesbians have the legal right to marry. In some parts of the world, however, progress toward equal rights and acceptance has lagged far behind. In some countries in Africa and the Middle East, large majorities disapprove of homosexuality (Pew Research Center, 2007), and in a few of those countries homosexual people may be subject to capital punishment. The marked cross-cultural and historical variation in treatment of homosexual people should remind us to be cautious in assuming that a currently unpopular or uncommon trait is pathological without careful and persuasive analysis. Sometimes it is culture that is the problem.

in review

· • What does each of the three examples of sociocultural influences on sexual practices and standards reveal about cultural differences and historical changes in what is considered acceptable and normal sexual behavior?

· • How has the psychiatric view of homosexuality changed over time? Identify a few key historical events that propelled this change.

Gender Dysphoria

In DSM-5, there is a new classification for the DSM-IV-TR “Sexual and Gender Variants” referred to as Gender Dysphoria. This reflects a change in the way these diagnostic groups are defined. The phenomenon of “gender incongruence” is emphasized instead of “cross-gender identification” that was emphasized in DSM-IV Gender Identity Disorder. We will examine two general categories: the paraphillias and gender identity disorders.

The Paraphilias

People with paraphilias have recurrent, intense sexually arousing fantasies, sexual urges, or behaviors that generally involve (1) nonhuman objects, (2) the suffering or humiliation of oneself or one’s partner, or (3) children or other nonconsenting persons. Paraphilias have challenged authors of past DSM editions for two main reasons. First, some paraphilias—especially pedophilia—are widely considered pathological even if the paraphilic individual does not experience distress. For example, consider a pedophile who has molested children but does not feel guilty. Most people believe that such a man has a mental disorder. In the past, pedophilia has been diagnosed even in the absence of distress; so have frotteurism and exhibitionism, both of which typically involve nonconsenting individuals in sexual acts. A second challenge has been that some other categories of paraphilias may be compatible with psychological health and happiness. For example, some men who have a foot fetish are comfortable with their sexual interest and even find willing partners who happily indulge them, while some others feel substantial shame and guilt (Bergner, 2009). In the past, only foot fetishists with intense shame and guilt (or other problems related to their fetish) would be diagnosed as paraphilic. But surely, both happy and distressed foot fetishists have the same paraphilia. A useful distinction to be included in DSM-5 is that between paraphilias and paraphilic disorders (Blanchard, 2010). Paraphilias are unusual sexual interests, but they need not cause harm either to the individual or to others. Only if they cause such harm do they become paraphilic disorders. Thus, foot fetishists have a paraphilia, but only those who suffer due to their sexual interest have a paraphilic disorder.

Although mild forms of these conditions probably occur in the lives of many normal people, a paraphilic person is distinguished by the insistence, and in some cases the relative exclusivity, with which his sexuality focuses on the acts or objects in question—without which orgasm is sometimes impossible. Paraphilias also frequently have a compulsive quality, and some individuals with paraphilias require orgasmic release as often as 4 to 10 times per day (Garcia & Thibaut, 2010 ). Individuals with paraphilias may or may not have persistent desires to change their sexual preferences. Because nearly all such persons are male (a fact whose etiological implications we consider later), we use masculine pronouns to refer to them (see Fedoroff et al., 1999 , for some possible examples of women with paraphilias).

No one knows how common different paraphilias are. Good prevalence data do not exist, in part because people are often reluctant to disclose such deviant behavior (Griffifths, 2012 ). The DSM-5 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 one’s genital area against a nonconsenting person). An additional category, paraphilias not otherwise specified, includes several rarer disorders such as telephone scatologia (obscene phone calls), necrophilia (sexual desire for corpses), zoophilia (sexual interest in animals; Aggrawal, 2011 ), apotemnophilia (sexual excitement and desire about having a limb amputated), and coprophilia (sexual arousal to feces). Although some of different paraphilias tend to co-occur together, we will discuss each of them separately. In addition, our discussion of pedophilia is postponed until a later section concerning sexual abuse.

FETISHISTIC DISORDER

In fetishism , the individual has recurrent, intense sexually arousing fantasies, urges, and behaviors involving the use of some inanimate object or a part of the body not typically found erotic (e.g., feet) to obtain sexual gratification (see “DSM-5 Criteria for Several Different Paraphilic Disorders”). As is generally true for the paraphilias, reported cases of female fetishists are extremely rare (Mason, 1997 ). Usually the fetishistic object is required or strongly preferred during sexual arousal and activity. Many men have a strong sexual fascination for paraphernalia such as bras, garter belts, hose, and high heels, but most do not typically meet diagnostic criteria for fetishism because the paraphernalia are not necessary or strongly preferred for sexual arousal. Nevertheless, they do illustrate the relatively high frequency of fetish-like preferences among men. Fetishism occurs frequently in the context of sadomasochistic activity but is relatively rare among sexual offenders (Kafka, 2010).

DSM-5 criteria for: Several Different Paraphilic Disorders

Fetishistic Disorder

· A. Over a period of at least 6 months, recurrent and intense sexual arousal from either the use of nonliving objects or a highly specific focus on nongenital body part(s), as manifested by fantasies, urges, or behaviors.

· B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

· C. The fetish objects are not limited to articles of clothing used in cross-dressing (as in transvestic disorder) or devices specifically designed for the purpose of tactile genital stimulation (e.g., vibrator).

Transvestic Disorder

· A. Over a period of at least 6 months, recurrent and intense sexual arousal from cross-dressing, as manifested by fantasies, urges, or behaviors.

· B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Voyeuristic Disorder

· A. Over a period of at least 6 months, recurrent and intense sexual arousal from observing an unsuspecting person who is naked, in the process of disrobing, or engaging in sexual activity, as manifested by fantasies, urges, or behaviors.

· B. The individual has acted on these sexual urges with a nonconsenting person, or the sexual urges or fantasies cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

· C. The individual experiencing the arousal and/or acting on the urges is at least 18 years of age.

Exhibitionistic Disorder

· A. Over a period of at least 6 months, recurrent and intense sexual arousal from the exposure of one’s genitals to an unsuspecting person, as manifested by fantasies, urges, or behaviors.

Sexual Sadism Disorder

· A. Over a period of at least 6 months, recurrent and intense sexual arousal from the physical or psychological suffering of another person, as manifested by fantasies, urges, or behaviors.

· B. The individual has acted on these sexual urges with a non-consenting person, or the sexual urges or fantasies cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Sexual Masochism Disorder

· A. Over a period of at least 6 months, recurrent and intense sexual arousal from the act of being humiliated, beaten, bound, or otherwise made to suffer, as manifested by fantasies, urges, or behaviors.

· B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Pedophilic Disorder

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

· B. The individual has acted on these sexual urges, or the sexual urges or fantasies cause marked distress or interpersonal difficulty.

· C. The individual is at least age 16 years and at least 5 years older than the child or children in Criterion A.

Note: Do not include an individual in late adolescence involved in an ongoing sexual relationship with a 12- or 13-year-old.

Frotteuristic Disorder

· A. Over a period of at least 6 months, recurrent and intense sexual arousal from touching or rubbing against a nonconsenting person, as manifested by fantasies, urges, or behaviors.

The mode of using these objects to achieve sexual excitation and gratification varies considerably, but it commonly involves masturbating while kissing, fondling, tasting, or smelling the objects. In the context of consensual sexual relationships, fetishism does not normally interfere with the rights of others. However, some partners who do not share an erotic fascination with a fetishistic object may understandably object to participating. Some paraphilic men are so ashamed of their desires that they cannot bring themselves to ask partners. Bergner (2009) relates the case of a foot fetishist who chooses chemical castration to suppress his desire rather than tell his wife.

To obtain the required object, some men with fetishes may commit burglary, theft, or even assault. The articles most commonly stolen by such individuals are probably women’s undergarments. In such cases, the excitement and suspense of the criminal act itself typically reinforce the sexual stimulation and sometimes actually constitute the fetish, the stolen article itself being of little importance. One example of this pattern of fetishism is provided in the case of a man whose fetish was women’s panties:

Panties A single, 32-year-old male freelance photographer … related that although he was somewhat sexually attracted by women, he was far more attracted by “their panties.” … [His] sexual excitement began about age 7, when he came upon a pornographic magazine and felt stimulated by pictures of partially nude women wearing “panties.” His first ejaculation occurred at 13 via masturbation to fantasies of women wearing panties. He masturbated into his older sister’s panties, which he had stolen without her knowledge. Subsequently he stole panties from her friends and from other women he met socially…. The pattern of masturbating into women’s underwear had been his preferred method of achieving sexual excitement and orgasm from adolescence until the present consultation.

One common hypothesis regarding the etiology of fetishism emphasizes the importance of classical conditioning and social learning (e.g., Hoffmann, 2012 ). For example, it is not difficult to imagine how women’s underwear might become eroticized via its close association with sex and the female body. But only a small number of men develop fetishes, so even if the hypothesis has merit there must be individual differences in conditionability of sexual responses (just as there are differences in the conditionability of fear and anxiety responses, as discussed in Chapter 6 ). Men high in sexual conditionability would be prone to developing one or more fetishes. We will return later to the role of conditioning in the development of paraphilias more generally.

TRANSVESTIC DISORDER

According to DSM-5, heterosexual men who experience recurrent, intense sexually arousing fantasies, urges, or behaviors that involve cross-dressing as a female may be diagnosed with transvestic disorder, if they experience significant distress or impairment due to the condition (see “DSM-5 Criteria” on p. 410). Although some gay men dress “in drag” on occasion, they do not typically do this for sexual pleasure and hence do not have the paraphilia transvestism. Typically, the onset of transvestism is during adolescence and involves masturbation while wearing female clothing or undergarments. Blanchard ( 1989 , 2010) has hypothesized that the psychological motivation of most heterosexual transvestites includes auto-gynephilia: paraphilic sexual arousal by the thought or fantasy of being a woman (Blanchard, 1991 , 1993 ; Lawrence, 2013 ). The great sexologist Magnus Hirschfeld first identified a class of cross-dressing men who are sexually aroused by the image of themselves as women: “They feel attracted not by the women outside them, but by the woman inside them” (Hirschfeld, 1948 , p. 167). Not all men with transvestic fetishism show clear evidence of autogynephilia (Blanchard, 2010). The others seem quite similar to typical fetishists, focusing on specifics of their preferred female clothing and without having clearly apparent fantasies of becoming women. Among transvestic fetishists, strength of autogynephilic fantasies strongly predicts gender dysphoria and desire for sex reassignment surgery (Blanchard, 2010). Like other kinds of fetishism, transvestic fetishism causes overt harm to others only when accompanied by such an illegal act as theft or destruction of property. Such acts are rare, and the vast majority of transvestites are harmless.

One large survey of over 2,400 men and women in Sweden estimated that almost 3 percent of the men and 0.4 percent of the women reported having engaged in at least one episode of erotic cross-dressing, but the actual prevalence of the disorder is likely much lower (Langstrom & Zucker, 2005 ). This same study reported on various demographic and experiential differences between the men who had cross-dressed and those who had not. Among the most interesting findings were that the men who had cross-dressed had experienced more sexual abuse before age 10, were more easily sexually aroused, had a higher frequency of masturbation, made greater use of pornography, and had other paraphilias. An earlier survey of over 1,000 men who frequently crossed-dressed reported that the vast majority (87 percent) were heterosexual, 83 percent had married, and 60 percent were married at the time of the survey (Docter & Prince, 1997 ). Many managed to keep their cross-dressing a secret, at least for a while. However, wives often found out and had a wide range of reactions, from accepting to being extremely disturbed. The following case illustrates both the typical early onset of transvestic fetishism and the difficulties the condition may raise in a marriage.

A Transvestite’s Dilemma Mr. A., a 65-year-old security guard, formerly a fishing-boat captain, is distressed about his wife’s objections to his wearing a nightgown at home in the evening now that his youngest child has left home. His appearance and demeanor, except when he is dressing in women’s clothes, are always appropriately masculine, and he is exclusively heterosexual. Occasionally, over the past 5 years, he has worn an inconspicuous item of female clothing even when dressed as a man, sometimes a pair of panties…. He always carries a photograph of himself dressed as a woman.

His first recollection of an interest in female clothing was putting on his sister’s bloomers at age 12, an act accompanied by sexual excitement. He continued periodically to put on women’s underpants—an activity that invariably resulted in an erection, sometimes a spontaneous emission, sometimes masturbation…. He was competitive and aggressive with other boys and always acted “masculine.” During his single years he was always attracted to girls….

His involvement with female clothes was of the same intensity even after his marriage. Beginning at age 45, after a chance exposure to a magazine called Transvestia, he began to increase his cross-dressing activity. He learned there were other men like himself, and he became more and more preoccupied with female clothing in fantasy and progressed to periodically dressing completely as a woman. More recently he has become involved in a transvestite network … occasionally attending transvestite parties.

Although still committed to his marriage, sex with his wife has dwindled over the past 20 years as his waking thoughts and activities have become increasingly centered on cross-dressing…. He always has an increased urge to dress as a woman when under stress; it has a tranquilizing effect. If particular circumstances prevent him from cross-dressing, he feels extremely frustrated….

Because of disruptions in his early life, the patient has 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 was accepting so long as he kept it to himself. Nevertheless, he felt guilty … and periodically he attempted to renounce the practice, throwing out all his female clothes and makeup. His children served as a barrier to his giving free rein to his impulses. Following his retirement from fishing, and in the absence of his children, he finds himself more drawn to cross-dressing, more in conflict with his wife, and more depressed.

Source: Adapted with permission DSM-IV-TR Casebook: A Learning Companion to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (pp. 257–59). (Copyright © 2002). American Psychiatric Association.

VOYEURISTIC DISORDER

A person is diagnosed with voyeurism according to DSM-5 if he has recurrent, intense sexually arousing fantasies, urges, or behaviors involving the observation of unsuspecting females who are undressing or of couples engaging in sexual activity (see “DSM-5 Criteria” on p. 410). Frequently, such individuals masturbate during their peeping activity. Peeping Toms, as they are commonly called, commit these offenses primarily as young men. Voyeurism often co-occurs with exhibitionism, and it is also associated with interest in sadomasochism and cross-dressing (Langstrom & Seto, 2006 ). Voyeurism is probably the most common illegal sexual activity (Langstrom, 2010).

How do some young men develop this pattern? First, viewing the body of an attractive female is sexually stimulating for most heterosexual men. In addition, the privacy and mystery that have traditionally surrounded sexual activities tend to increase curiosity about them. Third, if a young man with such curiosity feels shy and inadequate in his relations with the opposite sex, he may accept the substitute of voyeurism, which satisfies his curiosity and to some extent meets his sexual needs without the trauma of actually approaching a female. He thus avoids the rejection and lowered self-status that such an approach might bring. In fact, voyeuristic activities often provide important compensatory feelings of power and secret domination over an unsuspecting victim, which may contribute to the maintenance of this pattern. If a voyeur manages to find a wife in spite of his interpersonal difficulties, as many do, he is rarely well-adjusted sexually in his relationship with his wife, as the following case illustrates.

A Peeping Tom A young, married college student had an attic apartment that was extremely hot during the summer months. To enable him to attend school, his wife worked; she came home at night tired and irritable and not in the mood for sexual relations. In addition, “the damned springs in the bed squeaked.” In order “to obtain some sexual gratification,” the youth would peer through his binoculars at the room next door and occasionally saw the young couple there engaged in erotic activities. This stimulated him greatly, and he decided to extend his peeping to a sorority house. During his second venture, however, he was reported and was apprehended by the police. This offender was quite immature for his age, rather puritanical in his attitude toward masturbation, and prone to indulge in rich but immature sexual fantasies.

More permissive laws concerning “adult” movies, videos, and magazines in recent years have removed some of the secrecy about sexual behavior and also have provided an alternative source of gratification for would-be voyeurs. However, for many voyeurs, these movies and magazines probably do not provide an adequate substitute for secretly watching the sexual behavior of an unsuspecting couple or the “real-life” nudity of a woman who mistakenly believes she enjoys privacy. Moreover, the actual effect of these “adult materials” on voyeurism is a matter of speculation because there never have been good epidemiological data on the prevalence of this paraphilia, although it is thought to be one of the most common paraphilias (Langstrom, 2010). The large Swedish survey mentioned earlier that was conducted with over 2,400 men and women found that 11.5 percent of the men and 3.0 percent of the women had at some time engaged in voyeuristic activity (Langstrom & Seto, 2006 ). Among those who did report such activity, they also reported more psychological problems, less satisfaction with life, higher rates of masturbation, greater use of pornography, and greater ease of sexual arousability.

Although a voyeur may become reckless in his behavior and thus may be detected or even apprehended by the police, voyeurism does not ordinarily have any other serious criminal or antisocial behaviors associated with it. In fact, many people probably have some voyeuristic inclinations, which are checked by practical considerations such as the possibility of being caught and by ethical attitudes concerning the right to privacy.

EXHIBITIONISTIC DISORDER

Exhibitionistic disorder (indecent exposure in legal terms) is diagnosed in a person with recurrent, intense urges, fantasies, or behaviors that involve exposing his genitals to others (usually strangers) in inappropriate circumstances and without their consent (see “DSM-5 Criteria” on p. 410). Frequently the element of shock in the victim is highly arousing to these individuals. The exposure may take place in some secluded location such as a park or in a more public place such as a department store, church, theater, or bus. In cities, an exhibitionist (also known as a flasher) often drives by schools or bus stops, exhibits himself while in the car, and then drives rapidly away. In many instances the exposure is repeated under fairly constant conditions, such as only in churches or buses or in the same general vicinity and at the same time of day. In one case, a youth exhibited himself only at the top of an escalator in a large department store. For a male offender, the typical victim is ordinarily a young or middle-aged female who is not known to the offender, although children and adolescents may also be targeted (Murphy, 1997 ).

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

Exhibitionism, which usually begins in adolescence or young adulthood, is the most common sexual offense reported to the police in the United States, Canada, and Europe, accounting for about one-third of all sexual offenses (McAnulty et al., 2001 ; Murphy, 1997 ). According to some estimates, as many as 20 percent of women have been the target of either exhibitionism or voyeurism (Kaplan & Krueger, 1997 ; Meyer, 1995 ). Although there are no good epidemiological data on the prevalence of this paraphilia, the large Swedish survey of over 2,400 people mentioned earlier reported that 4.1 percent of the men and 2.1 percent of the women had had at least one episode of exhibitionistic behavior (Langstrom & Seto, 2006 ). It commonly co-occurs with voyeurism and also tends to co-occur with sadomasochistic interests and cross-dressing (Langstrom, 2010). Exhibitionism is associated with greater psychological problems, lower life satisfaction, greater use of pornography, and more frequent masturbation.

In some instances, exposure of the genitals is accompanied by suggestive gestures or masturbation, but more often there is only exposure. A significant minority of exhibitionists commit aggressive acts, sometimes including coercive sex crimes against adults or children. Some men who expose themselves may do so because they have antisocial personality disorder, as described in Chapter 10 , rather than a paraphilia (Langstrom, 2010).

Despite the rarity of aggressive or assaultive behavior in these cases, an exhibitionistic act nevertheless takes place without the viewer’s consent and may be emotionally upsetting, as is indeed the perpetrator’s intent. This intrusive quality of the act, together with its explicit violation of propriety norms about “private parts,” ensures condemnation. Thus society considers exhibitionism a criminal offense.

FROTTEURISTIC DISORDER

Frotteurism is sexual excitement at rubbing one’s genitals against, or touching, the body of a nonconsenting person. As with voyeurism, frotteurism reflects inappropriate and persistent interest in something that many people enjoy in a consensual context. Frotteurism commonly co-occurs with voyeurism and exhibitionism (Langstrom, 2010). Being the victim of a frotteuristic act is fairly common among regular riders of crowded buses or subway trains. Some have speculated that frotteurs’ willingness to touch others sexually without their consent means that they are at risk for more serious sexual offending, but there is currently no evidence supporting this concern (Langstrom, 2010). Because frotteurism typically requires unwilling participation of others, frotteuristic disorder is diagnosed if frotteuristic acts occur, whether or not the frotteurer is, himself, bothered by his urges.

SEXUAL SADISM DISORDER

The term sadism is derived from the name of the Marquis de Sade (1740–1814), who for sexual purposes, inflicted such cruelty on his victims that he was eventually committed as insane. In DSM-5, for a diagnosis of sadism, a person must have recurrent, intense sexually arousing fantasies, urges, or behaviors that involve inflicting psychological or physical pain on another individual (see “DSM-5 Criteria” on p. 410). Sadistic fantasies often include themes of dominance, control, and humiliation (Kirsh & Becker, 2007). A closely related, but less severe, pattern is the practice of “bondage and discipline” (B & D), which may include tying a person up, hitting or spanking, and so on to enhance sexual excitement. The large majority of sexually sadistic acts probably occur in the context of a consensual sexual relationship without any evident harm. In large urban communities, there is often a BDSM subculture consisting of individuals who enjoy mild sadism, masochism, bondage, and discipline. It is thus important to distinguish transient or occasional interest in sadomasochistic practices from sadism as a paraphilia. Surveys have found that perhaps 5 to 15 percent of men and women enjoy sadistic and/or masochistic activities voluntarily on occasion (Baumeister & Butler, 1997 ; Hucker, 1997 ).

A small minority of men with sexual sadism, in contrast, enjoy inflicting sadistic acts that are nonconsensual, serious, and sometimes fatal (Chang & Heide, 2009 ; Dietz et al., 1990 ; Krueger, 2010 ) In some cases, sadistic activities lead up to or terminate in actual sexual relations; in others, full sexual gratification is obtained from the sadistic practice alone. A sadist, for example, might slash a woman with a razor or stick her with a needle, experiencing an orgasm in the process. The pain inflicted by sadists may come from whipping, biting, cutting, or burning; the act may vary in intensity, from fantasy to severe mutilation and even murder. Paraphilic sadism and masochism, in which sadomasochistic activities are the preferred or exclusive means to sexual gratification, are much rarer; not uncommonly, they co-occur in the same individual (Kirsh & Becker, 2007). DSM-5 requires that the diagnosis of sadism be reserved for cases either in which the victim is nonconsenting or in which the sadistic experience is marked by distress or interpersonal difficulties. Many cases of sexual sadism have comorbid disorders—especially the narcissistic, schizoid, or antisocial personality disorders (Kirsh & Becker, 2007). Perhaps sexual sadists with these personality disorders are especially non-empathic and thus likely to act on their sexual urges.

Extreme sexual sadists may mentally replay their torture scenes later while masturbating. Serial killers, who tend to be sexual sadists, sometimes record or videotape their sadistic acts. One study characterized 20 sexually sadistic serial killers who were responsible for 149 murders throughout the United States and Canada (Warren et al., 1996 ). Most were white males in their late 20s or early 30s. Their murders were remarkably consistent over time, reflecting sexual arousal to the pain, fear, and panic of their victims. Choreographed assaults allowed them to carefully control their victims’ deaths. Some of the men reported that the God-like sense of being in control of the life and death of another human being was especially exhilarating. Eighty-five percent of the sample reported consistent violent sexual fantasies, and 75 percent collected materials with a violent theme including audiotapes, videotapes, pictures, or sketches of their sadistic acts or sexually sadistic pornography.

Notorious serial killers include Ted Bundy, who was executed in 1989. Bundy confessed to the murder of over 30 young women, nearly all of whom fit a targeted type: women with long hair parted in the middle. Bundy admitted that he used his victims to re-create the covers of detective magazines or scenes from “slasher movies.” Jeffrey Dahmer was convicted in 1992 of having mutilated and murdered 15 boys and young men, generally having sex with them after death. (He was subsequently murdered in prison.) Dennis Rader, the BTK Killer (for Bind, Torture, Kill), was captured in 2005 after committing 10 murders over 30 years in Wichita, Kansas. Rader exemplifies several interesting phenomena associated with homicidal sexual sadism. As a child he tortured animals and fantasized about tying up and torturing attractive children he watched on television. When he began enacting his fantasies, he stalked his victims for weeks to learn their habits before he attacked them. He enjoyed tying them up and then strangled them. Only after they were dead would he gratify himself sexually through masturbation. He often retained clothing of his victims, which he would sometimes wear. Sometimes in private he would practice bondage on himself because he found this erotic.

Dennis Rader was married with two children, an active member in his church, and a respected member of the community; he was also a serial killer known as the BTK killer.

What causes some men to be sexually sadistic killers? Although many sadists have had chaotic childhoods, Bundy, Dahmer, and Rader all came from apparently stable and loving families. Unfortunately, we do not have a good understanding of the causal factors involved in these extreme cases of sadism.

Sexual sadism is understandably an important concern of criminologists, law enforcement officers, and forensic mental health professionals. Unfortunately, the diagnosis of sexual sadism is not very reliable (Marshall & Hucker, 2006 ) or valid (Kingston et al., 2010), perhaps due to the sadist’s unwillingness to his sometimes appallingly violent sexual fantasies (Nietschke et al., 2012). This is concerning, given how important it is to detect dangerous sexual sadists and how stigmatizing a diagnosis of sexual sadism might be to someone whose sexual desires are harmless. One promising modification currently being considered is a dimensional approach that could distinguish sexual sadists who are dangerous from those who are not (Krueger, 2010 ; Marshall & Hucker, 2006 ). Another is to focus on behavioral indicators of sadism, which are sometimes more apparent (Nietschke et al., 2012).

SEXUAL MASOCHISM DISORDER

The term masochism is derived from the name of the Austrian novelist Leopold V. Sacher-Masoch (1836–1895), whose fictional characters dwelt lovingly on the sexual pleasure of pain. In sexual masochism, a person experiences sexual stimulation and gratification from the experience of pain and degradation in relating to a lover. According to DSM-5 (see “DSM-5 Criteria” on p. 410), the person must have experienced recurrent, intense sexually arousing fantasies, urges, or behaviors involving the act of being humiliated, beaten, bound, or otherwise made to suffer.

Consensual sadomasochistic relationships, involving a dominant, sadistic “master” and a submissive, masochistic “slave” are not uncommon in either heterosexual or homosexual relationships. Such masochists do not usually want, or cooperate with, true sexual sadists and prefer individuals willing to hurt or humiliate them within preset limits. Masochism appears to be more common than sadism and occurs in both men and women (Baumeister & Butler, 1997 ; Sandnabba et al., 2002 ). Sadomasochistic activities, including bondage and discipline, are often performed communally within “dungeons” popular in major cities. Such activities might involve men being bound and whipped by women called “dominatrixes,” who wear tight leather or rubber outfits and are paid to inflict pain and humiliation in a sexually charged sense. Most members of this sadomasochistic community are high functioning and do not appear to suffer because of their sexual interests (Krueger, 2010 ). Watch the Video Jocelyn: Exploring Sexual Sadism and Masochism on MyPsychLab.

Some rare forms of masochism are more problematic, however. One particularly dangerous form of masochism, called autoerotic asphyxia, involves self-strangulation. Although some writers have speculated that loss of oxygen to the brain intensifies orgasm, there is little evidence that this motivates practitioners of autoerotic asphyxia. In contrast, studies of such practitioners have found that their sexual fantasies are strongly masochistic (Hucker, 2011). Coroners in most major U.S. cities are familiar with cases in which the deceased is found hanged next to masochistic pornographic literature or other sexual paraphernalia. Accidental deaths attributable to this practice have been estimated to range between 500 and 1,000 per year in the United States (LeVay & Baldwin, 2012). Although autoerotic asphyxia is much more common in men, it can occur in women too, and it has occurred across many cultures going back hundreds of years. In some cases it occurs in a consensual or nonconsensual sadomasochistic act between two or more people (McGrath & Turvey, 2008 ).

Sadomasochistic activities, including bondage and discipline, are often performed communally within “dungeons” popular in major cities.

The following is a case of autoerotic asphyxia with a tragic ending.

“I Got Tangled in the Rope” A woman heard a man shouting for help and went to his apartment door….

The woman with her two sons … broke into the apartment. They found the man lying on the floor, his hands tied behind him, his legs bent back, and his ankles secured to his hands. A mop handle had been placed behind 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 kitchen the woman found a knife and freed him.

When police officers arrived and questioned the man, he stated that he had returned home that afternoon, fallen asleep on his couch, and awakened an hour later only to find himself hopelessly bound. The officers noted that the apartment door had been locked when the neighbors broke in … [and] when the officers filed their report, they noted that “this could possibly be a sexual deviation act.” Interviewed the next day, the man confessed to binding himself in the position in which he was found.

A month later, the police were called back to the same man’s apartment. A building manager had discovered him face down on the floor in his apartment. A paper bag covered his head like a hood. When the police arrived, the man was breathing rapidly with a satin cloth stuffed in his mouth. Rope was stretched around his head and mouth and wrapped his chest and waist. Several lengths ran from his back to his crotch, and ropes at his ankles had left deep marks. A broom handle locked his elbows behind his back. Once freed, the man explained, “While doing isometric exercises, I got tangled up in the rope.” …

Two years passed and the man moved on to another job. He failed to appear for work one Monday morning. A fellow employee found him dead in his apartment. During their investigation, police were able to reconstruct the man’s final minutes. On the preceding Friday, he had bound himself in the following manner: sitting on his bed and crossing his ankles, left over right, he had bound them together with twine. Fastening a tie around his neck, he then secured the tie to an 86-inch pole behind his back…. [By a complicated set of maneuvers he applied] pressure to the pole, still secured to the tie around his neck, [and] strangled himself.

Source: Adapted with permission from DSM-IV-TR Casebook: A Learning Companion to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (pp. 86–88). (Copyright © 2002). American Psychiatric Association.

Causal Factors and Treatments for Paraphilias

Many individuals with paraphilias have explanations for their unusual sexual preferences. For example, one amputee paraphilic (whose preference was a partner with a missing limb) recalled that his fascination with female amputees originated during adolescence. He was neglected emotionally by his cold family but heard a family member express sympathetic feelings for an amputee. He developed the wish that he would become an amputee and thus earn their sympathy (see First, 2005 , for a discussion of this paraphilia, known as apotemnophilia). This story raises many questions. Emotionally cold families are not uncommon, and sympathy for amputees is nearly universal. Certainly not every male in a cold family who detects sympathy for amputees develops an amputee paraphilia. Such stories do not necessarily have any validity because we are often unaware of the forces that shape us (Nisbett & Wilson, 1977 ).

Several facts about paraphilia are likely to be important in their development. First, as we have already noted, nearly all persons with paraphilias are male; females with most paraphilias are so rare that they are found in the literature only as case reports or a series of case reports (e.g., Fedoroff et al., 1999 ). Second, paraphilias usually begin around the time of puberty or early adolescence. Third, people with paraphilias often have a strong sex drive, with some men often masturbating many times a day. Fourth, people with paraphilias frequently have more than one. For example, the corpses of men who died accidentally in the course of autoerotic asphyxia were partially or fully cross-dressed in 25 to 33 percent of cases (Blanchard & Hucker, 1991 ). There is no obvious reason for the association between sexual masochism and transvestism. Why should it be so?

Men’s vulnerability to paraphilias such as fetishism may be a result of their greater dependence on visual stimuli. This in turn makes them more likely to form sexual associations to nonsexual stimuli such as women’s legs or high-heeled shoes, quite possibly through a process of classical conditioning.

Money ( 1986 ) and others have suggested that male vulnerability to paraphilias is closely linked to their greater dependence on visual sexual imagery. Perhaps sexual arousal in men depends on physical stimulus features to a greater degree than in women, whose arousal may depend more on emotional context such as being in love with a partner. If so, men may be more vulnerable to forming sexual associations to nonsexual stimuli, which may be most likely to occur after puberty, when the sexual drive is high. Many believe that these associations arise as a result of classical and instrumental conditioning and/or social learning that occurs through observation and modeling. When observing paraphilic stimuli (e.g., photographs of models in their underwear), or when fantasies about paraphilic stimuli occur, boys may masturbate, and the reinforcement by orgasm-release may serve to condition an intense attraction to paraphilic stimuli (e.g., Kaplan & Krueger, 1997 ; LeVay & Baldwin, 2012). This hypothesis cannot explain, however, why only a small minority of males develop fetishes for panties and bras, despite the nearly universal experience of masturbating to pictures or videos of women wearing them.

TREATMENTS FOR PARAPHILIAS

The vast majority of studies concerning the treatment of paraphilias have been conducted with sex offenders. The literature concerning treatment of men with paraphilias who have not committed any offense, or who have victimless paraphilias (e.g., masochism), consists primarily of case reports because most people with paraphilias do not seek treatment for these conditions. Thus we defer discussion of the treatment of paraphilias until we discuss the treatment of sex offenders, many of whom have paraphilias.

Gender Dysphoria

In DSM-5 Gender Dysphoria has replaced Gender Identity Disorder. “Gender dysphoria” is discomfort with one’s sex-relevant physical characteristics or with one’s assigned gender. The change in terminology is both usefully descriptive and theoretically neutral. That is, individuals who have been previously diagnosed with gender identity disorder certainly experience gender dysphoria, but whether or not this is always due to atypical gender identity development is less clear. Gender dysphoria also is consistent with a dimensional approach (the degree of dysphoria can vary) and may fluctuate over time within the same individual (Cohen-Kettenis & Pfafflin, 2010). Gender dysphoria can be diagnosed at two different life stages, either during adolescence or adulthood (i.e., gender dysphoria in adolescents and adults) or childhood (gender dysphoria in children). Watch the Video Travis: Gender Dysphoria onMyPsychLab.

DSM-5 criteria for: Gender Dysphoria

Gender Dysphoria in Children

· A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months’ duration, as manifested by at least six of the following (one of which must be Criterion A1):

· 1. A strong desire to be of the other gender or an insistence that one is the other gender (or some alternative gender different from one’s assigned gender).

· 2. In boys (assigned gender), a strong preference for cross-dressing or simulating female attire; or in girls (assigned gender), a strong preference for wearing only typical masculine clothing and a strong resistance to the wearing of typical feminine clothing.

· 3. A strong preference for cross-gender roles in make-believe play or fantasy play.

· 4. A strong preference for the toys, games, or activities stereotypically used or engaged in by the other gender.

· 5. A strong preference for playmates of the other gender.

· 6. In boys (assigned gender), a strong rejection of typically masculine toys, games, and activities and a strong avoidance of rough-and-tumble play; or in girls (assigned gender), a strong rejection of typically feminine toys, games, and activities.

· 7. A strong dislike of one’s sexual anatomy.

· 8. A strong desire for the primary and/or secondary sex characteristics that match one’s experienced gender.

· B. The condition is associated with clinically significant distress or impairment in social, school, or other important areas of functioning.

GENDER DYSPHORIA IN CHILDHOOD

Boys with gender dysphoria show a marked preoccupation with traditionally feminine activities (Zucker, 2010; Zucker & Bradley, 1995 ). They may prefer to dress in female clothing. They enjoy stereotypical girls’ activities such as playing dolls and playing house. They usually avoid rough-and-tumble play and often express the desire to be a girl. Boys with gender dysphoria are often ostracized as “sissies” by their peers.

Girls with gender dysphoria typically balk at parents’ attempts to dress them in traditional feminine clothes such as dresses, preferring boys’ clothing and short hair. Fantasy heroes typically include powerful male figures like Batman and Superman. They show little interest in dolls and increased interest in sports. Although mere tomboys frequently have many or most of these traits, girls with gender identity disorder are distinguished by their desire to be a boy or to grow up as a man. Young girls with gender dysphoria are treated better by their peers than are boys with gender dysphoria because cross-gender behavior in girls is better tolerated (Cohen-Kettenis et al., 2003 ; Zucker et al., 1997 ). In clinic-referred gender dysphoria, boys outnumbered girls five to one in one study (Cohen-Kettenis et al., 2003 ) and by three to one in another study (Cohen-Kettenis et al., 2006 ). An appreciable percentage of that imbalance may reflect greater parental concern about femininity in boys than about masculinity in girls.

The most common adult outcome of boys with gender dysphoria has been homosexuality rather than transsexualism (Zucker, 2005 ). In Richard Green’s ( 1987 ) prospective study of 44 very feminine boys from the community, only one sought sex change surgery by age 18. About three-quarters became gay or bisexual men who were evidently satisfied with their biological sex. However, several later studies of clinic-referred children have found that 10 to 20 percent of boys with gender dysphoria later were diagnosed as transsexual by age 16 or 18, and about 40 to 60 percent identified themselves as homosexual or bisexual, a percentage that may have increased by the time they were older (Zucker, 2005 ). There are several smaller prospective studies of girls with gender dysphoria that have shown that 35 to 45 percent may show persistent gender dysphoria (leading to a desire for sex reassignment surgery in many), and approximately half had a homosexual orientation. However, the largest prospective study to date, which followed 25 girls with gender dysphoria (ages 3–12) into young adulthood (average age 23), found somewhat lower rates of persistent gender dysphoria and homosexuality. At follow-up, three were classified as being dissatisfied with their gender, and two of these three wanted to have sex reassignment surgery. However, 32 percent had homosexual or bisexual fantasies, and 24 percent engaged in homosexual or bisexual behavior. These rates are clearly much higher than expected from base rates of gender dysphoria in the population but not as high as in boys with gender dysphoria (Drummond et al., 2008 ).

DSM-5 criteria for: Gender Dysphoria in Adolescents and Adults

· A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months’ duration, as manifested by at least two of the following:

· 1. A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or in young adolescents, the anticipated secondary sex characteristics).

· 2. A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics).

· 3. A strong desire for the primary and/or secondary sex characteristics of the other gender.

· 4. A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender).

· 5. A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender).

· 6. A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender).

· B. The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Given that many such children typically adjust well in adulthood, should they be considered to have a mental disorder as children? Some have argued that such children should not be considered “disordered” because the primary obstacle to their happiness may be a society that is intolerant of cross-gender behavior. However, many researchers who work with these children maintain that the distress and unhappiness these children and adolescents have about the discrepancy between their biological sex and their psychological gender are consistent with this being called a mental disorder (e.g., Zucker, 2005 , 2010). Moreover, these children are frequently mistreated by their peers and have strained relations with their parents even though their cross-gender behavior harms no one.

Research from non-Western cultures shows that stigma-tization of gender-nonconforming children is not universal (Vasey & Bartlett, 2007 ). In Samoa, very feminine males are often considered “Fa’afafine” (roughly meaning “in the manner of women”), a kind of third gender, neither male nor female. Fa’afafine are identified as young children by their behavior and usually are accepted by their families and culture. As adults these individuals are sexually attracted to other men and typically have sexual relations with heterosexual men. They generally do not recall that their childhood gender nonconformity was associated with distress. Because of this, some have argued that childhood gender dysphoria should not appear in DSM-5 (Vasey & Bartlett, 2007 ). Despite these objections, the diagnosis has been retained as gender dysphoria in children (Zucker, 2010).

Treatment Children and adolescents with gender dysphoria are often brought in by their parents for psychotherapy (Zucker et al., 2008 ). Specialists attempt both to treat the child’s unhappiness with his or her biological sex and to ease strained relations with parents and peers. Children with gender dysphoria often have other general psychological and behavioral problems such as anxiety and mood disorders that also need therapeutic attention (Zucker et al., 2002 ). Therapists try to improve peer and parental relations by teaching such children how to reduce their cross-gender behavior, especially in situations where it might cause interpersonal problems. Gender dysphoria is typically treated psychodynamically—that is, by examining inner conflicts. Controlled studies evaluating such treatment remain to be conducted (Zucker, 2005 ). If a child will eventually transition into the other sex, it is beneficial to prevent full sexual maturity from occurring in the original, unwanted sex. Thus, in the progressive Netherlands, under some circumstances, gender dysphoric early adolescents are given hormonal treatment to delay puberty while they decide how to proceed (Cohen-Kettenis, 2010).

Two related facts about gender dysphoria in children are especially important clinically. First, as we have noted, most gender dysphoric children do not become gender dysphoric adults. The problem generally remits during childhood (Wallien & Cohen-Kettenis, 2008). Second, individuals who are still gender dysphoric into adolescence are likely to remain so into adulthood, and they are also likely to take medical steps to transform their bodies. The crucial age period at which many gender dysphoric children desist or persist appears to be 10 to 13 (Steensma et al., 2011 ). Increasing numbers of parents of gender dysphoric children cooperate with their children’s wishes and allow them socially to assume an identity opposite their birth sex (Rosin, 2008). On the one hand, this surely decreases the anguish that such children feel. On the other hand, it is plausible that this strategy will ultimately lead to more transsexual adolescent or adult outcomes.

TRANSSEXUALISM

Transsexualism occurs in adults with gender dysphoria who desire to change their sex, and surgical advances have made this goal, although expensive, partially feasible. Transsexualism represents the extreme on a continuum of transgenderism, or the degree to which one identifies as the other sex (Cohen-Kettenis & Pfafflin, 2010). Transsexualism is apparently a very rare disorder. In the past, European studies suggested that approximately 1 in 30,000 adult males and 1 in 100,000 adult females seek sex reassignment surgery. However, more recent estimates suggest that about 1 in 12,000 men in Western countries has actually undergone the surgery (Lawrence, 2007 ). Until fairly recently, most researchers assumed that transsexualism was the adult version of childhood gender dysphoria, and indeed this is often the case. That is, many transsexuals had gender dysphoria as children (despite the fact that most children with gender dysphoria do not become transsexual), and their adult behavior is analogous. This appears to be the case for the large majority of female-to-male transsexuals (individuals born female who become male). Virtually all such individuals recall being extremely tomboyish, with masculinity persisting unabated into adulthood. Most, but not all, female-to-male transsexuals are sexually attracted to women.

In contrast to female-to-male transsexuals, there are at least two kinds of male-to-female transsexuals, with very different causes and developmental courses: homosexual and autogynephilic transsexuals(Bailey, 2003 ; Blanchard, 1989 ). Homosexual trans-sexual men are generally very feminine and have the same sexual orientation as gay men: They are sexually attracted to biological males (their preoperative biological sex). However, because these transsexual men experience their gender identity as female, they often define their sexual orientation as heterosexual and resent being labeled gay. Thus what is referred to in the research literature as a homosexual male-to-female transsexual is a genetic male seeking a sex change operation who describes himself as a woman trapped in a man’s body and who is sexually attracted to heterosexual male partners (Bailey, 2003 ). In contrast, autogynephilic transsexuals are motivated by autogynephilia —a paraphilia in which their attraction is to thoughts, images, or fantasies of themselves as a woman (Blanchard, 1991 , 1993 ). Although it may not be relevant for treatment purposes (both types of transsexuals are appropriate candidates for sex reassignment surgery), this distinction is fundamental to understanding the diverse psychology of male-to-female transsexualism. Moreover, estimates show an increased prevalence in Western countries of male-to-female transsexualism in recent years, and most of this increase is in autogynephilic transsexualism (Lawrence, 2007 ).

One important finding is that homosexual transsexuals generally have had gender dysphoria since childhood, paralleling what is found in female-to-male transsexuals, as discussed above. However, because most boys with gender dysphoria do not become transsexual adults (but instead become gay or bisexual men), there must be other important determinants of transsexualism. One hypothesis is that there are some prenatal hormonal influences affecting which children who develop gender identity disorder later become transsexuals (Meyer-Bahlburg, 2011). Another is that some families are more systematic in their support of boys’ defeminization compared with other families.

Autogynephilic (sometimes called heterosexual) transsexualism almost always occurs in genetic males who usually report a history of transvestic fetishism. However, unlike other transvestites, autogynephilic transsexuals fantasize that they have female genitalia, which can lead to acute gender dysphoria, motivating their desire for sex reassignment surgery. Autogynephilic transsexuals may report sexual attraction to women, to both men and women, or to neither. Research has shown that these subtypes of autogynephilic transsexuals (varying in sexual orientation) are very similar to each other and differ from homosexual transsexuals in other important respects (Bailey, 2003 ; Blanchard, 1985 , 1989 , 1991 ). For example, relative to homosexual transsexuals, the autogynephilic transsexuals have more fetishistic and masochistic tendencies, a stronger preference for younger and more attractive partners, and a stronger interest in uncommitted sex (Veale et al., 2008 ). Unlike homosexual transsexuals, autogynephilic transsexuals do not appear to have been especially feminine in childhood or adulthood, and they typically seek sex reassignment surgery much later in life than do homosexual transsexuals (Blanchard, 1994 ). The causes of autogynephilic transsexualism thus probably overlap etiologically with the causes of other paraphilias (with which they often co-occur) but are not yet well understood (Veale et al., 2008 ).

Mianne Bagger (a Danish-born Australian resident) is a male-to-female transsexual who has golfed professionally in women’s tournaments since 2003. She is the first known female professional golfer who was born male. Before she could play women’s tournaments, rule changes had to be implemented in Europe, Australia, and other countries so that it was no longer required that a competitor be female at birth.

Autogynephilia remains a controversial concept among some transgender individuals, who object that autogynephilia is inconsistent with their experiences and that their motivation to change their sex is not sexual. Some supporters of the theory of autogynephilia attribute the denial of autogynephilia to factors including sexual shame and stigmatization (Bailey & Triea, 2007 ). In DSM-IV-TR adult gender identity disorder, the distinction between homosexual and autogynephilic transsexualism was recorded as a specifier: the patient’s sexual orientation. This practice was intended to facilitate data collection regarding possible important clinical differences between the two types. However, for complex reasons a subgroup of transsexuals vehemently dislikes the idea that there are two different kinds of male-to-female transsexuals; they are especially hostile to the notion of autogynephilia (Dreger, 2008 ). For this reason, the specifier of sexual orientation has been removed from adult gender dysphoria in DSM-5. Sexual orientation (i.e., the distinction between homosexual and autogynephilic) appears to be a highly valid predictor of other differences between the two types of male-to-female transsexuals (Lawrence, 2010 ). However, this appears to be a case in which a trade-off was made between scientific rigor and social acceptability.

Treatment Psychotherapy is usually not effective in helping adolescents or adults to resolve their gender dysphoria (Cohen-Kettenis et al., 2000 ; Zucker & Bradley, 1995 ). The only treatment that has been shown to be effective is surgical sex reassignment. Initially, transsexuals who want and are awaiting surgery are given hormone treatment. Biological men are given estrogens to facilitate breast growth, skin softening, and shrinking of muscles. Biological women are given 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, and they generally must live at least a year as the gender they wish to become. If they successfully complete the trial period, they undergo surgery and continue to take hormones indefinitely. In male-to-female transsexuals, this entails removal of the penis and testes and the creation of an artificial vagina. One fascinating study of 11 male-to-female transsexuals found that the artificial vaginal tissue created from penile tissue showed signs of sexual arousal to male erotic stimuli if the person was a homosexual male-to-female transsexual, and to female erotic stimuli if the person was an autogynephilic trans-sexual (Lawrence et al., 2005 ). In general, the transsexual neo-vagina is sexually functional. Male-to-female transsexuals usually also undergo extensive electrolysis to remove their beards and body hair. They also learn to raise the pitch of their voice.

Female-to-male transsexuals typically are given mastectomies and hysterectomies and often have other plastic surgery to alter various facial features (such as the Adam’s apple). Only a subset of female-to-male transsexuals seeks an artificial penis because relevant surgical techniques are still somewhat primitive and very expensive. Moreover, the artificial penis is not capable of normal erection, so those who have this surgery must rely on artificial supports to have intercourse anyway. The others function sexually without any penis.

Does sex reassignment surgery help transsexuals lead satisfying lives? In 1990 a review of the outcome literature found that 87 percent of 220 male-to-female transsexuals had satisfactory outcomes (meaning that they did not regret their decisions) and that 97 percent of 130 female-to-male transsexuals had successful outcomes (Green & Fleming, 1990 ). More recent studies have reported similar findings. Thus the majority of transsexuals are satisfied with the outcome of sex reassignment surgery, although there is variability in the degree of satisfaction (Cohen-Kettenis & Gooren, 1999 ; Lawrence, 2006 ). The Lawrence study ( 2006 ) of 232 male-to-female transsexuals all operated on by the same surgeon found the participants to be least satisfied with vaginal lubrication and vaginal touch sensations, although overall level of satisfaction was still high. Regarding psychological adjustment, a recent follow-up showed that transsexuals who had sex reassignment surgery were less well-adjusted compared with normal controls (Dhejne et al., 2011 ). The optimal comparison, however, is not with normal controls but with transsexuals desiring but not given sex reassignment surgery. In spite of the reasonably good success record for transsexual patients who are carefully chosen, such surgery remains controversial because some professionals continue to maintain that it is inappropriate to treat psychological disorders through drastic anatomical changes.

in review

· • Define paraphilia, and cite six paraphilias recognized in the DSM, along with their associated features.

· • What two components characterize gender dysphoria?

· • Identify the two types of male-to-female transsexuals, and describe their developmental course as well as that of female-to-male transsexuals.

· • What are the most effective treatments for childhood gender dysphoria and adult transsexualism?

Sexual Abuse

Sexual abuse is sexual contact that involves physical or psychological coercion or at least one individual who cannot reasonably consent to the contact (e.g., a child). Such abuse includes pedophilia, incest, and rape, and it concerns society much more than any other sexual problem. It is somewhat ironic, then, that of these three forms of abuse, only pedophilia is included in DSM-5. This partly reflects the seriousness with which the society views these offenses and its preference for treating coercive sex offenders as criminals rather than as having a mental disorder (although obviously many criminals also have mental disorders).

Childhood Sexual Abuse

The past few decades have seen intense concern about childhood sexual abuse, with an accompanying increase in relevant research. There are at least three reasons for including some discussion of this here. First, as noted in previous chapters, there are possible links between childhood sexual abuse and some mental disorders, so such abuse may be important in the etiology of some disorders (see especially Chapters 3 , 5 , 8 , and 10 ). Second, much evidence suggests that, broadly defined, childhood sexual abuse is more common than was once assumed, and it is important to understand some of its causes. Third, some dramatic and well-publicized cases involving allegations of childhood sexual abuse have raised very controversial issues such as the validity of children’s testimony and the accuracy of recovered memories of sexual abuse. We shall consider all three of these issues in turn.

PREVALENCE OF CHILDHOOD SEXUAL ABUSE

The prevalence of childhood sexual abuse depends on its definition, which has varied substantially across studies. For example, different studies use different definitions of “childhood,” with the upper age limit ranging from 12 to as high as 19 years. Some studies have counted any kind of sexual interaction, even that which does not include physical contact (e.g., exhibitionism); others have counted only physical contact; others have counted only genital contact; and still others have counted consensual sexual contact with a minor. A recent review of data from 22 countries estimated that 7.9 percent of men and 19.7 percent of women had suffered sexual abuse prior to age 18. The highest rates were from African countries, and the lowest rates were from Europe; U.S. figures were intermediate. Obviously “prior to age 18” comprises a wide range of ages, and, for example, age 17 is not always viewed as part of childhood.

CONSEQUENCES OF CHILDHOOD SEXUAL ABUSE

Childhood sexual abuse may have both short-term and long-term consequences. The most common short-term consequences are fears, posttraumatic stress disorder (PTSD), sexual inappropriateness (e.g., touching others’ genitals or talking about sexual acts), and poor self-esteem, but approximately one-third of sexually abused children show no symptoms (e.g., Kendall-Tackett et al., 1993 ; McConaghy, 1998 ).

Associations between reports of childhood sexual abuse and adult psychopathology have been commonly reported (Maniglio, 2009). Specific examples include borderline personality disorder (Bandelow et al., 2005 ; Battle et al., 2004 ), somatization disorder with dissociative symptoms (Sar et al., 2004 ), and dissociative identity disorder (Maldonado & Spiegel, 2007 ; Ross, 1999 ). A wide variety of sexual symptoms have also been alleged to result from early sexual abuse (e.g., Leonard & Follette, 2002 ; Loeb et al., 2002 ; see review in Maniglio, 2009), ranging, for example, from sexual aversion to sexual promiscuity. A similar range of negative consequences has also been reported in a sample of about 3,000 male and female adults in China, although the rate of childhood sexual abuse in China is lower than in Western countries (Luo et al., 2008 ). Unfortunately, as discussed in Chapters 8 and 10 , knowledge about these hypothesized associations is very limited because of difficulties in establishing causal links between early experiences and adult behavior (see also “Unresolved Issues”).

CONTROVERSIES CONCERNING CHILDHOOD SEXUAL ABUSE

Several types of high-profile criminal trials have highlighted the limitations of our knowledge concerning questions of great scientific and practical importance. In one type of case, children have accused adults working in day care settings of extensive, often bizarre sexual abuse, and controversial issues have been raised about the degree to which children’s accusations can be trusted. In a second type of case, adults claim to have repressed and completely forgotten memories of early sexual abuse and then to have “recovered” the memories during adulthood, typically while seeing a therapist who believes that repressed memories of childhood sexual abuse are a very common cause of adult psychopathology. Many controversial issues have been raised about the validity of these “recovered” memories.

Children’s Testimony Several cases of alleged sexual abuse in day care settings shocked the country starting in the 1980s and continuing into the early 1990s. The most notorious was the McMartin Preschool case in California (Eberle & Eberle, 1993 ). In 1983, Judy Johnson complained to police that her son had been molested by Raymond Buckey, who helped run the McMartin Preschool, which her son attended. Johnson’s complaints grew increasingly bizarre. For example, she accused Buckey of sodomizing her son while he stuck the boy’s head in a toilet and of making him ride naked on a horse. Johnson was later diagnosed with acute paranoid schizophrenia, and she died of alcohol-related liver disease in 1986. By the time she died, prosecutors no longer needed her. Children at the preschool who were interviewed began to tell fantastically lurid stories—for example, that they were forced to dig up dead bodies at cemeteries, jump out of airplanes, and kill animals with bats. Nevertheless, prosecutors and many McMartin parents believed the children. Buckey and his mother (who owned the day care facility) were tried in a trial that took two and a half years and cost $15 million. The jury acquitted Ms. Buckey on all counts and failed to convict Raymond Buckey on any; however, he was freed only after retrial, after having spent 5 years in jail. The jurors’ principal reason for not finding the defendants guilty was their concern that interviewers had used leading questions or coercive methods of questioning. Moreover, subsequent research on children who reported satanic abuse found no evidence (including physical evidence) that such abuse had occurred, and so any such reports of satanic abuse are scientifically very doubtful (London et al., 2005 ). Despite these concerns, some day care workers accused of satanic sexual abuse have served years in prison.

Obviously, investigations of possible child sexual abuse will often depend on the reports and testimony of children. We have noted the tendency in recent times of people to believe children’s reports, no matter how unlikely they seem. Is the confidence in children’s reports of sexual abuse well-founded? In a very important series of studies, the psychologists Stephen Ceci and Maggie Bruck have shown that children can easily be led to concoct stories of events that never occurred (Bruck et al., 2002 ; Ceci et al., 2000 , 2007 ; London et al., 2005 ). The likelihood of concocting stories increases when interviewers have asked leading questions, repeated questioning, and reinforcing some kinds of answers more than others. This research shows that failure to proceed with care in interrogating children can easily lead to false accusations and injustice. In the legal case U.S. v. Desmond Rouse (2004), a federal appeals court (i.e., a court just below the U.S. Supreme Court) established new rules for evaluating the admissibility of children’s testimony based almost exclusively on the work of Ceci and Bruck.

Evidence has suggested that the use of anatomically correct dolls to question young children about where they may have been touched in alleged incidents of sexual abuse does not improve the accuracy of their testimony relative to verbal interviews alone.

Recovered Memories of Sexual Abuse In 1990, a young woman named Eileen Franklin testified in court that she had seen her father rape and murder an 8-year-old playmate 20 years earlier. Remarkably, despite her claim to have witnessed the murder, she had 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 overturned because of two serious constitutional errors made during the original trial that might have affected the jury’s verdict. In a different kind of case, Patricia Burgus sued her two psychiatrists in Chicago for false-memory implantation, claiming the doctors had persuaded her through hypnosis and other therapeutic techniques “to believe that she was a member of a satanic cult, that she was sexually abused by multiple men, and that she engaged in cannibalism and abused her own children” (Brown et al., 2000 , p. 3). In 1997 she was awarded $10.6 million.

As discussed in some detail in Chapter 8 , whether traumatic experiences can be utterly forgotten and then somehow recovered intact years later has been heatedly debated over the past several decades. Some have argued that repressed memories are common (e.g., Herman, 1993 ) and are responsible for a great deal of psychopathology. In the controversial but very popular book The Courage to Heal, journalists Ellen Bass and Laura Davis assert, “If you are unable to remember any specific instances [of sexual abuse] … but still have the feeling that something abusive happened to you, it probably did” (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 their clients, and those clients often do report “recovering” such memories. Those skeptical about recovery of repressed memories point out that even normal, unrepressed memories can be highly inaccurate and that false memories can be induced experimentally (Davis & Loftus, 2009; Loftus et al., 1995 ) (see Chapter 8 ). The debate about the validity of memories of childhood sexual abuse that arise during therapy remains extremely heated. Some researchers (the nonbelievers) maintain that the concept of repressed memory is wholly or largely invalid. In their view, virtually all “recovered memories” are false (Crews, 1995 ; Davis & Loftus, 2009; Thomas & Loftus, 2002 ). Others (the believers) maintain that false memories rarely occur and that recovered memories are typically valid. Still others believe that valid recovered memories are simply the remembering of events forgotten because, at the time, they were not traumatic (McNally & Geraerts, 2009 ). Psychologists equally familiar with the evidence have argued bitterly about this issue, and, as discussed in more detail in Chapter 8 , a task force assembled by the American Psychological Association to study the issue in the mid-1990s failed to reach a consensus, although an online guide urges caution (“Questions and answers about childhood sexual abuse,” 2013 ). Indeed, the debate concerning recovered memories of sexual abuse is one of the most important and interesting contemporary controversies in the domains of psychopathology and mental health, as discussed in the Unresolved Issues section in Chapter 8 . Despite the continuing controversy among scientists, cases of recovered memories of sexual abuse appear to have become much rarer. A survey conducted of the False Memory Syndrome Foundation—largely parents who say they have been accused by their children of sexual abuse based on recovered memories—showed that accusations peaked in 1991 and 1992, with 579 made during that time. In 1999 and 2000 only 36 accusations were made (McHugh & Kreek, 2004 ).

Pedophilic Disorder

According to DSM-5, pedophilic disorder —a paraphilic disorder not discussed earlier—is diagnosed when an adult has recurrent, intense sexual urges or fantasies about sexual activity with a prepubertal child; acting on these desires is not necessary for the diagnosis if they cause the pedophile distress (see “DSM-5Criteria” on p. 410). DSM-5 retains the wording of DSM-IV-TR, that a child is understood to be “generally age 13 or younger.” In doing so, the DSM-5 rejected two potentially important suggestions from the DSM-5subcommittee on paraphilias: first, that pedophilia be diagnosed according to the degree of physical maturity of the child (as rated by Tanner scores, which index degree of pubertal maturation), and second, that diagnostic criteria for pedophilia (attraction to prepubescent children) be changed to include men with hebephilia (attraction to pubescent children—children in the early stages of puberty). The debate over these proposals was heated, and the issues are interesting. We believe that DSM-5 should have made the changes. Read the Thinking Critically About DSM-5 to see if you agree.

Pedophiles’ sexual interaction with children frequently involves manual or oral contact with a child’s genitals; penetrative anal or vaginal sex is much rarer. Although penetration and associated force are often injurious to the child, injuries are usually a byproduct rather than the goal they would be with a sadist (although a minority of men diagnosed with pedophilic disorder are also sexual sadists; Cohen & Galynker, 2002 ).

Nearly all individuals with pedophilia are male, and about two-thirds of pedophilic offenders’ victims are girls, typically between the ages of 8 and 11 (Cohen & Galynker, 2002 ). Most pedophiles prefer girls, but perhaps one in four prefers boys. The rate of homosexuality among pedophiles is much higher than the analogous rate among normal adult-attracted men (Seto, 2008 ). Although some social conservatives have argued that this shows that gay men tend to commit pedophilic acts, this is an incorrect inference. Gay men are no more interested in male children than heterosexual men are in female children. Homosexual pedophilia is an entirely different erotic preference from normal male homosexuality (Herek, 2009). Homosexual pedophilic sex offenders tend to have more victims than heterosexual pedophilic sex offenders (Blanchard et al., 2000 ; Cohen & Galynker, 2002 ). One survey of pedophiles found that a majority have used childhood pornography (Seto, 2004 ).

Studies investigating the sexual responses of men with pedophilia have revealed several patterns of results (Barbaree & Seto, 1997 ; Seto et al., 2006 ). Such studies typically use a penile plethysmograph to measure erectile responses to sexual stimuli directly rather than relying on self-report. (A plethysmograph consists of an expandable band placed around the penis that is connected to a recording device.) Men with pedophilia typically show greater sexual arousal than matched nonoffenders in response to pictures of nude or partially clad girls—and greater arousal to such pictures than to pictures of adult women. But some men with pedophilia respond to children as well as to adolescents and/or adults (Seto, 2004 ; Seto et al., 1999 ).

DSM-5 THINKING CRITICALLY about DSM-5: Pedophilia and Hebephilia

Pedophilia has been understood and defined as attraction to prepubertal children, that is, children without any signs of puberty (e.g., no pubic hair, breast growth, or penis growth). However, studies of sex offenders, both of victim characteristics and of offender sexual arousal patterns, have unequivocably demonstrated the existence of a subgroup who are most aroused not to prepubescent children, but to pubescent children (children in the early stages of puberty). Scientists have called such men hebephiles. Pubescent children are not fully sexually mature, despite showing some signs of pubertal development. Pedophilia and hebephilia appear to be closely related, because it is not uncommon for pedophiles also to be attracted to pubescent children and hebephiles to prepubescent children. The DSM-5 paraphilias subcommittee proposed that the definition of pedophilia be expanded to include attraction to pubescent children. (That is, the proposal was that DSM-5 pedophilia would now include hebephilia as well as DSM-IV-TR pedophilia.) Furthermore, instead of diagnosing pedophilia based on the age of children to whom a man is sexually attracted (i.e., 13 years old and younger), the committee proposed that diagnosis be made based on the physical maturity of the children. They proposed that this be done on the basis of well-known developmental markers. (These markers, called Tanner scores, represent the degree of pubertal maturation and range from “none” to “completed.”) This would be more diagnostically accurate than relying on children’s ages because children mature at variable rates. A 12-year-old girl might be prepubescent, but in this day and age she is more likely to be pubescent because most girls in the United States have begun puberty by that age (Razzak, 2012 ).

In DSM-IV-TR, which relied on child victims’ ages, a diagnosis of pedophilia would be likely regardless of the girl’s level of physical maturity. But the DSM-IV-TR diagnostic criteria for pedophilia defined it as sexual attraction to prepubescent children. Thus, DSM-IV-TR diagnostic criteria for pedophilia often led to technically inaccurate diagnoses. Using physical maturity rather than age of desired children to diagnose pedophilia would require that clinicians think correctly about the meaning of pedophilia.

The proposed changes proved highly controversial because of the proposed expansion of pedophilia to include attraction to pubescent children. Opponents of its inclusion asserted that attraction to pubescent girls is characteristic of normal men (e.g., Rind & Yuill, 2012 ; Wakefield, 2012 ). The idea that normal men are attracted to pubescent children is largely mistaken, and represents a failure to appreciate the physical immaturity of children in the early stages of puberty, compared with children or adolescents who have completed puberty. In the end, the DSM-5 rejected both the expansion of the definition of pedophilia to include attraction to pubescent children and diagnosing pedophilia on the basis of desired children’s degree of sexual maturity (focusing on developmental markers of prepubescence and pubescence). Instead, DSM-5 retains the internally contradictory criteria of DSM-IV-TR, namely that pedophilia is attraction to prepubescent children, and that prepubescence is understood as “younger than age 13” even though many of such children are not prepubescent. Many people working in the area are not pleased that DSM-5 did not make the proposed changes. What do you think?

Child molesters are more likely than nonoffenders to engage in self-justifying cognitive distortions, including the beliefs that children will benefit from sexual contact with adults and that children often initiate such contact (Marziano et al., 2006 ). Motivationally, many pedophilic child molesters appear to be shy and introverted yet still desire mastery or dominance over another individual. Some also idealize aspects of childhood such as innocence, unconditional love, or simplicity (Cohen & Galynker, 2002 ).

Pedophilia usually is first recognized in adolescence and persists over a person’s life. Many pedophiles engage in work with children or youth so that they have extensive access to children. Some pedophiles never act on their preferences, but many do. It is currently impossible to estimate the proportion of men with pedophilia who remain child-celibate. Several studies show that adolescent and adult men with pedophilia are much more likely to have been sexually or physically abused as children than are rapists of adults (Daversa & Knight, 2007 ; Lee & Katzman, 2002 ). The meaning of this association remains unclear.

Recent research findings also support the importance of several neurobiological influences on pedophilia. Compared with non-pedophilic sex offenders, men with pedophilia have lower IQs (Cantor, Blanchard et al., 2005 ; Seto, 2004 ), threefold higher rates of non-right-handedness (Cantor, Klassen et al., 2005 ; Seto, 2004 ), higher rates of head injuries resulting in loss of consciousness, and differences in brain structure detected by brain-imaging techniques, at least some of which are critical for normal sexual development (Cantor et al., 2008 ; Schiltz et al., 2007 ). All these findings point to pedophilia involving certain perturbations of early neurodevelopment that may create a vulnerability to the disorder.

For several decades we have seen an increasing number of cases of child molestation among a group long considered to be highly trustworthy: the Catholic clergy. Although the majority of priests are innocent of sexual wrongdoing, the Catholic Church has been repeatedly forced to admit that a significant minority have sexually abused children. In a large study of the problem, 81 percent of complainants against Catholic clergy were male, and more than 40 percent of cases involved children aged 12 or younger when the alleged abuse began (John Jay College of Criminal Justice, 2004). At least 400 priests were charged with sexual abuse during the 1980s, and $400 million was paid in damages between 1985 and the early 1990s (Samborn, 1994 ). One very serious scandal involved James R. Porter, a 57-year-old father of four who was alleged to have sexually abused as many as 100 children when he was a priest in Massachusetts during the 1960s. (Complicating the case, some but not all of the accusations against him were based upon recovered memories.) Porter later admitted to some of his offenses and was convicted. The Church settled a multimillion-dollar suit with 25 men whom Porter was convicted of abusing.

Scandal in the Catholic Church erupted anew in 2002, with heightened publicity regarding revelations that not only had a substantial number of priests in many cities been sexually involved with children and adolescents, but a significant number had also been protected by their superiors. Indeed, this scandal led, after a prolonged public outcry, to the resignation of Cardinal Bernard Law of the Archdiocese of Boston. Over many years, Law had protected numerous priests who were guilty of sexual misconduct, allowing them to move from one parish to another after their sexual misconduct was discovered. Thus he allowed their sexual molestation to continue with more and more girls and boys. The Conference of Bishops subsequently adopted a policy of mandatory removal of any priest from his ministerial duties if he is known to have had sexual contact with a minor. This new policy seems to be working at least to some extent. In September 2005, for example, Cardinal Francis George of the Archdiocese of Chicago permanently removed 11 priests from public ministerial duties for reasons of sexual misconduct (Chicago Tribune, September 27, 2005). New cases continue to emerge, and there is no particular reason to expect they will stop anytime soon. Similar problems of priests engaging in abuse have also occurred in Ireland (LeVay & Baldwin, 2012).

Former priest John Geoghan was found guilty of sexually molesting two boys and accused of sexually molesting dozens more in several parishes in the Boston area.

Not all men with pedophilia molest children. In a confidential study of German men who sought mental health services because of their pedophilic feelings, 30 percent reported that they had never had sexual contact with a child. Most of those, however, had viewed child pornography (Neutze et al., 2011 ). The organization B4UAct (Before You Act) is intended to support law-abiding men with pedophilic feelings and to raise awareness that such men exist and suffer due to societal prejudice (Clarke-Flory, 2012 ). Another organization called Virtuous Pedophiles is intended to reduce stigma toward law-abiding pedophiles by raising consciousness about their existence (Clarke-Flory, 2012 ).

Incest

Culturally prohibited sexual relations (up to and including coitus) between family members such as a brother and sister or a parent and child are known as incest . Although a few societies have sanctioned certain incestuous relationships—at one time it was the established practice for Egyptian pharaohs to marry their sisters to prevent the royal blood from being “contaminated”—the incest taboo is virtually universal among human societies. Incest often produces children with mental and physical problems because close genetic relatives are much more likely than nonrelatives to share the same recessive genes (which often have negative biological effects) and hence to produce children with two sets of recessive genes. Presumably for this reason, many nonhuman animal species, and all known primates, have an evolved tendency to avoid matings between close relatives. The mechanism for human incest avoidance appears to be lack of sexual interest in people to whom one is continuously exposed from an early age. For example, biologically unrelated children who are raised together in Israeli kibbutzim rarely marry or have affairs with others from their rearing group when they become adults (Kenrick & Luce, 2004 ). Evolutionarily, this makes sense. In most cultures, children reared together are biologically related.

In our own society, the actual incidence of incest is difficult to estimate because it usually comes to light only when reported to law enforcement or other agencies. It is almost certainly more common than is generally believed, in part because many victims are reluctant to report the incest or do not consider themselves victimized. Brother—sister incest is the most common form of incest even though it is rarely reported (LeVay & Baldwin, 2012). The second most common pattern is father—daughter incest. It seems that girls living with stepfathers are at especially high risk for incest, perhaps because there is less of an incest taboo among nonblood relatives (Finkelhor, 1984 ; Masters et al., 1992 ). Mother—son incest is thought to be relatively rare. Frequently, incest offenders do not stop with one child in a family (Wilson, 2004 ), and some incestuous fathers involve all of their daughters serially as they become pubescent.

Some incestuous child molesters have pedophilic arousal patterns (Barsetti et al., 1998 ; Seto et al., 1999 ), suggesting that they are at 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 two respects (Quinsey et al., 1995 ). First, the large majority of incest offenses are against girls, whereas extrafamilial offenses show a more equal distribution between boys and girls. Second, incest offenders are more likely to offend with only one or a few children in the family, whereas pedophilic child molesters are likely to have more victims (LeVay & Baldwin, 2012).

In 2007 the world was shocked at revelations concerning the case of an Austrian incest perpetrator named Josef Fritzl. Years earlier Fritzl had kidnapped his own daughter Elisabeth when she was 18 and incarcerated her in a soundproof compartment he had built in his own basement. He forced her to write a note saying that she had joined a cult and that she wanted no further contact with the family. She lived there for 24 years without the knowledge of her mother and other family members who lived upstairs. During her long incarceration, her father repeatedly forced her to have sex. During those years she bore seven children (one of whom died in infancy). Three of the children were reared by the family upstairs, ostensibly having been left for the family by Elisabeth. The other three lived in the basement with her. It was due to a medical problem in one of the latter children that the ordeal finally ended. She begged Josef to let her take the child to the hospital, and he agreed. Hospital staff thought the Fritzls’ cover story to be suspicious and alerted police, who successfully investigated (Dahlkamp et al., 2008 ).

Rape

The term rape describes sexual activity that occurs under actual or threatened forcible coercion of one person by another (see Figure 12.1 ). In most states, legal definitions restrict forcible rape to forced intercourse or penetration of a bodily orifice by a penis or other object. Statutory rape is sexual activity with a person who is legally defined (by statute or law) to be under the age of consent (18 in most states) even if the underage person consents. In the vast majority of cases, rape is a crime of men against women, although in prison settings it is often committed by men against men.

It is important to note that forced sex is not unique to humans but rather occurs in many species in the animal kingdom, where it has often evolved as a reproductive strategy by males to produce more offspring. It has also existed in most human societies (including preliterate ones) at some time in history (Lalumière et al., 2005a ). Across history, rape is traditionally most frequent during and following wars, when it sometimes reaches epidemic proportions. This may be because during war, men perceive few costs for the offense and it is perceived as a good way to express antagonism and contempt toward the enemy (Lalumière et al., 2005a ).

PREVALENCE

The results of different studies estimating the prevalence of rape have varied widely. This is, at least in part, because of differences across studies in the precise definition of rape and the way information is gathered (direct or indirect questions, for example). For instance, the U.S. Department of Justice figures from 1998 estimated that one in three women would experience rape or attempted rape at some point in their lives, with many of these being attempted but not completed rapes; but other estimates have been substantially lower. Marital rape is now illegal in all 50 states in the United States and is estimated to occur in 10 to 14 percent of married women and 40 to 50 percent of battered women (Martin et al., 2007 ). Since the late 1970s, the prevalence of rape has diminished dramatically, from nearly 3 to fewer than 0.5 per 1,000 individuals per year (Bureau of Justice, 2011).

FIGURE 12.1 Age of Rape and sexual Assault Victims. Young women are most at risk.

Source: Data from U.S. Department of Justice, 2002.

IS RAPE MOTIVATED BY SEX OR AGGRESSION?

Traditionally, rape has been classified as a sex crime, and society has assumed that a rapist is motivated by lust. However, in the 1970s some feminist scholars began to challenge this view, arguing that rape is motivated by the need to dominate, to assert power, and to humiliate a victim 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 of violence and is certainly not a sexually pleasurable experience, whatever the rapist’s motivation.

In spite of the fact that feminist writers have argued that rape is primarily a violent act, there are many compelling reasons why sexual motivation is often, if not always, a very important factor too (e.g., Bryden & Grier, 2011; Ellis, 1989 ; Thornhill & Palmer, 2000). For example, although rape victims include females of all degrees of physical attractiveness, the age distribution of rape victims is not at all random but includes a very high proportion of women in their teens and early 20s, who are generally considered the most sexually attractive. This age distribution is quite different from the distribution of other violent crimes, in which the elderly are overrepresented because of their vulnerability. Furthermore, rapists usually cite sexual motivation as a very important cause of their actions. Finally, as we shall see, at least some rapists exhibit features associated with paraphilias and have multiple paraphilias (Abel & Rouleau, 1990 ; LeVay & Baldwin, 2012). Men with paraphilias are typically highly sexually motivated.

In the past few decades, several prominent researchers studying sex offenders have shown that all rapists actually have both aggressive and sexual motives but to varying degrees. For example, Knight and Prentky ( 1990 ) identified four subtypes of rapists, with two subtypes motivated primarily by aggression and two subtypes motivated primarily by distorted sexual motives (see also Knight et al., 1994 ). More recently, McCabe and Wauchope ( 2005 ) provided empirical support for a somewhat different classification system that also has four subtypes of rapists with differing amounts of sexual and aggressive motives. At present it is not clear which scheme of classification is best, and some rapists cannot readily be characterized (LeVay & Baldwin, 2012).

RAPE AND ITS AFTERMATH

Stranger rape tends to be a repetitive activity rather than an isolated act, and most rapes are planned events. About 80 percent of rapists commit the act in the neighborhoods in which they reside; most rapes occur in an urban setting at night, in places ranging from dark, lonely streets to elevators and hallways, and apartments or homes. About a third or more of all rapes involve more than one offender. The remainder are single-offender rapes in which the victim and the offender are acquainted with each other (in about two-thirds of rapes); this includes wives (Bennice & Resick, 2003 ) (see Figure 12.2 ).

In addition to the physical trauma inflicted on a victim, the psychological trauma may be severe, leading in a substantial number of female victims to PTSD (see Chapter 5 ), which, when caused by rape, is often also associated with severe sexual problems. A rape may also have a negative impact on a victim’s marriage or other intimate relationships. Although there has been little systematic study of men who have been raped, one study of 40 male rape victims revealed that nearly all experienced some long-term psychological distress following rape, including anxiety, depression, increased feelings of anger, and loss of self-image (Walker et al., 2005 ).

FIGURE 12.2 Most Rapes Are not Committed by strangers. The graph shows the relationships of perpetrators of rape and sexual assault to their victims. Source: Data from U.S. Department of Justice, 2002.

Rape, even at its least violent, is a bullying, intrusive violation of another person’s integrity, selfhood, and personal boundaries that deserves to be viewed with more gravity—and its victims with more compassion and sensitivity—than has often been the case. Nevertheless, the myth of “victim-precipitated” rape, once a favorite of defense attorneys and of some police and court jurisdictions, still remains in certain circles. According to this view, a victim (especially a repeat victim), though often bruised both psychologically and physically, is regarded as the cause of the crime, often on such grounds as the alleged provocativeness of her clothing, her past sexual behavior, or her presence in a location considered risky (LeVay & Baldwin, 2012; Stermac et al., 1990 ). The attacker, on the other hand, is regarded as unable to quell his lust in the face of such irresistible provocation—and therefore is not treated as legally responsible for the act. Fortunately, rape shield laws began to be introduced in the 1970s. These laws protect rape victims by, for example, preventing the prosecutor from using evidence of a victim’s prior sex history; however, many problems in these laws still remain (LeVay & Baldwin, 2012).

A recent example of the complexity inherent in the legal situation of rape prosecution is that of Dominique Strauss-Kahn (DSK), who was managing director of the International Monetary Fund and an aspiring French politician. In May 2011, he was accused by a New York City hotel worker of sexually assaulting her when she entered his hotel room to clean it. A police investigation confirmed that sexual contact had occurred, but DSK insisted that it was consensual. Subsequently another woman came forward accusing him of raping her years earlier in France. However, the 2011 case unraveled when prosecutors learned that DSK’s accuser had lied about other matters, including the claim that she had been raped in her country of origin. The charges were dropped. It is possible that DSK got away with rape. It is also possible that he was falsely accused. Cases such as the accusations against DSK highlight both barriers to prosecuting rape cases and the need for adequate protections for the accused.

RAPISTS AND CAUSAL CONSIDERATIONS

Information gathered by the FBI about arrested and convicted rapists suggests that rape is usually a young man’s crime. According to FBI Uniform Crime Reports, about 60 percent of all rapists arrested are under 25 years old. Of the rapists who get into police records, about 30 to 50 percent are married and living with their wives at the time of the crime. As a group, they come from the low end of the socioeconomic ladder and commonly have a prior criminal record (Ward et al., 1997 ). They are also quite likely to have experienced sexual abuse, a violent home environment, and inconsistent caregiving in childhood (Hudson & Ward, 1997 ).

One subset of rapists, date rapists (a date rapist is an acquaintance who rapes a woman in the context of a date or other social interaction), have a somewhat different demographic profile in that they are often middle- to upper-class young men who rarely have criminal records. However, these men, like incarcerated rapists, are characterized by promiscuity, hostile masculinity, and an emotionally detached, predatory personality (e.g., Knight, 1997 ; LeVay & Baldwin, 2012). Their victims are often highly intoxicated (Mohler-Kuo et al., 2004 ; Testa et al., 2003 ). What distinguishes them, primarily, is that incarcerated rapists show much higher levels of impulsive, antisocial behavior than date rapists.

As suggested earlier, there is evidence that some rapists are afflicted by a paraphilia (Abel & Rouleau, 1990 ; Freund & Seto, 1998 ). For example, rapists often report having recurrent, repetitive, and compulsive urges to rape. Although they typically try to control these urges, the urges sometimes become so strong that they act on them. Many rapists also have other paraphilias such as exhibitionism and voyeurism. They also frequently have a characteristic pattern of sexual arousal (Abel & Rouleau, 1990 ; Clegg & Fremouw, 2009; Lohr et al., 1997 ). Most rapists are similar to normal, nonoffending men in being sexually aroused by depictions of mutually satisfying, consensual intercourse, but many rapists are also sexually aroused by depictions of sexual assaults involving an unwilling victim (Clegg & Fremouw, 2009; Lalumière et al., 2005b ). A small minority of rapists are sexual sadists, characterized by very violent assaults and aroused more by assault than by sexual stimuli.

In terms of personality, rapists are very often characterized by impulsivity, quick loss of temper, lack of personally intimate relationships, and insensitivity to social cues or pressures (Giotakos et al., 2004 ), and a subset qualify for a diagnosis of psychopathy (e.g., Knight & Guay, 2006 ). Many rapists also show some deficits in social and communication skills (Emmers-Sommer et al., 2004 ), as well as in their cognitive appraisals of women’s feelings and intentions (Ward et al., 1997 ). For example, they are particularly deficient in skills involved in successful conversation, which is necessary for developing consenting relationships with women. In addition, they have difficulty decoding women’s negative cues during social interactions and often interpret friendly behavior as flirtatious or sexually provocative (Emmers-Sommer et al., 2004 ). This can lead to inappropriate behaviors that women would experience as sexually intrusive.

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 casual acquaintances usually occur in dark, lonely places.

Estimates are that only 20 to 28 percent of rapes are ever reported, compared to 60 percent of robberies, but the proportion of rapes being reported has increased over the past several decades (Magid et al., 2004 ). Among men who are arrested, only about half are convicted; of these, only about two-thirds serve a jail term (LeVay & Baldwin, 2012). Convictions often bring light sentences, and a jail term does not dissuade a substantial number of offenders from repeating their crimes. Consequently, the large majority of rapists are not in prison but out among us.

Treatment and Recidivism of Sex Offenders

For several decades in the United States there has been extreme concern about, and intolerance of, sex offenders who repeat their crimes. Soon after his release from prison, convicted sex offender Earl Shriner forced a 7-year-old boy off his bike in the woods near Tacoma, Washington, and then raped and stabbed him before cutting off the boy’s penis. Just before his release from prison, Shriner had confided to a cellmate that he still had fantasies of molesting and murdering children (Popkin, 1994 ). In a similar case, 7-year-old Megan Kanka was sexually molested and murdered by a convicted child molester living in her neighborhood. Cases such as these have inspired a number of measures to protect society from sexual predators (see “The World Around Us” box).

But are such stories representative? Are sex offenders typically incurable? Should they receive life sentences on the presumption that they are bound to offend again? Or have they been unfairly singled out by media sensationalism even though they really are responsive to treatment? The efficacy of treatment for sex offenders is controversial, and this is the topic to which we now turn (e.g., Fedoroff, 2009 ).

In general, sex offender recidivism is actually markedly lower than for many other kinds of crimes. Recidivism rates for some types of offenders are higher than they are for others, however (Mann et al., 2010 ). Specifically, sex offenders with deviant sexual preferences (e.g., exhibitionists, severe sadists, and those who are most attracted to children) have particularly high rates of sexual recidivism (Dickey et al., 2002 ; Langevin et al., 2004 ). One follow-up study of more than 300 sex offenders over 25 years found that over half were charged with at least one additional sexual offense (Langevin et al., 2004 ). A recent review found that sexualized violence—a preference for sadistic or coercive sex—was the strongest predictor of recidivism. Other predictors included negative social influences, poor cognitive problem-solving, and loneliness (Mann et al., 2010 ). The recidivism rate for rapists steadily decreases with age, as does performance of sexually deviant behavior more generally (Barbaree & Blanchard, 2008 ).

PSYCHOTHERAPIES AND THEIR EFFECTIVENESS

Therapies for sex offenders typically have at least one of the following four goals: to modify patterns of sexual arousal and attraction, to modify cognitions and social skills in order to allow more appropriate sexual interactions with adult partners, to change habits or behavior that increases the chance of reoffending, or to reduce sexual drive. Attempts to modify sexual arousal patterns usually involve aversion therapy, in which a paraphilic stimulus such as a slide of a nude prepubescent girl for a man with pedophilia is paired with an aversive event such as forced inhalation of noxious odors or a shock to the arm. An alternative to electric aversion therapy is covert sensitization, in which the patient imagines a highly aversive event while viewing or imagining a paraphilic stimulus, or assisted covert sensitization, in which a foul odor is introduced to induce nausea at the point of peak arousal (Beech & Harkins, 2012 ).

the WORLD around us: Megan’s Law

On July 29, 1994, 7-year-old Megan Kanka, from Hamilton Township, New Jersey, was walking home from her friend’s house when a neighbor invited her to his house to see his new puppy. The neighbor, Jesse Timmendequas, 33, was a landscaper who had lived across the street for about a year. Unknown to Megan, to Megan’s parents, or to anyone else in the neighborhood, he was also a twice-convicted child molester (who lived with two other convicted sex offenders). When Megan followed him inside, he led her to an upstairs bedroom, strangled her unconscious with his belt, raped her, and asphyxiated her with a plastic bag. Timmendequas then placed Megan’s body in a toolbox, drove to a soccer field, and dumped it near a portable toilet. Timmendequas was subsequently apprehended, convicted, and sentenced to death; however, because New Jersey abolished the death penalty in 2007, he will serve a life term in prison.

Megan’s murder sparked outrage at the fact that dangerous sex offenders could move into a neighborhood without notifying the community of their presence. In response, the New Jersey state legislature passed Megan’s Law, which mandates that upon release, convicted sex offenders register with police and that authorities notify neighbors that convicted sex offenders have moved in by distributing fliers, alerting local organizations, and canvassing door-to-door. Similar laws have been passed in many other states, and it is now possible in several states to visit a web-site containing pictures and addresses of convicted sex offenders, subject to that state’s Megan’s Law. Although Megan’s Laws have been enormously popular with state legislators and citizens, they have not been uncontroversial. Civil libertarians have objected to community notification requirements, which, they argue, endanger released offenders (who have arguably paid their debts to society) and also prevent them from integrating successfully back into society. Although the various Megan’s Laws are intended to protect potential victims rather than to encourage harassment of sex offenders, the latter has occurred, with up to one-third to one-half of registered offenders in some states experiencing one or more of the following: loss of a job or home, threats, harassment, property damage, and/or harm to family members (Levenson et al., 2007 ). In addition, the limited amount of relevant data has brought the effectiveness of Megan’s Laws into question. For example, since 1995 a number of studies have compared recidivism rates from the period before which registration as a sex offender was required to rates after these laws were passed. Unfortunately, the results have not really provided any reassuring evidence that notifying communities has enhanced community safety (Levenson et al., 2007 ). A recent analysis in New Jersey, where Megan Kanka lived and died, found that Megan’s Law had made no difference (Zgoba & Levenson, 2008 ).

Deviant arousal patterns also need to be replaced by arousal to acceptable stimuli (Maletzky, 2002 ; Quinsey & Earls, 1990 ). Most often, investigators have attempted to pair the pleasurable stimuli of orgasm with sexual fantasies involving sex between consenting adults. For example, sex offenders are asked to masturbate while thinking of deviant fantasies. At the moment of ejaculatory inevitability, the patient switches his fantasy to a more appropriate theme. Although aversion therapy has been shown to be somewhat effective in the laboratory (Maletzky, 1998 ; Quinsey & Earls, 1990 ), how well this therapeutic change generalizes to the patient’s outside world is uncertain if his motivation wanes. Further, although aversion therapy is still widely used for sex offenders, it is no longer used as a sole form of treatment (Marshall, 1998 ).

The remaining psychological treatments are aimed at reducing the chances of sexual reoffending. Cognitive restructuring attempts to eliminate sex offenders’ cognitive distortions because these may play a role in sexual abuse (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 number of implied distortions: that a child has the capacity to consent 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 to help sex offenders (especially rapists) learn to process social information from women more effectively and to interact with them more appropriately (Beech & Harkins, 2012 ; Maletzky, 2002 ; McFall, 1990 ). For example, some men read positive sexual connotations into women’s neutral or negative messages or believe that women’s refusals of sexual advances reflect “playing hard to get.” Training typically involves interaction of perpetrators with female partners, who can give the offenders feedback on their response to the interactions.

Although some studies in the treatment literature have reached positive conclusions (see Maletzsky, 2002 , for a review), other studies have found essentially no differences between treated and untreated offenders (Emmelkamp, 1994 ; Rice et al., 1991). A recent meta-analysis of 23 recidivism outcome studies revealed an advantage for treatment: 10.9 percent of treated sex offenders versus 19.2 percent of untreated offenders committed another sex crime (Hanson et al., 2009 ). The most effective treatment programs followed the Canadian “Risk-Need-Responsiveness” model, in which an offender’s risk is first assessed to determine who should get the most intensive treatment. Second, there is a focus on factors that directly increase chance of reoffending such as paraphilic desire or impulsivity. Third, correctional programs should be matched to offender characteristics such as learning style, level of motivation, and the offender’s individual characteristics. Such multifaceted cognitive-behavioral techniques appear to be more effective than older techniques such as aversion therapy. There are also indications in the literature that certain paraphilias respond better to treatment than others (Laws & O’Donohue, 2008 ). For example, one very long-term follow-up (5 to 15 years) of over 2,000 sex offenders who had entered a cognitive-behavioral treatment program found that non-pedophilic child molesters and exhibitionists achieved better overall success rates than pedophilic offenders and rapists (Maletzky & Steinhauser, 2002 ).

BIOLOGICAL AND SURGICAL TREATMENTS

In recent years antidepressants from the SSRI (selective serotonin reuptake inhibitor) category have been found to be useful in treating a variety of paraphilias by reducing paraphilic desire and behavior; they are not, however, useful in the treatment of sexual offenders. The most controversial treatment for sex offenders involves castration—either surgical removal of the testes or the hormonal treatment sometimes called “chemical castration” (e.g., Berlin, 2003 ; Bradford & Greenberg, 1996 ; Weinberger et al., 2005 ). Both surgical and chemical castration lower the testosterone level, which in turn lowers the sex drive, allowing the offender to resist any inappropriate impulses. Chemical castration has most often involved the administration of antiandrogen steroid hormones such as Depo-Provera and Lupron, which can both have serious side effects. One uncontrolled study of the drug Lupron yielded dramatic results: Thirty men with paraphilias reported an average of 48 deviant fantasies per week prior to therapy, and no such fantasies during treatment (Rosler & Witztum, 1998 ; see also Maletzky & Field, 2003 ). However, relapse rates upon discontinuation of the drug were very high (Maletzky, 2002 ).

Studies of surgical castration of repeat sex offenders with violent tendencies conducted in Europe and more recently in the United States had similar results (but without high rates of relapse; Weinberger et al., 2005 ). These studies have typically included diverse categories of offenders, from child molesters to rapists of adult women. Follow-up has sometimes exceeded 10 years. Recidivism rates for castrated offenders are typically less than 3 percent, compared with greater than 50 percent for uncastrated offenders (e.g., Berlin, 1994 ; Green, 1992 ; Prentky, 1997 ). Despite the apparently high success rates, many feel that the treatment is brutal, unethical, and dehumanizing (Farkas & Stichman, 2002 ; Gunn, 1993 ), although this assumption has been challenged (Bailey & Greenberg, 1998 ).

Interestingly, some recent cases have involved a request by the sex offender himself to be castrated in exchange for a lighter sentence (LeVay & Baldwin, 2012). In some states such as California, a repeat offender’s eligibility for probation or parole following childhood molestation is linked to his acceptance of mandated hormonal therapy (Scott & Holmberg, 2003 ). Oregon evaluated the success of requiring such treatment and found that those receiving chemical castration fared better in terms of committing fewer new offenses and fewer parole violations, and were less likely to return to prison (Maletzky et al., 2006 ). Nevertheless, civil libertarians, exemplified by the American Civil Liberties Union (ACLU), have argued that because of potentially severe side effects, such requirements violate the Constitution’s ban on cruel and unusual punishment. More research is desirable to determine whether, and under what conditions, such biological treatments should be used with some sex offenders (Rice & Harris, 2011). Such research should be a priority.

COMBINING PSYCHOLOGICAL AND BIOLOGICAL TREATMENTS

Not surprisingly, many treatment programs now use a combination of hormone therapy and cognitive-behavioral treatments, the hope being that the hormone treatment can be tapered off after the offender has learned techniques for impulse control (Maletzky, 2002 ). However, the single most important defect of nearly all available studies is the lack of randomly assigned controls who are equally motivated for treatment. Some have argued that denying treatment to sex offenders is unethical (e.g., Marshall et al., 1991 ). However, this would be true only if the treatment were effective, and it is not clear at this point whether it is. Thus others have argued that randomized controlled trials are crucial for making progress in his area (e.g., Seto et al., 2008 ). Research in this area is further complicated by the fact that the outcome variable in most studies is whether the man is convicted for another sex offense during the follow-up period. The fact that most sex offenses go unpunished (the offender is often never even caught, let alone convicted) might exaggerate the apparent effectiveness of treatment and underestimate the dangerousness of sex offenders. Given the social importance of determining whether sex offenders can be helped and how likely they are to reoffend, it is crucial that society devote the resources necessary to answering these questions.

SUMMARY

It is possible both to acknowledge that sex offenders cause immense human suffering and to feel sympathy for the plight of the many offenders who have been burdened with a deviant sexual arousal pattern that has caused them great personal and legal trouble. Society cannot allow these people to act on their sexual preference, nor can their past crimes be forgotten. Nevertheless, in deciding how to treat these people, it is important and humane to remember that many of them have a tormented inner life.

in review

· • What are the short-term consequences of childhood sexual abuse, and why are we less certain about its long-term consequences?

· • What are the major issues surrounding children’s testimony about sexual abuse and adults’ recovered memories of sexual abuse?

· • Define pedophilia, incest, and rape, and summarize the major clinical features of the perpetrators of these crimes.

· • Identify the main goals of treatment of sex offenders, and describe the different treatment approaches.

Sexual Dysfunctions

The term sexual dysfunction refers to impairment either in the desire for sexual gratification or in the ability to achieve it. The impairment varies markedly in degree, but regardless of which partner is alleged to be dysfunctional, the enjoyment of sex by both parties in a relationship is typically adversely affected. Sexual dysfunctions occur in both heterosexual and homosexual couples. In some cases, sexual dysfunctions are caused primarily by psychological or interpersonal factors. In others, physical factors are most important, including many cases of sexual dys-function that are secondary consequences of medications people may be taking for other, unrelated medical conditions (Baron-Kuhn & Segraves, 2007 ). In recent years, both explanations and treatments of sexual dysfunction have become more biological, although some psychological treatments have been empirically validated , and psychosocial factors clearly play a causal role as well (Heiman, 2002 ; Meston & Rellini, 2008 ; Segraves & Althof, 2002 ).

Today researchers and clinicians typically identify four different phases of the human sexual response as originally proposed by Masters and Johnson ( 1966 , 1970 , 1975 ) and Kaplan ( 1979 ). According to DSM-5, disorders can occur in any of the first three phases:

· • The first phase is the desire phase , which consists of fantasies about sexual activity or a sense of desire to have sexual activity.

· • The second phase is the excitement (or arousal) phase , characterized both by a subjective sense of sexual pleasure and by physiological changes that accompany this subjective pleasure, including penile erection in the male and vaginal lubrication and clitoral enlargement in the female.

· • The third phase is orgasm , during which there is a release of sexual tension and a peaking of sexual pleasure.

· • The final phase is resolution , during which the person has a sense of relaxation and well-being.

Although these four phases are described as if they were distinct, it is important to remember that they are experienced by an individual as a continuous set of feelings and biological and behavioral reactions. There are other conceivable ways to discuss and organize the sequence that occurs. Indeed, in DSM-5,female sexual interest/arousal disorder replaces two separate disorders in DSM-IV-TR, because research has not adequately demonstrated that sexual interest and arousal are distinguishable in women (Brotto, 2010 ; Graham, 2010 ).

research CLOSE-UP: Empirically Validated

Empirically validated treatments are treatments that have been determined to be helpful based on well-designed, scientific research by more than just one group of researchers.

How common are sexual dysfunctions? It is obviously difficult to do large-scale research on such a sensitive topic. Nevertheless, the National Health and Social Life Survey (Laumann et al., 1999 ) assessed sexual problems in 3,159 randomly selected Americans by asking them if they had experienced the symptoms of any of the different sexual dys-functions in the past 12 months. Sexual problems were very common, with 43 percent of women and 31 percent of men reporting having experienced at least one of these problems in the previous 12 months. For women, the reported rate of sexual problems decreased with age; for men it increased. Married men and women, and those with higher educational attainment, had lower rates of problems. For women, the most common complaints were lack of sexual desire (22 percent) and sexual arousal problems (14 percent). For men, climaxing too early (21 percent), erectile dysfunction (5 percent), and lack of sexual interest (5 percent) were reported most frequently. However, this study was criticized by Bancroft et al. ( 2003 ), who believe that these numbers overestimate how many people have true sexual dysfunctions. Although the Laumann and colleagues’ results are often referred to as being about sexual dysfunction, in fact, the investigators never asked people about whether the problems caused them distress or impairment in any way; yet these are necessary criteria for making a diagnosis in DSM-5. When Bancroft et al. ( 2003 ) did a related survey (although just in women), they found very similar percentages to those found by Laumann and colleagues. However, Bancroft and colleagues found that only about half as many reported that the problem caused them “severe distress.” Nevertheless, this is still a relatively high percentage of people experiencing sexual dysfunction at some point in their lives.

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

DSM-5 criteria for: Different Sexual Dysfunctions

Men

Delayed Ejaculation

· A. Either of the following symptoms must be experienced on almost all or all occasions (approximately 75%–100%) of partnered sexual activity (in identified situational contexts or, if generalized, in all contexts), and without the individual desiring delay:

· 1. Marked delay in ejaculation.

· 2. Marked infrequency or absence of ejaculation

· B. The symptoms in Criterion A have persisted for a minimum duration of approximately 6 months.

· C. The symptoms in Criterion A cause clinically significant distress in the individual.

· D. The sexual dysfunction is not better explained by a nonsexual mental disorder or as a consequence of severe relationship distress or other significant stressors and is not attributable to the effects of a substance/medication or another medical condition.

Erectile Disorder

· A. At least one of the three following symptoms must be experienced on almost all or all (approximately 75%–100%) occasions of sexual activity (in identified situational contexts or, if generalized, in all contexts):

· 1. Marked difficulty in obtaining an erection during sexual activity.

· 2. Marked difficulty in maintaining an erection until the completion of sexual activity.

· 3. Marked decrease in erectile rigidity.

· B. The symptoms in Criterion A have persisted for a minimum duration of approximately 6 months.

· C. The symptoms in Criterion A cause clinically significant distress in the individual.

Premature (Early) Ejaculation

· A. A persistent or recurrent pattern of ejaculation occurring during partnered sexual activity within approximately 1 minute following vaginal penetration and before the individual wishes it.

Note: Although the diagnosis of premature (early) ejaculation may be applied to individuals engaged in nonvaginal sexual activities, specific duration criteria have not been established for these activities.

· B. The symptom in Criterion A must have been present for at least 6 months and must be experienced on almost all or all (approximately 75%–100%) occasions of sexual activity (in identified situational contexts or, if generalized, in all contexts).

· C. The symptom in Criterion A causes clinically significant distress in the individual.

Male Hypoactive Sexual Desire Disorder

· A. Persistently or recurrently deficient (or absent) sexual/erotic thoughts or fantasies and desire for sexual activity. The judgment of deficiency is made by the clinician, taking into account factors that affect sexual functioning, such as age and general and sociocultural contexts of the individual’s life.

· B. The symptoms in Criterion A have persisted for a minimum duration of approximately 6 months.

· C. The symptoms in Criterion A cause clinically significant distress in the individual.

· D. The sexual dysfunction is not better explained by a nonsexual mental disorder or as a consequence of severe relationship distress or other significant stressors and is not attributable to thes effects of a substance/medication or another medical condition.

Women

Female Orgasmic Disorder

· A. Presence of either of the following symptoms and experienced on almost all or all (approximately 75%–100%) occasions of sexual activity (in identified situational contexts or, if generalized, in all contexts):

· 1. Marked delay in, marked infrequency of, or absence of orgasm.

· 2. Markedly reduced intensity of orgasmic sensations.

· B. The symptoms in Criterion A have persisted for a minimum duration of approximately 6 months.

· C. The symptoms in Criterion A cause clinically significant distress in the individual.

· D. The sexual dysfunction is not better explained by a non-sexual mental disorder or as a consequence of severe relationship distress (e.g., partner violence) or other significant stressors and is not attributable to the effects of a substance/medication or another medical condition.

Female Sexual Interest/Arousal Disorder

· A. Lack of, or significantly reduced, sexual interest/arousal, as manifested by at least three of the following:

· 1. Absent/reduced interest in sexual activity.

· 2. Absent/reduced sexual/erotic thoughts or fantasies.

· 3. No/reduced initiation of sexual activity, and typically unreceptive to a partner’s attempts to initiate.

· 4. Absent/reduced sexual excitement/pleasure during sexual activity in almost all or all (approximately 75%–100%) sexual encounters (in identified situational contexts or, if generalized, in all contexts).

· 5. Absent/reduced sexual interest/arousal in response to any internal or external sexual/erotic cues (e.g., written, verbal, visual).

· 6. Absent/reduced genital or nongenital sensations during sexual activity in almost all or all (approximately 75%–100%) sexual encounters (in identified situational contexts or, if generalized, in all contexts).

· B. The symptoms in Criterion A have persisted for a minimum duration of approximately 6 months.

· C. The symptoms in Criterion A cause clinically significant distress in the individual.

· D. The sexual dysfunction is not better explained by a nonsexual mental disorder or as a consequence of severe relationship distress (e.g., partner violence) or other significant stressors and is not attributable to the effects of a substance/medication or another medical condition.

Genito-Pelvic Pain/Penetration Disorder

· A. Persistent or recurrent difficulties with one (or more) of the following:

· 1. Vaginal penetration during intercourse.

· 2. Marked vulvovaginal or pelvic pain during vaginal intercourse or penetration attempts.

· 3. Marked fear or anxiety about vulvovaginal or pelvic pain in anticipation of, during, or as a result of vaginal penetration.

· 4. Marked tensing or tightening of the pelvic floor muscles during attempted vaginal penetration.

· B. The symptoms in Criterion A have persisted for a minimum duration of approximately 6 months.

· C. The symptoms in Criterion A cause clinically significant distress in the individual.

· D. The sexual dysfunction is not better explained by a nonsexual mental disorder or as a consequence of a severe relationship distress (e.g., partner violence) or other significant stressors and is not attributable to the effects of a substance/medication or another medical condition.

Men/Women

Substance/Medication-Induced Sexual Dysfunction

· A. A clinically significant disturbance in sexual function is predominant in the clinical picture.

· B. There is evidence from the history, physical examination, or laboratory findings of both (1) and (2):

· 1. The symptoms in Criterion A developed during or soon after substance intoxication or withdrawal or after exposure to a medication.

· 2. The involved substance/medication is capable of producing the symptoms in Criterion A.

· C. The disturbance is not better explained by a sexual dysfunction that is not substance/medication-induced. Such evidence of an independent sexual dysfunction could include the following:

The symptoms precede the onset of the substance/medication use; the symptoms persist for a substantial period of time (e.g., about 1 month) after the cessation of acute withdrawal or severe intoxication; or there is other evidence suggesting the existence of an independent non-substance/medication-induced sexual dysfunction (e.g., a history of recurrent non-substance/medication-related episodes).

· D. The disturbance does not occur exclusively during the course of a delirium.

· E. The disturbance causes clinically significant distress in the individual.

Note: This diagnosis should be made instead of a diagnosis of substance intoxication or substance withdrawal only when the symptoms in Criterion A predominate in the clinical picture and are sufficiently severe to warrant clinical attention.

Interestingly, a later study of 27,500 people across 29 countries all over the world revealed fairly similar results (Laumann et al., 2005 ). There were some differences, of course, in prevalence across countries, but the results were more similar than different. East Asian and Southeast Asian countries reported slightly higher rates of sexual problems than most other countries.

The “DSM-5 Criteria” box above summarizes each of the dysfunctions covered here.

Sexual Dysfunctions in Men

For cultural reasons, and possibly also for biological reasons, sex is thought to be especially important to men. Certainly the pharmaceutical industry has capitalized on men’s distress about sexual dysfunction, earning billions of dollars from sales of treatments for male sexual dysfunction, primarily erectile disorder . Whether men are actually more upset than women by sexual dysfunction or this is simply one more domain where women’s feelings have been ignored until recently, there is no dispute that we know far more about men’s sexual dysfunctions than women’s.

Male Hypoactive Sexual Desire Disorder

Hypoactive sexual desire disorder is diagnosed in men who have for at least 6 months been distressed or impaired due to low levels of sexual thoughts, desires, or fantasies. Men given this diagnosis are also assessed for the course of the dysfunction (i.e., lifelong or acquired) and possible causal factors, including problems emanating from partners, relationships, cultural beliefs or attitudes, personal vulnerabilities (e.g., poor body image), or medical conditions. Despite the historically higher level of attention to male than to female sexual dysfunctions, this is one disorder in men that has received relatively little attention—and substantially less than its parallel disorder in women (Brotto, 2010 ). In the large American survey conducted by Laumann et al. ( 1999 ), men in the oldest cohort (50–59 years old) were three times more likely to suffer from low desire compared with men in the youngest cohort (18–29 years old). Predictors of low desire included daily alcohol use, stress, unmarried status, and poorer health. In a large British survey, complaints of low interest in sex was the most common problem reported by men (17.1 percent; Mercer et al., 2003). However, only a small minority (1.8 percent) of the male sample had low desire for the required 6 month period to qualify for diagnosis. Most experts believe that male hypoactive sexual desire disorder is acquired or situational rather than lifelong. Typical situational risk factors include depression and relationship stress.

Treatment The treatment literature on low sexual desire in men is scant. In men whose testosterone levels are markedly low (including hypogonadal men whose testes make insufficient testosterone and men with HIV that diminishes their testosterone production), testosterone injections have helped (Brotto, 2010 ). Because psychological factors are more closely linked to low male sexual desire compared with hormonal factors, psychological treatments may be more effective for other men.

ERECTILE DISORDER

Inability to achieve or maintain an erection sufficient for successful sexual intercourse was formerly called impotence. It is now known as male erectile disorder and can be diagnosed only when the difficulties are considered to originate from either psychogenic or a combination of psycho-genic and medical factors (see “DSM-5 Criteria” on p. 432). In lifelong erectile disorder, a man with adequate sexual desire has never been able to sustain an erection long enough to accomplish a satisfactory duration of penetration. In acquired or situational erectile disorder, a man with adequate sexual desire has had at least one successful experience of sexual activity requiring an erection but is presently unable to produce or maintain the required level of penile rigidity. Lifelong erectile disorder is relatively rare, but most men of all ages occasionally have difficulty obtaining or maintaining an erection. Laumann et al. ( 1999 ) landmark study on the prevalence of sexual dysfunction estimates that 7 percent of 18- to 19-year-old men and 18 percent of 50- to 59-year-old men reported having erectile disorder.

Masters and Johnson ( 1975 ; Masters et al., 1992 ) and Kaplan ( 1987 ) hypothesized that erectile dysfunction is primarily a function of anxiety about sexual performance. In other reviews of the accumulated evidence, however, Barlow and colleagues (Beck & Barlow, 1984a ; Sbrocco & Barlow, 1996 ) have played down the role of anxiety per se—because under some circumstances, anxiety can actually enhance sexual performance in normally functioning men and women (Barlow et al., 1983 ; Palace & Gorzalka, 1990 ; see Sbrocco & Barlow, 1996 , for a review). Barlow ( 2002 ) emphasizes that it is the cognitive distractions frequently associated with anxiety in dysfunctional people that seem to interfere with their sexual arousal. For example, one study found that nondysfunctional men who were distracted by material they were listening to on earphones while watching an erotic film showed less sexual arousal than men who were not distracted (Abrahamson et al., 1985 ). Barlow and colleagues hypothesize that sexually dys-functional men and women get distracted by negative thoughts about their performance during a sexual encounter (“I’ll never get aroused” or “She’ll think I’m inadequate”). Their research suggests that this preoccupation with negative thoughts, rather than anxiety per se, is responsible for inhibiting sexual arousal (see also Weiner & Rosen, 1999 ; Wincze et al., 2008 ). Moreover, such self-defeating thoughts not only decrease pleasure but also can increase anxiety if the erection does not happen, and this in turn can fuel further negative, self-defeating thoughts (Sbrocco & Barlow, 1996 ). A related finding is that men with erectile dysfunction make more internal and stable causal attributions for hypothetical negative sexual events than do men without sexual dysfunction, much as depressed people do for more general hypothetical negative events (Nobre, 2010; Scepkowski et al., 2004 ). Combined with Bancroft and colleagues’ ( 2005 ) findings that fear of performance failure is a strong predictor of erectile dysfunction in both gay and heterosexual men, one can see how a vicious cycle develops in which fears of failure are sometimes followed by erectile dysfunction, which is then attributed to internal and stable causes, thereby perpetuating the problem.

Erectile problems occur in as many as 90 percent of men on certain antidepressant medications (especially the SSRIs) and are one of the primary reasons men cite for discontinuing these medications (Rosen & Marin, 2003 ). These problems are also a common consequence of aging. One large study of over 1,400 men found that 37 percent between ages 57 and 85 reported significant erectile difficulties, with the problems gradually increasing with age (Lindau et al., 2007 ). However, complete and permanent erectile disorder before the age of 60 is relatively rare. Moreover, studies have indicated that men and women in their 80s and 90s are often quite capable of enjoying intercourse (Masters et al., 1992 ; Meston & Rellini, 2008 ). For example, in one study of 202 healthy men and women between the ages of 80 and 102, it was found that nearly two-thirds of the men and one-third of the women were still having sexual intercourse, although this was generally not their most common form of sexual activity (Bretschneider & McCoy, 1988 ).

The most frequent cause of erectile disorder in older men is vascular disease, which results in decreased blood flow to the penis or in diminished ability of the penis to hold blood to maintain an erection. Thus hardening of the arteries, high blood pressure, and other diseases such as diabetes that cause vascular problems often account for erectile disorder. Smoking, obesity, and alcohol abuse are associated lifestyle factors, and lifestyle changes can improve erectile function (Gupta et al., 2011). Diseases that affect the nervous system, such as multiple sclerosis, can also cause erectile problems. For young men, one cause of erectile problems is having had priapism—that is, an erection that will not diminish even after a couple of hours, typically unaccompanied by sexual excitement. Priapism can occur as a result of prolonged sexual activity, as a consequence of disease, or as a side effect of certain medications. Untreated cases of priapism are likely to result in erectile dysfunction and thus should be regarded as a medical emergency (Morrison & Burnett, 2011).

Treatment A variety of treatments—primarily medical—have been employed in recent years, often when cognitive-behavioral treatments have failed. These include: (1) medications that promote erections like Viagra, Levitra, and Cialis; (2) injections of smooth-muscle-relaxing drugs into the penile erection chambers (corpora cavernosa); and (3) even a vacuum pump (Duterte et al., 2007 ; Rosen, 1996 ). In extreme cases, for example when erections are impossible due to nerve damage that can be a consequence of surgery for prostate cancer, penile implants may still be used. These devices can be inflated to provide erection on demand. They are made of silicone rubber or polyurethane rubber. Such treatments have generally shown success in clinical trials, although they are rather extreme interventions that often evoke bothersome side effects such as decreased penis size (Duterte et al., 2007 ). They were used in thousands of cases in the 1960s and 1970s before current medications were available.

In 1998 the revolutionary drug Viagra (sildenalfil) was introduced on the U.S. market and was received with a great deal of attention. Viagra works by making nitric oxide, the primary neurotransmitter involved in penile erection, more available. Viagra is taken orally at least 30 to 60 minutes before sexual activity. Unlike some other biological treatments for erectile dysfunction, Viagra promotes erection only if some sexual excitation is present. Thus, contrary to some myths, Viagra does not improve libido or promote spontaneous erections (Duterte et al., 2007 ; Segraves & Althof, 2002 ). Two other related medications introduced in 2003 to treat erectile dysfunction are Levitra (vardenafil; Stark et al., 2001 ) and Cialis (tadalafil; Padma-Nathan et al., 2001 ), with the effects of Cialis being longer lasting (up to 36 hours). Clinical trials of these medications have been impressive. In one early double-blind study, over 70 percent of men receiving at least 50 mg of Viagra reported that their erections had improved, compared with fewer than 30 percent of men receiving a placebo (Carlson, 1997 ; see also Gold-stein et al., 1998 ). Results with Cialis and Levitra are similar. Overall efficacy rates in terms of ability to obtain an erection are 40 to 80 percent, but levels of satisfaction are often much lower, perhaps because these medications do not increase sexual desire or satisfaction and perhaps because sexual desire and satisfaction are more closely intertwined with psychological and relationship factors. Side effects are relatively uncommon and not serious (e.g., the most common side effects are headache and facial flushing, seen in 10 to 20 percent of men), provided that the person had no serious preexisting heart problems (Duterte et al., 2007 ). When heart problems do exist, these medications should be prescribed with caution because they can interact in dangerous ways with heart medications. These medications have been highly successful commercially—for example, in 2008 almost $2 billion worth of Viagra was sold. Interestingly, however, many men who fill one prescription never refill it, according to the drug companies’ own statistics. The commercial success of drugs like Viagra and Cialis is an indication of both the high prevalence of sexual dysfunction in men and the importance that people attach to sexual performance. There are also a few studies showing that the usefulness of these medications may be further enhanced when used in conjunction with cognitive-behavioral treatment (e.g., Bach et al., 2004 ; Meston & Rellini, 2008 ).

EARLY EJACULATION

In DSM-5 “premature ejaculation,” is called early ejaculation disorder, the persistent and recurrent onset of orgasm and ejaculation with minimal sexual stimulation. It may occur before, on, or shortly after penetration and before the man wants it to (see “DSM-5 Criteria” on p. 432). The average duration of time to ejaculate in men with this problem is 15 seconds or 15 thrusts of intercourse. The consequences often include failure of the partner to achieve satisfaction and, often, acute embarrassment for the early ejaculating man, with disruptive anxiety about recurrence on future occasions. Men who have had this problem from their first sexual encounter often try to diminish sexual excitement by avoiding stimulation, by self-distracting, and by “spectatoring,” or psychologically taking the role of an observer rather than a participant (Metz et al., 1997 ). Early ejaculation decreases sexual and relationship satisfaction both in men who have it and their partners (Graziottin & Althof, 2011).

An exact definition of prematurity is necessarily somewhat arbitrary. For example, the age of a client must be considered—the alleged “quick trigger” of the younger man being more than a mere myth (McCarthy, 1989 ). Indeed, perhaps half of young men complain of early ejaculation. Not surprisingly, early ejaculation is most likely after a lengthy abstinence. DSM-5 acknowledges these many factors that may affect time to ejaculation by noting that the diagnosis is made only if ejaculation occurs before, on, or shortly after penetration and before the man wants it to. Early ejaculation is the most common male sexual dysfunction at least up to age 59 (Meston & Rellini, 2008 ; Segraves & Althof, 2002 ).

In sexually normal men, the ejaculatory reflex is, to a considerable extent, under voluntary control. They monitor their sensations during sexual stimulation and are somehow able, perhaps by judicious use of distraction, to forestall the point of ejaculatory inevitability until they decide to “let go,” with the average latency to ejaculation from penetration being 10 minutes for men with no sexual problems. Men with early ejaculation are for some reason unable to use this technique effectively. Explanations have ranged from psychological factors such as increased anxiety, to physiological factors such as increased penile sensitivity and higher levels of arousal to sexual stimuli. Presently, however, no explanation has received much empirical support, and it is clear that none of these possible explanations alone can account for all men with the problem (Meston & Rellini, 2008 ).

Treatment For many years, most sex therapists considered early ejaculation to be psychogenically caused and highly treatable via behavioral therapy such as the pause-and-squeeze technique developed by Masters and Johnson ( 1970 ). This technique requires the man to monitor his sexual arousal during sexual activity. When arousal is intense enough that the man feels that ejaculation might occur soon, he pauses, and he or his partner squeezes the head of the penis for a few moments until the feeling of pending ejaculation passes, repeating the stopping of intercourse as many times as needed to delay ejaculation. Initial reports suggested that this technique was approximately 60 to 90 percent effective; however, more recent studies have reported a much lower overall success rate (Duterte et al., 2007 ; Segraves & Althof, 2002 ). In recent years, for men for whom behavioral treatments have not worked, there has been increasing interest in the possible use of pharmacological interventions. Antidepressants such as paroxetine (Paxil), sertraline (Zoloft), fluoxetine (Prozac), and dapoxetine (Priligy), which block serotonin reuptake, have been found to significantly prolong ejaculatory latency in men with early ejaculation (Porst, 2011). Evidence suggests, however, that the medications work only as long as they are being taken.

DELAYED EJACULATION DISORDER

Sometimes called retarded ejaculation, delayed ejaculation disorder refers to the persistent inability to ejaculate during intercourse (see “DSM-5 Criteria” on p. 432). It occurs in only about 3 to 10 percent of men. Men who are completely unable to ejaculate are rare. About 85 percent of men who have difficulty ejaculating during intercourse can nevertheless achieve orgasm by other means of stimulation, notably through solitary masturbation (Wincze et al., 2008 ). In milder cases a man can ejaculate in the presence of a partner but only by means of manual or oral stimulation.

In other cases, delayed ejaculation can be related to specific physical problems such as multiple sclerosis or to the use of certain medications. For example, we noted that antidepressants that block serotonin reuptake appear to be an effective treatment for early ejaculation. However, in other men, these same medications—especially the SSRIs—sometimes delay or prevent orgasm to an unpleasant extent (Ashton et al., 1997 ; Meston & Rellini, 2008 ). These side effects are common but can sometimes be treated pharmacologically with medications like Viagra (Ashton et al., 1997 ).

Treatment Psychological treatments include couples therapy in which a man tries to get used to having orgasms through intercourse with a partner rather than via masturbation. Treatment may also emphasize the reduction of performance anxiety about the importance of having an orgasm versus sexual pleasure and intimacy in addition to increasing genital stimulation (Meston & Rellini, 2008 ; Segraves & Althof, 2002 ).

Female Sexual Interest/Arousal Disorder

Research suggests that women with low desire tend to have low levels of sexual arousal during sexual activity and vice versa. There are no common syndromes in which women with low sexual desire have normal levels of sexual arousal, or vice versa. Thus for women, DSM-5 has combined dysfunction-ally low desire with dysfunctionally low sexual arousal in the disorder Female Sexual Interest/Arousal Disorder . Another interesting change from DSM-IV-TR to DSM-5 is the elimination of sexual aversion disorder, in which a person shows extreme aversion to, and avoidance of, all genital sexual contact with a partner. A leading researcher on sexual dysfunction has recently argued that sexual aversion disorder should be considered as an anxiety disorder akin to simple phobias rather than as a sexual dysfunction (Brotto, 2010 ). Perhaps this is one reason why it was eliminated from the Sexual Dysfunctions section of DSM-5.

Research on the degree to which the diminished sex drive has a biological basis remains controversial, but in many (and perhaps most) cases (and especially in women), psychological factors appear to be more important than biological factors (Meston & Bradford, 2007 ; Segraves & Woodard, 2006 ). In the past, these people usually came to the attention of clinicians primarily at the request of their partners (who typically complained of insufficient sexual interaction), but as public knowledge about the frequency of this disorder has increased, more people are presenting for treatment on their own. This fact exposes one problem with the diagnosis, because it is known that preferences for frequency of sexual contact vary widely among otherwise normal individuals. Who is to decide what is “not enough”? DSM-5 explicitly indicates that this judgment is left to the clinician, taking into account the person’s age and the context of his or her life.

Prior or current depression or anxiety disorders may contribute to many cases of sexual desire disorders (Meston & Bradford, 2007 ). Although sexual desire disorders typically occur in the absence of obvious physical pathology, there is evidence that physical factors sometimes play a role. For example, in both men and women, sexual desire depends in part on testosterone (Alexander & Sherwin, 1993 ; Meston & Rellini, 2008 ). That sexual desire problems increase with age may be in part attributable to declining levels of testosterone, but testosterone replacement therapy is usually not beneficial, except in men and women who have very low testosterone levels (Meston & Rellini, 2008 ). In addition, medications from the SSRI category of antidepressants (see Chapters 7 and 16 ) not uncommonly reduce sexual desire. Different antidepressants vary considerably in their negative effect on sexual function, and psychiatrists have not always paid close enough attention to the impact that these effects have on patients’ general functioning (Serretti & Chiesa, 2009). Psychological factors thought to contribute to sexual desire disorders include low relationship satisfaction, daily hassles and worries, increased disagreements and conflicts, low levels of feelings, and reduced cues of emotional bonding (Meston & Rellini, 2008 ). In some cases a history of unwanted sexual experiences such as rape may also contribute.

Among the DSM-IV-TR diagnoses hypoactive sexual desire disorder was the most common female sexual dysfunction in the United States and most other countries across the world (Laumann et al., 1994 , 1999 , 2005 ), and there is no reason to doubt that female sexual interest/arousal disorder is the most common DSM-5 female sexual dysfunction. Despite this fact, disorders of female sexual desire have inspired far less research into its origins and treatment than have most male dysfunctions, especially erectile disorder and early ejaculation. One main reason for this disparity is doubtless the great importance that many men place on their ability to perform sexually. Until recently, there has also been a more general neglect of female sexuality and an implicit (though largely mistaken) societal attitude that women simply do not care much about sex.

Fortunately, this has been changing gradually in recent years (e.g., Althof et al., 2005 ; Basson, 2005 ; Meston & Bradford, 2007 ). One emerging finding is that it is uncommon for women to cite sexual desire as a reason or incentive for sexual activity. For many women, sexual desire is experienced only after sexual stimuli have led to subjective sexual arousal (Basson, 2003a ; Meston & Bradford, 2007 ), and for others, motivation for sexual activity may involve a desire for increasing emotional 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 supposedly linear sequence of desire leading to arousal, leading to orgasm that was originally posited for women as well as men by Masters and Johnson ( 1970 ) and the DSM is not very accurate for women (e.g., Basson, 2005 ; Meston & Bradford, 2007 ).

Until recently studied separately from low sexual desire, dysfunctionally low sexual arousal in women was formerly and somewhat pejoratively known as frigidity. In DSM-IVTR female sexual arousal disorder—the absence of feelings of sexual arousal and an unresponsiveness to most or all forms of erotic stimulation—was in many ways the female counterpart of erectile disorder (see “DSM-5 Criteria” on p. 433). Its chief physical manifestation was a failure to produce the characteristic swelling and lubrication of the vulva and vaginal tissues during sexual stimulation—a condition that may make intercourse quite uncomfortable and orgasm impossible.

Although the causes of low sexual arousal are not well understood, possible reasons range from early sexual traumatization; to excessive and distorted socialization about the “evils” of sex; to dislike of, or disgust with, a current partner’s sexuality; to her partner’s restricted repertoire of sexual activity. One interesting study also found that women with sexual arousal disorder show lower tactile sensitivity than is seen in other women; the lower their level of tactile sensitivity, the more severe their arousal dysfunction (Frolich & Meston, 2005). Biological causal factors include the use of SSRIs for anxiety and depression, the occurrence of certain medical illnesses (e.g., spinal cord injury, cancer treatment, diabetes, etc.), and the decreases in estrogen levels that occur during and following menopause. Some difficulties with physiological arousal and lubrication have been noted in 20 to 30 percent of sexually active women and in as many as 44 percent of post-menopausal women. Moreover, arousal problems in women very frequently co-occur with low levels of sexual desire; thus the new DSM-5 combined diagnosis. Indeed, having problems with sexual arousal may often lead to lack of desire (Meston & Bradford, 2007 ).

Treatment Although there has been interest since antiquity in the possibility that a drug to increase sexual desire might be found, no effective aphrodisiacs yet exist. As noted earlier, testosterone appears to be effective only in men and women who have very low levels of testosterone; that is, raising levels of this important sex hormone above normal levels has no beneficial effects (e.g., Meston & Rellini, 2008 ). Consistent with an effect of hormones, a German study showed that women using oral contraceptions, which sometimes work by raising estrogen levels, which in turn reduce testosterone levels, had somewhat lower levels of sexual desire and arousal compared with those who did not (Wallwiener et al., 2010 ).

Several studies have found that sustained use of bupro-pion (an atypical antidepressant), relative to placebo, improved sexual arousability and orgasm frequency in women who were in a committed relationship and had hypoactive sexual desire disorder (e.g., Segraves et al., 2004 ). Another drug, flibanserin, has been developed to increase sexual desire in women, but the Food and Drug Administration denied approval for this use in 2010, saying that there is not yet sufficient research (Wilson, 2010 ). Pharmaceutical companies are eager to find a treatment for low sexual desire in women, but some women have argued that the companies are more concerned about making money than about curing a legitimate illness (Segal, 2008).

There are no well-established psychotherapies for hypoactive sexual desire. Typically therapists focus on education, communication training, cognitive restructuring of dysfunctional beliefs about sexuality, sexual fantasy training, and sensate focus training (Meston & Rellini, 2008 ). Sensate focus exercises are also used in the treatment of several other forms of sexual dys-functions, as we will see. They involve teaching couples to focus on the pleasurable sensations brought about by touching without the goal of actually having intercourse or orgasm. Relationship problems often contribute importantly to low sexual desire, as do concerns related to body-image (Basson, 2010). Addressing these problems thus may be helpful.

Few controlled treatment studies of low sexual arousal in women have been conducted (Meston & Bradford, 2007 ), although clinical experience suggests that psychotherapy and sex therapy may play important roles in helping women with this disorder. Typically the techniques that are used are similar to those used to increase sexual desire. The widespread use of vaginal lubricants may effectively mask and treat the symptoms of this disorder in many women, but lubricants do not enhance genital blood flow or genital sensations.

In addition, because female genital response depends in part on the same neurotransmitter systems as male genital response, there has been great interest in the possibility that Viagra, Levitra, or Cialis would have positive effects for women analogous to their positive effects for men (Meston & Rellini, 2008 ). Unfortunately, enough research has now been performed to make it clear that such drugs are not as useful for women as they are for men (Basson et al., 2002 ; Meston & Rellini, 2008 ). Although these medications may enhance genital arousal and perceptions of physical sensations in women, they do not affect women’s psychological experiences of arousal. It is likely that women’s sexual desire and arousal are more dependent on relationship satisfaction and mood than they are in men.

GENITO-PELVIC PAIN/PENETRATION DISORDER

This disorder represents an important change in DSM-5. In past versions of DSM-IV-TR were distinguished two “sexual pain disorders”: vaginismus and dyspareunia. The disorders have been combined in DSM-5because scientific research did not support their distinction (Binik, 2010a , 2010b ). In particular, vaginismus has been believed to be an involuntary spasm of the muscles near the entrance of the vagina, preventing penetration and sexual intercourse. However, no scientific evidence exists that women with vaginismus have vaginal spasms or that vaginismus could be reliably diagnosed. In contrast, women diagnosed with vaginismus commonly complained of pain during penetration and anxiety before and during sexual encounters (Reissing et al., 2003 ). The latter symptoms made the distinction between vaginismus and dyspareunia (which is genital pain associated with sexual intercourse) unclear. That is, women with a past diagnosis of vaginismus were not clearly distinct from those with a past diagnosis of dyspareunia. Furthermore, as noted, the hallmark “symptom” of vaginismus, does not clearly occur, while the hallmark symptom of dyspareunia, genital pain during penetration, occurs commonly in women with vaginismus as well. Thus, in DSM-5 there is only one genito-pelvic pain/penetration disorder , which combines the genital pain of dyspareunia with muscle tension (not muscle spasms) and fear and anxiety related to genital pain or penetrative sexual activity.

Based on past studies of women with “sexual pain disorders” it appears that genito-pelvic pain/penetration disorder is more likely to have organic than psychological causes. Some examples of physical causes include acute or chronic infections or inflammations of the vagina or internal reproductive organs, vaginal atrophy that occurs with aging, scars from vaginal tearing, or insufficiency of sexual arousal. Understandably, dyspareunia is often associated with vaginismus, and some have questioned whether they are indeed distinct disorders.

Recently, some prominent sex researchers have argued against classifying sexual pain disorders as “sexual disorders” rather than as “pain disorders” (e.g., Binik, 2005 ; Binik et al., 2007 ). For example, Binik and colleagues argue that the pain in “sexual pain disorders” is qualitatively similar to the pain in other, nonsexual areas of the body and that the causes of “sexual pain disorder” are more similar to the causes of other pain disorders (e.g., lower back pain) than to the causes of other sexual dysfunctions. This concern is represented in the new name for the diagnosis (i.e., genito-pelvic pain/penetration disorder). It is also interesting to note in this regard that the disorder sometimes precedes any sexual experiences—for example, in some adolescent girls trying to use a tampon.

Treatment In past treatment studies of vaginismus and dyspareunia, cognitive-behavioral interventions have been effective in some cases. Cognitive-behavioral treatment techniques tend to include education about sexuality, identifying and correcting maladaptive cognitions, graduated vaginal dilation exercises to facilitate vaginal penetration, and progressive muscle relaxation (e.g., Bergeron, Binik et al., 2001 ). Medical treatments, such as surgical removal of the vulvar vestibule, a small area of the vulva between the labia minora, can be very successful (Binik, 2010a ). It is likely that genito-pelvic pain/penetration disorder comprises several distinct syndromes with different etiologies and potentially different treatments. If so, the more we learn, the better our treatment options will be.

FEMALE ORGASMIC DISORDER

The diagnosis of orgasmic dysfunction in women is complicated by the fact that the subjective quality of orgasm varies widely among women, within the same woman from time to time, and in regard to mode of stimulation (Graham, 2010 ). Nevertheless, according to DSM-5, female orgasmic disorder can be diagnosed in women who are readily sexually excitable and who otherwise enjoy sexual activity but who show persistent or recurrent delay in or absence of orgasm following a normal sexual excitement phase and who are distressed by this (see “DSM-5 Criteria” on p. 433). Of these women, many do not routinely experience orgasm during sexual intercourse without direct supplemental stimulation of the clitoris; indeed, this pattern is so common that it is generally not considered dysfunctional (Meston & Bradford, 2007 ). A small percentage of women are able to achieve orgasm only through direct mechanical stimulation of the clitoris, as in vigorous digital manipulation, oral stimulation, or the use of an electric vibrator. Even fewer are unable to have the experience under any known conditions of stimulation; this condition, which is called lifelong orgasmic dysfunction, is analogous to lifelong erectile disorder in males. More commonly, women experience difficulty having an orgasm only in certain situations or were able to achieve orgasm in the past but currently can rarely do so (Meston & Bradford, 2007 ). Laumann et al. ( 1999 ) found that rates of this disorder are highest in the 21- to 24-year-old age category and decline thereafter, and other studies have estimated that about one in three or four women report having had significant orgasmic difficulties in the past year (Meston & Bradford, 2007 ).

What causes female orgasmic disorder is not well understood, but a multitude of contributory factors have been hypothesized. For example, some women feel fearful and inadequate in sexual relations. A woman may be uncertain whether her partner finds her sexually attractive, and this may lead to anxiety and tension, which then interfere with her sexual enjoyment. Or she may feel inadequate or experience sexual guilt (especially common in religious women) because she is unable to have an orgasm or does so infrequently. Sometimes a nonorgasmic woman will pretend to have orgasms 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 being insensitive to her real feelings and needs. This in turn only adds to her sexual difficulties.

Possible biological causal factors sometimes contributing to orgasmic difficulties in women (as they do in men) include intake of the SSRIs as antidepressant medications. Many medical conditions already mentioned with other sexual disorders are also sometimes associated with orgasmic difficulties (Meston & Rellini, 2008 ). Recent evidence suggests that differences between women in their genital anatomy may allow some women to have orgasms during intercourse more easily than other women can (Wallen & Lloyd, 2011).

Treatment One important issue regarding treatment is whether women should seek it or not. Most clinicians agree that a woman with lifelong orgasmic disorder needs treatment if she is to become orgasmic. However, in the middle range of orgasmic responsiveness, our own view is that this question is best left to a woman herself to answer. If she is dissatisfied about her responsiveness, then she should seek treatment.

For those who do seek treatment, it is important to distinguish between lifelong and situational female orgasmic dysfunction. Cognitive-behavioral treatment of orgasmic dysfunction usually involves education about female sexuality and female sexual anatomy, as well as directed masturbation exercises. Later the partner may be included to explore these activities with the client. For those with lifelong orgasmic dysfunction, such programs can have nearly a 100 percent success rate in terms of the woman’s ability to have an orgasm at least through masturbation, but transition to having an orgasm with a partner can be slow and difficult in some cases (Meston & Rellini, 2008 ). “Situational” anorgasmia (where a woman may experience orgasm in some situations, with certain kinds of stimulation, or with certain partners, but not under the precise conditions she desires) often proves more difficult to treat, perhaps in part because it is often associated with relationship problems that may also be hard to treat (Althof & Schreiner-Engel, 2000 ).

in review

· • Compare and contrast the symptoms of the dysfunctions of sexual desire, arousal, and orgasm in men and women.

· • Why have common female sexual dysfunctions been studied less than male sexual dysfunctions?

· • What are the most effective treatments for male erectile disorder and premature ejaculation and for female orgasmic disorder?

UNRESOLVED issues: How Harmful Is Childhood Sexual Abuse?

Most contemporary Americans believe that childhood sexual abuse (CSA) is very harmful. This is reflected both in their concern for the victims of CSA and in their outrage at its perpetrators. The assumption of harmfulness is so deeply ingrained that many people find it shocking even to consider the alternative possibility that, at least sometimes, CSA is not very harmful. Surely, though, the issue of harm is answerable by empirical means. What do the results show?

In 1998 psychologist Bruce Rind of Temple University and two colleagues published, in the prestigious journal Psychological Bulletin, an article reviewing 49 previous studies that had asked college students about their sexual experiences during childhood (Rind et al., 1998 ). Furthermore, the studies assessed the students’ current adjustment, enabling Rind and colleagues to examine the association between early sexual experiences and mental health in young adulthood. Here are some conclusions of this study:

· • Correlations between childhood sexual abuse and later problems were of surprisingly small magnitude, suggesting that such experiences are not typically very harmful.

· • After general family problems had been statistically controlled for, the small association between CSA and adult problems was reduced to essentially zero, suggesting that the negative family environment in which child sexual abuse often occurs, rather than the sexual abuse per se, might explain much of the link between CSA and later problems. Indeed, poor family environment predicted adjustment problems an average of nine times more strongly than CSA did (Rind & Tromovitch, 2007).

· • Incest (sex with relatives) and forced sex were both associated with more problems than sex between nominally consenting, nonrelated individuals.

· • Age at which CSA was experienced was unrelated to adult outcome.

At first, the study’s provocative conclusions attracted little attention. However, after the conservative radio personality Dr. Laura Schlessinger learned of the study, she incited a firestorm of controversy. Both Dr. Laura and other critics accused Rind and his coauthors of giving comfort to child molesters and being insensitive to victims of CSA. The controversy culminated in 1999 with a resolution by the U.S. House of Representatives that condemned the study (Lilienfeld, 2002 ; Rind et al., 2000 ).

Rind’s study was attacked on two general grounds: First, some argued that it is socially dangerous to make the kinds of claims that the authors make in their article (Ondersma et al., 2001 ). Second, some argued that the study was not strong enough, scientifically, to justify such risky conclusions. Let us examine both criticisms.

Clearly, it would be wrong to understate the harm of CSA. Victims of CSA would suffer from having their pain unappreciated, and we may well invest too little in solving problems related to CSA. But overstating the harm of CSA may also entail significant costs. For example, people who are led to believe that they have been gravely and permanently harmed by CSA may suffer unnecessarily if CSA actually does not invariably have grave and permanent consequences. If CSA is often not very harmful, we need to know that.

Assessing the validity of Rind’s study is a scientific matter. Psychological Bulletin published a lengthy scientific critique of Rind’s study (Dallam et al., 2001 ) along with a reply by Rind and his coauthors ( 2001 ). One criticism of the original study was that it relied on college students, who may be unrepresentative. Perhaps they were able to attend college despite CSA because they were especially resilient. However, in another study, Rind analyzed data from community samples (samples not selected on the basis of educational attainment) and got virtually identical results (Rind & Tromovitch, 1997 ). Some of Rind’s statistical decisions and analyses have also been criticized, but he has shown that his results do not change much when he analyzes the data the way his critics would.

A later meta-analysis of a large representative group of nearly 1,800 adult Australians (ages 18 to 59) reported that CSA in women is associated with their having more symptoms of sexual dysfunction in adulthood (Najman et al., 2005 ). However, a later reanalysis of these data by Rind and Tromovitch (2007) showed that the magnitude of this relationship was quite small (similar to that in Rind et al.’s 1998 study). Moreover, Najman and colleagues did not statistically control for other important factors, such as poor family environment, that were shown to be even more important in Rind et al.’s 1998 study Rind ( 2003 , 2004 ) also extended his discussion to the issue of how harmful adult–adolescent sexual relationships are. The current American view, which has spread throughout the Western world, is that such relations are by definition also “childhood sexual abuse” even though marriages involving young teenagers were common in previous centuries. He reviewed evidence showing that current views on this topic are driven by ideology and moral panic rather than by any empirical research showing these experiences to be harmful—especially those between adolescent boys and adult females, where considerable evidence suggests that many teenage boys see perceived benefits from such relationships regarding their sexual confidence and self-acceptance. These are obviously controversial issues that deserve additional careful research in the future.

Clearly these studies do not yet definitively answer the question of “How harmful is CSA?” but future research must contend with their findings and pay close attention to the relative importance of other negative family factors that are usually highly correlated with CSA.

12 summary

· 12.1 Why is it difficult to define boundaries between normality and psychopathology in the area of variant sexuality?

· • Defining boundaries between normality and psychopathology in the area of variant sexuality is very difficult, in part because sociocultural influences on what have been viewed as normal or aberrant sexual practices abound.

· • Degeneracy theory and abstinence theory both maintained that sexual activity should only occur for purposes of procreation because wasting semen was harmful; both were very influential for long periods of time in the United States and many other Western cultures and led to very conservative views on heterosexual sexuality.

· • In contrast to Western cultures, in the Sambia tribe in Melanesia, homosexuality is practiced by all adolescent males in the context of male sexual initiation rites; these males transition to heterosexuality in young adulthood.

· • Until rather recently in many Western cultures, homosexuality was viewed either as criminal behavior or as a form of mental illness. However, since 1974 homosexuality has been considered by mental health professionals to be a normal sexual variant.

· 12.2 What do we mean by sexual and gender variants?

· • Sexual deviations in the form of paraphilias involve persistent and recurrent patterns of sexual behavior and arousal, lasting at least 6 months, in which unusual objects, rituals, or situations are required for full sexual satisfaction. They occur almost exclusively in males, who often have more than one of them. The paraphilias include fetishes, transvestic fetishism, voyeurism, exhibitionism, sadism, masochism, pedophilia, and frotteurism.

· • Gender dysphoria occurs in children and adults. Childhood gender dysphoria occurs in children who have unbold and dysphoria/distress about their biological sex. Most boys who have this disorder grow up to have a homosexual orientation; a much smaller number become transexuals. Prospective studies of girls who have this disorder have reported similar results.

· • Transsexualism is a very rare disorder in which the person believes that he or she is trapped in the body of the wrong sex and goes through elaborate steps necessary to change his or her sex. It is now recognized that there are two distinct types of male-to-female transsexuals: homosexual transsexuals and auto-gynephilic transsexuals, each with different characteristics and developmental antecedents. The only known effective treatment for transsexuals is a sex change operation. Although its use remains highly controversial, it does appear to have fairly high success rates when the people are carefully diagnosed before the surgery as being true transsexuals.

· 12.3 What are the three primary types of sexual abuse?

· • There are three overlapping categories of sexual abuse: pedophilia, incest, and rape. All three kinds of abuse occur at alarming rates today.

· • Pedophilia is defined as sexual interest in prepubertal children.

· • Incest involves sexual activity between blood relatives.

· • Rape describes sexual activity that occurs under actual or threatened forcible coercion by one person on another.

· • Treatment of sex offenders has not as yet proved highly effective in most cases, although promising research in this area is being conducted.

· 12.4 What is a sexual dysfunction?

· • Sexual dysfunction involves impairment either in the desire for sexual gratification or in the ability to achieve it. Dysfunction can occur in the first three of the four phases of the human sexual response: the desire phase, the excitement phase, and orgasm.

· • Male hypoactive sexual desire disorder is diagnosed in men when they have little or no interest in sex. In extreme cases they may actually have an aversion to sexual activity.

· • Erectile disorder occurs in men who are unable to attain or to maintain an adequate erection until the completion of sexual activity.

· • Formerly called premature ejaculation, early ejaculation occurs in men who persistently and recurrently have the onset of orgasm and ejaculation occurs after only minimal sexual stimulation.

· • Delayed ejaculation refers to the persistent inability to ejaculate during intercourse.

· • Female sexual interest/arousal disorder is diagnosed in women who persistently show a lack of interest in sexual activity and/or great difficulty getting adequately aroused enough to have an orgasm.

· • Genito-pelvic pain/penetration disorder is diagnosed in women who have persistent or recurrent difficulties in at least one of the following four areas:

· 1. Marked difficulty having vaginal intercourse/penetration

· 2. Marked vulvovaginal or pelvic pain during vaginal inter-course/penetration attempts

· 3. Marked fear or anxiety either about vulvovaginal or pelvic pain or vaginal penetration

· 4. Marked tensing or tightening of the pelvic floor muscles during attempted vaginal penetration

key terms

· autogynephilia 419

· delayed ejaculation disorder 436

· desire phase 431

· erectile disorder 433

· excitement (or arousal) phase 431

· exhibitionistic disorder 412

· female orgasmic disorder 439

· female sexual interest/arousal disorder 436

· fetishism 409

· frotteurism 413

· gender dysphoria 411

· genito-pelvic pain/penetration disorder 438

· incest 425

· male erectile disorder 434

· male hypoactive sexual desire disorder 434

· masochism 414

· orgasm 431

· paraphilias 409

· pedophilic disorder 422

· rape 425

· resolution 431

· sadism 413

· sexual abuse 420

· sexual aversion disorder 436

· sexual dysfunction 431

· sexual sadism disorder 413

· transsexualism 418

· transvestic disorder 411

· voyeuristic disorder 412