Title: Sexual strands: Understanding and treating sexual anomalies in men
Author(s): Ron Langevin
Affiliation: Clarke Institute of Psychiatry, Toronto
Citation: Langevin, R., Sexual strands: Understanding and treating sexual anomalies in men, Hillsdale, NJ: Erlbaum, 1983.
This document summarizes three chapters of the book:
This chapter describes approaches used to treat sexual anomalies in general—no distinction is made among the different types of anomalies, which have included homosexuality, transvestitism, pedophilia, and exhibitionism, among others. Treatment of sexual anomalies by behavioral methods is based on the theory of classical conditioning (developed by Pavlov in his 1903 study of dog salivation) and operant conditioning (developed in the 1920s by B.F. Skinner in his studies of rat behavior).
Aversion therapy was first used in 1935 by L. Max to convert one of his patients from homosexuality to heterosexuality. Max presented the patient with pictures of nude men followed by electric shock, causing him to lose his “homosexual fixation.” Max’s work went unnoticed until Freund used chemical aversion therapy for the same purpose—instead of electric shock he administered apomorphine which caused the patient to vomit. This therapy was successful in causing pictures of nude men to evoke nausea rather than sexual arousal among homosexual men.
Other attempts used scoline which resulted in temporary paralysis including an inability to breathe. Therapists eventually stopped using chemicals, partly due to criticisms that their use was inhumane, but mainly because their use was imprecise, difficult to control, and expensive. Their side effects were difficult to manage and included risk of gastric rupture, salt depletion, cardiovascular problems, fever, and delerium. One death was reported.
Covert sensitization was developed as a safer approach. In this method, both the deviant stimuli and the aversive stimuli are to be imagined by the patient.
Shame aversion therapy involves subjecting the patient to public shame or humiliation in conjunction with his anomalous behavior. Only a few cases have been reported in the literature. One reported that a transvestite attempted suicide after a treatment session.
Anxiety relief conditioning is used as a method of creating normal arousal to adult women. This is done by associating the pleasant end to an aversive stimulus (such as electric shock) with pictures of nude women. Thus the procedure involves presenting the patient with pictures of nude men or children, presenting the electric shock, then ending it while displaying pictures of nude women. The method has not been effective.
Systematic desensitization attempts to reduce the patient’s anxiety related to sex with women. The therapist begins by teaching the patient relaxation techniques. Then the therapist progressively describes romantic/sexual situations with women that are known to evoke more and more stress in the patient. With each situation, the patient applies the relaxation techniques to reduce his anxiety.
Positive classical conditioning attempts to transfer the patient’s anomalous arousal to normal stimuli. This is done by presenting the anomalous stimulus to arouse the patient, then presenting the normal stimulus while he is still aroused. Unfortunately, when this method seems to be effective, one cannot be sure that the patient is not still imagining the anomalous stimulus.
Orgasmic reconditioning has a goal similar to that of positive classical conditioning. The patient uses his anomalous fantasies to achieve arousal, then he switches to a normal fantasy just before orgasm.
Penile operant conditioning rewards the patient for arousal to normal stimuli. In this procedure, the therapist deprives the patient of liquids, and then reinforces penile reactions to normal heterosexual stimuli with liquid. The method was reported to be very effective with one homosexual patient. However, he later reported that while he achieved a reflexive erection to adult females, he felt no sexual attraction.
Assertion therapy attempts to rectify difficulties in heterosexual behavior. The therapist teaches the patient how to interact with women and how to express feelings and thoughts while respecting the rights of others.
Satiation therapy attempts to extinguish anomalous arousal by requiring the patient to masturbate to his anomalous fantasy, and continue masturbation past satiation and climax, perhaps for an hour or more. A few cases have reported success.
Several criticisms have been raised against these methods. First, psychotherapists claim that it only treats symptoms rather than the underlying problem. Thus, if these symptoms are eliminated, others will appear to take their place. However, evidence does not support this objection.
Another criticism is that the methods are successful with specific maladaptive behaviors (such as phobias, stuttering, and tics), but not with alcoholism or sexual anomalies. The author responds to this charge by writing that measures of success are relative, and behavior therapy is as effective as more expensive psychotherapy.
He does admit the validity of several other criticisms, however. Some procedures are not actually based on the theories of behaviorism, and some of the principles they are based on are not well established.
Furthermore, studies of their effectiveness generally ignore issues of validity and reliability. Less than 5% have used comparison groups, baseline data, and adequate follow-up. The treatment methods make no distinction between suppression and extinction. Some methods only result in suppression so that behavior recurs soon after treatment. It is unknown how many sessions are needed to permanently extinguish the behavior, or even whether it is possible. Furthermore, the methods assume that the conditioning stimuli are neutral—as they were in animal experiments—but erotic stimuli are not neutral.
Aversive methods have also been criticized as inhumane. The author writes,
It may be our abhorrence of sexual anomalies that make us want to use punishment procedures on them. Aversion methods were developed first and have been used most in the treatment of sexual anomalies…I do not believe we should persist in using inhumane methods like aversive procedures nor in using procedures that have no logical basis or demonstrated effectiveness. Moreover, the method should be applied to the anomaly with an understanding of the behavior involved. This usually has not been done…treatment of sexual anomalies is relatively new and not well understood. (pp. 53-54)
Thus, other methods should be considered.
In psychotherapy, the therapist creates and maintains a helping role modeled on the parent-child relationship. The therapist should exhibit respect, interest, understanding, maturity, and the belief in his power to help. He should encourage openness and honesty on the patient’s part.
The parent-like role gives him the power to influence the patient positively, and to interpret his self-defeating behavior and distorted beliefs about reality. For this method be effective, the patient must have the capacity and willingness to profit from it. His cooperation is always essential.
There are six aspects of effective psychotherapy:
However, psychotherapy applied to sexual anomalies has been poorly reported and analyzed.
Antiandrogen drugs, such as cyproterone acetate and medroxyprogesterone acetate, are used to reduce sex drive, but they do not change erotic preference. Thus they interfere with normal adult heterosexual functioning. It has been suggested that their dosage be adjusted to a level that eliminates sexual preoccupations, but still allows the patient to function with his wife.
Known reversible side-effects of these drugs include weight gain, fatigue, mood disturbance, and sometimes loss of body hair, hot and cold flashes, reduced sperm production, and sterility. Long-term use of these drugs is suspect and dangerous. It is not known if long-term use will cause the side-effects to become irreversible. The drugs may also cause liver damage, diabetes, and feminization. Cyproterone acetate has been linked with testicular atrophy.
Neuroleptic drugs also reduce sex drive. They have been studied less than anti-androgen drugs. Their side effects include stiffness, tremor, restlessness, blurred vision, nausea, constipation, photosensitivity, dry mouth, hypotension, fluid retension, amenorrhea, and tardive dyskinesia. The last side effect involves purposeless movements such as blinking, licking, chewing, and grinding, and may not appear until years after the drug is used. Terminating use of the drug worsens the symptoms.
Castration is irreversible and controversial, and does not always reduce sex drive. Possible temporary side effects include sweating and blushing. Permanent side effects include decreased body hair, thicker head hair, obesity, growth of breasts, softer flabby skin, strangely puckered face, heart disorders, respiratory difficulties, dorsalgia, night sweating, chronic body pain, rachiopathy, osteoporosis, depression, anger, feelings of inadequacy and isolation, and passivity. No systematic studies of psychological consequences have been performed.
The author writes:
It would be desirable in theory to understand what we are treating then apply the most efficient and humane treatment. Unfortunately, there are an abundance of theories about sexual anomalies and a severe shortage of facts…the goal of understanding what we are treating and then applying treatment is not available at present. (p. 62)
One needs to determine the criterion for treatment success. Society and the therapist may be satisfied with simply preventing future offenses. This is easily done: no treatment is necessary since repeat offense rates for sexual crimes are rather low—less than 20%, while rates for non-sexual crime average about 40%.
A distinction must be made between offenders who control themselves, feel remorse for their offenses, and want to change their sexual feelings, and offenders who lack remorse and are unwilling or unable to control their actions.
The former type of offender requires counseling to address his feelings about himself. In addition, if treatment only suppresses his urge to behave sexually, he is left with the pain and suffering that go with controlling socially unacceptable urges. This pressure could be relieved by altering his erotic preferences. In the case of the hostile offender, it is currently difficult to devise any treatment.
The author writes:
Court orders for treatment as opposed to jail or in addition to jail make it hard to enact any worthwhile treatment programs because treatment becomes a sentence rather than a therapy. Ultimately the willingness of the individual is most important…Overall it seems that society’s goals, and the therapist’s goals are best met by a consideration of the patient’s motivation and preferences. If the patient is willing to change, he will be best able to cope if his erotic preferences are changed so he is no longer aroused by sexually anomalous behavior.
Thus, much importance is placed on changing erotic preference. To determine the effectiveness of efforts to do so, the therapist or researcher should monitor the patient’s reaction to anomalous stimuli during the course of treatment to determine whether there is a steady decline.
In addition, there must be a follow-up on the rate of sexually anomalous behavior outside treatment and on the enjoyment of normal sexual intercourse. The ultimate indicator of success is the finding that normal sexual intercourse is newly preferred over the formerly preferred anomalous behavior.
Most reports of treatment in the professional literature fail seriously in many ways: many are case studies without comparison groups or controlled conditions. Even the use of a single case experimental design study would be a significant improvement over the current situation. The case studies used to support treatment approaches are unsystematic, uncontrolled, and generally so confounded that it is difficult to know what factors are operative in treatment outcomes.
The author describes a patient who seemed to be successfully treated for exhibitionism, at which time many therapists would have submitted for publication an article reporting successful treatment. However, two years later the man re-offended, and five years later he returned to the therapist and informed him that he had been faking all along. In another case, a patient faked his cure to please the therapist after falling in love with him.
In addition, without treatment, anomalous sexual behavior may decrease or stop in its own as offenders age, especially if they are adolescents at the time of the offense. Adolescents tend to engage in acts such as peeping, frottage, or homosexual activity before settling down into more conventional behaviors as adults. These reported “cures” may not be due to the therapy at all.
Thus, a large number of cases that seem to have been treated successfully is uninformative if there are no scientific controls. The author argues for controlled studies with larger samples, comparison groups, and long-term follow-up:
In conclusion, I think the reader should be skeptical of treatment approaches that do not meet these criteria. They mislead us all. We embark on ventures that are doomed to failure because they are improperly investigated. They offer a taste of plausibility and of cure, too often leaving the patient angry and disillusioned. If a treatment is to be used experimentally, the patient should know this and know that we do not have the answers. The therapeutic enterprise becomes a joint venture that involves cooperation and a surprising openness on the part of the patient. I feel this is the road to progress.
The author writes that even though attitudes toward homosexuality have been liberalized, most treatment methods developed for sexual anomalies have been used with homosexuals. Understandings gained from that history can be applied to other anomalous behavior that will not be socially acceptable in the near future.
Three types of theories have attempted to account for homosexuality:
Experimental evidence suggests that the typical homosexual responds to the mature male body and to a lesser extent to the developing and immature male body (as does the heterosexual to corresponding females), does not respond to females but shows no great aversion to them, exhibits somewhat feminine interests and behavior, and shows a moderate degree of feminine gender identity.
There is no evidence that dominance-submissiveness, sadism-masochism, or activity-passivity are important in partner choice. Preferred sexual behaviors are mutual masturbation, fellatio, and anal intercourse. Homosexuality is not consistently associated with any psychiatric abnormality, and there is no support for psychoanalytic or social learning theories. Organic theories have not yet been tested experimentally.
Social learning theories have resulted in behavioral therapies being the most commonly used approach to attempt to change erotic preference in homosexual men. Reports of these methods are characterized by moralistic overtones which may render them wholly unpleasant and ineffective.
Behavioral methods have included aversion therapy, covert sensitization, heterosexual enhancement, reciprocal inhibition, positive operant conditioning, positive classical conditioning, and fading. Multi-treatment methods—the use of several of these techniques to overcome multiple problems have also been proposed.
Compared to other treatment methods, studies of behavioral methods are the most detailed and controlled. However, even the best studies lack experimental rigor and appropriate controls. Multi-treatment methods seem most promising, although the studies of their effectiveness are the most poorly executed and followed up.
In general, the more careful the study, the more modest the claims. Cure rates range from 62% (for controlled group studies) to 91% (for uncontrolled case studies). However, when cure is defined as participation in heterosexual coitus, success rates range from 3% to 57%.
Psychotherapy seems about as successful as behavioral therapy. One review of these studies found them 40% effective. However, again, study methodology was poor, and no controlled studies exist. Psychotherapy seems promising, but there is little satisfactory systematic evidence that it is effective. It seems to help almost half of homosexuals perform heterosexually, but does not necessarily change erotic preference.
Masters and Johnson’s method gives the patient two choices:
Many therapies assume that homosexual males are sick and disturbed, but the empirical facts defy this belief. If a homosexual patient has a psychiatric illness, that illness, but not his homosexuality, needs attention. The author’s personal experience indicates that much more progress can be made when homosexuality is not part of the therapy. If sexual orientation is his only problem, then a few sessions in self-acceptance and an introduction to homosexual services may be all that is necessary.
Several problems have prevented researchers from developing an adequate understanding of pedophilia. The first is uncertainty about the definition of “child.” Various authors have used 12, 13, 15, 18, puberty, or an age difference between the participants (which vary from 4 to 10 years) as cut-off ages to define “child.”
Secondly, researchers often confuse incest with pedophilia, and homosexual pedophilia with heterosexual pedophilia. They also confuse pedophiles (who erotically prefer children) with offenders against children who prefer adults.
Various theories have been proposed to account for pedophilia:
Studies have found that most pedophiles are either heterosexual or homosexual—few are bisexual. These two groups may be very different. Homosexual pedophiles appear to prefer slightly older children than heterosexual pedophiles, and they tend to exhibit more preference for inner crural or anal intercourse, rather than fondling and exhibitionism. The two types of pedophilia may have different causes.
Heterosexual pedophiles’ response to males is the same as that of heterosexual gynephiles (preferentially attracted to women), suggesting that pedophilia is not generally linked to homosexuality. However, like homosexual androphiles (preferentially attracted to men), homosexual pedophiles show little arousal to females of any age.
The idealized homosexual androphile shows slight arousal to prepubescent boys, medium arousal to pubescent boys, and maximum arousal to adult males. The idealized homosexual pedophile exhibits the reverse pattern: slight arousal to men, medium arousal to pubescent boys, and maximum arousal to prepubescent boys. This suggests that aversion to adults is not a factor in pedophilia. This is confirmed by studies finding anywhere from 8% to 47% of homosexual pedophiles marry.
In terms of sexual experience (degree and type of sexual outlet), homosexual pedophiles are much more similar to homosexual androphiles than heterosexual pedophiles are to heterosexual gynephiles (preferentially attracted to women). The only real difference is object choice—child vs. adult.
The data also do not support the theories that pedophilia is due to fixation at an immature stage of development, to an inability to relate to women, to mental retardation, or to senility. Pedophiles usually exhibit IQ’s similar to those of the general population, although the distribution leans toward lower values.
One non-clinical study suggests that studies of clinical samples may be biased toward finding pathology which is not an inherent part of the sexual anomaly. There may be well-adjusted pedophiles living in the community.
Some evidence has suggested that brain pathology might be a factor in pedophilia, but the evidence is unconvincing. Most of the studies do not report based rates, and when they do, the results are disappointing. No studies have addressed genetic factors. One study of hormonal factors found no difference between pedophiles and controls.
Few studies have addressed personality pathology (such as emotional retardation, immaturity, passivity, or inferiority). Those that have suffer from numerous methodological problems: using prison or clinical samples, basing conclusions on scales that have not been validated, overlooking the potential dishonesty of offenders, or including incorrectly reported data.
One well-conducted study was unable to find any particular personality profile for pedophiles. Even when characteristic traits are found, they may be due to society’s reactions rather than be causes or correlates of pedophilia.
As for all sexual anomalies, the most common treatment of pedophilia involves aversive conditioning. And as is typical in this field, reports of treatment are almost all uncontrolled case studies. There are far fewer studies of pedophilia than there are of homosexuality.
Aversion therapy – Adapting the homosexual pedophile to the androphilic role might be the most successful method, although only two studies have attempted this. Case studies of aversion therapy for pedophiles suffer from additional problems: they usually do not make clear that the subjects began with an erotic preference for children, and faking by prisoners prevents accurate assessment of effectiveness. The few studies that have examined penile reaction after treatment have indicated little change. No controlled studies have been preformed.
Multiple treatment approach – Since patients tend to have many problems, addressing them through multiple methods seems promising. Positive case studies have supported this method, but again, the studies are marred by problems. They are not based on any understanding of pedophilia, and one is never certain which of the multiple treatments has the effect or if all are necessary. This is essentially a shot-gun approach which is time consuming and expensive.
Positive behavior therapy – This involves techniques such as assertion therapy, fading (a type of positive classical conditioning), systematic desensitization, and covert sensitization. These approaches are more humane than aversive approaches, and may be as effective. There have been positive case studies, but controlled studies are too few to conclude effectiveness. One study of fading failed to support its effectiveness, while another study found results similar to those of covert sensitization.
Group therapy – This gives members the opportunity to share experiences, gain insight, learn to control unacceptable impulses, and find acceptance. One review of studies found this method was widely used, but that studies of its effectiveness were based on contradictory premises, impossible to replicate due to vague descriptions, were not based on any theoretical understanding of pedophilia, did not include sufficient follow-up, and included vague assessments of effectiveness. Thus, the effectiveness of group therapy is unknown.
Individual psychotherapy – Only a few cases are available; there is insufficient data to determine effectiveness.
Sex-drive reducing drugs – Usually anti-androgen drugs are used. They must be taken indefinitely, and they involve undesirable side effects and physical risks. Since they decrease general sex drive rather than changing erotic preference, they can result in a lack of any sexual outlet at all, an intolerable situation to many men. They should be used only temporarily while some other type of therapy changes erotic preference.
Effective treatment is hampered by poor reporting of effectiveness in the literature, the practice of mixing heterosexual and homosexual pedophiles, and the confusion of offenders against adolescents and incest offenders with pedophiles. Since the “child” involved in the offense may be as old as 16 or even 18, treating the offender in this case as a pedophile is ineffective. The plethysmograph should be used to identify men who do not need treatment as pedophiles.
The author makes the following recommendations for working with “true pedophiles.” First, the homosexual pedophile should be assisted in adapting to sex with men. In all cases, it is important that the patient feels the therapist is on his side, and that the patient knows the therapist is aware of how important his object preference is for him. The therapist must express basic acceptance in order to enhance his self-esteem.
The major goal is to keep the patient out of trouble with the law. The therapist should stress the social and legal consequences of his acting on his erotic preference, suggest the use of masturbation to reduce sex drive, and help him take control over his environment to eliminate opportunities to act sexually. “Given a supportive relationship, different methods can be experimentally tested to adapt the patient to adults if he so wishes. It must be experimental because there is no satisfactorily proven method to change him to date.” (p. 296).