sexual variants

12 sexual variants, abuse, and dysfunctions

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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.”

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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.

·  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.

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.

·  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.

Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric Association.

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.

Source: Adapted with permission from the DSM III Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Case Book, (Copyright ©1981). American Psychiatric Association.

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 ).

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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 ove

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