Sexual Abuse

"Paraphilia" describes conditions previously called deviations or perversions, and implies sexually arousing fantasies, activities and gratification other than by willing genital intercourse between partners, and a departure from the cultural norm. A "normal' sexual relationship should be defined as one in which activities are acceptable and pleasurable to both partners without the degradation, exploitation or distress of either (Brandon, 1980). Behaviour that deprives others of their right of personal choice, or causes injury and takes advantage of a victim who does not or cannot give his or her consent, is considered deviant.

Sexual deviations are largely confined to males but exist at every physical, social and intellectual level (Brandon, 1980). The generally accepted association between sexually deviant and criminal behavior is unwarranted. Contrary to popular belief, the majority of sexual offences do not involve the use of force (Trimmer, 1978), and, for the majority, deviant sexual practices remain intensely private. However, doctors must be alert to the fact that an individual's sexual deviation may carry a threat to others, and that his responsibility to the victim or potential victim in this regard supersedes confidentiality with his patient.

Definition: sexual activity that is directed primarily towards objects rather than people, or sexual acts not usually associated with coitus, or coitus performed under bizarre circumstances. Arousal and orgasm are dependent on sexual fantasy featuring objects or acts which attenuate the links between sexual expression, genital congress and human contact (Meyer, 1980).

Characteristics: paraphilias are characterized by specialized sexual fantasies, and behaviour, sexual props and requirements of the partner. The influence of the fantasy and elaborations on behaviour may extend beyond the sexual sphere to pervade the person's life. Everyday erotic fantasies common to everyone are recognizable in bold relief in the "perversions" (Meyer, 1980). Many of these individuals have difficulty in establishing intimate relationships, and rely greatly on fantasy rather than expressions of affection. Furtiveness and secrecy surround most paraphiliacs, who rarely seek help, unless conflict, guilt and stress affect them or their family, or the victim, and result in family pressure or social crises, or an offence results in legal action. Occasionally an individual may present to discuss his deviation as an extension of his fantasy without a real desire to be helped.

Aetiology: family dynamics contribute significantly, but are insufficient to cause them. Constitutional factors may be involved, but experimental and psychological factors probably dominate in the formation of "perversions". There is no evidence of genetic or hormonal mechanisms (Meyer, 1980).

TRANSVESTISM (Cross dressing, eonism)

Definition: sexual excitement is obtained by fantasizing about or actual dressing in clothes of the opposite sex, as an adjunct to masturbation and/or coitus. Cross dressing enhances or is necessary for sexual arousal, and may come to replace it. It is a compulsion peculiar to predominantly heterosexual males, and is rare in women. Cross dressing usually begins in childhood or adolescence and only occasionally in adulthood.

Characteristics: most men are not feminine in manner, but when cross dressed the appearance of femininity may be striking. When not dressed in women's clothes, transvestite men may be hypermasculine in appearance and occupation (Meyer, 1980). Transvestites greatly value their genital organs, unlike transsexuals, and most deny homosexual or transsexual inclinations. Only a small percentage of gays enjoy cross dressing, and they form the small percentage of transvestites who are homosexual.

Cross dressing may occur strictly in private but may extend to membership of a transvestite subculture and may include masochistic activity. Many transvestites are married and may involve their wives in their crossdressing, and some are unable to become aroused unless they are cross dressed. This may be tolerated by the spouse, or cause distress and marital breakdown. Transvestites usually wear clothes of elegant conventional female styles, and unisex clothes have no appeal to them. Typically the cross dressing is fetishistic but may extend from one article to an entire wardrobe of clothing. Transvestites are prone to depression, and suicide attempts are common (Gadpaille, 1981).

Aetiology: this condition may be associated with parental rejection of the unwanted sex of the child which results in insecurity, inferiority and identity confusion, and the child crossdresses in order to become more acceptable; a poor male model in the father; the expression of feminine identification relieves separation anxiety by a symbolic merger with the mother (Meyer, 1980). When a child's cross dressing is accompanied by erotic arousal it is a phase which may not be outgrown, and early therapy may be indicated (Gadpaille, 1981a).

Presentation: few transvestites ever seek professional help. They usually do so only if exposed by stealing women's underclothes, or if their secret is discovered by their spouse, or if guilt or relationship problems become intolerable, or following a suicide attempt.

Treatment: the stability of the individual and the relationship, as well as the acceptance or rejection of the behaviour must be assessed. The individual's concept of his masculinity should be enhanced. If the problem is based on difficulties in heterosexual function, sex therapy may be curative. Behaviour therapy and psychotherapy are indicated. The spouse needs support during her husband's therapy particularly if he resists or does not respond to treatment. If the treatment is accepted it must be given by a psychiatrist who specializes in such disorders. The results are often disappointing and prognosis is poor for adults (Gadpaille, 1981b).

FETISHISM

Definition: an inanimate object or part of the woman's body, clothing or personal effects, which may be preferred to the person, is a necessary adjunct to sexual arousal and orgasm.

Characteristics: this is a common paraphilia among men and is rare in women. The man tends to be antisocial, immature and unable to form close personal relationships particularly with individuals of the opposite sex. The attraction is compulsive and irrational, substitutes the heterosexual stimulus, and becomes an aim in itself or an irreplaceable part of sexual behaviour pursued beyond reasonable limits (Van der Merwe, 1980). The fetish is usually linked to someone closely involved with the patient during his childhood, and is constant over time e.g. shoes, gloves, rubber or a corset. Individuals may become so compulsive in their need for the object of their desire that they may steal and clash with the law. For some men the object is an end in itself, some masturbate or have coitus while handling it, and some gain sexual satisfaction exclusively by fantasizing with it. The condition is basically harmless and does not usually conflict with the law but may create discomfort and embarrassment for the partner, and the relationship may be severely affected.

Aetiology: particular stimuli may create an erotic response and may become a conditioned response. Learning at an early age, before a mature concept of sexuality has developed, may permit bizarre associations to develop. The majority of fetishes can be understood to be an extension of the loved one which can acquire special importance if the development of more appropriate sexual relationships is blocked (Bancroft, 1983).

Treatment depends on the individual's desire to change. The behavioral approach, reconditioning to the object, and reinforcing sexual satisfaction from the partner may be effective. Couple therapy should focus on the relationship in a positive way rather than on the fetish.

EXHIBITIONISM (indecent exposure, flashing)

Definition: deliberate genital exposure, usually to a stranger, to create surprise or shock as a means of sexual gratification.

This is one of the most common paraphilias and is notoriously difficult to treat. It has a high incidence of recidivism and is often encountered as a medico legal problem.

Exhibition may be compulsive and repetitious and become the major source of sexual pleasure for the individual. Sexual excitement is enhanced if the victim reacts in some way, showing shock or anxiety. The deed may be performed in some favorite spot, impulsively or pre planned, and may or may not be associated with an erection and ejaculation. Masturbation may or may not take place during or after exposure. The act is thought to be beyond the capacity of the individual to control (Van der Merwe, 1980).

Characteristics:

The offender is usually a man in his third decade, weak, boyish and undemanding, with a poor relationship with his sexual partner, insecure and inhibited having been very restricted as a child. The exposure may be an attempt to assert and confirm his manhood and have power over his victim. Potency problems and difficulties in establishing heterosexual relationships usually exist.

The victims are often young females and children. Paedophiliac exhibitionists have high recidivism rates and carry a poor prognosis. Persistent exposers do not show a crossover from children to adult victims, but remain true to type (Van der Merwe, 1980).

The prevailing view that exhibitionists never become aggressive should be modified, as a review of cases indicates that there is often a history of exhibitionism proceeding to rape, or exhibitionists have contemplated rape. The aggressive factors should not be generalized, but properly evaluated in the chronic, recidivist sub group with other features of antisocial behaviour (Van der Merwe, 1980). On the other hand, Rooth (1973) considered that the violent minority may come from the ranks of the incidental rather than the habitual exposer, and Kolodny (1979) stated that exhibitions are unlikely to commit rape, but that this condition may be combined with other forms of aberrant sexual behavior.

Presentation: masturbatory acts accompanied by sexual fantasies may be played out in an act of exposure, but in some cases the penis is flaccid and there is no apparent sexual arousal. Sexual excitement is greater if the victim responds with shock. Laughing is totally aversive and the best way to manage the incident, as the man will usually turn and run. Exhibitionism is extremely alarming and distressing to the victim, but is usually an act in itself with no attempt to harm the observer or to have sexual intercourse.

Treatment: psychotherapy is indicated if the condition is associated with severe emotional immaturity or schizophrenia. Imprisonment or punitive fines are unlikely to modify this problem.

Behavior modification therapy should enable most patients to assume a more assertive role in their inter personal relationships, but requires regular supervision with supportive counseling for the whole family. If other sexual outlets are unavailable, advice on masturbation, emphasizing the need for heterosexual fantasy, will reduce the pressure to exposure.

OBSCENE PHONE CALLS (Scatologia)

The offender, usually a man, calls a woman whom he may or may not know, and he may masturbate while making lewd remarks,Victims may suffer recurrent distressing harassment although they are not likely to be subjected to assault. They should be advised to discourage the caller by informing that the police will be informed, by replacing the earpiece, or blowing a loud whistle into the mouthpiece. They should not engage in conversation of any sort.

VOYEURISM (Scopophilia, peeping Tom)

Definition: the individual obtains sexual gratification by observing others undressing or engaging in sexual activity.

Characteristics: the voyeur may go to enormous trouble in order to achieve this, and usually takes care not to be seen, but may draw attention to himself. The looking may be accompanied by masturbatory activities, but some of these men have a weak sex drive and suffer from psychogenic "impotence", and the act may be performed as a substitute for coitus. This activity carries no threat of sexual contact, failure or rejection, and the individual is not usually interested in sexual intercourse with his victim.

This condition has its root in fixation at infantile levels of sexuality, going back to curiosity and exploratory behavior. It is predominantly found in males who have feelings of inferiority, are compulsive, shy, usually obsessional, and who lack attraction to women. They do not voluntarily seek treatment unless there is a brush with the law.

Treatment must be individualized. Aversion therapy is little used today; instead positive conditioning of desired behavior and psychotherapy are preferred.

Drugs: where the condition is compulsive and excessive, cyproterone acetate, or medroxy progesterone acetate, or benpericlol have been used with some success (page 413) (Haslam, 1976).

SEXUAL SADISM

Definition: sexual pleasure and excitement are derived from inflicting pain and physical or psychological acts of humiliation, ritualized dominance or cruelty on the sexual partner. Flagellation with a whip or cane, punishing or bondage is used to arouse the individual to sexual excitement or orgasm and may replace the sex act. The sadist plays the active role in order to become sexually stimulated.

Characteristics: the central impelling fantasy involves degradation and humiliation and causing suffering. This condition is usually an expression of a personality disorder or a serious problem in the relationship. It is usually practiced in private with a willing partner, but problems arise when one partner complains of the abnormal behavior or of physical assault. It is not known whether sadism is related to child abuse or rape. It is not usually dangerous, but this condition receives most attention when the degree of suffering is miscalculated, with tragic results, as in cases of brutality or lust murder.

Treatment is directed at the emotional needs and sexual function of both partners and masturbation training using acceptable fantasies. Psychotherapy is indicated.

SEXUAL MASOCHISM

Definition: sexual pleasure is attained or heightened by seeking and experiencing pain, by being subjected to the will of a person usually of the opposite sex and/or being humiliated or abused. The masochist plays the passive role. Sexual activity with a partner, or solitary masturbation preferentially involves real or simulated degradation, subjugation and pain, inflicted in order to produce sexual excitement.

Characteristics: the individual enjoys pain of his or her own choosing, but not all pain. Some women who are inhibited and feel that sexual pleasure is sinful can only experience sexual pleasure if it is "not her fault" while being humiliated or restrained. Some fantasize being tied to the bed and then become uninhibited, and some indulge in self flagellation. This type of sexual activity can cause anger or humiliation and may result in relationship problems.

Aetiology: erection commonly occurs amongst pre adolescent boys when they are frightened. Some males persist with this pattern which may contribute to the development of masochistic preferences (Bancroft, 1983).

Treatment is rarely sought unless injury is severe or conflict arises. If treatment is requested, psychotherapy and behavior modification therapy are indicated.

PAEDOPHILIA (Infantosexuality)

Definition: adults who engage in sexual activities with pre pubertal children preferentially either in fantasy or in actuality.

Hebephilia indicates sexual attraction to adolescents and includes the same behavioural spectrum (Van der Merwe, 1980).

Paedorasty, a sub group of homosexual paedophilia, describes man boy anal intercourse (sodomy).

Incest is superficially related to paedophilia by the selection of an immature child as a sexual object and the subtle or overt element of coercion (Meyer, 1980) (page 409).

Paedophilia is more commonly identified because a child is the object, and the act is taken more seriously and greater effort is spent in tracking down the culprit than in other paraphilias (Meyer, 1980).

This practice may be indulged because of the fear of failure with a woman, as the child poses no threat to the man's masculine self-image. Paeclophiles may be exclusively homosexual or exclusively heterosexual.

Incidence: 3 times as many boys are assaulted as girls, most commonly those aged between 10 and 12 years. The victim is a stranger to the paedophile in only 10.3% of cases (Kolodny, 1979).

Characteristics: most paedophiles are males between 35 and 40 years of age. 70 80% have been married at some time, and have usually had sexual difficulties in heterosexual relationships and in some cases are "impotent". They tend to be prudish, moralistic, devoutly religious and conservative. Many have had an unhappy childhood and feel deprived of love. They experience loneliness, feelings of inadequacy and inferiority, and in some cases psychosis and alcoholism may be evident. Many .of these men devote much of their time and energy to the welfare of children. More than 80% are in the role of teachers or youth leaders (Ingram, 1979). At least 80% of incidents occur with a relative or family friend, neighbor or acquaintance, and often in the child's home or in the individual's home where the child has been bribed with treats (Schiller, 1981). Thus, telling children about "stranger danger" and not to take treats or lifts from strangers is not enough. It is important for a child to understand that his or her body is private, and anyone who crosses over that line dividing affection from exploring and handling is suspect. The child must be made to feel sufficiently comfortable to tell the parent of any such episode. Then he or she will be more likely to take appropriate action, stand up for humor herself and avoid molestation.

Sexual activity: the paeclophile gains pleasure out of being in the company of young boys and fondling them, particularly those who have no pubic hair, as this turns him off. He identifies with his small partner and does to children what he would like to experience himself, as he is often incapable of becoming involved in heterosexual relationships or meaningful mature relationships with adults. Emotionally deprived children may accept sexual attention as a form of affection.

The victim is usually treated with tenderness and the adult may make a game of it which overcomes the child's hesitation. Coitus is rarely attempted and the activity may include fondling the child's external genitalia, self or mutual masturbation, and oral genital contact. Masturbation may take place once the child has gone.

Although apparently only a small percentage of paeclophilic encounters result in injury or death, aggression and sadism are inherent components in paeclophilia. For the paeclophile who is frightened of adult partners, the opportunity to terrify rather than be terrified provides the component of erotically tinged aggression that is important in his arousal. In a situation in which the victim is comparatively helpless, physical injury may be inflicted in cold blood, in passion, or in panic (Meyer, 1980).

Treatment: the victim may be more disturbed by the parents' and teachers' overwhelming attitude of alarm and hostility and the examination and investigation than the molestation itself. The child should be handled gently and sensitively in the presence of someone he or she knows or trusts. Victims must be made aware that they are not guilty of a misdemeanour, and that the person was sick and behaved in an abnormal fashion. Parents must be guided to be supportive and not treat the child as if he or she is ill or to blame for something terrible. Sensitive counseling should continue to be given when the child reaches adolescence and adulthood or if there is evidence of anxiety or withdrawal from society, or difficulty in making relationships with members of the opposite sex. Men and women thus affected must be helped to separate the incident from their sexual partner and from the present time.

Paedophile; behavior modification therapy and psychotherapy should establish stronger masculine images and ways of interacting on an equal and intimate basis with adult sexual partners. Any tendency to aggressive behavior requires urgent specialized intervention, close supervision and drug therapy.

TRAUMATIC SEXUAL EXPERIENCES

Definition: an individual is subjected to a sexual act which causes or is likely to cause physical or psychological damage.

Sexual assault (indecent assault, sexual abuse) implies non consenting sexual activity (physical, visual or verbal). It includes being the victim of rape, voyeurism, exhibitionism, obscene phone calls and frotteurism (rubbing the penis against the victim's body, commonly in subways or buses), and coercive sexual contact between husband and wife. Sexual assaults are predominantly heterosexual male to female and are often preceded by excessive alcohol consumption (Bancroft, 1983).

Traumatic sexual experiences may be associated with any frightening, humiliating or aggressive sexual attack. Of the offenders who assault children, 75 80% are significant members of the victim's lives whom they know and trust (Snowden, 1982).

Childhood: incest, molestation, rape, paedophilia, exhibitionism.

Adolescence: homosexual or heterosexual seduction or rape; painful, forced or failed initial sex act; discovery and punishment during masturbation or intercourse; flirtatious behavior which changed to forced sexual intercourse. A man has the understanding (approval) of society that "he can no longer control himself during heavy petting once he has been led so far". However, it is remarkable that Seman's and the squeeze techniques used in the treatment of premature ejaculation and erectile impairment enable men to become aroused, even to the point of ejaculation, but that this can be controlled by stopping stimulation. Therefore it appears that in forced coitus, once the partner indicates her unwillingness to proceed, the continuing act becomes one of aggression.

Adulthood: rape; painful or coercive coitus; failed first coitus; discovery during coitus; unwilling partner to sadomasochism. An important and unresolved issue is that of marital rape.

Incidence: McLaughlin (1982) reported that an estimated 200000 500000 children between the ages of 4 and 13 are sexually assaulted every year in the USA, and that as many as 25 million women have been sexually assaulted as children.

Effects on sexual function

Negative emotions of guilt and anxiety destroy the delicate psycho physiological balance of sexual responsivity.

Males: inhibition of sexual desire, erectile impairment, premature or delayed or absent ejaculation may result, and performance anxiety and sexual avoidance may perpetuate the dysfunction.

Females: inhibition of sexual desire, and arousal or orgasmic dysfunction, sexual aversion or vaginismus may result.

Individuals who suffer these conditions do not invariably have a history of traumatic sexual experiences, and those who have had a traumatic sexual experience do not invariably develop impaired sexual function. The result depends on individual vulnerability, ego strength, family support and the handling of the incident at the time of the event. The shock and horror of the family may load a child with indescribable guilt in the event of rape, molestation or incest, and these effects may be far more traumatic than the experience, and make them believe that all sex is bad.

Treatment

Education: guilt must be removed. Victims must realize that if they were subjected to an aggressive attack as a child, they have needlessly borne a guilt which has affected their attitude to sexuality. Discussion has a cathartic value, and reduces guilt and the significance of the event, and places it in perspective in the present relationship. The overwhelming relief of individuals who have been counseled in this way reveals the tremendous burden they have carried for years. This can in itself be therapeutic.

Negative feelings about the event need to be resolved. Patients are invited to express their feelings to therapists without suppressing them, recognizing that although this may be uncomfortable, they can tolerate the recall without too much pain. Alternatively the patient can be asked to write down details of the incident, record his or her reactions and feelings, and put it aside for a few days when he or she should read it again, underline the emotionally charged aspects, concentrate on these, rewrite them and repeat the procedure until the emotional reaction is tolerated comfortably.

Sex therapy: in cases of initial failure or hurried unsuccessful coital attempts, education about the reflex nature of sexual response, supportive counseling and graduated sexual assignments should reduce performance anxiety. Specific therapy should be given for erectile impairment, premature or inhibited ejaculation, sexual aversion or vaginismus.

RAPE

Definition: unlawful sexual intercourse imposed or forced on a person without consent. The victim is almost invariably a woman, but Sarrell (1982a,b) described cases of male "rape" by women. Mezey (1987) reviews the subject of male victims of sexual assault by men.

Sexual intercourse may be gained by force, impersonation or threat, or when the victim is under the influence of drugs or alcohol.

Statutory rape: intercourse with a girl under the age of 16 with or without her consent.

Gang or group rape: forcible intercourse with a girl or woman by more than I man.

Homosexual rape may occur in male prisons. Buggery with violence or the threat of it may be considered a male version of rape.

Characteristics: 70% of arrested rapists have prior criminal records of assault, robbery or homicide. Rape often occurs as an accompaniment to another crime. The man always threatens his victim with fists, gun or knife and frequently harms her in non sexual ways as well. She may be beaten, wounded and in some instances, killed (Sadock, 1980). Not all men who commit rape have a criminal profile and the experience of workers in Rape Crisis has shown that rapists may emerge from a 11 normal" background. There is clearly no typical characteristic. 50% of rapists are known to the victim in varying degrees and 7% are close relatives (Sadock, 1980). Rapists are usually males aged 15 24 years and most victims are females 10 24 years old. Women of all ages have been victims of rape including children and elderly persons (cases have been reported from 15 months to 82 years). There is no evidence that a rapist chooses a woman on her physical appearance. It is not the woman's fault if she is raped while hitchhiking or participating in any other activity; only the rapist is responsible for his actions (Lenz, 1981).

Rape is an act of violence. It is a sexual expression of aggression and not an aggressive expression of sexual desire.

It is an extremely traumatic experience to the victim, particularly because of the associated violence And possible threat to life. Even when the attack does not cause physical injury, the sexual assault frequently has devastating psychological consequences. Rape is emotive and the whole family becomes involved. The trauma of reporting to the police and being examined and being exposed in court, with embarrassment to self, spouse and family, and an intense need for privacy, and unwillingness to re experience the trauma in the telling, deter many women from reporting rape. The authorities are often unsympathetic and make the woman feel that she is not as innocent as she makes out. The sense of shame, humiliation and fear suffered may extend for a year or more. Some women develop a sense of vulnerability and some become phobic, but some emerge apparently unscathed. The effects depend on the vulnerability of the women and the support system immediately available (Sadock, 1980).

Symptoms following rape:

Acute disorganization phase: actions are abnormal for the first few hours or days, ranging from hysteria, sobbing, muteness or trancelike state, to stoicism, indifference, flippancy, hostility, rigid self control, or apology.

"Rape trauma syndrome" has been described during the first few days to weeks. The victim has difficulty sleeping, disturbance of appetite, including anorexia, nausea and vomiting, focused or diffuse fear and anxiety, local or general physical complaints and repetitive thoughts about the assault.

The long term reorganization phase may last from months to years before disruption of routine, sleep disturbances and phobias are resolved (Miller, 1981).

Young victims of sexual assault manifest similar symptoms and they may develop problems in school and the parents may become overprotective.

Treatment:

Rape Crisis workers are experienced in assisting and counseling victims and their families, and should be involved in their management. The physical examination must be undertaken as soon as possible after the event. Privacy, calm and gentleness are essential and the girl or woman should be told what has to be done and why. The hospital team should include a person who can provide the necessary emotional support. If the victim is young, a stable parent may be comforting during the examination. If the parent is too distressed or cannot be contacted, another adult whom the child knows and trusts should be called. Clothing must be inspected for blood staining or soiling and the girl examined for injury, blood and semen and pubic hair. Life threatening injuries must be treated immediately. Swabs should be taken (from mouth, throat, vagina and anus) to exclude gonorrhoea.

Contraception: if the woman is not already on a contraceptive, pre existing pregnancy must be excluded and post coital contraception provided.

Sedation only delays resolution of feelings and should be avoided if possible.

Local injury may result in dyspareunia. Vaginismus may follow and requires specific treatment .

Supportive counseling must be given to minimize subsequent personality disturbance and sexual dysfunction. The woman should be helped to dissociate the act of aggression from acts of lovemaking and be advised to consider the rapist's penis as a weapon or stick rather than a penis or an instrument of sexual expression.

Follow up examination to exclude pregnancy and venereal disease and allow for discussion. Support may be needed during the court proceedings and long term counseling may be indicated.

Family: the therapist must ensure that the parents' horror, guilt, anxiety and rejection are replaced by a supportive, caring attitude. Above all, the girl and her family must realize that she has not committed an indecent act and has no cause for guilt or shame. She must be helped by them to gain her self respect and return to normal life.

Spouse or boyfriend requires counseling to minimize rejection and blame, and return to normal sexual function. The girl should be encouraged to set the pace for closeness and intimacy without forcing coitus until she feels ready. The spouse would seem the most appropriate person for the married victim to turn to, but he may be the least understanding of all. He may show an inability to adjust and this may result in subsequent divorce.

Supportive counseling must be available at any time, and follow up should continue at the discretion of the counselor.

Specific sex therapy may be needed at a later date, and it must be made clear that this will be available.