CH12

Learning Objectives
1. Provide a number of examples of sociocultural influences in sexual
practices and cultural standards and values.

**Male Hypoactive Sexual Desire Disorder: This disorder in men is

influenced by various factors, including cultural beliefs, attitudes,
personal vulnerabilities (like poor body image), and medical
conditions. For instance, predictors of low desire in men include daily
alcohol use, stress, unmarried status, and poorer health, reflecting the
influence of lifestyle and societal pressures on sexual desire.

**Erectile Disorder: This condition is not only influenced by medical

factors but also by psychological elements, such as anxiety about
sexual performance. The research suggests that cognitive distractions
and negative thoughts about sexual performance can significantly
impact erectile function. Men with erectile dysfunction are found to
make more internal and stable causal attributions for hypothetical
negative sexual events, showing how psychological and social factors
interplay in this disorder.

**Female Sexual Interest/Arousal Disorder: This disorder is seen to be

influenced more by psychological factors than biological ones.
Psychological contributors include prior or current depression or
anxiety disorders, low relationship satisfaction, daily hassles,
increased conflicts, and a history of unwanted sexual experiences like
rape. These factors highlight the sociocultural impact on women's
sexual functioning.
 **Genito-Pelvic Pain/Penetration Disorder: This disorder, which
results in significant distress due to physical pain during intercourse,
is a combination of what were previously considered two different
disorders – vaginismus and dyspareunia. The distinction was not
supported by scientific research, indicating the complex interplay of
physical, psychological, and social factors in women's sexual pain
disorders.

**Female Orgasmic Disorder: This condition is influenced by various

factors, including a woman's feelings about her partner's attraction to
her, sexual guilt, intake of SSRIs, and medical conditions. There's also
evidence that differences in genital anatomy might affect the ability to
achieve orgasm during intercourse, showing a biological influence. The
decision to seek treatment for orgasmic dysfunction is left to the
woman herself, highlighting the importance of individual and societal
perceptions of sexual satisfaction and functionality.

2. Define, give examples of, and describe the clinical features of the
following paraphilias: fetishism, transvestic fetishism, voyeurism,
exhibitionism, sadism, and masochism.

**fetishism 恋物癖

- Definition: Characterized by recurrent, intense sexual arousal

from the use of inanimate objects or specific body parts not
typically found erotic.
- Example: A man who is sexually aroused by women's
underwear, leading him to steal and hoard these items.
 - Clinical Features: The object of fetish is often necessary or
strongly preferred for sexual arousal. Fetishism frequently
occurs in the context of sadomasochistic activity and is rare
among sexual offenders

**transvestic fetishism 异装癖

- Definition: Marked by recurrent, intense sexually arousing

fantasies, urges, or behaviors involving cross-dressing.
- Example: A heterosexual man who becomes sexually aroused by
wearing women's underwear and nightgowns.
- Clinical Features: Often begins in adolescence and involves
masturbation while cross-dressing. May include autogynephilia,
where arousal is derived from the thought of being a woman.
This disorder is more prevalent in heterosexual men, and it can
cause significant distress or impairment in social or
occupational areas of functioning

**voyeurism 窥淫癖

- Definition: Involves recurrent, intense sexually arousing

fantasies, urges, or behaviors related to observing unsuspecting
people who are undressing or engaging in sexual activities.
- Example: A classic case is a "Peeping Tom" who watches people
undress or engage in sexual activities without their knowledge.
- Clinical Features: Often starts in young men, sometimes
accompanied by masturbation. It is associated with feelings of
power and secret domination over victims and may co-occur
with exhibitionism, sadomasochism, and cross-dressing

**Exhibitionism 露阴癖

- Definition: Characterized by recurrent and intense sexual

arousal from exposing genitals to an unsuspecting person.
- Example: An individual who exposes themselves in public
places like parks, stores, or buses.
 - Clinical Features: Often begins in adolescence or young
adulthood and is linked to causing emotional distress in viewers
due to its intrusive and norm-violating nature. It's one of the
most common sexual offenses reported and may co-occur with
voyeurism, sadomasochistic interests, and cross-dressing

**Sadism 虐待狂

- Definition: Entails recurrent and intense sexual arousal from

inflicting pain, either psychological or physical, on another
person.
- Example: A person who derives sexual pleasure from whipping,
biting, or otherwise hurting a sexual partner.
- Clinical Features: While most sexually sadistic acts occur within
consensual relationships, a small minority involve non-
consensual, serious acts. Sadistic fantasies often include themes
of dominance, control, and humiliation. Sadism may co-occur
with other paraphilias and is linked to certain personality
disorders

**Masochis 受虐狂

- Definition: Involves recurrent, intense sexual arousal from

being humiliated, beaten, bound, or made to suffer.
- Example: Participation in consensual sadomasochistic
relationships where one is a submissive "slave".
- Clinical Features: More common than sadism and occurs in
both men and women. Activities often performed within
“dungeons” in major cities. A dangerous form, such as
autoerotic asphyxia, involves self-strangulation for sexual
gratification but is associated with a high risk of accidental
death

3. Discuss the most effective treatments for paraphilias（性变态）, and

summarize causal factors implicated in their etiology（病因）.

**Effective Treatments for Paraphilias

Psychotherapies:

Goals include modifying patterns of sexual arousal and attraction,

modifying cognitions and social skills, changing habits that increase
the risk of reoffending, and reducing sexual drive.

- Aversion Therapy: Pairing a paraphilic stimulus with an

aversive event (e.g., noxious odors or electric shock).
- Covert Sensitization: Imagining an aversive event while viewing
or imagining a paraphilic stimulus.
- Replacing Deviant Arousal Patterns: Encouraging arousal to
acceptable stimuli, often by pairing orgasm with fantasies of sex
between consenting adults.

Biological and Surgical Treatments:

- Antidepressants (SSRIs): Useful in reducing paraphilic desire

and behavior but not effective for treating sexual offenders.
- Castration (Surgical and Chemical): Lowers testosterone levels
and sex drive, allowing the offender to resist inappropriate
impulses. Has shown significant results in reducing recidivism,
but raises ethical concerns.
- Hormonal Therapy: Involves administration of antiandrogen
steroid hormones like Depo-Provera and Lupron, which can
have serious side effects.

Combination of Psychological and Biological Treatments:

Combines hormone therapy with cognitive-behavioral treatments,

with the hope of tapering off hormone treatment after the offender has
learned impulse control techniques.

**Causal Factors Implicated in Paraphilias

Recidivism Predictors:

- Sexual recidivism is higher among offenders with deviant sexual

preferences (e.g., severe sadists, pedophiles).
 - Predictors of recidivism include sexualized violence, negative
social influences, poor cognitive problem-solving, and
loneliness.

Contributing Factors:

- Paraphilias are often accompanied by cognitive distortions and

inadequate social skills, particularly in processing social
information from potential partners.
- Psychological treatments aim to address these cognitive
distortions and improve social interaction skills.

Role of Age:

- The recidivism rate for paraphilic behaviors, including rape,

decreases with the offender's age.

Legal and Societal Measures:

- Laws like Megan’s Law mandate registration of convicted sex

offenders and community notification, but their effectiveness in
reducing recidivism is debated.

4. Define and describe the clinical features and treatment of the gender
identity disorders (gender identity disorder of childhood,
transsexualism).

Gender Dysphoria

**Definition:

- Characterized by persistent distress due to a mismatch between

one's assigned gender at birth and their gender identity.
- Can be diagnosed during childhood, adolescence, or adulthood.
**Clinical Features:

- In Children:
 Boys with gender dysphoria may show a preference for
traditionally feminine activities, such as playing with
dolls, playing house, dressing in female clothing, and
expressing the desire to be a girl.
 Girls with gender dysphoria often prefer traditional boys'
clothing, short hair, have male fantasy heroes, show little
interest in dolls, and increased interest in sports.
 Both may exhibit a strong rejection of their assigned
gender's typical toys, games, and activities.
- In Adolescents and Adults:
 Marked incongruence between one’s
experienced/expressed gender and assigned gender.
 Desire to be rid of one’s primary and/or secondary sex
characteristics due to incongruence with
experienced/expressed gender.
 Strong desire for the primary and/or secondary sex
characteristics of the other gender.
 Desire to be treated as the other or an alternative gender
different from one’s assigned gender.

Treatment:

**For Children and Adolescents:

- Psychotherapy is often used, addressing the child’s unhappiness

with their biological sex and easing strained relations with
parents and peers.
- In some cases, early adolescents with gender dysphoria are
given hormonal treatment to delay puberty.
- Treatment may also address general psychological and
behavioral problems like anxiety and mood disorders.

**For Adolescents and Adults:

 - The treatment approach is more focused on supporting the
individual's gender identity, which may include hormone
therapy and gender-affirming surgeries.
- Psychological support to deal with stress and discrimination
related to expressing cross-gender identification and
preferences.
- Addressing any comorbid mental health issues, such as mood
and anxiety disorders, is crucial.

5. Review what is known about the frequency and nature of childhood

sexual abuse. Discuss the controversies surrounding both childhood
testimony regarding sexual abuse and adult “recovered memories” of
childhood sexual abuse.

**Frequency and Nature of Childhood Sexual Abuse

- Prevalence: Globally, 1.6% of people report being victims of

childhood sexual abuse. In the United States, this figure is
higher, between 4 to 6%.
- Variability in Definitions: The prevalence rates vary depending
on the definition of childhood sexual abuse used in studies.
Definitions vary in terms of the age considered as 'childhood',
types of sexual interaction included (physical contact, genital
contact, exhibitionism, consensual contact with a minor), and
the inclusion of non-contact abuse.
- Consequences: Childhood sexual abuse significantly increases
the risk of mental disorders in later life, particularly
fear/anxiety and substance use disorders. Victims also have an
increased risk of suicidal thoughts and behaviors. A range of
sexual symptoms, from aversion to promiscuity, have been
attributed to early sexual abuse.

**Controversies Surrounding Childhood Testimony and Adult

Recovered Memories
 - Validity of Children's Testimony: High-profile cases have raised
doubts about the reliability of children's accusations, especially
in cases where the allegations are bizarre or extensive. There is
concern about the influence of leading questions or coercive
methods used during interviews with children.
- Adult Recovered Memories: There is controversy over the
legitimacy of 'recovered' memories of childhood sexual abuse
that surface in adulthood, often during therapy. Questions arise
about the accuracy of these memories and the influence of
therapeutic techniques

6. Define pedophilia (恋童癖), and summarize what is known about

pedophiles.

**Definition of Pedophilia (DSM-5)

- Diagnosed when an adult has recurrent, intense sexual urges or

fantasies about a prepubertal child (generally age 13 or
younger).
- Acting on these desires is not necessary for diagnosis if they
cause distress to the individual.

**Discussion about Pedophilia and Hebephilia

- Pedophilia: Attraction to prepubescent children (without any

signs of puberty).
- Hebephilia: Attraction to pubescent children (early stages of
puberty).
- DSM-5 committee considered but ultimately rejected expanding
the definition of pedophilia to include hebephilia.
- Proposal suggested diagnosing based on physical maturity
(Tanner scores) rather than age, due to variability in rates of
maturation.

**KNOWN Characteristics of Pedophiles

 - Predominantly male.
- About two-thirds of victims are girls, usually aged 8-11.
- Higher rate of homosexuality among pedophiles compared to
adult-attracted men.
- Homosexual pedophilia differs from normal male
homosexuality.
- Homosexual pedophilic offenders often have more victims than
heterosexual pedophilic offenders.
- Many pedophiles engage in the use of child pornography.

7. Review what is known about the frequency and nature of incest.

Definition of Incest

**Incest involves culturally prohibited sexual relations between family

members, such as between siblings or between a parent and a child.

Frequency of Incest

**It's difficult to accurately estimate the incidence of incest, as it often

comes to light only when reported to authorities.

**Incest is believed to be more common than generally acknowledged,

partly because many victims are reluctant to report it or do not
perceive themselves as victimized.

Nature of Incest

**Incest involves culturally prohibited sexual relationships between

family members, such as siblings or between a parent and child.

**The most common form is brother-sister incest, followed by father-

daughter incest. Mother-son incest is considered relatively rare.
 **Incest can result in mental and physical problems in offspring due to
the high likelihood of inheriting recessive genes with negative effects
from closely related parents.

**In some cases, incest offenders target multiple children within a

family, and some fathers may involve all of their daughters as they
become pubescent.

**Some incestuous child molesters exhibit pedophilic arousal patterns,

but they differ from extra-familial child molesters in that their offenses
are more likely to be against girls and limited to one or a few children
in the family.

8. Summarize what is known about rape and rapists, and discuss the
issues regarding the frequency of rape and the motivation of rapists.
Describe attempts to treat sex offenders.

Rape and Rapists

**Definition: Rape involves any non-consensual penetration,

regardless of the body part or object used, and includes oral
penetration by a sex organ of another person. The FBI updated this
definition in 2013.

**Prevalence: The prevalence of rape varies due to different definitions

and methods of data collection. The rate of rape and sexual assault
victimization has been declining in recent years.

**Motivation: Initially considered a crime of sexual desire, the 1970s

feminist movement posited that rape is more about domination,
power, and humiliation. However, sexual motivation also plays a
significant role, as evidenced by the age distribution of victims and
rapists' own admissions.

Treatment and Recidivism of Sex Offenders

 **Recidivism: Sex offenders with deviant sexual preferences have high
rates of sexual recidivism. Predictors of recidivism include sexualized
violence, negative social influences, poor cognitive problem-solving,
and loneliness.

**Psychotherapies: Aim to modify sexual arousal patterns, cognitive

distortions, social skills, and reduce sexual drive. Techniques include
aversion therapy, cognitive restructuring, and social-skills training.

**Effectiveness: Studies show mixed results, but cognitive-behavioral

techniques seem more effective than older methods. A meta-analysis
showed that treated offenders have lower recidivism rates compared to
untreated ones.

**Paraphilias and Treatment Response: Certain paraphilias respond

better to treatment than others. Nonpedophilic child molesters and
exhibitionists show better success rates in treatment compared to
pedophilic offenders and rapists.

Megan's Law: In response to high-profile cases, Megan's Law requires

convicted sex offenders to register with police and for neighbors to be
notified of their presence. The law's effectiveness is debated, with
some studies showing no significant impact on enhancing community
safety

9. Define the sexual dysfunctions, describe their general features, review

etiological theories, and summarize the major approaches to
treatment.

Definition - sexual dysfunction involves an impairment in the desire

for sexual gratification or in the ability to achieve it. Dysfunction can
occur in the first three phases of the human sexual response: the desire
phase, the arousal phase, and orgasm.

General Features

- Men
- Women
 Review Etiological Theories

- ????

Summarize major approach to tx

- psychotherapy
- medication (such as PDE5 inhibitors for erectile dysfunction),
- hormone therapy,
- sex therapy which may include education, communication skills
training, and techniques to reduce performance anxiety

10. Knowledgeably discuss the difficulty of deciding the extent of the

harm caused by childhood sexual abuse.

**Variability in Individual Responses: Individuals who experience CSA react and cope in
diverse ways, influenced by factors such as their age at the time of the abuse, the nature of
the abusive acts, the relationship with the abuser, and their personal resilience. While some
survivors show remarkable resilience and few long-term negative effects, others suffer
from significant and enduring harm.

**Physical and Psychological Trauma: CSA can result in immediate physical harm and
long-lasting psychological trauma. Psychological effects can include depression, anxiety,
post-traumatic stress disorder (PTSD), and a range of behavioral and emotional issues. The
severity and persistence of these effects vary widely among individuals.

**Difficulty in Diagnosis and Attribution: Linking specific psychological or behavioral

problems directly to CSA can be challenging. Many factors contribute to a person's mental
health, and survivors of CSA may also experience other life stressors that compound the
effects of the abuse.

**Underreporting and Memory Issues: Many cases of CSA go unreported, often due to
fear, shame, or manipulation by the abuser. Additionally, memory of the abuse can be
suppressed or distorted, particularly if the abuse occurred at a very young age or if the
survivor used denial or dissociation as coping mechanisms. This can complicate the
assessment of harm.

**Long-Term Impact: The long-term impact of CSA can manifest in various ways,
including difficulties in forming healthy relationships, sexual dysfunctions, substance
abuse, and other risky behaviors. Understanding the full extent of these impacts often
requires longitudinal studies, which can be complex and ethically challenging to conduct.
**Cultural and Societal Factors: Perceptions and reactions to CSA are influenced by
cultural, societal, and familial attitudes toward abuse and sexuality. In some cases, societal
stigma can exacerbate the harm caused by CSA, affecting the willingness of survivors to
seek help and receive adequate support.

**Variability in Abuse Characteristics: The nature and severity of the abuse (e.g.,
frequency, duration, the presence of violence or coercion, the abuser's relationship to the
child) play a crucial role in determining the extent of harm. For example, abuse by a
trusted caregiver might have different psychological implications than abuse by a stranger.

**Legal and Ethical Considerations: Determining the harm caused by CSA is not only a
psychological concern but also a legal and ethical one. In legal contexts, assessing harm
can influence sentencing and restitution. Ethically, mental health professionals must
navigate the balance between acknowledging the harm caused by CSA and supporting the
resilience and agency of survivors.