Chapter 14 - Sexual and Gender Identity Disorders.doc

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Konstantine Zakzanis

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Chapter 14 – Sexual and Gender Identity Disorders sexual and gender identity disorders – in DSM-IV, disorders comprising the paraphilias, sexual dysfunctions, and gender identity disorder Gender Identity Disorder - our sense of ourselves as male or female, our gender identity, is so deeply ingrained from earliest childhood that whatever stress is suffered at one time or another, the vast majority of people are certain beyond a doubt of their gender - in contrast, sexual identity or sexual orientation is the preference we have for the sex of a partner - for example, a man may be attracted to men – a matter of sexual orientation, without believing he is a woman – a matter of gender identity Characteristics of Gender Identity Disorder gender identity disorder (GID) – a disorder in which there is a deeply felt incongruence between anatomic sex and the sensed gender; transsexualism and gender identity disorder of childhood are examples transsexualism – the state of being a transsexual; a transsexual is a person who believes he/she is opposite in sex to his/her own biological endowment; sex-reassignment surgery is frequently desired - people with transsexualism have an aversion to same-sex clothing and activities; the evidence of their anatomy – normal genitals and the usually secondary sex characteristics, such as beard growth for men and developed breasts for women – doesn’t persuade them that they’re what others see them to be - Levine stated that the majority of GID cases are diagnosed as GIDNOS (gender identity disorder not otherwise specified) - that is, the person has symptoms that meet much of the description of GID, but there are some unique features that don’t fit the precise criteria for GID - although transvestites often dress in clothing typical of the opposite sex, they do not identify themselves as of the opposite sex - when GID begins in childhood, it is associated with cross-gender behaviors, such as dressing in opposite sex clothes, preferring opposite sex playmates, and engaging in play that would usually be considered more typical of the opposite sex (eg: a boy playing with Barbie dolls) - GID is associated with a developmental lag in achieving a sense of gender constancy or stability (i.e., acceptance that one is a boy or girl for life) - GID in a child is usually recognized by parents when the child is between 2-4 years old - twas found that GID is about 6.6 times more frequent in boys than in girls; twas concluded that social factors partly account for the difference in referral rates; cross-gender behavior is less tolerated when exhibited by boys and a higher threshold has to be met in order for a girl to be referred - most children with GID do not grow up to be disordered in adulthood, even without professional intervention; however, many become gay - excluded from GID are people with schizophrenia who on very rare occasions claim to be of the other sex, as well as hermaphrodites, so-called intersexed individuals, who have both male and female reproductive organs - a male with GID experiences his sexual interest in men as a conventional heterosexual preference, since he considers himself a woman - cross-dressing is less of a problem for women with GID because contemporary fashions allow women to wear clothing similar to that worn by men - people with GID often experience anxiety and depression, not surprising given their psychological predicament and the negative attitudes most people have toward them - GID in childhood is linked with separation anxiety disorder - the prevalence rates for GID are slight: 1/30,000 for men and 1/100,000 to 150,000 in women Causes of Gender Identity Disorder - researchers concluded that children who experience a sense of inappropriateness in the culturally prescribed gender role of their sex but who do not experience discomfort with their biological sex should not be considered to have GID - because of flaws in the DSM-IV-TR definition of mental disorder, and limitations of the current research base, there is simply not enough evidence to make any conclusive statement regarding children who experience discomfort with their biological sex - these same researchers said that GID in children should be removed from the DSM; they said that viewing GID as a mental disorder my contribute to a labeling process that stigmatizes those children with GID who go on to develop homosexuality - evidence indicates that gender identity is influence by hormones - other research shows that human and other primate offspring of mothers who have taken sex hormones during pregnancy frequently behave like members of the opposite sex an have anatomical abnormalities - many, perhaps most, young children engage in cross-gender behavior now and then; in some homes, such behavior may receive too much attention and reinforcement from parents and other relatives - interviews with the parents of children who show signs of GID often reveal that they didn’t discourage, and in many instances clearly encouraged, cross-dressing behavior in their atypical children - the child’s attractiveness is a factor that may contribute to this pattern of parental behavior - boys with GID have been rated as more attractive than control children, and girls with GID as less attractive - also, male patients with GID report having had a distant relationship with their fathers; females often report a history of physical/sexual abuse - our society has a low tolerance for boys who engage in activities more typical of girls, whereas girls can play games and dress in a manner more typical of boys and still conform to acceptable standards of behavior for girls Therapies for Gender Identity Disorder - there are 2 types of interventions available to help people with GID: one attempts to alter the body to suit the person’s psychology; the other is designed to alter the psychology to match the person’s body Body Alterations - a person with GID who enters a program that entails alteration of the body is generally required to undergo 6-12 months of psychotherapy - the therapy typically focuses not only on the anxiety and depression that the person has likely been experiencing, but also on available options for altering his/her body - some people with GID may choose to have only cosmetic surgery; a male-to-female transsexual may have electrolysis to remove facial hair and surgery to reduce the size of the chin and Adam’s apple - many transsexuals also take hormones to bring their bodies physically closer to their beliefs about their gender - many people with GID go no further than taking hormones, but some take the next step of having sex- reassignment surgery sex-reassignment surgery – an operation removing existing genitalia of a transsexual and constructing a substitute for the genitals of the opposite sex st - the 1 sex-reassignment operation took place in Europe in 1930 - sex-reassignment surgery is an option much more frequently exercise by men than by women - an review of 20 years of research showed an overall improvement in social adaptation rates because of the surgery, with female-to-male transsexuals having greater success than male-to-female transsexuals - of 130 female-to-male, about 97% could be judged satisfactory; of 220 male-to-female surgeries, 87% were satisfactory - preoperative factors that seemed to predict favorable post-surgery adjustment were:  reasonable emotional stability  successful adaptation in the new role for at least 1 year before the surgery  adequate understanding of the actual limitations and consequences of the surgery  psychotherapy in the context of an established gender identity program - a subsequent study indicated that sexual responsiveness and sexual satisfaction increased dramatically in both male-to-female and female-to-male transsexuals, with an overall high level of satisfaction with the results of the surgery - it’s estimated that each year in the US, more than 1,000 transsexuals are surgically altered to the opposite sex - if surgery is evaluated in terms of how happy such people are afterward, then it can probably be said that most GID patients who have crossed over anatomically are generally better off, although some are not Alterations of Gender Identity - gender identity was assumed to be too deep-seated to alter; some apparently successful procedures for altering gender identity through behavior therapy have been reported, however - cross-gender identity may be amenable to change; this can be done through shaping various specific behaviors, such as mannerisms and interpersonal behavior; they also included attention to cognitive components, such as fantasies - most transsexuals refuse such therapy programs that are aimed at changing gender identity The Paraphilias paraphilias – sexual attraction to unusual objects and sexual activities unusual in nature - paraphilias are a group of disorders involving sexual attraction to unusual objects or sexual activities that are unusual and in nature - in other words, there is a deviation (para) in what the person is attracted to (philia) - the fantasies, urges, or behaviors must last at least 6 months and cause significant distress or impairment - a person can have the behaviors, fantasies, and urges that a person with a paraphilia has (such as exhibiting the genitals to an unsuspecting stranger or fantasizing about doing so) but not be diagnosed with a paraphilia if the fantasies or behaviors are not recurrent or if he/she is not markedly distressed by them - the DSM diagnostic criterion of distress or impairment has created some problems because many people with the behavioral features of a paraphilia are neither distressed nor impaired - for example, according to the DSM criteria, someone who has repeatedly had sex with young children but is not distressed or impaired cannot be diagnosed as having pedophilia; therefore, many researchers in this field hold a more behavioral definition of paraphilias and ignore the distress and disability parts of the DSM definition - people often exhibit more than one paraphilia, and such patterns can be aspects of other mental disorders, such as schizophrenia, depression, or one of the personality disorders - the data indicate that most people with paraphilias, whatever their sexual orientation, are male; even with masochism and pedophilia, which do occur in noticeable numbers of women, men vastly outnumber women - as some persons with paraphilias seek non-consenting partners, these disorders often have legal consequences Fetishism fetishism – reliance on an inanimate object for sexual arousal - the person with fetishism, almost always a male, has recurrent and intense sexual urges toward nonliving objects, called fetishes (eg: women’s shoes), and the presence of the fetish is strongly preferred or even necessary for sexual arousal to occur - feet and shoes, sheer stockings, rubber products such as raincoats, gloves, toilet articles, fur garments, and especially underpants are common sources of arousal for fetishists - some can carry on their fetishism by themselves in secret by fondling, kissing, smelling, sucking, placing in their rectum, or merely gazing at the adored object as they masturbate - others need their partner to don the fetish as a stimulant for intercourse - the attraction felt by the fetishist toward the object has a compulsive quality; it is experienced as involuntary and irresistible; it is the degree of the erotic focalization – the exclusive and very special status the object occupies as a sexual stimulant – that distinguishes fetishisms from the ordinary attraction - the disorder usually begins by adolescence, although the fetish may have acquired special significance even earlier, during children; fetishists often have other paraphilias, such as pedophilia, sadism, and masochism Transvestic Fetishism transvestic fetishism – the practice of dressing in clothing of the opposite sex, for the purpose of sexual arousal - when a man is sexually aroused by dressing in women’s clothing, although he still regards himself as a man, the term transvestic fetishism, or transvestism applies - the extent of transvestism varies from wearing women’s underwear under conventional clothing to full cross-dressing - some transvestites may enjoy appearing socially as women; some female impersonators become performers in nightclubs, catering to the delight that many sexually conventional people take in observing skills cross-dressing; however, these impersonators aren’t considered transvestic unless the cross- dressing is associated with sexual arousal - transvestism should not be confused with the cross-dressing associated with GID or with the cross- dressing preferences of some homosexuals - the term autogynephilia refers to a man’s tendency to become sexually aroused at the thought or image of himself as a woman; autogynephilia is typically, but not always, found in association with transvestism - transvestic fetishism usually begins with partial cross-dressing in childhood or adolescence - transvestites are heterosexual, always males, and by and large cross-dress episodically rather than on a regular basis - they tend to be otherwise masculine in appearance, demeanor, and sexual preference; many are married - cross-dressing usually takes place in private and in secret and is known to few members of the family; this is one of the paraphilias for which the DSM distress and disability criteria do not seem to apply at all - the urge to cross-dress may become more frequent over time and sometimes is accompanied by gender dysphoria – discomfort with one’s anatomical sex – but not to the extent found in GID - transvestism is comorbid with other paraphilias, notably masochism Pedophilia and Incest pedophilia – the sexual disorder of a pedophile; a pedophile is a person with a marked preference for obtaining sexual gratification through contact with youngsters defined legally as underage; pedophilia is a paraphilia - according to the DSM, individuals who practice pedophilia (pedos, Greek for “child”) are adults who derive sexual gratification through physical and often sexual contact with prepubescent children unrelated to them - DSM-IV-TR requires that the offender be at least 16 years old and at least 5 years older than the child - research doesn’t appear to support the DSM’s statement that all pedophiles prefer prepubescent children; research revealed that some of them victimize postpubescent children who are younger than the legal age to consent to having sex with an adult - pedophilia occurs much more frequently in men than in women - pedophilia is often comorbid with mood and anxiety disorders, substance abuse, and other paraphilias - the pedophile can be heterosexual or homosexual - in recent years, the Internet has played an increasing role in pedophilia; pedophiles use the Internet to acquire child pornography and to contact potential victims - a recent study found that a child pornography offence is a stronger diagnostic indicator of pedophilia than is an actual history of sexually offending against child victims! - violence is seldom a part of the molestation, although it can be - sometimes the pedophile is content to stroke the child’s hair, but he may also manipulate the child’s genitalia, encourage the child to manipulate his, and, less often, attempt intromission - molestations may be repeated for weeks, months, or years if they’re not discovered by other adults or if the child doesn’t protest - a minority of pedophiles, who might also be classified as sexual sadists or anti-social (psychopathic) personalities, inflict serious bodily harm on the object of their passion - these individuals, whether psychopathic or not, are perhaps best viewed as child rapists and are different form the pedophiles in that they wish to hurt the child physically or at least as much as they wish to obtain sexual gratification incest – sexual relations between close relatives, most often between daughter and father or between brother and sister - incest refers to sexual relations between close relatives for whom marriage is forbidden; it’s most common between brother and sister; the next most common form is between father and daughter - brother-sister incest was associated with a much higher frequency of sexual penetration - the taboo against incest seems virtually universal in human societies, a notable exception being the marriages of Egyptian pharaohs to their sisters or other females of their immediate families; in Egypt, it was believed that the royal blood should not be contaminated by that of outsiders - the incest taboo makes sense according to present-day scientific knowledge; the offspring from a father- daughter or a brother-sister union have a greater probability of inheriting a pair of recessive genes, one from each parent; for the most part, recessive genes have negative biological effects, such as serious birth defects - the incest taboo, then, has adaptive evolutionary significance - there’s evidence that the structure of families in which incest occurs is unusually patriarchal (characteristic of rule by men) and traditional, especially with respect to the subservient position of women - parents in these families also tend to neglect and remain emotionally distant from their children - it’s believed that incest is more prevalent when the mother is absent of disabled, as mothers usually protect their daughters form intrafamilial sexual abuse - incest is listed in the DSM-IV-TR as a subtype of pedophilia st - several major distinctions are drawn between incest and pedophilia; 1 , incest is by definition between members of the same family; 2 , incest victims tend to be older than the victims of a pedophile’s desires - it is more often the case that a father becomes interested in his daughter when she begins to mature physically, whereas the pedophile is usually interested in the youngster precisely because he/she is sexually immature - the term gynephile refers to an adult who is incestuous with a child in the absence of a mature, adult sex partner - a study examined the nature of incest vs. extrafamilial (outside the family) forms of child sexual abuse and found that incest had an earlier onset and longer duration; also, victims of incest has comparatively greater levels of physical injury and emotional distress - almost 2/3 of the incest offenders reported having non-incestuous victims as well, which suggests that they’re also pedophiles; twas concluded that for these men, the main issue is one of opportunity; they have a general sexual attraction to children that may indeed go beyond members of their own family - for men, the penile plethysmograph measures changes in the circumference of the penis by means of a strain gauge, consisting of a very thin rubber tube filled with mercury; as the penis is engorged with blood, the tube stretches, changing its electrical resistance, which can then be measured by a suitably configured polygraph - data from penile plethysmography studies confirmed that men who molest children unrelated to them are sexually aroused by photographs of nude children - men who molest children within their families show more arousal to adult heterosexual cues - plethysmograph measures have been described as “phallometric tests”, and they have been used to identify males with pedophilic interests - although phallometric testing is used routinely with sex offenders, concerns have been raised about the reliability and validity of these measures; some people may possibly fake their responses when measured - researchers concluded that pornography only plays a role among men who are already predisposed to sexually offend; men who aren’t predisposed show little effect - rather than using explicitly pornographic materials, child molesting men appeared to construct in their minds their own sexually stimulating material from sources generally viewed as innocuous - pedophiles generally know the children they molest; they’re neighbors or friends of the family - alcohol use and stress increase the likelihood that a pedophile will molest a child - research suggests that child molesters have sexual fantasies about children when their mood is negative, perhaps as a way to cope with their unease; however, it also appears that having a pedophilic fantasy enhances the negative affect; perhaps this downward spiral can eventually lead to the person’s acting on the impulse to molest a child - data suggests that pedophiles are low in social maturity, self-esteem, impulse control, and social skills - most older heterosexual pedophiles are or have been married - one half of all child molestations, including those that take place within the family, are committed by adolescent males - about 50% of adult offenders began their illegal behavior in their early teens; these juveniles have typically experienced a chaotic and negative family life; their homes often lack structure and support - research has shown that these teenagers were themselves sexually abused as children; a history of sexual abuse increased the likelihood that the molester would choose boys as victims - overall, adolescents who engage in child molestation are more socially isolated and have poorer social skills than peers who are in trouble with the law for nonsexual crimes; academic problems are also common - in general, these young males (females are much less often found among the ranks of sex offenders) are what one would call juvenile delinquents, in frequent trouble with the police for a wide variety of lawbreaking - conduct disorder and substance abuse are frequent diagnoses made of these youths; anxiety disorders and depression are also common features - a brief measure known as the Screening Scale for Pedophilic Interests (SSPI) and have shown that this screening instrument is quite successful in distinguishing pedophilic child molesters and non-child molesters who have abused older victims - greater pedophilic interest in present when an unrelated victim is involved - a study of pedophiles found that lower levels of intellectual functioning are associated with greater interest in boys and in younger children in general Focus on Discovery 14.2 Child Sexual Abuse: Effects on the Child and Modes of Intervention - more than 4/5 victims are females - pedophilia and incest are forms of child sexual abuse child sexual abuse – sexual abuse of children that involves direct physical contact, such as pedophilia or incest Effects on the Child - the majority of children are negatively affected, with problems including anxiety, depression, low self-esteem, and conduct disorder - several factors likely contribute to how CSA affects a child; one is the nature of the abuse itself - sometimes the aftermath of CSA is PTSD - a high level of self-blame and lack of a supportive family environment also increase the chances that the CSA will produce negative reactions - a history of CSA is found among patients in many diagnostic categories – notably, dissociative identity disorder, eating disorders, and borderline personality disorder; it has also been proposed that CSA is related to the development of depression - a history of CSA is also associated reliably with sexual revictimization - CSA is also related to sexual dysfunctions - some sexually abused children may even become suicidal in subsequent years Prevention - for CSA, prevention efforts have focused on elementary schools - common elements of the ESPACE program include teaching children to recognize inappropriate adult behavior, resist inducements, leave the situation quickly, and report the incident to an appropriate adult; children are taught to say no in a firm assertive way when an adult talks to or touches them in manner that makes them feel uncomfortable Dealing with the Problem - the primary data regarding CSA must come from the child’s self report - pedophilic offences, when the perpetrator is not a member of the family, are more frequently reported to police and prosecuted in court - in closing, we should point out that both incest and pedophilia occur much more often in the majority North American culture than was formerly assumed Voyeurism voyeurism – marked preference for obtaining sexual gratification by watching others in a state of undress or having sexual relations - for some men, voyeurism is the only sexual activity in which they engage; for others, it is preferred but not absolutely essential for sexual arousal - the looking, often called peeping, is what helps the individual become sexually aroused - the voyeur’s orgasm is achieved by masturbation, either while watching or later, remembering what he saw - sometimes the voyeur fantasizes about having sexual contact with the observed person, but it remains a fantasy; in voyeurism, there is seldom contact between the observer and the observed - a true voyeur, almost always a man, doesn’t find it particularly exciting to watch a woman who is undressing for his special benefit - the element of risk seems important, for the voyeur is excited by the anticipation of how the woman would react if she knew he was watching - voyeurism typically begins in adolescence; it’s thought that voyeurs are fearful of more direct sexual encounters with others, perhaps because they lack social skills; their peering serves as a substitute gratification and possibly gives them a sense of power over those watched - it may be that the increased availability of completely frank pictorial and written material, typically used in masturbation, partially satisfied the needs that had made voyeurs of some men in the absence of other outlets Exhibitionism exhibitionism – marked preference for obtaining sexual gratification by exposing one’s genitals to an unwilling observer (sometimes a child) - it typically begins in adolescence - as with voyeurism, there’s seldom an attempt to have actual contact with the stranger - sexual arousal comes from fantasizing that one is exposing himself or from actually doing so, and the exhibitionist masturbates either while fantasizing or even during the actual exposure - voyeurism and exhibitionism together account for a majority of all sexual offences that come to the attention of the police - the frequency of exhibitionism is much greater among men, who are often arrested for what is legally termed indecent exposure - the urge to expose seems overwhelming and virtually uncontrollable to the exhibitionist, or flasher, and is apparently triggered by anxiety and restlessness, as well as by sexual arousal - apparently, exhibitionists are so strongly driven that at the time of the act, they are usually oblivious to the social and legal consequences of what they are doing - generally, exhibitionists are immature in their approaches to the opposite sex and have difficulty in interpersonal relationships; over half of all exhibitionists are married, but their sexual relationships with their spouses are not satisfactory - compared with normal people and with sex offenders who had committed violent assaults, the exhibitionists showed significantly greater arousal in response to slides of fully clothed women in nonsexual situations, such as riding on an escalator or sitting in a park, but they showed similar levels of sexual interest in response to erotic and sexually explicit slides - these results are consistent with the hypothesis that exhibitionists misread cues in the courtship phase of sexual contact, in the sense that they construe certain situations as sexual that are judged non-erotic by non-exhibitionists Frotteurism frotteurism – a form of sexual disorder or paraphilia in which an individual receives sexual pleasure from rubbing against people in public places - frotteurism involves the sexually oriented touching of an unsuspecting person - the frotteur may rub his penis against a woman’s thighs or buttocks or fondle her breasts or genitals - these attacks typically occur in places that provide an easy means of escape, such as a crowded bus or sidewalk - frotteurism has not been studied very extensively; it appears to begin in adolescence Sexual Sadism and Sexual Masochism sexual sadism – a marked preference for obtaining or increasing sexual gratification by inflicting pain or humiliation on another person - a marked preference for obtaining or increasing sexual gratification by inflicting pain or psychological suffering (such as humiliation) on another is the key characteristic of sexual sadism sexual masochism – a marked preference for obtaining or increasing sexual gratification through subjection to pain or humiliation - a marked preference for obtaining or increasing sexual gratification through subjecting oneself to pain or humiliation is the key characteristic of sexual masochism - both of these disorders are found in heterosexual and homosexual relationships, though it is estimated that upwards of 85% of people with these disorders are exclusively or predominately heterosexual - alcoholism is common among sadists - the disorders seem to begin in early adulthood - the majority of sadists and masochists lead otherwise conventional lives, and there is some evidence that they are above average in income and educational status - the majority of sadists establish relationships with masochists to derive mutual sexual gratification - the sadist may derive full orgasmic pleasure by inflicting pain on his/her partner, and the masochist may be completely gratified by being subjected to pain - for other partners, sadistic and masochistic practices, such as spanking, are a prelude to or an aspect of sexual intercourse - masochists outnumber sadists - the manifestations of sexual masochism are varied; examples include restraint (physical bondage), blindfolding (sensory bondage), spanking, whipping, electric shocks, cutting, humiliation (eg: being urinated or defecated on, being forced to wear a collar and bark like a dog, or being put on display naked), and taking the role of a slave and submitting to orders and commands - the term, infantilism, refers to a desire to be treated like a helpless infant and clothed in diapers - one particularly dangerous form of masochism, called hypoxyphilia, involves sexual arousal by oxygen deprivation, which can be achieved using a noose, a plastic bag, chest compression, or a chemical that produces a temporary decrease in brain oxygenation by peripheral vasodilation Paraphilias Not Otherwise Specified - the DSM-IV-TR also lists several disorders in the category of “paraphilias not otherwise specified” - this includes such disorders as necrophilia (sex with dead people), zoophilia (bestiality: sex with an animal), telephone scatalogia (repeated urge to make obscene phone calls), and coprophilia (the use of feces for sexual excitement) Etiology of the Paraphilias Psychodynamic Perspectives - the paraphilias are viewed by psychodynamic theorists as defensive in nature, protecting the ego from having to deal with repressed fears and memories and representing fixations are the pregenital stages of psychosexual development - the person with a paraphilia is seen as someone who is fearful of conventional heterosexual relationships, even or heterosocial relationships that do not involve sex - his (less often, her) social and sexual development is immature, stunted, and inadequate for both social and heterosexual intercourse with the adult world Behavioral and Cognitive Perspectives - some theorists operating within a behavioral paradigm hold the view that the paraphilias arise from classical conditioning that by chance has linked sexual arousal with classes of stimuli deemed by the culture to be inappropriate causes of sexual arousal - overall, the orgasm-conditioning hypothesis has very little empirical support - most current behavioral and cognitive theories of the paraphilias are multidimensional and propose that a paraphilia results when a number of factors impinge on an individual - the childhood histories of individuals with paraphilias reveal that often they were subjected to physical and sexual abuse and grew up in a family in which the parent-child relationship was disturbed - these early experiences may well contribute to the insecure attachment style usually found among sex offenders in general and the low level of social skills, low self-esteem, loneliness, and lack of intimate relationships often seen among those with paraphilias - alcohol and negative affect are often triggers of incidents of pedophilia, voyeurism, and exhibitionism - cognitive distortions also play a role in the paraphilias - from an operant conditioning perspective, many paraphilias are considered an outcome of inadequate social skills or reinforcement of unconventionality by parents or relatives; case histories of transvestites, for example, often refer to childhood incidents in which the little boy was praised and fussed over for looking cute in his mother’s dresses Biological Perspectives - as the overwhelming majority if people with paraphilias are male, there has been speculation that androgen, the principal male hormone, plays a role; findings of hormonal differences between normal people and people with paraphilias are inconclusive, however - as to differences in the brain, a dysfunction in the temporal lobe may be relevant to a minority of cases of sadism and exhibitionism Therapies for the Paraphilias - because most paraphilias are illegal, many people diagnosed with them are imprisoned and their treatment is ordered by the court - recidivism increases as the years go by, especially after 2 years have passed since termination of treatment - as we have seen with substance abusers, sex offenders often lack the motivation to try to change their illegal behavior - undermining (discouraging) their motivation for treatment are such factors as denial of the problem, minimization of the seriousness of their problem, a belief that their victims will not be credible witnesses, and the confidence that they can control their behavior without professional assistance - there are several methods to enhance their motivation to commit to treatment:  therapist can empathize with the offender’s reluctance to admit that he/she is an offender, thereby reducing the defensiven
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