The Prevention

of Sexual Disorders
ISSUES AND APPROACHES
 PERSPECTIVES IN SEXUALITY
Behavior, Research, and Therapy

Series Editor: RICHARD GREEN

State University of New York at Stony Brook

NEW DIRECTIONS IN SEX RESEARCH

Edited by Eli A. Rubinstein, Richard Green, and Edward Brecher
PROGRESS IN SEXOLOGY
Edited by Robert Gemme and Connie Christine Wheeler
HANDBOOK OF SEX THERAPY
Edited by Joseph LoPiccolo and Leslie LoPiccolo
THE PREVENTION OF SEXUAL DISORDERS: Issues and Approaches
Edited by C. Brandon Qualls, John P. Wincze, and David H. Barlow
The Prevention
of Sexual Disorders
ISSUES AND APPROACHES

Edited by
C. Brandon Qualls, John P. Wincze,
and David H. Barlow
Brown University
Providence, Rhode Island

Springer Science+ Business Media, LLC

 Library of Congress Cataloging in Publication Data
Main entry under title:
The Prevention of sexual disorders.
(Perspectives in sexuality)
Includes index.
1. Sexual disorders - Prevention - Addresses, essays, lectures. 1. Qualls, C. Bran.
don. II. Wincze, John P., 1943. III. Barlow, David H. [DNLM: 1. Sex dis.
orders - Prevention and cpntrol. 2. Sex offenses. 3. Sex deviation - Prevention and
control. WM611 P944 ]
RC556.P74 616.6 78·1700
ISBN 978-1-4684-2471-3 ISBN 978-1-4684-2469-0 (eBook)
DOI 10.1007/978-1-4684-2469-0

© 1978 Springer Science+ Business Media New York

Originally published by Plenum Press, New York in 1978
Softcover reprint of the hardcover 1st edition 1978

Ali rights reserved

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Contributors

John Bancroft, M.D., MRC Reproductive Biology Unit, Edin-

burgh EH1 2QW, Scotland
Mary S. Calderone, M.D., Sex Information and Education Coun-
cil of the United States, Hempstead, New York 11545
Richard Green, M. D., Department of Psychiatry, State University
of New York at Stony Brook, Stony Brook, New York 11794
Julia Heiman, Ph.D., Department of Psychiatry, School of
Medicine, State University of New York at Stony Brook,
Stony Brook, New York 11794
Robert C. Kolodny, M.D., Reproductive Biology Research Foun-
dation, St. Louis, Missouri 63108
Joseph LoPiccolo, Ph.D., Department of Psychiatry, School of
Medicine, State University of New York at Stony Brook,
Stony Brook, New York 11794
C. Brandon Qualls, M.D., Section of Psychiatry and Human Be-
havior, Brown University, Providence, Rhode Island 02912
Paul A. Walker, Ph.D., The Johns Hopkins University School of
Medicine, The University of Baltimore, Baltimore, Maryland.
Present address: The Gender Clinic, The University of Texas
Medical Branch, Galveston, Texas
W. Cody Wilson, Ph.D., Graduate School of Social Work, Adelphi
University, Garden City, New York 11530

v
Preface

As new faculty members in the Section of Psychiatry and Human

Behavior at Brown University, we began collaborating on research
into assessment and treatment of sexual problems in the fall of
1975. Although each of us arrived with clinical and research in-
terests in the broad field of sexual problems, the idea for this book
grew out of our early discussions and a consensus on the future
direction of research. We noted that there had been an extremely
rapid increase in knowledge of human sexual behavior as well as
sexual disorders and their treatment over the last few decades. It
has also become increasingly apparent that sexual problems,
broadly conceived, comprise a sizable fraction of the problems for
which people seek treatment, and that, although the treatment of
sexual problems was achieving some success, treatment was for the
most part slow, costly, and without any guarantee of successful
outcome. Furthermore, there were many people with sexual prob-
lems for whom treatment was not available. With these ideas in
mind, it seemed timely for investigators in the field of human sex-
uality and its disorders to turn their attention to the problem of
prevention.
Organizing a symposium on the topic enabled us to invite
leading investigators in the study of sexual behavior to address this
area. The chapters in this volume are an outgrowth and refinement
of the formal papers delivered at the symposium, which was held
in the spring of 1976. The symposium itself was designed to in-
vii
viii Preface

volve a number of speakers in different areas of human sexuality

and to encourage them to begin the process of thinking through
the question of prevention with regard to their particular area of
interest in the field of human sexuality. For most speakers, this
was a novel idea. Some expressed considerable doubt on the feasi-
bility of such a project at this time, but all were intrigued by the
notion and agreed to consider the issue of prevention as it applied
to their area of interest. The results of their efforts as contained in
this volume amply demonstrate to us that our initial enthusiasm
about this topic was well founded, and that this is indeed a fruitful
area for further investigation. The edited papers are presented
here along with an introductory chapter that presents an overview
to the problem of prevention. It is our hope that the contributions
in this volume will stimulate others to investigate the question of
prevention as it applies to sexual disorders.
As with any endeavor of this sort, numerous people have as-
sisted in bringing our initial idea to fruition. We would like to ac-
knowledge the generous assistance of the Butler Hospital Grand
Rounds Committee, including Linda Brisco, Jeanne Moore, Ed
Fink, Mary Hostetler, and Peter Babbitt, whose efforts greatly
contributed to the success of the symposium, and also to Frank
Delmonico and the Butler Hospital administration for providing
the facilities and support necessary for this undertaking. In particu-
lar, we would like to thank Linda Brisco for her help in preparing
the manuscript, Jane Qualls for her help in preparing the Index,
and Richard Green for refining some of our early ideas. Lastly, it
would seem appropriate to dedicate this book to the next genera-
tion and, in particular, our own children: Alyssa, Brent, Deneige,
Jeffrey, Jeremy, and Larissa.

C. Brandon Qualls, M. D.
John P. Wincze, Ph.D.
David H. Barlow, Ph.D.

Providence
Contents

Chapter 1
The Prevention of Sexual Disorders: An Overview . . . . 1
C. Brandon Qualls

Chapter 2
The Role of Cultural Values in the Prevention and
Treatment of Sexual Problems ..................... 43
Joseph LoPiccolo and Julia Heiman

Chapter 3
Intervention and Prevention: The Child with Cross-Sex
Identity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 75
Richard Green

Chapter 4
The Prevention of Sexual Offenses. . . . . . . . . . . . . . . . .. 95
John Bancroft

Chapter 5
The Role of Antiandrogens in the Treatment of Sex
Offenders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 117
Paul A. Walker
ix
x Contents

Chapter 6
Is Sex Education Preventative? . . . . . . . . . . . . . . . . . . . .. 139
Mary S. Calderone

Chapter 7
Can Pornography Contribute to the Prevention of
Sexual Problems? ................................ 159
W. Cody Wilson

Chapter 8
Ethical Issues in the Prevention of Sexual Problems . .. 183
Robert C. Kolodny

Index . ......................................... , 197

 1
The Prevention of Sexual
Disorders: An Overview
c. BRANDON QUALLS

While human sexuality has long been the subject of intense inter-
est, particularly in its prescriptive and proscriptive aspects, only in
the past 100 years has it become an area of legitimate scientific in-
quiry. Prior to that time, interest in sexuality centered on sexual
instincts and sexual deviations (Ellenberger, 1970), but the work of
von Krafft-Ebing, Ellis, and Freud, the three major figures who
dominated the study of sexuality at the tum of the century, set the
stage for the systematic study of this most controversial area of
human behavior and experience. Their pioneering example has
continued to the present, and in the past 25 years there has been a
rapid expansion in our knowledge and understanding of human
sexual behavior, so much so that no single researcher can en-
compass the entire field. Major contributions to this progress have
come from a variety of different sources and fields, each lending its
own perspective to the vast range of sexual experience and its at-
tendant disorders. This period has witnessed the investigation of
the range of sexual behavior in our own culture (Kinsey, Pomeroy,

C. Brandon QuaIls • Section of Psychiatry and Human Behavior, Brown University,

Providence, Rhode Island 02912.
1
2 C. Brandon ~alls

& Martin, 1948; Kinsey, Pomeroy, Martin, & Gebhard, 1953) and
of widely variant cultures (Ford & Beach, 1951; Marshall & Suggs,
1971), of the physiology of the human sexual response (Masters &
Johnson, 1966), of new measures of sexual arousal (Zuckerman,
1971; Barlow, 1977; Hoon, Wincze, & Hoon, 1976), of biological
contributions to gender identity (Money & Ehrhardt, 1972), and of
gender identity formation (Money & Ehrhardt, 1972; Green &
Money, 1969; Green, 1974), to name but a few of the most recent
developments.
With these advances a greater appreciation of the sexual prob-
lems and disorders that affiict people has also developed. In fact,
the investigation of sexual disorders themselves has deepened our
understanding of human sexual development and has thrown new
light on the complexity of this development as, for example, in
gender identity formation. These advances in tum have spurred
new developments in the treatment of sexual disorders so that the
prominence of psychoanalysis, the major therapeutic modality dur-
ing the early part of this century, has given way to a wide variety of
psychotherapies with therapeutic techniques tailored to each spe-
cific disorder. There now exist specific treatments for sexual dys-
functions (Masters & Johnson, 1970; Kaplan, 1974), sexually de-
viant behavior (Bancroft, 1974; Barlow, 1974; Brownell & Barlow,
in press), and transsexualism (Green & Money, 1969; Barlow,
Reynolds, & Agras, 1973). These new treatment techniques have
been basically short-term in nature and have utilized a variety of
behavioral techniques to change or alter the sexual disorder in
question. With the exception of surgical treatment for transsex-
ualism, these treatments share the common assumption that sexual
disorders and problems are for the most part learned behaviors
that are not indicative of severe underlying psychopathology, an as-
sumption that was the basis for the psychoanalytic treatment of
these disorders. These treatment techniques have achieved a mod-
est degree of success and there is great promise for the future as
they evolve.
While the field of sexual disorders has progressed, there are in
fact many questions regarding the development and treatment of
these disorders that remain unanswered and must be answered if
The Prevention of Sexual Disorders: An Overview 3

we are to develop a truly comprehensive understanding of human

sexuality. For example, almost all treatment for the sexual dis-
orders focuses on intervention after the onset of the disorders.
Little attempt has been made to intervene prior to the develop-
ment of the disorder except in the area of atypical sex role behav-
ior. Because children who display atypical sex role behavior have a
significant chance of developing atypical sexual patterns such as
transsexualism in adulthood, childhood intervention holds out the
promise of "preventing" the development of more serious sexual
disorders (see Chapter 3). Questions concerning the development
of sexual disorders have only begun to be investigated. For ex-
ample, what are the factors that place an individual at risk for the
development of a sexual disorder? Is it possible to define popula-
tions that are at risk for the development of a disorder? Can inter-
ventions be formulated that will reverse the development of a
disorder? What are the cultural factors that influence the develop-
ment of sexual disorders? These and similar questions have gener-
ally been the focus of the field of prevention, a heretofore unex-
plored area in human sexuality. In the face of the many recent
developments in the field, it would seem timely to explore this
issue with the goal of formulating some of the issues as they apply
to sexual disorders and stimulating new ideas and research that
address the question of prevention. It must be recognized that the
extent of our present knowledge about sexual disorders and the
power of even the newest treatment techniques do not approach
those available in the traditional areas of prevention, for example,
of infectious diseases. However, the concepts of prevention pro-
vide a yardstick against which to measure our progress as well as
our limitations. Our goal in this endeavor is to raise issues rather
than to present solutions.

1. Why Prevention?

Traditionally, preventive medicine has sought not only to pre-

vent the occurrence of disorders but also to promote health and
well-being, and to prevent total disability through rehabilitation. In
4 C. Brandon Qualls

a sense these goals in and of themselves provide an answer to the

question posed in this section. Sexual disorders require treatment
intervention for their alleviation, thereby making prevention a rel-
evant issue. More pertinent, however, is whether sexual disorders
constitute a significant enough problem to justifY preventive inter-
ventions and/or whether the treatment of sexual disorders is not
sufficiently advanced to make prevention unnecessary.
Preventive medicine has had to provide answers to questions
such as these whenever preventive measures have been enter-
tained for a specific disorder. For example, a strong case can be
made for the prevention of dental caries in terms of its incidence
and prevalence, whereas it has been more difficult to justifY pre-
ventive measures for the rarer inherited metabolic disorders. Simi-
lar considerations are relevant to the prevention of sexual disor-
ders. However, the answers to these questions in this case can only
be tentative given the present available data.
Before reviewing some of this data, we would do well to note
that the issue of prevention is influenced by factors other than in-
cidence and prevalence. First, there have been and will continue
to be vast societal and cultural factors that will have relevance to
prevention (see Chapter 2). The dissemination of our increased
knowledge about human sexual behavior and its treatment through
the public media as well as the more open treatment of sex and
sexuality, both leading to changing public attitudes (Athanasiow,
1973), has heightened people's awareness of their sexual function-
ing. The realization that their sexual functioning may not approach
or equal the sexual functioning to which they are being exposed, or
that they are being led to believe is within their grasp, has in-
creased expectations as well as increased demands for treatment.
While precise data on this issue are not available, sexual problems,
broadly conceived, comprise an increasing percentage of the prob-
lems for which people seek treatment. These changes will in tum
alter incidence and prevalence figures as well as influencing etio-
logical and risk factors associated with a particular disorder. Fur-
thermore, these societal and attitudinal changes may also lead to al-
ternative conceptualizations of what constitutes a sexual disorder or
problem, as LoPiccolo and Heiman point out in Chapter 2. Such a
The Prevention of Sexual Disorders: An Overview 5

change has in fact already happened with the recent vote to ex-
clude homosexuality as a psychiatric diagnosis by the American
Psychiatric Association.
Second, changes in psychology, psychiatry, and other medical
specialities have paralleled those in the public sector. In part, the
scope of sexual disorders depends on their recognition. Burnap and
Goldern (1967) have demonstrated that over 66% of physicians who
routinely inquire about sexual problems identifY significant sexual
problems in at least 50% of their patients. However, over 75% of
physicians who do not inquire actively about sexual problems es-
timate that less than 10% of their patients have sexual problems.
Thus an active inquiry into a patient's sex life on the part of physi-
cians as well as other health professionals will lead to the recogni-
tion of more sexual problems. Training in human sexuality will
lead, therefore, to greater numbers of identified sexual problems.
In 1960 only three medical schools had courses in human sexuality
whereas in 1970 almost all medical school curricula involved a for-
mal course on human sexuality (Ebert & Lief, 1975). One can
safely predict that the numbers of problems identified in patients
will increase in the future as patients are more willing to seek help
for problems and health professionals make more active inquiries.
This increase in tum will make the need for a preventive approach
to sexual disorders more apparent and in all likelihood more press-
ing than at present.
Finally, there is the question of which sexual disorders should
be considered within the context of prevention. The range of sex-
ual problems for which people seek treatment is extremely broad
and includes such problems as complaints about sexual frequency
and satisfaction, inadequate sexual functioning, sexual partner
choice, and deviant sexual arousal and behavior, as well as nu-
merous others. Because the range is so broad and the multitude of
sexual symptoms have not been systematically investigated, we re-
strict our discussion to sexual dysfunctions, gender identity disor-
ders, and sexual deviations, recognizing that while these three
areas would be included in any discussion of sexual disorders, they
are not complete. Furthermore, each of these areas is relatively
discrete. although for any given patient there may be considerable
6 C. Brandon QuaIls

overlap. Finally, for these disorders there exist data relevant to

the issue of prevention.

1.1. Sexual Dysfunctions

The sexual dysfunctions include a group of disorders that have
as their basis an impairment in the physiological sexual response
system for which there exists no organic cause. Masters and John-
son (1970) included within this group erectile dysfunctions, both
primary and secondary; premature ejaculation and retarded ejacu-
lation for males; and primary and secondary orgasmic dysfunctions,
dyspareunia, and vaginismus for females. They have also estimated
that half the marriages in this country are either now dysfunctional
or in danger of becoming so, but they have also pointed out that
there are no studies of the actual incidence or prevalence of sexual
dysfunctions. However, there are related studies that bear on this
issue.
There are a number of studies sampling the self-reported
frequency of orgasm for women. The most famous of these is Kin-
sey et al. (1953), in which it was observed that 25% of women had
not achieved orgasm by the end of the first year of marriage and
that 11 % of women had not achieved orgasm by the 20th year of
marriage. Butler (1976) reported that 8% of women in her study
had never achieved orgasm. Fisher (1973) found the slightly lower
figure of 5%. Wallin (1960) reported that 28% of women stated that
they never had or only sometimes achieved orgasm. In the study
just cited, Butler (1976) reported that 58% of the women in her
sample pretended to have orgasm. Leaving aside the question of
whether or not it is possible for every woman to achieve orgasm
with coitus, these figures indicate that primary orgasmic dysfunc-
tion constitutes a significant problem for many women and that a
large number of women feel that it is necessary to convince their
partner that they are orgasmic whether they are or not. Figures for
other female dysfunctions such as secondary orgasmic dysfunction,
vaginismus, and dyspareunia are not now available but would add
to the overall problem of sexual dysfunctions for females.
Much less is known about comparable sexual dysfunctions for
The Prevention of Sexual Disorders: An Overview 7

males. Kinsey et al. (1948) found that only 6 out of 4,108 cases
exhibited true retarded ejaculation, indicating that this is a rare
condition. This rarity is also reflected in the fact that there were
only 17 cases of retarded ejaculation among the 448 male sexual
dysfunctions seen by Masters and Johnson (1970). Erectile dysfunc-
tions are more common. Kinsey et al. (1948) found that erectile
dysfunction was present in only 0.4% of males under age 25 and in
less than 1% of males under age 35. The number of males with
erectile dysfunction increased slowly until age 50, when 6.7% of
males exhibited dysfunction. By age 60, 18.4% were affiicted; by
age 70, 27% and by age 80, 75%. Thus the percentage of males
with erectile dysfunction increases markedly after age 50. Presum-
ably males who have never been able to achieve coitus (primary
erectile dysfunctions) are included within these figures. Masters
and Johnson (1970) saw only 37 cases of this dysfunction out of 448
male cases. No figures are available for premature ejaculation al-
though Masters and Johnson (1970) saw 186 cases, indicating that
in their sample it was almost as common as secondary erectile dys-
function with 213 cases. H anything, the actual prevalence of male
dysfunctions is higher than that cited but further data are needed.
In the treatment of sexual dysfunctions, Masters and Johnson
(1970) have reported the only large major study with an adequate
follow-up of five years. Their initial failure rate for primary erectile
dysfunctions was 40.6% and for secondary erectile dysfunction,
26%. Premature ejaculation was the easiest male dysfunction to
treat, with an initial failure rate of 2.2%. The five-year follow-up
showed no reversals of treatment for the primary erectile dysfunc-
tions but an increase in the failure rate for secondary dysfunctions
from 26% to 31%. For females the initial failure rate for primary
orgasmic dysfunctions was 17% and for secondary (situational)
orgasmic dysfunction, 23%. The five-year follow-up showed only a
slight increase in these figures. Overall the treatment results for all
forms of sexual dysfunction were virtually the same for males and
females, with a 20% failure rate. This constitutes a considerable
achievement on the part of Masters and Johnson. Whether these
results can be equaled in other clinics throughout the country
remains to be seen. As Masters and Johnson have noted, the
8 C. Brandon Quails

overall failure rate of 31 % for secondary erectile dysfunctions rep-

resents a specific challenge. One might add that primary erectile
dysfunctions, with an overall failure rate of 40.6%, also constitute a
challenge. These data are important since there is some indication
that the longer the duration of the erectile dysfunction, the poorer
the response to treatment (Johnson, 1965), particularly if the erec-
tile dysfunction is greater than two years in duration.
While these data on treatment are encouraging, there is still a
significant percentage of dysfunctional men and women who do not
respond to treatment. Only in the case of premature ejaculation is
treatment truly successful. For orgasmic and erectile dysfunctions,
17-41 % of the cases did not respond. Furthermore, a significant
number of women, probably greater than 5%, are anorgasmic very
early in their sexual lives, while a significant number of males ex-
perience erectile dysfunctions late in their sexual lives. If we con-
servatively estimate that even 5% of the adult population are sex-
ually dysfunctional at any given time, then it is clear that we do not
have sufficient resources to treat everyone even if we so desire.
Given that there are strong cultural influences on sexual function-
ing and that these influences affect the prevalence of the dysfunc-
tions, prevention may be a more appropriate way to promote effec-
tive sexual functioning than our present treatment, a remedial
effort at best.

1.2. Gender 1dentity Disorders

Gender identity disorders comprise a heterogeneous group of
disorders that involve alterations in an individual's sense of male-
ness or femaleness (core gender identity) and/or gender role behav-
ior, that is, those behaviors that are dimorphic for males and fe-
males in a given culture. The most severe of the core gender
identity disorders is transsexualism. These individuals think, feel,
and act as members of the opposite biological sex. Other disorders
include atypical sex role development, particularly in children.
Green (Chapter 3) includes disorders of sexual partner choice (ho-
mosexuality) within this category, and Stoller (1975) includes fe-
tishistic cross-dressing (transvestism) and various disorders of
The Prevention of Sexual Disorders: An Overview 9

intersexuality (Turner's syndrome, Klinefelter's syndrome,

adrenogenital syndrome, male pseudohermaphroditism, androgen
insensitivity syndrome, and temporal lobe abnormality) in which
there may be a discrepancy between biological sex and core gender
identity. Because homosexuality and transvestism are most often
included under sexual deviations, they are discussed there.
Data concerning the prevalence of gender identity disorders
are sparse indeed. Pauly (1969) has given a minimal estimate of the
prevalence of male transsexualism of 1: 100,000 of the general popu-
lation and for female transsexualism approximately 1:130,000
(Pauly, 1974). He considers the male:female ratio of transsexualism
to be between 3:2 and 2:l. No proven treatment for transsexualism
now exists other than sex reassignment surgery (Green & Money,
1969) although behavior principles have been used to modifY core
gender identity in at least three cases (Barlow, Reynolds, & Agras,
1973; Barlow, Abel, & Blanchard, 1978), and a fourth case ap-
parently responded to faith healing (Barlow, Abel, & Blanchard,
1977). The present status of the field, at least with regard to trans-
sexualism, was best summarized by Pauly (1974) when he stated
that there is an increasing
need for prevention of this problem, as treatment aimed at reversing the
gender identification is usually impossible by the time the problem is
brought to medical attention. Parents ought to be more aware of the need to
positively reinforce all infants for those gender characteristics which are con-
sistent with their biological identity. I can think of very few worse fates than
to be the life-long victim of the kind of family discord or ignorance which
breeds gender identity problems. Despite the strides forward which we have
made in our understanding and treatment of this condition, all would agree,
including the transsexual, that transsexualism would be far better prevented
than treated. (p. 522)
Prevalence figures for atypical sex role development in chil-
dren are not available. Green (1976) has followed five feminine
preadolescent boys in collaboration with John Money: "Four of
the boys appear to be primarily or exclusively homosexual, and the
fifth is bisexual. A sixth feminine boy initially seen at the onset of
puberty was reinterviewed during his later teens. At that time he
requested sex change surgery" (p. 200). Zuger (1966) reported on
six men who had been seen for boyhood femininity. Three were
10 C. Brandon QuaIls

homosexual and one possibly transsexual. Lebovitz (1972) assessed

16 men who had been feminine as young boys, and 3 were trans-
sexual, 1 transvestic, 2 homosexual, and 10 heterosexual. These
studies suggest the seriousness of childhood femininity in young
boys and the potential for developing later atypical sexuality. The
effectiveness of treatment in this condition has not been thoroughly
evaluated, but guidelines have been developed (Green, 1976).
Stoller ("Stoller Urges Treatment," 1976) feels that competent
treatment currently exists. He in fact urges prompt treatment of
femininity in males even though there has been considerable con-
troversy over the issue of sex roles for males and females in our so-
ciety. He also acknowledges that prevention would be the best
treatment, "if only we knew enough to advise parents how to raise
their children" (p. 20).

1.3. Sexual Deviations

Sexual deviations comprise a heterogeneous group of disor-
ders, including fetishism, pedophilia, transvestism, exhibitionism,
voyeurism, sadism, masochism, rape, lust murder, necrophilia,
bestiality, sodomy, and others (Sadoff, 1976). Homosexuality is also
often included within this group as a deviation and will be consid-
ered as such for the following discussion. In all these categories, an
individual's sexual interest is directed either toward objects other
than people of the opposite sex or toward coitus but under bizarre
circumstances. Whether there are any other features common to
this group is unclear, although Stoller (1975) has suggested a com-
mon underlying dynamic of perversion.
There are no data regarding the prevalence of these various
modes of behavior, with the exception of homosexuality. Gebhard
(1972) estimated that 4% of white college-educated males and be-
tween 1% and 2% of adult females are predominantly homosexual.
Certainly more data are needed regarding the prevalence of sexual
deviations.
Besides being psychiatric problems, the sexual deviations also
constitute a legal problem, and homosexuality shares with the
1he Prevention of Sexual Disorders: An Overview 11

other sexual deviations the feature of being legally proscribed in

many states. Whether one agrees with the legal proscription of all
sexual deviations or only selected deviations (see Chapters 6 and
7), certain of them constitute a major societal problem, and as a
societal problem, the data regarding the occurrence of these sexual
deviations that come from within the legal system bear on the issue
of prevention.
The legal system is concerned with sex offenders, a grouping
that includes the sexual deviations and also prostitution, lewdness,
adultery, and many other offenses not properly considered sexual
deviations. As a result the data from the legal system must be
viewed as only partially relevant to our discussion. The Federal
Bureau of Investigation in the Uniform Crime Reports for the
United States in 1974 estimated that the total number of arrests in
that year for sex offenses (including statutory rape, "offenses against
chastity, common decency, morals and the like," but excluding
forceable rape and prostitution) was 64,600. This number com-
pared with 26,380 arrests for rape. In 1974, 10,103 persons were
actually charged for sex offenses. Of these, 49% were found guilty
and 24.5% had their cases dismissed. For rape, 2,948 persons were
charged; 28% were found guilty of the offense, 12% were found
guilty of a lesser offense, and 37% were acquitted. Between 1969
and 1975, there was a 41% increase in reported rape, with 50,000
cases being reported in 1975 (i.e., one rape victim for every 2,000
women) but less than a 1% conviction rate for rapists ("Prevention
Said Priority," 1977). The actual incidence and prevalence of sexual
deviations is unknown, but these data do suggest the scope of the
problem, particularly for rape.
Within the prison system, the National Prisoner Statistics for
admissions and releases in 1970 indicate that 15,000 persons were
admitted with commitments of one year or greater to the state
prison systems in 33 of the 50 states reporting statistics. During
this same year 15,007 persons obtained their first release for sex of-
fenses in the same 33 states. These data gave some idea of the
problem as it exists within the prison system, but it must be re-
membered that there are severe limitations in these data also be-
12 c. Brandon QuaIls

cause many are imprisoned for legal offenses such as lewdness,

prostitution, pornography, etc., who would not be considered to
have a sexual deviation.
In certain states sex offenders receive psychiatric evaluations,
and these evaluation reports shed more light on the makeup of
those imprisoned. Not all persons arrested under sex laws are nec-
essarily sexual deviates. Pacht, Halleck, and Ehrmann (1962) re-
ported on 1,605 male sex offenders committed for diagnostic pur-
poses under the Wisconsin Sex Crimes Law from July 1951
through May 1960. This law provides that any person convicted of
rape, attempted rape, or indecent sexual behavior with a child
must be committed for evaluation and that the court may commit
others who are also convicted of offenses that are prompted by a
desire for sexual gratification. Of the 1,605 males evaluated, 49%
were found to be sexually deviated; that is, they gave evidence of
immaturity in the development of their sexual functions and also
showed "deviation of the individual's normal sexual aim or object
which he has little ability to control by conscious rational thought"
(p. 804). No data were reported as to type of deviation. Brancale,
Vuocolo, and Prendergast (1972) reported on the New Jersey Sex
Law for the period of April 1949 through June 1969. This law pro-
vides that convicted sex offenders be evaluated at the New Jersey
State Diagnostic Center. A total of 7,119 persons were evaluated
and 28.8% were judged to be sexually deviant and in need of spe-
cialized treatment; that is, they exhibited repetitive, compulsive
sexual behavior. In a sub study of 1,206 evaluated male sex of-
fenders, 47.6% had no previous arrest record, 27.9% had previous
arrests on nonsexual charges, and 24.5% had previous arrests on
sexual charges. Thus these two studies together suggest that the
legal category of sex offender includes a heterogeneous population,
29-50% of whom may have a sexual deviation.
Some studies have appeared that describe the most common
types of sexual deviations that are present among those sex of-
fenders judged to be deviates. Apfelberg, Sugar, and pfeffer (1944)
evaluated 242 convicted sex offenders over the course of 13 months
in New York City. The most frequent arrest category was indecent
exposure (36%), followed by pedophilia (31%), homosexuality
The Prevention of Sexual Disorders: An Overview 13

(11 %), statutory rape (10%), sex with force (7%), and incest (4%).
Brancale et al. (1972), in the previously cited study, reported on
1,206 consecutively examined convicted male sex offenders. Exhi-
bitionism was the most frequent offense and constituted 26.5% of
the sample. Carnal abuse and noncoital abuse, both of which in-
volve victims under the age of 16 (presumably pedophilia), were
21.9% and 17.8%, respectively. Homosexuality was 19%, and sex-
ual assault and rape were 5% and 4.8%, respectively. Frisbie and
Dondis (1965) reported on 1,921 admissions to a state hospital for
"sexual psychopaths" and found that 79% of the admissions were
for pedophiles, 13% for exhibitionists, and 4% for sexual aggres-
sives. Exhibitionism, pedophilia, sexual assault and rape, and ho-
mosexuality are the most frequent sexual deviancies encountered
within the legal system. As societal, legal, and psychiatric attitudes
change (see Chapters 6 and 7), fewer homosexuals will be sub-
jected to incarceration, and exhibitionism, pedophilia, and rape
will become the major sexual deviations within the legal system.
An important consideration related to the above is the ques-
tion of recidivism. Surprisingly, few sex offenders recidivate with a
new sex crime. In a major study on recidivism rates (Christiansen,
Elers-Nielsen, LeMaire, & Stump, 1965), 2,934 male sex offenders
were reexamined up to 24 years after their initial conviction, and
their overall recidivism rate was only 10% for new sex crimes. The
recidivism rate for first offenders was even less, 6.9% for new sex
offenses. Persons who had a previous history of sex offenses had a
recidivism rate of 23% for new sexual offenses. Persons who had a
previous history of mixed sexual and property offenses had a recidi-
vism rate of 25% for new sex offenses and a total recidivsm rate of
45%. Gray and Mohr (1965) found that the general recidivism rate
in court populations for convicted sex offenders was between 13%
and 17%. Exhibitionism and homosexual pedophilia had the high-
est rates, between 20% and 30%. Stump (1968) also found that for
exhibitionism and pedophilia, recidivism is most likely to involve
the same sexual behavior. Thus overall recidivism is low for first
sex offenders but considerably higher for multiple offenders,
thereby indicating a lack of control over their sexual behavior.
Pedophilia and exhibitionism appear to have the highest recidivism
14 c. Brandon QuaIls

rates, and these deviations are most in need of effective treatment

to "prevent" recidivism.
Various treatment programs have been instituted, particularly
within the state hospital and prison systems. Unfortunately the
usual outcome measure for this treatment is recidivism rate, hardly
a reliable measure of treatment efficacy (Group for the Advance-
ment of Psychiatry, 1977). Pacht et al. (1962) found that of the 475
males treated and paroled as of May 1960, 9% (43) of these violated
their parole by committing another sex crime. Of 414 men dis-
charged from parole and/or an institution, 6.3% (26) committed
another sex offense. No data are available regarding length of
follow-up. In California, Morrow and Peterson (1966) found that
sex offenders paroled from a state hospital had a cumulative recidi-
vism rate of 26.6%, which was only slightly below the rate for sex
offenders paroled from prison. Frisbie (1966) found that recidivism
among these patients varied widely, ranging from approximately
10% for incest behaviors to 47% for patients convicted for
voyeurism, transvestism, and lewd behavior. These treatment re-
sults are not particularly encouraging. The Group for the Advance-
ment of Psychiatry (1977) has concluded, after a major study, that
the sex offender statutes have failed and that these laws should be
repealed. Treatment is advocated for sex offenders but not through
sex offender statutes.
Thus the legal approach of incarceration with or without treat-
ment for the sexual deviates has not been successful. Furthermore,
because pedophilia and exhibitionism have high rates of recidivism
and rapists, for the most part, never even enter the legal system,
little protection is afforded to society and the victims of these of-
fenders. Moreover the sexual deviates themselves receive little
relief from their uncontrolled sexual behavior through the legal sys-
tem. Other interventions are necessary. However, the treatment
results of studies not connected with the legal system are not en-
couraging either.
A disorder of sexual partner preference, homosexuality, has
been the object of a great deal of study. Bancroft (1974) and Barlow
(1974) have both noted that the use of behavioral techniques, par-
ticularly aversion therapy, have not been successful in the suppres-
The Prevention of Sexual Disorders: An Overview 15

sion of homosexual arousal patterns. Bancroft has summarized the

overall treatment results for behavioral treatments that have in-
cluded chemical aversion, electrical aversion, avoidance learning,
and systematic desensitization. Overall improvement was 40%,
with a range of 25-66%. Follow-up ranged from three months to
eight years, depending on the study. These results are strikingly
similar to the results obtained with traditional psychotherapies.
The combined improvement rate for two major studies (Bieber,
Dain, Dince, Drellich, Grand, Grundlach, Kremer, Rifkin, Wil-
bur, & Bieber, 1962; and Mayerson & Lief, 1965) was 39%. Other
deviant sexual behaviors, such as pedophilia, transvestism, exhibi-
tionism, and sadomasochism, have also been treated with behavioral
techniques with some encouraging results, particularly for trans-
vestites (Marks, Gelder, & Bancroft, 1970) and exhibitionists
(Wickramasekera, 1976). However, the number of cases treated is
too small to yield any definite conclusions.
In summary, these data on sexual dysfunctions, gender identity
dIsorders, and sexual deviations suggest that sexual disorders con-
stitute a significant problem for individuals as well as for society.
For many, this most important area of human functioning and ex-
perience is entirely closed. Furthermore, with the exception of
sexual dysfunctions, treatment results have been limited, although
there have been encouraging results with certain techniques. How-
ever, even if treatment were successful, the number of qualified
therapists in this area is small when compared with the numbers of
people needing such treatment. Our economic resources are prob-
ably not sufficient to provide treatment for all as it is currently de-
livered. For reasons such as these, the issue of prevention of sexual
disorders must be raised. Prevention at the very least may provide
a less costly and more effective form of intervention than is now
available.

2. Concepts of Prevention

While concepts of prevention have been an integral part of

medicine for many years, recognition of preventive medicine as a
16 C. Brandon Qualls

medical speciality is a comparatively recent phenomenon, dating

from 1948. In this discipline, many of the concepts were originally
developed in relationship to the control of infectious diseases; they
have since been extended to numerous other disorders. As a re-
sult, there is now a comprehensive body of concepts that can be
applied to most disorders, including those that are primarily psy-
chiatric and psychological in origin. Infectious disease remains the
classic model of prevention, and the results in that area and others
have amply demonstrated that prevention is an obtainable goal
when the techniques of preventive medicine are used.
Regardless of the area of application, the goals of prevention
have remained essentially the same. Leavell and Clark (1965) have
defined preventive medicine as "the science and art of preventing
disease, prolonging life, and promoting physical and mental health
and efficiency" (p. 10). Preventive measures have sought to
decrease the pain, suffering, and disability associated with a variety
of different illnesses and disorders as well as to decrease the need
for treatment and rehabilitative services, and in certain instances to
prevent the occurrence of those diseases or disorders for which
there exists no effective treatment.
Preventive medicine emphasizes overall health care and
stands in contrast to the traditional American medical, psychiatric,
and psychological services, which are primarily devoted to disease
care. As a result, the public health techniques that have been
adopted differ markedly from the traditional clinical approaches
that focus on the individual patient with a specific complaint. Im-
plicit in this latter approach is the assumption that the way to com-
bat disease or disorders is to increase the number of services avail-
able to the individual. This approach is costly in both time and
money, and it has become increasingly clear that our limited re-
sources are not now sufficient to combat the multitude of disorders
that affect people, nor is there any indication that they will ever be
sufficient. As a consequence, public health techniques have tradi-
tionally focused not on the individual but on susceptible popula-
tions and have attempted to provide uniform services to all its
members. Through mass techniques the incidence of morbidity
and mortality associated with a disorder have been reduced. While
The Prevention of Sexual Disorders: An Overview 17

this emphasis on mass techniques has been successful, the prob-

lems of individual compliance and psychosocial factors associated
with diseases have come to the forefront of prevention. And as a
consequence, the types of problems faced by preventive interven-
tions have become increasingly relevant to questions such as the
prevention of sexual disorders.
Preventive medicine has looked upon disease as developing
from multiple causes. Even for an infectious disease such as tuber-
culosis, the presence of the tuberculosis organism results in clinical
tuberculosis in only a fraction of infected patients. Multiple other
factors determine the actual development of the clinical disease.
Thus, while the model of disease used in preventive medicine is
based on infectious diseases, it is applicable to other types of dis-
orders.
The model itself looks at the interaction of three major factors
in the development of a disorder. The first of these involves the
host, that is, the individual or the group of individuals who are at
risk for the development of the particular disorder under study.
Host factors include age, sex, genetic makeup, phenotype, habits,
customs, and psychological characteristics, to name a few. The sec-
ond major factors involve the agent, that is, those factors or sub-
stances that may initiate or perpetuate the process leading to a
disorder and are necessary for the occurrence of that disorder. An
agent may be nutritional, physical, chemical, biological, or psycho-
logical. Their contribution to the production of a disorder depends
on their physical, chemical, biological, or psychological character-
istics as well as on the types of interactional patterns that they
develop with man. Finally, there are the environmental factors, that
is, all external factors and influences, other than the agents that af-
fect an individual or a group of individuals who are at risk for the
development of the disorder. Environmental factors may include
not only physical aspects of the environment but also social, eco-
nomic, biological, and psychological factors, any of which may in-
teract with the host and the agents to play a role in the develop-
ment of a disorder.
While the interaction of the host, agent, and the environment
produce the disorder, the disorder itself must be seen as develop-
18 C. Brandon Qualls

ing over time. In the absence of any intervention, this develop-

ment constitutes a natural history of the disorder. This view of
disorders as developing over time allows the specialist in preven-
tive medicine to categorize his interventions as primary, secon-
dary, or tertiary (Leavell and Clark, 1965). Caplan (1964) has ap-
plied this same categorization of preventive interventions to
psychiatry.
Primary prevention reduces the incidence of a disorder in a
given population. Primary prevention procedures are divided into
those that promote health in general and those that offer specific
protection for a particular disorder prior to its development. Secon-
dary prevention restricts the development of a disorder after its ini-
tial occurrence and thereby decreases the duration of the disorder,
reduces the disability and associated morbidity, and prevents the
development of complications or sequelae to the disorder. The em-
phasis here is on the early detection and treatment of a disorder
under the assumption that early detection and treatment will lead
to a better outcome and less morbidity. Efforts in this area often in-
volve early case finding. Finally, tertiary prevention reduces the
impairment that may result from a disorder as well as rehabilitating
the individual to his pre morbid state as rapidly as possible. The
emphasis in tertiary prevention is on the rehabilitation necessary to
return those affiicted to the communities so they may live and
work with as little interference from their disorder as possible
(Leavell & Clark, 1965).
Thus prevention may take place at any given level in the
progression of the natural history of a disorder and depends upon a
knowledge of the interaction of host, agents, and environmental
factors for its implementation. Prevention attempts to alter the in-
teractional pattern so as to prevent the natural progression of the
disorder. Success in prevention depends upon knowing the neces-
sary factors in the development of the disorder, developing strat-
egies of intervention, and actually applying those strategies effec-
tively. In this view, treatment is an integral part of prevention to
the extent that it interrupts the development of the disorder.
As noted, the development of appropriate preventive inter-
ventions depends to a large extent on our assumptions regarding
The Prevention of Sexual Disorders: An Overview 19

the etiology of a disorder. Clearly, different conceptions of the

etiology of a disorder will determine the types of interventions that
mayor may not be appropriate. Caplan and Nelson (1973) pointed
out that what we do about a problem depends to a major extent on
how we define it and that problem definitions are often based upon
the presumed causes of a problem. This point is of particular im-
portance when one is dealing with psychological and psychiatric
disorders. In these areas, etiology is virtually unknown. If a psy-
chological disorder such as obsessive-compulsive neurosis is consid-
ered to be "caused by" various factors associated with the person,
such as psychosexual conflicts, then preventive interventions would
be directed toward changing that person's psychic state. But, if ob-
sessive-compulsive neurosis is considered to be a maladaptive
learned behavior, then preventive interventions would be directed
toward changing the person's behavior. Alternatively one might
conceptualize this disorder as "caused by" environmental factors
outside the person and direct preventive efforts in that area. Re-
alistically all these factors may be involved in the development of
this disorder. Unfortunately there has often been a tendency to
emphasize only one of the factors without giving adequate consid-
eration to other possible factors that may be involved. While these
considerations may have more relevance to psychiatry and psy-
chology, fields in which it is particularly difficult to establish etio-
logical factors, they are also pertinent to medical disorders because
of the increasing relevance of psychosocial factors in the etiology of
these disorders and in the preventive efforts that have been ap-
plied to them.
Traditionally, primary preventive interventions have been
directed toward modifYing environmental factors as well as making
individuals less susceptible to a disorder. For example, malaria has
been controlled in the United States by the clearing of swamps and
wetlands near population centers so that the mosquito carrier lacks
an appropriate environment to develop. Similarly milk is fortified
to prevent the development of rickets, iodine is added to salt to
prevent goiter, and drinking water is fluoridated to prevent dental
caries. These are examples of interventions aimed at altering fac-
tors in the environment that impinge upon the individual.
20 C. Brandon Qualls

Preventive interventions have also been directed specifically

at individuals. The vaccines for smallpox, measles, and poliomye-
litis are designed to render the individual less susceptible to devel-
oping these diseases. While specific interventions have been devel-
oped for those diseases that have a known specific agent, it has
become increasingly clear that interventions directed at the indi-
vidual are highly susceptible to individual behavioral patterns. For
example, as of 1974, 36% of children 1-4 years of age were not vac-
cinated for measles, and in 1974 only 60% were immunized against
poliomyelitis, whereas in 1963, 83% were (Ryan, 1976). As a result
the number of cases of poliomyelitis and measles has increased
(Hiatt, 1975). Individual compliance is a major issue in these types
of programs (Becker & Maiman, 1975) even though effective pre-
ventive measures exist.
It is obvious that much more attention must be paid to com-
pliance factors in both primary and secondary preventive pro-
grams, such as mass screening techniques designed for early case
detection, (e.g., the Papanicolaou test for cancer of the cervix,
breast palpation and mamography for breast cancer, blood pressure
measurement for hypertension, and tonometry for glaucoma).
Screening techniques such as these have been designed to detect
early instances of these disorders, as well as untreated cases. Stam-
ler, Stamler, Reidlinger, Algera, and Roberts (1976) have shown
that in their population hypertension was undetected but present
in 27.7% of cases, detected but untreated in 10.7%, and treated
but uncontrolled in 16.7%. Individual compliance is an important
factor in the development of preventive programs and must be
considered a very powerful host factor in the implementation of
such programs.
The importance of other psychosocial factors in preventive
medicine has led to a greater concern with individual behavior as
well as with the need to teach individuals how to protect them-
selves. Nowhere is this more clearly demonstrated than in the risk
factors that lead to atherosclerotic coronary artery disease: systemic
hypertension, cigarette smoking, elevated serum cholesterol levels,
diabetes mellitus, and emotional stress (Eliot & Forker, 1976).
Williams and Wynder (1976) point out that if we are to prevent
The Prevention of Sexual Disorders: An Overview 21

atherosclerosis, as well as tobacco-related cancers and stroke, we

must give a high priority to modifying current life styles, for ex-
ample, dietary changes to decrease the consumption of saturated
fats and cholesterol, the encouragement of nonsmoking, and the
maintenance of body weight and physical fitness. While some of
these factors can be modified through the development of less
harmful cigarettes, through antismoking programs, and possibly
through the encouragement of the food industry to alter the satu-
rated fat and cholesterol content of our diets, most of the change
will have to come through altering life-styles. Kristein, Ar-
nold, and Wynder (1977) described a program, "Know Your Body"
(KYB), involving 3,000 children between the ages of 11 and 14
years. KYB emphasizes actual health screening for selected risk fac-
tors along with educational intervention in the schools and with the
parents and children themselves. This program attempts to alter
life styles, radically in some cases.
Eliot and Forker (1976) have emphasized also the importance
of emotional stress in the development of coronary artery disease.
Friedman and Rosenman (1974) call attention to the so-called type A
behavior pattern as an important coronary risk factor. While more
clarifying research must be done to determine what the objective
quantitative psychosocial risk factors are for the development of
coronary artery disease, sufficient evidence has accumulated to in-
dicate that if prevention is going to be successful, it will have to in-
volve a radical alteration of life styles, including changing diet, al-
tering smoking habits, and increasing physical exercise, as well as
altering the way tasks are accomplished, goals are set, and so on.
Preventive medicine has come a long way from the early con-
cepts of infectious disease and preventive interventions. The notion
of multiple causation in the development of disorders is the rule
rather than the exception. In addition, there is increasing recogni-
tion of the necessity of focusing on individual behavior, such as
compliance, and psychological styles as well as on the environ-
mental factors that affect individual behavior. Obviously these
questions are of great importance for psychiatry and psychology as
they raise the general issue of the relationship of psychosocial fac-
tors to the development of medical disorders. Prevention in this
22 C. Brandon Qualls

area has necessitated the development of psychosocial interven-

tions as well as set the stage for more active prevention in other
psychological disorders, hence its relevance to the prevention of
sexual disorders.

3. Prevention in Psychiatry

While much progress has been made in the prevention of

medical disorders, particularly in the area of primary prevention,
the prevention of psychological disorders is much less advanced.
Preventive psychiatry is a relatively recent development of the past
20 years, although the goal of preventing mental illness was an im-
portant part of the work of men such as Adolph Meyer and Clifford
Beers. In the early part of the 20th century, Clifford Beers, along
with others, started the mental hygiene movement, which sought
to promote mental health (Weston, 1975). This general approach to
the problem of prevention requires that there be a reasonable defi-
nition of mental health and assumes that the promotion of mental
health is a way of preventing mental illness (Zusman, 1975a). How-
ever, the definition of mental health is at best problematic since
mental health and mental illness are not mutually exclusive cat-
egories and are not analogous to physical health and physical ill-
ness. Mental health education, a related area, has been another
general approach to the prevention of mental illness. J. A. Davis
(1965) has reviewed much of this effort and has concluded that
many mental health or mental hygiene slogans are rather vague
and cannot be put into practice. He concluded that little of sub-
stance has come from this particular approach to prevention.
Contrasted to this general strategy is the approach that con-
centrates directly on specific disorders as in preventive medicine.
Here also, prevention can be divided into primary, secondary, and
tertiary types. Primary preventive efforts are now in their infancy
but have been discussed with regard to crisis reactions, schizo-
phrenia, affective disorders, and developmental attrition (Zusman,
1975a; Eisenberg, 1975). Crisis intervention has built on the pio-
neering work of Lindemann (1943) and has been extended by Cap-
The Prevention of Sexual Disorders: An Overview 23

Ian (1964). This type of intervention seeks to prepare individuals

in advance to deal with the crises that they will be exposed to so
that the stress of the crisis is reduced. This approach, as outlined
by Caplan (1964), involves cognitive preparation as well as emo-
tional and experiential preparation and has been used in training
programs to prepare personnel for difficult or hazardous situations.
In principle it is at least applicable to the crises of everyday life, al-
though the occurrence of a crisis is often not predictable, and for
the most part, one is faced with the aftermath of the crisis.
The primary prevention of schizophrenia has progressed very
little. The incidence and prevalence of schizophrenia has remained
stable for many years under a variety of circumstances. Genetic
studies have demonstrated that there is a genetic component in the
development of the disorder. Unfortunately methods do not exist
to differentiate the child at risk from its sibling or other children
not at risk. For primary preventive efforts to be successful, criteria
must be developed to identify the population at risk. Available re-
trospective data suggest that adolescents who are relatively iso-
lated, friendless, and withdrawn seem to have a higher probability
of later illness (Bower, Schellhamer, & Daily, 1960). Further retro-
spective and prospective studies in adolescent populations could
delimit some of the social risk factors for the development of a later
psychotic episode. Eisenberg (1975) concluded that at present,
primary prevention is not possible except for genetic counseling.
Affective disorders are subject to the same lack of data. There ap-
pears to be a genetic component present as in schizophrenia, but
there is little information available regarding populations at risk.
Zusman (1975a) concluded that primary prevention remains an un-
proven hope.
Greater progress has been made in secondary prevention.
Early diagnosis and treatment is the goal, since it is assumed that
treatment is more effective and the disorder less disabling after
early intervention. For the most part, this is an untested notion in
psychiatry, although for certain disorders such as school phobias
early intervention seems indicated (Lassers, Nordan, & Bladholm,
1973; Zusman, 1975b). The key to secondary prevention is early
case finding. Unfortunately there exist no clear-cut screening
24 c. Brandon Qualls

methods to identifY the early cases of major disorders such as the

psychoses. Zusman (1975b) also made the point that early diagnosis
may serve only to disable a symptomatic individual further through
the application of a diagnostic label and that some cases are best
left untreated or treated with minimal intervention. One might add
that early intervention techniques may be quite different from the
treatment techniques required for cases with manifest psychosis.
Much more to the point in this area are crisis intervention ser-
vices that use brief treatment techniques that focus exclusively on
resolving the crisis. With the introduction of community mental
health centers in 1963, a wide variety of crisis intervention services
have become available. Polak, Egan, Vandenbergh, and Williams
(1975) utilized preventive crisis intervention in families after the
occurrence of a death. Crisis intervention holds intuitive appeal in
this case, but in their study, they were not able to demonstrate
that such interventions prevented sequelae.
The early 1960s also saw the development of suicide preven-
tion centers in many of the major cities in the United States. While
these centers have sought to identifY early cases through 24-hour
availability and a high community profile, the effectiveness of these
efforts remains in question. To date, widespread efficacy of suicide
prevention centers has been difficult to demonstrate (Bridge, Pot-
kin, Zung, & Soldo, 1977).
The effective treatment of disorders such as schizophrenia and
the affective disorders also constitutes secondary prevention by re-
stricting the development and duration of these disorders and
thereby preventing the associated morbidity and sequelae. Present
treatment techniques have evolved to the point that once full inter-
vention is necessary, they make a significant impact on the devel-
opment of these disorders. Present-day hospital psychiatry is no
longer custodial but oriented toward short-term treatment and the
return of the individual to the community as rapidly as possible.
The success of this approach rests heavily on the development of
effective pharmacological treatment for acute psychotic episodes.
Antipsychotic medication, such as the phenothiazines and lithium
carbonate, has allowed numerous individuals who would have been
The Prevention of Sexual Disorders: An Overview 25

chronically hospitalized in the early part of this century to resolve

their psychotic episodes and return to the community.
Tertiary prevention, the prevention of long-term disability as-
sociated with a disorder, has also been an area of major advance in
psychiatry (Zusman, 1975c). The chronic deteriorated stage of the
major mental disorders in the early 20th century was the result of
warehousing individuals without effective treatment. The de-
velopment of effective acute treatments and the use of mainte-
nance medications have allowed many to live outside the hospital.
In a review of maintenance therapy in schizophrenia and affective
disorders, Davis (1975, 1976) concluded that maintenance anti-
psychotics can prevent relapse in a substantial proportion of schizo-
phrenic patients at risk for relapse and that maintenance treatment
in mania and depression can prevent recurrent episodes of these
disorders. Thus maintenance medication represents a major ad-
vance in both secondary and tertiary preventive approaches to
schizophrenia and affective disorders. Social therapies also have an
integral part to play in this approach.
This brief review of prevention in psychiatry indicates that
much remains to be done, particularly in the areas of primary and
secondary prevention. While great strides have been made in sec-
ondary and tertiary prevention for the major psychotic disorders,
prevention of other disorders has not reached the level of success
achieved there.

4. Sexual Disorders and Prevention

To be effective, prevention requires a detailed knowledge of

the natural history of a disorder, including those agent, host, and
environmental factors that playa role in the disorder, as well as the
development of preventive interventions to be applied at various
points in its natural history. For many medical disorders, preven-
tion has progressed to the point of having well-defined disease enti-
ties with risk factors and appropriate preventive interventions. Un-
fortunately our understanding of sexual disorders has not reached
26 c. Brandon QuaIls

this level of development. First, data on the natural history of the

development of disorders such as sexual deviancies and sexual dys-
functions do not exist except in the most rudimentary form. Signifi-
cant strides have been made in the area of gender identity dis-
orders (Green, 1974), but much work also remains to be done in
this area. Second, reliable incidence and prevalence figures do not
exist in any of these areas, as has already been noted. Third, risk
factors are also unknown for most sexual disorders. Finally, for the
sexual disorders, it is not even clear that the various categories of
disorders form well-defined entities.
This latter question regarding diagnosis for the sexual dis-
orders constitutes a more fundamental problem, for there exists no
generally accepted diagnostic nomenclature for the sexual disor-
ders. A number of questions in this area remain to be answered.
For example, does a given disorder exist in any particular psycho-
logical or psychiatric sense? Is it merely the creation of various so-
cial, cultural, and legal factors? Is the disorder discrete, or does it
overlap with other disorders? What symptoms and signs should be
grouped together to form a disorder? These questions have impor-
tant implications for the categorization of sexual disorders.
It is doubtful that the various sexual disorders will ever consti-
tute diagnoses as suggested by Feighner, Robins, Guze, Woodruff,
Winokur, and Munoz (1972). These researchers have outlined five
criteria for the establishment of a psychiatric diagnosis. First, there
must be a clinical description of the disorder, including clinical fea-
tures as well as other associated features. Second, the development
of laboratory studies that are reliable and precise would permit fur-
ther refinement of the clinical description. Third, the disorder
must be delimited from other disorders by the specification of
exclusion criteria. Fourth, follow-up studies must establish
whether or not the original patients are suffering from another
disorder that could possibly account for the original clinical presen-
tation. Fifth, family studies can establish an increased prevalence
of the disorder among close relatives of the original patients,
thereby providing further validity for the disorder. In this sense,
the various sexual disorders do not now constitute diagnoses, with
the possible exception of the most severe disorders, such as trans-
The Prevention of Sexual Disorders: An Overview 27

sexualism. At best the sexual disorders constitute a series of labels

that specify clinical features, but these features are generally not
mutually exclusive with other disorders. In fact, there is consider-
able overlap in these clinical features from disorder to disorder.
Nowhere has this latter point been more clearly demonstrated
than in the major changes that our understanding of sexual dis-
order has undergone since the early 20th century, when it was felt
that sexual disorders were manifestations of underlying psycho-
pathology requiring long-term psychoanalysis. While this may be
true for certain disorders (but it is not at all obvious which ones), it
is not true for all or most disorders. If anything, the development
of the new short-term treatment techniques that rely primarily on
behavioral interventions has shown that many sexual disorders are
seemingly not reflective of underlying psychopathology. Instead
many sexual disorders are autonomous and can be reversed with-
out long-term psychotherapeutic interventions. This realization has
lead to increased efforts to study the details of sexual disorders.
What has emerged from this study is a more complete view of sex-
ual disorders in which sexual functioning is made up of a number of
different components that must be assessed and treated indepen-
dently of one another. Each component is made up of identifiable
behaviors that allow for independent assessment and treatment.
We are now moving away from a strict diagnostic classification
toward a componential analysis of sexual behavior. This point of
view will be clearer if we examine the three areas of sexual disor-
ders: sexual deviation, sexual dysfunction, and gender identity dis-
orders.
Sexual deviations include a quite heterogeneous group of dis-
orders, such as fetishism, pedophilia, transvestism, exhibitionism,
voyeurism, sadism, masochism, and others (Sadoff, 1976). Until
recently this group of disorders included homosexuality, but homo-
sexuality has been removed from the Diagnostic and Statistical
Manual of Mental Disorders by vote of the American Psychiatric
Association. The definition of sexual deviations depends in part on
the presence of socially unacceptable behavior, which is defined by
various legal, societal, and cultural norms as well as by psycho-
logical and psychiatric considerations (Bancroft, 1974). Whether
28 C. Brandon Qualls

these deviant behaviors hold anything in common with one another

other than the fact that they are defined as socially unacceptable
has not been established. Recently Stoller (1976) has proposed a
definition of perversions based on psychodynamic considerations
that would include most of the deviancies and other forms of sexual
behavior as well. However, as Stoller noted, his definition does
not constitute a diagnosis. Sexual deviation and the specific
deviancies, such as exhibitionism, at present constitute only labels
for maladaptive sexual behavior.
In the assessment of sexual deviations, Barlow (1974) has em-
phasized the importance of analyzing sexual deviations into four
components: excesses in deviant arousal, deficits in heterosexual
arousal, deficits in heterosocial skills, and gender role deviation.
Abel (1976), in discussing the assessment of rapists, emphasized as-
sessing various behavioral excesses and deficits as well as the exces-
sive arousal to rape stimuli, deficient arousal to nonrape sexual
stimuli, and deficits in social skills such as heterosexual skills, as-
sertive skills, sexual performance, and gender role behavior. All of
these areas have been shown to be important in the treatment of
sexual aggressors as well as in the treatment of other sexual de-
viants. To a large extent, each of these areas is independent of the
other and may be treated independently.
Sexual dysfunctions are also not a homogeneous group of dis-
orders. During the past 50 years, there has been increasing refine-
ment of the categories recognized in dysfunctional patients. Not
long ago impotence included premature ejaculation, an inability to
achieve an erection, and an inability to ejaculate. Similarly frigidity
included a lack of orgasm, lack of sexual enjoyment, and other sex-
ual problems. Masters and Johnson (1970) have emphasized impor-
tant distinctions in separating these disorders based in part upon
the physiological response system (Masters & Johnson, 1966). Kap-
lan (1974) has presented a slightly different group of sexual dys-
functions, but most recently, Sharpe, Kuriansky, and O'Connor
(1976) have divided sexual dysfunctions into five major areas. The
first includes disturbances of the physiological response cycle in
males and females during the arousal phase, the orgasmic phase,
and the resolution phase as well as dyspareunia. The second major
The Prevention of Sexual Disorders: An Overview 29

area includes disturbances of the perceptual component in the sex-

ual response cycle: hypersexual feelings, hyposexual feelings, and
anesthesia. The third area includes disturbances of subjective satis-
faction, and the fourth distress associated with false beliefs or lack
of sexual knowledge. The fifth area involves sociosexual distress in
a sexual relationship. These categories are not considered to be
diagnostic in nature but are descriptive dimensions that can de-
scribe individual functioning on a number of levels. As a result, a
given patient may be described in terms of each of these different
dimensions, with treatment interventions designed for each dimen-
sion.
Gender identity disorders also include a number of disorders,
ranging from atypical sex role behavior in children to the most ex-
treme gender identity disorder, transsexualism. This latter disorder
and the gender identity disturbances underlying it are increasingly
being viewed as composed of several distinct syndromes. Evidence
for this view has come from the study of transsexuals seeking sex
change operations. Bentler (1976) has reviewed this area and found
that transvestic and homosexual components are most consistently
reported in the literature as being interwoven with the more clas-
sical presentation of transsexualism. Bentler himself reported data
on 42 postoperative transsexuals, whom he divided into three
types: homosexual, asexual, and heterosexual transsexuals. This
typology is based upon prior sexual experience. The homosexual
transsexual gives a history of homosexual experience with little suc-
cessful heterosexual experience. The heterosexual transsexual is
typically married and reports having had pleasant, successful inter-
course with a female. The asexual transsexual does not consider
himself homosexual, has never had pleasant and successful inter-
course with a female, and has never been married, as have the het-
erosexual transsexuals. Thus, within the gender role category of
transsexualism, there are probably at least three different types
with different sexual histories that are relevant to treatment.
While the sex change operation has been the primary treat-
ment for transsexuals, Barlow et al. (1973) have reported gender
identity change in a transsexual using behavior modification tech-
niques. From our point of view, this case is of interest in that the
30 C. Brandon QuaIls

treatment depended upon breaking down complex sex role behav-

ior into gender-specific motor behavior, social behavior, vocal char-
acteristics, sexual fantasies and attitudes, and patterns of sexual
arousal and required changing each component sequentially. These
researchers also stated that each component seemed to be rela-
tively independent of the others. This treatment has since been
replicated in two cases (Barlowet al., 1978).
In all three of these areas there is emerging a trend away from
viewing the various sexual disorders as distinct entities and toward
a componential analysis of sexual functioning. Researchers are em-
phasizing the need to view sexual functioning as a multifaceted
aspect of human behavior in which different components of sexual
functioning may become disordered. In keeping with this view is
the fact that a given person with a sexual disorder may well have
disturbances in many different areas and that there may be no uni-
tary category that adequately describes his disorder except in a
most general fashion. For example, a sexually dysfunctional male or
female may have disturbances of poor body image, marital incom-
patibility, hyposexual feelings, and anxiety during sexual perfor-
mance, as well as disturbances in the sexual response cycle. Simi-
larly a male with problems in sexual partner preference may also
exhibit problems in the area of sexual functioning, as well as
gender role behavior problems. These observations suggest that
sexual disorders can best be viewed in terms of the components of
sexual functioning rather than as diagnostic entities.
In this view, preventive interventions, particularly primary
and secondary, must be directed not toward the disorders them-
selves but toward the components of sexual functioning just as
treatment has been. Because sexual disorders differ from the dis-
ease entities of preventive medicine, so must prevention differ as
applied to sexual disorders. Furthermore each component of sexual
functioning has different developmental sequences. For example,
the three categories of gender identity as described by Green
(Chapter 3) develop at different times during the course of child-
hood. Similarly the sexual arousal system is activated at various
times with the addition of behavioral, cognitive, and affective com-
ponents depending upon the stage of development. Social and in-
The Prevention of Sexual Disorders: An Overview 31

terpersonal skills also develop differentially for members of the

same sex and the opposite sex. The same is true of the sexual value
system discussed by Masters and Johnson (1970). Investigating sex-
ual functioning at different points in the life cycle allows then for
the development of preventive measures designed to affect each
component differentially. Each of the components can be influ-
enced by individual, familial, peer group, societal, cultural, and
legal factors. These influences wax and wane in importance during
the life cycle.
It is important to note that adult sexual behavior is for the
most part learned behavior that can overshadow biological impera-
tives (Money & Ehrhardt, 1972). Socialization processes establish
core gender identity in the first 2-3 years of life, just as a mother's
attitude about masturbation influences final masturbatory behavior
in females (Fisher, 1973). Environmental and cultural factors also
influence this developmental process. This point of view makes
sexual disorders somewhat relative to the particular culture in
which they occur. Sexual disorders themselves can be taken as a
generic idea to mean the various sexual problems that are manifest
in a particular culture. The influence that a culture has determines
the nature of the disorder as well as the incidence of cases. For ex-
ample, the Irish culture described by Messinger (1971) has an ex-
tremely narrow view of adult sexuality. Female anorgasmia has a
probable prevalence of 100% in that culture, whereas in the
Mangaian culture described by Marshall (1971), the prevalence is
close to zero because of the radically different cultural attitudes
toward sexuality.
The purpose of this book is to explore some of the concepts of
prevention as they apply to the various sexual disorders. There are
reasons to suggest that preventive measures may potentially be
more fruitful in this area than has been the case with other psy-
chological disorders. For most sexual disorders, there are identifi-
able behaviors associated with the disorders, and to the extent that
this is true, it is more feasible to identify the components of the
sexual disorder and to identify the developmental sequences upon
which they are based. While the details of these developmental
sequences are not known at present, the outlines are beginning to
32 C. Brandon QuaIls

emerge and therefore become available to primary interventions.

Second, as developmental sequences are identified, populations at
risk become identifiable for preventive measures. Third, as Money
and Ehrhardt (1972) have demonstrated, even though genetic and
biological factors are important in sexual development and gender
identity formation, early psychological intervention can lead to the
successful resolution of these problems.
In terms of the preventive public health model, the task of
primary prevention would be to identifY those risk factors that play
a role in the development of a sexual disorder and those popula-
tions that are at risk for its development, as well as to formulate an
intervention that is appropriate. Secondary prevention would in-
volve the early detection and treatment of the disorder. Tertiary
prevention may include secondary prevention and would also seek
to diminish the aftereffects of various sexually related problems,
such as mastectomy, paraplegia, and anatomical developmental
anomalies.

5. Controversies

Prevention has often been controversial. This has been true

for both medical prevention and prevention in the psychological
and psychiatric areas. While vaccinations for smallpox and vaccines
for poliomyelitis may not seem controversial today, one has only to
think back a few years to remember the controversy surrounding
fluoridation of water. As of 1972 in the United States, only 60% of
the water supply was artificially fluoridated (Hiatt, 1975). Similar
controversies now exist in other areas of medical prevention. Wil-
liams and Wynder (1976) have advocated aggressive interventions
in pediatric populations for the prevention of arteriosclerosis in
later life. Nora and Nora (1976), on the other hand, have empha-
sized that there are not sufficient data to support such interven-
tions, and so the debate continues.
In and of itself, prevention is a praiseworthy endeavor de-
signed to alleviate human suffering and promote health and effec-
tive functioning, whether it be physical or psychological. To this
most would agree. However, it is in the application of preventive
The Prevention of Sexual Disorders: An Overview 33

interventions that controversy arises. First, these interventions

often mean the redistribution of precious resources, particularly in
the practice of medicine (Hiatt, 1975). It is certainly conceivable
that as increasing amounts of scarce economic resources are de-
voted to secondary and tertiary prevention, less and less attention
will be focused on primary prevention, and consequently less re-
sources will be devoted to it.
Second, preventive interventions often result in the accusation
of invasion of individual privacy. Medical and psychological ser-
vices have traditionally been based upon the request of the con-
sumer, even though the consumer may not have much influence
on the type of service he receives. Yet many do not seek these ser-
vices even though they may be in desperate need. As a nation, we
have invested a great deal in personal privacy as a primary value.
Each person has a right to mind his own business and have others
mind theirs, or so we would like to believe. Controversies around
preventive interventions such as the fluoridation of drinking water,
an effective intervention that could cut in half dental caries in
children, often center on issues of privacy. Similarly sex education
has been a controversial endeavor that has been fought by a
number of groups primarily on this very issue. Because the pre-
vention of sexual disorders involves an area of human experience
and behavior that has a great deal of privacy associated with it, one
would expect controversy to surround any proposed interventions.
Altering sexual attitudes, sexual behavior, or child-rearing practices
in a systematic way, as for example in a pediatric population that is
at risk for the development of gender role disturbances, also carries
with it a great responsibility for those proposing such interventions
(see Chapters 3 and 8). If the interventions run counter to prevail-
ing attitudes, controversy naturally results. Questions such as these
have already arisen and will continue to arise as we debate these is-
sues.
Prevention often means a reordering of societal values even at
the level of individual behavior. In the area of medicine, proposals
have been made to alter the nation's attitudes regarding physical
fitness, smoking, diet, and stress. In the area of human sexuality,
one could argue that masturbation is a developmental stage in sex-
34 C. Brandon Qualls

ual responsiveness and that for most people effective adult sexual
functioning requires masturbation as an important part of the de-
velopmental sequence (Lassen, 1976). Should masturbation be a
part of child-rearing practices in this country as it is in certain other
cultures (Marshall, 1971)? Suggestions such as these raise a number
of ethical and societal issues (see Chapter 8).
Finally, even if one agrees that the prevention of sexual dis-
orders is desirable, the question arises as to which sexual disorders
should be prevented. As societal attitudes change, the prevention
of certain sexual disorders such as homosexuality may become con-
troversial. Those who view homosexuality as an alternative life
style or who encourage sexual experimentation with members of
the same sex would view preventive interventions in this area as
presumptuous at the very least. To the extent that any given group
forms its identity in terms of its sexual functioning, controversy and
polarization will develop.
While this discussion is hardly complete, it at least serves to
highlight the types of questions that will occur as we begin to
explore the issues of prevention in detail.

6. Summary

This is the first attempt to apply the concepts of prevention to

sexual disorders, and it must be viewed in that light. Even in the
face of the many major advances that have occurred during the last
25 years, much remains to be learned about the nature and course
of sexual disorders. The risk factors and the populations at risk are
virtually unknown. The treatment of sexual disorders has only re-
cently developed, and while much progress has been made, much
remains to be learned. Ethical, moral, religious, and legal ques-
tions also form an important part of any discussion of human sexu-
ality. In this book, we hope to explore some of these issues as they
apply to the major sexual disorders.
The Prevention of Sexual Disorders: An Overview 35

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 2
Editors' Introduction

Cross-cultural perspective indicates that the range and expression

of human sexuality is enormous and, more importantly, that the
sexual "problems" experienced by one culture may not be consid-
ered problems at all by other cultures. LoPiccolo and Heiman pro-
vide a unique look into our own (North American) culturally linked
sexual values.
The chapter begins with a review of sexual values and beliefs
of the late 19th century and the 20th century. This historical re-
view dramatically illustrates the ever-changing nature of these val-
ues and 'beliefs. It is quite clear that what would have been con-
demned and "prevented" at one time in our history is now often
not only accepted but, in certain cases, encouraged and considered
therapeutically valuable.
LoPiccolo and Heiman's chapter should be required reading
for all professionals dealing with sexual problems. It points out not
only the changing values of the past but also the influences on our
sexual beliefs and values today. Certainly contemporary literature
and the media lead us to strive toward almost Herculean sexuality.
Many couples whose sexual functioning is objectively entirely nor-
mal are now seeking sex therapy. This should be of great concern
in light of Frank, Anderson, and Curtis's (1977) * findings that up
to 75% of couples who rate their marriages as successful and sex-
* Frank, E., Anderson, C., & Curtis, E. The incidence of sexual difficulties in
"norma" couples. Paper presented at the annual meeting of the Eastern Associa-
tion for Sex Therapy, New York, March 1977.
41
42 Editors' Introduction to Chapter 2

ually nonnal experience definable sexual dysfunctions. The ques-

tion is thus raised as to why one person is happy with his or her
sexual behavior while another person demonstrating the same be-
havior is unhappy and seeks help. Should the therapist try to
change the unhappy person's sexual behavior or try to make this
person happy with his or her behavior the way it is? For LoPiccolo
and Heiman, the prevention of such sexual problems becomes an
attempt to examine therapeutic biases about sexuality and thus
reduce the range and types of behaviors considered problems.
 2
•
The Role of Cultural Values In
the Prevention and Treatment of
Sexual Problems
JOSEPH LoPICCOLO AND JULIA HEIMAN

1. Introduction

The psychotherapist is often perceived as an objective, dispas-

sionate arbiter of mental health, free of cultural biases. In point of
fact, however, the psychotherapist is influenced by the culture in
which he or she lives (London, 1964). The therapist's concep-
tualization of human personality is inevitably shaped by the values
of the dominant elements of his or her society. The danger in this
cultural bias of therapists is that psychotherapy may become noth-
ing more than an acculturation process. Culturally valued behavior
may become synonymous with "mental health," and culturally dis-
approved behavior may be labeled "mental illness," a point that
has been made repeatedly by Szasz (1960). In such a situation, the

Joseph LoPiccolo and Julia Heiman • Department of Psychiatry, School of Medicine,

State University of New York at Stony Brook, Stony Brook, New York 11794. Preparation of
this chapter was supported in part by a research grant from the National Institute of Mental
Health, U.S. Public Health Service.
43
44 Joseph LoPiccolo and Julia Heiman

psychotherapist may tend to emphasize cultural conformity at the

expense of the client's individual needs.
The value-determined nature of psychotherapy is particularly
problematic when cultural values conflict with what seem to be
basic human needs or when cultural values change rapidly. Both of
these conditions apply in regard to sexual behavior. Historically,
Western Judeo-Christian society has been biased against sexuality,
while admitting that people are inherently sexual. Furthermore,
the last century in America has been characterized by rapid
changes in our attitudes toward sexuality.
The issue of therapists' cultural biases has implications that go
far beyond the content of the therapy that their individual patients
receive. Because therapists, through their writings and public pro-
nouncements, tend to tum unsystematized cultural values into for-
mal definitions of "sexual problems," therapists' biases in a sense
create some sexual problems. That is, when a respected expert on
human behavior defines a common sexual practice as "abnormal," a
new class of potential patients is created, and agents of social con-
trol try to prevent this disordered behavior from developing in
their charges. Thus, at various points in time, major social and
therapeutic effort has been devoted to "preventing" or "curing" ac-
tivities such as masturbation, premarital intercourse, and homosex-
ual behavior.
It would appear, then, that many sexual problems are iat-
rogenic diseases. The therapist's efforts are devoted to "curing"
(eliminating) sexual behaviors that are "abnormal" simply because
the therapist, systematizing his culture's biases, has so defined
them. Put more simply, in the words of the comic strip character
Pogo, "We have met the enemy and he is us." Thus one fruitful
approach to the prevention of sexual problems is to examine thera-
peutic biases about sexuality and thus reduce the range of behav-
iors that are considered problems that need to be prevented.
In this chapter an examination is made of the effects of cultural
values on the psychotherapeutic definition of "normal" human sex-
uality. The effects of our Judeo-Christian heritage are discussed as
prime shapers of our culture's sexual attitudes. The works of the
late-19th-century and early-2Oth-century sex researchers are exam-
The Role of Cultural Values 45

ined for cultural biases, as are the writings of Freud. Kinsey's

research and Masters and Johnson's contributions are discussed in
terms of their effects on our culture and hence on therapeutic
definitions of normality. The role of the mass media in replacing the
family as the major acculturation agent (McLuhan & Fiore, 1967)
for sexual values is explored. Finally, present trends in both popu-
lar culture and therapeutic views of sexuality are discussed.

2. The Cultural Heritage: Sin, Sex, and Physical Health

Until approximately 100 years ago, sex was not an acceptable

subject for discussion in medical and scientific circles. In the late
19th century, however, physicians and researchers began to pub-
lish books dealing with sexual behavior. While Havelock Ellis's
seven-volume Studies in the Psychology of Sex (1899-1928) and
Kraffi-Ebing's Psychopathia Sexualis (1902) are best remembered
today, a number of other works written for the lay public had both
larger sales and wider influence. *
The culture in which these tum-of-the-century sex researchers
worked was overwhelmingly antisexual. General society, as well as
the vast majority of the medical and scientific community, consid-
ered sexual intercourse to be both sinful and physically dangerous.
The pioneer sex researchers worked to foster acceptance of human-
ity's sexual nature, to revise negative attitudes toward sexuality,
and to suggest utopian principles for morals, marriage, and sexual
behavior (Chall, 1961). Yet these researchers remained victims of
their culture's antisexual bias, and this bias strongly colored their
views.
The roots of this negative sociosexual climate go far into the

* Best-sellersof the period include Francis Cook's Satan and Society (1881),
August Forel's The Sexual Question (1906), Bernard MacFadden's The Virile
Powers of Superb Manhood (1900), and the noted phrenologist Orson Fowler's
Amativeness, or Evils and Remedies of Excessive and Perverted Sexuality, Includ-
ing Warnings and Advice to the Married and Single (1875). Other scientific works
of this period were Molls's Die Kontraere Sexuelimpfindung (1893) and Magnus
Hirschfield's] ahrbuch fur Sexuelle Zwischenstufen (1899-1921).
46 Joseph LoPiccolo and Julia Heiman

past and cannot be precisely traced. It is clear, however, that the

Judeo-Christian ethic, and Catholic doctrine particularly, has been
extremely influential in producing an antisexual social climate over
the last 20 centuries. The apostle Paul, in his sermon to the Corin-
thians, stated what was to become a dominant premise-that true
holiness and service to God came only with celibacy. Thus mar-
riage, and therefore sexual expression, were allowed only for the
purpose of procreation. Reproduction was valued, since the status
of early Christianity as a persecuted minority religion made an
increase in population desirable.
The negative view of sexual expression was stated more di-
rectly in the fourth and fifth centuries by St. Augustine and Pope
Gregory the Great. Their thesis was that sexual intercourse re-
mained a sin, even within marriage and even when conception was
the result, if the husband or wife obtained pleasure from the act.
Since sexual expression was inherently sinful, it was also forbidden
on 3 days of every week and for 40 days prior to both Easter and
Christmas (Taylor, 1970).
The belief that sexual activity was inherently sinful was
strongly associated with the view of woman as a basically evil
temptress who led men from the path of grace. Beginning with the
story of Eve in the Garden of Eden, the eventual results of this
view included the doctrine of Immaculate Conception, the cult of
virginity, the persecution of women as witches, and the still-
prevalent notion that goodness and morality in women must be in-
compatible with sexuality (Hunt, 1959).
The prohibition against marriage for the priesthood was at
least a contributing factor in the Protestant Reformation. Martin
Luther, however, argued for marriage as simply the best practical
way of containing the basically sinful nature of man, as "He who
does not marry must misconduct himself' (quoted in Cole, 1961).
Both Luther and Calvin felt that while marriage was necessary and
sacred, sexuality and especially pleasure obtained from coitus were
shameful, unclean, and sinful (Bailey, 1970).
The view that pleasure is not an acceptable, sufficient motiva-
tion for coitus is still reflected indirectly in the Catholic position on
birth control. Furthermore the notion that pleasure is both natural
The Role of Cultural Values 47

and legitimate in marital sexual intercourse was directly rejected as

recently as 20 years ago by Pope Pius XII, who cautioned that to
seek pleasure in the sex act was:
un-Christian-even here couples must know how to restrict themselves
within limits of moderation-they must not abandon themselves without re-
straint to the impulses of the senses. . . . Banish from your minds the cult
of pleasure and do your best to stop the diffusion of literature that thinks it a
duty to describe in full detail the intimacy of conjugal life under the pretext
of instructing, directing, and reassuring. (Quoted in Clemens, 1961, p. 229)

This position against sensuality was reinforced by the Vatican

Council in January 1976 in an encyclical that also condemned mas-
turbation, premarital sex, and homosexuality. The Rabbinical
Council of America affirmed this document and added that "height-
ened eroticism" was responsible for the rising divorce rate.
It was only during the Enlightenment of the late 18th and
early 19th centuries that discussion of sexuality became separated
from religious morality. With the rise of modem biology and the
theory of evolution, human reason rather than divine revelation
was advanced as the basis for understanding and regulating human
behavior.
With this humanistic-rational viewpoint came the first sexual
reformers: Robert Owen and John Noyes, founders of the Harmony
and Oneida communes; Dr. Charles Knowlton, author of Fruits of
Philosophy (our first marriage manual, published in 1832); and Ezra
Harvey Heywood author of the first book on open marriage,
Cupid's Yokes, or the Binding Forces of Conjugal Life (1876).
These men, by publicly advocating sexual freedom and reform as
part of a larger plan for a utopian society, created the social climate
in which the work of the tum-of-the-century sex researchers such
as Ellis and Kraffi-Ebing was at least possible, if not acceptable.
These early reformers paid a price for their views: Owen was cas-
tigated in the press for immorality, Knowlton was fined and jailed,
and Heywood was repeatedly prosecuted for obscenity under the
Comstock Laws of 1873.
Although the early sex researchers rebelled against the preva-
lent negative view of sexuality, they were unable to escape entirely
from their cultural heritage. That is, the early researchers were un-
48 Joseph LoPiccolo and Julia Heiman

able to consider sexual expression as a physically and psycholog-

ically harmless entity and continued to see it as a dangerous force
that needed careful control, even within marriage. The sexologists
basically argued that moderate pleasure gained from sexual expres-
sion within marriage was not sinful but rather was a "natural" com-
ponent of the human reproductive process and of the highest spiri-
tual love between man and woman. Their plea was to make
knowledge about sexuality available to the public, as sexuality was
necessary for a good marital relationship---an idea that was consid-
ered revolutionary, immoral, and obscene in 1900. However, while
accepting moderate marital coitus, the early researchers were un-
able to accept masturbation or "excessively" frequent and unre-
strained intercourse. Thus, while preventing the marital/sexual
problems caused by ignorance, these workers created another class
of problems by defining some virtually universal sexual acts as ab-
normal.
The attitudes toward masturbation were especially extreme.
Havelock Ellis considered himself a sexual radical, as shown in his
famous statement, "What others have driven out of consciousness
as being improper or obscene, I have maintained or even held in
honor" (Colles, 1959). Yet Ellis described the following as results of
"excessive" masturbation: epilepsy, eye disease, acne, asthma,
headaches, mammary hypertrophy, warts on the hands, deafness,
cardiac murmurs, painful menstruation, feeblemindedness, in-
sanity, and criminality (Ellis, 1910, Vol. 1, p. 259). Kraffi:-Ebing's
works added to this catalog. At various points in his writings, he
blamed masturbation for "neuroses of the sexual apparatus" and
"weakness of the center governing erection, ejaculation, and plea-
sure in coitus." There was also psychological damage: Kraffi:-Ebing
held that the effect of masturbation was to "contaminate, even to
exhaust the source of all noble and ideal sentiment," to induce
emotional indifference to the opposite sex, with only "coarse ani-
mal desires for satisfaction remaining" (Kraffi:-Ebing, 1902, pp.
188-189). It has been stated that Kraffi:-Ebing viewed "masturba-
tion as a cause of almost everything unpleasant" (Brecher, 1969,
p.51).
Popular authors of the period were even more extreme in
The Role of Cultural Values 49

their views. Everything from bad breath to nymphomania, convul-

sions, and even death were credited as effects of masturbation. The
public's concern was raised to the point that a lively commerce de-
veloped in devices to prevent masturbation. In the early years of
this century, the U.S. Patent Office granted patents to metal mit-
tens, an alarm that rang in the parents' bedroom if their child's bed
was moving, and a variety of other restraining straps and garments
for the prevention of masturbation.
Excessively frequent or pleasurable intercourse received a
similar treatment from the early sexologists. MacFadden's 1900
book, which opens with the reformer's dedication "To assist in
stifling that horrible curse of prudishness and the ignorance of sex
which it entails, is the object which has influenced the writing of
this book," notes that
many married people will give themselves up to the embrace daily.
But not only its frequency, but the manner in which it is performed, are so
unnatural and studiously licentious, that the most desperate cases of paraly-
sis and epilepsy are frequently the direct and immediate result. (p. 34)

In his discussion of the dangers of frequent sexual intercourse,

Fowler reiterated the cultural view of the "good" woman as asexual
and the acceptance of marriage as a spiritual relationship. He saw
the woman as "final umpire" of intercourse frequency and stated
that a husband who "tenderly loves a delicate wife" should find no
difficulty in being continent, because he loves her too much to
"subject her to what would be injurious."
The "treatment" for sexual problems advocated by the pio-
neers in sex research followed logically from their view of sex as a
natural but dangerous part of human nature. To deal with mastur-
bation in children, Ellis advocated allowing the child the minimum
time in the bath, no closed bedroom doors, and advised parents
to watch their servants carefully, as "this is an affiiction most often
practiced by the lower classes." Kraffi-Ebing viewed childhood
masturbation as an especially difficult treatment problem for the
clinician. He noted that in his own practice, in cases involving a 4-
and a 7-year-old girl brought by concerned parents, "even a white
hot iron applied to the clitoris had no effect in overcoming the
50 Joseph LoPiccolo and Julia Heiman

practice." This seems a classic example of therapy that is more

damaging than the condition it attempts to treat.
Thus, while the first sex researchers were reformers who ad-
vocated an acceptance of sex education and sexual expression in
marriage, they mirrored the dominant cultural values that sex was
a force that must be carefully controlled lest physical and mental
harm result from masturbation, "unnatural" sexual practices, or
simply too frequent "natural" marital intercourse. The dichotomy
between good women and sexual women continued unchallenged.
Patients consulting these experts came primarily to regulate their
sexual drives, to stop the masturbation of their children, and to be
freed from "unnatural" inclinations. One can only speculate that
the response of one of the early sex therapists to a female patient
complaining of lack of orgasm, inability to enjoy sex, or low
frequency of desire for sex would have been to reassure such a
woman that she was indeed a normal, decent, virtuous woman.
Similarly, patients troubled by their enjoyment of masturbation,
frequent intercourse, or oral-genital contact were not likely to be
reassured by the sex experts but may instead have been subjected
to harmful "treatment." "Prevention of sexual disorders" became
synonymous with suppression of common sexual activities, and
treatment focused on elimination of masturbation or frequent co-
itus.
It is ironical that these experts, while attempting to increase
acceptance of sexuality, may actually have had the opposite effect.
While legitimizing moderate marital intercourse, their work re-
placed sin with physiological and psychological damage as the basis
for prohibiting what we now accept as normal and harmless sexual
behaviors.

3. The Cultural Message of the First Half of the 20th

Century: "Sex Is Good, but Only for Men"

By the 1920s sex had gone public. It was more openly dis-
cussed, somewhat more common premaritally, and beginning to
emerge as a social phenomenon as a result of postwar adjustments.
The permission to be sexual, however, was still enjoyed more
The Role of Cultural Values 51

by men than by women. Although cultural conditions encouraged

the presence of a double standard, Freud's work provided the the-
oretical nutrition. Freud brought sex out of the Victorian closet and
made it the core of his view of personality development. Most in-
fluential in the definition of sexual dysfunction were Freud's ideas
regarding female sexuality, male and female differences, and sexual
pleasure.
Freud's conceptualization of sex, and thus personality, was an
anatomical one: given the genital sex of a person, the stages of
gender and personality development were preordained. His deter-
ministic view of human sexuality included a rigid definition of
"healthy" female sexuality: female sexuality was compensatory-a
poor facsimile of the male's equipment-and her development
could be considered healthy only if she gave up clitoral pleasures
and became exclusively vagina-centered. Once a young girl real-
ized that boys had penises and she had (only) a clitoris, penis envy
set in. Freud saw a woman's social inferiority as resulting primarily
from her realization of what female anatomy lacked. For Freud, it
was predictable that she "began to share the contempt felt by men
for a sex which is the lesser in so important a respect" (Freud,
1925, p. 192). Upon discovering her clitoral inferiority, a young girl
developed intense feelings against masturbation. This was good in
Freud's view, since "masturbation, at [sic] all events of the clitoris
is a masculine activity and the elimination of clitoral sexuality is a
necessary precondition for the development of femininity" (Freud,
1925/1959, p. 144). The frequently noted distinction between
vaginal and clitoral orgasms-the former preferred and superior,
the latter inferior and immature-grew to become a psychoanalytic
cornerstone of female sexuality.
An equally germane aspect of early Freudian theory that per-
meated therapy and blended with cultural biases was the distinc-
tion between masculinity and femininity. While he subscribed to a
theory of bisexuality, bisexuality for Freud was a pointillistic ag-
gregation of distinctly masculine and distinctly feminine qualities.
Masculinity was active, dominant, and directive; femininity was
passive, submissive, and responsive. In terms of sexuality, Freud
(1905/1962) went even further:
52 Joseph LoPiccolo and Julia Heiman

Indeed, if we were able to give a more definite connotation to the concepts

of "masculine" and "feminine," it would even be possible to maintain that
libido is invariably and necessarily of a masculine nature, whether it occurs
in men or in women and irrespective of whether its object is a man or a
woman. (p. 121)

Although Freud's views became more androgynous in later years,

the impact of his initial work and the regard of sexual desire as a
masculine phenomenon remained. This left women with few psy-
choanalytically sanctioned ways in which to express their sexuality.
It is almost surprising that women, viewed within a Freudian
framework, were expected to be orgasmic at all. That, in fact, was a
question implied by Deutsch, who felt that the most "feminine"
kind of orgasm had no orgasmic quality at all but was a "passive
sucking action ending in easy slow relaxation" (Sherfey, 1973, p.
24).
Another aspect of Freudian theory that is important to under-
standing the function of culture and therapy was the concept of
pleasure. Sex was viewed as a dangerous force, one that society
had to channel (or sublimate) into work and/or monogamous bonds.
Sex-a raging, chaotic form of energy-had to be tamed into con-
structive modes of behavior. The result was civilization, a repres-
sive but orderly and productive society. Thus, as Marcuse (1955)
noted:
civilized morality was mobilized against the use of the body as a mere object,
means, instrument of pleasure; such reification was tabooed and remained
the ill-reputed privilege of whores, degenerates, and perverts. (p. 183)

Freud saw coitus as the only permissible form of sexual plea-

sure. Whereas earlier sexologists considered masturbation and oral
and anal sex as likely to cause physical damage, Freud saw these al-
ternatives as immature relics of infantile "polymorphous perverse"
sexuality.
To some extent, Freud was reflecting traditional Jewish patri-
archal attitudes on sex. In Gordon's (1972) words, " 'Infantile,' 'im-
mature,' 'personality defect' is just name-calling and the substitu-
tion of Freudian pseudoscientific language for the prohibitions of
the Talmud" (p. 27). Detail for detail, Freud's theories were far
The Role of Cultural Values 53

from unanimously accepted by even his closest disciples. However,

his ideas about personality and development did gain slow accep-
tance by the literary intelligentsia in the United States, and psycho-
analytic terms became part of the popular and academic vernacu-
lar. The question is, of course, Why did this happen? Perhaps the
historical upheaval between 1920 and 1960 helped to sustain the
masculine-feminine dichotomy and the concept of sublimated
erotic drives. Certainly there was plenty of evidence that sexual at-
titudes were remarkably resistant to change: from the banning of
the jitterbug as "suggestive" at Duke University in 1942 to the dis-
missal of philosopher Bertrand Russell from the City College of
New York for his tolerant views on homosexuality and premarital
sex (Manchester, 1973-1974). And yet, the experience of two world
wars and a national economic depression in and of themselves can
hardly be responsible for the static nature of sex roles and attitudes
and thus the ready acceptance of Freudian theory. More plausible
is the fact that other cultural factors, including religion and close
family ties, may have contributed to maintaining the premises on
which Freudian psychoanalysis capitalized (antiwoman attitudes,
double standards, sex as a dangerous force), in spite of national and
international crises.
Whatever the cultural predisposition over these 40 years, the
effect of Freudian theory on individuals who sought treatment for
sexual problems was potentially devastating. In this regard, Sher-
fey (1973) pointedly asked, "Could many of the sexual neuroses
which seem to be almost endemic to women today be, in part, in-
duced by doctors attempting to treat them?" More specifically, one
wonders how many women patients developed feelings of sexual
inferiority as a result of the therapeutic view of women as second-
rate substitutes for men. Views about the immaturity of the clitoral
orgasm and masturbation practices must have contributed to many
women's being labeled as "masculine." Sexual desire itself was,
after all, thought to be a "masculine" prerogative. For the woman
in or out of therapy who took these messages seriously, the possi-
ble consequences appear rather dire: guilt, shame, fear, self-hate,
and denial seem to be likely outcomes. Additionally it is possible to
imagine a woman's restricting her sexual activities as a result of
54 Joseph LoPiccolo and Julia Heiman

therapy and growing less interested in those activities she pre-

viously enjoyed.
Of course, given the cultural zeitgeist, it is unlikely that anti-
female-sexuality attitudes would permeate only therapeutic rela-
tionships based on Freudian psychoanalysis. Quite assuredly, a
woman who felt guilty about masturbation in 1942 would get little
support from her male therapist regardless of his theoretical orien-
tation. Yet traditional psychoanalytic theory was more proscribed
than the cultural mores; it was structurally dogmatic, the categories
as inflexible as the anatomical system on which they were based.
DeBeauvoir (1949) saw this as a problem with the psychoanalytic
view of development: "Replacing value with authority, choice with
drive, psychoanalysis offers an Ersatz, a substitute for moraHty-
the concept of normality" (p. 45). One wonders to what extent
Freud's theories emerged as his justification for cultural biases
against women and female sexuality. Since healthy sexual develop-
ment was fixed, an adult woman who masturbated clitorally to
orgasm was by definition "arrested" at an immature level of devel-
opment. At this point, any social efforts at prevention of sexual
problems in women would almost certainly have been undone by
the Freudian definition of a major component of female sexuality as
abnormal and immature.
Of course, men as well as women patients of psychoanalysis
felt pressured to conform to a gender role. The clear distinction of
masculine and feminine roles enforced burdens on male sexuality.
After all, to be healthy, a male must be readily erect throughout
the seduction of a woman. At the same time, he must be on guard,
for women were potentially insatiable, especially if they had some
masculine (clitoral) inclinations. The double standard provoked
double-bind situations: men felt the need to have sex frequently (to
affirm their maleness) with women who (being psychoanalytically
mature) should be only mildly, indirectly, and passively interested
in sex. The male, then, was culturally and therapeutically sup-
ported for being the pursuer, the taker, the aggressor, the con-
queror. Should he run into a performance (erectile) problem, it
was likely to be interpreted as an unresolved Oedipal problem. If
the complaint was a difference in desire, with the woman more in-
The Role of Cultural Values 55

terested in sex than he, she might be viewed as masculine or,

worse, polymorphous perverse. One is left with a rather unclear
idea of what a good sexual interaction was supposed to be. Was it a
variation of Rhett and Scarlett's aggressive-coy courtship in Gone
with the Wind (1935)? Was the enjoyment of clitoral stimulation
ever something other than masculine and immature? Was female
attention to the male's penis, orally or genitally, merely an expres-
sion of homage to a lost object (for her) or a fixation at some
pregenital level of development (for both of them)?
In dealing with these questions, traditional psychoanalysis,
like other forces working within the culture, helped maintain the
status quo on sex roles, female sexuality, and the meaning of sexual
pleasure. A new concept (fixation or immaturity) replaced earlier
concepts of sin and physical harm as the reason for controlling sex-
ual expression; sexual dysfunction was regarded as a manifestation
of serious developmental psychopathology (Kaplan, 1974). As
deBeauvoir mentioned, psychoanalysis developed extremely rigid
rules about "normalcy." Therapists within this system had a poten-
tially more powerful influence over the small percentage of the
population who were their patients than did the culture, whose
rules were more easily violated without punishment.
Some therapists tried to reexamine analytic theory. Homey
(1924) immediately challenged the notion of the overwhelming im-
portance of penis envy. Bruno Bettelheim, Clara Thompson, and
others, including Erikson (1964), also contradicted this concept,
adding that "womb envy" might be a parallel stage for men and
that the presence of a uterus, rather than the absence of a penis,
was the important source of sexual gratification for women (Bard-
wick, 1971). Sherfey (1973) has recently attempted to reconcile an-
alytic theory with new data. Addressing the problem of the cli-
toral-vaginal transfer, Sherfey stated that:
we seem to be in a strange dilemma of having a developmental theory that
explains so much so well, and conforms to many women's life histories and
felt experiences, yet one that has shown surprisingly little therapeutic effec-
tiveness and has had only a questionable basis in biology. (pp. 21-22)
To go one step further, it may be that psychoanalysis seems to
"explain so well" because it reflects shared cultural stereotypes and
56 Joseph LoPiccolo and Julia Heiman

that it "confonns to life histories" because in a rigid society, cul-

tural stereotypes detennine the contents of life histories for all but
the rebellious few.
In sum, Freudian theory capitalized on anatomical sexual dif-
ferences as a basis for explaining the development of normal and
abnonnal sexuality. Various forms of sexual expression no longer
necessarily resulted in physical hann or religious punishment, but
psychopathology threatened everyone who did not resolve his or
her "immature," "polymorphous" urges. Freud continued a tradi-
tion, nevertheless, of defining sexual nonnality in an extremely
narrow fashion: intercourse was the only acceptable activity,
women were expected to have no sexual drive, and pleasure during
sex was kept at a minimum, lest its dangerous forces undo civiliza-
tion. Prevention of sexual problems remained synonymous with
suppression of the wider range of sexual behavior. Not until the
late 1940s did a change in these century-old themes occur.

4. The Post-1940s Message: "Sex Is OK for Both Males

and Females and You Better Be Good at It"

The importance of Freud's views on sexuality were gradually

overshadowed by several new influences, both scientific and ex-
trascientific. Within the scientific community, the two vanguards of
change were the works of Alfred Kinsey and, later, the contribu-
tions of William Masters and Virginia Johnson. The impact of these
researchers was extensive; our purpose here is to look specifically
at the manner in which they both challenged and adhered to their
cultural heritage, and the meaning of their findings in tenns of sex-
ual function and dysfunction. Particular attention is focused on the
themes of the previous section, namely, female sexuality, male-
female sex differences, and the concept of pleasure.

4.1. Kinsey's and Masters and Johnson's Legacies

An obvious, yet revolutionary (to sex research) aspect of Kin-
sey's work was that it quantified sexual behavior in a descriptive
The Role of Cultural Values 57

manner. Whereas Freudian ideas of sexuality were based on in-

terpretations of a limited number of clinical cases, Kinsey's data
were presumably more representative as they were collected from
a national sample and reported as a cross-tabulation of objective
categories. Such an approach was well in line with Kinsey's profes-
sional background as an established researcher in evolutionary
theory. His volumes essentially provide a taxonomy of sexual be-
haviors, their frequencies, and their relationships to demographic
factors, a research strategy that had been used on a limited scale in
the 1920s and 1930s (Davis, 1929; Hamilton, 1929; Dickinson &
Beam, 1932). People were now able to estimate how often males
and females actually performed "prohibited" activities. Over 90%
of the men reported that they had masturbated, and over 50% of
the women and 83% of the men had participated in premarital in-
tercourse. Even more surprising, Kinsey reported that oral sex was
far from uncommon, and extramarital affairs included 50% of the
men and 25% of the women interviewed.
The publication of such facts shocked almost everyone. Kin-
sey's work remains the most exhaustive attempt to develop an un-
derstanding of what kinds of activities really were practiced by the
average person (granted the problems with the Kinsey volunteer
sample). The discrepancy between actual and culturally prescribed
behavior was something that individuals within a post-Freudian,
guilt-laden culture could identifY and compare to their own experi-
ence. One of the obvious effects of the dissemination of the Kinsey
information was to "normalize" the sexual activities that were a part
of people's sexual repertoires, in spite of religion, laws, and Freud.
It was Kinsey and his associates' second book, Sexual Behavior
in the Human Female (1953), that was the most controversial. This
was not surprising, given the repressed, ideally asexual nature of
the Victorian-Freudian conception of women. Kinsey reported that
62% of women eventually masturbated and that 84% of them relied
primarily on labial and clitoral stimulation. These percentages,
drawn from a sample of 5,940 women, were too substantial to allow
anyone to hold to a belief that all of these women were "immature"
and! or "masculine." Furthermore Kinsey's data showed that a good
predictor of female orgasm during coitus was the experiences of
58 Joseph LoPiccolo and Julia Heiman

orgasm by any means (including masturbation). This fact, along

with the high incidence of orgasm during oral and manual petting
activities, challenged the biological "naturalness" of coitus as the
only real form of sexual satisfaction. Thus the realities of female
sexuality gained some empirical identity through Kinsey. Accep-
tance of female sexuality as healthy, however, was far from unani-
mous. In 1954 Bergler and Kroger published a book entitled Kin-
sey's Myth of Female Sexuality, a rather inBuential work in the
therapeutic community.
Kinsey's descriptive methodology did little to blend the
sharply defined ideas of masculine and feminine stereotypes of sex-
ual behavior or, more specifically, to break down the double stan-
dard regarding sexual activity. His data, in fact, supported the
thesis that men had the greater libido; certainly they were more
sexually active from an earlier age than were females. Women mas-
turbated in fewer numbers, began intercourse later, and were less
orgasmic than men. The nature of Kinsey's methodology suggested
that this state of affairs was probably "natural," reBecting the inher-
ent biological differences between the sexes, rather than being ef-
fects of sex differences in the social learning of sex roles.
Kinsey left us with a clearer idea of what was going on sexually
by social class, education, age, and geographic area. Yet he did not
consider the ways in which these relationships evolved nor in-
terpret the data in terms of cultural or collective personal history
inBuences. The result was that many people interpreted the sex
differences that Kinsey described as biological givens, as the natu-
ral pattern of sexuality. This was especially true in the case of dif-
ferences between males' and females' sexuality, since these general
relationships held up across education, social class, and, to some
extent, age. Kinsey's view of much of sexual behavior as an immu-
table biological given, of course, implied that efforts at prevention
or treatment of sexual problems were inevitably doomed to failure.
It was the Masters and Johnson research (Human Sexual Re-
sponse, 1966) that contributed some illuminating data regarding
female sexuality and challenged former ideas on male-female dif-
ferences. Most important, they concluded that during the sexual
response cycle, men and women responded more similarly than
'The Role of Cultural Values 59

dissimilarly. During sexual arousal, both sexes experienced in-

creased heart rate, blood pressure, genital vasocongestion, muscle
tension, rate of breathing, and skin flush. Orgasmic contractions
occurred at the same intervals for both men and women. Sexual
response was indeed a total body involvement for both sexes. One
major confrontation between Masters and Johnson's results and
traditional assumptions about female sexuality centered around the
importance of the clitoris, masturbation, and multiple orgasm.
With the data on over 300 women and some 7,000 sexual response
cycles, they concluded that all orgasms were the result of clitoral
stimulation. They completely discounted the distinction between
clitoral and vaginal orgasms, saying:
From an anatomic point of view, there is absolutely no difference in the
response of the pelvic viscera to effective sexual stimulation, regardless of
whether the stimulation occurs as a result of clitoral-body or mons area ma-
nipulation, natural or artificial coition, or, for that matter, specific stimula-
tion of any other erogenous area of the female body. (p. 66)

Regarding masturbation, not only were women able to mas-

turbate to orgasm in roughly the same amount of time as men, but
masturbatory orgasms were also more physiologically intense
(though not always psychologically more satisfYing) than coital
orgasms. This finding suggested several rather startling possibil-
ities: (1) masturbation, physiologically, was not a poor substitute for
intercourse, for it not only produced arousal and pleasure, but it
also could be a means of orgasmic satisfaction; (2) intercourse alone
was not necessarily the most arousing kind of stimulation; and (3)
manual or oral stimulation of the clitoral area was essential for
arousal and orgasm. The message to therapists and the general
public was that women who desired masturbation, foreplay, oral-
genital stimulation, and direct clitoral attention were not odd or
perverse. Whereas Kinsey had implied this conclusion in his
frequency tables, Masters and Johnson substantiated it with precise
and replicated observations.
The only strong sex differences identified by Masters and
Johnson concerned ejaculation and multiple orgasm. Their research
was the first to demonstrate scientifically that women do not ejacu-
late, a belief that had been part of the male-dominated folklore of
60 Joseph LoPiccolo and Julia Heiman

sex for some time. The presence of multiple orgasm in the female
was perhaps the more intriguing sex difference. Though Kinsey did
mention that 10% of the orgasmic women were multiply orgasmic,
Masters and Johnson produced physiological data showing that a
far greater percentage of women (perhaps all of them, as Sherfey
believes) are capable of multiple orgasm.
Masters and Johnson's second book, Human Sexual Inade-
quacy (1970), finally turned the tables on the Freudian therapeutic
approach to sexual dysfunction. Their results included posttherapy
effectiveness accounts and a five-year follow-up on all of the major
sexual dysfunctions. Their cure rate was astonishingly high, enough
to make people search for key factors in the success of their proce-
dure.
Most significantly, Masters and Johnson challenged the tradi-
tional notion of sexual dysfunction as the "tip of an iceberg," a
reflection of deep-seated emotional problems. In its place, they of-
fered the premise of "sex as a learned skill." Certainly, Masters and
Johnson's procedures did incorporate more teaching than
psychological interpretation. From doing conjoint physical exami-
nations labeling the sexual parts, to giving "homework" assignments
for the couple to work on, the therapist was cast more in the role of
instructor than had been the case in other forms of treatment for
sexual dysfunction. This change was important to the broader view
of sexuality. Because sexual problems were therapeutically concep-
tualized as a lack of proper information, the therapist had merely to
maximize the opportunity to learn, and in a sense, both prevention
and treatment became synonymous with education. The resulting
ingredients were the mainstays of the Masters and Johnson pro-
gram: slow, gradual progress, beginning with sensual pleasuring
activities that are easy and enjoyable; a nondemanding, nonthreat-
ening atmosphere; and feedback techniques to facilitate commu-
nication.
Masters and Johnson emphasized pleasure. Pleasure as a posi-
tive goal had been kept underground for centuries. In the past, sex
therapists had stressed a utilitarian, procreative, or religious ratio-
nale to justifY sexual activity. The emphasis on pleasure was an im-
portant change. The giving and receiving of pleasure had to be
The Role of Cultural Values 61

taught in sex therapy; breaking down this remnant of the Puritan

mentality remains a major part of the treatment of sexual dysfunc-
tion.
Looking at the general contributions of Kinsey and Masters
and Johnson, we notice the following:
1. Kinsey set the stage for studying sex directly, describing
sex as a variety of activities, positions, limbs, organs, and orifices.
Intercourse, whatever the cultural and legal proscription about it,
was only one of many sexual activities that men and women prac-
ticed. In short, by 1953 we had a descriptive account of what sex-
ual behaviors were going on and how often-a roughly normative
and objective base from which to evaluate another person's behav-
ior.
2. While Kinsey delivered women from Victorian-Freudian
assumptions of female asexuality, Masters and Johnson redefined
women's clitoral and orgasmic needs as positive, rather than imma-
ture and perverse, qualities.
3. Masters and Johnson also equalized the physical sexuality
of men and women by demonstrating the similarity of male and
female sexual response.
4. People not only practiced noncoital varieties of sexual ex-
pression (Kinsey), but these varieties turned out to be healthy for a
satisfYing sexual relationship. An exclusively intercourse-centered
pattern contributed, in fact, to many couples' distress (Masters and
Johnson, 1970).
However, as much as these recent sex researchers have repu-
diated many of the destructive myths of the past, revised values
have placed new demands on individuals' sexual expectations. Kin-
sey did not alter the cultural viewpoint that it is the male's respon-
sibility to initiate sex and maintain erection, and if anything, he
suggested that it is natural for men to be more sexually active than
women. By the time the Masters and Johnson books were cul-
turally digested, two additional shifts had occurred: one was the
reconceptualization of women's sexuality as not only orgasmic but
potentially multiply orgasmic; and the second was the clinical em-
phasis of doing sex right (Le., being a skilled lover). Being success-
ful at sex was now based on objective data: length of foreplay, erec-
62 Joseph LoPiccolo and Julia Heiman

tile latency, staying power, latency to orgasm, number of orgasms,

and intensity of orgasm.
The fact that women's sexual needs were considered bona fide
put new pressures on men. The events of the 1960s (including sex
research, social change, and media dispersion of information) actu-
ally expanded the performance demands from exclusively male to
jointly male and female responsibilities. No longer was the male
just expected to perform well, he was expected to arouse his fe-
male partner, too. Meanwhile women began to feel a pressure to
experience at least one orgasm while also helping to arouse and
satisfY their partners. Though these sorts of mutual performance
demands were part of a cycle that Masters and Johnson were intent
upon breaking, the message to the public, primarily a result of
media information, that one should be sexually accomplished re-
mained. Sex-once evil, then a conjugal duty, then psychologically
dangerous-had come to be an expected accomplishment.
To illustrate the influence of performance expectations in the
definition of sexual function and dysfunction, we would like briefly
and tentatively to draw a comparison between the trends in sexual
dysfunction across Masters and Johnson's and our own data.
Currently there may be a shift in the frequency with which
men with erectile failure and women with secondary inorgasmic
difficulty are requesting therapy. If we compare Masters and John-
son's data from the early 1960s (total cases = 773) with our own
over the last four years (total cases = 168), complaints of erectile
failure appear to be decreasing, while complaints of secondary in-
orgasmic disorders are increasing. Of the four major sexual dys-
functions, Masters and Johnson reported that of their total case
load, 32% were erectile failures, 24% were premature ejaculators,
25% had primary female inorgasmic dysfunction (total absence of
orgasm), and 19% were secondary female inorgasmic dysfunction
(absence of orgasm during coitus). We have found that the percent-
age of cases of premature ejaculation and primary orgasmic dys-
function have remained virtually identical in our sample (25% and
25%). However, erectile failure cases have decreased to 18%,
while secondary inorgasmic cases have increased to 32%.
If we assume, temporarily, that these differences are not just
The Role of Cultural Values 63

artifacts of differences in patient screening procedures or popula-

tion differences but reflect real trends, a few speculations are in
order. More women are complaining of lack of orgasm during in-
tercourse. For some of them, this dysfunction is a sign of their real-
ization that orgasmic pleasure during intercourse need not be the
exclusive domain of their male partners. For other women, lack of
coital orgasm may be due either to improper techniques of their
partner or to the couple's difficulty in communicating their sexual
needs to each other. In each of these cases, there is a certain
amount of tension between partners that is reflected in other
aspects of their relationship. This tension, to a great extent, plays
off mutual performance demands for being a good lover and a suit-
able companion in general. Though men are often as ego-involved
in coital orgasm as women, our impression is that secondary in-
orgasmic women are somewhat more committed to realizing their
orgasmic potential. Consequently we feel that this commitment is
reflected in the increased demands that women are putting on
their own sexuality, their partner's performance, and their rela-
tionship in general.
Of course, relationship problems also characterize erectile
problems in men. In fact, many therapists think that the women's
liberation movement has caused a dramatic increase in the number
of men suffering from erectile failure. On the contrary, our data
show a mild decline in the number of such cases appearing for
therapy. We suggest that rather than necessarily threatening male
sexuality, the feminist ideals of women's assuming responsibility for
their own sexuality and of deobjectifying, and thus personalizing,
sex may have helped take pressure off penis-centered, performance-
anxious men. Our clinical sample of erectile failure cases paints the
following composite of a typical couple: an easily stressed man who
constantly monitors his own performance and is worried about los-
ing his masculinity, and a rather demanding, critical, not particu-
larly liberated woman, who interprets his lack of response as a neg-
ative evaluation of her sexual appeal or ability. It appears, then,
that personal and interpersonal issues, rather than the effects of
women's liberation per se, may be the ones necessary to deal with
for therapeutic change. Sex role redefinitions, of course, may cause
64 Joseph LoPiccolo and Julia Heiman

sexual difficulties; a woman in the initial throes of identity change

is likely to disrupt a great deal of her life, both sexual and nonsex-
ual. The point is that other influences-people's interpersonal
style, their background, and their exposure to the sexual messages
of the media-seem to be far more important to sexual function
and dysfunction than any single factor, such as the women's libera-
tion movement. Prevention of sexual problems can not be ac-
complished by a simple focusing on anyone theme.

5. The Role of the Media in Defining Sexuality

Currently cultural definitions of sexual function and dysfunc-

tion are generated by the mass media at least as much as by the
writings of sex researchers and sex therapists. Unfortunately the
media's depiction of sexuality is one that causes problems for many
people. In such cases, the therapist must help the client to deas-
similate cultural values that are causing him or her distress. In this
sense, one major effective approach to prevention would be to
change the media's depiction of male and female sexuality.
A major problem is created by the peculiar mixed message
about sexuality transmitted in the media. On the one hand,
beauty, seductiveness, flirtatiousness, and the ability to be sexually
stimulating are required for media success. These traits have there-
fore been incorporated in our cultural definition of a successful per-
son. Yet, while the media glorifY looking and acting "sexy," they
phobically avoid or actively punish the simple presentation of di-
rectly sexual content. The heroine in television productions is gen-
erally beautiful, sexy-and celibate or even virginal. Typically, if
the heroine is actively sexual (especially in regard to non marital
sex), she will be dead, disgraced, or at least miserably unhappy by
the end of the program.
The media depiction of the ideal female creates two problems
for the women we currently see in sex therapy. First, many of our
patients suffer from extremely low esteem, in part, because they
do not resemble the idealized beautiful woman presented in the
media. Body concerns about age, weight, wrinkles, breast and hip
The Role of Cultural Values 65

size, and so forth, greatly inhibit many of our patients from full ex-
ploration and enjoyment of their body's sexual potential. The
average American woman, with perhaps career, child-rearing, and
home management responsibilities, simply does not have the time
or the money to lavish on herself that an actress does. Thus ther-
apy aims to increase the woman's acceptance and enjoyment of her
body, free of the negative effects of the media's artificial standards
for physical appearance.
Second, at least partially as a function of the media's negative
presentation of the sexual woman, many of our patients are uncom-
fortable about directly expressing their sexuality. It is difficult for
them to be sexually assertive and uninhibited with their husbands.
Consequently a major part of our therapy is aimed at producing
positive attitude change, through having the patient read positive
material about female sexuality, through therapeutic discussion,
and through the female therapist's disclosing her own enjoyment of
active sexuality (LoPiccolo & Lobitz, 1972). Of course, men also
suffer from this negative view of the sexual woman. Often, as a
woman begins to change in therapy, her husband balks and begins
to sabotage treatment gains, despite his stated goal that his wife
become more sexually active. Typically such a man has some
lingering media-generated ambivalence about "sexual women."
Will his wife become promiscuous, unfaithful, or dissatisfied with
him as a lover as she changes? Again, for therapy to succeed, the
therapist must deal with these fears and reassure the male that a
"good" woman can also be a "sexual" woman.
The media also create problems for males in regard to sex
roles and sexuality. The media's role model for a "real man" speci-
fies that he be sexually agressive, assertive, and free of sexual or
emotional concerns. As Paul Goodman (1960) has noted, "To boast
of actual or invented prowess is acceptable, but to speak soberly of
a love affair or sexual problem in order to be understood is strictly
taboo" (p. 124). This attitude often makes it very difficult for men
with a sexual dysfunction to accept the need for therapy. Discus-
sions with our referring gynecologists and urologists indicate that
while most women accept a diagnosis of no organic basis for dys-
function and will consider a referral for sex therapy, the majority of
66 Joseph LoPiccolo and Julia Heiman

men will not. Furthermore the men who do accept the referral
tend to enter therapy with very low self-esteem, feeling that they
are total failures as men, rather than that they simply have an
isolated problem. Again, the therapist must deal with these atti-
tudes before the actual tactics of therapy can be effective.
Our cultural definition of masculinity, as reflected in the
media, creates another barrier to the establishment of good sexual
and emotional relationships between men and women. Just as the
direct expression of sexuality is disapproved of for women, expres-
sions of tenderness, caring, affection, and dependency are taboo for
"real" men. Again, in sex therapy the therapist gives the man per-
mission to break out of the rigid "machismo" stereotype, to enter
into a more fluid and expressive relationship with his wife. Of
course, the wife must support this effort by indicating that she will
not lose respect for her husband or think him unmanly if he makes
such a change.
If television creates one set of problems by its presentation of
male and female sexuality, the recent flood of sex novels, sex maga-
zines, and sex columns in many women's magazines has created
another type of problem. Much of this material is pejorative and
demands that women must be aroused, multiply orgasmic, and
skilled at manual, oral, and other techniques of lovemaking. Simi-
larly, a man must be hypersexual and able to produce every sort of
orgasm for his wife. As a result of this literature, couples whose
sexual functioning is objectively entirely normal are now seeking
sex therapy. Concerns of such couples include inability of the wife
to have multiple orgasms, occurrence of coital orgasm on only
three or four out of five weekly lovemaking sessions, and the male's
wish for the wife to have coital orgasm to preserve his self-esteem.
It is ironic that the new availability of physiologically accurate
information concerning female sexuality, which should reassure
couples about their sexual adjustment, is having exactly the op-
posite effect in some cases. Somehow the popular media have
transformed "women are sexual and can have multiple orgasms"
into "real women must be hypersexual and have multiple
orgasms." Hopefully the present generation of therapists will not
accept this doctrine uncritically but will assure couples traumatized
The Role of Cultural Values 67

by it that they are functioning normally and are not in need of sex
therapy. In such cases, the therapist should give the patients "per-
mission" to enjoy those sexual activities that already provide satis-
faction for them (Annon, 1974). To move beyond the individual pa-
tient, a change in this media presentation of sexual competence
would prevent many people from ever defining themselves as hav-
ing sexual problems.
If the media have overreacted to recent research data on sexu-
ality and have thus been raising demands for goal-oriented sexual
performance, a subcultural rebellion against this trend is currently
emerging. This quiet revolution has begun to de-emphasize "good
technique" and "genital response with orgasm" and instead empha-
sizes sensuality and the use of the whole body for pleasure as the
way to approach sexual functioning. This change has come about
partly as a function of a new awareness fostered by the women's
movement. It is now acceptable, in many people's minds, for men
to be sensual, emotionally expressive, and passive. Similarly
women are beginning to accept overt sexuality as a positive ele-
ment of their personality and are beginning to be sexually assertive
and to show sexual initiative.
Another and perhaps more powerful source of this resen-
sualization of sex has been the sex researchers and sex therapists
themselves. Masters and Johnson (1970) helped introduce the sen-
sual into sex and de-emphasize performance goals when they spoke
of "total body involvement," "sensate focus," and "performance
anxiety and the spectator role." Sex therapy continues to empha-
size personalization, sensuality, and communication. Partner-
specific pleasuring with feedback, rather than an invariant sex man-
ual set of "good techniques," is what current sex therapy teaches.
Perhaps more important is the fact that researchers and thera-
pists no longer see sexual behavior as the Freudian tip of the per-
sonality iceberg. While they do not argue that sex is unrelated to
other aspects of personal and interpersonal functioning, sexual be-
havior is no longer seen as the primary reflection of developmental
maturity, psychological health, and unresolved intrapsychic con-
flicts. This reconceptualization has had positive effects on both
therapy and the larger culture. In therapy, sex therapists now work
68 Joseph LoPiccolo and Julia Heiman

with increased effectiveness directly on the dysfunctional "symp-

toms" rather than on the postulated "underlying" personality de-
fect. In the general culture, freeing sexual behavior from the role
of diagnostic barometer of psychological health has allowed people
to experiment and expand their sexual patterns without fear of
being evaluated as sick or perverse. In this vein, Alex Comfort
(1972) provided an obvious contrast to KraH't-Ebing and Freud:
In writing descriptively about sex, it is hard not to be solemn, however
unsolemnly we play in bed. In fact, one of the things still missing from the
"new sexual freedom," is the unashamed ability to use sex as play-in this,
psychoanalytic ideas of maturity are nearly as much to blame as old style
moralisms about what is normal or perverse. (p. 14)

The sex therapists and researchers of the 1970s, then, value

sensual pleasure, giving and receiving, communication, and experi-
mentation. While these values are in some ways reflections of
emerging subcultural trends in the general society, it also seems to
be the case that the therapeutic definition of sexual functioning
currently is based more on accumulating research data and on a
concern for patients' personal welfare than on rigid cultural values.
It will be interesting to see how sex researchers and therapists of
the next century regard current therapeutic efforts: as a valuable
contribution to individual growth or merely another chapter illus-
trating cultural biases in theories of personality, sexuality, and psy-
chotherapy procedures?

6. Conclusion

Over time a number of negative themes regarding sexual con-

duct have emerged; it was seen first as sinful, then as physically
dangerous, next as a symptom of psychological immaturity, and fi-
nally as a required ability. Our culture has found it difficult to ac-
cept a view of sexuality as simply an expression of basic human
needs for pleasure, closeness, love, sharing, and play, and continues
to portray sex in the media and elsewhere as a powerful force that
must be controlled at society's peril. The lack of any evidence that
sexual expression is physiologically or psychologically harmful has
The Role of Cultural Values 69

not affected this view. Similarly the stability and success of sexually
free cultures (in the South Pacific, for example) have had no effect
on the view of unrestrained sexuality as destructive of societal sta-
bility.
Over the centuries, religious, therapeutic, and media-
generated norms for sexuality have constricted and confined people
in roles and behaviors that have not allowed the full range of their
sexual and emotional potentials. To the contrary, these norms have
engendered inhibition, fear, guilt, and shame over sexual behavior.
We now realize that many of these cultural norms were sustained
in ignorance of knowledge of human biology and personality and
simply reflected an antisexual bias of the culture.
In the context of a rapidly changing culture, each patient's
personal experience must remain the one fixed reference point for
the therapists and researchers who generate the definitions of sex-
ual function and dysfunction. It is incumbent upon therapists,
therefore, to focus their efforts upon allowing their patients max-
imal freedom to explore and develop their sexuality in the manner
that provides each one of them with the greatest personal satisfac-
tion.
To some extent, this approach requires a countercultural ther-
apeutic perspective: one that questions narrow cultural definitions
of "good" and "bad" sexuality, and one that reduces the value-
dispensing authoritarian qualities of therapeutic interaction. If such
a position of cultural and personal self-consciousness can be main-
tained, and if research on familial and cultural factors that lead to
sexual dysfunction expand, programs for the prevention of sexual
dysfunction can become a common reality, and treatment may
become a rarity.

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LoPiccolo, J., & Lobitz, W. C. The role of masturbation in the treatment of
The Role of Cultural Values 71

primal)' orgasmic dysfunction. Archives of Sexual Behavior, 1972, 2,

153-164.
MacFadden, B. The virile powers of superb manhood. New York: Physical Culture
Publishing Co., 1900.
Manchester, W. The glory and the dream: A narrative history of America,
1932-1972. Boston: Little, Brown, 1973-1974.
Marcuse, H. Eros and civilization: A philosophical inquiry into Freud. New York:
Vintage, 1955.
Masters, W. H., & Johnson, V. E. Human sexual response. Boston: Little, Brown,
1966.
Masters, W. H., & Johnson, V. E. Human sexual inadequacy. Boston: Little,
Brown, 1970.
McLuhan, M., & Fiore, Q. The medium is the message. New York: Random
House, 1967.
Moore, B. E. Panel report: Frigidity in women. Journal of American Psychoana-
lytic Association, 1961, 9, 571-584.
Sherfey, M. J. The nature and evolution of female sexuality. New York: Vintage,
1973.
Szasz, T. The myth of mental illness. American Psychologist, 1960, 15, 113-118.
Taylor, G. R. Sex in history. New York: Harper, 1970.
 3
Editors' Introduction

Transsexualism, which is the most extreme form of a sexual iden-

tity disorder, is the most severe and disabling sexual problem en-
countered by health professionals. The only "treatment" for trans-
sexualism with some evidence of effectiveness is irreversible sex
reassignment surgery. And yet, ironically, preventive efforts are
further advanced in this area than in any other area of sexual disor-
ders. This progress is due largely to the efforts of Richard Green,
who is one of the foremost authorities on the variety of sexual iden-
tity problems.
Green begins by reviewing the types of sexual identity prob-
lems, ranging from the child who is beginning to display some
atypical gender role behavior to adults with mistaken gender iden-
tity, and discusses the types of conflict that emanate from each of
these conditions. After raising some basic questions on what behav-
ior within these various conditions should be prevented, Green
discusses possibilities for primary preventive action during child-
hood, which he illustrates with some clinical excerpts. This section
is followed by a review of specific programs, most of which are cur-
rently undergoing evaluation for the primary prevention of sexual
identity problems. But prevention is not without its risks or its
dangers, and a discussion of these risks is followed by a compelling
proposal for a solution to the conflict between risks and benefits in-
herent in any early primary preventive effort.

73
 3
Intervention and Prevention: The
Child with Cross-Sex Identity
RICHARD GREEN

1. Introduction: Sexual Identity Conflict

Prevention of conflict over sexual identity is an area that engages

research and ethical issues and cuts across lines of contemporary
social change. Politicalization has occurred during recent years in a
fashion unprecedented in other areas of psychotherapy. It invests
the contemporary social fabric as our society refashions acceptable
sexual lifestyles.
A working definition of sexual identity is in order. Discussion
may be rendered more comprehensible by the dissection of sexual
identity into three components. First there is an individual's earli-
est and enduring awareness of belonging to one of the two sexes.
This is core-morphologic identity: "I am male; I am female." Sec-
ond there is gender role behavior: masculinity and femininity. It
consists of those behaviors that are behaviorally dimorphic for
males and females in a given culture at a given time. Third there is
sexual partner preference: other, same, or either sex; heterosex-

Richard Green • Department of Psychiatry, State University of New York at Stony

Brook, Stony Brook, New York 11794.
75
76 Richard Green

uality, homosexuality, or ambisexuality. These components appear

to be developmentally sequential. Core-morphologic identity
emerges during the first year or two of life, gender role behavior
during the next two or three years, and sexual orientation, while
clearly manifest during adolescence, appears to have harbingers
during the later prepubertal years or even earlier.
The three components of sexual identity may be typical or
atypical in any combination for a given individual. Thus a person
may have a self-concept discordant with anatomy, behave in either
a feminine or a masculine way, and have a sexual partner prefer-
ence for males or females. An individual may have a core-
morphologic identity consistent with anatomy but behave in a
cross-gender-role fashion, again with a sexual orientation to males
or females. And, an individual may be content with anatomic sex,
show culturally typical masculinity or femininity, and experience
sexual attraction toward persons of either sex. Thus the combina-
tions of sexual identity are several and engage different societal re-
actions of sanction or acceptance.
Patterns of atypical sexual identity that can induce conflict and
that present to clinicians include (1) adult or adolescent males or
females, anatomically normal, with varying degrees of cross-gender
behavior who want to change sex; (2) adults or adolescents who fe-
tishistically cross-dress (typically males who achieve erotic arousal
from wearing women's clothes); (3) adults with a same-sex-partner
preference desirous of heterosexual reorientation; (4) preteen chil-
dren with dramatically atypical gender role behavior; and (5) very
young children with ambiguous genitalia, or their families, who
may be experiencing conflict regarding which sex of assignment is
proper for the child. Clinically these conditions differ, the degree
to which prevention is possible differs, the age at which interven-
tion might be invoked differs, ethical considerations differ, and
societal reactions to the behaviors differ.
Consideration of the range of atypicality enables one to focus
on the types of conflict that emanate from each. For the transsex-
ual, at any point in the life cycle, conflict is profound. The individ-
ual experiences a most basic contradiction between self-image and
visible anatomy. With increasing age, from childhood to teenage to
The Child with Cross-Sex Identity 77

adulthood, and the development of secondary sex chamcteristics,

this dichotomy augments. During childhood the conflict is so ex-
treme that suicide may be considered the only exit from the di-
lemma. More commonly, tmnssexuals relentlessly pursue physi-
cians to transform their bodies into concordance with their
anatomic self-image. Years of conflict may finally culminate in sex
reassignment surgery with the hope that ensuing years will be less
conflict-ridden. Data so far indicate that most tmnssexuals do bet-
ter in the immediate years after surgery but continue to experience
some problems. Long-term follow-up will tell whether conflict ex-
perienced prior to sex reassignment has scarred the psyche and
indelibly left its mark.
Another form of atypical adult sexual identity is transvestism.
Here the individual feels a compelling need to cross-dress periodi-
cally. This cross-dressing is typically accompanied by sexual arousal
and may be a requirement for sexual arousal. The conflict experi-
enced by such persons is often considerable. They are frequently
in jeopardy oflegal sanctions in those localities in which cross-dress-
ing is forbidden. If not married, they are limited with respect to
dating partners. These heterosexual males must find a partner will-
ing to permit the cross-dressing on a regular basis and perhaps per-
mit at least partial cross-dressing as a component of their sexual
relationship. If the transvestite marries and the couple have chil-
dren, the dilemma arises as to whether the children should be per-
mitted to witness the father cross-dressed. Further, the logistics of
keeping the cross-dressing secret from neighbors frequently
requires considerable ingenuity so that the atypical behavior does
not become public gossip in the event a neighbor visits unan-
nounced or the tmnsvestite is seen entering or exiting the house,
cross-dressed, in less than perfect disguise.
During adolescence the emerging transvestite is frequently
plagued by his fetish, typically has no one to tum to for feedback
regarding the meaning or incidence of such behavior, and experi-
ences considerable anxiety regarding the "freak" nature of his
emerging sexuality. There are no data reporting the natural course
of early adolescent fetishism or cross-dressing. While most adult
transvestites report that their cross-dressing dates back to early ad-
78 Richard Green

olescence or earlier (Prince & Bentler, 1972), we have no data on

how many individuals have passed through a similar phase to
emerge as typical adults.
Consider next the heterosexual male content with his ana-
tomic sex who appears grossly "feminine" to the public. This per-
son is frequently mistaken for a homosexual by the public and as-
sumes a burden comparable to the effeminate homosexual in a
sexist and homophobic society. Such persons reveal that styles of
affect more typically considered "feminine" may be incorporated as
a personality component in males who are content with their core-
morphologic identity, who do not wish to appear as women, and
who have no interest in sex relationships with males. This con-
stellation remains an enigmatic facet of psychosexual development.
Thus the spectrum of atypical sexual identity engages several
aspects of personality development and generates several issues at
the interface between an individual's behavior and societal expecta-
tion. A transsexual requires surgical and hormonal intervention far
more than social tolerance for a wider range of what is considered
acceptable "masculinity" and "femininity." By contrast, the fem-
inine-appearing heterosexual male or the masculine-appearing het-
erosexual female would benefit from society's broadening its defini-
tion of "appropriate" behaviors for males and females. At
mid-ground is the transvestite, who needs to incorporate his atypi-
cality comfortably into his aspirations for a conventional family life.
To him, this goal takes precedence over public skepticism with re-
spect to cross-dressing.

2. Possibilities for Prevention

Which of these atypical sexual patterns should be prevented?

What components should be prevented? Can they be prevented?
Are there dangers in attempting prevention? Do the dangers out-
weigh those of ignoring the behaviors? Which are the more extant
and serious errors, those of omission or of commission?
Granting that the atypical person, at any stage in the life
cycle, is experiencing conflict, four alternatives for coping come to
'The Otild with Cross-Sex Identity 79

mind: the individual can change the behaviors that induce conflict;
the individual can hide the source of conflict from the external
world; the individual can flaunt the typical behavior and attempt to
ignore societal reaction; or the individual can attempt to change so-
ciety so as to accommodate his or her atypical behavioral pattern.
Probably it is with homosexuality that these four possible patterns
of coping manifest most clearly, although to a lesser degree they
are also brought into use for transvestism and transsexualism.
During the adult phase in the life cycle, there may be more
flexibility in choosing a style of coping than during childhood. The
child is at a significant disadvantage, having little capacity to
change society and living under considerable pressure from a peer
group whose selection he or she cannot control because of required
school attendance and lack of geographic mobility.
Direct and indirect evidence supports the contention that
there is a population of conflicted children. Almost all adult trans-
sexuals recall their cross-sex identity as beginning during early
childhood (Benjamin, 1966; Stoller, 1968; Green, 1974). If one ac-
cepts these histories, there is a population of troubled, pretranssex-
ual children. Beyond this, there appear to be other children simi-
larly troubled over their sexual identity who may not evolve into
transsexuals but who also experience profound conflict. The study
of a sample of 500 transvestites revealed that half commenced
cross-dressing prior to puberty (Prince & Bentler, 1972), and a
study of 90 adult homosexual males revealed that two-thirds
showed considerable "girllike" behavior during grade school
(Saghir & Robins, 1973). However, there are typical heterosexual
males who were also "feminine" during childhood.
Since children do not walk about with foreheads stamped
"pretranssexual," "pretransvestic," "prehomosexual," or "pre-
feminine-heterosexual male," there is no way to identifY the dif-
ferent subgroups of children with similar patterns of cross-gender
behavior. Indeed it is this issue that is at the hub of the con-
troversy surrounding questions of prevention and intervention dur-
ing childhood.
An assumption of the title of this book is that prevention is
possible with respect to the atypicalities of sexual identity. This as-
80 Richard Green

sumption has not been proved at this time in the history of psycho-
sexual research. While there are clincial reports (Green, Newman,
& Stoller, 1972) indicating that children with what appeared to be
an atypical sexual identity show change toward the more typical
range of behaviors with intervention, the evidence is not yet in that
the change is permanent or that later conflict has been prevented.
Perhaps if prevention were already demonstrated for the various
atypicalities, our task would be more clear. However, because of
the largely theoretic and experimental nature of strategies of pre-
vention, the issue has engaged controversy.
If one accepts the premise that prevention is possible, the
next question is, Prevention of what? Is it prevention of the mani-
festation of atypicality? Is it prevention of distress due to the atypi-
cality? Should persons learn to live with it, hide it, or flaunt it?
Should society change to accommodate the person, or should the
person change to accommodate society?
We are in a remedial, catch-up situation when we deal with
the adult. The last decade has witnessed a dramatic evolution, if
not revolution, in attitudes toward the plight of the adult who feels
himself or herself "trapped in the wrong body." Whereas a decade
ago most patients were forced to go out of this country for surgery,
today there are dozens of medical centers in the United States per-
forming sex reassignment procedures. The indications and con-
traindications for surgery, the techniques of surgery, and the early
follow-up data on operated patients can be obtained from other ref-
erences (Benjamin, 1966; Stoller, 1968; Green & Money, 1969;
Green, 1974).
Data on prevention of future conflict for the transvestite is
limited to those in distress who seek therapy to control compulsive
cross-dressing, which may be a requirement of erotic arousal. The
most promising results have been with behavior therapy, typically
linking faradic stimulation via a wrist electrode with fantasies of, or
the practice of, cross-dressing (Gelder & Marks, 1969).
Prevention of conflict in the adult homosexual is addressed to
those persons unhappy over not experiencing heterosexual arousal
or to those persons content with their sexual orientation, who are
having difficulties within a homosexual context. With respect to
The <ltild with Cross-Sex Identity 81

modifYing sexual orientation, some 20-40% of highly motivated in-

dividuals may experience sexual reorientation through behavior
modification techniques, group therapy, or long-term individual
psychotherapy (Bancroft, 1974). Additionally, many counseling
centers exist for helping homosexuality oriented persons to adjust
to their life-style.

3. Prevention during Childhood

Discussions of prevention are generally addressed to the child-

hood years. Here ethical and research questions abound. First, do
we know what we are preventing? Typically we have a femininely
behaving boy. We have a boy who prefers to dress in girl's or
women's clothing, and does this whenever he can. When denied
access to genuine articles of women's clothing, he improvises them
from available materials. "Barbie" is probably his favorite toy.
When he role-plays characters from television or movies, or when
he plays "house" or "mother-father" games, he typically takes fe-
male roles. His peer group is female; he does not get along well
with boys, complaining that boys play too rough. He is called
"sissy." He may state, "I want to be a girl."
Some clinical excerpts follow.
Family A
Dr.: How often does he dress up?
Mother: . . . Almost every day . . . It seems like every character
that he plays is a girl.
Dr.: When did he first begin dressing up?
Mother: I guess it's about two years now, when he was fuur.
Dr.: What was your feeling the first time you saw him dress up?
Mother: I probably thought it was cute.
Dr.: Has he ever said to you, "I want to be a girI"?
Mother: He has more or less said that he would like to be a girl, and
"I am a girl."
Family B
Father: . . . Most of it is that he still wears my wife's shoes to go to
class, and he'll drag out all her shoes. . . and he'll wear any-
thing on his head, scarf or towel, or he'll wear her
skirts . . .
82 Richard Green

Mother: When he was two, the other boys (would) say, "What do you
want to be when you grow up?" He would say he wants to
grow up to be a mommy. We just kind oflaughed at it at first
. . . and he plays with little girls alI the time. He likes to
play house and he's the mamma.

Family C
Dr.: Have you ever wished you'd been born a girl?
Boy (age 5): Yes.
Dr.: Why?
Boy: Girls, they don't have to have a penis . . . They can have
babies . . . . I wish I was a girl. You know what? I might be a
girl. (Green, 1974)

Who will these boys be in 5, 10, 20 years? Will they be trans-

sexual; will they be transvestic; will they be homosexual; will they
be ambisexual; will they be heterosexual? Three follow-up studies
exist of previously evaluated feminine boys (Zuger, 1966; Lebovitz,
1972; Green, 1974). The total number is small: 26. Of these, 14 are
transsexual, transvestic, or homosexual. But 12 are heterosexual.
Those clinicians who have counseled adult transsexuals on
their way to what they consider to be the final solution to their
problem-sex-change surgery--can attest to the years of misery ex-
perienced on the way. Only long-term follow-up will permit us to
know the degree to which this long-sought goal fulfills the antici-
pated promise. Nevertheless, even if it does, many years of relent-
less trauma preceded this dramatic life change. Clinicians who
have counseled those transvestites (probably a minority) plagued
by the compulsion to cross-dress, the inability to achieve penile
erection unless cross-dressed, and troubled over whether their
children should see them dressed as women recognize that such
persons experience considerable conflict and guilt. Those who have
counseled the minority of homosexuals who wish heterosexual
reorientation but are unable to achieve heterosexually oriented
genital arousal and who desperately desire the life-style associated
with heterosexuality are witness to the conflict experienced by
these persons.
Yet the evidence that the boys with the behavioral picture de-
scribed above will mature into any of these atypical sexual life pat-
The Child with Cross-Sex Identity 83

terns remains largely indirect. It is based on the retrospective stud-

ies of transsexuals, transvestites, and homosexuals cited earlier.
Even if these boys do not mature into these atypical patterns,
can the case be made for intervention that may not be prevention?
The feminine boy experiences considerable conHict if he desires to
be of the other sex. Independent of societal reactions toward atypi-
cal behavior, irrespective of whether the child is evolving into a
person with a typical or an atypical sexual identity, the conHict ex-
perienced in childhood feels the same.
Where lies the therapist's responsibility when he or she is
consulted by a troubled family? Typically the parents are desirous
of behavioral change in their child and are concerned over his
unhappiness at being teased and ostracized. The child is typically
unhappy over the peer group reaction to his behavior and unhappy
over not being what he cannot be (someone of the other sex). Does
the therapist have a responsibility to reduce that immediate con-
Hict, whether or not it is a harbinger of later atypical behavior and
later conHict? Should the therapist be a cultural idealist espousing
the philosophy that an individual's gender role behavior is private
business and not the province of the peer group or the larger soci-
ety? Should the therapist assert that the child should be permitted
to behave in any way currently and evolve into any behavioral pat-
tern later, so long as it is not physically harmful to self or others?
This ideal may be easier to espouse on paper than in a real-life
clinical situation with a hurting family.
In spite of all that has been said and written regarding a uni-
gendered or unisexed movement "sweeping" the country, consid-
erable sexism continues in this culture, especially in the pediatric
age group. The message of a unisexed culture has not filtered into
the pediatric ethos, and the atypical child of today is taunted with
the same epithets as the atypical child of a generation ago.
When parents and child want intervention directed at behav-
ioral change, is it ethical for the therapist to withhold intervention
based on the therapist's ethic? Or is it the therapist's responsibility
to meet the needs of the family so long as these needs are not dem-
onstrably harmful to a family member?
If the therapist elects intervention, a variety of strategies exist.
84 Richard Green

Intervention can be directed at enabling the child to live with his

atypical behavior. The style might be similar to enabling a child to
live with any condition that might evoke teasing. More difficult,
however, would be enabling the child to live with the inner wish of
wanting to be of the other sex. Here a therapist wishing to reduce
conflict might educate the child to the impossibility of magically
changing sex and finding sufficient basis for contentment with the
sex of birth. Is it ethical to tell the child, "You can change sex, but
not until you are eighteen, or twenty-one, so 'hang in there' for the
next twelve years and then ask for a sex-change operation"? What
of the years of misery until then?
Is intervention to be directed toward molding the child into
the sex-role-stereotypic male? Should he be transformed into a
heroic, rough-and-tumble, aggressive sports-oriented lad? Should
he be denied access to female playmates or culturally feminine ar-
ticles and toys? Can a compromise be reached?

4. Principles of Intervention with Children

Some basic principles of intervention have been developed

over the years in my work with John Money, Robert Stoller, and
Lawrence Newman. They include exploring the child's under-
standing of the nature of the anatomic distinction between the
sexes, educating the child to the impossibility of magically chang-
ing sex, and emphasizing the positive aspects of the sex to which
the child belongs. There is detailed discussion of why the child
prefers being a member of the other sex and the activities, toys,
and roles that the child considers the sole province of persons of
the other sex. Distortions are corrected and the opportunity for
children of either sex to participate in these activities is revealed.
Male playmates are found who are not roughhouse, athletics-
oriented boys, who enjoy sedentary activities, and who are not stig-
matized as "sissies." Such children may need to be "bussed" into
the neighborhood for after-school and weekend recreation.
Where parents have been encouraging behavior that is causing
the child conflict, this is spotlighted. For example, some parents
The Child with Cross-Sex Identity 85

supportively laugh at and show off their cross-dressed sons, giving

positive reinforcement by considering it "cute."
The father may have "written off" his "sissy son," devoting his
time to siblings or out-of-house activities. The father needs to ap-
preciate the uniqueness of his son and to recognize that while he
will not participate with the father in sports or roughhouse play,
there are alternative father-son activities that can be mutually en-
joyable, benefit the relationship, and promote the boy's male iden-
tification. The Indian Guide program, available in some areas of
the country, promotes group father-son activities such as handi-
crafts, camping out and cooking, and de-emphasizes competitive
sports.
Many children have little or no idea what their father does
during the long workday away from home. A series of trips to the
job helps fill this void and can be another mutual recreational activ-
ity. In families without fathers, a Big Brother, uncle, grandfather,
neighbor, or male friend of the mother may serve as a father surro-
gate. Finally, the therapist should be of the same sex as the child
so that identification with the therapist may be another by-product
of intervention (Green, 1974).
Little attention has so far been paid here to atypical sex role
development in females. There are adolescent and adult females
who seek out physicians for sex reassignment procedures. The ratio
of females to males requesting sex reassignment, however, appears
to be about 1 to 3. With respect to transvestism, there is practically
no reporting of females who experience sexual arousal as an accom-
paniment of cross-dressing. For all intents and purposes, the fe-
male equivalent of male fetishistic cross-dressing does not exist.
Additionally females have a wider social latitude with respect to
sex-typed clothing than males and may wear masculine clothing
more readily than males may wear feminine clothing. Further, the
incidence of homosexuality for females, according to the data of
Kinsey, Pomeroy, and Martin (1948) and Kinsey, Pomeroy, Mar-
tin, and Gebhard (1953) appears to be about one-half that for
males, and the social sanctions against female homosexuality are
considerably less. Thus there are fewer conflicted adult females
with an atypical sexual identity.
86 Richard Green

By contrast, during the childhood years "tomboyism" is more

common than its counterpart "sissiness." Cultural reaction to the
two behavioral patterns is quite disparate. The pediatric culture
gives higher-priority status to masculine behavior for both males
and females. Thus "tomboys" do not receive comparable social os-
tracism to that given "sissies" and may achieve higher-priority
status than the more feminine female members of their age group.
Conflict experienced by grade-school girls with a more than
average masculine identity is considerably less than that experi-
enced by boys with a more than average feminine identity.
Most "tomboys" are content being anatomically female but
find that their gender role preference is for activities that the cul-
ture defines as masculine. They enjoy rough-and-tumble play and
sports, like to wear shirts and pants rather than dresses, and may
not enjoy doll play. However, some "tomboys," a minority, are
unhappy over being female and are evolving toward an atypical
adult identity. Most adult female-to-male transsexuals report that
they had wanted to be boys from early childhood (Benjamin, 1966;
Green, 1974; Stoller, 1976). Thus within the population of "tom-
boys" there is a small subgroup with a basic identity that is male
who are evolving toward transsexualism. However, the current
state of the science does not permit a clinical diagnosis of childhood
transsexualism. Nevertheless there are female children who experi-
ence conflict similar to that of their male counterparts because they
cannot be of the other sex. Intervention with a female who desper-
ately wants to be male would be addressed to the irrevocability of
anatomic sex, coupled with pointing out that female children can
participate in a variety of activities that might be more typically
considered masculine. Participation in such activities does not
require that one be male. Thus intervention is comparable to that
with very feminine boys who wish to be girls. The goal, again, is to
reduce immediate conflict with the potential of preventing sub-
sequent conflict. Androgyny is approached from the other end of
the gender role spectrum.
Intersexed children raise different issues of intervention.
Guidelines for decision making regarding initial sex of assignment
or possible subsequent reassignment have been detailed elsewhere
The Child with Cross-Sex Identity 87

(Stoller, 1968; Money, 1975). A summary guide is that initial sex of

assignment is dictated in large part by the prospective functioning
of the genitalia with endocrine and surgical treatment, coupled
with transmitting to the parents an unequivocal message that the
child is male or female. When there is persisting ambivalence,
and/or when the question of subsequent reassignment arises, the
age of the child and the emerging sexual identity must be consid-
ered. While dispute remains, the consensus among the most expe-
rienced clinicians is that sex-reassignment after the initial three
years of life is hazardous, unless sexual identity is pointing in the
direction of reassignment. The degree of conflict over adjustment
to a different sex role must be weighed against the degree of con-
flict over the appearance and function of the genitalia. Prevention
here is proper diagnosis and sex assignment during the neonatal
period.

5. Risks of Prevention

Are there dangers in treating children with sexual identity

conflict? We live in a time of skyrocketing malpractice suits and in-
formed consent forms replete with the gory details of what might
go wrong during treatment. Having recently undergone surgery
and being conscientious enough to read the entire preoperative
consent form, I was soothed by reading that I could meet death,
hemorrhage, or paralysis. The informed-consent document for a
patient agreeing to sex-change surgery, detailing exquisitely what is
to be done during the operation, is a startling piece of literature.
One clinician has suggested that we cast aside all standard criteria
for a preoperative diagnosis of transsexualism and adopt the defini-
tion of a transsexual as anyone who signs the consent form.
The risk accompanying clinical intervention with male or fe-
male children with extremely atypical sexual identity may not be as
bloodcurdling, but potential risks do exist. Focus on the behavior
may initially cause greater anxiety and result in the atypical behav-
ioral pattern's becoming intensified. Or the child may attempt to
push all the "offending" behaviors underground so as to appear
88 Richard Green

more like other same-sex children and to reduce parental and peer
pressure.
What is the effect of this suppression? A positive effect might
be that if the boy (for example) behaves in a more "masculine"
way, he will be treated as a more masculine boy by the peer group
and will experience modification of his self-image. The modification
could become internalized and permanent. A negative effect is that
if it does not become internalized but merely simmers below the
surface until such time as defenses are weaker and pressures
greater, there will be a dramatic resurgence of the previous behav-
ioral patterns. A likely phase of the life cycle for this resurgence is
during the normal psychosexual turmoil of early adolescence. An-
other potential danger is a product of a particular style of therapy
(for the boy, again as example) that systematically punishes all be-
haviors remotely "feminine" and rewards all "macho" actions
(Reekers & Lovaas, 1974). Displays of aesthetic sensitivity and gen-
tleness may be replaced by callousness, insensitivity, and aggres-
sion.
It may be argued that to induce intervention (which may be
prevention) reinforces societal sexism. Regrettably, to a degree it
does. But while we have a responsibility to reduce sexism, we also
have a responsibility to an individual child caught in the cross fire
between sex role idealism and the real world in which he is em-
bedded.
Arguments for or against intervention are not always rational.
It is ironic that those who most vocally decry attempts to change
the behavior of very feminine boys also decry the same behavior
when shown by girls. There is inconsistency shown by those who
espouse the ethic of eradicating sex role stereotypes but, in so
doing, would permit exclusive play with "Barbie" dolls and frilly
dress-up clothes for boys, but not for girls.

6. Changes in Society

There is another responsibility to the family: helping society

accommodate to the atypical behavior. The clinician as social scien-
The Child with Cross-Sex Identity 89

tist has the potential for influencing social change. The clinician can
work to enable persons of all ages who have an atypical sexual iden-
tity to live their lives within a cultural framework that does not
stigmatize. Some of us have been active in implementing sex-reas-
signment programs at university medical centers so that transsex-
uals may be properly evaluated and given responsible medical
care. Some of us have been involved in litigation to eliminate stat-
utes prohibiting public cross-dressing. Some of us have worked to
delabel homosexuality as a mental illness from the American Psy-
chiatric Association's Diagnostic and Statistical Manual of Mental
Disorders and to repeal antihomosexual laws. Some of us have
worked with homosexual parents striving for the same consider-
ations in courts of law as given heterosexuals in matters of child
custody and visitation after divorce (Green, 1977). Some others are
actively engaged in the examination of preschool and grade-school
mass media with the goal of reducing the dichotomy with which
the social roles of males and females are portrayed. The belief here
is that from the earliest years children should have role models of
both sexes portrayed in roles of teacher, doctor, nurse, cook, exec-
utive, and secretary. Further, programs can be made widely avail-
able to children that meet their individual needs and do not penal-
ize the nonathletic male. Programs of arts and crafts, playacting,
and competition board games can be as available as Little League.
Toy stores could have sections for parents wishing to purchase
androgynous toys rather than machine guns for sons and tea sets
and dolls for daughters.
A mother I saw a few years ago best articulated a rationale for
intervention with very feminine boys. She identified herself as a
feminist. She was living with a man whose prior sexual experiences
had been primarily with other males. In the current relationship
sexuality was mutually satisfying, with the male having no erectile
difficulty. She had borne her child from a marriage several years
prior to the current relationship. Her young boy was very femi-
nine. Her concern was that if he remained so, without some modu-
lation of the feminine traits, he would not, as he grew older, have
the same option as her current lover: the option to choose rather
than be programmed into an exclusive sexual orientation.
90 Richard Green

7. Toward Androgyny?

I contend that an androgynous solution can be found. I con-

tend that a comfortable mixture of what our culture has called
"masculine" and what our culture has called "feminine" can be-
come the personality style for persons of all ages. However, the
male children described above are dramatically atypical; they are
more feminine than many female children. Intervention (and per-
haps prevention) can be designed to strike a more equitable bal-
ance so that immediate social conflict is reduced and the qualities
that we value in males and females can be found in one and the
same child. Hopefully this child will mature into an adolescent and
an adult imbued with sensitivity and compassion, content with
inborn anatomic sexual insignia and comfortable in a wide range of
social situations.
Our research program is conducting a longitudinal evaluation
of very feminine boys and very masculine girls plus matched con-
trast groups of children showing culturally typical sex-typed behav-
ior. Long-term follow-up may help delineate those childhood be-
havioral patterns associated with an emerging atypical pattern of
sexual identity for subsequent adolescent and adult years. Those
children who, with their parents, have chosen and received inter-
vention may help answer the question: Is intervention also preven-
tion? If so, prevention of what?

References
Bancroft, J. Deviant sexual behavior. London: Oxford University Press, 1974.
Benjamin, H. The transsexual phenomenon. New York: Julian Press, 1966.
Gelder, M. D., & Marks, I. M. Aversion treatment in transvestism and transsex-
ualism. In R Green & J. Money (Eds.), Transsexualism and sex reassign-
ment. Baltimore: Johns Hopkins University Press, 1969.
Green, R Sexual identify conflict in children and adults. New York: Basic Books,
1974; London: Gerald Duckworth; Baltimore: Penguin.
Green, R Thirty-five children raised by homosexual or transsexual parents. Amer-
ican Journal of Psychiatry (in press).
Green, R, & Money, J. Transsexualism and sex reassignment. Baltimore: Johns
Hopkins University Press, 1969.
The Child with Cross-Sex Identity 91

Green, R., Newman, L., & Stoller, R. Treatment of boyhood "transsexualism."

Archives of General Psychiatry, 1972,26,213-217.
Kinsey, A. C., Pomeroy, W. B., & Martin, C. E. Sexual behavior in the human
male. Philadelphia: Saunders, 1948.
Kinsey, A. C., Pomeroy, W. B., Martin, C. E., & Gebhard, P. A. Sexual behavior
in the human female. Philadelphia: Saunders, 1953.
Lebovitz, P. Feminine behavior in boys: Aspects of its outcome. American Journal
of Psychiatry, 1972,128, 1283-1289.
Money, J. Sex assignment on anatomically intersexed infants. In R. Green (Ed.),
Human sexuality: A health practitioner's text. Baltimore: Williams & Wilkins,
1975.
Prince, V., & Bentler, P. Survey of 504 cases of transvestism. Psychological Re-
ports, 1972, 31, 903-917.
Reekers, G., & Lovaas, I. Behavioral treatment of deviant sex-role behaviors in a
male child. Journal of Applied Behavioral Analysis, 1974,7, 173-190.
Saghir, M., & Robins, E. Male and female homosexuality. Baltimore: Williams &
Wilkins, 1973.
Stoller, R. Sex and gender: On the development of masculinity and femininity.
New York: Science House, 1968.
Stoller, R. The transsexual experiment. London: Hogarth, 1976.
Zuger, B. Effeminate behavior present in boys from early childhood. Journal of
Pediatrics, 1966,69, 1098-1107.
 4
Editors' Introduction

The urgency of prevention of sexual offenses is clear because of the

violence of many sexual offenses and the rates of recidivism. And
yet the difficulties of prevention are nowhere more apparent, since
there is no clear evidence as yet on the factors that are responsible
for the development of sexually aggressive behavior. Such knowl-
edge, presumably, is necessary if we are to determine successful
preventive efforts. In this chapter Bancroft provides an up-to-date
summary of data on those social and psychological factors that seem
to be responsible for the development of aggressive sexual behav-
ior, and he follows this summary up with what might be the first
serious effort to describe potentially preventive programs for these
most serious disorders. These programs approach the problem
from the primary and secondary preventive points of view. In the
next chapter Walker describes a tertiary (rehabilitation) preventive
program for this population.
Bancroft begins by defining types of sexual behavior that fall
into the category of sexual offenses and the interaction of these sex-
ual offenses with the law. Following this introduction, Bancroft
presents a model of sexual development that involves three impor-
tant parallel elements: (1) gender identity and gender role, (2) sex-
ual responsiveness, and (3) the formation of dyadic relationships.
He then proposes problems that may arise in these three areas of
sexual behavior that could lead to the development of sexually of-
fensive behavior. In addition to these issues, the problem of self-
93
94 Editors' Introduction to Chapter 4

control, which is an issue in all criminal behavior, is discussed

within the context of sexually offensive behavior. After developing
these issues, Bancroft applies this model to specific problems such
as sexual assault, sexual relationships with children, and exhibi-
tionism and proposes some very innovative suggestions for both
primary and secondary prevention of these problems.
 4
The Prevention of Sexual Offenses
JOHN BANCROFT

Arriving at any plan of prevention that is likely to be effective

requires rational appraisal. The field of sex in general and sexual of-
fenses in particular has not been characterized by rational thinking.
Often the way that the law is framed serves to reinforce and main-
tain our more emotional reactions to this behavior. It is thus clearly
desirable that we should strive for as rational and objective an anal-
ysis of the problem as possible.
At the same time, we must be aware of our feelings on these
matters and be prepared to declare them. One of the lessons to be
learned from recent years is that in this very emotive area of
human sexuality one must decide one's own personal values and
those values must be made clear to others to avoid misinterpre-
tation.
Thus this chapter begins with a discussion of which sexual be-
haviors, in the writer's opinion, should be controlled by law and
where major changes in social attitudes and hence the law are
likely to occur. This discussion is followed by consideration of pos-
sible determinants of such behavior and, finally, the possibilities of
prevention.

John Bancroft • MRC Reproductive Biology Unit, Edinburgh EHI 2QW, Scotland.
95
96 John Bancroft

1. Sexual Behavior and The Law

At the present time the law relating to sexual offenses has

three main objectives. These are (1) protection of the individual, (2)
the avoidance of social disruption caused by explicit sex in public
places, and (3) the discouragement of certain forms of sexual behav-
ior considered for one reason or another to be undesirable.
With the first, protection is on the one hand against assault,
the use of physical force or the threat of it to achieve sexual ends,
and on the other hand against exploitation. Protection against as-
sault as an objective of the law is hardly likely to be a controversial
issue. There are one or two gray areas requiring clarification, such
as the use of force within marriage and the legal procedure for
dealing with evidence in rape cases. Nevertheless our values are
not likely to change greatly on this issue.
Protection against exploitation is again an issue that most
would accept in principle, though there will be dispute about what
constitutes exploitation and there are already some changes, for ex-
ample, in relation to "breach of promise" cases. The most obvious
example is exploitation of the child, and here the disagreement is
likely to be on matters of detail such as the age of consent and
whether a sexual relationship with a child is necessarily an exploita-
tive one. This is an area where there is scope for change, but
exploitation of a child will undoubtedly remain an undisputed rea-
son for legal protection.
The second main objective, the avoidance of social disruption,
is likely to remain in some form. Men and women as social beings
need, and probably always will need, some constraint on public
sexuality. Even if we return to the institutionalized public orgies of
the past, they will be only on specified days. There are few socie-
ties, if any, where sexual behavior is not required to be in private
except on special occasions.
The third main objective, discouragement of certain forms of
sexual behavior, is certainly the area where the most controversy
and probably the most change are likely to occur. Homosexuality is
the prime example. One can speculate why society has rejected
such behavior in the past. The devaluation of nonprocreative sex at
The Prevention of Sexual Offenses 97

times when the maintenance of population was a primary biological

or social need is perhaps some explanation, though it is unlikely
that this explains more than a part of society's antihomosexual atti-
tudes. In any case, that particular justification has been put
strongly into reverse. There is no justification now for the applica-
tion of legal constraints to sex simply on the basis of the gender of
participants.
The value that underlies this view is of sex as a form of inter-
personal closeness and communication, a shared intimacy that is
mutually rewarding and beneficial in the short term and binding in
the long term. To start with, the law has no place in discouraging
relationships of that kind because they happen to be between peo-
ple of the same sex. Furthermore that value system and the way in
which it conHicts with many prevailing cultural values, is very rele-
vant to the question of prevention (see Chapter 8).
There are types of sexual offense that do not fit neatly into
these categories. Prostitution, which is the principal form of female
sexual offense, is one example--society is confused and ambivalent
about prostitution. Incest is the second example, combining the
need for protection against exploitation with some universal taboo,
which may have an important biological or social function. But nei-
ther prostitution nor incest will be considered here. This chapter
concentrates on the three main types of male sexual behavior that
are acceptable as appropriate for legal control: (1) sexual assault,
forcing a sexual act upon an unwilling partner; (2) sexual rela-
tionships with children; and (3) exhibitionism.

2. Determinants of Sexual Offenses

Let us consider how sexual development as we understand it

relates to these three forms of behavior. Unfortunately the starting
point is a knowledge of normal sexual development that is sketchy
and impressionistic. Nevertheless it is possible to extract from
these impressions a simple model that allows consideration of sex-
ual offenses.
98 John Bancroft

Sexual development can be seen as involving three important

parallel elements:
1. Gender identity and gender role, the behavior that mani-
fests the individual's identity and that may serve to stabi-
lize or strengthen that identity. Obviously much gender
role behavior is not clearly sexual, but how we behave in
sexual relationships is an important aspect of how mascu-
line or feminine we feel.
2. Sexual responsiveness, the responsiveness of our physiolog-
ical mechanisms that underlie sexual acts.
3. The formation of dyadic relationships, learning how to get
close to people both emotionally and physically and how to
maintain close and rewarding relationships.
The development process involves the interaction of these
three elements, and while it has its periods of maximum change
and possibly critical or sensitive periods of special development, it
is a process that continues, with varying pace, well into late adult
life.
Data on the sexual development of offenders are unfortunately
no more complete than for people in general. The major study is
by Gebhard and his colleagues (Gebhard, Gagnon, Pomeroy, &
Christenson, 1965) at the Kinsey Institute, and there are a few
other smaller studies, such as that by Mohr, Turner, and Jerry
(1964) on pedophilia and exhibitionism. In these studies there is no
shortage of evidence of the factors, such as deprived home back-
grounds and difficulties in maintaining interpersonal relationships,
that one finds commonly among both psychiatric and prison popu-
lations. But there is relatively little to explain why sexual offenses
per se are committed and, especially, why the particular form of of-
fense was involved.
Two problems in the sexual development of sexual offenders
seem to be of central importance, however: (1) difficulty in incorpo-
rating sexual responsiveness into good dyadic relationships either
(a) because sex is a primary threat which needs to be avoided or
hidden and hence kept out of dyadic relationships or (b) because of
problems primarily in forming dyadic relationships, or both; and (2)
The Prevention of Sexual Offenses 99

the use of sexual behavior to reinforce gender identity, but at the

expense of dyadic relationships. There is a third problem that is of
central importance to sexual offenses and without which the first
two problem areas would probably be insufficient to lead to sexual
offenses. This problem is (3) inability or disinclination to use self-
control.

2.1. Difficulty in Incorporating Sexual Responsiveness into

Dyadic Relationships
Factors that might be important here are:
1. Fear of sex, which makes it a taboo subject and hence a
very private experience. In this respect early learning and
parental influences are obviously important.
2. Difficulties with physical intimacy, being able to touch or
to show affection through physical contact. Again parental
influences and social learning are likely to be important, al-
though constitutional factors may playa large part.
3. Isolation from the peer group and hence the main source of
appropriate sexual learning during adolescence. This isola-
tion may be because of generally poor peer group rela-
tionships or because physical development is out of phase
with the chronological peer group development (too early
or too late).
A very important stage of sexual development and one that is
probably very relevant to the understanding of deviant patterns of
sexual response involves the attribution of appropriate meaning to
emerging sexual responses. In one of the early studies of the Kin-
sey organization Ramsey (1943) documented the reports of prepu-
bertal boys, many of whom described genital responses (i.e., penile
erection) to a variety of nonspecific but arousing stimuli or situa-
tions, either pleasantly exciting or frightening. It is likely that these
nonspecific responses become more discriminated as sexual devel-
opment and learning proceeds, but social learning, particularly
from the peer group, plays an important part in shaping these
responses appropriately. Studies of children with precocious pu-
100 John Bancroft

berty indicate, not surprisingly, that the attribution of meaning to

sexual feelings, and hence the form that sexual fantasies develop, is
determined by the level of cognitive development of the child
(Money & Alexander, 1969). As Gagnon and Simon would say, the
script given to the child's sexual experience is a child's script, not
an adult's. Early onset of sexual responsiveness is not only a prob-
lem in that respect but may also serve to alienate the individual
from his or her peer group, who are not as yet troubled by these
pubertal stirrings.
However, an important aspect of this process requires clarifi-
cation and further research. For most people the kind of stimulus
that is sexually arousing is modified as development proceeds. For
example, sexual fantasies accompanying masturbation change and
evolve over time. Whereas conditioning through association with
orgasm or sexual arousal may playa part in endowing certain stim-
uli with erotic properties (McGuire, Carlisle, & Young, 1965), this
is nevertheless an ongoing process, new stimuli becoming effective
and old ones losing their appeal. Yet for some individuals there is
an apparent fixity: certain stimuli or fantasies remain, often from a
relatively early stage of prepubertal or pubertal development, as
the principal and sometimes the only effective sexual stimulus.
What produces this apparent fixity in a small proportion of the pop-
ulation is not clear. We do not know whether this is a result of cer-
tain situational factors operating at sensitive periods of develop-
ment or whether there is something more idiosyncratic about the
individual's capacity for learning. This is one of the issues we need
to know more about before we can claim understanding of this im-
portant phase of sexual development.

2.2. Sexual Behavior Reinforcing Gender Identity

It is in this area that we meet the greatest conflict between the
values of dyadic sex, already discussed, and cultural or subcultural
determinants of sexual behavior.
Gagnon and Simon (1973) described the homosocial phase of
development, where the self-esteem of the adolescent is deter-
mined more by the opinions and reactions of the same-sex peer
The Prevention of Sexual Offenses 101

group than by those of the opposite sex. Heterosexual behavior

thus becomes a way of gaining homosocial status, very much an
aspect of the adolescent's sense of gender. Females become
"scores" to males rather than potential mates. While it is true that
in many respects this is a transient phase of development, and pos-
sibly even a necessary one, it is also true that the values underlying
such behavior are reinforced in many ways in society-possibly in
working-class groups more than in the middle class and certainly in
some cultures where they are more or less institutionalized. The
concept of the male as a sexual predator and the female as the vic-
tim is a familiar one in biology and most probably had some biolog-
ical function in the Darwinian sense. It seems likely, however, that
this function was made redundant in human development some
time ago and is now counterproductive.
This affects our behavior and attitudes in many different ways.
Gebhard and his colleagues (Gebhard et al., 1965) describe:
The socially approved pattern for feminine behavior according to which the
woman is supposed to put up at least token resistance murmuring "no, no,
we mustn't." Any reasonably experienced male has learned to disregard such
minor protestations and the naive male who obeys his partner's injunctions
to cease and desist is often puzzled when she seems inexplicably irritated by
his compliance. (p. 177)

A corollary of this behavior is sometimes called a masochistic streak

in a proportion of women-a desire to be sexually overpowered.
Fantasies of rape or of being sexually "used" are quite common in
adolescent female development. At least in fantasy such a female
can enjoy the sexual experience without any feeling of being re-
sponsible for what is happening-a perfect anodyne for sexual guilt
and one that may have a very formative influence on that female's
sexual development. In some males growing up in a very sexually
repressive environment, masochistic fantasies and responses may
develop for rather similar reasons.
Gender identity development can of course interact and affect
sexual behavior in other ways. Lack of confidence in one's gender
identity can seriously impair the individual's ability to cope with
sexual relations and reinforce patterns of isolated sexual respon-
siveness.
102 John Bancroft

2.3. Problems with Self-Control

Whatever the fantasies or desires of the individual, why is it
that some people, while knowing the risks they are taking, give
way to impulses that are likely to get them into trouble? This, of
course, is a general question about criminal behavior, but in rela-
tion to sexual behavior it takes us to a fundamental issue-that of
"sexual drive." One of the reasons that sexual offenses are cat-
egorized separately is the widespread belief that the sexual drive
is a basic biological force. Gagnon and Simon (1973) had the follow-
ing to say:
The Freudian and Kinseyian traditions share the prevailing image of the sex-
ual drive as a basic biological mandate that presses against and must be con-
trolled by the cultural and social matrix. This drive reduction model of sex-
ual behavior, mediated by cultural and social controls, is pre-eminent in
sexological literature. Explanations of the sexual behavior that flow from this
model are relatively simple. The sex drive presses for expression, and in the
absence of controls which exist in laws and mores or in appropriate in-
ternalized repressions learned in early socialization, there will be outbreaks
of "abnormal sexual activity." (p. 11)

Sex is the "beast" within us that needs to be controlled. The

difference between the civilized member of society and the sex of-
fender, it is commonly supposed, is in the lack of this control in the
latter. Gagnon and Simon were right to challenge these widely
held assumptions. Whether they were right to draw the contrary
conclusion, that of all the areas of our functioning it is in the sexual
area that the sociocultural force has the most control of the biologi-
cal, is another matter. This is another crucial area that needs clarifi-
cation and research if we are to understand not only sexual offenses
but sexual behavior in general. Currently a very common explana-
tion, and needless to say a justification, for a sexual offense is that
the individual is "oversexed." In working with people with sexual
problems of various kinds it seems clear that what appears at first
to be innately high or low sexual drive can be readily altered by situa-
tional changes or psychological mechanisms. In some married cou-
ples the husband's daily urge for sex is in painful conflict with the
wife's almost total indifference or even distaste; after counseling,
the wife begins to enjoy sex, and the husband, perhaps because of a
The Prevention of Sexual Offenses 103

lessening of evidence of his own sexual failure or shortcomings in

the relationship, is surprised to find his interest has waned consid-
erably. The isolated man with sexual problems who masturbates
seven or eight times a day, seemingly insatiable but none the less
extremely anxious about his sexuality, when offered help for his
relationship problems may report a dramatic drop in masturbation
frequency even before treatment has started. Thus it seems that
how the individual interprets the sexual situation has a consider-.
able bearing on how "powerful" or "uncontrollable" the sexual urge
is that is experienced by him. Nevertheless, it is premature to
dismiss the possible contribution of the biological component,' par-
ticularly when we are trying to understand some of the more ex-
treme forms of sexual offense behavior, and for the moment we
should keep an open mind. But until more is known, we should be
circumspect in attributing sexual offenses to overpowering im-
pulses in people with weak control and strive to understand what
was the meaning of the situation that in some way permitted the
offender to offend.
Also to be considered is the offense as a maladaptive form of
coping with a crisis. Just as the child may react to family difficulties
with open masturbation or a return to bed-wetting, so the adult
may react to an interpersonal problem by commiting an otherwise
inexplicable sexual offense. This reaction will reappear when we
consider exhibitionism.

3. Sexual Offenses

It is now possible to apply some of these more general com-

ments to specific categories of offense.

3.1. Sexual Assault

This is a wide range of behavior varying from the misinterpre-
tation of a victim's resistance as "token" to a very deliberate use of
force to ensure compliance, to express hostility, or to enhance
arousal. It is probably true that the more sadistic and hostile forms
104 John Bancroft

of sexual assault are rare. In the Gebhard study (Gebhard et ai.,

1965) the interest in sadomasochistic fantasies was most common
among the heterosexual aggressors but even then was only re-
ported by a small proportion of them. The large majority of such
offenses represent the carrying of the "male predator" role beyond
the bounds of social acceptability.
A very striking illustration of how prevailing social attitudes
toward the pattern of male-female sexual relationships may affect
the incidence of sexual assaults has been given by Le Vine (1959) in
his description of sex offenses amongst the Gusii of southwestern
Kenya. A very warlike form of male-female marital sexual rela-
tionships has become institutionalized in the Gusii culture. The
wife normally puts up a struggle and there is certainly no sexual
tenderness. For the unmarried male, sexual relationships with his
own clan are severely sanctioned, and in the past his tendency to
obtain sexual gratification by abducting girls from other clans or
tribes had been effectively controlled by means of unofficial capital
punishment. Following the takeover by the British and the elimi-
nation by them of these more traditional methods of behavior con-
trol, there has been a devastating increase in the incidence of rape
of women by men from other clans. Le Vine convincingly linked
this epidemic with the aggressive pattern of sexual relationships
that otherwise prevail among the Gusii.
Although this is an extreme example, it illustrates an impor-
tant point about our own society. Frequently the sexual assaulter
comes from a background where sexual dominance and exploitation
of the girl not only is acceptable in certain situations-"the easy
lay" or "the girl who is asking for it"-but is rewarded within the
peer group by enhanced status.
The game playing already referred to-the token resistance by
the female-can lead to ambiguous and conflicting signals that for
the naive and socially inept individual can easily be misinterpreted,
leading to a situation that gets out of control.
Other forms of sexual behavior that are in any case illicit-for
example, homosexual contacts or contacts with children-may be
associated with sufficient fear or anonymity to make the eruption of
violence more likely. The acting out of aggression in the sexual act,
The Prevention of Sexual Offenses 105

though relatively rare, is probably less uncommon within casual

and anonymous homosexual relationships, and here the neurotic
response to social stigma often underlies the aggression.
In all these cases, therefore, the sexual offense is determined
to some extent by prevailing social attitudes.

3.2. Sexual Relationships with Children

Offenders in this category are again a rather heterogeneous
group. Many of them have no particular sexual preference for chil-
dren but have become involved with them incidentally. However,
the largest subgroup is what is usually called the pedophiliac
group: men whose sexual preferences are for children, in the ma-
jority of cases for children aged 8 or older.
There is some suggestion from available data that many of
these men have had difficulty in forming rewarding heterosexual
relationships in adolescence and later. Their earlier and by compar-
ison successful prepubertal sex experiences, then, have taken on a
special importance for them (Gebhard et al., 1965; Mohr, Turner,
& Jerry, 1964). The difficulty with adult relationships is not neces-
sarily of a sexual kind and may reflect problems of being dominated
or controlled, problems that they feel can be avoided in their rela-
tionships with children. In many instances, their interest in chil-
dren is more than just sexual, representing the kind of interper-
sonal contact with which they feel most comfortable.
The feature that attracts our attention particularly is the possi-
bility that adolescent problems of heterosexual adjustment may be
facilitating the development of the pedophiliac pattern. It is con-
ceivable that at least in some cases help to overcome these difficul-
ties could be provided, though the tendency for these men to have
difficulty in maintaining mature adult-to-adult relationships in
other respects underlines the fundamental and often intractable
personality problems involved.

3.3. Exhibitionists
This is not only the most common form of sexual offense in the
United Kingdom but also the most difficult to understand. The
106 John Bancroft

rewards from such behavior are far from clear, probably rather
varied, and in most cases not clearly sexual. What does seem to be
relevant is the reaction that the act produces in the victim.
Rooth (1971) described a common theme in the descriptions of
the ideal exposure as one of dominance and mastery:
The exhibitionist, usually timid and unassertive with women, suddenly chal-
lenges one with his penis, briefly occupies her full attention and conjures up
in her some powerful emotions such as fear and disgust, or sexual curiosity
and arousal. For a fleeting instant he experiences intense involvement in a
situation where he is in control. The reaction he most dislikes is indifference.

Genital display has long been regarded as a form of threaten-

ing or insulting behavior, and ethologists have observed such be-
havior in subhuman primates also (Ploog & McLean, 1963). What
is perhaps relevant is that this form of transient hostility is
frequently shown by men who are dominated by their wives and
who were previously dominated by their mothers.
In some instances, the wish to expose is a prevalent and
chronic one, the individual giving way to these urges intermit-
tently. In others, the individuals may go for long periods with no
such urge, only to succumb more or less "out of the blue." There
are often the instances, mentioned earlier, when the exposure
seems to be the exhibitionist's way of coping with a crisis situation.
The effect may be to "punish" the wife, who is humiliated by her
husband's offense and the publicity that follows, or to punish him-
self at a time when he is depressed; but we remain uncertain about
whether these consequences determine the behavior in the first
place. In some instances, there is considerable excitement and ex-
hilaration associated with the offense, and in others it is associated
with much anxiety. But in the majority of cases, it is difficult to
comprehend the act as a primarily sexual one, and hence sexuality
is less clearly relevant to prevention.

4. Primary Prevention

Obviously we should consider both primary and secondary

prevention. Primary prevention, the prevention of sexual offenses'
The Prevention of Sexual Offenses 107

occurring in the first place, is the ideal, but by now it should be

clear that any realistic ambition in this respect must be modest.
Many of the problems stem from personality difficulties of a very
heterogeneous kind, and it is meaningless to talk of prevention pro-
grams for such a gamut of personality problems. There are, how-
ever, two approaches that emerge from the above discussion. The
first is attempting to influence social attitudes toward certain
aspects of sexual behavior, and the second is individual counseling
for the sexually vulnerable adolescent. Neither of these is likely to
have a major impact on the incidence of sexual offenses, and if
there were no other benefits from them, they would be hard to jus-
tifY in terms of cost effectiveness. But in fact they would both, if
they were at all effective in their primary goals, lead to much wider
benefits both socially and individually.

4.1. Modifying Social Attitudes

Change in social attitudes is not something that one can di-
rectly control in a free society. There will always be forces acting in
an opposite direction-perhaps in such an emotive area, that is a
good thing. Nevertheless change is undoubtedly occurring, and
some important factors, such as modem fertility control, are facili-
tating these changes. We can at least fe d ideas into the system in
the hope of directing this change to some extent.
The change that is most relevant is related to the so-called
homosocial determinants of sexual behavior, the male sexual pred-
ator-female victim model: the expectation that a girl will say no
when she means yes, the very different allocation of responsibility
for sexual behavior between males and females, and the tendency
to consider it unmanly or at best" soft" for a boy to take a share of
the responsibility for whether sexual activity occurs. What we need
is to see that these values go, to be replaced by others that stress
the importance of communication, trust, and mutual reward in sex-
ual relationships and of gaining self-esteem not from the "score"
but from the quality of the relationship.
Although such comments may seem unremarkable, there are
situations or cultures in which some of these ideas border on the
108 John Bancroft

revolutionary. The pitfalls of trying to spread American middle-

class values to other subcultures are obvious. Nevertheless I firmly
believe in the intrinsic interpersonal and social value of what one
might call the American middle-class Masters and Johnson sexual
ethic.
The benefits as far as sexual offenses are concerned will be a
reduction in that type of sexual behavior that from time to time
spills over into a sexual assault, forming a large porportion of that
offense category. In addition, if more positive attitudes toward
homosexuality prevailed-and this would be entirely consistent
with the change already mentioned-there would be not only a re-
moval of many homosexual acts from the offense category but a
reduction of some of the hostility that underlies many homosexual
assaults.
If we can agree on these aims and principles, then the most
appropriate area for their application would be as part of a sex edu-
cation program in schools and through the media.

4.2. Individual Counseling

The other approach is more difficult to implement but would
possibly have greater success once implemented. This is the provi-
sion of individual counseling to the vulnerable adolescent. In the
great debate on sex education it is often said that the proper person
to do the educating is the parent. While this approach seems rea-
sonable through early childhood, the situation changes around pu-
berty and adolescence. Here the parent and child are too involved
in coping with the sexuality of their relationship with each other for
the parent to be able to provide appropriately detached but sup-
portive counsel. It is therefore desirable for the young adolescent
to have someone else he can talk to as well as his parents. Ob-
viously there are many sources of such a person, but the role of the
school counselor is gaining acceptance, and I certainly think that
there is a need for such people to offer supportive relationships to
adolescents who seem vulnerable, particularly those who are more
or less isolated from their peer group.
But much more is required than the mere availability of such
The Prevention of Sexual Offenses 109

counselors. The young adolescent is likely to be highly defensive

about his sexual feelings and will open up and discuss his anxieties
and uncertainties only in a relationship in which he feels comfort-
able and secure. Such a relationship takes time as well as the right
approach on the counselor's part. However, if rapport is es-
tablished, the counselor may be able to help the adolescent sort
out the meaning of his emerging sexual feelings and responses and
to reduce the likelihood that inappropriate patterns of sexual re-
sponse will become established. Of particular importance is the op-
portunity for the adolescent to discuss his sexual fantasies and to be
given reassurance about their meaning. In addition, difficulties and
anxieties about how to cope with interpersonal relationships, par-
ticularly of the sexual kind, can be discussed and counseling given.
This type of counseling, whatever situation it is given in, should be
free from the stigma associated with psychiatric services.

5. Secondary Prevention

It is an unpalatable fact that at present and most likely in the

future the most effective method of secondary prevention requires
the use of legal sanctions. Sex offenders have a lower reconviction
rate than other types of offender, particularly if they have not also
been convicted of nonsexual offenses (Gunn, 1976). There is a sub-
stantial problem of recidivism, however, and likelihood of reconvic-
tion is much increased after the second conviction. The irony is
that while for the substantial majority of first offenders the convic-
tion and the penalty prove to be sufficient to keep them out of fur-
ther trouble, it is among this group that the wider benefits of treat-
ment and intervention would be greatest. Confining treatment to
recidivists results in the most difficult and intractable problems'
being tackled. It is for this reason that we should have modest ex-
pectations of success.
It is important at this juncture to make a crucial distinction be-
tween psychotherapy or counseling and social control. Psycho-
therapy or counseling requires a therapist-client relationship of
mutual trust and respect. It is a traditional form of helping rela-
110 John Bancroft

tionship and one that works only if the client wants the help and is
prepared to take the responsibility for much of what happens. *
Social control is the use of legal machinery or other devices
such as drugs to control an individual's behavior for the benefits of
society and regardless of whether the individual welcomes that
control. Both forms, counseling and social control, are necessary;
the important thing is that one should not be confused with the
other. All of the psychological methods of modifying behavior can
be expected to work only within the first type of therapist-client
relationship and in addition are probably ethical only within such
relationships. Drugs can of course be used in both types of inter-
vention, though usually with sex offenders it is in the category of
social control that drug use should be placed. I shall not consider
the use of drugs further, as that is the subject of Chapter 5. What
follows is a brief consideration of the various approaches to psycho-
logically based therapy or counseling that can be used in secondary
prevention.
The first difficulty is the establishment of an appropriate
therapist-client relationship in a setting in which the client has
reduced freedom. If help given is quite detached from the courts
or prisons, then this is not a problem. For a prisoner, someone on
probation, or someone committed to a special hospital, it is very
much a problem.
Attempts are being made currently to use psychophysiological
methods of assessing offenders' sexual responses in such a way as to
evade the subject's own defensiveness. Obviously an offender is
likely to present himself in the most favorable light possible, partic-
ularly if it is likely to have any bearing on his release. Is it possible
by means of psychophysiological techniques to avoid this defen-
siveness and uncover the truth-by some form of sexual lie detec-
tor? Not only do I have serious doubts that such a thing is possible
with sufficient validity to make it of any practical significance, I
would also regard it as ethically unacceptable if it were possible.
* Itshould be distinguished from an "illness" type of relationship, where because
of the disturbed mental state of the patient, responsibility has to be taken over
by the doctor. Such a relationship is not relevant to the vast majority of sex of-
fenders.
The Prevention of Sexual Offenses 111

The idea of a computerized psychophysiological laboratory moni-

toring the subject's otherwise secret sexual preferences and re-
sponses is a horrifying one. Such psychophysiological methods are
useful, but as adjuncts to an otherwise trusting therapeutic rela-
tionship. They may serve to clarifY the nature of the sexual stimu-
lus leading to an offense and hence its avoidance. A recent study of
rapists showed significantly greater penile responses in the rapists
to scenes of a young girl being simply abducted than in the normal
control group 0. Hinton, personal communication). Such a re-
sponse is worth further investigation, and much useful information
about the determinants of rape behavior might be so obtained. But
such information should and probably could be obtained only
within the kind of trusting relationship described above. When the
appropriate relationship can be established, the general trend now
is toward helping individuals to learn rewarding and socially ac-
ceptable forms of behavior. If the offender is married, marital ther-
apy can be used, aimed at either the sexual relationship or other
aspects of the relationship, such as the wife's dominance, which is a
common feature of exhibitionists.
For the socially inept, social skills training can be used. A
recent study of such training of sex offenders in a hospital setting,
where both sexes were present, showed promising results, though
whether the observed improvement in social behavior would ex-
iend outside the institution is another question (Crawford, uno). If
sexual fantasies that are linked to the offense behavior continue,
then there are various approaches to helping the individual modifY
those fantasies. Gradual shaping of fantasies during masturbation is
probably the best approach (Bancroft, 1974). Evans (1970) has
shown that exhibitionists who masturbate with exhibitionistic fan-
tasies have a greater likelihood of repeating their exposing behavior
than those who showed normal masturbation fantasies.
There are also ways to help individuals increase their self-con-
trol. Unfortunately, the degree of motivation and self-discipline
that is required to make use of such methods is beyond most of-
fenders, but some do benefit. What is involved is a careful analysis
of the sequence of behavior that normally leads up to the offense.
In those with a predictable pattern it may be possible to divert the
112 John Bancroft

sequence at an early stage by the adoption of alternative and in-

compatible behaviors or by the use of techniques such as covert
sensitization to reduce the attractiveness at the later stages (Ban-
croft, 1977). It is in this area that aversive techniques may still have
a small part to play: once the individual has experienced an aver-
sive procedure, it may be easier for him to disrupt the sequence of
behavior either by recalling the aversive stimulus or by other
means. Such techniques, of course, are totally useless, apart from
being unethical, if used for someone who is not seriously commit-
ted to changing his behavior.
In general, behavior therapists are recommending a broad-
based approach to these problems using a selection of the available
procedures as part of a multifaceted and individually tailored pro-
gram (Bancroft, 1974). The emphasis is educational rather than cu-
rative. Responsibility for change remains with the client or of-
fender. A recent study of rapists in a Canadian penitentiary showed
modest superiority of this type of broad spectrum behavior therapy
over a more traditional group therapy program (Williams, 1976).
Once again, however, one is uncertain of the benefits that would
extend outside the prison setting. While we should continue to
pursue these approaches, we should not expect too much. At the
same time, we should not be neglecting the possibilities of primary
prevention that have been mentioned, however difficult and intan-
gible they might be.

References

Bancroft, J. H. J. Deviant sexual behavior: Modification and assessment. Oxford:

Clarendon Press, 1974.
Bancroft, J. H. J. The behavioral approach to treatment of sexual problems. In
J. Money & H. Musaph (Eds.), Handbook of sexology. Amsterdam: Elsevier,
1977.
Crawford, D. Social skills treatment programme for sexual offenders. Paper pre-
sented at the Special Hospitals Research Unit Symposium, London, May
1976.
Evans, D. R. Subjective variables and treatment effects in aversion therapy. Be-
havior Research Therapy, 1970,8, 147-152.
The Prevention of Sexual Offenses 113

Gagnon, J., & Simon, W. Sexual conduct: The social sources of human sexuality.
Chicago: Aldine, 1973.
Gebhard, P. H., Gagnon, J. H., Pomeroy, W. B., & Christenson, C. V. Sex of-
fenders: An analysis of types. New York: Harper & Row, 1965.
Gunn, J. Sexual offenders. British Journal of Hospital Medicine, January 1976,
57~5.
Hinton, J., O'Neill, M., & Woolbridge, J. The psychological assessment of sex of-
fenders. Paper presented at the Special Hospitals Research Unit Symposium,
London, May 1976.
Le Vine, R. A. Gusii sex offenses: A study in social control. American Anthropol-
ogist, 1959, 61 (6), 965-990.
McGuire, R. J, Carlisle, J. M., & Young, B. G. Sexual deviation as conditioned
behavior: A hypothesis. Behavior Research and Therapy, 1965,2, 185-190.
Mohr, J. W., Turner, R. E., & Jerry, M. B. Pedophilia and exhibitionism: A
handbook. Toronto: University of Toronto Press, 1964.
Money, J., & Alexander, D. Psychosexual development: Absence of homosexuality
in males with precocious puberty: Review of 18 cases. Journal of Nervous
Mental Diseases, 1969,148, 111-123.
Ploog, D. W., & McLean, P. D. Display of penile erection in squirrel monkeys
(Saimiri sclureno). Animal Behavior, 1963, 11, 532.
Ramsey, G. V. The sexual development of boys. American Journal of Psychology,
1943, 56, 217.
Rooth, F. G. Indecent exposure and exhibitionism. British Journal of Hospital
Medicine, 1971, 5, 521-533.
Williams, W. The treatment of rapists. Unpublished doctoral dissertation, Queen's
University, OntariG, HJ76.
 5
Editors' Introduction

This chapter is unique to this book in that it describes a highly in-

novative, experimental and yet clearly defined procedure for the
prevention of sexual offenses. It is perhaps the only example in this
book of a truly tertiary preventive or rehabilitative effort. This
procedure also illustrates some basic differences between preven-
tion and cure, since no one would claim that antiandrogen therapy
is a treatment (in the curative sense) for sexual offenses. Primary
preventive efforts for sexual offenses are only now beginning to
take shape, as evidenced by Bancroft's enlightened discussion in
Chapter 4. In their absence, some would argue that this type of
tertiary preventive effort is extremely important for society and the
individual at this time in view of the extreme dangerousness and
high recidivism rate for these disorders and the suffering caused to
the individual by uncontrollable, repetitive sexually aggressive fan-
tasies.
Walker begins with a brief discussion of what constitutes sex-
ually offensive behavior and describes his own guidelines for deter-
mining when to intervene. After commenting on the relative
dearth of evidence of the effectiveness of traditional psychological
procedures for these people, Walker describes the history of hor-
monal therapy, the pharmacological effects of this therapy, and its
indications and contradictions. A detailed description of this treat-
ment as it is actually applied is followed by a review of the prelimi-
nary evidence, mostly from Johns Hopkins, on the effectiveness of
115
lI6 Editors' Introduction to Chapter 5

the procedure. Walker concludes with a discussion of the future of

this tertiary preventive or rehabilitative effort. The highly experi-
mental and innovative nature of this procedure raises major ethical
problems briefly described by Walker and treated in a more gen-
eral way by Kolodny in Chapter 8.
 5
The Role of Antiandrogens in the
Treatment of Sex Offenders
PAUL A. WALKER

1. Introduction

1.1. Purpose
The purpose of this chapter is to present data and discussion per-
taining to the use of an antiandrogenic hormone, in combination
with psychologic counseling, in the treatment of sex offenders.
As with all types of treatment, the treatment of sex offenders
requires, on the part of the therapist, certain decision-making
steps. These steps include deciding what to treat, who to treat,
when to treat, where to treat, and finally how to treat. The deci-
sional step of why to treat affects each of the other steps.
In this chapter, the what, who, when, where, and why of
treatment are discussed first. Then a specific therapeutic technique
is presented as one answer to the question of how to treat. As is
discussed below, this particular form of treatment may be used in
Paul A. Walker • The Johns Hopkins University School of Medicine, The University of
Baltimore, Baltimore, Maryland. Supported by grants from the Grant Foundation, The
Erickson Educational Foundation, and The Upjohn Company: Project Directors-John
Money, Ph.D., and Claude Migeon, M.D. Dr. Walker's present address is The Gender
Clinic, The University of Texas Medical Branch, Galveston, Texas.
117
lIS Paul A. Walker

primary and secondary prevention. Most often the sex offender is

undiagnosed prior to his first overt acts. In such cases, secondary
prevention of recidivism may be attempted. Occasionally it is pos-
sible to diagnose, with a relatively high degree of certainty, the po-
tential sex offender who reports an awareness of and a concern
regarding his impending illegal activity. Primary prevention can
then be attempted. The particular form of therapy discussed in this
chapter has no role in the prevention of the original etiological fac-
tors that contribute to sexually offensive behavior. In fact, very
little is really known about these factors.

1.2. What to Treat

"Sexually offensive behavior" is a category that at one time or
another, in one place or another, has included perhaps every imag-
inable behavior to which a sexual label could be applied. In our
own time, in Western society, the list of sexual behaviors that are
psychiatrically, religiously, or legally proscribed as psychopatho-
logic, sinful, or illegal is extensive. Included are behaviors that
result in obvious and serious physical or emotional harm to the par-
ticipants: lust murder, rape, assaultive child sexual abuse, etc.
In some places, for some people, behaviors are proscribed which
have been hypothesized to be but are not obviously harmful to the
participants: sodomy, incest, prostitution, the use of pornography,
"excessive" masturbation, etc. Also proscribed by some are behav-
iors that are not necessarily claimed to cause harm or sickness but
that are supposedly prima facie evidence of sickness: adultery,
group sex, bisexualism, homosexualism, anonymous "tearoom" sex
(Humphreys, 1970), sodomy, discipline and bondage, etc.
Oftentimes harm does come to those engaging in a proscribed
behavior that in and of itself causes no harm. An example of such
behavior may be sexual activity in a gay steam bath or bookstore
that is raided by the police. Large monetary fines, jail terms, and
public embarrassment often ensue. Also the guilt and anxiety suf-
fered by some homosexuals and also by some masturbators, while a
function more of stigmatizing labels than of the behavior itself, do
Antiandrogens in the Treatment of Sex Offenders 119

cause harm that may require treatment. No treatment need neces-

sarily be warranted should the proscriptive ban be lifted.
The question of harm aside, proscribed behaviors may also be
categorized into those involving mutual consent (as in sodomy,
prostitution, etc.) and those in which mutual consent is absent (as
in exhibitionism or voyeurism). The decision to intervene or not to
intervene in consensual sexual activity is made difficult when one
of the "consenting" partners is juvenile (like the juvenile prostitute)
or when, in the case of adults, the consensual behavior is masochis-
tic self-murder.
Many proscribed behaviors mayor may not require psycho-
therapeutic intervention, depending on chronicity. A single lust
murder or rape may indeed warrant psychotherapeutic attempts
aimed at future prevention. A single act of streaking at a college
dance by an inebriated student may riot warrant psychotherapeutic
intervention, although legal intervention may occur. Compulsive
repetitive exhibitionism probably does warrant psychotherapeutic
intervention, especially if the exhibitionist suffers harm because of
repeated fines and incarcerations.
The question of what to treat, therefore, often requires analy-
sis of harm, consent, and chronicity. Evaluation of these three fac-
tors necessarily involves subjective value judgments based, in pari,
on the sociocultural, religious, and political biases of the therapist
and on what role, if any, he or she believes psychotherapy should
have as an agent of law and religion.
In the clinic from which the data reported herein were gath-
ered (The Office of Psychohormonal Research, The Johns Hopkins
Hospital: John Money, Ph.D., Director) and in this author's own
newly established clinic (The Gender Clinic, The University of
Texas Medical Branch at Galveston), the following working rule is
applied to the question of what to treat: any form of sexual expres-
sion warrants an attempt at treatment when that expression
requires that the sexual partner be a nonconsenting adult or child
or, even with consent, when the outcome of the sexual activity
brings grievous bodily or emotional harm to one or both partners.
The working rule-interpreted and applied in each individual
120 Paul A. Walker

instance and based on extensive behavioral analysis of the behavior

of concern, its antecedents, and its documented or predicted re-
sults-may, for example, result in accepting for therapy the homo-
sexual or transvestite who is panic-stricken, suicidal, or otherwise
severely distressed. However, this working rule would exempt
from therapy the homosexual or transvestite who is not in distress
and who harms no one. Likewise, this working rule may exempt
from therapy the late adolescent couple engaging in consensual in-
cest while accepting for therapy the older male engaging in "con-
sensual" incest with his 5-year-old sister. The adult couple playact-
ing a sadomasochistic fantasy with such props as watered-down
catsup might be exempted from therapy, whereas the couple en-
gaging in consensual mutual mutilation may be encouraged to par-
ticipate in therapy.
Nowhere does this working rule prevent those who wish ther-
apy from receiving it. Nor does the rule enforce therapy on those
not wishing it (even those who use harm or nonconsent in their
sexual expression). The rule simply places priorities for therapy on
certain types of behavior and removes the stigma of "needing ther-
apy" from other types of behavior. The rule answers the question
of "why and what" with an emphasis on preventing force and harm
and otherwise makes no further socioreligious, psychiatric, or legal
assumptions.
The above emphasis on force and on consent is congruent with
Bancroft's opinion (see Chapter 4, this volume) that sexual assault
is a behavior for which legal controls are appropriate. Sexual rela-
tionships with children, also listed by Bancroft as appropriate for
legal control, certainly involve questionable consent. However,
depending on the age of the child, his or her individual maturity
level and sociocultural heritage, and the exact nature of the specific
sexual act performed, legal or psychotherapeutic control or inter-
vention may not always be indicated. It usually is indicated, how-
ever.
Bancroft also lists exhibitionism as appropriate for legal control
and, by implication, as appropriate for psychotherapeutic interven-
tion. Surely if an exhibitionist requests therapy, that request
should be honored. However, perhaps Western society should
Antiandrogens in the Treabnent of Sex Offenders 121

reevaluate its traditional ban on public nudity. In most cases of

exhibitionism, the "victim" is harmed only to the degree of ex-
periencing shock and perhaps repugnance. In a world full of shock-
ing surprises and of repelling occurrences (the bloodbath of televi-
sion for example or the next door neighbor's dog who leaves urine
and feces on our doorstep), it is absurd to focus legal retaliation
against the graven image of the human groin. Perhaps we need to
reassess our laws against nudity (nudist camps, nude beaches, nude
stage plays, etc.) and allow a place in this world for the exhibi-
tionist (with some limited controls).

1.3. Whom to Treat

More often than not, those who engage in harmful or forceful
nonconsenting sexual behavior do so repetitively. Such persons,
usually male, are in most cases properly diagnosed as paraphiliacs.
The paraphiliac is totally reliant on a particular behavior or erotic
image for sexual expression. The particular required behavior or
image is an imperative essential for erotic arousal, erection, and
orgasm. it is not an dective option such that other nonhannful or
nonforceful behaviors or fantasies could also provide erotic arousal.
Some paraphiliacs may seem to engage in a variety of sexual behav-
iors apparently unrelated to the supposed imperative. However, in
such cases, interview data and perhaps also projective test data and
dream analysis usually quickly reveal that every sexual act per-
formed by the person is dependent on the private fantasy or imag-
ery of the imperative act.
Thus chronicity of sex-offensive imagery and fantasy becomes
a variable of importance in patient selection. The person who
engages in or fantasizes about a particular sex offense act only
once, or rarely, while inebriated and thereby disinhibited, or dur-
ing a transient period of sexual experimentation, may not require
any sexual therapy at all or may require a sexual therapy quite dif-
ferent from the one required by the chronic paraphiliac.
An understanding of the definition and psychodynamics of the
paraphiliac, as briefly discussed above, provides a clue to under-
standing why the paraphiliac often has such a high frequency of im-
122 Paul A. Walker

pulsive sexual acting out. While perhaps all persons (male and
female) have their favorite sexual fantasies, these fantasies usually
require some form of subtle pursuit, mutual interest, tenderness,
and opportune time and place. The paraphiliac's cue stimulus for
sexual arousal is, for example, "a woman inside a house not looking
at me" (voyeur) or "a woman looking at me but not expecting any-
thing" (exhibitionist) or "a woman who doesn't want to have sex"
(rapist) or "a child at play" (pedophile). When the environment
provides the cue stimulus that matches the fantasy, erotic arousal
occurs. While this is perhaps an oversimplified view of things, one
can easily see that the paraphiliac, by the very nature of his reli-
ance on an imperative fantasy, can easily, frequently, and immedi-
ately be sexually aroused. One need only talk to a pedophile and
hear how the sound of children laughing or the sight of a prepuber-
tal child on television can immediately trigger an erection and the
desire for orgasm to understand at least one factor that contributes
to the high frequency of recidivism.

1.4. When to Treat

Most psychotherapists would agree that a patient's motivation
or readiness for therapy is a primary factor in therapy success or
failure. Many people do not want and will not cooperate with ther-
apeutic attempts on their behalf unless they are hurting. The hurt
may be physiologic (as during a diabetic crisis or after a particularly
bad episode of masochistic near-suicide) and the hurt can be be-
havioral (as during periods of fear of death and illness or guilt as-
sociated with an episode of exhibitionism). When the person is not
hurting (the controlled diabetic, the nonbleeding masochist, the
unfearful and non guilty exhibitionist), help is not sought and is in
fact unwanted and often refused (just as the occasional diabetic
stops taking insulin as soon as he or she is symptom-free).
The paraphiliac sex offender usually does not want and will not
accept therapy until and unless he is hurting. He hurts usually only
when arrested or near arrest. As soon as the charges are dropped,
the fine is paid, or the 30-day sentence is served, the hurt disappears
and the person is again unwanting of therapy. Accordingly, be-
Antiandrogens in the Treatment of Sex Offenders 123

cause of the very nature of paraphiliac behavior, therapeutic inter-

vention is best offered when the patient is under legal duress. It is
precisely at the time of legal duress that persons are nowadays
legally being defined as incapable of giving informed consent for
therapy, or at least investigational therapy. We are therefore, as a
society rightfully concerned about prisoners' rights, establishing a
legal precedent preventing the offering of therapy to paraphiliacs at
the time they want it, and making therapy available to them when
they don't want it. This paradoxical situation is too often, in this au-
thor's opinion, ignored when prisoners' civil rights are discussed.

1.5. Where to Treat

Sexually offensive behavior has historically been defined as
immoral and sinful (and treated by the priests and shamans) or
illegal (and treated by the prisons) or psychopathologic (and treated
by the psychiatrists and psychologists). In all three definitions the
behavior is stigmatized as being the fault of either an imperfect
soul, an imperfect will, or an imperfect mind.
Treatment of a harmful and forceful sexual behavior rightfully
belongs in medicine (whether in psychiatry or medical psychology).
Ideally medicine is nonjudgmental. Symptoms, diseases, tumors,
etc. (even VD), are not reacted to with anger or moral righteous-
ness but rather are impassionately studied and hopefully cured or
eradicated. The alternative place of "treatment" is the prison,
where, rather than nonjudgmentalism, vindictive punishment is
often the mode of treatment.

2. Background of Therapeutic Attempts

2.1. N onhorrrwnal Therapies

Probably the entire arsenal of psychotherapeutic techniques
has been tried with sex offenders. An exhaustive review of these
techniques is not attempted here.
124 Paul A. Walker

In choosing a therapeutic technique and in evaluating the

results of such techniques, one must recall that (1) the paraphiliac
behavior to be treated includes harm and force; (2) the paraphiliac
behavior is more than a pattern of observable overt neuromuscular
motions-it is centered in covert fantasy and imagery (behaviorally
studied via the patient's verbal reports and his erectile response to
erotic pictorial or narrative stimuli); and (3) the paraphiliac behav-
ior (overt and covert) usually occurs at high frequencies with rela-
tively short latencies from onset of the fantasy, as triggered by a
cue stimulus, to completion of the sexual act (either the paraphiliac
act itself or masturbation with the fantasy of that act).
Ideally any therapy used with this group of patients for these
paraphiliac behaviors should be able to promise rapid results-
especially if the behavior under treatment is homicidal sadism,
suicidal masochism, lust murder, rapism, or assaultive child sexual
abuse.
The so-called dynamic, analytic, or insight-oriented psycho-
therapies for the repetitive sex offenders have progressively fallen
into disfavor in recent decades. The success of such therapies, if
any, is too often dangerously delayed. In recent years aversion or
behavior modification therapy, under various names and idiosyn-
cratic techniques, has gained increasing favor. However, even
these therapies have been recently criticized for not producing the
dramatic effects their early proponents claimed.
An annotated bibliography (Shorkey & Cangelosi, 1975) of
reports on behavior modification therapies published between 1960
and 1975 includes 24 reports on therapies for male sex offenders
(excluding homosexuals with age-appropriate partners). A total of
59 offenders were treated, with 19 of the 24 reports being single
case studies. Although "successful" therapy (variously defined) was
claimed in most of these reports, follow-up was usually only for 6
months or less. Such brief follow-up periods do not allow for obser-
vation of relapse or recidivism as expected in the repetitive or com-
pulsive sex offender (Frisbie & Dondis, 1965).
Recently, several of the major proponents of behavioral ther-
apy for sex offenders have stated that for most sex-offensive behav-
ior, behavior modification has been ineffective, or that if at all ef-
fective, these forms of therapy primarily increased "normal"
Antiandrogens in the Treatment of Sex Offenders 125

heterosexual activity without concurrently decreasing the deviant

behavior (Freund, 1976; Bancroft, 1970, 1975; Barlow, 1973).
Theoretically, since the key to understanding paraphiliac be-
havior lies in erotic fantasy (Money & Ehrhardt, 1972), it is quite
reasonable to assume that even should some form of psychotherapy
result in diminishment of the overt paraphiliac behavior, the final
result might be either total sexual apathy (since the power of the
imperative stimulus to evoke an erotic response is now missing) or
unfettered continuation of paraphiliac imagery during socially ac-
ceptable acts.

2.2. Hormonal Therapy

In the early 1960s Laschet and others (see Laschet & Laschet,
1975; Money, 1970) began clinical trials using antiandrogens (cy-
proterone acetate) for the treatment of sex offenders. This tech-
nique provided a dose-dependent temporary and therefore revers-
ible reduction in target organ (especially central nervous system)
sensitivity to circulating androgens. The result is a diminution of
erotic arousal, desire, libido, and activity.
In 1966 Money (1968, 1970) and his co-workers began a clini-
cal trial of the antiandrogen medroxyprogesterone acetate (Depo-
Provera, Upjohn), combined with psychologic counseling, in the
case management of a heterosexually married male with a history
of transvestism and homosexual incestuous pedophilia. It is this
particular form of combined psychoendrocrine therapy that is the
subject of the remainder of this chapter.
While the history of this particular form of therapy is still
young, already proponents (Bancroft, 1975; Freund, 1976) of be-
havior modification therapies have endorsed antiandrogen therapy
as the therapy of choice in certain severe sex-offensive cases.

3. Current Program

3.1. Medroxyprogesterone Acetate

While cyproterone acetate has been the antiandrogen of
choice in West Germany, Switzerland, Italy, England, and
126 Paul A. Walker

Belgium, it is not yet available for clinical trials in the United

States. Here, medroxyprogesterone acetate (MPA) is apparently
the most effective available antiandrogen. The clinical experience
with MPA in this country has primarily been that of John Money at
The Johns Hopkins Hospital in Baltimore (Money, 1968, 1970;
Money, Wiedeking, Walker, & Gain, 1976; Money, Wiedeking,
Walker, Migeon, Meyer, & Borgaonkar, 1975).
MPA acts by lowering the levels of plasma testosterone pro-
duced by the testes. This effect is accomplished physiologically in
several ways, including (1) by the lowering of gonadotropin release
by the pituitary; (2) by directly affecting testosterone synthesis by
the testes; (3) by increasing testosterone clearance by the liver; (4)
by partially displacing testosterone from the appropriate sex steroid
binding protein; and (5) by interfering with the peripheral action of
testosterone by changing its metabolism by fibroblasts (see Meyer,
Walker, Wiedeking, Money, Kowarski, Migeon, & Borgaonkar,
1977). MPA also is believed to have a direct effect on the sexual-
arousal-mediating mechanisms of the hypothalamus.
The goal of this therapy is to reduce erotic desire (as measured
by patient self-reports of imagery, erections, and orgasm frequen-
cies and by verbal reports from the patient's appointed informant)
so that the patient is given a "vacation" from his previous sex life.
The central nervous system (eNS) thresholds or barriers that block
the release of erotic arousal and behavior are apparently temporar-
ily and beneficially raised, so long as the medication continues.
During this period of lessened sexual arousability, psychologic
counseling is offered and the patient achieves a new ability of self-
regulation, which is maintained as the medication schedule is re-
duced.
The usual dosage regimen is 400 mg/week for six months,
given intramuscularly. Thereafter the dosage is gradually lowered
in 5O-mg increments so long as maximal testosterone depletion is
maintained and sexual arousal and behavior are still within tolera-
ble and self-controllable intensities, as verbally reported by the pa-
tient and his informant. The combined endocrine therapy and
weekly psychologic counseling are then continued long-term (six
months to two years, or longer) until such time as a gradual final
Antiandrogens in the Treatment of Sex Offenders 127

weaning from the medication seems warranted. In case of a relapse

or suspected imminent relapse, endocrine therapy may be re-
started at any time. Dependent on the patient's body mass and on
the severity of his paraphiliac behavior (as in extreme sadism), the
beginning dosage may be set at 500 mg/week. The medication is
used in its intramuscular form because (1) there is greater variabil-
ity in the amount of active agent entering the blood stream when
MPA is taken orally and because (2) the 1M mode of administration
allows for better supervision, ensuring that the patient is indeed
taking his medicine.
Rather than complaining about sexual apathy and impotence,
the primary effects of MPA, the patients thus far studied have al-
most unanimously reported a sense of relief that the nagging in-
trusive sexual compulsion no longer bothers them. One patient, a
pedophile with a long history of arrests, penal incarceration, psy-
chiatric admissions, and outpatient psychotherapy, commented
that in the past when he saw a juvenile male playing, he (the pa-
tient) would without hesitation approach the boy and make a sexual
proposition. When he was on MPA therapy, he stated that, at
worst, when he saw such a juvenile, he only smiled "with apprecia-
tion" for the boy's good looks and otherwise kept about his busi-
ness.
In our most recently published follow-up studies (Money et
al., 1975; Money et al., 1976), data were reported on the treatment
of 23 men, 15 of whom were sex-offending paraphiliacs, including
pedophiliacs (heterosexual and homosexual), exhibitionists, a maso-
chist, and an incestuous pedophiliac transvestite. The othe, 8 men
treated were impulsive antisocial 47,XIT males without histories of
paraphiliac behavior. Most of those treated had experienced arrest
and incarceration. Therapy was initiated, in most cases, outside of
the prison environment and carried out, in a few cases, in the
prison if the patient was so confined during therapy-usually be-
cause of a pretherapy offense.
Of these 23 men, 2 were self-referred, 3 were referred by
ministers, 1 by an attorney, 1 by a family member, and 16 by med-
ical professionals. .
Pretreatment plasma testosterone values ranged from 212 to
128 Paul A. Walker

1170 ng/lOO m!. During treatment the lowest levels of plasma tes-
tosterone ranged from 23 to 236 ng/l00 m!. In the laboratory used
in this study, the normal adult male plasma testosterone value is
575± ISO ngil00 m!. The normal value for the normal adult female
is 40± 13 ng/l00 m!.
Of the 23 men treated, 6 dropped out of the program prior to
completion of the minimum six months' treatment protocol; 8
others remained in treatment at the time of the follow-up report;
and 9 others had completed the therapy program (minimum of six
months of therapy). Duration of treatment for the 17 nondropouts
ranged from 6 to 35 months.
All 17 males who completed at least six months of therapy
with MPA evidenced a significant decrease in erotic imagery and of
frequency and intensity of erections. This effect was observed in
the sex offenders and in the non-sex-offenders.
In those patients for whom an adequate period of posttherapy
follow-up was possible (N = 15, 6 dropouts and 9 who completed
the therapy; follow-up ranged from 3 to 57 months), the behavioral
effects of MPA were reversed; that is, the frequency and intensity
of erotic behavior/fantasies, erections, orgasms, masturbations, and
sexual activity with a partner returned to near pretreatment levels.
However, most of the 9 who completed therapy reported a greater
ability to self-regulate or predict erotic arousal and thus a greater
ability to avoid sex-offending behavior. Posttreatment, 5 of the sex
offenders reported a change of erotic imagery from socially unac-
ceptable to socially acceptable (from homosexual pedophilia to ho-
mosexual attraction toward same-age partners; from transvestism
and homosexual incest to normal heterosexual arousal; from homo-
sexual pedophilia to heterosexual arousal with adults; from homo-
sexual activity and vengeful heterosexually incestuous imagery to
normal heterosexual arousal; and from exhibitionism to heterosex-
ual marriage without public exhibitionism).
Changes in nonsexually offensive, impulsive, antisocial, or ag-
gressive behavior were not consistently documented in our studies.
However, the criteria for behavioral change (effectively an all-or-
none criteria) were strict and therefore may have masked partial
Antiandrogens in the Treatment of Sex Offenders 129

beneficial change if it occurred (many patients, their family mem-

bers, and counselors were convinced that some beneficial change
did occur).
To date, the only observed somatic complaints during therapy
are (1) some weight gain (of 2-21 kg) and (2) a slight increase in
nocturnal sleeping time. The patients did not complain of impo-
tency but rather welcomed the loss of intrusive and inconvenient
erotic arousal. Posttherapy, no long-term somatic complaints were
noted. The long-term effects of MPA on sperm production and on
integrated concentration of cortisol (both reduced while on MPA)
are not known (for more detail on the blood chemistry effects of
MPA, see Meyer et al., 1977).
Currently in therapy, either in Baltimore (Money) or in Texas
(Walker), are patients including rapists, a particularly dangerous
sadist, and at least three homicidal pedophiliacs (including one who
may properly be diagnosed as a lust murderer, i.e., one for whom
the act of murder, with dismemberment and cannabalism of the
victim's genitals, is the imperative erotic fantasy). Follow-up stud-
ies are being conducted on these individuals.
No direct correlation is here claimed between the levels of
circulating testosterone and sexual aggression or libido. Rather, the
mechanism of action of MPA seems to be reduction of serum tes-
tosterone below a certain critical level. Below this level sexual
arousal is difficult or, in some cases, impossible. Above this ievel,
sexual arousal and activity are apparently quite possible-the in-
tensity and direction being determined primarily by sociocultural
conditioning that occurred during the early years of gender identity
formation (Money & Ehrhardt, 1972). The conjectured direct CNS
effect of MPA (see above) is at present based primarily on theory
and patient anecdotal data. Further studies are needed to clarify
this point.
While the use of MPA for the treatment of adult male sex of-
fenders is still considered investigational (and subject to FDA ap-
proval), clinical experience with the drug since 1966 would seem to
warrant its use on a broader scale. Certainly, chronic sex offenders
who have not responded favorably to conventional psychotherapies
130 Paul A. Walker

would benefit by a clinical trial with this medication. Also, prisoners

caught in the Catch-22 paradox of being eligible for parole only if
they respond to therapy and who are not offered all possible thera-
pies would benefit by having MPA therapy available to them.
In general, MPA therapy is indicated when a sex offender
whose sexual activity involves force or harm evidences a history of
chronic paraphiliac imagery. This therapy will probably be the
therapy of first choice in cases of extreme force or harm, such as
rapism, lust murder, assaultive child sexual abuse, homicidal sa-
dism, and suicidal masochism. The therapy is also appropriate as a
first-choice therapy for most other sex offenders, especially if recid-
ivism is expected.
MPA therapy, in this author's opinion, is contraindicated in
cases of nonforceful and nonharmful sexual behavior-even if such
behavior is legally proscribed. Perhaps all therapies are contrain-
dicated in such cases. It is also contraindicated in cases where
eventual fertility is desired by the patient (the long-term effects of
MPA on fertility are unknown) and in cases where the patient is
unlikely to complete a full course (6-24 months) of treatment.

3.2. Concurrent Psychotherapy: Cure versus Rehabilitation

While a controlled comparison study of the therapeutic ef-
ficacy of MPA alone, psychotherapy alone, and the two combined
has not yet been systematically attempted, clinical experience with
the combined mode of treatment leaves this author biased against
either single approach modality.
The effects of psychotherapy alone have already been dis-
cussed above. MPA alone affects only the intensity of erotic
arousal, not its direction. MPA therefore has a rehabilitative effect
in that it helps to remove a problematic behavior, but it is not cu-
rative in the sense of totally and permanently removing that behav-
ior and substituting "normal" or "healthful" behavior in its stead.
Some form of concurrent psychotherapy is therefOre indicated if
behavioral substitution is desired. MPA can be said to have a facili-
tatory effect OB psychotherapy in that it allows the patient to par-
Antiandrogens in the Treabnent of Sex Offenders 131

ticipate in psychotherapy relatively undistracted by consistent and

persistent unwanted fantasies and actions.
For society at large MPA has the advantage of causing a rela-
tively rapid cessation of potentially dangerous behavior. Psycho-
therapy alone, and even incarceration, cannot promise that.
Often the goal of therapy cannot realistically be set as com-
plete elimination of a particular paraphiliac image if that image has
been exclusive, intense, and of many years' duration. In such
cases, elimination of the acting out of that imagery may be a so-
cially desirable goal. The patient, in such cases, may be explicitly
encouraged to maintain the imagery of the previously acted-out be-
havior. When given such permission, a patient can then utilize his
only available paraphiliac image in masturbatory activity or in other
nonforceful sexual activity with an adult partner. Without permis-
sion to have that fantasy, such a patient finds himself sexually dys-
functional if "normal" activity is attempted, as the anxiety of trying
to rid himself of an intrusive fantasy prevents erotic arousal. Psy-
chotherapy concomitant with MPA is also best directed toward aid-
ing the patient to identify and reduce the sources of tension and
aggravation in his day-to-day life. A rational~motive behavioral
therapy can be used. In most cases, the paraphiliac is most vulner-
able to acting out his illegal fantasy when he is under social stress
(family, financial, or employment problems). Psychotherapy that
can reduce such stress will aiso reduce the iikeiihood of further
illegal sexual activity. Psychotherapy should also be directed to-
ward assisting the patient to recognize the imminent onset of sex-
ually offensive behavior so that he may be able to leave the scene
of a potential offense before an illegal act occurs. The patient may
be taught behaviors that can abort, or are incompatible with, his
illegal behavior.
One other important topic for the psychotherapeutic treat-
ment of sex offenders, one that is perhaps the most important, is
the psychology of the "denial of illness." Many sex offenders,
socialized to believe that their sexual activity is subject to volitional
control, declare themselves totally cured after experiencing during
therapy, perhaps for the first time in their lives, a period of three
132 Paul A. Walker

or six months without acting out their sexually offensive behavior.

At that point they often quit therapy and are usually rearrested
before the month is out. Psychologic counseling for the sex offender
should address this issue. The offender chosen for therapy should
be aware, or should be made aware, that his behavior is most likely
a chronic condition, present until death, that will never truly be
cured. Like alcoholics, sex offenders who do not accept the fact of
the basic chronicity of their behavior will return to self-destructive
behavior in time. It is destructive to therapy for the patient or the
therapist to believe that" self-control" can be obtained. Instead, the
patient needs the external guidance of the therapist to learn how to
restructure his day-to-day life in order to minimize those external
cues that trigger his behavior.

4. The Role of Antiandrogens in the Prevention of

Sex-Offensive Behavior: Future Research

Thus far MPA has been discussed as a form of after-the-fact

treatment for the repetitive paraphiliac. What role MPA may have
in the prevention of sex-offensive behavior is, at this point in his-
tory, unclear. However, two possible roles can be discussed.
. First, when a,Hrst-time offender presents voluntarily for psy-
chotherapeutic help or is arrested and is diagnosed as a paraphiliac
with a long history of fantasized sex-offensive behavior, MPA along
with some form of nonpunitive psychotherapy may be the treat-
ment of choice. Such a medical approach surely is preferable over
penal incarceration. Most of the sex-offending patients seen by the
author have repeatedly experienced highly judgmental treatment
by families, counselors, and the legal and medical professions. In
effect, the offender is told that he could stop his illegal behavior, all
by himself, if he really "wanted" to. The use of nonjudgmental psy-
chologic counseling, along with a pharmacologic agent, redefines
the patient's problem as a medical problem rather than a legal or
moral problem. By itself this nonjudgmental mode of treating the
patient probably helps to effect behavioral change independent of
the direct pharmacologic effects of MPA.
Antiandrogens in the Treabnent of Sex Offenders 133

Early intervention, as opposed to psychotherapeutic interven-

tion only after the full arsenal of retaliatory and punitive legal steps
has been exhausted, should increase the success rates for therapy.
However, in today's world it is becoming increasingly rare and/or
difficult to give an arrested person the early choice between jail
and therapy. Such is not really a choice at all. The contingencies
are obvious, and most would "elect" therapy. Zealots claiming to
be protecting the rights of the arrested person have, paradoxically,
in the name of preserving the prisoner's "free will" denied him the
choice of "enforced" therapy, thus leaving him with only one alter-
native: enforced incarceration. Until the pendulum of concern over
informed consent returns to a more normal and realistic position,
MPA will probably not be available for early treatment and preven-
tion. Perhaps an initial solution to this dilemma could be tried
whereby a prisoner's ability to give informed consent could be cer-
tified by an impartial third party (other than the prisoner or the
therapist). Such a third party would best be a panel of persons
including a judge, an attorney, another prisoner, and another ther-
apist. In this way, the right of a prisoner to receive the therapy of
his choice could be evaluated on a case-by-case basis. At present,
prisoners are, as an entire class, often denied the right to investiga-
tional therapy.
A possible second role MPA may have in the prevention of
sex-offensive behavior is its facilitatory effect on (1) relatively rap-
idly stopping the patient's unwanted behavior, thus rewarding the
patient for staying on therapy, and (2) decreasing the patient's irri-
tability, nervousness, anxiety, guilt, and hypersexuality and there-
fore providing a means whereby the patient can more actively and
more undistractedly cooperate with his own psychotherapy. Thus
more research data, and more reliable data, on the psychobiology
(e.g., biographic, neuroendocrine, and psychodynamic data) of the
sex offender should be obtainable. Such data are sorely needed
before any truly preventive model can be prepared.
As a method of secondary prevention, the beneficial effects of
MPA therapy combined with nonpunitive psychotherapy are being
documented.
The question of how to formulate a model of primary preven-
134 Paul A. Walker

tion for sex-offensive behavior is not directly addressed by our ex-

perience with MPA. However, most of the sex offenders seen by
this author report histories of minimal or absent preadolescent sex
education and also a history of "knowing," in some amorphous way,
that their sexual fantasies were not normal and could not be shared
with any counselor, if available to them, for fear of punishment.
Like Bancroft's, this author's experience indicates that early, com-
plete, nonjudgmental, and individual sex education and sexual
counseling should be made more available to the adolescent. More
importantly, however, such education and counseling should be
provided prior to adolescence, probably during preschool or at the
latest during the early school years.
Clinical experience is a dangerous phrase suggesting a lack of
documentation, which in fact we do lack, in part because of the dif-
ficulties of obtaining research data on the sexuality of adults and
certainly of children. Such data are sorely needed. However, clini-
cal experience with sex offenders such as pedophiliacs, exhibi-
tionists, rapists, voyeurs, and sadomasochists leads this author to
conjecture that such behavior is not simply a convenient substitute
for repressed or inhibited heterosexual behavior. Rather, it is a
manifestation of a sex education gone wrong. The sex offender
behaves as though sexual activity with an adult member of the op-
posite sex is somehow cheap, dirty, illegal, and immoral. Their be-
havior implies an ethic of "a willing partner is a cheap whore and
therefore undesirable." The only appropriate sexual partner be-
comes the innocent and pure partner-the unwilling, the un-
suspecting, or the child. The madonna becomes erotically arousing,
the whore is not. Certainly our society can avoid instilling such an
ethic by teaching the joys of sexuality along with the social need for
personal responsibility in sexual matters.
Research may show that sexual behavior, including sexual atti-
tudes, is not as amenable to change as most psychotherapists think.
Marital therapy, social skills training, etc., may help the sex of-
fender, but his basic problem is more probably one of faulty early
conditioning, a conditioning that is relatively resistant to extinction.
Primary prevention, therefore, is best directed at the early condi-
Antiandrogens in the Treabnent of Sex Offenders 135

tioning experience, not at cleaning up the psychic mess after it has

occurred.
Sex education, pornography, and early childhood sexual activ-
ity are discussed elsewhere in this book. Data on these and cer-
tainly other topics are essential for a preventive model of sexually
offensive behavior. Until such a primary prevention model is de-
veloped and its utility is demonstrated, MPA therapy in conjunc-
tion with a rational, nonjudgmental form of multiple-treatment psy-
chotherapy may be the best approach to rehabilitating the people
for whom most psychotherapies are ineffective.

References

Bancroft, J. A comparative study of aversion and desensitization in the treatment

of homosexuality. In L. Bums & J. Worsley (Eds.), Behaviour therapy in the
1970's. Bristol, England: Wright, 1970.
Bancroft, J. The behavioral approach to sexual disorders. In H. Milne & S. Hardy
(Eds.), Psycho-sexual problems. Baltimore: University Park Press, 1975.
Barlow, D. Increasing heterosexual responsiveness in the treatment of sexual
deviation: A review of the clinical and experimental evidence. Behavior Ther-
apy, 1973,4, 655-671.
Freund, K. Diagnosis and treatment of forensically significant anomalous erotic
preferences. Canadian Journal of Criminology and Corrections, 1976, 18,
181-189.
Frisbie, T.. v., & Dcndb, E. H. rtt::c.iuivism among treated sex offenders. Re-
search Monograph No.5. Department of Mental Hygiene, State of California,
1965.
Humphreys, L. Tearoom trade. Chicago: Aldine, 1970.
Laschet, U., & Laschet, L. Antiandrogens in the treatment of sexual deviations of
men. Journal of Steroid Biochemistry, 1975, 6, 821-826.
Meyer, W. J., Walker, P. A., Wiedeking, C., Money, J., Kowarski, A., Migeon,
C., & Borgaonkar, D. Pituitary function in adult males receiving medroxy-
progesterone acetate. Fertility and Sterility, 1977,28, 1072-1076.
Money, J. Discussion on hormonal inhibition of libido in male sex offenders. In
R. P. Michael (Ed.), Endocrinology and human behavior. London: Oxford
University Press, 1968.
Money, J. Use of an androgen-depleting hormone in the treatment of male sex of-
fenders. The Journal of Sex Research, 1970, 6(3), 165-172.
Money, J., & Ehrhardt, A. Man and woman; bOI} and girl: The differentiation and
136 Paul A. Walker

dimorphism of gender identity from conception to maturity. Baltimore: Johns

Hopkins University Press, 1972.
Money, J., Wiedeking, C., Walker, P. A., & Gain, D. Combined antiandrogenic
and counseling program for treatment of 46, xy and 47, XYY sex offenders. In
E. Sacher (Ed.), Horrrwnes, behavior and psychopathology. New York: Raven
Press, 1976.
Money, J., Wiedeking, C., Walker, P. A., Migeon, C., Meyer, W., & Borgaon-
kar, D. 47, XYY and 46, XY males with antisocial and/or sex offending behav-
ior: Antiandrogen plus counseling. Psychoneuroendocrinology, 1975, 1,
165-178.
Shorkey, C., & Cangelosi, S. Modification of sexual behavior: Summary and anno-
tated bibliography. Washington, D. C.: American Psychological Association
OSAS Document MS 1114), 1975.
Walker, P. A. Medroxyprogesterone acetate as an antiandrogen ror the rehabili-
tation of sex offenders. In R. Gemme & C. Wheeler (Eds.), Progress in
sexology, selected proceedings of the 1976 international congress of sexol-
ogy. New York: Plenum Press, 1977.
 6
Editors' Introduction

Sex education in social institutions often attracts controversy and

evokes emotionality. It is not uncommon to find strong vocal op-
position to sex education in communities across North America.
Ironically opposition to sex education is strong at a time when psy-
chiatrists, psychologists, and sex therapists are alarmed by the lack
of sexual knowledge found in increasingly large numbers of sexually
troubled individuals. There seems to be little doubt that sexual ig-
norance is often linked with serious sexual problems (Caird &
Wincze, 1977).* Therefore, it is of keen interest to explore
whether. or not sex education is of value.
In this chapter, Mary Calde-rone- we-ave-s toge-thP.f important
research studies and years of experience as president of the Sex In-
formation and Education Council of the United States (SIECUS)
into an informative and sensitive discussion of sex education as a
prevention model. The goals of sex education are easily misunder-
stood. Calderone points out that it is unlikely that sex education
will ever have an impact on unwanted pregnancies or venereal
disease rates. Rather, sex education can promote but not assure
healthy sexual attitudes. Sex education is for the most part primary
prevention, and as such it is extremely difficult to evaluate. Only
exhaustive longitudinal studies in the future will yield clues to the
preventive value of sex education.

*Caird, W. K., & Wincze, J. P. Sex therapy: A behavioral approach. Hagerstown,

Md.: Harper & Row, 1977.
137
138 Editors' Introduction to Chapter 6

Calderone discusses at length the failure of parents to provide

adequate sex education for their children. Punctuated by a per-
sonal anecdote, these shortcomings are more than adequately illus-
trated. The point is not that parents cannot educate their children
about sex and sexuality but that for the most part they do not.
More distressing is the reality that parents often impart negative
and destructive attitudes toward sex.
Supposedly we are living in a more permissive and open era,
yet it is not unusual to see patients lacking the most fundamental
sexual knowledge. More often than not, individuals gain their sex-
ual knowledge (or information) through close friends rather than
parents. Calderone scorns the hit-or-miss system that now exists
and calls for a comprehensive multidisciplinary effort toward good
sex education.
 6
Is Sex Education Preventative?
MARY S. CALDERONE

1. Introduction

In approaching the topic of prevention as it applies to sex education

of children and young people, one discovers certain immediate dif-
ficulties in placing sex education within the proper perspective of
preventative interventions in the field of public health. In attempt-
ing to answer this question, one must look first at a definition of sex
education to determine both what it is and what it is not, second at
its goals, and third at the settings in whi~h it takes place_ All of
these factors can be reasonably expected to influence the answer to
the question, "Is sex education preventative?"
Calderone and her SIECUS colleagues have worked consis-
tently toward developing a broad conception of sex education (Kir-
kendall, 1965). While early efforts in the area of sex education dealt
primarily with the physical changes at puberty, menstruation (spe-
cifically for girls), reproduction, and venereal diseases, this early
narrow focus was broadened to include sexuality as one aspect of
personality structure, including within it genital and erotic activity
(Thomas, 1965). This change in emphasis was dictated by the

Mary S. Calderone • Sex Infonnation and Education Council of the United States,
Hempstead, New York 11545.
139
140 Mary S. Calderone

emergence of new lmowledge about psychosexual development in

children and youth (Group for the Advancement of Psychiatry,
1968), better information on the range and variety of sexual behav-
ior (Kinsey, Pomeroy, & Martin, 1948; Kinsey, Pomeroy, Martin,
& Gebhard, 1953), more comprehensive studies of sexual function-
ing itself (Masters & Johnson, 1966), systematic investigations of
the concerns and questions of children and youth (Byler, 1969),
societal changes related to alternative life-styles and premarital sex-
ual standards (Reiss, 1976), and studies demonstrating the lack of
knowledge about sexuality of college-aged youths (Zelnik & Kant-
ner, 1972). Furthermore there has been a major change toward
openness and franlmess in the treatment of sex by the professional
as well as in the mass media. All of these factors have led to more
comprehensive views of sexuality itself as well as of the process
called sex education. For the most part, planned educational ap-
proaches to the achievement of healthy sexuality in the developing
child have had to take place within the context of those social insti-
tutions that focus on more formalized approaches to education in
general: schools, churches, and colleges. But although the crucial
role of parents has long been noted (Money & Erhardt, 1972;
Green, 1974), little effort has been made to formalize their prepa-
ration for effectiveness in this role.
The often-stated goal of sex education has been and must
remain the achievement of healthy sexuality. A simple working
definition of a sexually healthy person might be: one who is correct
and certain about his or her gender identity; who enjoys the
gender role that has been programmed by his or her surrounding
culture; who is free to enjoy his or her genitality and, as maturity
advances, has an increasing sense of responsibility not only in its
use but toward assuring the fulfilling or positive effects of such en-
joyment for the self, the partner, and the society.
This definition of healthy sexuality implies the absence of the
sexual disorders discussed elsewhere in this book. Although to this
extent sex education is preventative in its goals, one must ask what
else sex education might prevent. Burleson (1973) noted that the
public is most often interested in whether, for example, sex educa-
tion can decrease the incidence of unmarried teenage pregnancies
Is Sex Education Preventative? 141

or cases of venereal disease. To date there is little empirical evi-

dence bearing on the role of sex education programs in problems
such as these. However, it is perhaps unrealistic to expect sex edu-
cation programs to decrease the incidence of teenage pregnancies
and venereal diseases since the factors that affect these issues pre-
sumably involve community mores, family background, peer rela-
tionships, social environment, and social policies, to name but a
few of the multiple factors that might be presumed to exert influ-
ence. Similarly it is perhaps unrealistic to expect sex education
alone to decrease the incidence of the sexual disorders discussed in
this book because they too are an outgrowth of multiple factors in-
volving cultural, societal, interpersonal, and specific experiential
events. Rather, it is more realistic to evaluate sex education in
those areas in which it can be reasonably expected to exert its im-
pact.

2. Goals for Sex Education

First and foremost, sex education must imply acquisition of

knowledge and information regarding human sexuality. Second,
sex education should involve capacitation of interpersonal com-
munication about sexuality. Third, sex education hopefully will
deal positively with ailiiuues and values regarding human sexual-
ity. Fourth, although sex education may induce various behavioral
changes toward greater responsibility, for the most part it can deal
only indirectly with the actual sexual behavior of students, and for
obvious reasons, rarely are changes attempted or measured in that
arena. Sex education, then, can presumably only promote rather
than assure healthy sexual attitudes and can be only one factor in a
preventative approach to sexual disorders and problems. To deter-
mine whether or not sex education has a preventative role, param-
eters will have to be established for sex education itself, for re-
search and control populations in schools, and for the attitudinal,
cognitive, and behavioral changes that might realistically be ex-
pected to be shown by research populations before empirical con-
clusions could be reached. Unfortunately, no significant body of
142 Mary S. Calderone

research meeting these standards now exists, even though there

are some tentative research findings that bear upon these ques-
tions. Yet the importance of sex education to the question of pre-
vention cannot be denied, and with all this in mind, it is now possi-
ble to examine what little is known regarding the impact of sex
education on sexuality as it has been applied in school settings and,
second, to begin to examine the role of parents in sex education, a
topic about which even less is known.

3. Sex Education in Schools

Burleson (1973) has emphasized the existing lack of compre-

hensive research on sex education. Bidgood (1973) in an article that
reviews the existing research literature has also emphasized the
paucity of actual studies. He pointed out that there have rarely
been clearly defined goals against which to measure progress and
that most studies differ markedly in terms of their sex education
programs, their teachers, and their student populations, thereby
making comparisons almost impossible. In summarizing the studies
that do exist, he grouped them into three broad categories:
changes in knowledge regarding sexuality, attitudinal or value
changes, and behavioral changes. Sexual knowledge has been as-
sessed in school-aged children (Byler, 1969), and distinct dif-
ferences in knowledge have been shown in one study conducted
among lower-class ethnic populations (Schwartz, 1969). In at least
one study (McCreary-Juhasz, 1967) performed in a college setting,
there was little relationship between students' self-ratings of sexual
knowledge and their scores on a sexual knowledge test. Sex edu-
cation programs have been demonstrated to result in significent
gains in knowledge of sexuality in college students (Perkins, 1959;
Bardis, 1963) and in fifth- and sixth-grade students (Coates,
1970).
In the area of change of sexual attitudes or values, Coates
(1970) could not show that the gains in sexual knowledge were par-
alleled by significant changes in sexual attitudes in his population.
Is Sex Education Preventative? 143

On the other hand, Crosby (1971) has demonstrated significant

gains in self-image and self-acceptance in junior- and senior-high-
school students during a program in sex education. Carton and
Carton (1971) have shown changes in permissiveness in sexual atti-
tudes in junior-high-school-aged students. Olson and Gravatt
(1968) have also found changes in sexual attitudes at the college
level during a marriage-and-family course.
While changes in sexual attitudes or values are difficult to
measure, changes in behavior are perhaps even more so. The be-
havioral changes that have been most often noted as directly re-
lated to involvement in a sex education program are "increased
ease, openness, and satisfaction in parent-child communication and
interaction about sex" (Bidgood, 1973). An often-voiced concern
regarding the behavioral effects of sex education programs is that
they promote sexual acting out. In a retrospective study Wiech-
mann and Ellis (1969) were able to demonstrate with a large sam-
ple of college students that sex education programs themselves
were not a factor that significantly influenced premarital petting or
coital behavior. Bidgood (1973) points out that though there have
been no major studies to show any direct relationship between sex
education programs and venereal diseases or unwanted pregnan-
cies, there are some indications that such programs may increase
the rate of reporting of venereal diseases and may be effective in
lowering unwed pregnancy rates (E. Gendel, private communica-
tion, 1972), and that sex education programs combined with un-
seling and other ancillary programs have reduced the recidivism
rate of teenage unwed mothers (Sarrel, 1967).
A small unpublished study that also bears on these issues was
conducted by J. Elias of the Institute for Sex Research in 1969. A
total of 203 eleventh- and' twelfth-grade male and female students
in two high schools in a large midwestern city were given sex at-
titude and sex knowledge tests, and a small number were inter-
viewed in addition. Of the 203, 115 later participated in a sex edu-
cation course (the experimental group) and 88 did not (the control
group). All were given the attitude and knowledge tests following
the course and some were also reinterviewed.
144 Mary S. Calderone

A comparison of the experimental group with the control

group (which thereby showed the effects of sex education) yielded
the following salient findings (P. Gebhard, private communication,
1976);
1. Sex education made students more permissive about kiss-
ing and hugging but more conservative about sexual inter-
course.
2. Sex education made students more tolerant about sexual
relationships wherein both persons cared for one another
and behaved responsibly and less tolerant of exploitive re-
lationships.
3. Sex education made the students more aware of ethical
considerations and the feelings of others and in general
made the students somewhat more conservative about
sex.
4. Sex education substantially increased knowledge of sexual
anatomy and reproductive functions.
Iverson (1975) studied a group of 135 middle-class suburban
adolescents ranging in age from 11 to 19 years of age who were tak-
ing a sex education course offered by local churches. She demon-
strated that students completing the course became more liberal in
their sexual attitudes, but only in the sense that they believed that
individual choice rather than society or public law should regulate
sexual behavior. Their own basic standards of sexual behavior were
found to be unchanged, and the course was not found to lead to
promiscuous sexual behavior. As with Elias's study, Iverson found
that "an overwhelming majority of adolescents believed sex should
be associated with love-related relationships." She also found that
sex education could have a remedial effect, in that sex-educated ad-
olescents coming from homes conservative regarding nudity be-
came more liberal in their attitudes, and that adolescents who per-
ceived sex role stereotyping as extreme in their homes became
more flexible in sex role assignment. Dearth (1976) found greater
differences in attitudes of male college students versus those of
females before a first course in human sexuality than in the post-
test, the changes being slightly greater in the males and in the di-
Is Sex Education Preventative? 145

rection of "liberalism," that is, leading to greater similarity in lib-

eral attitudes.
In summary, then, these studies have shown that sex educa-
tion programs can modify knou:1edge about sexuality and develop
more liberal attitudes about sexuality, while also promoting more
conservative and responsible sexual behavior.
Nowhere has the importance of sex education been so amply
demonstrated as in the training of physicians. Burnap and Golden
(1967) have clearly demonstrated that a practicing physician's com-
fort with problems of human sexuality correlates directly with the
number of sexual problems he encounters in his practice: physi-
cians who obtain a sexual history from their patients routinely find
a much greater percentage of sexual problems than those who do
not. Lief (1965) has demonstrated that while medical students are
more knowledgeable about sexuality than nonmedical under-
graduate students and are also more capable of rejecting sexual
myths, they are significantly more conservative in sexual attitudes
and significantly less knowledgeable than nonmedical graduate
students. For example, 15% of medical students still believe that
masturbation is causally related to mental illness. Greenbank (1961)
found that 50% of medical students held to this sexual myth. While
medical students have become more knowledgeable since 1961,
presumably as a result of an increase in the number of sex educa-
tion programs in medical schoois, much work remains tu Le done
in this area (Lief, 1965). In the sense that sex education programs
have an impact on physicians' attitudes, feelings, and knowledge
regarding human sexuality, these programs can be presumed to
affect their behavior, at least at the level of inquiring about sexual
problems in their patients. Identification of a sexual disorder or a
problem may then constitute a preventative action on the part of
the physician.
While the number of studies in the area of sex education has
been small, there is at least some suggestion that sex education
does modify knowledge, attitudes, and behavior in a positive direc-
tion. Much work obviously remains to be done in this area. How-
ever, the question, "Is sex education in schools preventative?" can
be answered with a yes, even if only tentatively.
146 Mary S. Calderone

4. Sex Education by Parents

The question "Is sex education by parents preventative?" is

easier to answer, since even less is known about this! Actually, one
is free to respond categorically and positively in the affirmative, for
it is safe to postulate that sex education by parents has indeed been
preventative-Df healthy (judged objectively), fulfilling (judged
subjectively) sexual lives! Leaning on the mounting retrospective
evidence provided by sex therapists and counselors, it can be stipu-
lated that sex education by most parents has to date been either
nonexistent, actively negative, threatening, frightened, or capri-
cious, and sometimes seductive. Given the enormous difficulties
today placed in the path of carrying out sex-related research with
any group under the age of 18 (Elias, for instance, spent two years
in locating a school willing to permit the study reported earlier), it
is hard to predict when we will be able to depend on evidence
gathered directly in the field.
So the initial postulation must depend on indirect evidence of
the root causes of sex dysfunction, garnered from the research of
such as Dickinson (1949); Kinsey, Pomeroy, and Martin (1948);
Kinsey, Pomeroy, Martin, and Gebhard (1953); Masters and John-
son (1970); Money and Erhardt (1972); Schaefer (1973); and Green
(1974), among others.
Additionally, as Burleson (1973) and Bidgood (1973) have
pointed out, adequate parameters for sex education as a process do
not at present exist. It also seems certain that although what every-
body has in mind in using the phrase sex education almost always
relates it to high-school young people (the sexual Achilles' heels of
society today), it would appear from the work of researchers in the
gender identity field that in all probability, the most powerful sex
education a child ever experiences occurs before the age of 5. It is
therefore surprising that investigators working in the field of early
childhood education and socialization do not include sexuality in
their research.
Two assumptions are commonly made: that children from
birth to 3 years almost without exception exhibit signs of an emerg-
ing and quite overt sexuality; and that parents of young children
Is Sex Education Preventative? 147

also without exception experience twinges of anxiety and some-

times panic when their babies and toddlers fondle their genitals.
Yet White (1975), who has been working within the especially criti-
cal years of 0-3 and involves mothers by using trained teachers
who visit the home to teach them how to deal most fruitfully with
the cognitive development of young children, has not included ef-
forts to test these two almost universally held assumptions.
Thanks to the now classic taxonomic work of Masters and
Johnson (1970), various sexual dysfunctions that appear to be be-
havioral in origin have been classified. They and a number of other
researchers have demonstrated, postulated, or intuited the possible
or even probable ways in which these dysfunctions originate. But
as to how to prevent them, few today can offer valid answers. How-
ever, there is one broad general statement that may prove useful if
only to provoke specialists to tear it apart and disprove it: From
what we know at present about sexual dysfunctions of all types, ex-
cepting those specifically related to an anatomical, metabolic, or
genetic defect, these dysfunctions are not inborn but are made
because of the necessary fact that the human infant must spend the
greatest percentage of its prepubertal years in close contact with
adults.
In the process of a child's growing up, parents probably do the
least harm (in terms of quantity) in the area of gender identity; they
probably create a good deal of confusion in the evolution of gender
roles and gender-linked behavior in some children; but they almost
surely act most destructively (qualitatively and quantitatively) in
terms of negative attitudes about body image and eroticism. Fur-
thermore the potential damage is compounded because of the firm
conviction in the parent (usually the mother) that he or she is act-
ing for the child's ultimate and greatest good.

5. Knowledge and Eroticism

In the sexual evolution of young children, the first place for

parent-<:hild conflict is, in all probability, genital self-pleasuring.
This begins very early in practically all children, well before the
148 Mary S. Calderone

age of 1 year, when during diapering or bathing, their hands

wander around, as they do in habitual exploration, and discover
the genital area. It is unknown whether the presumed origins of
the word masturbation (numus, "hand," and stuprare, "to defile,"
both from the Latin) restricted its application specifically to
manual-genital-pleasuring-resulting-in-orgasm. Even young babies
have been said to behave in ways that would indicate some kind of
a sexual climax (Kinsey et al." 1948, 1953). Regardless, when a
baby plays with its genitals (and in the case of a boy automatically
and visibly thereby achieves erection), the observing parent,
usually the mother, quite often is thrown into panic, perhaps with
visions that her boy will grow up to be a sex maniac or her girl a
prostitute. Whatever her reaction, it is almost certain to be nega-
tive in effect, thereby starting the long, almost inevitably damaging
chain of associations that can later interfere in one way or another
in the sexual life of the adult her child will be.
If I may be autobiographical: I have for 70 years known fully
and surely that I was female and liked the idea. Although I was a
tomboy and had a driving intellect, I enjoyed my own femininity
and admired that of others (for instance, of Norma Shearer). It was
about my eroticism (which emerged so early that I don't even
remember being without it) that my mother and I clashed violently
for possession and control of what I looked upon as exclusively
mine: my body and its pleasures. The fact that from that period on
I associated the rage of being forced to go to bed with metal mitts
on my hands with sexual arousal and orgasm explains, I believe,
some sexual dysfunctions in which my adult relationships have suf-
fered. I early sensed that my father's sexuality was intense and that
even then in his marriage he behaved with great freedom, as, I
have learned since, did most of the artists and many of the elite of
those pre-World War I days. I have since concluded that I was a
victim of my mother's Puritan anger against her husband. Also in
retrospect, I have sensed that she herself was strongly erotic, and
this has only served to underline my conviction that in her despair
and frustration at what she probably correctly interpreted as her
husband's loss of sexual interest in her, she vented her resultant
Is Sex Education Preventative? 149

Puritanism in attempts to control what she often openly called my

"inherited oversexed tendencies."
Of course, many other factors play roles. Will the right to the
cognitive (sex information) as well as to the sensual (sex feelings) be
accorded to the child by its authority figures in time and in such
ways as to weigh positively rather than negatively in the evolution
of the child's sexuality? Positive cognitive ways should certainly
include simple and clear information on the structure, names, and
roles of the male and female genital organs early enough in life to
avoid the usual silly and distorting euphemisms. Furthermore
there should be consistently calm, assuring attitudes that the geni-
talia of all human beings are meant not only for procreation but
also to be sources of pleasure and that the enjoyment of this plea-
sure, in private, is everyone's prerogative-including the child's.
The accordance of privacy in such a permission-giving attitude
should enter in early, not with a parental attitude that masturba-
tion is bad or shameful or to be hidden but rather with the same at-
titudes that we apply to a number of family-centered decisions or
attitudes: just as what each of us does in our own closed-door bed-
rooms is our own business, so what we do in our mmily is our own
private business and not necessarily to be judged in relation to atti-
tudes and activities about sex in other families.
Furthermore in our attitudes about masturbation we cannot
afford any longer, to hedge our bets with the halfhearted "but not
too much" (especially in view of the mct that "too much" is un-
definable) or with the unrealistic and untrue "you'll outgrow it for
more grown-up behavior." The latter, of course, goes contrary to
the established finding that the proportion of people who find self-
pleasuring useful throughout their adult lives is high and will in all
probability be higher when we finally do accept this as mct.
It would seem, therefore, that positive attitudes about the
child's eroticism might be of the most profound importance for
parents to develop as early as possible in their earliest child-bear-
ing years. Inevitably this development must, at least at first, entail
the involvement of those who first see the young parents and who
follow the child from birth on. Whether physician, social worker,
150 Mary S. Calderone

public health nurse, or child-care-center worker, one of the earliest

questions to be included in history taking in the periodic health
visit should be, "How does it make you feel when your child plays
with its sex organs?" (Note that in accordance with well-developed
and accepted methods of taking sexual histories [Pomeroy, 1974],
the question is asked in a way that takes for granted that the activ-
ity indeed has occurred or most certainly will occur.) The second
question should be, "Do you remember back to when you did the
same thing and how your mother felt and how that made you feel?"
The emphasis on how the mother herself feels about erotic activity
in her own baby tells her that her reactions are important to the
doctor and therefore must be of importance to her child. This in-
terchange can be the open sesame for a wide range of sex educa-
tion and counseling opportunities that could serve the welfare of
both parents, not merely as parents but as man and woman, which
in tum would serve the child's welfare at a presumably productive
and preventative level early in the child's and therefore in the fam-
ily's evolution.

6. Morals and Values

One area closely related to cognitive and affective develop-

ment is that of moral reasoning. Kohlberg's (1974) excellent work
on the stages of moral reasoning is based on Piaget's stages of cog-
nitive development. It is not possible for behavioral scientists to
avoid this area much longer, for parental sex education will not get
far unless it is taken into account that the basis of much irrational
opposition to school sex education programs is a kind of circular
thinking that goes like this:

You cannot teach sex education without teaching about

morality;
You cannot teach morality without bringing in religion
(particularly the Christian religion);
You cannot teach religion in schools; ergo,
You cannot teach sex education in schools. QED.
Is Sex Education Preventative? 151

The point is, of course, that one cannot and should not teach
children about anything at all without consideration of the moral
values that relate to what is being taught. Furthermore moral val-
ues are not the exclusive terrain of the religious. All education
should deal with the weighing of values relative to all actions,
including sexual ones. Human sexuality per se must be regarded as
morally neutral. As with all of our endowments and faculties,
though, it is how we use it that inevitably has moral implications.
Similar moral questions will arise about how to use natural re-
sources, including molecular energy, or how we will (or will not)
"use" other people who are not as strong or favored as our-
selves.

7. Sexual Health

Somewhere in this quagmire of us, buts, and assumptions,

there must lie at least some answers to what constitutes sexual
health. A World Health Organization Technical Report (1975) re-
sulted from a four-day meeting of 24 physicians representing 13
countries, who, in considering the broad area of sex education and
therapy and the training of health professionals, arrived at the fol-
lowing:
Sexual health is the integration of the somatic, emotional, intd!ed m1 ::md
sociai aspects of sexual being, in ways that are positively enriching and that
enhance personality, communication and love. Fundamental to this concept
are the right to sexual information and the right to consider sexuality for
pleasure as well as for procreation.

In spite of this encouraging outlook there exist serious prob-

lems today that impede the acceptance of sex education programs.
Currently we have a political and economic climate that will place
all "frill" programs at risk. For example, New York City, which had
excellent curricular and peer-counseling programs in family life ed-
ucation that included sex education, closed down this entire proj-
ect. Its director, who had worked at the Board of Education level,
has been returned to the role of school nurse and her job as super-
visor of the special programs has been abolished. We are really at
152 Mary S. Calderone

risk in all this. We are also at some risk-and every local commu-
nity is at risk-because the organized anti-sex-education forces are
growing vocal again. They have money and they have influence
with people who are probably very well-meaning but unaware.
They can panic people in their communities into electing school
board members who, without bothering to inform themselves of
the truths, are sure to be against any kind of sex education pro-
grams. This has been reported as a fundamental aim of the John
Birch Society, to replace school board members allover the
country with people of their own persuasion who can then be
counted on to tear pages out of books and punish teachers who
read SIECUS or other similar materials (Haims, 1973; Hottois &
Milner, 1974). There is also one state in the nation, Louisiana, that
actually forbids all sex education in any school, private, parochial,
or public. Six states (Hawaii, Kentucky, Maryland, Michigan, Mis-
souri, and North Dakota) and Washington, D. C., however, now
mandate it as a part of general health education. Studies on exactly
what is happening in these six states need to be undertaken.

8. Summary

It took about 50 years for family planning to be accepted as a

health concept and, therefore, as a part of medical practice, first by
the American Public Health Association in 1959 and subsequently
by the American Medical Association and the World Health Orga-
nization. It has taken only 12 years for the human sexuality move-
ment, first in this country but increasingly across the world, to be
accepted by the various health-related professions as intrinsic in
their professional practices. The central importance of his or her
own sexuality to the well-being of every individual, therefore, can
now be accepted. However, we have no way of showing in the
near future (short of the laborious, longitudinal studies that at this
time it is unrealistic to hope for) what the "good" or preventative
effects might be of planned sex education, whether in the home or
in the school.
Is Sex Education Preventative? 153

But the available data enable us, with entire justification, to

point to the drastic ill effects that the present hit-and-miss system
clearly has had on human lives. It is time for science, religion, and
education to join forces to develop programs by which home,
church, school, and community can support each others' efforts
toward good sex education. As a starter, some basic premises might
be accepted:
1. We are born sexual and remain so until death.
2. Our sexual learnings, experiences, and fantasies, acting on
our inborn genetic bases, determine the highly individual
sexuality patterns of each one of us as we go through life.
3. What happens sexually to the child from birth to age 5
within the family determines or at the very least pro-
foundly influences in unknown but undoubtedly large mea-
sure its sexuality for the rest of its life.
4. Sexuality itself is morally neutral; as with our other facul-
ties, it is how we use it in our lives that has moral implica-
tions.
5. These moral implications can and should transcend dif-
ferences in religious dogma.
6. We are not our neighbor's sexual keepers. In our pluricul-
tural patterns, such an attitude is indefensible. To be
keepers only of one's own sexual values and actions
requires moral strength as well as nonjudgmental attitudes,
as we who work, teach, or research in the sexuality field
must be the first to demonstrate
Possession of scientific knowledge alone, no matter how solid,
should not be permitted to lead to a kind of sexual elitism that is
empty of warmth, compassion, empathy, and shirt-sleeve efforts on
behalf of those who have not had the good fortune to become as
enlightened as we workers in the human sexuality movement feel
ourselves to be. Considering the antisexual forces that remain
aligned against sexual enlightenment and responsible freedom, a
coalition of efforts on behalf of the true sexual needs and rights of
people of all ages is called for and is indeed long overdue.
154 Mary S. Calderone

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 7
Editors' Introduction

In the previous chapter, Calderone emphasized that sex education

in social institutions may serve a preventive role by promoting
healthy sexual attitudes, which are achieved in part through the
provision of accurate information about sexual behavior. Wilson
argues that to a large extent, pornography also provides individuals
with educational information about sexual behavior. Furthermore
pornography may play a role in reducing anxiety about sexual be-
havior and in facilitating communication about sexual matters be-
tween partners. In this chapter, Wilson carefully analyzes perti-
nent research findings and convincingly demonstrates the potential
value of pornography as a source of prevention of sexual problems.
There is little question that our society is worried about the
harmful effects of pornography, as evidenced by the recent prose-
cution of an actor in a pornographic movie and of a publisher of a
pornographic magazine. This sort of prosecution seems ironical in
light of Wilson's discussion of the use of pornography and sexual
abnormality: the empirical evidence strongly suggests that so-called
sexually abnormal persons are much less likely than sexually nor-
mal persons to have used pornography during adolescence. One
might well wonder what we are being protected from by the well-
meaning prosecutors. Wilson's chapter is compelling and certainly
controversial.

157
 7
Can Pornography Contribute to
the Prevention of Sexual
Problems?
W. CODY WILSON

1. The Probkm

Consider for a moment the precept regarding sex that has in the
past dominated in our society and still prevails today. In childhood
and adolescence an individual should know nothing about sex,
should have no interest in sex, and certainly should have no experi-
ence with sex. When the individual becomes an adult and marries
(typically sometime during the decade between ages 18 and 27), an
official representative of the society will issue a permit and utter an
incantation at a ritual, the individual will go with a partner to a
private chamber, and, without even a perfunctory education in the
mysteries, will become a fully and adequately functioning sexual
being from that point on.
Contrast this precept with what we know generally about
human functioning. A long period of learning is required for the
development of all systems of social behavior; this is no less true for
W. Cody Wilson Graduate School of Social Work, Adelphi University, Garden City,
New York 11530.
159
160 W. Cody Wilson

sexual behavior than for other systems of behavior (Zigler & Child,
1968). Indeed, experimental studies indicate that even rats, dogs,
and monkeys require prior social learning experiences before
reaching maturity in order to develop adequate copulatory behav-
ior as adults (Ford & Beach, 1951; Harlow, 1962). Human beings,
too, must have appropriate learning experiences before reaching
adult status if they are to be fully and adequately functioning sexual
beings as adults.
This contrast between the societal precept regarding sex and
the social-psychological reality regarding human development of
competency in the sexual realm has two logical consequences. Ei-
ther the society will develop latent mechanisms for providing the
manifestly proscribed but functionally necessary opportunities for
learning about sex and to be adequate sexually, or the society will
have a high level of sexual problems and sexual inadequacy. It is
possible, of course, that latent mechanisms may exist but function
at less than perfect efficiency and consequently that relatively high
levels of sexual problems would exist concomitantly.
The existence of both a high incidence of sexual problems and
latent mechanisms for providing sexual learning in our society are
confirmed by formal empirical observation.
One-fifth of the respondents in a survey of a national probabil-
ity sample of nearly 2,500 adults in the United States rated their
current sex life as "unsatisfactory" (Wilson, 1975). In this same sur-
vey, only 58% of the married respondents reported that there had
been no significant sexual problems in their marriage. Indeed,
Masters and Johnson (1970) estimated that at least half the mar-
riages in this country are either currently sexually dysfunctional or
imminently so.
As for the existence of latent mechanisms for sexual learning,
Abelson, Cohen, Heaton, and Suder (1971) reported a negative
correlation between adults' preferred sources of information about
sex for young people and young people's actual sources of informa-
tion.
Further analysis of the situation could lead to a plausible argu-
ment that pornography is a part of the latent mechanism by which
our society provides opportunities for learning about sex and thus
Pornography and the Prevention of Sexual Problems 161

that pornography does or can help to prevent sexual problems. In-

deed, such arguments have been made; one example is that pre-
sented by Hyman (1970). The ultimate basis for conclusions about
such relationships, however, should be formal empirical observa-
tion and not logical analysis and argument; we shall turn, shortly,
to an examination of the available empirical evidence.
First, however, let us clarifY the term pornography.

2. The Definition of Pornography

The word pornography derives from the Greek, meaning

"writing of or about prostitutes." By extension it refers today to
depictions that are sexually arousing. Note that this definition is
not in terms of objective characteristics of material but rather in
terms of human subjective reaction to the material. Empirical evi-
dence indicates that both verbal and pictorial depictions of human
nudity, genitalia, and sexual activity produce some degree of sexual
arousal in substantial numbers of adults in our society today
(Cairns, Paul, & Wishner, 1962; Johnson, Kupperstein, & Wilson,
1970). Thus descriptions and illustrations relating to sex are prop-
erly labeled pornography.
Pornography shlJulcl he differentiated from obscenity, a term
that refers to things that are "offensive," especially in public dis-
play. In contemporary American legal usage, obscenity is limited to
sexual materials and thus may overlap extensively with por-
nography. Explicit depictions of sex must meet all of three criteria,
however, in order to be classified as legally obscene and therefore
legally proscribed: (1) they must appeal to a prurient interest in
sex; (2) they must be offensive according to contemporary stan-
dards; and (3) they must be lacking in serious social value. Note
again that these criteria refer not to objective characteristics of the
material but to subjective reactions to it. These criteria are cur-
rently in considerable flux, and it's very difficult to determine
whether or not a given material is legally obscene until a legal ac-
tion is brought against it and carried to a final decision.
The important point for the present discussion is that por-
162 W. Cody Wilson

nography and obscenity are not identical but are quite different
concepts. A given exemplar of pornography may be legally obscene
but it is not necessarily so, and many, if not most, materials that
may properly be classified as pornography are not legally obscene.
The term pornography should properly have no connotation of
legal proscription!
Pornography, as used in this paper, refers to depictions of
genitalia and sexual activity, either verbal or pictorial, that are po-
tentially sexually arousing for substantial segments of the popula-
tion. The term is approximately synonymous with "explicit sexual
material. "
Now let us examine the empirical research literature relevant
to the question, "Can pornography contribute to the prevention of
sexual problems?"

3. The Empirical Research Literature

Only one major study that I am aware of approaches this issue

directly. This study is of sufficient import that it should be de-
scribed in some detail.
Abelson and his colleagues (1971) reported findings of a na-
tional survey conducted for the U.S. Commission on Obscenity
and Pornography. The survey involved face-to-face interviews with
a probability sample of 2,486 adults aged 21 years and older in the
contiguous continental 48 states. The interviews, presented as an
"opinion survey on current social issues," were conducted by expe-
rienced female interviewers who received special training for this
project. The interviewer first asked general questions about book
and magazine readership and movie theater attendance, which
were expected to present minimal emotional difficulty to the re-
spondents. Next came a series of questions on involvement and ac-
tivity with regard to general social issues as defined by the respon-
dent. Similar questions were then asked about a specific social
issue-sex education-and these were followed by several ques-
tions about the respondents' own experience with sex education.
Only at this point, after rapport had been established and the topic
Pornography and the Prevention of Sexual Problems 163

of sex had been introduced in a natural and nonthreatening way,

were more explicit questions regarding sexual depictions in-
troduced.
The interview inquired into experience with depictions of five
different sexual contents: nudity with sex organs exposed, mouth-
sex organ contact between a man and a woman, a man and a
woman having sexual intercourse, sexual activities between people
of the same sex, and sex activitie~ that included whips, belts, or
spankings. Each of these five contents were questioned about in
three modes: verbal descriptions, still pictures, and moving pic-
tures. Then the respondent was asked a series of questions regard-
ing the effect of seeing or reading these kinds of sexual materials on
themselves and on others whom they knew personally. A more de-
tailed description of this survey may be found in reports by Wilson
and Abelson (1973) and LoScuito, Spector, Michels, and Jenne
(1971).
Before turning to the responses regarding the effects of ex-
posure to these sexual materials, let us consider for a moment the
question of the validity of the responses.
First, we should note that fewer than 0.5% of the interviews
were terminated, once they began, before they were completed.
Indeed, in response to a question at the end of the interview, over
half of the respondents said that they were glad they had been in-
terviewed, whereas only 7% said that they wished they had not
taken the time for it.
Second, in response to a series of candor questions at the end
of the interview, only 5% said that they had been less than candid
in responding to the questions asked about their experiences with
sexual materials.
Finally, additional support for the validity of these data came
from a small pilot study comparing the information obtained with
this survey interview with information obtained in a more intensive
and longer clinical interview (Kant, Goldstein, & Lepper, 1971).
The study found that the data elicited by the two interview tech-
niques were very similar.
Thus we have a basis for believing that these self-reports were
reasonably valid reports of actual experience.
164 W. Cody Wilson

What effects relevant to our question did this representative

sample of American adults report as a result of viewing por-
nography?
Twelve percent of men and 8% of women reported that such
materials had improved the sex relationship within their marriage.
Eleven percent of men and 4% of women reported that in
their own case these sexual materials had caused husband and wife
to do "new things" sexually.
Two percent of men and 1% of women reported that in their
own case sexual materials had given relief to sex problems.
If these figures are projected to the entire adult population of
the United States, we can conservatively estimate that more than
10 million Americans have had the experience that looking at or
reading pornography has improved the sexual relations in their
marriage! And more than 1 million Americans have had the per-
sonal experience of obtaining relief from a sex problem by looking
at or reading pornography.
These are reports of direct effects. It is quite possible that por-
nography brings about additional indirect effects by preventing dif-
ficulties or problems from arising in the first place.
The principle sources of sexual dysfunction and sexual prob-
lems appear to be lack of information, general anxiety about sex,
and inability to communicate about sex with partners-not physical
abnormality, medical illness, nor deep-seated psychiatric prob-
lems--and modem, sexual therapies are directed in large part to
providing appropriate information, lowering anxiety, and facilitat-
ing communication between partners (Kaplan, 1974; Masters &
Johnson, 1970).
If pornography can make a contribution to the prevention of
sex problems, it will likely be in these same areas.

4. Information-Providing Function 0/ Pornography

Several studies have attempted to test the idea that one of the
functions of pornography is to provide information about sex that is
not available from other, "legitimate" sources by looking for a rela-
Pornography and the Prevention of Sexual Problems 165

tionship between the amount of information obtained from the le-

gitimate source and the amount of exposure to pornography. If a
negative correlation is observed, this would be consistent with the
proposition that people seek out pornography to fill the void
created by lack of information from legitimate sources.
Elias (1971), in a study of a random sample of 405 white llth-
and 12th-grade students in a large midwestern suburban-industrial
area, found no relationship between whether or not parents had
talked with the student "about the facts of life" and amount of ex-
posure to depictions of nudity with genitalia showing or of hetero-
sexual intercourse. Propper (1971) found no relationship between
the amount of talk about sex within the home and exposure to por-
nography among 476 males aged 17-20, mostly black and Puerto
Rican, living in New York City.
Berger, Gagnon, and Simon (1971a) used data from 1,177
respondents in a national probability sample of college students in
the United States to test this idea. They found no relationship be-
tween potential amounts of information from other sources-
frequency of sexual conversations in the home, amount of nudity in
the home, amount of technical sex material read during high school
years, and whether or not the person had taken a sex education
course in high school-and frequency of exposure to pornographic
materials during the college years.
That there is no negative relationship between amount of po-
tential information from "legitimate" sources and exposure to por-
nography would seem to be a reasonably valid empirical fact. It
does not seem sufficient, however, to conclude, as Berger et al.
(1971a) did, that the hypothesis that pornography is used as an
information-providing medium should be rejected. To draw this
conclusion would require two assumptions: (1) that the existing
legitimate sources would relatively completely satisfy the need for
sex information so that there would be no need to seek more from
pornography; and (2) that the function of pornography is to provide
information about sex.
Berger et al. did hedge their conclusion by asserting that it
should not be interpreted to deny that pornography may provide
some information to those exposed to it. Rather, they felt that in-
166 W. Cody Wilson

formation is an incidental by-product of exposure to pornography

and that it is clear that pornography is not usually sought out with
an information-seeking purpose in mind.
Now, is there any direct evidence relevant to the issue of the
information-providing function of pornography? The answer is
"Yes, several studies have developed empirical evidence on this
issue. "
Berger, Gagnon, and Simon (1971b), in a different study from
the one discussed above, provided data from a sample of 473 ado-
lescents aged 14-18 living in a predominantly working-class neigh-
borhood in Chicago. Of the males (half of whom were aged 17 or
18), 95% had seen pictures of nudes with genitals exposed and 77%
had seen pictures of heterosexual intercourse. Of the females (half
of whom were aged 15 or 16), 65% had seen pictures of nudes with
genitals exposed and 35% had seen pictures of intercourse. These
exposure figures are quite consistent with the results of other stud-
ies of adolescent experience with pornography (Wilson, 1971).
Forty-five percent of the boys and 44% of the girls reported
that exposure to explicit sexual materials had taught them aspects
of sexuality that they didn't know before, and 45% of the boys and
43% of the girls reported that these sexual materials had given
them an idea of what people actually do.
Propper (1971), in the study mentioned above, reported a pos-
itive correlation between amount of exposure to pornography and
the accuracy of sex information.
Winick (1971) carried on a "discussion-interview" with a quota
sample of 100 male patrons of heterosexual adult movies in five cit-
ies in the United States. The interviewees were similar in demo-
graphic characteristics to 5, ()()() patrons of such movies observed in
10 locations in the United States; that is, they were conventionally
dressed, white, predominantly middle-class, and aged 19--60. The
"interviews" averaged about one hour in length, were of a "conver-
sational" nature (that is, with no formal questions but with general
"probes" to direct and maintain the conversation), and focused on
patterns of usage of pornography, social context of viewing such
movies, and the "functions" that viewing such movies performed.
Of these patrons, 56% identified aspects of information as signifi-
Pornography and the Prevention of Sexual Problems 167

cant elements in these pornographic films that they had just seen.
Indeed, 21% of the patrons' total comments regarding the movies
were directed toward the information-providing dimension. Nawy
(1971) administered questionnaires to 251 patrons of two "adult"
movie theaters in San Francisco. In response to the question of
why they attended these movies, 36% said that they did so to get
ideas about sexual matters.
Another study (Glide Foundation, 1971) asked 199 participants
in training courses in human sexuality about their previous experi-
ence with pornography and their reactions to this experience.
Nearly all had been exposed to movies depicting intercourse. Over
three-quarters of these people reported that they were usually
aroused by such movies-thus they were indeed pornographic.
Moreover, 45% of the men and 30% of the women reported that
their usual reaction to these movies includes a feeling of being "in-
formed."
Walker (1971) reported that nearly two-thirds (65%) of a sam-
ple of 60 male college students age 21 and older in Waco, Texas
(half Caucasian, half Negro) answered "Yes" to the interview ques-
tion, "Did you learn anything about sex from these materials
(books, pictures, movies that show people without clothes on in-
volved in sex acts)?" Over half of 30 white members of men's ser-
vice clubs (Toastmasters, Je's, etc.) in Waco answered "Yes" to this
question.
These findings, based on studies of selected nonrepresentative
samples, that substantial numbers of people in our society report
information about sex to be an important product of viewing por-
nography, are confirmed by the national survey described earlier
(Abelson et al., 1971). Over a quarter (27%) of the adult men and
over one-fifth (21%) of the adult women reported that they per-
sonally had the experience of acquiring information from por-
nography.
From these data we may conclude that it is a valid empirical
fact that substantial numbers of people have acquired information
about sex from pornography.
We may note also that a larger proportion of adolescents and
college students report this phenomenon than do older adults. This
168 w. Cody Wilson

difference may be more apparent than real. Obviously much of the

learning about sex takes place in adolescence and young adulthood.
Since the information acquisition is relatively recent for adolescents
and young adults, they can better remember the specific circum-
stances of acquisition and the sources, whereas for older adults the
primary information acquisition process occurred some years ago
and they do not recall specific circumstances and sources. Thus the
incidence of acquiring information about sex from pornography
may well be greater than the results of the national survey of adults
indicates.
Our initial analysis suggested that opportunities to learn about
sex could help to prevent the development of sex problems. The
empirical evidence indicates that materials classified as por-
nography provide sex information to a substantial proportion of the
population in our society, especially to adolescents. Is there any
empirical evidence to indicate that this information gained from
pornography does help to prevent sex problems?
The empirical evidence on this question is, unfortunately,
both meager and somewhat indirect.
One line of relevant enquiry is to inquire into the past experi-
ences of people who have sexual problems to try to describe their
degree of exposure to pornography.
Goldstein (1973) described the results of a research project
exploring the relationship between experience with pornography
and the development of "normal" or "abnormal" sexual behavior in
adult life. The research used an ex post facto design that compared
several groups, the members of which had manifested some sexual
"abnormality," with a comparison group whose members had man-
ifested no sexual abnormality, in terms of their experience with por-
nography during adolescence. The groups with "abnormal" sexual
behavior were institutionalized sex offenders (rapists, male-
oriented pedophiles, and female-oriented pedophiles who were
recent admissions to Atascadero State Hospital in California), non-
institutionalized male homosexuals (obtained through the coopera-
tion of One, Incorporated, a homophile organization in Los Ange-
les), and transsexuals (males who had applied for sex change
therapy at the UCLA Gender Identity Clinic). The "normal" group
Pornography and the Prevention of Sexual Problems 169

were males from randomly selected blocks in the Los Angeles com-
munity selected to match the sex offenders in terms of age, ethnic
group membership, and educational level. There were 19 rapists,
20 male-oriented pedophiles, 20 female-oriented pedophiles, ·37
homosexuals, 13 transsexuals, and 53 controls. Data were collected
by trained interviewers in long "clinical" interviews that were tape-
recorded. Information was coded from the interview tapes with a
relatively high degree of reliability. The interview included, among
other items, questions dealing with experience with various types
of pornography during the individual's adolescence.
The finding of particular interest to us here is that generally
the groups manifesting "abnormal" sexual behavior reported having
had less exposure to pornography during adolescence than the
"normal" comparison group. This difference was particularly
marked with regard to pictorial depictions of heterosexual inter-
course. That is, the individuals who later engaged in "abnormal"
sexual behavior as adults had had a markedly low frequency of ex-
posure (in comparison with individuals who as adults engaged in
"normal" sexual behavior) to pictorial depictions of "normal mature
sexuality"-heterosexual intercourse.
It should be noted that these findings, when they were first
reported, were highly unexpected and somewhat shocking. They
were quite contrary to rather widely held cultural beliefs. Indeed
there were whispered speculations about the possibility that "nor-
mal" people living in Southern California might be a little peculiar.
But similar findings were reported for research conducted in
other geographical locations.
Walker (1971) compared institutionalized rapists in Texas with
(1) a matched group of non-sex-offenders in the same institutions
and (2) college students and members of men's service clubs in
Waco, Texas. The rapists had had less experience with por-
nography in general than the college students and the service club
members, and they had had a later initial exposure to depictions of
heterosexual intercourse than the similarly institutionalized non-
sex-offenders.
Cook and Fosen (1971) studied 63 sex offenders (indecent
liberties and attempted rape) and 66 criminal code offenders (bur-
170 W. Cody Wilson

glary, homicide, forgery, and robbery) in the Wisconsin State

Prison. These two groups were reasonably well matched in terms
of education, general intellectual abilities, and age. The sex of-
fenders reported significantly less experience with pornography
during preadolescence and adolescence than did the criminal code
offenders.
Johnson, Kupperstein, and Peters (1971) compared a repre-
sentative sample of 47 white males convicted of sex crimes (rapists,
homosexuals, pedophiles, and exhibitionists) in Philadelphia and
placed on probation with a national probability sample of males in
the same age range, in terms of their experience with por-
nography. The sex offenders reported a later initial experience with
pornography (over one-quarter were not exposed to pornography
until age 21 or older) than did the normal adults.
These several studies have some weaknesses. They are all es-
sentially correlational when we really need experimental-longi-
tudinal designs to establish that the experience with pornography
helps to prevent development of socially disapproved patterns of
sexual conduct. There exists the possibility within the limitations of
design of these studies that deprivation of experience with por-
nography and development of deviant sexual patterns are not caus-
ally related but are rather both the effects of some unidentified
third variable. Further, it is not conclusively obvious that these
research findings regarding "deviant" or "abnormal" adult sexual
patterns are generalizable to more socially acceptable sexual prob-
lems, such as marital sexual dysfunction. However, I do not know
of any formal research studies using comparison groups that have
inquired into the empirical relationship between experience with
pornography in adolescence and marital sexual dysfunction.
Nevertheless we may conclude on the basis of these several
findings that it is a relatively valid empirical fact that adult males
who manifest "deviant" sexual behavior, such as rape, pedophilia,
homosexuality, and transsexualism, have had less experience with
pornography in adolescence than have comparison groups who
manifest more "normal" sexual behavior.
Thus we have two well-established facts: (1) substantial
numbers of people obtain sexual information from pornography;
and (2) people who manifest "deviant" sex behavior in adulthood
Pornography and the Prevention of Sexual Problems 171

have been relatively deprived in tenns of amount of experience

with pornography in adolescence. If we add to these facts the con-
necting link that in the opinion of modem sex therapists a principal
contributor to sexual dysfunction is lack of appropriate infonnation,
we are led to the tentative conclusion that pornography, in our so-
ciety, can-indeed does-contribute to the prevention of sex prob-
lems by providing necessary infonnation for the development of
appropriate, mature sexual functioning.

5. Anxiety- and Inhibition-Relieving Function of

Pornography

The amount of empirical infonnation relating to the anxiety-

and inhibition-relieving function of pornography is much less than
that relating to the infonnation-providing function. However, there
are a couple of experimental studies of the effects of viewing por-
nography that have incidentally generated data on these issues.
Byrne and Lamberth (1971) studied the reactions to a single
session of viewing pornography of 42 married student couples at
Purdue University who were recruited by means of public solicita-
tion to participate in research dealing with opinions about por-
nography. The participants filled out a questionnaire, were then
shown 19 pornographic slides twice, filled out another question-
naire, and were given a follow-up questionnaire to fill out one
week later and mail back to the researchers.
Viewing the pornographic stimuli resulted in significant
changes in self-ratings of sexual arousal and anxiety: sexual arousal
increased and anxiety decreased following viewing the por-
nography.
This single session viewing of 19 slides did not have a massive
impact on sexual behavior during the week following; responses to
items about sexual behavior during the week tended to cluster
around the scale point "about the same as usual." However there
were a few reports of increased sexual behavior and a few reports
of qualitative differences in experience. These qualitative dif-
ferences were positive ones: increased love, increased willingness
to experiment, and increased feeling of closeness.
172 W. Cody Wilson

Mann, Sidman, and Starr (1971) conducted an experimental

study of the effects of attending one pornographic film-viewing ses-
sion a week for four weeks (a total of seven films) on 83 married
couples who had been married for at least 10 years. The couples
were predominantly white, upper-middle-class, living in the vicin-
ity of Palo Alto, California. Over one-fifth of the participants, both
male and female, reported lowered sexual inhibitions toward
spouse and a similar proportion reported increased urge to try new
sexual techniques. In addition, although there was no general in-
crease in sexual activity during the month in which the film ses-
sions occurred, there was a very marked increase in marital sexual
activity on the film-viewing nights.
In a questionnaire study of 251 patrons of two different adult
movie theaters in San Francisco, one-fifth of the respondents re-
ported that they attended such theaters in order to become "sex-
ually primed" prior to having sexual relations with their regular
sexual partners (Nawy, 1973). Indeed, one "elderly" couple com-
pleted the questionnaire together and stated that they had experi-
enced a reawakening of sexual activity as a result of attending por-
nographic movie theaters.
In a correlational study, Mosher (1973) found, among a sample
of 194 single undergraduate males at the University of Connecti-
cut, a significant negative correlation between exposure to por-
nography and sex guilt and a positive correlation between sex guilt
and an inhibition regarding expressing sexuality.
This evidence, although it is sparse, does suggest that viewing
pornography can reduce sexual inhibitions within a marriage.
Unfortunately there are no data regarding the question of
whether or not exposure to pornography in adolescence produces
less guilt, anxiety, and inhibition regarding sex in adulthood.

6. Communication Facilitation Function of Pornography

Again there exists relatively little formal empirical research ev-

idence regarding the capacity of pornography to contribute to the
ability of sexual partners to communicate with each other.
Pornography and the Prevention of Sexual Problems 173

The experimental study by Mann et al. (1971) cited previously

also presents data relevant to this issue. The interpretation of the
data is somewhat ambiguous, however, and it will be necessary to
describe the study in more detail. The subjects, couples married at
least 10 years, were recruited to participate in a survey of married
couples' sexual patterns, and each member of a couple was
required to spend a couple of minutes daily for a period of 12
weeks separately completing a checklist of sexual activity engaged
in during that 24 hours. The experimental treatment of viewing
pornography was inteljected incidentally after the fourth week. At
the end of the 12-week period the participants completed several
questionnaires.
At the end of the 12-week period, 43% of the males and 40%
of the females reported that participation in the study had pro-
duced increased openness in discussing sex. It is not clear how
much of this change had resulted from filling out the daily ques-
tionnaire and how much from viewing the pornographic films.
However, the participants were also asked to rate the extent to
which each component of the study had influenced their sexual
patterns. Filling out the daily reports was rated the most influen-
tial, but seeing the movies was rated almost as high in terms of in-
fluence. The pornographic movies were actually perhaps of greater
influence; these ratings are confounded because they also included
some subjects who saw nonpornographic films (the control group).
The interpretation that the film viewing contributed to the
facilitation of communication is supported by a result reported by
Mosher (1973). In an experimental study of 194 males and 183
females, single undergraduates at the University of Connecticut,
the one "sexual behavior" that was found to increase significantly in
the 24 hours following the viewing of a pornographic film was "con-
versation about sex." The increase was greater for the females than
for the males.
Davis and Braucht (1971) also reported increased conversation
about sex in the 24-hour period after a session of watching three
short pornographic movies. The subjects were 121 male college
students from three ethnic backgrounds (Caucasian, black, and
Hispanic) in the Denver, Colorado area.
174 W. Cody Wilson

On the other hand, Byrne and Lamberth (1971) reported no

significant change in the rate of talking about sexual matters in the
week following brief exposure to still pornographic pictures nor fol-
lowing reading brief paragraph verbal descriptions of sexual activ-
ity. This study differed from the previous studies in three ways that
might have produced the inconsistent results: (1) the time of re-
porting was one week later and the impact may have dissipated by
that time; (2) the stimuli were still pictures and verbal descriptions;
and (3) the exposure was relatively brief.
As a group these studies demonstrate that pornographic mov-
ies, if not other types of pornography, have the impact of facilitat-
ing communication--{)f increasing the activity of talking with
others-about sex.

7. Additional Considerations

Viewing of pornography has one other potential impact on the

individual that has quite interesting implications for the prevention
of sex problems. The subjects in the study conducted by Mann et
al. (1971) reported an increased frequency of awareness of sexual
arousal as one change in sexual pattern that they attributed to par-
ticipation in the study. This finding raises the interesting possibility
that some people don't know when they are sexually aroused!
This possibility is indirectly confirmed by a comparison of the
results of two types of studies. In interview-type studies, both sur-
vey and clinical, where people are asked to report whether or not
they have been "sexually aroused" by viewing pornography, in-
variably more men report sexual arousal than do women (Kinsey,
Pomeroy, Martin, & Gebhard, 1953; Abelson et al., 1971; Berger
et al., 1971a). However, when in experimental situations people
are asked to report on various physiological symptoms of sexual
arousal (e.g., erection and genital sensations), as many women as
men report physiological symptoms of sexual arousal in response to
viewing pornography.
It is certainly possible that women do not appropriately attach
the label of "sexual arousal" to physiological symptoms of sexual
Pornography and the Prevention of Sexual Problems 175

arousal because they have not been labeled for the women in
childhood, adolescence, or young adulthood. In the case of the
male, the physiological symptom of sexual arousal is external and
very obvious to others; thus it is likely to be labeled for him. On
the other hand, the physiological symptoms of arousal for females
are internal and can not easily be observed by others; hence these
symptoms may not be properly labeled via social experience.
Pornography may potentially serve to help to prevent or to
help to remedy sexual dysfunction by aiding individuals in learning
to properly identifY the phenomenological experience of sexual
arousal.
Pornography aids in preventing serious sexual dysfunction in
still another, quite indirect way. Pornography has been increas-
ingly used in the past decade in the training of professionals who
deal with sex problems (Wilson, 1972). Two descriptions of pio-
neering efforts in this direction have been reported (Money, 1971;
Glide Foundation, 1971). To the extent that professionals who have
been trained in part by planned exposure to pornography are suc-
cessful in alleviating incipient sexual dysfunction in clients, por-
nography makes a contribution to the prevention of sex problems.

8. Conclusion

We have reviewed above formal empirical research relating to

three potential consequences of viewing pornography: (1) providing
information; (2) reducing inhibitions; and (3) facilitating com-
munication.
The existing research on these topics is somewhat limited, yet
it demonstrates that several propositions may be considered to be
relatively valid:
1. Substantial proportions of both men and women in our so-
ciety report that they have acquired sex information from
pornography--especially in adolescence.
2. Males who develop deviant patterns of sexual behavior in
adulthood have suffered relative deprivation of experience
with pornography in adolescence.
176 W. Cody Wilson

3. Adults manifest lessened sexual inhibitions with their regu-

lar sexual partners after viewing pornography.
4. People who view pornographic movies manifest an in-
creased inclination to discuss sex with others in the day or
so following such experiences.
Modem sex therapy focuses on providing appropriate informa-
tion, reducing anxiety and inhibitions, and facilitating com-
munication between sexual partners in treating sexual dysfunction;
thus it seems reasonable to conclude that pornography-since it ac-
complishes these same ends---can contribute to the prevention of
sexual problems.
The conjunction of two facts and one diagnosis-viz., por-
nography provides sex information in adolescence, lack of appropri-
ate knowledge leads to sexual inadequacy, and males who manifest
deviant sexual behavior in adulthood are relatively deprived of ex-
perience with pornography in adolescence-suggests that por-
nography not only can but does help to prevent sex problems.
This conclusion is borne out by the direct testimony of adults
in our society. The projection of the results of a survey of a proba-
bility sample of adults in this country provides a conservative es-
timate that 10 million adults in this country have had the experi-
ence that exposure to pornography has improved the sexual
relations in their marriage, and 1 million adults have had the per-
sonal experience of obtaining relief from a sexual problem by
means of exposure to pornography.
To conclude from these empirical facts that pornography can
and does contribute to the prevention of sex problems is not to
argue that pornography is the best or potentially the most effective
way of preventing sex problems; nor is it to argue that the preven-
tion of sex problems is the only or even the primary function or im-
pact of pornography. Rather, it is simply a description of "what is"
in our imperfect world.

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 8
Editors' Introduction

Discussion of ethics in therapy or research is usually a dialogue be-

tween scientists and practitioners on the one hand and ethicists on
the other. This dialogue often results in confusion to one or both
parties since terms must be defined and issues raised with which
one or the other party has little familiarity. Thus it is refreshing
indeed to read a chapter on ethics written by a respected scientist
and practitioner who has made it a point to become acquainted
with the pressing and important ethical issues of our time. As our
technology advances, ethical issues are arising in every area of
health care. But in few areas are the issues more pervasive and
emotionally tinged as in the prevention and treatment of sexual
disorders. In this chapter Kolodny presents a very balanced view of
the various ethical issues encountered throughout the preceding
chapters in this book. After noting the difference between deciding
an issue on empirical grounds and on ethical grounds, Kolodny
goes on to discuss how cultural personal values may interact with
the prevention of sexual disorders. He notes that the widespread
movement to liberalize cultural values regarding some sexual be-
havior could be an unethical solution to the problem of preventing
sexual disorders. In this context, the tendency for some health care
professionals to educate adults as to what their sexual value system
should be can be very dangerous. Kolodny discusses ethical con-
cerns in the prevention of atypical sex roles and in preventative
programs for sex offenders and concludes with a realistic set of
guidelines for approaching ethical issues in the prevention of sexual
disorders.
181
 8
Ethical Issues in the Prevention of
Sexual Problems
ROBERT C. KOLODNY

To discuss the prevention of sexual problems, we must begin by

recognizing that the definition of sexual problems is no simple mat-
ter. There is wide cross-cultural variation in detennining the con-
text of sexual problems; there is equally great disparity as a function
of the sweep of history. Even if the discussion is limited to the
present day and the United States, there is surprising discordance
of definition, both among the general public and among profes-
sionals, regarding what constitutes a sexual problem. For example,
although the American Psychiatric Association has removed homo-
sexuality from its category of mental illness, many psychiatrists
continue to regard homosexuality as a sexual disorder, many states
continue to proscribe it legally, and many social, economic, and
emotional forces that have been highly visible in recent decisions
within our anned forces, school systems, and religious organiza-
tions perpetuate the view of homosexuality as a problem behavior.
To define what is meant by ethical poses an equally complex
problem. Webster's New Collegiate Dictionary (1969) defines ethic
as: "the discipline dealing with what is good and bad and with

Robert C. Kolodny • Reproductive Biology Research Foundation, St. Louis, Missouri

63108.
183
184 Robert C. Kolodny

moral duty and obligation" and "a set of moral principles or values
. . . the principles of conduct governing an individual or group"
(p. 285). Essential to the concept of ethical is a moral value judg-
ment-while the criteria for this moral judgment (and, inferen-
tially, the measure of its validity) are subject to widely differing
views. For instance, moral values of a religion may conflict with
moral values of a society; personal values may openly oppose politi-
cal or legal or scientific ideology. To what or to whom does the in-
dividual owe allegiance? These are questions that cannot be lightly
or easily answered.
Ryan (1975) has described two kinds of morality in our society:
a morality of general welfare and a morality that tries to define
"possible" or "impossible" human behavior. We might also con-
sider the dilemma implicit in Shakespeare's famous lines: "To thine
own self be true,! And it must follow, as the night the day,! Thou
canst not then be false to any man." Should the values of the indi-
vidual supersede the values of society, defined in terms of the
greatest good for the greatest number? Do we make such judg-
ments in terms of the consequences of decisions or actions, or do
we use universal principles of right action as final arbiters of ethical
problems? Should we follow Kant's dictum: "Act always so as to
treat people as ends and not merely as means only"? Does the
Golden Rule of Judeo-Christian thinking suffice as a necessary and
sufficient measure of what is ethical? The answers to these ques-
tions are the study of ethics.
My own bias is away from absolute, immutable rules govern-
ing what is right action. I am more frightened of the contradictions
that grow out of Aristotelian or Kantian thought, transposed to an
evolving world, than unwilling to struggle with an approach of
moral pluralism. In the domain of human sexual behavior, the di-
chotomy between insights into the real world gained by careful
study and the inflexible view promulgated by absolute criteria of
good and bad is readily apparent when one reads the recent Vati-
can statement concerning sexual ethics ("Declaration on certain
questions concerning sexual ethics," translated by the National
Catholic News Service, Origins 5(31):485--494, 1976).
Ethical Issues in the Prevention of Sexual Problems 185

Nevertheless I would like to make a straightforward distinc-

tion that separates empirical decisions from ethical decisions. Em-
pirical reasoning is based upon building a reliable data base about a
problem and correctly interpreting this data base to solve the prob-
lem. Ethical reasoning is based upon the application of value judg-
ments to dilemmas, with data about the problem being of signifi-
cance only as they allow one to make finite assessments or rough
approximations about potential outcomes (consequences) of the dif-
ferent courses of action or inaction that define the ethical problem.
For instance, in the context of providing health care services, we
need data to assess the risk:benefit ratio of a therapeutic interven-
tion-the ethical decision (to treat or not to treat, or how to treat)
is based only partly upon the empirical model. The risk benefit
ratio may be used by the health care professional in his or her eval-
uation of an ethical problem, but therapeutically, the ethical ques-
tion can be answered only with knowledge of the value that the pa-
tient places on both sides of that ratio.
Some would have us think that there is only one ethical an-
swer to any problem. In mct, there are frequently alternate solu-
tions to a problem where, by ethical analysis, no clear-cut superior-
ity is associated with a single choice. In such instances, personal
preferences as well as value judgments may be exercised in the
selection of an action. Since we are primarily examining issues in
the prevention of sexual disorders within a medical model in this
book, it is helpful to keep in mind the possibility of equivalent
ethical solutions and the necessity of separating our usual and use-
ful empirical thought processes from the value judgments that are
required in ethical awareness. Finally, let us recognize that ethical
decisions, although rationally based, are often made on the basis of
incomplete knowledge, particularly in terms of the consequences of
an action:
Clearly it is impossible to list all the possible consequences [in reaching an
ethical decision], even if we could predict them-just as in the scientific
method, it is impossible to list all the variables that must be controlled for in
a particular experiment. . . . This means, in the end, that we must always
take action on the basis of some degree of uncertainty. The goal is to reduce
that uncertainty to manageable proportions. (Brody, 1976)
186 Robert C. Kolodny

1. Cultural Values, Personal Values, and Prevention

of Sexual Dysfunction

Despite increasing interest in treatment of sexual dysfunc-

tion in the past decade, there currently are no reliable preva-
lence figures describing even the approximate dimensions of this
problem from a population viewpoint. The often-quoted estimate
of Masters and Johnson that half of the marriages in this country
suffer from some form of sexual distress is usually mistakenly in-
terpreted as a specific measure of sexual dysfunction, when in fact
sexual distress is not at all synonymous with sexual dysfunction. In-
dividuals in a marriage, without being dysfunctional, may have
widely divergent sexual preferences as to frequency, types of activ-
ity, timing, and style that create conflict, tension, or frustration.
Sexual partners may be distressed by boredom, changes in their
partner's physical attractiveness, and a host of other factors that are
encountered on a daily basis by the marriage counselor or the psy-
chotherapist.
What is required to assess prevalence is a national study cross-
ing ethnic, socioeconomic, and religious lines to identifY sexual
dysfunction in a carefully delineated research population. Without
such data available, it is difficult to evaluate many of our theoretical
formulations about the causation of sexual dysfunction. We can
infer causation--or more realistically, predisposition-from com-
monly encountered clinical histories that are frequently associated
with a particular dysfunction. However, it is not possible to verify
our working hypotheses by this type of analysis.
If one examines some of the cultural values that have assigned
a negative connotation to certain sexual behaviors, ethical problems
that appear in the context of prevention become apparent. When
viewed from the perspective of group psychology, restrictions on
permissible behaviors of any sort are mandatory to ensure orderly
survival of the group. These group standards or norms are
frequently highly visible in defining relative and absolute restric-
tions (taboos) in sexual behavior-but there is wide variation from
one culture to another in what is prescribed behavior versus what
is proscribed.
Ethical Issues in the Prevention of Sexual Problems 187

The culture that codifies and encourages certain dominant

forms of social interaction also provides a consistent matrix of sex-
ual values that support, and are supported by, the social model.
Apart from the question of legality, the individual is constrained by
this matrix of sexual values only to the extent to which he or she in-
ternalizes it and continues to apply these values in a consistent
fashion.
When we consider modifYing cultural values and attitudes
regarding sex, we must consider the many possible consequences.
If we speak of our society, do we even have enough information to
know in which direction such modification should occur? Let us
look at a possible change that might be made.
Liberalize cultural values regarding sex to conform to the view-
point that any private sexual behavior between mutually consenting
adults is acceptable as long as no one is hurt. In the context of
prevention of sexual dysfunction, there is simply no evidence that
such a change would operate to reduce the occurrence of impo-
tence, premature ejaculation, vaginismus, or other sexual dysfunc-
tions. (In the legal domain, however, it would have obvious im-
pact.) No matter that many of us would be highly comfortable with
this direction of change philosophically because it is in harmony
with our personal beliefs, it is ethically not the solution to the
problem of preventing sexual dysfunction. Even if implemented,
this change in cultural values would not decrease sexual dysfunc-
tion arising from restrictive childhood backgrounds, traumatic sex-
ual experiences, anxiety expressed as fears of performance, ineffec-
tive interpersonal communication, intrapsychic pathology, or a
variety of other possible causes of sexual dysfunction. Not only is
there little promise of efficacy in solving the problem of preven-
tion, there are other consequences of such a change in cultural val-
ues that might increase, rather than decrease the incidence of sex-
ual dysfunction. For example, it is possible that such moral
permissiveness might create greater social pressures; it is probable
that in some instances this would lead to sexual coercion between
individuals; and it is certain that in other instances it would lead to
overt conflict with religious teachings. Finally, there is the di-
lemma posed by the conditional phrase "As long as no one is hurt."
188 Robert C. Kolodny

If it is narrowly interpreted to mean that neither adult participating

in the mutually agreeable sexual activity is hurt, we have some dif-
ficulty in knowing how to predict, in advance of a sexual encoun-
ter, that it will not be painful in one way or another. In a broader
interpretation, there is the unmeasurable risk that another (third)
person will be hurt in this situation-unintentionally-by virtue of
rejection, jealousy, or embarrassment. In both the narrower and the
broader views, there is also strong potential for deception in the
motivation for, objectives of, attitudes toward, or effects of such
sexual activity.
When we talk about changing cultural values, in a sense we
are really considering normative values. There will always be indi-
viduals whose feelings or beliefs place them at variance with such
norms. This raises an important ethical question: Should people
whose values conflict with or vary from cultural norms about sexu-
ality be reeducated to alter their values? Let us assume for this dis-
cussion that it is possible to achieve such a change. (In doing so,
we necessarily avoid very practical and pertinent questions about
the possibility of producing lasting changes in personal values.)
What are the ethical problems with this approach? To the extent
that the individual with different sexual values and preferences is
indoctrinated (reeducated) to conform to norms, there is a loss of
personal identity. This loss of personal identity may be construed
as either good or bad, depending on whether one values the integ-
rity of the individual more highly than a process that benefits the
stability of a larger social order. It might be argued that the process
of conformity in this instance would lead to greater happiness for
both the individual and society-albeit happiness measured by dif-
ferent yardsticks. With the loss of one value set being balanced by
replacement with another more socially acceptable value set, for
the individual there might indeed be a greater happiness as well as
growth.
On the other hand, we can approach this problem by asking
whether society has the moral right not simply to place restrictions
on behavior but to impose arbitrary value systems on people's
lives. It is one thing to live surrounded by people who have dif-
ferent values than your own; it is quite another to be made to in-
Ethical Issues in the Prevention of Sexual Problems 189

temalize alien values and substitute them for those you believe in.
I am unable to find an acceptable ethical line of reasoning to allow
this to occur. However, even if we were to conclude that society
does have such a moral right, who is to judge in which direction it
should move and in what manner be implemented? I would
suggest that even if such a right exists, it is certainly not the
prerogative of the members of the health care community. Ideally
this would be a responsibility of moral philosophers; more realis-
tically, in our far from perfect world, it would be legislated into and
out of existence by politicians.
The point of these observations is that there is an attempt
being made at present by some health care professionals to educate
adults as to what their sexual value system should be. This is often
done in the best educational spirit, with the salutary objectives of
prevention of sexual dysfunction or sexual problems as well as
promoting mental health, but it fails to recognize adequately some
major ethical problems implicit in the situation. For instance, do
we have the right to say or teach that an active sexual life is
healthier or happier than a life of celibacy? Is there any reliable ev-
idence that this is in fact the case for all people? Furthermore there
are individuals who have attended some programs that have at-
tempted to "reassess" sexual attitudes only to find that they have
been severely pressured by the educational leaders and/or group
members into positions of psychic and physical vulnerability that
are threatening or traumatizing to them. For example, an individ-
ual firmly committed to a sexual value system of monogamous het-
erosexual behavior may be belittled for rejecting, strictly on the
grounds of personal values, other models of sexual behavior. Such
a person may be challenged by the idea: "How can you judge if you
haven't tried it?" This argument has a hollow ethical ring, since
many choices are made in our lives to avoid things that fall outside
our personal value systems for precisely that reason. Examination
of our sexual attitudes can be a positive experience, particularly
when guided by knowledgeable and sensitive educators. On the
other hand, when such assessment of our personal beliefs about sex
and sexuality is conducted in the shadow of advocacy of an "ideal"
set of sexual values, the risks can be significant.
190 Robert C. Kolodny

There is a strong distinction to be made between the need to

work with people who request help in changing their sexual value
systems-whether this is in a situation of prevention or treatment
of a sexual dysfunction-as opposed to the caution that is required
in the education, counseling, or treatment of people who are happy
with their sexual values but wish to attain some other goal. Some
feel that psychotherapy of sexual dysfunction almost automatically
requires alteration of people's sexual values. Although this might
be an efficient tool of such psychotherapy, it is wisely reserved for
only those cases where an individual requests such change.
To illustrate this point, consider a situation that is sometimes
encountered at the Reproductive Biology Research Foundation. A
couple presents for treatment of sexual dysfunction, and one or
both of the partners believes that masturbation is sinful, degrading,
or dirty. Furthermore, they are comfortable with that belief and
have no wish to change it. We would never tell these people that
they must have a different attitude toward masturbation, or that
they should change their values, or that they should discard the
teachings of their religion. Our personal values may be quite dif-
ferent, and our scientific knowledge may be useful in correcting
misinformation, but we do not believe in imposing a different set of
morals on these individuals. Thus we would acknowledge the dig-
nity of their personal beliefs and work with this couple so as not to
compromise their own value framework.
Needless to say, there may be unique situations where per-
sonal values concerning sexual activity preclude the possibility of
working with a couple in psychotherapy. In such instances, the
couple is informed that we are unable to work effectively within
our mode of psychotherapy with the limitations imposed by their
values-but we also point out alternate approaches to psycho-
therapy that may be suitable.

2. Ethical Problems in Prevention of Atypical Sex Roles

Some provocative points were raised by Green in Chapter 3

regarding ethical problems in the area of prevention of atypical sex
Ethical Issues in the Prevention of Sexual Problems 191

role development. In consideration of the innovative and practical

suggestions that he outlined, it may be helpful to recognize that
there is a very thin line between what is research and what is treat-
ment. In fact, these areas may purposefully be merged. However,
there are somewhat different ethical issues raised in matters of
research versus therapeutics. In the examples of a variety of inter-
ventions possible for atypical sex role development in different
clinical contexts, it was acknowledged that there are few long-term
follow-up data describing the results of intervention or the outcome
without intervention. This lack of follow-up data presents some
problems.
First, our culture poses certain paradoxes in identifYing the
existence of a sexual problem. The cross-dressing adult male is a
transvestite by definition. However, the woman who wears men's
clothing is not labeled as having any sex role identity problem. In
fact, she may be quite fashionable. The boy who plays with dolls,
who cooks, who wears his hair frilled, or puts on perfume is iden-
tified immediately as a problem. The tomboyish girl is ordinarily
not viewed in the same context. Similarly, although we talk about
the prevention of adult homosexuality, no one inquires about child-
hood interventions to prevent adult heterosexuality. Cultural
biases dictate definitions of "problems" and "disorders."
Second, to develop preventative programs, we need to know
what it is that we're preventing. So far, there have not been long-
term prospective longitudinal studies without intervention that de-
scribe the natural history of boys who appear feminine at age 5 or
8. What happens to them at age 15 or 20 or 30? A set of childhood
predictors of transvestism is also needed if we are going to continue
to define these as problem areas. Only after we have adequately
defined what the natural progression of these problems is can in-
tervention be justified, because otherwise we have no way of
knowing in what it is that we're intervening.
Third, accurate data on risk are required. For example, in a
group of boys with classical feminine behavior, how many will
become transsexuals? If it's 50 out of 100, intervention may be im-
portant. If it's 1 out of 10,000, is there any point in intervention?
Data on the relative success of intervention are also needed, but
192 Robert C. Kolodny

these, of course, can come only after definition of the natural his-
tory of the problem. The results of intervention might be more
problematic than the original difficulty. Finally, we need informa-
tion on the cost effectiveness of such intervention programs.
In Chapter 3, Green mentions some dangers implicit in possi-
ble outcomes of intervention by acknowledging that increased anxi-
ety caused by intervention might in fact intensify the problem
rather than ameliorate it or that a problem might simmer below
the surface as a result of a certain intervention, only to recur at a
later time. There is another problem that is perhaps of more con-
cern. A preventative program working with both parents and chil-
dren has the potential danger of precipitating other psychological
problems. The scrutiny or pressure of such an intervention may
trigger stresses that result in other problems of psychological matu-
ration, self-esteem, or social interaction. This is, of course, simply
speculation. Nevertheless, it is important to assess this possibility.
From an ethical viewpoint, treatment or research involving
minors necessitates appropriate mechanisms for obtaining informed
consent. We currently do this by informing and obtaining the con-
sent of the parents or legal guardian; however, such individuals
may be in a difficult position, particularly when they're dealing
with rather nebulous problem areas. In fact, they may be coerced
in a way that we cannot evaluate, by the stress of the emotion of
seeing Johnny at age 8 throwaway the baseball bat and pick up the
doll. Whether parents or guardians truly can provide informed
consent in such situations, where little is known about outcome of
interventions, is a very difficult question.
Ethical problems also exist involving the effects of labeling
boys or girls at early ages, even when the label is no more specific
than that of being the subject of a research investigation on atypical
sex role development. How much will the labeling influence the
subsequent behavior of the child, and how much does the labeling
influence the behavior of the parents-particularly parents of chil-
dren in control groups, where no interventions are made?
Invasion of privacy is another potential problem. Is it ethical
to enter the life of a family or of the vulnerable 5- or 6- or 7-year-
Ethical Issues in the Prevention of Sexual Problems 193

old child and make observations or ask questions about sexual prac-
tices, sexual attitudes, sexual beliefs, and gender-appropriate be-
havior? In my mind, there is no question that there is invasion of
privacy in research of this sort. The ethical question is: Can such
intrusion be justified by attempts to minimize the trauma that
might result from this process and maximize the degree of con-
fidentiality provided, balancing both with the promise of potential
knowledge that may be gained from the research?
Finally, we need to acknowledge a problem that recurs again
and again in any research setting: How will the observer influence
change the natural history of the phenomenon that is being inves-
tigated?

3. Ethical Concerns in Prevention Programs for Sex

Offenders

A related set of problems marked by somewhat different em-

phases is encountered when one is dealing with known sex of-
fenders. Once again, we are speaking about therapeutic research-
a recognized and valuable form of research-which poses some
decidedly difficult ethical concerns in this particular context. Since
the most direct difficulty lies in the need to obtain informed con-
sent from subjects of therapeutic research, it may be useful to
discuss briefly the major elements that define informed consent.
First, the individual who is going to give consent must understand
the procedures in the particular study or treatment in which he or
she is engaging. Second, the individual must be consenting to par-
ticipate by his or her free will. In other words, there is no coer-
cion, deceit, or force operating to obtain such consent. Third, the
individual must be as fully aware as possible of the attendant risks
of all facets of study participation, including risks involved with
placement in a control group instead of a treatment group. Fourth,
the individual must be aware of the fact that he or she is free to
withdraw from participation in a project at any point along the way
without penalty. These four points are equally valid for a therapeu-
194 Robert C. Kolodny

tic model as for a research model. That is to say, a patient is

equally free to withdraw from a treatment program as is the subject
to withdraw from a research project.
If, in fact, people with paraphilias are hurting "only when the
cops are knocking at the door" to use Walker's phrase in Chapter
5, this implies that there is definite evidence of coercion involved
in any attempt to obtain informed consent from such an individual.
The strong implication is that these people do not wish to be
helped and that they seek help as a way of recognizing and alleviat-
ing the legal dilemma that they may be in and the restrictions
placed upon them.
On the other hand, incarceration undoubtedly limits au-
tonomy to a far greater degree than that accruing from drugs that
decrease testosterone and suppress or obliterate libido. Further-
more, there are numerous situations where varying degrees of cir-
cumstantial pressures subtract from freedom of choice. We might
draw the analogy-not a direct parallel, to say the least--<>f obtain-
ing informed consent from a woman who wishes to undergo an
abortion. This woman does not consent to the abortion in advance
of becoming pregnant. She reaches the decision after she has
knowledge of her pregnancy-thus the fact of the pregnancy is a
coercive element in a more or less subtle way. There are eco-
nomic, social, and psychological pressures that are brought to bear
by the knowledge that she is pregnant and that if something is not
done, the pregnancy will result in her having a child. We accept
without question the ability of this woman to provide informed
consent when she understands the possible risks and benefits of
this procedure. However, despite recognizing that free will is an
ideal that may not always be met by conditions of real life, there
are important distinctions between this analogy and the situation of
treating paraphiliacs with antiandrogens. First, these people do not
request help when they are aware of their condition-they await
actual or threatened legal entanglement. Second, they are request-
ing participation in therapeutic research, not in a fully developed
treatment program. Third, they are not free to withdraw their proj-
ect participation without penalty if their terms of parole or proba-
tion are contingent upon their continuing to receive treatment.
Ethical Issues in the Prevention of Sexual Problems 195

The reason that cyproterone acetate, an antiandrogen, is not

available in this country is that it has not yet moved out of the in-
vestigational stages in animal and human studies necessary for ap-
proval by the federal government. This does not mean that it will
not be available, and in fact there are promises of use for an-
tiandrogens within a medical context that has nothing to do with
the depression of libido for obliterating sexual behavior. For ex-
ample, these drugs may be quite useful in treating very severe
cases of acne or hirsutism in women at different dosage levels than
those required in males. If the risks and benefits of antiandrogen
treatment of sex offenders were fully known, there would be far
less difficulty in approaching a man awaiting trial or just sentenced
to jail to obtain informed consent in just the same way that he
would be approached if he had gallstones and was asked to consent
to a cholecystectomy. But informed consent for research purposes
must be a more rigid process to guard against abuses that have
been clearly documented in past years. Consent for treatment can
be more flexible.

4. Guidelines

I would like to end by suggesting four guidelines for approach-

ing ethical issues in the prevention of sexual problems. These
guidelines are offered in a preliminary manner, with the intention
of stimulating further deliberation and discussion.
1. Preventive programs of all varieties must be based on the
availability of secure research data, describing the causes,
incidence, and natural history of the particular disorder in
question.
2. The dignity of the individual must be preserved.
a. This requires that there be no deception or coercion in-
volved with participation in a preventive program.
b. Understandably, this necessitates appropriate means of
obtaining informed consent.
c. Assurance of confidentiality is the responsibility of all
involved professionals.
196 Robert C. Kolodny

3. The potential benefits must clearly and significantly out-

weigh the potential risk of any preventative program.
4. Appropriate mechanisms for objective peer and community
review must be utilized at all phases of such programs.
To conclude, ethical constraints should not be viewed as an
obstacle to research, to treatment, or to prevention but as an inte-
gral component of the respect for the quality of life with which we,
as professionals, all are concerned.

References
Brody, H. Ethical decisions in medicine. Boston: Little, Brown, 1976.
Ryan, A. Two kinds of morality: Causalism or taboo. The Hastings Center Report,
1975, 5(5), 5--7.
Webster's Seventh New Collegiate Dictionary. Springfield, Mass.: C. & C. Mer-
riam Company, 1969, p. 285.
Index

Androgeny, 86, 90 Deutsch, Helene, 52

Antiandrogen therapy, 117, 125,
194-195 Ellis, Havelock, 1, 47, 48
contraindications, 130 Eroticism
effects, 127 in childhood, 147-150
goals, 126, 131 Ethical issues
indications, 130 coercion, 194-195
prevention, 132-134 conflicting values, 188-190
primary, 133-134 dangers of intervention, 192
secondary, 132-133 effects of labeling, 192
with psychotherapy, 125, 126, empirical and ethical reasoning distin-
130-132 guished, 184-185
somatic complaints, 129 ethics defined, 183-184
study described, 127-129 guidelines, 195-196
use, 126-127 informed consent, 87, 123, 133,
192-195
Bancroft, John, 120, 134 invasion of privacy, 33, 192-193
Behavior modification, 14-15, 29-30, and liberalization of cultural values,
81, 111-112, 124-125 33-34, 186-188
Bettelheim, Bruno, 55 in prevention (see also Prevention)
Bisexuality of atypical sex roles, 190-193
Freud's views on, 51-52 programs for sex offenders, 193-195
Body image, 30, 64-65 sex education, 150-151
in childhood, 147 of sexual dysfunctions, 186-190
types of morality, 184
Calvin, John, 46 uncertainty in ethical judgments, 185
Comstock Laws, 47 and use of psychophysiologic techni-
Cross-dreSSing, 8, 76, 77, 78, 80, 89 ques, 110-111
in children, 77, 79, 81-82, 84-85 Exhibitionism, 10, 28, 98, 103, 119, 120,
Cross-gender behavior, 76 121, 122, 127, 128, 134, 170
Cyproterone acetate (see also Antian- coping mechanisms, 106
drogen therapy), 125-126, 195 dominance and mastery in, 105-106
197
198 Index

Exhibitionism (cant.) Green, Richard, 8, 190, 192

fantasies, III Gregory the Great, Pope, 46
and pornography, 170
Heiman, Julia, 4
recidivism, 13, 14
Heywood, Ezra Harvey, 47
as sexual offense, 13
Homosexuality, 8, 9, 29, 47, 76, 118,
treatment, 15
120,125,127,128,168,169,170
coping patterns, 79
Fantasies, 80, 129, 153
cross-gender behavior in childhood,
with masturbation, 100, 124
79,83
modification of, 111, 128
delabeling as mental illness, 5, 89
and paraphilia, 121-122, 124, 125,
incidence for females, 85
128, 131, 132, 134
legal constraints, 96-97
of rape, 101
and pornography, 168-170
sadomasochistic, 104, 120
prevalence, 10
in sex offenders, 100
prevention of, 34
Female sexuality (see also Gender iden-
as sexual offense, 12-13
tity disorders, Sexuality), 61
society's attitude toward, 108, 183
Freud's view, 51-56
suffering, 82
Kinsey's view, 57-58
treatment statistics, 14-15, 80-81
Masters and Johnson's view, 58-60
media's view, 67 Incest, 13, 97, 125, 127, 128
Feminine boys, 79, 191 recidivism, 14
follow-up studies, 9-10, 81-82 Informed consent, see Ethical issues
and intervention, 83-84 Intersexed children, 8-9, 76
and prevention, 10 guidelines for intervention, 86-87
principles of intervention, 84-87
Fetish (see also Cross-dressing), 8, 76, John Birch Society, 152
77,85 Johnson, Virginia, see Masters, William
Freud, Sigmund, 1, 45, 51, 52, 56, 68 Judeo-Christian heritage, 44, 46-47,
47,XXY males, 127 184

Kant, Emmanuel, 184

Gender identity disorders, 5, 8-10, 76
Kinsey, Alfred, 45, 56-58, 61
atypical sex role development, 3,
Knowlton, Charles, 47
9-10,85
Kraffi-Ebing, Richard von, 1,45,48-49,
coping with atypical patterns, 78-79
68
ethical problems in prevention,
190-193 Luther, Martin, 46
pre transsexual children, 79
prevention of, 10, 81-84, 84-88, Male sexuality (see also Gender identity
190-193 disorders, Sexuality)
social change, 88-89 Freud's view, 51-56
treatment of atypical patterns in chil- Kinsey's view, 57-58
dren, 80, 83-87 Masters and Johnson's view, 58-60
types, 8-9, 29-30 media view, 65-66
Index 199

Masters, William, 7, 45, 56, 58-62, 108, Pornography (cont.)

186 contrasted to obscenity, 161-162
Masturbation, 47, 53, 54, 58, 59, 103, defined, 161-162
111, 118, 128, 131, 190 effect on sexual problems, 162-164,
attitude of early sexologists, 48-50 171,175-176
in childhood, 31, 147-150 inhibition-reducing function, 171-172
a developmental stage, 33-34 information-providing function,
early treatment of, 49 164-168, 175
and paraphilia, 124, 131 mechanism for sexual learning,
M edroxyprogesterone acetate (M P A) 160-161, 164-171, 175-176
(see also Antiandrogen therapy), and prevention of sexual problems,
125-132 168-171,175-176
action, 126, 129 sex offenders' use of, 168-171, 175
dosage regimen, 126-130 sexual arousal, 161-162, 171, 175-175
effects, 127 use in training, 167, 175
results of treatment, 127-129 Premarital sex, 47
Money, John, 84, 119, 129 Prevention
affective disorders, 23-25
Newman, Lawrence, 84 agent factors in, 17
Noyes, John, 47 atypical sexual identity, 76, 80, 81-90
Obscenity compliance issues, 17, 20
defined, 161-162 controversies, 32-34, 78-80
Orgasm, 62, 66, 121, 128, 148 and crisis intervention, 22-23, 24
statistics on, 6, 57-58 environmental factors in, 17
vaginal and clitoral, 51, 53, 59 and etiological assumptions, 18-19, 21
Owen, Robert, 47 goals of, 3, 16
host factors in, 17
Paraphilia, 122, 123, 124, 125, 127, 130, identification of children with cross-
131, 194 gender behavior, 79
defined, 121 and mental hygiene movement, 22
motivation for treatment, 122-123 model of a disorder, 17-18, 25
Pedophilia, 10, 15, 27, 98, 122, 125, 127, natural history of a disorder, 17-18
128, 129 need for in sexual disorders, 3-15
adolescent adjustment, 105, 134 primary, 18, 19-20,22-23,25,32,33,
and pornography, 168-170 73, 118, 133-134
recidivism, 13, 14 in psychiatry, 22-25
as a sex offense, 12-13 psychosocial factors in, 4, 20-21
Penis envy, 51 in schizophrenia, 23-25
Pius XII, Pope, 47 secondary, 18, 20, 23-25, 32, 33, U8,
Pornography 133
anxiety-reducing function, 171-172, and sexual disorders, 25-32, 191
176 and suicide prevention centers, 24
as communication facilitator, techniques of, 16-17, 19-20
172-174, 176 tertiary, 18, 25, 32, 33
200 Index

Protestant Refonnation, 46 Sex education (cant.)

Psychiatric diagnosis criteria, 26 pornography as latent mechanism,
Psychotherapy 160-161, 164-168, 175
cultural biases, 43-44 prevention
and psychophysiological techniques, limitations, 140-141
110-111 in pediatric age group, 149-150
with sex offenders, 110-111, 124, in schools, 142-145
130-132 of unwanted pregnancy, 140-141,
versus social control, 109-110 143
of venereal disease, 140-141, 143
research in described, 142-145,
Rabbinical Council of America, 47
146-147
Rape, 10,28,97,118, 122,124,129,134
and sex offenders, 134-135
antiandrogen therapy, 130
and sexual dysfunctions, 146-148
arrests and conviction statistics, 11
sexual health defined, 140, 151
assessment of rapists, 28
Sexism
behavior therapy, 112
and prevention of atypical sexual iden-
determinants of, 111
tity, 88
in Gusii culture, 104
Sex therapy ( see also Sexual disorders,
and pornography, 168-170
2, 28-29, 67, 164)
and sex offenses, 12-13, 14
use of pornography, 175-176
sexual assault, 103-105, 120
Sexual arousal (see also Paraphilia), 2, 30,
and sexual dominance, 104
80, 99, 102-103, 121, 122, 125,
Reproductive Research Foundation, 190
148, 149
Russell, Bertrand, 53
and antiandrogen therapy, 126, 130
and pornography, 161-162, 171,
St. Augustine, 46 174-175
Sex education, 162 Sexual behavior, 33, 44, 67-68, 121,
in adolescence, 108-109, 168 134, 189
anti-sex-education forces, 1, 33, and cultural values, 186-190
150-152 and law, 96-97
attitude change, 141-145, 149 as learned, 31, 147, 159-160
behavior change, 141, 143-145 and pornography, 171-172, 173-174
body image, 147 and recidivism, 13-14
for children under 5, 146-150 reinforcing gender identity, 100-101
defined broadly, 139-140 and sex education, 141, 143-145
eroticism, 147-150 Sexual development, 30-31
first appearance, 48 fonnation of dyadic relationships,
goals, 140-142 98-99
knowledge about sexuality, 141-145, homosocial phase, 100-101, 107-108
149 a model, 75-76, 93, 97-98
masturbation in childhood, 147-150 of sex offenders, 98-99
moral implications, 150-151 sexual responsiveness, 98-99
parental influence, 146-150 and transsexuals, 76-77
for physicians, 5, 145 and transvestism, 77-78
Index 201

Sexual deviations (see also Sexual of- Sexual dysfunctions (cant.)

fenses), 1, 2, 5, 10-15 inadequacy of epidemiological data,
assessment, 28 186
components of, 28 and miseducation, 146-147
heterogeneous groups, 10, 27-28 and prevention, 68-69, 186-190
legal problem, 10-11 statistics of dysfunction for males and
and pornography, 168-171, 175 females, 6-7, 62-64
and sexual offenses, 10-14 treatment statistics, 7-8
treatment, 14-15 Sexual identity (see also Gender identity
Sexual disorders (see also specific disorders), 2
disorder), 2 in childhood, 146-147
componential analysis, 27-31 core-morphological identity, 75-76
cultural biases in treatment, 43-44, definition, 75
49-50, 53-55, 56, 58, 61-62 developmental sequence, 76
cultural factors in definition, 4, 31, gender role behavior, 50-56, 58-61,
44-45, 183, 191 63-64, 75-76
and diagnosis, 26-27, 30, 183 and role models, 89
distinguished from sexual problems, 5 sexual partner preference, 75-76
early types of prevention, 50 Sexuality, 4
early types of treatment, 49-50 attitudes of early sexologists, 47-50
effect of Freudian theory on treat- attitudes of first sexual reformers, 47
ment,53-56 basic premises of, 153
identification by professionals, 5 Catholic view, 46-47
Kinsey's view of treatment and pre- children, 146-150
vention,58 current views, 67-68
lack of appropriate information con- effect of cultural values on, 43-69
tributing to, 159, 170-171 Freud's view, 51-56
lack of natural history data, 26, 186, healthy, defined, 140, 151
191, 195 Jewish view, 47
as learned, 31, 147 Kinsey's view, 56-58, 61
Masters and Johnson's view of treat- Masters and Johnson's view, 58-61
ment and prevention, 60 media view, 64-68
prevention of, 3, 4, 15, 25-32, 34, performance expectations, 61-62
174-175 Sexual offenses (see also Sexual devia-
prevention through use of media, tions)
64-68 arrest and convictions statistics, 11
problems with definition, 183 criterion for treatment, 119-120
tertiary prevention, 115 cultural biases, 118-119, 123, 132
treatment, 2, 7-8, 9-10, 14-15, 27 cultural factors in sexual aggression,
"Sexual drive," 102-103 104
Sexual dysfunctions (see also Sexual dis- defined, 118-119
orders), 2, 5, 6-8, 60 "denial of illness," 131-132
changing trends in, 62-64 determinants, 97-103
components of, 28-29 distinguished from sexual deviants,
heterogeneous group, 28 11-12
202 Index

Sexual offenses (cant.) Sexual problems (cant.)

evaluation, 118-123 effect of pornography on, 162-164
exhibitionism, 105-106 inadequate learning, 159-161, 164
experience with pornography, prevention, 170-171, 189
168-171, 175 recognition of, 5, 145
failure of sex-offender statutes, 14 Sexual responsiveness
honnonal therapy, 125-135 attribution of meaning to, 99-100
legal issues, 122-123, 133 Shakespeare, William, 184
legal objectives, 96-97 SIECUS, 137, 139, 152
legal sanctions, 109 Stoller, Robert, 84
as paraphiliacs, 121-123
prevention, 93, 117-118, 193-195 Testosterone, 126, 127, 128, 129, 194
primary, 106-109, 133-135 Thompson, Clara, 55
secondary, 109-112, 132 Tomboys, 86, 191
tertiary, 117-135 Transsexualism, 2, 3, 8, 83, 87, 169, 170
rational appraisal needed, 95 conflicts, 76-77
recidivism, 13-14, 109, 122, 124 coping patterns, 78-79
and sex education, 134-135 and pornography, 169
self-control, 102-103, 132 pretranssexual children, 79
sexual assault, 103-105 prevention, 9, 191-192
sexual development, 98-99 prevalence, 9
social attitude change, 107-108 suffering, 82
social control of, 110 and tomboys, 86
treatment, 117-135 treatment, 2, 9, 29-30, 78, 80
antiandrogen therapy, 126-130 types, 29
aversion therapy, 80, 112 Transvestism, 8, 9, 10, 29, 83, 120, 125,
behavior modification, 14-15, 81, 127
124-125 absence of female cases, 85
counseling in adolescence, conflicts, 77-78, 82
108-109, 134 prevention, 191
in legal system, 14 recidivism, 14
nonjudgmental attitude, 123, 132 suffering, 82
psychotherapy, 110-111, 124, treatment, 15, 80
130-132 type of atypical sexual identity, 76-78
psychotherapy with hormonal
therapy, 130-132 U.S. Commission on Obscenity and
review of techniques, 123-125 Pornography, 162
social skills training, III
types of deviations, 12-13 Vatican Council, 47
Sexual problems (see alsa Sexual disor- Voyeurism, 10, 27, 119, 122, 134
ders), 4, 5, 31, 44, 49, 175 recidivism, 14
consequence of cultural attitudes,
159-161, 191 Walker, Paul, 129