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Sexual disorders encompass the full range of human sexual thoughts, feelings, and actions that are generally regarded as abnormal, dysfunctional, or disordered. With three exceptions (homosexuality, sexual addictions, and rape), the disorders discussed here are listed in the Diagnostic and Statistical Manual Version IV (DSM-IV) used in psychiatry and psychology as a means of listing the various diagnostic categories treated with psychotherapy or medications. Since the DSM-IV represents our current cultural values regarding human sexuality, it will serve as the basis for identifying various “disorders” that we feel are unacceptable in mainstream society. The disorders discussed are listed under “sexual and gender identity disorders” in the DSM-IV. The gender identity disorders, while they begin in childhood, have a profound effect on adult behavior and the ways in which adults cope with this disorder. Homosexuality has been excluded from the DSM-IV but remains a topic in the sexual disorders literature and cannot be excluded as a form of sexual variation that has significant socio-cultural history. The sexual addictions are included in this discussion for information purposes since the terminology has been used extensively in the public literature and media. Finally, rape, which is not represented in the DSM-IV, is discussed in this research paper, although we emphasize its aggressive and violent nature rather than sexual nature. Rape, as with such crimes as murder, are usually considered symptoms of other underlying problems, not a disturbance in itself.
Outline
I. Introduction
II. Gender Identity Disorders
A. Gender Identity Disorder of Childhood
B. Gender Identity Disorder of Adolescence or Adulthood (Nontranssexual)
C. Transsexualism
D. Etiology of Gender Identity Disorders
E. Treatment Approaches to Gender Identity Disorders
III. The Paraphilias
A. Pedophilias
B. Incest
C. Voyeurism
D. Exhibitionism
E. Fetishism
F. Transvestism
G. Sadomasochism (S-M)
H. Miscellaneous Paraphilias
IV. Causal Models and Treatments
V. Sexual Addiction
VI. Rape
VII. Homosexuality
A. Prevalence
B. Treatments
C. Differences in Health and Personality
I. Introduction
Few topics regarding human behavior hold as much interest and as much pathos as that of deviations and dysfunctions in human sexuality. What constitutes deviations and dysfunctions, however, are heavily dependent on contemporary cultural attitudes and values and these are often blind to the past history of sexuality in the culture.
We know, for example, that sexuality was represented in the rock art of the earliest human cultures. Paleolithic (30,000 to 10,000 B.C.) rock art, for example, is replete with both human and animal fertility symbols that were thought to endow the represented forms with abundant offspring. The Egyptians (3000 B.C.) are thought to have added power to the concept of fertility as represented in their symbols. In Western culture, our sexual values came mostly from the Judeo-Christian traditions. The Judaic tradition emphasized reproductive sexual behavior without guilt. The core concern was to protect the integrity of marriage with all other considerations of secondary value. Strict laws of adultery were applied to women but the husband was instructed only to “not covet your neighbor’s wife… ,” otherwise sex outside the marriage was tolerated. While the Jews were nomadic and their values emphasized family and procreation, sexual values for the Greeks emanated from their more settled agricultural lifestyle. Here family was still central but the Greeks allowed far more freedom of sexual expression in varied forms. For example, bisexuality was common among Greek males. Since beauty was the primary value or attraction, sexual behavior and arousal could arise in response to both boys and young or mature women of beauty. With the rise of Christianity more ascetic beliefs began to emerge. In general, sex had a procreative function, not the pleasure role noted with the Greeks and Hebrews. By the 18th century, religious views of life shifted from emphasis on eternal life in heaven to attaining happiness on earth and romantic love was valued. Sexual “deviations” started to become cultural issues with particular emphasis on homosexuality and masturbation. As venereal diseases became widespread, cultural values shifted to the physician as the arbiter of sexual morality, and to the repression of sexual behavior, particularly that of males. In the 20th century sexual notions are clearly shifting towards a continuum of behaviors. Modern sexologists not only have described the physiological, emotional, and psychological aspects of sexual behavior but have also highlighted the various forms of sexual behavior that exist whether in overt or covert forms.
This research paper deals with the full range of human sexual thoughts, feelings, and actions that are generally regarded as abnormal, deviant, or disordered. Our focus will be on these extremes but it should be noted that “deviant” and “disordered” are concepts that rest upon the assumption of a medical, disease, or psychiatric model of behavior that dichotomizes human actions into two qualitatively separate categories of “normal” and “abnormal.” Some sexologists, on the other hand, view these sexual behavior variations not as diseases to be cured but as atypical expressions representing quantitative rather than qualitative differences. To them, sexual behavior falls on a broad continuum with the extremes being vulnerable to labels like “disordered” and “abnormal.” Here we are dealing with differences in intensity and narrowness of behavior rather than qualitatively different behaviors. We can see this, for example, in the husband who might be aroused by his wife wearing lingerie versus the fetish individual who can only become sexually aroused by lingerie. Furthermore, the demarcation between abnormal and normal categories is not fixed or absolute. Rather, it consists of an ever changeable subjective value judgment derived from psychiatric, cultural, and political forces. For example, masturbation, once considered a sin then a disease, is now acceptable and understood. Likewise, homosexuality was actually removed from the psychiatric nomenclature due to political pressures and changes in culture norms. These are examples of the changeable nature of categorization and labeling and the subjective social value judgments they represent.
Our discussion will follow closely the psychiatric nomenclature and diagnostic categories since these represent our current values regarding human sexuality and the types of behaviors that are considered unacceptable in mainstream society. We will use the terms or labels often used in psychiatry and law to denote these patterns. Although it is not a psychiatric disorder, we will discuss homosexuality since it is a form of sexual behavior that has socio-cultural historical relevance and is still a controversial topic among some peoples. We will also discuss rape, gender identity disorders, and sexual addictions which are listed in the psychiatric diagnostic system but not under sexual disorders.
The behavioral area of sexual dysfunctions is not discussed since it usually represents inhibitions in sexual drive or performance and is not as comprehensive a manifestation of one’s being as are the problems and stresses characteristic of sexual disorders. Finally, we will briefly discuss the topic of rape, emphasizing its aggressive and violent nature rather than sexual nature.
Our starting place in discussing sexual disorders is to focus on the notion of “sexual identity.” A person’s sexual identity can be seen as an interrelationship among the three basic elements of human sexual behavior, namely, biological sexual characteristics, gender identity, and sexual orientation. In the diagram below you can see that sexual identity is formed from the interaction between biological sex characteristics (such as male and female sex organs, hormones, etc.), gender identity (or one’s identification with or feeling of femininity or masculinity), and sexual orientation (homo-, bi-, heterosexual, or other objects of stimulation as found, for example, in the paraphilias). In examining the gender identity disorders we will be discussing biological sex and gender identity. On the other hand, when we discuss the paraphilias, we will be focusing in part upon sexual orientation.
II. Gender Identity Disorders
A person with gender identity disorder (GID) experiences a confusion or mismatch between biological sexual characteristics and their culturally assigned gender identity. The identity problem is psychological in nature rather than a biological ambiguity. Biologically, they are dimorphic (male vs female) in terms of chromosomal, gonadal, genital development, and hormonal levels. The ambiguity exists in terms of the individual’s identification with culturally defined traits that constitute being a woman or man, i.e., the degree of femininity or masculinity the person exhibits through thoughts, feelings, and their actions. Not all people are comfortable with what they feel is their true sense of being a woman or man and their biological sex. The amount of disturbance can range from a mild sense of inappropriateness, to feeling like a woman trapped in a male’s body, and vice versa.
GID should not be confused with transvestism, homosexuality, and hermaphroditism. Transvestites, as we will see later in more detail, cross-dress for fetishistic pleasure, and, with few exceptions, rarely find an incongruity between their sex and gender. A person who is emotionally and sexually attracted to a member of their same sex is, likewise, not inherently disturbed in regards to their gender identity. Finally, the hermaphrodite has to some degree the sexual organs for both sexes. Since this confusion stems from being biologically intersexed, the hermaphrodite’s dilemma is not considered a psychological disorder. Once again, those with GID are unambiguously biologically formed in one sex, and their confusion is at the emotional and psychological levels.
GIDs are conceptually divided into three categories: GID of childhood, GID of adolescence and adulthood (not transsexual), and transsexualism. Let us look at each of these three categories.
A. Gender Identity Disorder of Childhood
GID of childhood is reserved for prepubescent children and is relatively uncommon. The sex ratio for the population in general is unknown, yet through clinical work it appears that there are many more boys than girls diagnosed with this condition. Generally, the age of onset for both sexes is age 4; however, in some cases it may appear as early as age 2. The majority of children will return to their expected gender roles by puberty, while the remaining minority will continue experiencing what is called “gender dysphoria” or role confusion. Reliable predictions of adult pathology, based upon nontypical childhood behavior have proved elusive. The primary symptoms needed to make a diagnosis are: (1) a persistent and severe discomfort regarding her or his own biological sex, and (2) a belief that they are, or desire to be, of the opposite sex. Such feelings and behaviors are chronic and problematic, thereby transcending any normal variation of stereotypical gender roles, such as being a “tomboy” or a “sissy.”
A female with this disorder exhibits intense feelings of frustration at being a girl with a corresponding desire to become a boy, or, in some cases, they may even believe that they are of the opposite gender already. They often seek male peers and are repulsed by traditional feminine toys, games, etc., preferring instead the masculine equivalents. Lastly, there is an intense disgust toward and rejection of their anatomy, often illustrated by beliefs that they will grow a penis or not go through normal female pubescent body changes. The overall pattern with males is identical to the female description except that the specifics are reverse. For example, GID boys typically show severe distress at being a boy, they engage in cross-dressing, and prefer female toys, peers, and so on. They are repulsed by their genitalia, often wishing that it would disappear or that they would grow up and become a woman.
A major difference between the two sexes is found in the fact that many more boys than girls are treated for this condition. It is thought that differential socialization patterns may account for the discrepancy in prevalence rates. For example, boys are more often subjected to rigid parental expectations and therefore any nontypical gender behavior is often more apparent. Boys also tend to display more signs of secondary pathology, e.g., depression, anxiety, and withdrawal, perhaps due to harsher social consequences from peers for their feminine-like behavior. On the other hand, females who cross the gender line (“tomboys”) tend to be more readily accepted than “sissies,” or boys who violate gender expectations.
B. Gender Identity Disorder of Adolescence or Adulthood (Nontranssexual)
A person with this condition must have reached puberty, exhibit reoccurring discomfort with their biological sex, and habitually cross-dress. Motivation for wearing the apparel of the opposite sex is for emulation purposes, not for fetishistic pleasure. They are psychologically identified with the opposite sex and exhibit intermittent to constant cross-dressing. Despite the person’s sense of discomfort, they usually have no preoccupations with changing their sex to match their gender identity.
Some researchers theorize that GIDs should be conceptualized on a continuum rather than as separate diagnostic categories. Accordingly, they might prefer the term transgenderism, which can be seen as an intermediate stage between the two extremes of GID of childhood and secondary transsexualism, i.e., someone who after a period of time decides to make a sex change. The transgenderist is someone who is living permanently in the role of the opposite sex but does not have the desire for a complete sex change. Essentially, their change is in gender, not in sexual biological characteristics.
C. Transsexualism
The transsexual condition can be distinguished from other GIDs essentially because of a life-long sense of gender incongruence or inappropriateness and a persistent preoccupation or obsessive quest for sex realignment or “reassignment” surgery. This preoccupation for sex change surgery must be present for at least 2 years to be diagnosed transsexualism. As you can see, we are now at the more extreme end of the GID continuum.
Some theorists have attempted to distinguish between primary and secondary transsexualism, with the former evidencing a history of gender dysphoria since childhood while the latter may be long-term cross-dressers or transgenderists but they seek reassignment surgery later in life usually after experiencing a traumatic stressor.
Secondary pathology for transsexuals is common and most often includes anxiety and depression. For those who are driven to change their sex, the difficulty in getting the funds to pay for surgery can result in self-mutilation and even suicide. In a culture that defines their dilemma as pathological and abnormal, transsexuals have many stories to relate about the pain and suffering they experience. This brief glimpse into the recollection of a girl “trapped” in a male body should partially convey their struggle for recognition as legitimate human beings:
… I wanted above all to walk down the hall at school and be looked at and respected as were the normal girls. Yes, normal girls; for I was a girl with all my heart, but I was not a normal girl. I was a freak of a girl, one who had to look like a boy . . . . (Benjamin, 1966, p. 199)
It is generally believed that transsexualism is present in about 1 out of 30,000 males and 1 out of every 100,000 females. More males seek out treatment than females, with ratios as high as 8 to 1. In the United States alone, it is estimated that there are between six and ten thousand postoperative transsexuals, i.e., people who have had sex change operations.
D. Etiology of Gender Identity Disorders
As the current body of knowledge now stands, the causal roots of GID remain undiscovered. The various approaches that attempt to explain this particular disorder can be broken down into the biological/medical, psychodynamic, and developmental/learning models. The first approach purposes genetic, hormonal, neurological, and chromosomal abnormalities as a causal factor. Despite a few leads, such as the effects of prenatal hormones on gender behavior, there is a meager amount of data to support the notion of biology as a sole or even major influence. The psychodynamic model emphasizes early childhood and personality development. Causal roles are attributed to difficulty with mother-child relations and the failure to psychologically identify with the parent of the opposite sex. Again, this is not a universal or even major phenomenon. Furthermore, it is very difficult to tease out what is the chicken and what is the egg. In other words, do parents shape children’s behavior or does the child’s behavior shape the parents’ difficulty with the relationship ? Finally, the importance of socialization processes and the acquisition of atypical childhood behaviors via modeling or conditioning represents the learning and developmental point of view. Unfortunately, contrary to both the psychodynamic and learning models, there is very little indication that the family environment has any serious effect in the development of gender identity disorders for substantial numbers of cases. For example, in a study by R. Green (American Journal of Psychiatry, 1978), of 16 children who were raised by transsexuals all were found to have heterosexual orientation with no disturbance in their gender identity.
E. Treatment Approaches to Gender Identity Disorders
The general consensus is that many or all behavioral and psychodynamic treatments for GID are ineffective. Behavioral therapies have produced a few “successes” in strongly motivated clients, but even then some of the behavioral modification techniques used have raised disturbing moral questions. For example, reports of behavior therapies describe asking children to overemphasize the gender identity differences so as to produce aversive social reactions which, presumably, would diminish these opposite-sex behaviors and attitudes. In contrast, psychodynamic treatments aim at resolving childhood conflicts in the hope of producing acceptance of one’s sex and the corresponding gender identity. After many case histories and grueling therapeutic hours, personality reorganization approaches have almost always ended in total failure. Both approaches subject children to personal pain in addition to the feelings of failure they must experience in therapies are ineffective.
For transsexuals, sex reassignment treatment (sex change surgery) has proven in a majority of cases to be successful in bringing happiness and relief. After a careful screening process, a qualified individual must undergo intensive counseling and instruction on matters of grooming, vocation, legal rights, voice training, and the proper use of stereotypical gender role mannerisms. Then they may begin hormonal therapy in order to produce the desired secondary sex characteristics, e.g., breasts in males, facial/body hair modification, changes in body fat distribution, and some voice alteration. After living and working in one’s new gender role for 1 to 2 years, only then can the candidate undergo genital reconstruction. The artificially constructed vagina is much more realistic in appearance and function than its male counterpart. While female genitalia is capable of lubrication and orgasm, the penis is less sensitive and lacks natural erectile capacities. Though limited in number and with sometimes inconclusive findings, some follow-up studies have indicated an 80 to 85% satisfaction rate for transsexual operations, with male-to-female transsexuals usually faring better than their counterparts. Dissatisfaction is usually the result of poor surgical techniques and personal and social instability that preceded surgery.
III. The Paraphilias
The term parapbilia is derived from the notion of a deviation or separation (para-) from what most people are attracted to (-philia). Originally, these were called “perversions,” but modern terminology generally describes them as “deviations” or, more recently, as “variations.” The DSM-IV describes these deviations as ” . . . recurrent sexually arousing fantasies, sexual urges, or behaviors generally involving either (1) nonhuman objects, (2) the suffering or humiliation of oneself or one’s partner, or (3) children or other nonconsenting persons.” The diagnosis, however, is made only if the person has acted on their urges or is greatly disturbed or distressed about them. Paraphilic fantasy (such as sex with animals, arousal from undergarments, sado-masochistic thoughts, cross-dressing, or sex with children, etc.) as such is not sufficient to warrant clinical diagnosis. These preoccupations must be intense and recurrent, or undesired and disturbing to the individual, the preferred or exclusive forms of sexual gratification, or acted out overtly to be considered pathological. The paraphilias are usually multiple in nature rather than singular. They are almost exclusively confined to men with the exception of masochism, in which we see a significant number of females.
Current views of paraphilias have been heavily influenced by Freudian theory and analysis of sexual behavior. Within the psychodynamic model, a healthy or natural sexual relationship consists of opposite sexed partners whose object is coitus (sexual gratification through intercourse). These deviations in sexual orientation involve the use of an object other than the opposite sex partner, such as one of the same sex (homosexual), children (pedophilia), close relative (incest), animals (zoophilia), inanimate objects (fetish), or even dead people (necrophilia), as sexual objects. Likewise, instead of seeking coitus, departures include watching others (voyeurism), exposing genitals (exhibitionism), infliction of pain (sadism), or suffering pain (masochism) as deviant aims. In the paraphilias, the erotic object has a role or characteristic that is more important than their personality and personal characteristics of the object and the aim is to enact the paraphilic fantasy.
Mainstream diagnostic systems have been strongly influenced by these two major departures from object and aim. Alternatively, others have argued that perhaps the impact on others should be used as the diagnostic criterion. Here, fetishes and transvestism, and perhaps gender identity disorders, would be excluded in that they usually have little or no direct negative impact on others. All this is brought to your attention to highlight the subjective and consequently changing nature of diagnosis and categorization. Basically, as with most other mental illness categories, we are dealing with social value judgments rather than specific “diseases” and as such cultural and political values and attitudes influence the diagnostic process.
A. Pedophilias
The pedophile (derived from the Greek for “child lover”) sexually prefers children of either sex for erotic gratification. It is usually thought that perpetrators must be at least 10 years older than their victims, but this age difference may differ considerably depending on circumstances. Pedophilia is also called “child sexual abuse” and “child molestation.” Child molestation is most often perpetrated by males and usually involves such actions as manipulation of the child’s genitalia, stroking of the body, forcing the child to manipulate the adult’s genitalia, and, to a lesser degree, intromission. Pedophilia is the most common form of paraphilias and involves the most vulnerable victims – children.
Heterosexual men are responsible for most sex abuse against girls. Two out of three sexually abused children, however, are girls. Conservative estimates are that 10% of females and 2% of males were sexually abused as children. There is no well-delineated personality for the pedophilic. However, the concept of the “dirty old man” as perpetrator is misguided in that most pedophiles are in their late 30s with only about 5 % being aged men. If we had to generalize, we could say that pedophiles are generally immature developmentally even though they may have married and have children of their own. Second, we often see the behavior under stress, i.e., during stressful life periods often accompanied by marital and sexual problems. Alcohol is consistently involved in pedophilic encounters. The majority of victims are relatives, neighbors, or acquaintances; and encounters, while usually brief, occur in series of extended contacts. Generally the younger the child, the more immature the perpetrator. Actual penetration and coitus occur in only 4% of cases. Interestingly, the vast majority (80%) of perpetuators have themselves been abused as children.
B. Incest
Incest is treated here as a subcategory of pedophilia. However, since pedophiles differ in age from their victims, incest may not necessarily meet the criteria. For example, the majority of incest cases seem to involve cousins and siblings who might be similar in age. Incest (from the Latin “impure”) is a form of pedophilia involving close relatives, most commonly between cousins but parent-child or sibling-sibling incest is the most repugnant and most often the focus of treatment or criminal proceedings. Taboos against incest are present in all cultures, particularly against mother-son incest. Surveys among adults indicate that 14% of males reported having had sexual contact with a relative before adulthood (95% of which were heterosexual in nature) and 9% of females have had such contact. Most of these experiences were with cousins and essentially involved some form of “petting.” Among a university sample, however, 10% of females reported incestuous relationships with their fathers (including stepfathers). Almost 90% of cases brought to court for incest involve father-daughter while only 5% are father-son incidents. Transgenerational incest seems to occur in about 10% of incest cases but probably has different dynamics than immediate parents and children or children and children.
The studies of incest have concluded that these events occur within seriously disturbed or dysfunctional families and that a code of silence develops in which these events are not spoken about and often repressed by the victims. Furthermore, the parents in this unhappy marriage typically consist of a domineering, authoritative, and impulsive husband and a dependent and emotionally distant wife. The husbands often also abuse the wives as well as the children.
Incest is a criminal as well as psychological disorder. The experience of incest is traumatic and psychologically damaging to the children involved (and even to those who know about it). Criminal prosecution does not erase the trauma of incest. These deep psychological scars must eventually be addressed in order for the victim to heal and live a fully mature life.
C. Voyeurism
Voyeurs are also called “peepers” or “Peeping Toms.” The psychiatric diagnostic system describes this condition as a recurrent, intense, and sexually oriented “act of observing unsuspecting people, usually strangers, who are either naked, in the process of disrobing, or engaging in sexual activity . . . . “Looking (or “peeping”) provides sexual arousal but no actual sexual contact with the observed person is sought. Orgasm, usually produced by masturbation, may occur during the voyeuristic activity, or later in response to the memory of what the person has witnessed. Often these people enjoy the fantasy of having a sexual experience with the observed person, but in reality this does not occur. In its severe form, peeping constitutes the exclusive form of sexual activity.
Lady Godiva’s ride through the streets of Coventry to remit an oppressive tax was watched by no one from the town–out of respect and gratitude for her actions–with the exception of Tom the tailor, who peeped through the curtains and for this act went blind. The “Peeping Tom” of today does not go blind literally but they are almost always men. To be considered a paraphilia, there must be a recurrent and intense preoccupation with looking from hiding or secret places. Just looking at live nudes or pictures of nudes is not a paraphilia.
Voyeurs tend to be younger men (convicted age is 23.8 years), unmarried and with little or no alcohol, drug, or other mental illness problems. While they tend to be heterogeneous as a group, they do commonly have deficiencies in heterosexual relationships. As a matter of fact, it has been conjectured that the voyeuristic practices are a safe and protected way of avoiding a possible relationship with a woman.
D. Exhibitionism
The legal term for exhibitionism is “indecent exposure” because of the shock or offensive value of the act to others. Again, this is mainly a male disorder. Like other paraphilias, it involves repetition, intensity, and sexual urges or arousing fantasies of at least 6 months duration. For the exhibitionist or “flasher” gratification seems to come from the disgust, shock, fear, and surprise of the unsuspecting usually female victims. There is usually a compulsive, driven quality to this behavior (as with most paraphilias) but they are also prone to be caught as they return to the same situation or place repeatedly. There is some evidence that at some level they may wish to be caught and that this consequence is deliberate and desired. The exhibitionists’ behavior has a distinctive hostile air to it and this, coupled with the fact that they often have serious sexual problems might suggest intense, perhaps unconscious, hostility exists toward women. As a group they tend to be younger (30s) with about 30% married, 30% divorced or separated, and 40% never married. They are often above average in intelligence and do not have more serious forms of mental illness.
Anxiety, which forms a part in all the paraphilias, is also apparent in exhibitionists both in terms of the excitement or anxiety associated with the act itself and with the desire for anxiety relief that results from the act. There is also evidence that exhibitionists are sexually aroused by stimuli that usually have little or no arousal potential for most people (such as seeing fully clothed women in normal activities) and thus may misread the motives and intentions of others (perhaps seeing them as sex crazed as they are). A fairly large percentage of women (between 45 and 50%) report having seen or had direct contact with a “flasher.”
E. Fetishism
Fetishism involves sexual arousal from some inanimate or nonliving object. Exposure to the object or preference for the object is usually necessary to maintain erectile states. Common objects include shoes, sheer stockings, gloves, toilet articles, undergarments particularly underpants, and many tactilely stimulating substances (soft fetishes) such as fur, velvet, and silk garments, and smooth solid objects (hard fetishes) that can be rubbed and fondled such as shoes, leather objects, and so on.
In ancient cultures, fetishes were objects that had magical powers. For the fetishist the object itself is endowed with sexual power and the owner is of little or no interest. Panties, stockings, and garters may be alluring and channel excitement to the wearer but to the fetishist, the object itself is the allure and goal, not the user.
Almost any object can acquire fetish properties. One mechanism for acquisition is classical conditioning in which a neutral object comes to acquire arousal properties by association with sexual arousal and stimulation (i.e., masturbating with the object present). By this process, any stimulus, even body parts, can become a fetish object.
Orgasm may occur with the fetish alone or the fetish object may need to be present during intercourse in order to maintain stimulation toward orgasm. Again, poorly developed heterosexual relationships are found in fetishes as in other paraphilias. Here, however, there is usually a strong mother-son bond with the fetish individual. Fetishes usually develop during adolescence. Fetishists are seldom distraught enough by the behavior to seek out psychotherapy and they are usually not overt or foolish enough to be arrested or detected.
F. Transvestism
The Latin trans meaning “across” and vestia meaning “dress” for the term for “cross-dressing” or “transvestism.” As pointed out earlier, transsexuals often manifest cross-dressing as a first expression of opposite sex feelings. This behavior, along with men who dress in “drag” to attract other men for sexual purposes, is not usually considered manifestations of transvestism. Likewise, female impersonators and actors who play female parts are not included under this diagnosis. To qualify as transvestism, there must be a compulsive desire to cross-dress and an intense frustration when the practice is interfered with. The transvestite is usually heterosexual in orientation, married, and otherwise masculine in appearance, demeanor, and sexual preference. The cross-dressing, while compulsive, is done in secret and does not lead to homosexuality or gender identity problems–although transvestites report feeling like a woman during the cross-dress episodes. Often wives will be overt or covert conspirators in the cross-dressing activities. Cross-dressers will often seek each other out for social occasions while made up as women.
The compulsion to cross-dress begins by adolescence, although most children who cross-dress will “grow out of it” by adulthood. Some male transvestites recall their parents forcing them to wear girls clothing as a form of humiliation and punishment. As an adult, however, the wearing of women’s clothing usually has more significance than just sexual arousal or punishment. It affords the transvestite male an opportunity to escape from pressures and responsibilities. Some males only partially cross-dress, usually by covertly wearing female undergarments under their male clothing. Others are complete cross-dressers, who overtly carry out this practice either occasionally or, for some, all the time.
G. Sadomasochism (S-M)
The term sadomasochism is derived from the family names of two historical characters. The first is the French nobleman Marquis de Sade (Donatien Alphonse Francois was his “first” name, 1740-1814), whose writing consisted of vivid accounts of pain inflicted on one partner in sexual encounters of various kinds. Sexual sadism is defined as the infliction of physical pain and/or personal humiliation and degradation on a sexual partner. While de Sade portrayed infliction of excruciating pain on individuals, most sadism involves mild to moderate pain. It is estimated that about 5% of men and 2% of women have obtained sexual pleasure by inflicting pain on a regular basis.
While sadists inflict pain on willing or nonconsenting partners, sexual masochists (from Leopold von Sacher-Masoch, a German novelist who described this behavior in the late 19th century) enjoy suffering for erotic excitement as a preferred form of sexual activity. While sadists overwhelmingly tend to be men, masochists are more often females. The study of sadomasochism has only just begun. What little is known about these practices comes mainly from case studies, i.e., examination of S-M activities at centers for such activities or through paid dominance and submission sexual surrogates hired for these purposes.
Sadomasochistic activities center on use of dominance-aggression and submission in sexual activities. Terms that denote these activities abound such as bondage and domination (B-D), master-mistress, dominatrix, humiliation, restraints, whipping, leather/rubber, slave, bottom or submissive, and so on. Activities often involve elaborate interactions, sometimes with predetermined code words that will lead to the immediate release of a victim if desired and often use fetishistic trappings such as leather/rubber garments, chains, whips, shackles, harnesses, and other props. Rarely do sadomasochistic practices lead to physical injury, mutilation, or death. Victims, however, may be nonconsenting or willing and, not infrequently, paid sexual partners.
There is a well-defined S-M subculture that includes paraphernalia sex shops, stages for bondage scenes, magazines, prostitutes trained in S-M skills, and videos. Participants are predominantly heterosexual males with a greater concentration of bisexual female participants. Sadomasochistic activities are defined as paraphilias if they are recurrent and intense. To just tie up a sexual partner occasionally is not S-M activity.
H. Miscellaneous Paraphilias
Sexual arousal can become conditioned to a wide variety of eliciting stimuli. In this section, we will describe some relatively uncommon paraphilias that involve unusual and sometimes noxious objects of sexual arousal. The miscellaneous paraphilias described below not only occur rarely but are often not detected due to their secretive nature and the fact that persons who engage in these acts are rarely motivated to seek treatment for their behavior.
A number of paraphilias are difficult to clarify. Some seem closely linked to fetishism but instead of body parts, body discharges take on erotic significance. Coprophilia, for example, involves erotic fascination with feces; klismaphilia with enemas; urophilia with urine; and mysophilia with filth. These stimuli may excite or be used for orgasm. Soiling others – by urinating or defecating on them – can also serve sadomasochistic purposes and is sometimes seen in assaults and rape situations.
Some paraphilias may have a sexual goal that is not immediately obvious. For example, pyromania (fire setting) and kleptomania (stealing for excitement)are thought to sometimes represent sexualized activities and thereby qualify as paraphilias.
Frotteurism (or toucherism) is a paraphilia that involves sexual gratification or arousal by rubbing against or fondling an unsuspecting, nonconsenting person. The frotteur acts on urges to touch, rub, or fondle usually in crowed places, often accompanied by fantasies of having sex with the singled-out person. Contact is brief to avoid detection.
Finally, the 20th century has brought a host of telephone scatologia, or efforts to seek sexual gratification by making obscene telephone calls. Anonymity and escape from detection are enhanced in use of this media for contact.
IV. Causal Models and Treatments
Several key observations and assumptions should be noted before addressing the etiology and treatment of sexual disorders. First, contemporary sexologists have had little success in identifying specific causal factors and in designing and implementing successful treatment modalities. Such a state is due, in part, to limited theoretical models and problematic methodology. Criticism of existing causal models has been in terms of their myopic and/or reductionistic focus. In other words, most theories have focused solely on cognitive/emotional, behavioral, or environmental elements rather than on how all three elements interact and affect an individual’s sexual identity. Another factor may be methodological problems, e.g., the difficulty in forming operational definitions for, and measuring such abstract concepts as, gender identity or sexual orientation. A more important and subtle point however, is the view that by separating the range of sexual behaviors into specific categories and calling these “abnormal,” we are, by this process alone, not asking the critical questions about how sexual identity and orientation develop as a phenomenon. Instead, we are caught up in treating our categorizations as if they are real and true medical diseases or abnormalities. In fact, it appears that sexual expression can vary greatly and lies on a continuum. Even though experience and socialization can affect the location of one’s position on the continuum, we know very little about how individuals get to a particular place on the continuum in the first place.
Biological theories have predominated as causes of sexual disorders. The specific biological determinant or process would have to be in the male and not female structures. No absolute causative biological mechanisms have been identified. Most behavioral scientists see very little value in the psychoanalytic or psychodynamic theories. Both deficient psychosexual development and Oedipal fixations have been used to account for sexual disorders. Repressed hostility is thought to be at the roots of most paraphilias and the disorder allows a symbolic acting out of these repressed urges.
Learning theory models emphasize classical conditioning or associative learning linking sexual arousal with previously neutral objects or situations, masturbation becoming a key activity for this linking to occur. Learning theory seems to account for some paraphilias and for some portion of the sexual disorders but it lacks sufficient empirical power and predictability.
As mentioned previously, treatments for the paraphilias and other sexual disorders are very ineffective and positive effects seem to be confined to highly motivated clients with milder forms of the disorders. Biological treatments essentially attempt to dull or reduce sexual drive. The behavior therapies utilize counter-conditioning and desensitization methods. Various forms of group therapies (structured in a self-help manner) seem to be effective with the motivated client.
V. Sexual Addiction
How far do normal sexual activity levels extend? Where do we draw the line for pathological levels of sexual activity? Again, changes in social values have defined different patterns and points on the sexual activity continuum as pathological at different times. As a matter of fact, lack of precision in defining this category and the subjective nature of judgments resulted in the elimination of sexual addiction from the paraphilias in the DSM-III-R edition.
The terms “sexual addiction” and “sexual compulsion” began to appear in the scientific and clinical literature in the 1970s. They soon became popular terms to describe individuals who seemed obsessed with sexual behavior, i.e., nymphomaniacs, etc. Usually, sexual activity had to reach a level where it interfered with their job, relationships, career, or even their health. The behavior was often described as uncontrolled sexual behavior but functional analysis showed that it tended to lower anxiety states and probably helped enhance self-esteem and the sense of power and control.
Critics of the use of these concepts or diagnostic categories argued that they lacked precision and behavioral clarity, that they were often unreliable, and full of subjective judgments. Critics pointed out that the concepts did not fit our knowledge of the addictions nor of the compulsive processes. Furthermore, they were often applied to gay men with many partners and thus seemed discriminatory.
Supporters of this category argued that frequency was not the issue, rather one had to look at the purpose and meaning to the individual as critical components. Here, seeking out transient relationships in an indiscriminate manner certainly had the ring of self-defeating and self-destructive patterns of behavior that qualified as paraphilias. At this point, however, sexual addiction is an historical term.
VI. Rape
Rape (Latin, “to seize”) or the actual act of seizing a person by physical force or threat is an extreme form of sexual aggression and coercion. Rape is technically a legal term but it can be viewed from a psychological perspective. Current definitions of rape have extended the violation to deliberate intrusion into the emotional, physical, or rational integrity of the individual and even debasement through voyeurism (“visual rape”). Legally, rape is divided into statutory (seduction of minor) and forcible seizure of an unwilling partner over age 18. Recent attention has been focused on “date rape” or the use of coercion by dates, acquaintances or even boyfriends. The victims are almost always women. No woman is entirely safe from rape. Almost 100,000 rapes are reported each year but estimates are the majority of rapes go unreported. Most occur outside or in the victim’s home. National studies have found that the incidence of rape has increased more rapidly than any other type of violent crime.
There are many factors and levels of causation to rape. Certainly, cultural and subcultural attitudes toward women and about men contribute to the setting for rape. Psychological studies of rapists have identified some broad typologies of rapists. These types were derived from a psychological examination of rape cases. In none of these cases was it found that rape was motivated by sexual satisfaction. All the cases were characterized by a predominance of power motive or anger. This led to the classification of rapists as (1) power assertive types (intimidation and control), (2) power reassurance types (to compensate for an underlying sense of weakness and inadequacy), (3) anger-retaliation type (rage, hatred, and violence predominate), and anger-excitation rape (the pathological sadist).
Prediction of rape from psychological profiles is not possible even though a proportion of rapists are obviously disturbed. The literature in this area is replete with instances of rape, in which, prior to the attack, the rapist had given no hint whatsoever of being a dangerous person. Conviction rates for rape are low and treatment or therapeutic interventions have generally been ineffective and disappointing. In addition to the need to develop adequate predictive and therapeutic measures for rapists, there is a tremendous need to improve treatments for the traumatized victims of these violent crimes.
VII. Homosexuality
Sexual orientation, as it relates to homosexuality, is one’s erotic attraction toward the same sex. Sexual orientation is a part of one’s sexual identity, which, in turn, is primarily related to physical and emotional disposition, and is simultaneously interconnected yet distinct from biological and gender identity.
In Western culture, the most prominent means of conceptualizing sexual orientation is in terms of hetero- versus homosexuality. Traditionally, such distinctions are oversimplified and create oppositional positions. For these reasons, some theorists would rather conceive of orientation as being on a continuum, with heterosexuality and homosexuality at either end and in between a vast gradation of overlap reflecting bisexuality. Dichotomous thinking, coupled with rigid cultural values biased in favor of the heterosexual majority have led to a lengthy history of intolerance towards and oppression of homosexual and bisexual individuals.
Two forces helped shape negative and oppressive attitudes toward homosexuality. The first was Judeo-Christian values and beliefs that held that nonprocreative sexual acts were regarded as “sins against nature” and consequently frowned on in the culture. The second force was the rise of medicine and psychology as powerful authorities and arbiters of social morality by defining and controlling “deviant” and “diseased” behaviors. This control led to the condemnation of many fringe or nontraditional sexual practices with homosexuality in the forefront. Psychiatry, for example, included homosexuality in their diagnostic manual thus sanctioning intervention and treatment. Sin was now replaced by pathology. Being identified as mentally ill meant that homosexuals could be stripped of their civil and human rights while the heterosexual population looked on.
Under fire from within and outside their ranks, on December 15, 1973, the American Psychiatric Association board of trustees voted to remove homosexuality from the categories of mental illness. After much struggle and debate, homosexuality was replaced with a new category, ego-dystonic homosexuality, denoting those homosexual individuals who were distressed by their orientation and wanted to become heterosexual. This compromise category did not last for long, as many professionals and lay persons could see that it was just another more subtle means of perpetuating prejudice and oppression. Finally, all reference to homosexuality was removed from the official nomenclature.
A. Prevalence
The problem in measuring the prevalence of homosexuality is that it must be operationally defined. Renowned sex researcher Alfred Kinsey chose to operationally define sexual orientation on a continuum in terms of behavior frequency of homo-, hetero-, and degree of combined sexual behaviors. The following scale was developed:
0. Exclusive heterosexual with no homosexual
1. Predominately heterosexual, only incidental homosexual
2. Predominately heterosexual, but more than incidental homosexual
3. Equally heterosexual and homosexual
4. Predominately homosexual, but more than incidental heterosexual
5. Predominately homosexual, but incidental heterosexual
6. Exclusively homosexual
What resulted from his pioneering assessment of the sexual practices of the American public was surprising. Kinsey found that 37% of males surveyed had had physical contact to the point of orgasm, at least once, with another man. In addition, another 4-6% were either primarily or exclusively homosexual. It was found that of the females questioned, 13 % had at least one such encounter with another female.
To conceive of homosexuality in strict behavioral terms challenged the more prevalent practice of using the terms to represent a personality deficit. The latter approach, of course, leads to social stigmatization. Kinsey also avoided applying sexual orientation labels in an either/or manner, by conceiving of sexuality as a range of behaviors on a continuum. Despite his popularity, his results were criticized on methodological and theoretical grounds. Specifically, grave doubts were raised about the generalizability of his data from the limited sampling he used. Other researchers conducting surveys with better sampling methods found similar to much lesser rates of incidence; usually between 4 and 16% homosexual behavior of some kinds. Theoretically, Kinsey was criticized for being too reductionistic by trying to conceptualize the homosexual experience in terms of the frequency of same sex behaviors. Regardless of the precise percentages and how one exactly conceives of it, homosexuality is and has been a pervasive part of our culture and population.
Since the early 1970s, there appears to have been a radical rethinking of how we treat those of homo or bisexual orientations. Still, some lay persons and professionals find these orientations pathological and must seek causes and roots for these disorders. Katchadourian responds to these efforts in the following manner:
Those who accept homosexuality as an illness seek its causes. Those who do not, object to this approach. “Causes” implies that there is something wrong; why not seek the “causes” of heterosexuality? The search for the origins of sexual orientation–homosexual or heterosexual–is a more legitimate quest.
The causal agents responsible for producing any sexual orientation are basically unknown. If we hope to gain insight by relying on a single explanation, then we will surely miss the dynamic and interactive nature of sexual identity. Whether the theoretical model is based upon genetic inheritance, developmental influences, or psychodynamic conflict, the nature of sexual orientation, regardless of sexual preference, seems better understood as having multiple roots.
B. Treatments
Contemporary thought rejects the outdated notion of homosexuality and bisexuality as diseases to be treated and cured. Attempts by professional to change or convert homosexuals into heterosexuals have almost always been exercises in futility. Despite long and intensive therapeutic hours, psychoanalysis has had no success. With their aversive counter-conditioning techniques, the behavioral therapies have only faired marginally better. Irrespective of the theoretical model, when a person (homosexual or not) is forced into the therapy room, not only is change highly unlikely but the chances for negative psychological consequences are greatly increased.
An apparent exception to this lack of success was the Masters and Johnson sex therapy study, which reported to have “helped” two-thirds of those who volunteered for a 2-week treatment program. Criticisms of their work include the fact that the male and female participants were carefully screened to ensure that they exhibited high levels of desire to change and were the beneficiaries of very supportive partners. In addition to such biases in sampling, further analysis of the follow-up data revealed that the claimed failure rate of only 28% was probably too low. Perhaps a rate of about 45 % would be more accurate.
C. Differences in Health and Personality
As pointed out earlier, psychiatrists have conceptualized the homosexual as inherently pathological and heterosexual as “normal.” Numerous scientific studies have compared homosexuals who sought treatment against normal heterosexuals who were not in treatment. Differences were found between these groups on health and personality variables. More recent studies, with improved methodology, have shown that very few differences in pathology actually exist between equivalent heterosexual and homosexual samples. Differences in depression and suicide rates previously attributed to pathology or flaws in the individuals are now seen from a broader socio-psychological level of causation, i.e., environmental pressures to live up to one’s societal status as deviant.
Another area in which scientific bias has played a mystifying role is in the realm of personality differences between homo- and heterosexuals. Specifically, there have been studies showing gay men were more feminine than straight men and that lesbians were more masculine than their heterosexual counterparts. Once again, such findings have been shown to be based on methodologically flawed clinical/nonclinical designs. Once corrected for biased sampling, such studies show that the differences in gender identity are minimal. Yes, “butch” lesbians and effeminate gays exist, but as a stereotype they are not representative of the homosexual and bisexual population as a whole.
Bibliography:
- American Psychiatric Association. (1994). “Diagnostic and Statistical Manual,” 4th ed. Washington, DC.
- Bancroft, J. (1983). “Human Sexuality and Its Problems.” Churchill Livingston, London.
- Bayer, R. (1987). “Homosexuality and American Psychiatry: The Politics of Diagnosis.” Princeton University Press, NJ.
- Benjamin, H. (1966). “The Transsexual Phenomenon.” Julian Press, New York.
- Bullough, V. L., & Brundage, J. (1982). “Sexual Practices in the Medieval Church.” Prometheus, Buffalo, NY.
- Carnes, P. J. (1983). “The Sexual Addiction.” CompCase, Minneapolis.
- Doctor, R. F. (1988). “Transvestites and Transsexuals: Toward a Theory of Cross-Gender Behavior.” Plenum, New York.
- Freeman, E. B. (1988). “Intimate Matters: A History of Sexuality in America.” Harper and Row, New York.
- Finkelhor, D. (1984). “Child Sexual Abuse.” Free Press, New York.
- Gonsiorek, J. C., & Weinrich, J. D. (Eds.)(1991). “Homosexuality: Research Implications for Public Policy.” Sage, Newburry Park.
- Katchadourian, H. A. (1989). “Fundamentals of Human Sexuality,” 5th ed. Holt-Rinehart and Winston, San Francisco.
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