Sexual Deviancy
Neil S. Kaye, M.D.
Forensic Psychiatrist Dr. Neil S. Kaye M.D. is a specialist and expert witness in Forensic Psychiatry, his testimony has had a major impact on high profile cases and studies.
His Curriculum Vitae, credentials and information can be found at www.courtpsychiatrist.com .
Introduction:
Sexual deviancy is a rather broad and vague term. Its usage connotes that there are recognized norms of sexual behavior which are accepted by society in general. In fact, “normal” sexual behavior has never been well categorized. Rather, aberrant behaviors, sufficiently unacceptable to most persons, have been lumped together to comprise sexual deviancy. These of course may vary over time and across different cultures, although there are probably some behaviors which almost everyone would label deviant.
Research into these behaviors is made more complex by the scientific controversy as to what is normal sexual activity, unclear definitions of deviancy, and the heterogeneity of those who’s behaviors lead to their being labeled by the not necessarily equivalent terms of deviant, offender, or perpetrator. Often, the multiple disciplines involved in studying this area speak different languages and indeed have different reasons for their interest. Therefore, it should not be surprising that law, medicine, psychology, social work and criminalistics may reach different conclusions after reviewing similar data and at times resort to attacking each other or to being attacked by the public for their differences. Indeed, someone found guilty of a criminal sexual offense (e.g: rape) may not meet any formal diagnostic criteria from a clinical perspective.
The review period included articles on a host of topics but quite clearly, the majority of the literature relates to child sexual abuse. Daily, the public is reminded of this tragedy in the media. Perhaps no other area is more worthy of study to help define the magnitude of the problem, to understand its etiology, to lead to better assessments whether for clinical or forensic purposes, to discover effective treatment interventions, and to hopefully lead to preventative strategies. Papers in the area of sexual deviancy but not directly related to child sexual abuse will be incorporated in the review.
Child Sexual Abuse
One of the most important papers is that by Haugaard and Emery [1]. They start with questioning why the incidence of child sexual abuse in the literature varies so widely. Their critical evaluation of research methodologies examines the effects of sampling bias, methods of data collection, survey response rates and definitions of child abuse. Co-ed undergraduates (n=1,089) completed questionnaires asking demographic information and current social and sexual relationships as well as inquiring about sexual contact with another child before age thirteen, sexual contact with an adult over age sixteen before the subject was thirteen and any unwanted sexual contact after the subject was thirteen years old.
Information on the type, frequency, intensity, degree of coercion, whether the subject told anyone of the abuse and if so their response, experiences with social service agencies and the court, and therapy was obtained. The Comrey Personality Scales and Texas Social Behavior Inventory were also used to help assess the consequences of abuse in the areas of lack of trust in others, emotional instability and difficulties in sexual and intimate relationships, all of which have been reported in the literature many times.
Ordering of questions did not have a significant effect on the results. Participation rates appeared to influence prevalence rates as did motivating factors for completing the study; some persons found their experiences too difficult to recount while others more eagerly participated for “extra credit.” Using broad criteria a prevalence of 9.3% was found. Using narrower criteria, this rate fell to 7.0% and when the most restrictive criteria were used the rate fell to 1.7%.
Rather than searching for the ideal definition of abuse it seems more appropriate for each researcher to carefully define what are the inclusion criteria and to accurately describe for the reader what events were included in the definition of “abuse” for the particular study.
Krug [2] reports on a group of eight boys who were sexually abused by their mothers. This is a rare phenomenon and as such these cases are a welcome addition to the literature. In none of the cases was the mother psychotic which contradicts much common wisdom. In seven of the cases the abuse started when the son was prepubescent and continued until at least early adolescent. In half the cases the women were married at the time. The difficulties encountered by these boys as men is described. All had problems maintaining long term relationships, 88% experienced depression as adults, 63% used drugs and 38% had sexual identity problems. Unfortunately, no information about the mother’s own abuse history is available and the accounts are anecdotal, the byproduct of psychotherapy.
Through this report, Krug raises our awareness of another form of child sexual abuse and recognizing the delicate nature of this topic reminds us that we must often ask our patients directly about their sexual histories, in essence, inviting them to tell us of embarrassing, humiliating, and deviant occurrences.
Prevalence:
Wild [3] reports on a most disturbing phenomenon, child sex rings. This promotes repeated abuse of the same child as well as reinforcing the behavior in the adult perpetrator. Large numbers of children may be abused in this manner. As these rings often reward slightly older children for their assistance in securing victims, the degree of corruption is increased. Study in this area has been limited by lack of professional and police awareness and the difficulty in investigating such a ring. Thirty-one rings were located over a two year period from a population of 710,000 which included 145,000 children below age sixteen. In a pyramid effect, forty-seven perpetrators abused at least 334 children of both sexes. In twenty-two rings, one or more children acted as a ringleader and recruited new victims, usually in return for money. A high proportion of parents had tacit knowledge of their children’s involvement and had themselves abused the children in the home, laying the foundation for later participation in a sex ring.
Previously, sex rings have been divided into solo, transitional and commercial types. Wild’s sample is predominantly of the solo variety and like most samples probably has an under-representation of boys involved in adolescent prostitution. Accurate statistics in this area are obviously not possible as cases are discovered only when the legal authorities intervene. In addition, there may be more vigorous prosecution of those abusing children who are pre-pubertal as opposed those abusing pubertal children or adolescents.
Briere and Runtz [4] remind us that most research in the area of sexual abuse comes from incarcerated subjects or persons who are otherwise convicted sex offenders. They assumed that university undergraduate students would be substantially different from actual offenders in their predilection for sexual contact with children. Keeping this in mind, various theoretically relevant variables were used to predict several indices of males’ self-reported sexual interest in children.
One hundred ninety-three male subjects participated. Variables included sexual violence against woman, pornography, child abuse history, sexuality scales and sexual interest in children.
Their results confirm that male sexual response to children is quite common; 21% admitted at least some sexual attraction to small children; nine percent reported fantasies about sex with a child; five percent masturbated at least once to such a fantasy; seven percent indicated a likelihood of having sex with a child if this were possible without detection or punishment. Given the presumed social undesirability of these behaviors, these figures may be low. Obviously, depending upon the definition at least five percent and perhaps as many as twenty percent of male university undergraduates could be classified as pedophiles. It is unknown if any of these persons has or would progress to the offender stage.
Etiology:
In his Invited Essay, Marshall [5] treats the reader to a delightful historical review with emphasis on the general theory of sexual offending. Focusing on failure to achieve intimacy in relations with adults and the resultant aggressive disposition is seen as key in the development of the offender. The roles of socio-cultural influences, biological underpinnings, developmental experiences and conditioning processes are included. Marshall has written extensively in this area and this article draws together much of what he has learned to date. The paper is thought-provoking and illustrates a critical flaw in the development of the sexual offender.
Marshall adeptly develops his thesis beginning by first questioning what is intimacy, its development, its benefits, and the failure to achieve intimacy. He incorporates clinical and research observations and ends with a discussion of the implications of his research for assessment and treatment.
Although theoretical in its orientation, this is an important article and lends credence to the notion that thinking and developing concepts and hypotheses to test is often more influential in the long run than is merely running studies and collecting questionnaires.
In a similar vein, Prentky et al [6] compare and contrast single sexual murderers and serial sexual murderers. Few groups have access to the latter population and Prentky et al have the most experience in this area of any with which I am familiar. Most clinicians will never see such an offender. With seventeen single sexual murders and 25 serial sexual murderers statistical analysis begins to be meaningful.
A number of people have postulated a fantasy-based drive mechanism in sexual homicide. The model with its five components-impaired development of attachments early in life, formative traumatic events, patterned responses that serve to generate fantasies, a private internal world that is consumed with violent thoughts leaving the person isolated and self pre-occupied and a feedback filter that sustains repetitive thinking patterns-was tested.
Classification of a crime scene as organized or disorganized has proven useful to crime scene investigators and in reaching conclusions about life history. More organized crime scenes are associated with a richer fantasy life.
In the serial murderer group, the authors found support for their three hypotheses: 1) a higher prevalence of paraphilias, 2) a higher prevalence of organized crime scenes and 3) a higher prevalence of violent fantasies. Although one can only speculate as to the functional role of repetitive fantasy and assaultive behavior, the presence of violent fantasies in 86% of serial sexual murderers and in only 23% of single sexual murderers is impressive.
The authors hope that these preliminary findings might come to play a role in secondary prevention and in the always grey area of predicting future violence. Still, no one knows what brings an individual to translate any fantasy into action. More focus on manifest behavior is indicated.
Assessment:
Fundudis [7] presents a review article addressing children’s memory and its relationship to the assessment of possible sexual abuse. A child who claims or is suspected to have been abused is certain to be interviewed multiple times by a host of experts, police and legal authorities. The reliability of their memory assumes a very important role in establishing credibility during the evaluation and follow-up proceedings.
A distinction is made between recognition and free recall. Children have the capacity for recognition at a much younger age than that for free recall. Some investigators have found good recognition in children as young as two years of age. Using only free recall, younger children do not perform as well as do children above the age of ten years. Episodic and script memory are also contrasted and good examples of their relationship to specific questions are provided for the reader.
The personal significance of an event, suggestibility and intelligence are also implicated in the reliability of children’s memory. All of these have clear implications in the assessment of children who might have been subjected to abuse. Together, they impact on the credibility of these potential witnesses and all experts need be aware of this material to assure that proper techniques are employed in gathering data and to assure validity of any conclusions.
Sexual Deviancy Treatment:
Kosky [8] in a brief editorial raises most of the issues that accompany the question: should sex offenders be treated? He does so in a fair manner and he presents a relatively well-balanced argument. He asks important questions including whether or not sex offenders are sick, is treatment effective, and is there a cycle of abuse? His citation of 34 references is impressive for an editorial. Although he concludes that prevention and treatment are possibly effective and therefore worth pursuing, he is not yet ready to abandon the model of punishment and morals in this area of human behavior. He begs the question as to the management of offending behaviors in young persons.
Kitchur and Bell [9] make a reasonable attempt to review much of the literature on group therapy with sexual abuse victims. Clearly, any developments in the area of treatment have a place and it is in their description of an inner-city group for eleven year old and twelve year old girls that their paper excels. A description of each of the sixteen sessions is provided and the reader has a good chance to evaluate which techniques were effective and which failed.
The authors are candid in the assessment of their work which is refreshing. Certainly, the use of journals and writing exercises along with the support of a group model were key in their apparent success. This type of research does not lend itself well to follow-up or outcome studies or measures and as such the use of the Piers-Harris Children’s Self Concept Scale and the Child Behavior Checklist seem forced. The list of suggestions for conducting groups is clear and eminently useful for clinicians as is the chance to learn of other’s pitfalls.
Outcome:
Indest [10] does a superb job reviewing the problems faced by medical personnel in detecting and proving sexual abuse. As an esteemed attorney in this area, his observations and comments achieve an even greater significance. He reminds the reader of the adversarial nature of the legal system. Physicians must remember their participation in this arena is for legal and not medical ends. In addition, the reasoning process in medicine and law are polar opposites; the language spoken by the disciplines are foreign to one another.
The article addresses the admissibility of medical evidence and records and includes observations about specific techniques and tests used for the collection of such evidence. A comprehensive summary of the steps to be followed in the examination of suspected sexual abuse is included. Topics covered include semen and sperm detection, acid phosphatase testing, choline testing, semen specific protein tests, saliva testing, testing for sexually transmitted diseases, lubricants, and toluidine blue testing.
In short, Indest provides a short course in forensics for the reader. This should be required reading for anyone involved in the assessment of suspected child sexual abuse. The only chance of influencing outcome is through adherence to professional standards in performing the evaluation. Unfortunately, many cases can not be closed until the lawyers and courts have had an opportunity to further open the wound during the legal proceedings. Last, he reminds us that not all allegations are true.
Along similar lines, Dalgleish and Drew [11], in an excellent study of 152 cases of suspected child abuse, attempt to operationally define criteria for courts to use in deciding to separate children from their families. They make the point that consistency across jurisdictions is necessary for fairness and efficiency. They acknowledge that risk assessments by social workers vary substantially and do not appear to be related to years of experience.
In addition, courts have not generally made use of intermediate levels of separation (temporary placement, court ordered treatment and education, etc) but traditionally decide only whether or not to separate the child from the family. The use of a clearly defined outcome measure allows for clear conclusions to be drawn regarding how courts evaluate the data with which they are presented.
A number of indicators of the risk for ongoing sexual abuse have been described including: severity of abuse, aspects of parenting, assessment of parents, aspects of marital relationship, assessment of the child, aspects of the family’s social system, family’s lack of cooperation, age of the child, sex of the child, and type of abuse.
The authors found that severity of abuse, parenting, and the family social system were shown to be determinative of outcome. This implies that these should be clearly addressed in the assessment phase and also provide direction for future training of child protection workers and others routinely involved in these areas.
Prevention:
Many schools have adopted programs to educate children in the identification and management of unwanted sexual contact. Little scientific basis exists for these programs. Commonly, programs present the stereotype of an older male stranger. In actuality, abusers are more likely to be young, known to the victim and employ an array of techniques to access the victim. Other common themes in these programs include concepts of body ownership, secrets, good and bad touching, saying no, telling adults, and trusting one’s intuition.
Budin and Johnson [12] surveyed 72 incarcerated child sexual abusers to learn of how they identified victims and their modus operandi in gaining access to these children. In addition, inmates identified what issues that felt were important for prevention programs.
Their suggestions to children include: 1) avoid too-friendly friends of parents, 2) don’t let strangers close enough to touch you, 3) threaten the perpetrator you won’t be their friend, 4) stay close to home and to grown ups you know, 5) say you are on your period or sick, 6) hit, kick, bite where it hurts the most, 7) don’t tell last name to people, 8) don’t walk around the house in underwear, 9) mothers can abuse you by denying you privacy.
To parents they suggest: 1) provide potential victims with emotional fulfillment, kids don’t tell because they don’t trust their parents, 2) provide good supervision while in institutional settings, 3) be involved in your child’s life, 4) a loved and cared for child stands a better chance of not becoming a victim, 5) ask kids periodically if they have been abused or had a pass made at them.
Although only those who have been caught and successfully prosecuted participated, the results are striking are relevant to laying a foundation for child sexual abuse prevention programs. It must be assumed that the inmates cooperated and were truthful in their responses. Further clarification as to types of victims in certain locales, types of bribes in various age categories and differences between incest and non incest victims are suggested and research in this area is encouraged.
Annotated References and Recommended Reading on Sexual Deviancy:
* of interest
** of outstanding interest **
Haugaard, J. J. and Emery, R. E.: Methodological Issues in Child Sexual Abuse Research. Child Abuse & Neglect 1989, 13: 89-100.
The authors do a good job in pointing out that the quality of articles on sexual abuse has not necessarily kept up with the increase in quantity. They focus on the influences of response rate, ordering of questions, and definition of childhood sexual abuse on results. In their study, response rates affected prevalence rate estimates and the varying definitions of abuse affected estimates of both prevalence and consequences. This is a valuable reminder to all doing research and may lead to a better understanding of the conflicting statistics concerning childhood sexual abuse.
Krug, R. S.: Adult Male Report of Childhood Sexual Abuse by Mothers: Case Descriptions, Motivations and Long-Term Consequences. Child Abuse & Neglect 1989, 13: 111-119.
Eight case histories of male children who were sexually abused by their mothers are reported. In no case was the mother psychotic. In seven cases the abuse began when the child was prepubescent and continued until at least early adolescence. All of these victims had difficulty maintaining intimate emotional and sexual relationships as adults. Depression and substance abuse was frequent. Although the number of subjects is too small to allow for statistical conclusions, this is a welcome addition to a rather sparse literature. *
Wild, N. J.: Prevalence of Child Sex Rings. Pediatrics 1989, 83,4: 553-558.
31 Child sex rings were identified over a two year period from a population of 710,000. 47 male perpetrators age 16-83 and 334 children ages 4-15 were involved. In some, children acted as the ringleaders, recruiting victims, in exchange for money. These rings accounted for 4.6% of all child abuse cases reported to the police and 6.6% of subsequent prosecutions.
*
Briere, J. and Runtz, M: University Males’ Sexual Interest in Children: Predicting Potential Indices of “Pedophilia” in a Nonforensic Sample. Child Abuse & Neglect 1989, 13: 65-75.
A survey of 193 male undergraduate students regarding their sexual interest in children. Twenty-one percent reported sexual attraction to some small children, nine percent describe sexual fantasies involving small children, five percent admitted to masturbating to such fantasies, and seven percent indicated some likelihood of having sex with a child if they could avoid detections and punishment. These sexual interests were associated with early negative sexual experiences, masturbation to pornography, self-reported likelihood of rape, frequent sexual partners, and attitudes supportive of dominance over women. Understanding base rates in a nonforensic population is important for experts in terms of describing what is deviant.
**
Marshall, W. L.: Intimacy, Loneliness and Sexual Offenders. Res. Ther. 1989, 27,5: 491-503.
This invited essay reviews the theory that a failure to achieve intimacy in relations with adults produces emotional loneliness, which leads to an aggressive disposition, and a tendency to persue sex with diverse partners in the hope of finding intimacy through sexuality or through less threatening partners. Suggestions are made for including problems of intimacy and loneliness in the assessment and treatment of sexual offenders.
*
Prentky, R., Burgess, A., Rokous, F., Lee, A., Hartman, C., Ressler, R., Douglas, J.: The Presumptive Role of Fantasy in Serial Sexual Homicide. American Journal of Psychiatry 1989, 146,7: 887-891.
The authors examined the role of fantasy as an internal drive mechanism for repetitive violent sexual behaviors. Twenty-five serial sexual murders were compared with seventeen single sexual murders. Working from extensive records, a questionnaire was constructed to evaluate three hypotheses resting on the argument that an internal drive mechanism consisting of an intrusive fantasy life would be manifest in 1) a higher prevalence of paraphilias, 2) a higher prevalence of organized crime scenes, and 3) a higher prevalence of violent fantasies. All three hypotheses were supported. Although retrospective in nature, these researchers have substantial experience in the area of repeat offenders and as such their findings are valuable.
**
Fundudis, T.: Children’s Memory and the Assessment of Possible Child Sex Abuse. Journal of Child Psychology and Psychiatry 1989, 30,3: 337-346.
A child who claims or is considered to have been sexually abused is likely to be interviewed repeatedly by professionals and the police. The reliability of the child’s memory, therefore, assumes a very important role in establishing credibility. The author emphasizes the difference between recognition and free recall. Effects of age, language and conceptual level of development are addressed. Although numerous authors have described the necessity to avoid leading or suggestive questions and the difficulties inherent in anatomically correct dolls, these can not be restated enough. Anyone involved in the assessment of potential child abuse should be familiar with this paper.
*
Kosky, R.: Should Sex Offenders Be Treated?. Australian and New Zealand Journal of Psychiatry 1989, 23: 176-180.
Although this is an editorial comment, the author does a particularly concise job in raising many of the questions and dilemmas facing society and treaters of sex offenders. Issues include: are offenders sick?, is treatment effective?, morals, does punishment have a role?, and cycles of abuse.
*
Kitchur, M. and Bell, R.: Group Psychotherapy with Preadolescent Sexual Abuse Victims: Literature Review and Description of an Inner-City Group. International Journal of Group Psychotherapy 1989, 39,3: 285-310.
As the detection of child sexual abuse has risen so has the need for treatment. Group therapy offers a number of possible advantages over other types of therapy in this arena. The authors do a good job of reviewing the literature in this field. More interesting is their description of a sixteen week therapy group of seven eleven and twelve year old girls. Although the numbers preclude statistical conclusions, their observations and suggestions will interest anyone involved in or planning for similar groups. The use of journal writing exercises is highlighted.
**
Indest, G. F.: Medico-Legal Issues in Detecting and Proving the Sexual Abuse of Children. Journal of Sex & Marital Therapy 1989, 15,2: 141-160.
This article critically reviews the problems faced by medical and investigative personnel in detecting and proving sexual molestation of children. The legal consequences of medical assessment and record keeping are reviewed as are the pitfalls that may later face those experts trying to bring the matter forward in court. Admissibility of medical records as evidence in courts is reviewed as well as emerging forensic tests and techniques. An excellent summary of the steps to be taken during the physical examination of a potential case of child sexual abuse, emphasizing the importance of a strict, through procedure for protecting the interests of the patient, the physician and society is provided. Written by a respected lawyer, this paper is comprehensive and timely.
**
Dalgleish, L. I. and Drew, E. C.: The Relationship of Child Abuse Indicators to the Assessment of Perceived Risk and to the Court’s Decision to Separate. Child Abuse & Neglect 1989, 13: 491-506.
Authors operationally define a set of indicators for the separation decision, acknowledging that this extreme action is a most serious decision and has not been uniform across jurisdictions. 152 cases were followed. The indicators most associated with separation included extent of abuse, parenting, and the family social system. Suggestions are made to apply this information to the training of new child protection workers.
**
Budin, L. E. and Johnson, C. F.: Sex Abuse Prevention Programs: Offender’s Attitudes About Their Efficacy. Child Abuse & Neglect 1989, 13: 77-87.
Currently, many school based programs for raising children’s awareness of sexual abuse are being used. Little scientific basis exists to support what should be the actual content of an ideal program. Criticism of the current stereotype of the perpetrator is leveled. Seventy-two inmates incarcerated for sexual abuse were surveyed to evaluate their attitude of the effectiveness of current approaches used to prevent sexual abuse. These men described their modus operandi and described which topics they thought would be of most value. Inmates stressed the need for parental involvement. Information from abusers is useful and should be incorporated in the design of future classroom prevention programs.