The interesting phenomenon of sexual deviations and perversions

K Y Mak 麥基恩

HK Pract 2003;25:491-502

Summary

Sexual behaviour is broadly divided into sexual functions and sexual practices. A normal sexual practice is difficult to define and is also affected by the current social norms. Paraphilias or sexual deviations (formerly called perversions) form a special category with the characteristic feature of sexual arousal in response to an inappropriate sexual stimulus, and may interfere with the capacity to establish sexual relationships. Such behaviours may be harmless or injurious, physically or psychologically, and can become sexual offences in the absence of consent. The true prevalence rate is unknown, and milder forms are not detected. Treatment is not easily achieved, and recidivism is high. Psychological and medical therapies have been tried, and a comprehensive approach including legal considerations, appears most promising.

摘要

性行為可慨括地分為性功能和性習慣。因受社會 行為標準影響，較難為正常性習慣寫下定義。 性律倒錯（以前稱為性變態）是一種特殊類別，它的特徵是對不適合的性刺激產生性反應， 因而可能妨礙建立正常的性關係。此種行為可能對身體或精神上造成傷害。而且在未得對方同意下進行， 更可構成刑責。其普遍程度不詳，而較輕微的情形更不會被察覺。治療並非容易，同時更常有累犯的情況。 心理治療和醫藥治療已經被嘗試使用，而一個全面的，包括法律上考 慮的方法則更為湊效。

Introduction

Abnormal sexual behaviour is broadly divided into abnormal sexual functions and abnormal sexual practices. Throughout history, such abnormal sexual behaviours were often censored by the society and regarded as sinful, immoral, unnatural or even wicked and deserving punishment rather than treatment. Yet different cultures have different standards for normal sexual behaviour. While ancient Judaism condemned homosexuality, bestiality, transvestism and even masturbation, the Greeks culture was more tolerant to the extent that sex between an adult male and a "young boy" was seen as a form of respectable education.¹ Sexual activities with animals and sexual interest in corpses were recorded in Buddhist texts over 2000 years ago.

Sexual perversions became a scientific discipline of study in the late nineteenth century when Richard von Kraft-Ebing published the first masterpiece Psychopathia Sexualis in 1887. In this book, the author described fetishism, flagellation, sadism, necrophilia and other abnormal sexual behaviour. In 1918, Magnus Hirschfeld founded the Institute of Sexual Science in Berlin, Germany to study human sexuality especially that of sexual anomalies including homosexuality. Other prominent sexologists included Henry Havelock Ellis in the United Kingdom and Alfred Kinsey and his colleagues of the United States. Changing social attitudes and social movements especially feminism and sexual liberation modified the types of sexual deviations considered as such. In 1973, the Gay Liberation groups protested to the American Psychiatric Association, resulting in the deletion of homosexuality from the Diagnostic and Statistical Manual of Mental Disorders. Nowadays, serious problems concerning various aspects of sexuality do occur. They are now more noticeable and likely to be reported by the mass media, especially that of child prostitution, sexual abuse and sexual harassment. Some are associated with criminal charges e.g. teachers molesting school children and are often headlines in the newspapers.

Definitions

In the past, various types of sexual behaviour have been labelled as sexual deviations. In fact historically, the term "sexual deviation" was preceded by that of "sexual perversion", both of which denote a sense of right and wrong, good and bad. According to Bancroft,² sexual deviation denotes "any sexual behaviour which is socially unacceptable, stigmatised, and in many instances legally prohibited". To be more specific, Scott³ defined it as "a sexual act or fantasy other than genital intercourse with a consenting partner of the opposite sex of similar sexual maturity and acceptable blood relationships, and such behaviour is frequently repeated, contrary to cultural norms". With the changing morality in Western countries, the term "sexual deviation" is sometimes changed to "sexual variations" instead. According to de Silva,⁴ it refers to "sexual desires and behaviours outside what is considered to be the normal range". In the U.S., the neutral term "paraphilias" (meaning deviated attractions) is used, and is defined as recurrent, intense sexually arousing fantasies, sexual urges, or behaviours generally involving 1) non-human objects, 2) the suffering or humiliation of oneself or one's partner, or 3) children or other non-consenting persons, that occur over a period of at least 6 months. To qualify fully for such a diagnosis, there should be clinically significant distress or impairment in social, occupational or other important areas of functioning.

Prevalence

The prevalence of sexually deviated behaviour is difficult to ascertain. For one thing, it depends on the degree of reportability of cases. Sadomasochistic fantasies, for example, will probably never be reported. On the other hand, child molestation is reported in increasing frequency, perhaps with better awareness and social concern. For example, in the U.S., among all maltreated children only 9% were that of sexual abuse in 1983;⁵ but this increased to 16% in 1986. Clinical records are helpful but may not reflect the true extent of the situation. Perhaps those activities with criminal implication can be more clearly defined, but again it depends very much on the police detection rate (detectability) which often depends on the honesty of the criminals' stories and the reliability of the victims' testimonies. Nevertheless, it should be stated clearly that not all sexual deviations are crimes, and there are usually no psychotic symptoms exhibited. Therefore, the patients should not be stigmatised as criminals or lunatics.

In the U.K., sexual offences account for 1% of all indictable crimes, and the percentage clear-up rate is 75%. However, recidivism can be as high as over 50%.⁶ Hospital or clinic records could give some estimates, but again they may represent a selected sub-group (recordability). Abel et al⁷ analysed (confidentiality assured) sex offenders against children coming for evaluation at the out-patient setting and recorded the average number of assaults per offender (Table 1). The results proved a gross under-reporting of such assaults in police records. Population survey is expensive and not practical, as such intimate questions are famous for inaccurate answers. The most famous national survey was that by Kinsey and his colleagues,^8,9 but the report was criticised for under-recognition of sexual child abuse. And figures quoted in studies in the West cannot be extrapolated to other cultures, because of the importance of socio-cultural variables. For example, it is very likely that there is under-reporting of sexual abuses among Chinese societies, as sexual taboos are strong and family secrets are strongly hidden.

As regards individual sexually deviated disorder, there is a great variation in the prevalence rate and the socio-demographic data of the perpetrator and the victims from one another.

Classification

There is still no satisfactory classification of sexual deviations to-date, and a person may progress from one form to another. At one time in history, oral sex was considered a sexually perverted behaviour.¹⁰ Homosexuality was removed from the psychiatric classification only a few decades ago. Likewise, societal censored behaviour like adultery, premarital sex, concubines, etc. are not included as sexual deviations.

In the first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-I) of the American Psychiatric Association, Sexual Deviations were listed under the heading of "Sociopathic Personality Disturbance" which was within the category of "Personality Disorders". In the 2nd edition (DSM-II), Sexual Deviations became an entity of its own, and the term Paraphilia started to appear in DSM-III. According to the DSM-IV, the disorders under Paraphilia are slightly modified, and are listed below (Table 2), and it is not unusual for a person to have more than one paraphilia.

Clinically speaking, the majority of paraphilics could have sex without fantasies, and deviant sexual behaviour can occur together with non-deviated sex. Furthermore, paraphilics often engage in different types of deviated sexual behaviours. Finally, the DSM-IV here did not take into account the criminal sexual intent as in rape. In the U.K. clinic setting, the more common disorders were fetishism, transvestism, sadism and masochism.⁴

From a social point of view, the following grouping is easier to understand.

1. Acceptable sexual activity in inappropriate places

Such behaviours are usually quite normal if performed in private, but become offensive to many people if done in public, and are labelled as "indecent exposure", example of which are:

1. Masturbation and self-exploration of the body, especially of the genitalia;
2. Stripping (disrobing) especially genital exposure; and
3. Urination, thereby exposing the genitals.
2. Culturally-determined acceptable sexual behaviour

Such behaviour can be quite normal in certain races or cultures, but become taboos in others. Examples of such unlawful sexual acts (either homosexual or heterosexual) are:

1. Sexual relationship with other residents or inmates in an institution (especially if the other party is a minor);
2. Sexual relationship with staff or subordinates (including teacher-student and doctor-patient relationship).

The sexual act can either be active or passive. If there is any monetary transaction for the act, it can be charged as either soliciting material gain (usually the female party) or prostitution (mostly the male party).

3. Unacceptable sexual behaviour

These are often acts involving inappropriate sexual stimuli or non-consenting partners:

1. Indecent assault
2. Rape
3. Voyeurism (peeping-Tom)
4. Paedophilia (gross indecency with children)
5. Fetishism and transvestism
6. Sado-masochism
7. Obscene language

Aetiology

Most people can and do have some kind of perverted sexual fantasies, but they do not act them out. Why do a few individuals who are consumed by these fantasies act out, even infringing on the human rights of another person? Different types of sexual deviations can have different causes, but each one usually occurs as a result of a combination of biological, psychological and social factors.

1. Biological
1. Genetic: since most paraphilics are male, many have thought that the Y chromosome should have an important role to play. So far, only the XXY (Kleinfelter Syndrome) had been associated with an increased rate of sexual deviation. Nielsen¹¹ found that among 411 subjects with XXY chromosome, 15 (3.6%) were homosexuals, 10 (2.4%) transvestites, 8 (1.9%) paedophiles, and 2 (0.5%) other sexual perversions. Nevertheless, there is still a possibility that the gender role and identity-development after birth having an influence on these incomplete males and the attitudes of their parents towards them as "sons" could have contributed to such deviated behaviour.
2. Hormonal: testosterone has been associated with aggressive behaviour (including sexual), but clear-cut correlations are lacking. Rada¹² found that the testosterone levels were higher among violent rapists, compared to that of child molesters and controls.
3. Brain damage: the connection between brain functions and sexual disturbances are complicated. The Kluver-Bucy or temporal lobe syndrome (hypersexual behaviour with decrease in anger and fear) was observed in human beings after removal of bilateral anterior temporal lobes.¹³ On the other hand, temporal lobe epileptic patients often have hyposexuality with reduction in libido and genital functions, though a few had episodes of hypersexuality, especially after the abrupt termination of seizure.¹⁴ Furthermore, patients with varying degrees of dementia (involving mainly the frontal lobe) often exhibit disinhibited sexual behaviours e.g. genital exposure, compulsive masturbation, etc.¹⁵ Although elderly paedophilia has been attributed to senile dementia, the psychosocial factors of loneliness and social isolation appear to be more important.¹⁶
4. Substance abuse: many sexual offences, noteworthy that of rape, were committed under the influence of alcohol, partly due to the disinhibition effect of alcohol, and partly because of the direct effect of alcohol on the aggression and sexual centres of the brain.¹⁷
5. Psychiatric disorders: Kafka¹⁸ found a high incidence of major affective disorders in male paraphilics, as these behaviour could be regarded as sexual dysregulation, similar to that of the eating dysregulation like bulimia nervosa. On the other hand, paraphilics could be regarded as having obsessive-compulsive disorders with sexual compulsions.¹⁹ Finally, psychotic patients may carry out bizarre sexual acts while under the influence of their delusions and hallucinations.
2. Psychological

There are many psychological theories for different types of sexual deviations. For example, that for child abuse and paedophilia, are very different from those for sado-mashochism. The reasons behind rape, for instance, could be totally different from those behind exhibitionism. Commonly accepted viewpoints are put forward here, including classical and operant conditioning and social learning. It should be noted that a lot of different psychological factors including personality characteristics are often involved. It is very difficult to lump them together without being over-simplistic.

1. Conditioning: in classical conditioning the deviant sexual behaviour is somehow paired with a pleasurable stimulus resulting in eroticised response, and perhaps internalised (to a fantasy) and reinforced by masturbation excitement. Due to lack of reinforcement, other normal sexual stimuli lose attraction and become extinguished, especially if these acts were associated with unhappy events. Operant conditioning further suggests that if the operant consequence of the deviant behaviour is positive, the habit is strengthened and vice versa. An example is that the negative result of an arrest of an exhibitionist may temporarily stop his exposure until other factors reinstituted the behaviour. Laws and Marshall²⁰ added that habituated behaviour consists of "functionally linked sequences of instrumental acts" with one sequence triggering the next (chaining effect).
2. Social learning theory: the offender acquired the deviated act by normal or faulty learning, i.e. observing and modelling the actions of others who are being rewarded or punished. Nowadays, cognitive-developmental theories are more prominent, and internal cognitions such as beliefs, expectations, imageries and fantasies, etc. are discussed, which in turn are influenced by past learning experience and socio-cultural factors. The concept of cognitive distortions helps to explain the reasons why the paraphilics sustain and even justify their sexually deviated behaviour. For example, a paedophile would consider that the gestures of a child are seductive acts directed towards him.
3. Psychoanalytic theory: perversion is the result of regressive defences against the castration anxiety (a man with the fear of castration if he develops heterosexual identification with the father) and the Oedipal complex (an ambivalent relationship with the care-taking "breast" mother) in early childhood. Sexual perversion is a kind of hypertrophied primitive infantile sexual drive, a fixated libido in a person who has failed to transform from infancy into adult genital maturity.²¹ Freud defined sexual perversion as deviated sexual aims. He regarded voyeurism as deviated looking, frotteurism and sexual harassment as deviated touching, exhibitionism as deviated showing, etc.
   Neo-Freudians and others have since modified Freud's theories to explain the sexual perversion, with less emphasis on libido but more on relational or interpersonal difficulties. For example, Fenichel²² regarded exhibitionism as a desire to expose the genitals to counteract castration anxiety, but object-relational theorists like Stoller²³ considered this as a need to avenge the humiliation by women and a means to regain maleness. Likewise, transvestism was viewed as fantasising the mother possessing a penis, but object relation theorists would view this as a kind of psychic maternal object.²⁴
   Finally, the psychodynamic theorists discuss how sexually deviated behaviour results from the influence of personal characters in adjustment to life. For example, the neurotic character may use the behaviour to enhance genital potency, while the narcissistic character as a repair of self defects and past trauma, and the borderline character as a sign of ego fragmentation and impulsive deficits.²⁵
3. Social

A variety of cultural, family and social factors during the upbringing period contribute to the development of abnormal sexual behaviour. Bancroft² talked about the pull and push factors and applied them to the development of human homosexuality. Using this concept, one can compose a few such factors for paraphilics (Table 3).

Management

Many patients with sexual deviations do not accept such treatment voluntarily, but are forced to do so by their spouses, family members or even by the law. Those who are motivated for help often have co-existing sexual dysfunctions such as erectile difficulties. Therefore, the motivation for change is often tinted, and a good doctor-patient relationship may not be easy to develop. However, motivation is a very important factor for success, and thus a multi-disciplinary approach with clear explanation about therapies is needed.

First of all, the usual comprehensive psychosocial history is helpful to rule out any psychiatric disorder, be it organic or functional. Secondly, time should be spent in getting a detailed psychosexual history that covers the developmental, past and current sexual experience and practices. This usually includes sexual knowledge (and sources), gender orientation and gender role, normal and abnormal sexual behaviour, and the circumstances leading to sexual arousal (including the sexual stimulus needed as well as the mood and thinking at the time of sexual intercourse or masturbation). For example, a husband may just use masturbation in the toilet to release tension, while the wife must think of a romantic affair with a lesbian stranger before getting an orgasm during sexual intercourse. A penile plethysmography may be useful to clarify genuine sexual interests.²⁶ Thirdly, additional information from the victim(s) and other witnesses must also be considered especially for a sexual offender. Last but not the least, the risk of violence and recidivism should also be assessed.

If there is any underlying psychiatric disorder, e.g. an obsessive-compulsive disorder, the appropriate psychiatric therapies should be given. For example, Kafka¹⁸ had treated with success paraphilics with antidepressants; while Ward²⁷ cured a man with bipolar affective disorder and a two-year history of transvestism with lithium. As regards more definitive treatment for sexual deviations, there are both medical and psychological therapies, and they should be differentially applied when treating each individual disorder.

1. Medical
1. Medications or hormones: these are of doubtful use, with the purpose of decreasing libido.

1. Anti-androgens: medroxyprogesterone acetate (Depo-Provera) and cyproterone acetate (CPA) have been used in the U.S. to treat paraphilics, especially those associated with hypersexuality e.g. nymphomania in women. The medication reduces plasma testosterone level, and researchers observed significant decrease in sexual tension, fantasies and preoccupation.²⁸ A major criticism is that though the drive is reduced (during the treatment period only), the direction of the drive is not.

2. Other medication: Perilstein et al¹⁹ had successfully treated one patient with paedophilia, one with exhibitionism and one with voyeurism/frotteurism, with fluoxetine. All these patients denied that they were depressed.

2. Surgery: with similar purpose in mind as using medications, but more drastic and permanent.

1. Surgical castration (bilateral orchidectomy) and stereotaxic psycho-surgery (tractomy and limbic leucotomy) has been performed in the past, usually for repeated sex offenders especially that of rape and paedophilia. But the results were unreliable, not to mention the ethical dilemma involved for such irreversible procedures. For example, Heim and Jursch²⁹ found that 40% of castrated men continued to have sexual intercourse years after surgery. Rieber and Sigusch³⁰ reviewed the cases in Germany and concluded that there were too many deficiencies in the procedure to be of use.

2. "Revision surgery" (sex change operations) is a more acceptable treatment for transsexualism, consisting of penile resection or reconstruction, vaginal reconstruction, augmented by hormonal therapies to boost up the secondary sexual characteristics.

2. Psychotherapies

1. Psychoanalytic therapy: early therapists target in developing insight into the castration and oedipal dynamics in personal development. Later, object relational therapists aim at the interpretation of inner sexual fantasies of the person and its relations with character development. By interpreting the transference and the various defences within the therapeutic relationship, the patient tries to develop a more mature and normal sexual relationship in life. Some therapists would take a more active, directive approach to effect behavioural and responsible changes in the patient.

2. Behavioural therapy: behavioural therapists in the past used aversion therapy (often via electric shocks to induce pain) to alter the perverted behaviour. Another approach, a method sometimes called "covert sensitisation", is to train the patient to pair up the deviant sexual desire with a noxious feeling or thought (e.g. an arrest by a policeman). However, this only suppresses the problem behaviour rather than eliminates it, and consent has to be sought in advance. With the patient's cooperation, the technique of "orgasmic reconditioning" can be employed. Firstly, the patient is asked to masturbate with his deviated fantasy and when orgasm is imminent, to switch to normal sexual fantasies. The ensuring orgasm becomes a strong reinforcer for the new sexual behaviour. This point of switching is then brought forward in subsequent sessions until the masturbatory orgasm can take place with these normalised fantasies. Lastly, the procedure of masturbatory satiation can be employed. Initially, the patient masturbates while fantasising normal sexual activity, but is compelled to continue to masturbate (say for another 50 minutes) while thinking about the deviated sexual scenes, and any sexual excitement related to the deviant will be lost.

3. Cognitive therapy: in recent years, more emphasis is placed in modifying the underlying deficits and incompetence via various cognitive (and behavioural) techniques. The cognitive-restructuring technique aims at identifying the faulty thinking of the patient and tries to help him realise the impact of his behaviour on the victims. The self-control techniques, such as thought-stopping, help the patient gain control over his deviant feelings and acts.

The above treatment modules can be conducted individually and sometimes in groups, with the latter having the additional benefits of group modelling and peer pressure for change. In addition to the different therapies, relaxation exercise, stress management training and interpersonal skills are sometimes used as adjunctive measures to combat anxiety and stress which may have triggered off the deviated behaviour. Other provoking factors, if found, should also be tackled. As many patients learn about sex from pornographic literature, proper sex education is often necessary, including information and skills about normal sexual functioning. Indeed, it may be necessary to help the patient in attaining sexual satisfaction through normal or socially acceptable outlets. Quite often, marital/couple therapy is needed, and the spouse is advised to shape the abnormal behaviour systematically into more acceptable sexual activities. Group therapy is sometimes organised, especially for sex offenders, and the participants learn through group processes and pressure.

3. Legal treatment

Persons having sexual deviations often perform in secret, and they try to hide their behaviour from others especially their close relatives. When they are caught, they often deny strongly at least some of their past acts. Therefore, it is not common for the patients to seek help from their primary care doctors. However, the relatives (especially the spouses and parents) do sometimes seek advice about such deviated sexual behaviour from their general practitioners. To these frontline doctors, they may face the dilemma of reporting the patients when their sexual deviations break the law.

In determining the criminality of sexual offence, the presence of consent (and the capacity to consent) is very important. There is also often an age limit factor to be considered. Many patients are referred to treatment involuntarily, and their motivation for change may not be genuine, and perhaps a conditional term such as probation or parole may be useful to motivate the sex offender to change. Unfortunately, the rate of recidivism is high, and long-term supervision may be necessary. To the serious sex offender, confinement to an institution maybe a sure way to stop the deviated behaviour, but is not really treating the underlying psychopathology.

Conclusion

The classification of sexual behaviour is often affected by changing social norms (such as the normalisation of oral sex and decriminalisation of homosexuality), and the commercial exploitation of sex in recent years sometimes makes deviated sexual behaviour appear normal. There should be a balance between the pros and cons of including a sexual behaviour pattern as an illness into the classification, and limits should be set to avoid over-inclusion of trivial and harmless sexual acts. On the other hand, sexually deviant patterns of life often influence the individual's choice of occupation, sexual partner, hobbies and other daily activities. Exposure of their behaviour sometimes results in a breakdown of relationships between friends, partners and even family, and may lead to bribery and other criminal behaviour. Recent advances in psychotherapy are beneficial to a number of perpetrators, and sometimes a trial of medication is justified. Legal penalty is not a curative measure, and a holistic approach with contribution from professionals of various disciplines with both therapy and rehabilitation is ideal to prevent recidivism. Finally, there remains an issue as regards the ethics in castrating criminals with refractory sexual deviated behaviour (e.g. paedophiles), for the sole purpose of protecting society.

Key messages

1. Sexual behaviour was often censored by society and different religions, but in recent decades changing social attitudes and social movements modified the types of sexual behaviour considered as sexual perversions.
2. The prevalence of sexually deviated behaviour is difficult to ascertain, because of problems such as detectability and confidentiality. There is great variation among different disorders; under-reporting is likely and there are also socio-cultural variables.
3. Apart from psychiatric classifications such as the DSM-IV, grouping according to the social acceptability could also provide useful perspectives.
4. Although we should be aware of the various possible biological factors in the aetiology, there are also various psychological theories as well as cultural, family and social factors that are proposed to explain the development of sexual deviations.
5. Each type of sexual deviation is likely to be a result of a combination of these biological, psychological and social factors.
6. Motivation is a very important factor for successful management, yet many patients with sexual deviations do not come for treatment voluntarily.
7. While medications or surgery could have a role in treating those who need more drastic measures, recent advances in psychotherapy are beneficial to a number of patients.
8. A holistic and multi-disciplinary approach with therapy and rehabilitation is needed in order to prevent recidivism of those who offended.