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Archives of Sexual Behavior, Vol. 30, No. 4, 2001

Gay and Bisexual Adolescent Boys’ Sexual Experiences With Men: An Empirical Examination of Psychological Correlates in a Nonclinical Sample Bruce Rind, PhD1

Over the last quarter century the incest model, with its image of helpless victims exploited and traumatized by powerful perpetrators, has come to dominate perceptions of virtually all forms of adult–minor sex. Thus, even willing sexual relations between gay or bisexual adolescent boys and adult men, which differ from father–daughter incest in many important ways, are generally seen by the lay public and professionals as traumatizing and psychologically injurious. This study assessed this common perception by examining a nonclinical, mostly college sample of gay and bisexual men. Of the 129 men in the study, 26 were identified as having had age-discrepant sexual relations (ADSRs) as adolescents between 12 and 17 years of age with adult males. Men with ADSR experiences were as well adjusted as controls in terms of self-esteem and having achieved a positive sexual identity. Reactions to the ADSRs were predominantly positive, and most ADSRs were willingly engaged in. Younger adolescents were just as willing and reacted at least as positively as older adolescents. Data on sexual identity development indicated that ADSRs played no role in creating same-sex sexual interests, contrary to the “seduction” hypothesis. Findings were inconsistent with the incest model. The incest model has come to act as a procrustean bed, narrowly dictating how adult–minor sexual relations quite different from incest are perceived. KEY WORDS: gay and bisexual boys; man–boy sex; incest model; psychological correlates; homosexual development.

INTRODUCTION A quarter century ago, attention to the issue of sexual encounters between adults and minors increased markedly in the United States (Jenkins, 1998). This 1 Department

of Psychology, Temple University, Philadelphia, Pennsylvania 19122. 345 C 2001 Plenum Publishing Corporation 0004-0002/01/0800-0345$19.50/0 °

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increased attention was an outgrowth of initiatives taken by the women’s movement, which first focused on the problem of rape and shortly thereafter the problem of incest (Finkelhor, 1984). Rape served as a model for understanding father– daughter incest (Okami, 1990), and incest in turn quickly became the dominant model for understanding sexual encounters in general between men and girls (Finkelhor, 1984). Based on the rape and incest models, these encounters came to be seen as a form of power abuse and violence that exploited unwilling and powerless victims, inflicting lasting psychological trauma in the process (Okami, 1990). The burgeoning child abuse profession, given a major boost in 1974 by passage of the Child Abuse Prevention and Treatment Act, rapidly spread this view across society, where it has remained well-entrenched ever since (Gardner, 1993; Jenkins, 1998). As child abuse researchers expanded their domain of inquiry in the early 1980s, research began to include sexual encounters between men and boys, and eventually between women and boys (West, 1998). The incest model also strongly influenced how researchers, other professionals, and the lay public attempted to understand these encounters, including those between adolescent boys and unrelated adults (Jenkins, 1998; Rind, 1998). For example, Masters et al. (1985) rejected the findings of Sandfort (1983) who concluded that a mostly adolescent sample of Dutch boys experienced their sexual relationships with men predominantly positively. They argued, consistent with the incest model, that these relationships were inherently abusive and exploitative and therefore necessarily negative, regardless of contrary claims by the boys themselves. In rejecting the boys’ reports of positive reactions, Masters et al. speculated that they made them up because they were intimidated by the men. Similarly, the media have frequently also exhibited the influence of the incest model. In one typical example, an editorial in a major U.S. newspaper asserted that sexual encounters between adolescent boys and men are “profoundly damaging,” because they “invariably involve the imposition of power and exploitation, in the most fearfully private of all ways . . . [which leaves] emotional scars, distrusts, [and] self-contempt that last through lifetimes” (Philadelphia Inquirer, 1984, p. 22A). Recent reviews of the nonclinical literature suggest that the incest model, along with its assumptions of intimidation, violence, and pathogenicity, is not valid for boys in the general population who participate willingly in sexual relations with adults—“willing” indicates simple as opposed to informed consent (see Rind et al., 2000, for a complete discussion). Bauserman and Rind (1997), in a review of the nonclinical literature on boy–adult sex, found that willing relations were associated with neutral or positive reactions. Rind et al. (1998), in their meta-analytic review of college samples, found that boy–adult sex was not associated with symptoms when the boys were willing participants. In these samples, most boys with experiences labeled child sexual abuse reacted positively or neutrally (66%), whereas most girls reacted negatively (72%). These gender differences, which appeared to an

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equal degree in the national probability samples meta-analytically reviewed by Rind and Tromovitch (1997), imply that it is generally not valid to extrapolate from girls’ experiences, especially father–daughter incest, to those of boys. Nonclinical studies reporting data on woman–boy sex (e.g., Condy et al., 1987; Fromuth and Burkhart, 1987; West and Woodhouse, 1993; Woods and Dean, 1984) have generally found that boys react predominantly positively to these encounters, especially if they are adolescents at the time. Presumably, most of the boys in these studies were heterosexual, given the predominance of heterosexuality in the general population. It follows that, if adolescent heterosexual boys respond predominantly positively to sexual relations with older females, then adolescent gay or bisexual boys may respond similarly to such relations with older males. This inference differs markedly from expectations that follow from the incest model. It was the purpose of this study to examine these competing predictions. Background: Research on Gay and Bisexual Boy–Man Sex Relatively little research has directly examined age-discrepant sexual experiences of gay or bisexual boys (Doll et al., 1992). A brief review of research that has been done is presented next. Clinical, clinic-based, nonclinical, and cross-cultural data are examined. Myers (1989) reported on 14 men (eight of whom were gay) from his clinical practice who experienced sexual abuse as adults or boys. Half the gay patients as boys had sexual contacts with men. One, at age 11, was abused on a camping trip by his teacher, who attempted fellatio and sodomy. He felt “dirty” from the experience and felt “frozen and scared stiff” for several weeks, reacting with hyperalertness and insomnia. Another reported that, at age 13, he was raped repeatedly for hours by two men after he was drugged, gagged, and tied down by all four extremities. For the next half year, he had flashbacks of the rapes and nightmares of suffocation and death. Both of these patients currently suffered from depression. Half the gay patients were intensely homophobic. Dimock (1988) reported on 25 patients who experienced overt sexual contact as boys that they felt powerless to resist and that they or he believed had produced harmful results. He found that 64% of his sample, including both homosexual and heterosexual patients, exhibited some confusion about their sexual preference. Doll et al. (1992) examined 1,001 homosexual or bisexual men attending sexually transmitted disease clinics. Thirty five percent were encouraged or forced by an older or more powerful male to have sex before age 19 (their median age was 10; their partners’ was 21). Reactions at the time were 27% positive, 15% neutral, and 58% negative. Half the episodes involved some form of force, and 43% were incestuous. Force was the strongest predictor of negative reactions. Positive reactions were associated with lengthier relationships. Bartholow et al. (1994), using the same data set, reported that this early sex was associated with

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more mental health counseling/hospitalization and drug abuse, less social support, and an altered process of sexual identity development (e.g., less comfort regarding sexual attractions). These associations, however, were all small. Many other researchers have also expressed concern that man–boy sex may interfere with sexual development. Finkelhor (1984) reported that college males who had sex as boys with older males were four times more likely to be currently engaging in homosexual activity. He attributed this to a stigma effect, in which boys with such experiences label themselves homosexual and thereby become one. Various researchers have used this result along with others (e.g., Johnson and Shrier, 1985) to argue that homosexuality is an adverse outcome of man–boy sex (e.g., Mendel, 1995; Urquiza and Capra, 1990). “Seduction” as an important contributor to homosexual development is a staple of some schools of psychoanalytic thought, reflected in the opinion expressed by the National Association for Research and Therapy of Homosexuality (NARTH), an organization of psychoanalysts and psychoanalytically oriented psychologists committed to treating, curing, and preventing homosexuality (http://www.narth.com). In contrast to clinical or clinic-based studies, a number of studies based on convenience samples consisting of gay or bisexual men obtained through advertisements placed in gay magazines, bars, bookstores, or conferences have frequently yielded a predominantly positive profile of gay and bisexual boys’ sexual experiences with men (e.g., Fellows, 1996; Hart, 1995; Jay and Young, 1977; Spada, 1979). They also have generally pointed out the commonness of early sexual attractions to and desires for older adolescent and adult males. For example, Spada (1979), who examined 1,038 male homosexuals aged 16–77 across the United States through mail questionnaires, reported that In the case of a respondent’s first youthful experience taking place with an adult, it is usually stressed by the respondent that it was he who made the first advance, he who desired and initiated the encounter, and that no coercion or seduction by the adult took place. Several dozen did describe their first experience as a seduction, but just three reported the use of force (p. 30).

In an illustrative case of the generally positive reactions reported, a respondent recalled that, when he was 12, his scoutmaster fellated him. He commented, “I liked it. It felt good and I think it made us closer as friends and someone I could turn to when I had problems.” West and Woodhouse (1993), based on a college sample, reported similar findings in terms of homosexually oriented boys’ initiation of and positive reactions to sex with adult males. Jay and Young (1977) obtained data from 4,239 gay or bisexual male respondents aged 14–82. They found that boyhood crushes and fantasies regarding older males were common. One respondent, who looked at men’s underwear models in catalogs when he was 9 or 10 years old, remembered that “[I] prayed very sincerely and faithfully that God would put those men in a locked room that only I had a key to, and would obey me like robots” (p. 83). Sexual experiences with

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older males were often positive. One respondent recalled that, at age 11, he was seduced by a man in his 20s living in his house. He remembered that it “was a little shaky at first but after it began I realized I liked it” (p. 90). Only a few experiences involved force or violence. The authors provided a sampling of 16 opinions to the question “whether sexual contacts with adults were helpful or not” (p. 97): most were positive (69%) or neutral (12%). In March 1999 the Rind et al. (1998) meta-analysis came under intense attack by social conservatives (see Rind et al., 2000, for details). The Philadelphia radio talk show host who initiated the nationwide attacks pressured the Philadelphia gay and lesbian bookstore to remove all materials on intergenerational sex (e.g., books, newsletters). The owner yielded, but protested that “I have thought it interesting that so many gay men I know report having had positive sexual experiences with adults when they were boys” (Giovanni’s Room press release, March 24, 1999). Reacting to this comment and the controversy surrounding the meta-analysis, two journalists for a Philadelphia gay publication conducted interviews at various gay youth centers with male teen volunteers who had had sexual relations with men (Nickels and Hocker, 1999). Results supported the bookstore owner’s observation: most of the nine volunteers reacted positively and none reacted negatively. Rejecting the notion that they had been abused, the teens instead identified various psychological, emotional, and educational benefits that the relationships conferred. The research just reviewed has focused on the age-discrepant sexual experiences of gay and bisexual boys in a society that has traditionally condemned homosexuality and currently anathematizes man–boy sex. It is thus instructive to examine how homosexually oriented boys in other cultures that do not share these attitudes react to such experiences. Williams (1996) has provided relevant data based upon field research among Native Americans and Polynesians, in which he interviewed “two-spirit” persons (i.e., Native American berdaches and Polynesian mahus). Two-spirit men are differently gendered and are accepted and appreciated in their societies for their unique contributions. They are usually homosexually oriented and play the passive role in sexual relations with masculine males; these relations are socially sanctioned and generally begin before puberty. Williams found that the vast majority of his interviewees expressed pleasant memories of their boyhood sexual experiences with older males. For example, one man had a relation with a 40-year-old man when he was eight. He commented: “Since he was good to me and for me, it was considered by my family to be okay and my own business—no one else’s” (p. 428). Williams came across only one interviewee who felt traumatized by an age-discrepant experience, which involved being raped by his alcoholic grandfather. He also found that masculine-oriented males who had sexual relations with older males as boys found them to be predominantly positive. He concluded that culture is an important factor in determining how boys perceive these relations; when it is accepting, these relations tend not to be problematic and may even help a boy’s maturation.

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Current Study The review of research on gay and bisexual boys’ sexual encounters with older males shows a wide range of reactions. Clinical case studies, consistent with the incest model in their findings, appear to be highly unrepresentative of this population. Causal attributions regarding symptoms are problematic, because clinical subjects often come from disorganized family environments—Dimock (1988) described all of his subjects as coming from chaotic homes. The clinic-based research of Bartholow et al. (1994) and Doll et al. (1992) was not especially supportive of this model, because psychological correlates of these sexual encounters were all small and comfort regarding sexual attractions was high on average among subjects with these experiences (M = 1.6, where 1 = very comfortable, 5 = very uncomfortable), contrary to Bartholow et al.’s erroneous description of “lack of comfort” (Bartholow et al., 1994, p. 755). The generalizability of this sample is limited because men of low socioeconomic status were overrepresented—which could account for the high percentage of force and incest cases relative to national samples (cf. Rind et al., 1998). Its relevance to gay and bisexual adolescent males is limited because most subjects in this study had their sexual encounters with older males when they were preadolescent. The nonclinical and cross-cultural data were completely inconsistent with the incest model. An important shortcoming of this research, however, is that no data based on standard measures of psychological adjustment were gathered. The purpose of the current study was to add to scientific knowledge in this area by presenting research that avoided the shortcomings just discussed. A nonclinical, mostly middle class sample of young adult gay and bisexual males was examined. Both adjustment and reaction data were analyzed, as were data concerning sexual orientation development. Consistent with the nonclinical and cross-cultural research just reviewed, and contrary to predictions from the incest model, it was expected that age-discrepant sexual relations (ADSRs) between gay or bisexual males and adult men would be experienced predominantly nonnegatively and would not be associated with adjustment problems. Furthermore, contrary to psychoanalytic theorizing and labeling theory, it was not expected that homosexual interests would be the “adverse” outcome of ADSRs. In the current study, ADSR was defined as a sexual encounter or relationship involving at least genital contact between a gay or bisexual boy aged less than 18 with a man aged at least 18 and at least 5 years older than the boy. METHOD Overview This study drew its data from research conducted by Savin-Williams (1997), a Cornell University psychologist who interviewed two samples of young adult gay

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and bisexual males to examine gay/bisexual identity development. Some of the data were obtained directly from Savin-Williams; other data were obtained from his 1997 report summarizing this research. Savin-Williams employed an interpretive interview approach, in which he requested his subjects to ground their memories in specific details during face-to-face interviews and to tell “their own story” (p. 11). He argued, citing supporting methodological research (Kessler and Wethington, 1991; Ross, 1984), that this technique, along with the fact that subjects were generally only several years or months removed from important developmental sexual experiences or milestones, added to the validity of the results. Savin-Williams’ focus when examining the first sample was exploring the role that sexual behavior during childhood and adolescence plays in forming a gay or bisexual identity. In accordance, he asked subjects about all sexual relations they had prior to graduating from high school. Thus, it was possible to divide this sample into a control and an ADSR group. For his second sample, his goals changed in that sexual behavior per se was not a chief focus. Accordingly, he asked these subjects only about their first sexual experience and their first romantic experience. As such, although Sample 2 can be divided into a control and an ADSR group, the control group cannot be considered as pure in that it likely contained a small subset of subjects who experienced ADSR. In the current study, Sample 1, because of its clear separation of control and ADSR subjects, was used as the primary basis for assessing the relationship between ADSR and psychological adjustment. As a secondary means of assessing this relationship, Sample 2 was employed, with the caveat that interpretation of its results must be seen as tentative because its control group likely contained several ADSR subjects. ADSR subjects from both samples were used to evaluate how gay/bisexual boys react to ADSRs. Subjects Subjects were recruited through announcements made in appropriate classes at Cornell University and other local colleges, posters and flyers put on campus bulletin boards and distributed at relevant local establishments (e.g., local bar, bookstore, cafe), and advertisements placed in local gay newsletters and Internet list-serves. Many subjects volunteered based on word-of-mouth information from subjects who had already participated. The study was described to prospective subjects as an attempt to understand the ways gay and bisexual men come to recognize their sexual identity during childhood and adolescence. Sample 1 The first sample consisted of 43 male subjects, with a mean age of 21 (SD = 1.4) and a range from 17 to 23. Most of these subjects were White (91%). Their

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religions were (a) 27% Protestant, (b) 22% Jewish, (c) 17% Catholic, and (d) 34% none. Only 16% came from urban settings; 38% came from small cities, medium towns, or suburbs; nearly half (47%) came from small towns, rural communities, or farms. Subjects’ mean Kinsey rating (on a scale from 0 to 6, where 6 indicates exclusively homosexual) was 5.49 (SD = .94): 70% were exclusively homosexual, 16% were mainly homosexual with a small degree of heterosexual interest, and the remaining 14% had substantial interest in both sexes. Thirteen (30%) of the 43 subjects had ADSR experiences, all of which occurred between ages 12 and 17. Sample 2 The second sample consisted of 86 subjects, with a mean age of 21.3 (SD = 2.2) and a range from 17 to 25. Most subjects were White (72%). Their religions were (a) 13% Protestant, (b) 21% Jewish, (c) 24% Catholic, (d) 4% other, and (e) 37% none. Twenty nine percent came from urban settings; 37% came from small cities, medium towns, or suburbs; 35% came from small towns, rural communities, or farms. Their mean Kinsey rating was 5.45 (SD = .90): 66% were exclusively homosexual, 19% were mainly homosexual with a small degree of heterosexual interest, and the remaining 13% had substantial interest in both sexes. The only demographic variable that differed significantly between Samples 1 and 2 was ethnicity: the first sample was less ethnically diverse, containing a greater proportion of Whites (91%) than did the second sample (72%), χ 2 (1, N = 129) = 5.84, p < .02, effect size r = .21. Thirteen of 86 subjects were identified as having experienced ADSR, all of which occurred between ages 12 and 17, as in Sample 1. ADSR-Identified Sample No statistically significant differences emerged between ADSR and control subjects in their demographics. The 26 ADSR-identified subjects from the two samples had a mean age of 20.8 (SD = 2.6) and a range from 17 to 25. Most were White (85%); 8% were Black and 4% each were Latino and Asian. Fifteen percent were Protestant, 19% Jewish, 27% Catholic, and 38% had no religious affiliation. Almost a third each came from urban communities (31%) or small cities, medium towns, or suburbs (31%); 38% came from small towns, rural communities, or farms. Their mean Kinsey rating was 5.46 (SD = 1.03), with 69% exclusively homosexual, 19% mainly homosexual with a small degree of heterosexual interest, and 12% with substantial interest in both sexes. Measures and Procedure In their study on the mental health of lesbian, gay, and bisexual youths, Hershberger and D’Augelli (1995) found that the single largest predictor of the

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youths’ mental health was self-acceptance, as measured by the Rosenberg SelfEsteem Inventory (Rosenberg, 1965) and an item on comfort, which asked how comfortable subjects currently felt about being gay or lesbian. Savin-Williams (1997) also assessed self-esteem, using the Rosenberg scale; scores could range from 0 to 30, where 30 indicated high self-esteem. Additionally, Savin-Williams (1997) reported the age at which subjects first developed a positive sexual identity. This construct is analogous to Hershberger and D’Augelli’s construct of comfort (Hershberger and D’Augelli, 1995) in that it assesses self-acceptance; it follows therefore that it is an indicator of psychological adjustment. In the current study, the self-esteem and positive sexual identity data obtained from Savin-Williams were used to assess the relationship between ADSRs and adjustment. Reaction data for ADSR subjects were also analyzed. In conducting his interviews, Savin-Williams (1997) took notes on subjects’ feelings about their sexual experiences, including the ADSR experiences. ADSR narratives were obtained for the current study from Savin-Williams as well as from his book. For each of the 26 narratives, one for each ADSR subject, the author of the current study and two other sex researchers coded each subject’s reaction to the ADSR and his level of consent. Specifically, reactions were coded as follows: 1 = very negative, 2 = negative, 3 = neutral or mixed, 4 = positive, and 5 = very positive. Level of consent was coded as follows: 1 = forced (partner used threat or force to get subject to participate); 2 = obligated (subject not forced, but subject felt unable to say no); 3 = acquiesced (subject participated without real interest; he did it to accommodate partner); 4 = mutual (subject wanted to do it, but didn’t necessarily initiate it; it was two-way mutual); 5 = encouraged (subject actively initiated and wanted it). Cronbach’s alphas computed on the coders’ ratings indicated good intercoder reliability: alphas = .97 and .87 for reactions and consent, respectively. Reaction and consent scores for each subject were computed as the mean of the three coders’ corresponding ratings. Additionally, the author and one other rater coded several characteristics of the ADSRs. One was the relationship between the boy and the man: 1 = stranger (ADSR on first meeting); 2 = acquaintance (ADSR after first meeting, but before becoming friends); 3 = friend. Another was frequency of sexual contact: 1 = once only; 2 = more than once. A third was duration: 1 = less than a month; 2 = 1–6 months; 3 = 6 months to one year; 4 = more than 1 year. A fourth was type of sex (coded as the most intensive type that occurred): 1 = masturbation; 2 = oral; 3 = anal. Percent agreements ranged from 81% to 96%. Discrepancies were resolved by discussion. Finally, Savin-Williams (1997) collected data on subjects’ age of puberty, age of first awareness of sexual attractions to other males, and age at which they first labeled their attractions “gay” or “homosexual.” The latter two variables, in conjunction with subjects’ beginning age of ADSR experiences, were used to evaluate claims that early sex with older males causes homosexuality.

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RESULTS Psychological Adjustment If ADSRs have adverse effects on the adjustment of gay/bisexual males, it would be expected that, in comparison with controls, ADSR subjects should have lower self-esteem and greater difficulty in attaining a positive sexual identify (i.e., the age of achieving this milestone should be delayed). In Sample 1, self-esteem scores were not lower for ADSR subjects (M = 23.82) than for control subjects (M = 23.46), t(37) = −.17, p > .10 (all tests reported here are two-tailed), with effect size r = −.03 (positive effect sizes indicate better adjustment for controls; negative effect sizes indicate better adjustment for ADSR subjects). Attainment of a positive sexual identity was not delayed for ADSR subjects (M = 18.00) compared to controls (M = 18.35), t(23) = −.43, p > .10, r = −.09. Assessment of this attribute commenced a third of the way into the interviews; data are missing for nearly equal proportions of ADSR (31%) and control (33%) subjects. Of those who were asked about achieving a positive sexual identity, the proportion of ADSR subjects (89%) and control (85%) subjects who had achieved this milestone did not differ, z = −.28, p > .10, r = −.05. Table I provides adjustment statistics for both samples. In Sample 2, self-esteem scores were not lower for ADSR-identified subjects (M = 21.00) than for control subjects (M = 21.96), t(84) = .62, p > .10, r = .07. Attainment of a positive sexual identity occurred earlier rather than later for ADSR-identified subjects (M = 16.80) relative to controls (M = 19.10), t(70) = −2.89, p < .01, r = −.33. The proportion of ADSR-identified subjects (77%) and control subjects (85%) achieving a positive sexual identity did not differ, z = .72, p > .10, r = .08. Sample 1 results provide no evidence for adverse effects of ADSR. Sample 2 results, although in need of qualification because the control sample was likely Table I. Self-Esteem and Age of Attainment of Positive Sexual Identity as a Function of Having Experienced ADSR Sample 1 Adjustment measure Rosenberg self-esteem M SD n Positive sexual identity M SD n % achieved

Sample 2

ADSR

Controls

ADSR

Controls

23.82 5.47 11

23.46 6.24 28

21.00 4.74 13

21.96 5.25 73

18.00 2.14 8 89

18.35 1.77 17 85

16.80 3.05 10 77

19.10 2.21 62 85

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to be impure, are consistent with those of Sample 1, reinforcing the conclusion of no evidence for adverse effects. Combining results from the two samples metaanalytically (Rosenthal, 1984) yielded a very small and statistically nonsignificant effect size for self-esteem (r = .04, N = 125, 95% confidence interval = −.14 to +.21), a medium and statistically significant effect size for age of positive sexual identity (r = −.27, N = 97, 95% confidence interval = −.45 to −.07), and a small and statistically nonsignificant effect size for proportion having achieved a positive sexual identity (r = .05, N = 115, 95% confidence interval = −.14 to +.23). All of these results are inconsistent with the traumagenic view (e.g., incest model) of ADSR, particularly the negative effect size for age of achieving a positive sexual identity, which is consistent instead with a beneficial effect. The ADSR Experiences The Appendix contains narratives from all 26 ADSR subjects, which are ordered according to subjects’ and partners’ ages. The narratives generally provide information on the context in which the ADSRs occurred, the level of familiarity between the partners, the frequency and duration of the sexual relationships, the types of sex involved, subjects’ reactions, and their level of consent. SavinWilliams took more notes on first sexual or romantic experiences; as such, these narratives contain more details. Characteristics The mean age at which subjects had their first ADSR experience was 15.31 (SD = 1.67), with a range from 12 to 17. The mean age of their older partner was 28.62 (SD = 7.66), with a range from 20 to 46. Thus, on average, there was a 13.31 (SD = 7.83) year age difference between the boys and their older partners, with a range from 5 to 30 years. Forty two percent of the cases involved contacts with strangers; 35% involved contacts with acquaintances; and 23% involved friends (one of these involved an older brother). About two thirds (68%) of the cases involved multiple sexual contacts. Nearly half of the sexual relationships (42%) lasted less than a month, whereas a quarter (25%) lasted more than a year. Of the 19 cases for which type of sex could be identified, 21% involved masturbation as the most intense form, 42% involved oral sex, and 37% involved anal intercourse. Almost all subjects (96%) were aware of their sexual attraction to males before their ADSR experience—mean age of awareness was 7.92 (SD = 4.10), with a range from 3 to 17. Ninety-six percent had reached puberty at an earlier age (one reached puberty in the same year as his ADSR experience)—mean age of puberty was 11.46 (SD = 1.21), with a range from 10 to 14. Three quarters (76%) had already labeled their interests “homosexual” or “gay” before the ADSR

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occurred (16% labeled their interests in the same year as the ADSR)—mean age of labeling was 12.52 (SD = 3.02), with a range from 7 to 18. These results regarding age of awareness of attractions and labeling call into question the role of ADSRs in causing same-sex interests. Reactions Subjects’ mean reaction was positive (M = 3.94, SD = 1.25), although individual reactions ranged from very negative to very positive. Overall, reactions were as follows: 38.5% very positive, 38.5% positive, 7.7% neutral/mixed, 3.8% negative, and 11.5% very negative. Combining categories and rounding, 77% were positive, 8% were neutral, and 15% were negative. Consent Overall, subjects were mutually consenting (M = 4.15, SD = .51); consent ranged from acquiescing to encouraging. Thus, forced or coerced contact was not a factor in this sample. To the contrary, nearly a quarter (23.1%) encouraged the contacts and about two-thirds (69.2%) mutually consented; 7.7% acquiesced. Thus, 92% evidenced positive desire for the sexual involvement. Correlations Table II presents correlations among the various ADSR characteristics; statistical significance is based on two-tailed tests. Doll et al. (1992) reported that greater age difference was associated with more negative reactions at time of interview in their sample of gay/bisexual men. In the current sample, this association was not found, r (24) = .12, p > .10. Moreover, younger boys did not react more negatively (or less positively) than older ones, r (24) = −.23, p > .10, and they were just as consenting as older boys, r (24) = −.01, p > .10. Further, contrary to age difference posing a problem for the boys, their willingness and interest in participating in sexual relations increased as the difference in ages between them and the men increased, r (24) = .39, p < .05, and as the ages of their partners increased, r (24) = .40, p < .05. Positivity of reactions increased with a greater degree of familiarity with the men, r (24) = .56, p < .01, multiple as opposed to single sexual encounters, r (23) = .60, p < .01, longer lasting sexual relationships, r (22) = .52, p < .01, and greater willingness and interest in participation, r (24) = .43, p < .05. Greater familiarity was associated with more frequent sexual encounters, r (23) = .47, p < .05, and longer lasting sexual relationships, r (22) = .69, p < .01. Younger boys tended to be more familiar or friendly with their partners, r (24) = −.43, p < .05. Finally, two one-way ANOVAs were performed to examine whether reactions and consent were related to type of sex

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Table II. Correlations Among ADSR Characteristics

Boys’ age Men’s age Age difference Relationship Frequency Duration Reaction

Men’s age

Diff

Relat

Freq

Dur

React

Consent

.01

−.20 .98∗∗

−.43∗ −.06 .03

.01 .18 .17 .47∗

−.22 .23 .27 .69∗∗ .64∗∗

−.23 .07 .12 .56∗∗ .60∗∗ .52∗∗

−.01 .40∗ .39∗ .30 .29 .36 .43∗

Note. Boys’ age = boys’ ages when ADSR began; men’s age = men’s ages when ADSR began; age difference = difference between partners’ ages; relationship = familiarity between the partners; frequency = single vs. multiple sexual contacts; duration = length of sexual relations; reaction ranges from very negative to very positive; consent ranges from forced to encouraging (see text for exact definitions). Correlations based on N = 26, except for those involving frequency or duration, which involve N = 25 and N = 24, respectively. ∗ p < .05 two-tailed; ∗∗ p < .01 two-tailed.

experienced. Results were nonsigificant in both cases: F(2, 16) = .25, p > .10, and F(2, 16) = .36, p > .10, respectively. DISCUSSION Psychological Adjustment In the current study, ADSRs between gay or bisexual boys and men were examined. Contrary to conventional assumptions, derived in part from the influential incest model, these relations were not associated with damaged self-esteem or sexual identity development. The self-esteem of subjects who experienced ADSRs was as high as those who did not. ADSR subjects were not delayed in achieving a positive sexual identity; to the contrary, in the two samples combined, ADSR subjects actually reached this milestone earlier than did control subjects. Given Hershberger and D’Augelli’s research (Hershberger and D’Augelli, 1995) on middle-class college-aged gay and bisexual men, which showed that self-esteem and comfort with being gay are strong predictors of mental health, results of the current study imply that ADSRs were not associated with psychological maladjustment. This finding is inconsistent with conventional professional and lay views, which reflect the incest model, but is consistent with empirical findings on willing boy–adult sex based on college samples (Rind et al., 1998). Given that willing ADSRs predominated in the current sample and that the current sample was composed mostly of college students, this consistency is not surprising. Sexual Identity Development Before gay liberation, professionals frequently expressed concern that man– boy sex was pathogenic, because they believed it was likely to cause boys to become

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homosexual (Rind, 1998). A number of child abuse researchers and other professionals continue to express this concern (e.g., Bartholow et al., 1994; Mendel, 1995; http://www.narth.com; Urquiza and Capra, 1990), despite well-grounded empirical evidence to the contrary (e.g., Bell et al., 1981). Data from the current study are relevant to this continuing debate. Consistent with a growing literature (see Savin-Williams, 1997, for a review), subjects in the current study became aware of their sexual attraction to other males years before puberty on average— in the case of ADSR subjects, 3.5 years before. All but one ADSR subject became aware of these attractions prior to having their first ADSR. Three quarters of these subjects labeled their attractions as “gay” or “homosexual” before their ADSR, whereas another 16% labeled their attractions at the same age of their ADSR (leaving in doubt for these latter subjects which event occurred first). The timeline suggested by these events is, for most of these subjects, as follows: becoming aware of same-sex attractions, labeling these interests as gay, then experiencing ADSRs. This timeline contradicts the seduction hypothesis. Clinical findings of sexual confusion and homophobia among gay and bisexual men who experienced ADSRs (e.g., Dimock, 1988; Myers, 1989) do not extend to the current sample. This is evidenced not only by the positive sexual identity data already discussed, but also by subjects’ narratives. Only a few subjects showed adverse reactions (see Appendix for Cases 9, 11, 16, and 19). Two of these subjects explicitly commented that their ADSR made it difficult to accept their homosexuality (Cases 11 and 16). Importantly, these cases constituted a small minority. The vast majority of narratives provide no evidence of harm to sexual identity formation. Contrary to stereotypes of harm, Savin-Williams (1997) concluded from his interviews that many of the ADSRs helped “the adolescent more readily identify as gay, feel better being gay, and learn much about himself ” (p. 178). Reactions and Consent The incest model offers the image of a frightened child, powerless to resist, coerced into a traumatizing sex act. This image fits some case studies presented in clinical research on gay boys’ ADSRs (e.g., Myers, 1989), but does not fit the typical ADSR in the current sample. To be sure, several cases were quite negative (Cases 9, 11, 16, and 19). In three of these cases, however, the narratives indicate that the circumstances were important in affecting subjects’ reactions. One subject initially felt accomplishment in having experienced the sex, but later felt the circumstances cheapened the event (Case 11). Another felt the sex was unclean because it was anonymous (Case 16), and the third one felt unclean about sex in a cemetery with a stranger to whom he was not attracted (Case 19). It was positive and very positive reactions that predominated (77% of the cases). These narratives are reminiscent of those found in other nonclinical research

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on gay youths’ sexual experiences (e. g., Jay and Young, 1977; Spada, 1979) and in cross-cultural research (Williams, 1996). One 12-year-old said he “practically had to force sex” on the man, which he thought was great when if finally occurred (Case 1). Another 12-year-old thought the sex was physically great, fell in love with the man, and continued the relationship for 10 years (Case 2). A 13-year-old, who had a sexual relationship with his adult brother, said he liked it and wanted to do it again and again (Case 3). Another 13-year-old was glad to have engaged in mutual masturbation with a man he met in a shopping mall, and tried unsuccessfully to meet the man again for a repeat (Case 4). Still another 13-year-old found the sex to be incredibly erotic, a tremendous release, and very pleasurable (Case 5). A 14-year-old felt excitement, love, and affection in his relationship (Case 7). A 16-year-old reacted to his ADSR by asking himself, “Is this what it is? Is this what it is? Do I like it? Do I like it?” He answered with, “Yes! Yes! Yes! Yes!” (Case 14). Another 16-year-old described his ADSR as the best sex he had ever had (Case 15). This predominance of positive ADSRs is strongly at odds with the image forwarded by most feminists, child abuse professionals, and media commentators. The boys in these cases were not frightened, powerless to resist, or coerced into traumatizing sex acts. Instead, the vast majority either mutually consented to the relations or actually initiated them. In contrast to the clinical and clinic-based samples discussed previously, force and coercion played no role in the current sample, the boys were not involved in ADSRs before puberty, and incest was rare ( just one case—Case 3 was brother–brother incest). These differences in coercion, childhood versus adolescent contacts, and incest may reflect differences in socioeconomic status and family stability, which were both more favorable in the current sample. Noteworthy is the finding that age difference, the sine qua non of the power abuse perspective, was not associated with type of reaction and was positively, rather than negatively, associated with level of consent. The boys were more willing to be sexually involved as the difference in ages between them and the men increased. Moreover, the younger boys (aged 12–14) did not react more negatively than the older ones—to the contrary, they all reacted positively. This contradicts the conventional wisdom that younger participants would be vulnerable to negative outcomes because they are too naive sexually. Contrary to this presumption of naivet´e or “innocence,” however, almost every boy in the current sample had already become aware of his sexual attractions to other males prior to his ADSR. Additionally, these sexual attractions, whether felt by boys who experienced ADSRs or not, often involved significantly older males. As Savin-Williams (1997) noted Those who monopolized their attention were occasionally same-age boys, but were more often older teenagers and adults—male teachers, coaches, cousins, or friends of the family. Public male figures were also sources of fantasies—Superman, Scott Baio, Duran Duran, John Ritter, Bobby Ewing, and Hulk Hogan. Others turned pages in magazines and catalogs to find male models in various stages of undress; especially popular were underwear advertisements (p. 24).

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Savin-Williams (1997) provided several examples of these early age-discrepant attractions. One subject remembered his kindergarten naps: “Dreams of naked men and curious about them. Really wanting to look at them” (p. 21). Another subject at age 7 shared a room one night with a 21-year-old athlete, who was nude in his sleeping bag. The subject commented: “. . . I kept wondering . . . I just knew I wanted to get in with him . . . I didn’t sleep the whole night” (p. 24). Still another remembered: “As a child I knew I was attracted to males. I was caught . . . looking at nude photographs of men . . . [I] enjoyed my keen curiosity to see male bodies” (p. 26). Rather than seeing older males as a threat to abuse them, these boys often regarded them with “excitement, euphoria, mystery” (p. 24). This favorable predisposition may account for the receptivity, and hence generally positive reactions, to the ADSRs that occurred in this sample. It also suggests that the reports of positive ADSRs were generally valid, rather than artifacts of psychological or social pressure to present their homosexual history in a favorable light. The Incest Model: A Procrustean Bed The discrepancy between findings in the current study and expectations based on the incest model is so great as to warrant further consideration. Summit (1983) wrote an influential paper based on clinical incest cases, in which he described the “child sexual abuse accommodation syndrome.” He cautioned that his syndrome “should not be viewed as a procrustean bed which defines and dictates a narrow perception of something as complex as child sexual abuse” (p. 180). Despite this warning, in the very next paragraph, even though his syndrome was built almost entirely on cases of father–daughter incest, he asserted that “male victims are at least as frequent, [and] just as helpless” (p. 180). This sort of extrapolation has become commonplace since the early 1980s. Sexual phenomena that have only age-discrepancy in common with incest are reshaped in a narrow, rigid manner to fit the demands of the incest model. Media commentators conclude that willing sexual relations between adolescent boys and unrelated men are invariably profoundly damaging (e.g., Philadelphia Inquirer, September 13, 1984, p. 22A). Professionals reject or distort data regarding these relations that are inconsistent with the incest stereotype, reaching instead the obligatory conclusion of pervasive harm (e.g., Bartholow et al., 1994; Masters et al., 1985). A 1993 case in London, Ontario, illustrates paradigmatically the procrustean influence of the incest model when applied too broadly. The Canadian Broadcasting Corporation (CBC) documented on its premier informational show IDEAS (1994, 1995, 1999) what it termed the biggest sex scandal in North America. About 60 men sexually involved with adolescent boys were arrested in the midst of a “moral panic . . . generated by the police, with the help of therapists and social workers, and . . . fueled by the media” (IDEAS, 1994, p. 29). CBC interviews with the boys indicated that they generally were gay or bisexual, were “sexually active teenagers

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who were having sex for fun or for profit” (IDEAS, 1994, p. 31), engaged willingly, had reached Canada’s age of consent of 14 when the sex occurred, and were treated well by the men. For example, one teen commented: I knew what I was doing. . . . I wanted it. . . . [I]t’s not a recruitment thing, it’s not that you’re forced into it. . . . [W]hen you’re 14 and gay it’s as natural to want to be with a man as it is when you’re 14 and straight and want to be with a girl . . . I was doing it when I was 14. I was picking up the guys. It wasn’t them picking me up. And you can’t be a victim unless you’re forced into something. (IDEAS, 1995, pp. 55, 56)

The teens’ willing participation and their predominantly positive perceptions of the experience are completely consistent with the findings of the current study, as well as the other nonclinical research reviewed previously. Nevertheless, as the CBC series documented, the London media, social workers, and police treated the affair following the dictates of the incest model, with serious distortion and iatrogenic harm ensuing. The media consistently and repeatedly exaggerated and misrepresented the affair from the start, presenting it as a child pornography ring victimizing children as young as eight, when in fact almost none of the men knew each other, 95% of the cases did not involve pornography, and teenagers were involved, not young children. Social workers proceeded from the premise that the relations were coerced and nonconsenting—even though most boys were above the age of consent—because of a “power differential;” they also tended to believe that men and boys get their “power needs” met through sex. The CBC series documented further that the social workers involved in the cases were distressed that the boys did not see themselves as victims, and many had a declared agenda to make the boys see themselves as victims. They wrote “victim impact statements” for the courts, in which they interpreted the boys’ refusal to talk with them about the sex as a traumatic reaction to the sex itself. Finally, the CBC series documented how the police, operating under the premise that the boys were victims and were being “ruined” by the sex, used threats, bribes, deception, and harassment to coerce them into providing state’s evidence. Teens interviewed for the series recounted how the police pressured them to claim in court that they felt victimized when in fact they did not. The CBC series was critical of the actions taken by the three London institutions just discussed, pointing out examples of harm imposed on the individuals brought “into a system of interrogation and confession and squealing, a system of punishment and therapy, humiliation and incarceration” (IDEAS, 1995, p. 61). The series presented an interview with a gay spokesman, who argued that “it was the whole criminal proceedings that caused them to feel victimized or caused damage to their lives, not the sex trade” (IDEAS, 1995, p. 57). Another London commentator opined that the police and social workers should stop treating these teens as if they were “damaged heterosexuals”; the president of a Detroit group organized to protect homosexuals against violence and discrimination added that “they’re damaged now because of heterosexuals, in this case the police” (IDEAS,

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1995, p. 53). The producer of the series summed up the procrustean influence of the incest model when applied to teenage males involved in willing relations with unrelated adults: . . . the modern and useful feminist analysis of the reasons young women suffer in horrible incest cases—that analysis has been inappropriately used in an attempt to understand an entirely different set of circumstances. A blurring of motives and psychological effects has taken place, which has created a powerful and misleading narrative that produces neither justice nor happiness. (IDEAS, 1999)

CONCLUDING REMARKS Findings in the current study are limited in a number of ways. The sample of gay and bisexual males was mostly middle-class, college-educated, and White. Generalizations to other populations cannot be safely made without further investigation. The ADSRs all involved adolescents rather than preadolescents; inferences to how preadolescents respond to such relationships cannot be safely made without further study. The ADSRs were predominantly of a willing nature; inferences to unwanted relations are thus unwarranted. The control group in the second sample likely consisted of some subjects who experienced ADSRs, rendering inferences about self-esteem and positive sexual identity tentative in that sample. Consistency with the findings in the first sample, however, suggests its value in assessing adjustment. Finally, the mostly positive nature of these ADSRs cannot be assumed to extend to those of heterosexual adolescent boys with men, where reactions are more mixed, tending to be negative to neutral for unexpected or casual encounters and neutral to positive for encounters occurring within the context of a friendship (see Bauserman and Rind, 1997, for a review). These caveats aside, the current findings are consistent with those of other nonclinical research in demonstrating that adolescent boys’ willing sexual experiences with older persons are very poorly described by victimological models (i.e., rape and incest) that evolved in the early 1970s to describe women’s and girls’ unwanted sexual experiences. Alternative models should be sought that incorporate the consistent finding that adolescent boys generally react neutrally or positively to ADSRs that are willingly engaged in and involve adults of the gender consistent with the adolescent’s sexual orientation. APPENDIX Narratives of 26 Cases of Sexual Relations Between Gay/Bisexual Adolescent Boys and Men Case 1 (boy = 12, man = 22). It lasted 9 months with his science teacher. “It developed over time and was great. We became friends and I invited him over

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once when my parents weren’t home. I practically had to force sex on him because he was afraid about losing his job. Ended when I went away for the summer and he wasn’t a teacher at my school no more” (p. 163). Case 2 (boy = 12, man = 35). The man was a family friend; the sex was mutually initiated, oral, off and on for 10 years (a couple of times per month), and “physically great.” It confused the subject that the man was married, yet was willing to have sex with him. “Eventually I fell in love with him; knew I was gay but did not broadcast this; I was curious because of the age difference. Mutual oral sex happened after he fondled me; it was the first orgasm I ever had.” Case 3 (boy = 13, man = 22). Subject and adult brother often massaged each other. “This time, however, I got a little hard and then he noted I had grown so much since he last saw me naked. He asked me jokingly if he could suck my dick. I said ‘yes’ so we got off on each other. He did me and then I did him. He came all over me but I did not. This lasted a month until he headed back to work. I do miss him as a friend and a brother. Was nothing romantic.” Subject added, “I liked it, felt good. I wanted to do it again and again. I already knew my brother was gay and that I was attracted to men so this did not prove or disprove that I was gay” (p. 77). Case 4 (boy = 13, man = 32). Met a stranger at a shopping mall, who “asked me for a light. I said I had to go to the bathroom. He followed me into the bathroom. He came and I think I did. He initiated the fondling in the stall but it was honestly mutually wanted. I was curious but a little nervous that someone would walk in. He asked me to come back to his place but I was afraid something would happen to me, like kidnap me. I was pleased, glad, and scared. I wanted to do more. I wanted a man in my life who was accepting, there, and caring. I told no one and I didn’t want to. Society said ‘bad’ so I didn’t talk about it. I wanted it to repeat so I returned to the mall, but I never saw him again” (p. 77). “Scared” was in the context of the excitement of the sex—he wanted to do lots more except he did not know what to do or how to inititate it. Case 5 (boy = 13, man = 38). “Family friend. I initiated on a camping trip; we were in same tent at state park; oral sex to orgasm for both of us; several times during the night; incredibly erotic, tremendous release, very pleasurable. Not real close; didn’t enjoy kissing. Afterwards scary because I enjoyed it so much. Not wanting to be near him on the trip because afraid others would notice. Once per month for the next 4 years that I initiated; never talked about it; sex was all it was. Wished I was straight so the attractions would go away, because the sexual gratification was so strong.” Case 6 (boy = 14, man = 20). The man was a boy scout leader so they knew each other for some time. The man initiated it by asking if he could have sex with the subject after a sex conversation at the man’s house. Mutual masturbation to orgasm for both ensued (one contact only). Subject said: it had no real meaning; he never thought about it much; it felt good afterwards; it was a one-time opportunity and he took advantage of it.

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Case 7 (boy = 14, man = 26). “It was with a stranger; he initiated it; it involved oral and mutual masturbation, we did it 10 more times. I was excited, was loved and in love, got affection, but was not prepared for sex. It was not so much that I wanted his affection; I was attracted to him. This relationship lasted a week then three months later we met again and we were sexual.” Case 8 (boy = 14, man = 26). “It lasted about a month. This friend was a friend of this guy, and he intoduced us. This guy invited me to a party the next night and I went. That night we slept together. I was thoroughly infatuated with him. It was my third experience and it never did get beyond the infatuation stage. I finally woke up and realized this wasn’t what I wanted. He kept on visiting me and hanging around and sort of helping me with my physics. He left to go back to the West Coast when I told him it wouldn’t work out” (p. 176). Case 9 (boy = 15, man = 22). The man was a stranger and initiated the sex (oral and anal). It happened only once. Subject said he was scared, excited, and wanted to explore the sex, but felt threatened. He said afterwards he felt violated and cried; it was very negative. Case 10 (boy = 15, man = 27). “[It was with] the mailman, honest to God! On and off for two years. The first time was when I came to the door to get a special delivery package in my sheer designer underwear, from American Male. I was changing to go back to school. He sprouted a boner, I got hard, he grabbed mine, I grabbed his, and we were off and running. Every day I’d come home for lunch; my mother worked. I had to be quick so he’d not get docked for late deliveries. He had a real thing for redheads like me. He was very forward, connected with me, and told me how hot I was. Talked about our backgrounds. It ended when he suddenly got transferred and contact became difficult. We visited each other and had sex, but it was hard and we agreed mutually because of the distance that it was better that we be friends and not lovers” (p. 172). Case 11 (boy = 15, man = 45). With a stranger (only once); mutually initiated oral sex. Subject said he later felt cheap because it was a stranger. “I met him at a gay theater. I came out thinking, finally I did it! I guess this is what is supposed to happen. I was nervous but I had a fake ID to get in. Looking back it made me feel really cheap. I didn’t like it because of the circumstances. Not dirty but it made it difficult to accept the whole gay thing until I fell in love in college” (p. 83). Case 12 (boy = 16, man = 21). Met at a science fiction club; became friends. “He was like an older brother to me; he came out to me as bisexual; said he loved me and asked how I felt; no problem for me; not repelled so I asked lots of questions. First time we were together we were not intimate but he just touched my chest. I went over to his house a lot and eventually he gave me a massage; later became sexual; he was active with masturbation and oral sex; very pleasurable but I tried to make myself not ejaculate because I knew society said it was wrong. Happened seven more times. I decided I needed to be heterosexual so we stopped seeing each other. He was afraid that maybe he was just using me for sex and he wanted me to be emotionally with him; overall it was a very enjoyable experience but I knew I

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couldn’t tell anyone about it. Only later in college when I came into contact with gay culture did I see I could label myself as gay.” Case 13 (boy = 16, man = 21). With a stranger, who initiated it (mutual masturbation, only once). “Met him at a book store and he cruised me; we were talking and went to the restroom; we masturbated each other for 15 minutes; it was pleasurable at the time. I had no emotional reaction, no guilt. I wanted to leave the restroom. I knew I was gay before so it had no effect.” Case 14 (boy = 16, man = 23). With a neighbor. “. . . he felt like my mentor, like my chaperon, that he was going to lead me out of my state of wilderness . . . We went for a walk and we were smoking cigarettes. He asked if I had a girlfriend and I said, ‘No,’ and then he asked if I had a boyfriend and I said, ‘No.’ Later, at his house, he started kissing me and suddenly everything clicked—this is homosexuality! He declared himself, that is, he had tagged himself. I pushed him away but I wanted to do it. I left . . . and then I just cried. He apologized two days later and then he began crying and we did it in a very loving, emotional way. Now we’re the best of friends after this put some distance between us. During the process I kept saying, ‘Is this what it is? Is this what it is? Do I like it? Do I like it?’ And the answers were, ‘Yes! Yes! Yes! Yes!’ It did confirm my sexual identity because I enjoyed it so much” (pp. 88, 89). Case 15 (boy = 16, man = 25). “I went to gay pride in Boston and on the subway I was cruising two guys and they gave me their address. When in town next I called them and we fooled around; best sex I’ve ever had; caring, warm; saw them again several months later and they introduced me to a guy my age and we dated and went to the senior prom.” Case 16 (boy = 16, man = 28). With a stranger; met at a shopping mall. The man initiated it (oral sex, only once). Subject said it was awful; unclean because it was anonymous sex. It was a very bad experience, but with no apparent “scarring for life.” Subject said he was later able to put it in perspective, but wished he had “saved” himself. The sex was not dirty, but it made it more difficult to accept the whole gay thing. Case 17 (boy = 16, man = 35). With a married neighbor, who initiated mutual masturbation. It lasted two more years off and on. “It fulfilled my fantasies. First time was in his house; I was nervous because of my body—not that anything was wrong with my body but just felt uncomfortable having someone see my body. We had always been ‘touchy’ and kept going further and further with no resistance on my part. I’m just as much ‘at fault’ because I did nothing to stop it. Rebellion was my motivation since he was my dad’s best friend. We both came. I already knew I was gay; had fantasized this interaction many times. There was no change in my feelings toward him; we’re still friends.” Case 18 (boy = 16, man = 46). “I answered a personal ad. He wanted youth and I wanted age! I’m ‘slender, fun-loving, and cute’; he was ‘bearded, masculine, and worked out.’ We were together for ten months until I finally came to Penn State. I never lived with him. I’d go there to Pittsburgh maybe once a week or

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once every two weeks. He was very conservative and didn’t want to take me out publicly. He hates outward displays of affection and he didn’t want people to think he was my father. He sends me holiday and birthday cards. I think of him as my uncle. It was good for the time” (p. 164). Case 19 (boy = 17, man = 22). “Met him at a porno theater, where I went for sex. He sat next to me and rubbed his leg against mine. We went to the cemetery and had oral and anal sex with both having orgasm. I felt unclean, guilty, doomed, hopeless. It brought me down; it was just sex and I didn’t like myself in this contact; I was not attracted to him.” Case 20 (boy = 17, man = 22). “I met him through friends at the lake. We obviously liked each other and we went to his place where we fooled around. We spent a lot of time together. We had similar interests in music, movies, and clothes. It ended, however, when I had to go overseas, so it lasted just the summer. We’re still friends and we do correspond. When I came back, things just didn’t pick up where they were. There were a couple of weeks in which we were extremely sexual before I had to leave” (p. 174). Case 21 (boy = 17, man = 23). “We were dating; he initiated the sex; it went on for 18 months. I was underage at the time and this posed a problem in my eyes. We had been dating for a while and the first time was in his apartment and we did everything, oral and anal—the anal later on. We were in love and it was a very affectionate relationship and only ended when I went away to college. We grew apart.” Case 22 (boy = 17, man = 24). “He was a complete stranger. I was on vacation and our eyes met. He followed me and I knew. We talked for an hour and later got together for drinks. We were not drunk; did everything—oral, anal; it was mutually initiated. I felt guilty for using this person for my pleasure. I felt confused because this was a new facet of my identity. We had sex two more times and then I ignored him. I felt proud I could get someone; this just allowed me to do homosexuality. I knew I was gay because of thoughts and fantasies.” Case 23 (boy = 17, man = 32). Met at a floral shop; a month later the man asked him out on a date. On the date, the subject initiated sex at the man’s house; it involved touching and body contact. Subject said it felt good and he was mentally involved, but did not have an orgasm. Subject said then the man fucked him; it was an intense feeling with an orgasm. They fell in love and dated for 2 years. Case 24 (boy = 17, man = 32). “Just before I signed up for military, I went to a gay bar and met an older man there. No one ever suspected us because he was a drag queen so they thought we were a hetero couple. We went together for three weeks before I went into the military. It was great sex, but I wasn’t in love with him. It was mostly oral sex.” Case 25 (boy = 17, man = 35). With a married neighbor. “. . . we made eye contact during lunch one day. He was very nice looking and it was very obvious that he was attracted to me. He initiated all of the contact. I was very nervous and yet very excited. We had lunch a couple of times and then he invited me over to

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his penthouse after work one day. I definitely wanted to go; I went on my own free will. It was a very positive experience. He was the right person for me for the first time. I knew I liked him and I knew that I wanted to do something, but I didn’t know what to do. So I let him take the lead. The first time there was no anal intercourse but we had full sex. I was also nervous because I was late for home after school. I already knew that I was gay long before this. We had several more experiences” (p. 82). Case 26 (boy = 17, man = 40). “I was on family vacation and went looking for sex on the ‘fire island’ of Europe where there was a nudist beach. I met three men—one 40ish and a couple in their late 20s. We did everything, oral, anal—and not gentle (my first time) so I felt a little used. We met again the next time at the beach and again had extensive sex. I wanted to stay but my family was leaving. I liked it and was always looking for action and getting away from the family.” Note. Quotes for cases 1, 3, 4, 8, 10, 11, 14, 18, 20, and 25 were taken from Savin-Williams’ (Savin-Williams, 1997) book—page numbers are provided. Other quotes and descriptions were obtained directly from Savin-Williams. Ages of subjects and older partners when the sexual relations began are provided after the case numbers. A few subjects had additional sexual contacts with other men (Case 1 at age 14, then 15; Case 4 at age 17; Case 9, three more at age 16; Case 21, two more at age 17). Details were not recorded for these episodes. REFERENCES Bartholow, B. N., Doll, L. S., Joy, D., Bolan, G., Harrison, J. S., Moss, P. M., and McKirnan, D. (1994). Emotional, behavioral, and HIV risks associated with sexual abuse among adult homosexual and bisexual men. Child Abuse Negl. 18: 747–761. Bauserman, R., and Rind, B. (1997). Psychological correlates of male child and adolescent sexual experiences with adults: A review of the nonclinical literature. Arch. Sex. Behav. 26: 105–142. Bell, A. P., Weinberg, M. S., and Hammersmith, S. K. (1981). Sexual Preference: Its Development in Men and Women, Indiana University Press, Bloomington, IN. Condy, S., Templer, D., Brown, R., and Veaco, L. (1987). Parameters of sexual contact of boys with women. Arch. Sex. Behav. 16: 379–394. Dimock, P. T. (1988). Adult males sexually abused as children. J. Interper. Violence 3: 203–221. Doll, L. S., Joy, D., Bartholow, B. N., Harrison, J. S., Bolan, G., Douglas, J. M., Salzman, L. E., Moss, P. M., and Delgado, W. (1992). Self-reported childhood and adolescent sexual abuse among adult homosexual and bisexual men. Child Abuse Negl. 16: 855–864. Fellows, W. (1996). Farm Boys: Lives of Gay Men From the Rural Midwest, University of Wisconson Press, Madison, WI. Finkelhor, D. (1984). Child Sexual Abuse: New Theory and Research, Free Press, New York. Fromuth, M., and Burkhart, B. (1987). Childhood sexual victimization among college men: Definitional and methodological issues. Violence Vict. 2: 241–253. Gardner, R. (1993, February 22). Modern witch hunt—Child abuse charges. The Wall Street Journal. Giovanni’s Room press release (1999, March 24). Access to information about pedophilia and the outrages of child abuse. Hart, J. (1995). My First Time: Gay Men Describe Their First Same-Sex Experience, Alyson, Boston. Hershberger, S. L., and D’Augelli, A. R. (1995). The impact of victimization on the mental health and suicidality of lesbian, gay, and bisexual youths. Dev. Psychol. 31: 65–74.

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IDEAS (1994). The trials of London, Parts 1 and 2. First broadcast October 7 and 14, 1994 on the CBC. (Transcript available at http://www.radio.cbc.ca/programs/ideas) IDEAS (1995). The trials of London, Parts 3 and 4. First broadcast May 11 and 12, 1995 on the CBC. (Transcript available at http://www.radio.cbc.ca/programs/ideas) IDEAS (1999). Victims of justice, Parts 1 and 2. First broadcast May 13 and 14, 1999 on the CBC. (Audio file available at http://www.radio.cbc.ca/programs/ideas) Jay, K., and Young, A. (1977). The Gay Report, Simon and Schuster, New York. Jenkins, P. (1998). Moral Panic: Changing Concepts of the Child Molester in Modern America, Yale University Press, New Haven, CT. Johnson, R. L., and Shrier, D. K. (1985). Sexual victimization of boys: Experience at an adolescent medicine clinic. J. Adolesc. Health Care 6: 372–376. Kessler, R. C., and Wethington, E. (1991). The reliability of life event reports in a community survey. Psychol. Med. 21: 723–738. Masters, W., Johnson, V., and Kolodny, R. (1985). Human Sexuality, 2nd edn., Little, Brown and Company, Boston. Mendel, M. P. (1995). The Male Survivor, Sage, Thousand Oaks, CA. Myers, M. F. (1989). Men sexually assaulted as adults and sexually abused as boys. Arch. Sex. Behav. 18: 203–215. Nickels, T., and Hocker, S. (1999, June 22–28). Transgenerational sex: Framing the question. Youth respond. Au Courant 3: 10, 12, 16, 17. Okami, P. (1990). Sociopolitical biases in the contemporary scientific literature on adult human sexual behavior with children and adolescents. In Feierman, J. R. (ed.), Pedophilia: Biosocial Dimensions, Springer-Verlag, New York, pp. 91–121. Rind, B. (1998). Biased use of cross-cultural and historical perspectives on male homosexuality in human sexuality textbooks. J. Sex Res. 35: 397–407. Rind, B., and Tromovitch, P. (1997). A meta-analytic review of findings from national samples on psychological correlates of child sexual abuse. J. Sex Res. 34: 237–255. Rind, B., Tromovitch, P., and Bauserman, R. (1998). A meta-analytic examination of assumed properties of child sexual abuse using college samples. Psychol. Bull. 124: 22–53. Rind, B., Tromovitch, P., and Bauserman, R. (2000). Condemnation of a scientific article: A chronology and refutation of the attacks and a discussion of threats to the integrity of science. Sex Culture 4: 1–62. Rosenberg, M. (1965). Society and the Adolescent Self-Image, Princeton University Press, Princeton, NJ. Rosenthal, R. (1984). Meta-Analytic Procedures for Social Research, Sage, London. Ross, M. (1984). Relation of implicit theories to the construction of personal histories. Psychol. Rev. 96: 341–357. Sandfort, T. (1983). Pedophile relationships in the Netherlands: Alternative lifestyle for children? Altern. Lifestyles 5: 164–183. Savin-Williams, R. C. (1997). “. . . And Then I Became Gay:” Young Men’s Stories, Routledge, New York. Spada, J. (1979). The Spada Report, Signet, New York. Summit, R. (1983). The child sexual abuse accommodation syndrome. Child Abuse Negl. 7: 177–193. Urquiza, A. J., and Capra, M. (1990). The impact of sexual abuse: Initial and long-term effects. In Hunter, M. (ed.), The Sexually Abused Male: Prevalence, Impact, and Treatment, Vol. 1, Lexington Books, Lexington, MA, pp. 105–135. West, D. J. (1998). Boys and sexual abuse: An English opinion. Arch. Sex. Behav. 27: 539–559. West, D., and Woodhouse, T. (1993). Sexual encounters between boys and adults. In Li, C., West, D., and Woodhouse, T. (eds.), Children’s Sexual Encounters With Adults, Prometheus, New York, pp. 3–137. Williams, W. L. (1996). Two-spirit persons: Gender nonconformity among Native American and Native Hawaiian youths. In Savin-Williams, R. C., and Cohen, K. M. (eds.), The Lives of Lesbians, Gays, and Bisexuals, Harcourt Brace College, New York, pp. 416–435. Woods, S. C., and Dean, K. S. (1984). Sexual Abuse of Males Research Project, Child and Family Services of Knox County, Inc., Knoxville, TN. www.narth.com. Web site for the National Association for Research and Therapy of Homosexuality.

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Sexual Dysfunction: A Neglected Complication of Panic Disorder and Social Phobia Ivan Figueira, MD,1,4 Elizabete Possidente, MD,2 Carla Marques, MD,2 and Kelly Hayes, MA3

Little is known about sexual dysfunctions comorbid with anxiety disorder. The aim of this study is to evaluate retrospectively the sexual function of social phobic patients in comparison with a panic disorder sample. Using a semistructured interview (SCID-I), 30 patients with social phobia and 28 patients with panic disorder were examined. The DSM-IV criteria were employed to diagnose sexual dysfunctions in this sample; however, the “C” criterion, which states that “the sexual dysfunction cannot be related to other Axis I disorders,” was excluded. Panic disorder patients reported a significantly greater proportion of sexual disorders compared with social phobics: 75% (21/28) vs. 33.3% (10/30) (p = .0034). Sexual aversion disorder was the most common sexual dysfunction in both male (35.7%; 5/14) and female (50%; 7/14) panic disorder patients, and premature ejaculation was the most common sexual dysfunction in male social phobic patients: 47.4% (9/19). These results suggest that sexual dysfunctions are frequent and neglected complications of social phobia and panic disorder. KEY WORDS: sexual dysfunctions; phobic disorders; panic disorder; anxiety disorders.

INTRODUCTION Clinicians and researchers, employing both psychoanalytical and behavioral perspectives, have long noted the relationship between sexual dysfunction and anxiety (Cooper, 1969; Rachman, 1961; Stekel, 1927; Wolpe, 1958) . The majority of 1 Anxiety

and Depression Program, Federal University of Rio de Janeiro. and Depression Program, Federal University of Rio de Janeiro. 3 University of Chicago, History of Religions Program, Divinity School, University of Chicago, Chicago, Illinois. 4 To whom correspondence should be addressed at Rua Dona Mariana 182, Block 1 Apartment 1503, Botafogo, Rio de Janeiro. RJ., Brazil, 22280-020. 2 Anxiety

369 C 2001 Plenum Publishing Corporation 0004-0002/01/0800-0369$19.50/0 °

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these authors worked with patients who had sought treatment for sexual problems (Kaplan, 1988). Trying to discern the etiology of their patients’ sexual problems, these authors focused on anxiety as one of the major components in these multiply determined problems. But, because of the nature of their patient population, the data they obtained about the relationship between sexual dysfunction and anxiety were based on sexual dysfunction samples. More recently, psychiatrists have approached this relationship from a different angle. Because of the increased use of selective serotonin reuptake inhibitors (SSRIs), some psychiatrists have begun to study sexual problems in anxiety disorder samples (Kindler et al., 1997). Because of the discovery of sexual dysfunction as an important side effect of these medications, psychiatrists are increasingly aware of the relevance of obtaining data about the sexual dysfunctions and the sexual history of their patients before beginning treatment (Labbate et al., 1998; Waldinger and Olivier, 1998). Currently, the SSRIs are considered the medication of choice in the treatment of panic disorder and social phobia (Gorman and Kent, 1999); however, given their great impact upon sexuality, there have been few studies of the occurrence of sexual dysfunction among panic disorder and social phobic patients (Kaplan et al., 1982; Sbrocco et al., 1997). To begin to fill this gap, we conducted a retrospective study of sexual dysfunction and sexual history in patients with social phobia and compared them with a panic disorder sample. METHODS We retrospectively evaluated the sexual function and the sexual history of 30 patients with social phobia and 28 patients with panic disorder. We used the DSM-IV criteria to identify the different sexual dysfunctions (American Psychiatric Association, 1994); the sexual history was obtained through a semistructured anamnesis developed for this study. In terms of sexual history, we asked about the following variables: (1) virginal status; (2) patient’s age at first sexual relationship; (3) with whom they first had sexual intercourse (prostitute, boyfriend /girlfriend, or other); (4) frequency of sexual intercourse; (5) masturbatory practices; (6) presence of current sexual partner, (7) sexual orientation (homosexual or heterosexual); and (8) occurrence of panic attack during sexual intercourse. We used a semistructured interview (SCID- I) (First et al., 1995) to obtain the diagnoses of social phobia and panic disorder according to the DSM-IV; however, we excluded the “C” criterion which states that “the sexual dysfunction cannot be related to other Axis I disorders.” We did this because we judged that this criterion prevents awareness of the impact of anxiety disorders upon sexuality. After obtaining informed consent, we evaluated the patients retrospectively, asking questions about their sexual life at the time when they first entered the Anxiety and Depression Program of the Federal University of Rio de Janeiro. This group of

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patients had been under psychopharmacological treatment (for social phobia and panic disorder) in the Program for a median time of 2.4 years. None of these patients were taking psychopharmacological medication at the time they first entered the Program. The following exclusion criteria were adopted: (1) presence of comorbid depressive disorder, psychotic disorder, borderline or antisocial personality disorder; (2) concomitant medical conditions that could affect sexual functioning; and (3) sexual dysfunctions induced by clinical medications. Based on the above exclusion criteria, 20 patients were eliminated of the 78 who were initially interviewed: 8 patients with depressive disorder, 2 with psychotic disorder, and 10 with sexual disorders probably induced by clinical medications. To ensure uniformity, one interviewer was employed to conduct all 78 interviews. The categorical variables were analyzed with the χ 2 -square test with Yates correction or Fishers’ Exact Text. The continuous variables were analyzed with the t test of Student. The significance level was at p < .05. RESULTS Age (mean ± SD) was similar in social phobia (36.46 ± 11.38 years) and panic disorder (34.39 ± 7.39 years) patients (t = 0.8282; p = .4115; NS) (unpaired t test with Welch correction). There was also no significant difference in the proportion of male patients with social phobia compared with panic disorder: 63.3% (19/30) versus 50% (14/28) (χ 2 = 0.3752; p = .37521 with Yates correction). However, there was a statistically significant difference in terms of marital status: most of the social phobic patients were single compared with the panic disorder patients: 63.3% versus 17.9% (χ 2 = 12.61; df = 2; p = .0018). Comparing both disorders divided by gender, only the males differed in terms of marital status: male social phobics had a significantly higher percentage of singles compared with male panic disorder patients: 63.1% (12/19) versus 0% (0/13) ( p = .0004; Fishers’ Exact Test); there was no difference in the percentage of singles among women: 70% (7/10) versus 35.7% (5/14) ( p = .2141) (χ 2 = 1.54; p = .2141 with Yates correction) Comparing both groups, we found that panic disorder patients reported a significantly greater proportion of sexual disorders than social phobics did: 75.0% (21/28) vs. 33.3% (10/30) (χ 2 = 8.5; p = .0034 with Yates correction). In terms of the frequency of specific sexual dysfunctions, two main results were found, (Tables I and II): (1) sexual aversion disorder was the most common sexual dysfunction in both male (35.7%; 5/14) and female (50.0%; 7/14) panic disorder patients; and (2) premature ejaculation was the most common sexual dysfunction in male social phobic patients: 47.4% (9/19). Comparing the frequency of different sexual disorders in panic disorder and social phobic patients, based on gender, we observed that (1) sexual aversion

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Table I. Frequency of Sexual Dysfunction in Male Patients—Social Phobia vs. Panic Disorder Social phobia

Panic disorder

Sexual dysfunction

%

(N )

%

(N )

p

Hypoactive sexual desire disorder Sexual aversion disorder Male erectile disorder Male orgasmic disorder Premature ejaculation

0.0 0.0 0.0 5.3 47.4

(0/19) (0/19) (0/19) (1/19) (9/19)

14.3 35.7 7.1 0.0 21.4

(2/14) (5/14) (1/14) (0/14) (3/14)

NSa .0084 NS NS NS

a NS

= statistically nonsignificant.

disorder was the only sexual dysfunction that presented a statistically significant difference in both male ( p = .0084) and female groups ( p = .0078), being higher in panic disorder patients; and (2) among males, premature ejaculation occurred with somewhat greater frequency in social phobic patients (47.4%) compared with panic disorder patients (21.4%); however, this did not reach statistical significance. Comparing the sexual history of male social phobic patients with that of male panic disorder patients (Table III), we found a significant difference in the following variables (social phobia vs. panic disorder): (1) higher age of first sexual intercourse (17.2 vs. 16.5 years); (2) higher percentage of those engaging in masturbation (80% vs. 10.7%); (3) lack of current sexual partner (31.6% vs. 0.0%); and (4) while social phobics frequently had had prostitutes as their first sexual partners (57.9% vs. 14.3%), the majority of panic disorder patients initiated their sexual life with girlfriends (26.3% vs. 85.7%). In terms of sexual history (Table IV), female social phobic patients differed from female panic disorder patients in the following variables (social phobia vs. panic disorder): (1) lower percentage of those with boyfriends as their first sexual partner (36.4% vs. 92.8%); and (2) higher percentage engaging in masturbation (81.8% vs. 7.1%).

Table II. Frequency of Sexual Dysfunction in Female Patients—Social Phobia vs. Panic Disorder Social phobia

Panic disorder

Sexual dysfunction

%

(N )

%

(N )

p

Hypoactive sexual desire disorder Sexual aversion disorder Female sexual arousal disorder Female orgasmic disorder Dyspareunia Vaginismus

0.0 0.0 0.0 18.2 0.0 0.0

(0/11) (0/11) (0/11) (2/11) (0/11) (0/11)

21.4 50.0 0.0 7.1 7.1 0.0

(3/14) (7/14) (0/14) (1/14) (1/14) (0/14)

NSa .0078 NS NS NS NS

a NS


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Table III. Sexual History in Male Social Phobic and Panic Disorder Patients Social phobia

Panic disorder

%

(N )

%

(N )

p

57.9 26.3 47.4

(11/19) (5/19) (9/19)

14.3 85.7 21.4

(2/14) (12/14) (3/14)

.0297 .0025 NSa

78.9 31.6 10.5 5.3 0.0

(15/19) (6/19) (2/19) (1/19) (0/19)

14.3 0.0 0.0 0.0 35.7

(2/14) (0/14) (0/14) (0/14) (5/14)

.0009 .0272 NS NS .0084

Sexual history Prostitute as first sexual partner Girlfriend as first sexual partner Frequency of sexual intercourse less than 2 times/month Masturbation Lack of current sexual partner Homosexual orientation Virgin Occurrence of panic attack during sexual intercourse

(years ± SD) 17.2 ± 2.2

Age at first sexual intercourse a NS

(years ± SD) 16.5 ± 2.7

.0351


DISCUSSION Sexual aversion disorder was the most common sexual dysfunction in panic disorder patients (42.9%; 12/28), while premature ejaculation was the most frequent sexual disorder in male social phobic patients (47.9%; 9/19). The high frequency of sexual aversion disorder in both male (35.7%; 5/14) and female (50.0%; 7/14) panic disorder patients was much greater than the prevalence of this sexual disorder in the general population, which has been estimated to be lower than 2% (Kaplan, 1987). The work of Kaplan (1987) supports our findings of an association between sexual aversion disorder and panic disorder. Table IV. Sexual History in Female Social Phobic and Panic Disorder Patients

Sexual history Prostitute as first sexual partner Boyfriend as first sexual partner Frequency of sexual intercourse less than 2 times/month Masturbation Lack of current sexual partner Homosexual orientation Virgin Occurrence of panic attack during sexual intercourse Age at first sexual intercourse a NS


Social phobia

Panic disorder

%

(N )

%

(N )

p

0.0 36.4 72.7

(0/11) (4/11) (8/11)

0.0 92.8 71.4

(0/14) (13/14) (10/14)

NSa .0072 NS

81.8 45.5 0.0 27.3 0.0

(9/11) (5/11) (0/11) (3/11) (0/11)

7.1 78.6 0.0 7.1 0.0

(1/14) (11/14) (0/14) (1/14) (0/14)

.0002 NS NS NS NS

(years ± SD) 19.5 ± 4.0

(years ± SD) 18.5 ± 2.1

NS

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They reported a high prevalence of symptoms of panic disorder spectrum (63%) in patients who had not responded to traditional behavioral–cognitive treatments for sexual dysfunction. In all these cases, panic disorder preceded sexual aversion disorder in terms of temporal sequence. In our series as well, sexual aversion was secondary to panic disorder. While our patients, similar to Kaplan’s, said that they avoided sexual intercourse because they feared having a panic attack, only five reported that they indeed had suffered a panic attack during intercourse. Taken together, these facts suggest that sexual aversion may be part of the agoraphobic spectrum; that is, because of fear of panic attack patients become aversively conditioned to avoiding sexual intercourse. Kaplan et al. (1982) tested their hypothesis that sexual aversion was a consequence of the patient’s fear of panic attack by treating these patients with medications appropriate for panic disorder, and found positive results in both conditions. Considering Kaplan’s findings, the question arises: why has sexual aversion disorder not been recognized as a complication of panic disorder? One possible explanation is that sexual aversion disorder entered the official diagnostic system only in 1987 (DSM-III-R), being the last sexual disorder to be included in the American taxonomy (Vroege et al., 1998). Because of the recent nature of this diagnosis and the scarcity of studies, Kaplan (1987) called sexual aversion disorder “[a] Neglected Sexual Disorder.” Another finding of our study was the high prevalence of premature ejaculation in male social phobic patients: 47.4%. While community studies (Laumann et al., 1999) show that premature ejaculation is found in 21% of males, and clinical studies (Read et al., 1997) estimate prevalence at circa 30%, our rate is higher. But we could not compare our clinical sample data because, to the best of our knowledge, there are no other studies on the prevalence of premature ejaculation in social phobic patients. We speculate that the absence of data on sexual dysfunction and social phobia could be caused in part by the great uneasiness provoked by sexual issues in patients with social anxiety (and their doctors), hence the difficulty in obtaining data on these problems. However, other studies have shown an association between performance anxiety and premature ejaculation. Indeed, Redmond et al. (1983), reviewing the literature on the topic, cited Sterba’s report of spontaneous ejaculation occurring in two boys during school examinations (Sterba, 1942). The reviewers observed that “[a]nxiety and fear related specifically to sexual performance might lead to premature spontaneous ejaculation as part of a more general pattern of sexual arousal accompanied by severe anxiety” (p. 1165). More research is needed to determine if premature ejaculation is more associated with social anxiety than with other forms of anxiety such as panic attacks. Our sexual history data support the idea that social phobia has a greater negative impact than does panic disorder on quality of life issues such as the ability to engage in love or sexual relationships. We found that male social phobics,

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as compared with male panic disorder patients, reported a significantly higher rate of the following variables: (1) prostitutes as their first sexual partners; (2) lack of current sexual partner; and (3) percentage of single patients versus married patients. Females differed statistically in only one variable: female social phobics had a lower percentage of boyfriends as their first sexual partners than female panic disorder patients had. However, we think that in larger samples, the greater negative impact of social phobia probably will also be detected in female patients. Other studies have confirmed our results. For instance, the negative impact of social anxiety upon sexuality was demonstrated in a survey conducted by Leary and Dobbins (1983) in a US sample of 260 college students. They found that those students with higher scores in heterosexual anxiety differed from those with lower scores by having had fewer previous sexual partners, lower frequency of sexual intercourse, higher incidences of sexual difficulties, less probability of engaging in oral sex, greater unhappiness in their sexual encounters, and, particularly for females, problems in being assertive and asking their partner to use a condom. Leary and Dobbins (1983) observed that social anxiety is accompanied by disaffiliative reaction—“[b]ehaviors that function to reduce the amount of social contact the anxious individual has with others” (p. 1348). This disaffiliative behavior diminishes the opportunities of socially anxious individuals to meet and get to know others. According to Leary and Dobbins, this results “[i]n a smaller pool of potential dating, romantic and sexual partners. Because they date less frequently, socially anxious individuals may become involved in fewer relationships that include a sexual dimension and, thus, may be less sexually experienced than others of their age” (p. 1348). Our sexual history data also suggest that the aversive impact of panic attack upon sexuality may be linked to two other sexual history variables: (1) frequency of panic attacks during sexual intercourse; and (2) frequency of masturbation. We think that it is not a coincidence that a statistically greater number of patients with panic disorder reported having a panic attack during sexual intercourse. All of the five panic disorder patients who reported panic attacks during sexual intercourse also reported a sexual dysfunction: two with sexual aversion disorder, one with hypoactive sexual desire disorder, one with premature ejaculation, and one with male erectile dysfunction. However, we cannot explain the fact that all of these patients were male, a finding that may reflect the cultural conditioning of sexual expression. Because in most cultures men have a more active sexual role than women, we speculate that as a consequence, men may have a higher rate of autonomic activation which could be interpreted by them as a panic attack (and which, in fact, can trigger one). However, we have to be cautious in attributing a causal relationship between panic attack and sexual aversion disorder because this sexual disorder is produced by the interaction of multiple variables beyond biological ones (e.g., developmental neglect, abuse, religious beliefs, etc.).

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Two limitations of our study are the small sample and the retrospective design. Because of the retrospective design, some patients may not have accurately remembered the sexual problems and behaviors they suffered when they first entered our research program (2.4 years previously). Two instances illustrate the clinical implications of the comorbidity between anxiety disorders and sexual dysfunctions in terms of the development of a pharmacological treatment strategy: 1. Patients with comorbid premature ejaculation and anxiety disorder may benefit from medications with strong serotonergic agonism (e.g., SSRIs). Since SSRIs have a documented efficacy in the treatment of both social phobia (Liebowitz, 1999) and premature ejaculation (Balon, 1996), this class of medication could be used to treat the two disorders simultaneously. Further studies should be carried out to assess if there may be a subgroup of social phobics with coexistent premature ejaculation who would benefit more from using SSRIs than other pharmacological treatments (e.g., benzodiazepines, MAOIs) because of this double therapeutic action. 2. Patients with comorbid sexual aversion disorder and panic disorder may benefit from treatment with an antipanic agent, as the sexual dysfunction may be secondary to the panic attack. Such a pharmacological strategy may also facilitate the psychological treatment of sexual aversion disorder. REFERENCES American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders, American Psychiatric Association, Washington DC. Balon, R. (1996). Antidepressants in the treatment of premature ejaculation. J. Sex Marital Ther. 22: 85–96. Cooper, A. J. (1969). A clinical study of “coital anxiety” in male potency disorder. J. Psychosom. Res. 13: 143–147. First, M. B., Spitzer, R. L., Gibbon, M., and Williams, J. B. W. (1995). Structured Clinical Interview for DSM-IV Axis I Disorders—Patient Edition, New York State Psychiatric Institute, New York. Gorman, J. M., and Kent, J. M. (1999). SSRIs and SNRIs: Broad spectrum of efficacy beyond major depression. J. Clin. Psychiatry 60 (Suppl. 4): 33–38. Kaplan, H. S. (1987). Sexual Aversion, Sexual Phobias, and Panic Disorder, Brunner / Mazel, New York. Kaplan, H. S. (1988). Anxiety and sexual dysfunction. J. Clin. Psychiatry 49 (Suppl.): 21–25. Kaplan, H. S., Fyer, A. J., and Novick, A. (1982). The treatment of sexual phobias: The combined use of antipanic medication and sex therapy. J. Sex Marital Ther. 8: 3–28. Kindler, S., Dolberg, O. T., Cohen, H., Hirschmann, S., and Kotler, M. (1997). The treatment of comorbid premature ejaculation and panic disorder with fluoxetine. Clin. Neuropharmacol. 20: 466–471. Labbate, L. A., Grimes, J., Hines, A., Oleshansky, M. A., and Arana, G. W. (1998). Sexual dysfunction induced by serotonin reuptake antidepressants. J. Sex Marital Ther. 24: 3–12. Laumann, E. O., Paik, A., and Rosen, R. C. (1999). Sexual dysfunction in the United States: Prevalence and predictors. JAMA 281: 537–544. Leary, M. R., and Dobbins, S. E. (1983). Social anxiety, sexual behavior, and contraceptive use. J. Pers. Soc. Psychol. 45: 1347–1354. Liebowitz, M. R. (1999). Update on the diagnosis and treatment of social anxiety disorder. J. Clin. Psychiatry 60 (Suppl. 18): 22–26.

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Rachman, S. (1961). Sexual disorders and behavior therapy. Am. J. Psychiatry 118: 235. Read, S., King, M., and Watson, J. (1997). Sexual dysfunction in primary medical care: Prevalence, characteristics and detection by the general practitioner. J. Public Health Med. 4: 387–391. Redmond, D. E., Jr., Kosten, T. R., and Reiser, M. F. (1983). Spontaneous ejaculation associated with anxiety: Psychophysiological considerations. Am. J. Psychiatry 140: 1163–1166. Sbrocco, T., Weisberg, R. B., Barlow, D. H., and Carter, M. M. (1997). The conceptual relationship between panic disorder and male erectile dysfunction. J. Sex Marital Ther. 23: 212–220. Stekel, W. (1927). Impotence in the Male, Liveright, New York. Sterba, R. (1942). Introduction to the psychoanalytic theory of the libido. Nervous and Mental Disease Monograph Series 68: 56. Vroege, J. A., Gijs, L., and Hengeveld, M. W. (1998). Classification of sexual dysfunctions: Towards DSM-V and ICD-11. Compr. Psychiatry 39: 333–337. Waldinger, M. D., and Olivier, B. (1998). Selective serotonin reuptake inhibitor-induced sexual dysfunction: Clinical and research considerations. Int. Clin. Psychopharmacol 13 (Suppl. 6): S27–S33. Wolpe, J. (1958). Psychotherapy by Reciprocal Inhibition, Stanford University Press, Stanford.

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Comparison of Men’s and Women’s Attempts to Dissuade Sexual Partners From the Couple Using Condoms Renee M. Oncale, RN, BSN,1 and Bruce M. King, PhD2,3

Undergraduate students were asked about their use of condoms and their attempts to dissuade sexual partners from the couple using condoms during sexual intercourse. Nearly 14% of women and nearly 17% of men who had engaged in sexual intercourse admitted to having actively tried to dissuade a partner from the couple using condoms. Thirty percent of the men and 41% of the women said that a sexual partner had tried to dissuade them. Attempts to dissuade partners from the couple using condoms were most common among students who reported having 10 or more lifetime sexual partners. For both men and women, the most frequently employed categories of verbal strategies were (1) sex feels better without a condom, (2) will not get pregnant, and (3) will not get a sexually transmitted disease. These three categories accounted for about three-fourths of the lines used. Avoidance of condoms because of a perceived decrease in physical pleasure poses a particular problem for sex and health educators. KEY WORDS: condoms; birth control; safer sex.

INTRODUCTION In the early 1990s, the U.S. Public Health Service made an increase in the use of condoms a primary national health objective for the year 2000 (Public Health Service, 1991). Several recent national surveys have, in fact, found an increase in use of condoms by teenagers and young adults (Bankole et al., 1999; Centers for Disease Control and Prevention, 1998; Murphy and Boggess, 1998; Piccinino 1 Pendleton

Memorial Methodist Hospital, New Orleans, Louisiana 70127. of Psychology, University of New Orleans, New Orleans, Louisiana 70148. whom correspondence should be addressed at Department of Psychology, University of New Orleans, New Orleans, Louisiana 70148; e-mail: [email protected].

2 Department 3 To

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and Mosher, 1998; Sonenstein et al., 1998). Nevertheless, only a minority of men and women who engage in sexual intercourse uses condoms regularly (Bankole et al., 1999; Catania et al., 1995), and men with many lifetime sexual partners tend to use them less than men with fewer partners (Centers for Disease Control and Prevention, 1992). Other surveys have found that even among college students who are knowledgeable about the risks associated with having unprotected sexual intercourse, many do not practice safer-sex behaviors (e.g., DiClemente et al., 1990; Gray and Saracino, 1989; Ku et al., 1992). Several reasons have been found why some individuals do not use condoms consistently, including lack of availability when one is in the mood to have sex (Franzini and Sideman, 1994), embarrassment about buying condoms (Choi et al., 1994), use of alcohol and drugs (Ku et al., 1994), negative social meaning of condoms in desired close relationships (Afifi, 1999), and inexperience in interpersonal negotiations (Fisher and Fisher, 1992; Hillier et al., 1998; Lear, 1995; Polit-O’Hara and Kahn, 1985; Whitaker et al., 1999; Wight, 1992; Wingood and DiClemente, 1998). Among college students and adolescents, the ability to talk about a desire to use condoms has been found to be associated with a greater use of condoms (Catania et al., 1989; Fisher and Fisher, 1992; Polit-O’Hara and Kahn, 1985). However, what has not been widely looked at is that some individuals attempt to verbally persuade partners to have sexual intercourse without using condoms. In a recent study, Carter et al. (1999) reported that men were more likely than women to try to talk their partners out of the couple using condoms, but little other data were provided, including the percentage of men and women who had attempted to verbally dissuade partners from the couple using condoms during sex. To ascertain whether verbal attempts to convince partners to have sex without a condom are common, the present study surveyed college students about their verbal attempts to dissuade sexual partners from the couple using condoms, and also compared the verbal statements used by men and women when trying to dissuade sexual partners. METHOD Subjects Participants in the survey were undergraduate students enrolled in a human sexuality course at a large, southern, urban, state university. The freshman-level course has no prerequisites and a very large enrollment, thus potentially is taken by a cross section of entering students at the university. Of the 954 students that participated in the survey, most were young (71.0% were under 21), single (91.8%), heterosexual (96.2%), Catholic (55.3%), and Caucasian (54.1%) or African-American (29.7%). Sexual orientation was self-defined. The large proportion of Catholics is


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representative of the greater metropolitan area population. More detailed demographics are presented in Table I. Measures and Procedure A questionnaire developed by the authors was administered during class time to all students who were in attendance. Although students were informed that they did not have to participate, the compliance rate was 99.6%. The survey was completed anonymously, and in addition to the demographic items, included questions about whether or not the student had engaged in sexual intercourse, number of lifetime sexual partners (defined in verbal instructions as sexual intercourse), and percentage of sexual interactions in which condoms were used (for first sexual intercourse with a new partner and for all experiences of sexual intercourse). Those students who were sexually experienced were then asked whether or not (a) they had “ever used a ‘line’ (statement) to keep a potential sex partner from using condoms,” and (b) anyone had ever “used a ‘line’ (statement) on you to keep you from using a condom.” “Line” was defined as a direct verbal statement. In both cases, the participants were asked to write all the lines they recalled and to rate how successful the lines had been (1 = always, 2 = most of the time, 3 = sometimes, 4 = never). The importance of giving honest responses was emphasized to the students before they began. As had been done throughout the course, classroom behavior was strictly enforced (e.g., no talking) during the survey. After the surveys were collected, a preliminary review was made of the lines used by, or used on, students to dissuade sexual partners from the couple using condoms. Based on common themes, eight categories were constructed: will not get pregnant, will not get a sexually transmitted disease, sex feels better without a condom, lack of spontaneity/no condom available, love/intimacy, allergy, want to have a baby, and unclassifiable. The lines were independently placed in the categories by the two authors. The intercoder reliability (percentage agreement in placement of lines into categories) was 97.4%. The subjects gave their age and estimated number of sexual partners. These data also were organized into categories (determined beforehand) so that the results could be presented in table form. As has been done in other surveys, for number of sexual partners 10 was selected as the lower limit of the last category. In the Results, Discussion, and Tables I and II, “sexually experienced” is defined as having had sexual intercourse.

RESULTS Of the 569 female participants, 105 (18.5%) indicated that they had not yet engaged in sexual intercourse. Of the 385 male participants, 78 (20.3%)

382

Female Inexperienced Experienced Male Inexperienced Experienced

Group

Age

Marital status

Ethnicity

Sexual orientation

Religion

92.4 67.0 88.4 65.4

78 307

61.5 57.5

38.1 54.4 16.7 28.8

31.4 32.0 2.6 6.2

9.5 8.0 14.1 2.9

17.2 3.9

5.1 4.6

3.8 1.7

98.7 97.4

100 94.8

1.3 1.6

0 0.9

0 1.0

0 4.3

64.5 55.3

48.1 56.2

14.4 17.2

30.8 24.8

21.1 27.5

21.1 19.0

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0 6.5

0 12.1

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0 100 10.8 87.9

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9.0 25.2

7.6 22.2

17–20 21–25 26+ Single Married/div. White Black Hispanic Asian Other Hetero Homo Bisex Catholic Protestant Other

105 464

n

Table I. Demographic Characteristics of Subjects (Expressed as % of n)

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were sexually inexperienced. Although the large majority of sexually experienced participants reported having used condoms (93.1%), condom use was sporadic (see Table II). Only about 20% of sexually experienced participants used condoms for all occasions of sexual intercourse, and only about 50% had always used condoms during first sexual intercourse with a new partner. Women were less likely than men to have used condoms in all their sexual interactions χ 2 = 4.96, d f = 1, p < .05, $ = .080; categories for 0–75% collapsed for analysis), but there were no significant differences between the sexes at first intercourse with a new partner. Of the 464 sexually experienced females, 63 (13.6%) indicated that they had attempted to dissuade a sexual partner from the couple using condoms. Fifty-two (16.9%) of the 307 experienced males said they had done so. Thus, there was no difference proportionately between experienced males and females who had attempted to dissuade a partner (χ 2 = 1.65, d f = 1, p > .10, $ = .046). There were also no significant differences among ethnic groups (χ 2 = 0.96, d f = 2, p > .10, $ = .035) or religious groups (χ 2 = 0.91, d f = 2, p > .10, $ = .034). The number of individuals who self-defined themselves as homosexual (nine across all groups), as well as the number of males who said they were bisexual (n = 3), was too small to allow for meaningful analysis. The remainder of the Results section focuses on a comparison between men and women. To determine whether attitude about condom use was related to number of lifetime sexual partners, a comparison was made between individuals with fewer than 10 partners and those with 10 or more partners. Students who had attempted to dissuade a sexual partner from the couple using condoms were more likely than other sexually experienced students to have had 10 or more sexual partners (χ 2 = 9.99, df = 1, p < .001, $ = .114). One-third of the males and 20.6% of the females who had attempted to dissuade reported 10 or more lifetime sexual partners (compared to 18.8% and 11.7%, respectively, of those who had not dissuaded others). Individuals who had attempted to dissuade a sexual partner from the couple using condoms were also less likely to have consistently used condoms (Table II; χ 2 = 17.88, df = 1, p < .001, $ = .152; categories for 0–75% collapsed for analysis), with no significant difference between men and women. The 52 men who had attempted to dissuade a partner from the couple using condoms reported having used 84 lines to do so. The lines used most commonly by men to try to dissuade a sexual partner from the couple using condoms were (by category, in descending order) sex feels better without a condom (36.9%), will not get pregnant (21.4%), will not get a sexually transmitted disease (13.1%), and lack of spontaneity/no condom available (13.1%). Representative examples of the lines in these categories are given in Table III. Twenty-seven of the men reported using two or more lines, and nearly half (23) used lines from at least two different categories. The men reported these lines to be moderately successful (mean = 2.15, with no category being significantly more successful than others).

37 13 13 401 217 130 54

Catholic Protestant Other Nondissuaders Caucasian African-American Other

Catholic Protestant Other

144 35 76

255 149 68 38 22.2 20.0 30.3

24.3 28.9 14.7 23.7

21.7 0 7.1

41.7 37.1 34.2

38.8 40.9 30.9 44.7

34.8 21.4 28.6

18.8 22.9 14.5

18.0 17.4 20.6 15.8

17.4 57.2 7.1

17.4 20.0 21.0

18.8 12.8 33.8 15.8

26.1 21.4 57.1

33.3 25.9 45.0 25.0

91.7 94.3 89.5

91.4 90.6 94.1 89.5

95.7 85.7 92.9

92.3 100 90.0 50.0

94.0 92.9 91.7

100 100 100 93.3 92.6 95.4 90.7

100 100 100 100

Yes

8.3 5.7 10.5

8.6 9.4 5.9 10.5

4.3 14.3 7.1

7.7 0 10.0 50.0

6.0 7.1 8.3

0 0 0 6.7 7.4 4.6 9.3

0 0 0 0

No

14.7 8.6 18.4

15.0 18.1 7.5 15.8

12.5 7.7 23.1

14.0 11.1 15.0 25.0

16.6 15.2 19.8

16.2 30.8 23.1 16.9 20.5 7.9 23.1

20.6 22.9 10.5 33.3

0

7.7 2.9 1.3

5.1 6.0 4.5 2.6

12.5 7.7 7.7

10.0 14.8 5.0 0

10.6 6.1 12.3

10.8 15.4 7.7 9.8 11.0 8.7 7.7

11.1 11.4 5.3 22.2

25

7.7 14.3 7.9

8.7 8.7 3.0 18.4

4.2 15.4 15.4

10.0 14.8 5.0 0

7.4 9.1 7.4

5.4 23.1 7.7 7.8 6.4 9.5 9.6

9.5 5.7 21.1 0

50

14.7 5.7 13.2

13.0 11.4 14.9 15.8

29.2 30.8 23.1

28.0 22.2 35.0 25.0

16.1 9.1 13.6

18.9 23.1 30.8 13.9 11.4 17.5 15.4

22.2 17.1 31.6 22.2

75

55.2 68.6 59.2

58.3 55.7 70.1 47.4

41.7 38.5 30.8

38.0 37.0 40.0 50.0

49.3 60.6 46.9

48.6 7.7 30.8 51.6 50.7 56.4 44.2

36.5 42.9 31.6 22.2

100

9.8 5.7 10.5

9.4 10.7 6.0 10.5

4.2 7.7 15.4

8.0 3.7 10.0 25.0

6.0 7.1 7.4

0 0 0 6.5 7.3 3.2 11.5

0 0 0 0

0

21.7 8.6 15.8

18.1 24.2 4.5 18.4

29.2 15.4 38.5

28.0 29.6 30.0 0

25.4 22.2 37.0

46.0 46.2 46.2 27.0 29.7 21.4 28.9

46.0 51.4 31.6 55.5

25

14.7 17.1 9.2

13.4 12.8 11.9 18.4

12.5 15.4 15.4

14.0 14.8 10.0 25.0

16.1 15.2 13.6

16.2 46.2 23.1 15.4 14.6 15.9 17.3

23.8 20.0 36.8 11.1

50

28.7 40.0 34.2

31.9 28.9 41.8 26.3

41.7 61.5 23.1

42.0 44.5 45.0 25.0

35.0 26.3 29.6

32.4 7.7 30.8 31.7 29.2 34.9 34.6

27.0 22.9 31.6 33.3

75

25.2 28.6 30.3

27.2 23.5 35.8 26.3

12.5 0 7.7

8.0 7.4 5.0 25.0

17.5 29.3 12.4

5.4 0 0 19.4 19.2 24.6 7.7

3.2 5.7 0 0

100

384

Nondissuaders Caucasian African-American Other

23 15 14

25.5 29.6 25.0 0

11.9 7.1 16.7

18.9 38.5 7.7 11.7 12.4 10.8 11.1

20.6 28.6 10.5 11.1

10+

11:13


29.4 25.9 25.0 75.0

19.3 20.2 23.8

21.6 23.1 15.4 20.5 20.7 23.1 13.0

20.6 14.3 26.3 33.3

5–9

Condom use (% of all intercourse)

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11.8 18.5 5.0 0

39.4 48.5 33.3

27.0 15.4 53.8 40.4 39.2 43.1 38.9

30.2 25.7 42.1 22.2

2–4

Condom use (% of first intercourse)

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29.4 24.2 26.2

32.4 23.1 23.1 27.4 27.7 23.1 37.0

28.6 31.4 21.1 33.3

1

Ever used a condom

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Male Dissuaders Caucasian African-American Other

218 99 84

63 35 19 9

Female dissuaders Caucasian African-American Other


n

Group (subgroup)

#Lifetime sexual partners

Table II. Sexual History of Sexually Experienced Subjects Who had Either Attempted or Who had Not Attempted to Dissuade Partners From the Couple Using Condoms (Expressed as % of n)

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Table III. Representative Lines Used to Dissuade Sexual Partners From the Couple Using Condoms Category: Sex feels better without a condom I hate them—they don’t feel right. (m) It just doesn’t feel the same. (m) It doesn’t feel real. (m) Sex doesn’t feel as good with a condom. (m) I can’t feel anything when I use a condom. (m) I can’t get enough sensations. (m) I don’t like the way it feels. (f) It feels better without a condom. (f) Take it off; it doesn’t feel the same. (f) It feels like plastic. (f) I want to know what it really feels like to be inside you. (m) I want to feel you inside me without a condom. (f ) I want to feel the hardness of your dick. (f ) It’s too tight and it hurts. (m) It hurts after a while. (f) The condom is irritating. (f) The condom is too dry and uncomfortable. (f ) It takes away my vaginal moisture. (f) I don’t like them. I can’t feel you and they burn. (f ) You don’t need that. I want it naked. They irritate me. (f ) I don’t stay hard with one on. (m) They are uncomfortable and I lose my erection because I can’t feel as much. (m) I don’t like the way it feels. I don’t cum. (m) I only reach orgasm without a condom. (f ) If I wear a condom it will hurt you more. (m) I can make it feel much better for you without it. (m) Category: Will not get pregnant I promise; I’ll pull out right before I cum. (m) I promise; I won’t cum in you. (m) Just for a little while. . . . I’ll pull out. (m) I’m not going to get you pregnant. (m) Don’t worry about it—just pull out. (f) Don’t worry; I’m on birth control. (f) I’m on the pill; don’t worry about it. (f) I’m on my period. Nothing will happen. (f ) I can’t get pregnant this time of the month. (f ) Aren’t you on the pill? (m) I’m sterile. I can’t have babies. (m) You won’t get pregnant. I have a low sperm count. (m) Category: Will not get a sexually transmitted disease What’s wrong; don’t you trust me? (m) I don’t have anything. You trust me don’t you? (m) Don’t you trust me? (f) I feel that a condom shows that you don’t trust me. (f ) Are you fucking someone else? (f) If you’re not having sex with anybody else; why should I use it? (m) I don’t have anything. Why are you using that? (f ) I never had an STD. (m) I don’t have sex with anyone else. (m) I just came from the doctor. I don’t have anything. (m) (Continued)


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Oncale and King Table III. (Continued )

I am a virgin. There’s nothing to worry about. (m) Don’t worry about it. I’m clean. (f) There’s nothing to worry about. I don’t have anything. (f ) It’s OK. I’ve only had sex with my wife. (m) I haven’t had sex in three weeks with anyone but my baby’s father. (f ) Category: Lack of spontaneity/no condom available I don’t have one and the store is too far away. (m) It takes too much time to put it on. (m) I’m tired of being interrupted—it ruins the mood. (m) Don’t stop; the mood will be gone. (f ) You’re going to ruin the mood. (f) Don’t put it on. It takes too long. (f) I want that big dick in my pussy right now. (f ) Category: Love/intimacy If you love me; you wouldn’t make me use it. (m) If you love me; we don’t need one. (f ) If you love me; you won’t. (f) We love each other. We don’t need that. (f ) I want to be able to express my love for you without anything between us. (m)

The 63 women who had attempted to dissuade a partner also reported having used 84 lines. The categories of lines most frequently used by women to dissuade a partner from the couple using condoms were (in descending order) sex feels better without a condom (48.8%), will not get pregnant (28.6%), will not get a sexually transmitted disease (10.7%), and love/intimacy (5.9%). Proportionately, this was only slightly different than what was found for males (χ 2 = 11.60, df = 5, p < .05, $ = .262), with the minor categories lack of spontaneity/no condom available and “other” (allergy, want to have a baby, unclassifiable) accounting for most of the difference. Twenty women had used two or more lines, but only 11 had used lines from more than one category. Representative examples are provided in Table III. The women generally reported use of these lines to be successful (mean = 1.82, with no significant difference among the categories). When the sexually experienced subjects were asked if anyone had ever attempted to dissuade them from the couple using a condom during sexual intercourse, 91 men (29.6%) and 190 women (41.0%) responded that a sexual partner had done so (χ 2 = 9.59, df = 1, p < .005, $ = .112). The men recalled 118 lines, while women listed a total of 272 lines. The most frequent categories of lines were the same as before (with no significant difference between men and women): sex feels better without a condom (42.4% and 46.7% of the lines told to men and women, respectively), will not get pregnant (21.2% and 22.4%), will not get a sexually transmitted disease (13.6% and 12.9%), and lack of spontaneity/no condom available (9.3% and 7.7%). Sixty-seven women and 23 men had been told multiple lines, over two-thirds of them from different categories. Overall, both men and women reported these lines to be relatively unsuccessful (mean success


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scores of 2.66 and 2.95, respectively). These were significantly different from the success rates reported for the students’ own use of lines (χ 2 = 33.08 for females and 25.87 for males, df = 3, p < .001, $ = .463 and .327, respectively). DISCUSSION The present results reveal that attempts to talk a sexual partner out of the couple using condoms are not uncommon. Interestingly, there was no significant difference between the proportion of sexually experienced men and women who reported having attempted to dissuade a partner. About 17% of sexually experienced men and nearly 14% of sexually experienced women indicated that they had done so, whereas nearly 30% of experienced men and 41% of experienced women said that a sexual partner had tried to dissuade them from the couple using condoms. The discrepancy between reports of one’s own behavior and the behavior of partners may be due to underreporting in the self-reports of attempts to dissuade others. A problem common with any survey of people’s sexual behavior is that some individuals may attempt to make themselves look good by engaging in selfdeception or lying (Clement, 1990; Meston et al., 1998). In a time period when sex educators and health officials are stressing sexual responsibility, one might expect underreporting of attempts to dissuade partners from the couple using condoms. However, the discrepancy may also have been due to the fact that the survey was not taken of closed couples. The difference in results between one’s own behavior and the behavior of partners might also be due to misperceptions and distortions when couples attempt to communicate about sex (Buysse and Van Oost, 1997; Metts and Fitzpatrick, 1992). One partner may not think that he or she was trying to dissuade the other from the couple using condoms, but the other may interpret that there had been an attempt. Whether the accurate figure is 14–17% (self-reports) or 30–40% (reports of behaviors of others), it can nevertheless be concluded that a sizeable minority of young people use verbal persuasions not to promote condom use, but to prevent use of condoms during sexual intercourse. Individuals who had verbally attempted to discourage use of condoms were much more likely to have had 10 or more lifetime sexual partners. This was particularly true of men, and is consistent with the previous finding that males with numerous lifetime partners are less likely than others to use condoms (Centers for Disease Control and Prevention, 1992). The combination of multiple sexual partners and active dissuasion of partners from the couple using condoms poses a serious challenge to educators in HIV/AIDS prevention programs. Men and women reported similar patterns in the verbal statements they employed to dissuade partners from the couple using condoms. For reports of one’s own attempts and attempts by others, the three most commonly used statements were (1) sex feels better without a condom, (2) will not get pregnant, and (3) will not get a sexually transmitted disease. These accounted for at least 71% of


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the lines used by men and over 80% of the lines used by women. Other studies have found that men give the unavailability or inconvenience of condoms as the most common reason for not using condoms (Carter et al., 1999; Franzini and Sideman, 1994), whereas women use the perception of low risk or a desire for a caring and meaningful relationship as the most common reason for not wanting a partner to use condoms (Browne and Minichiello, 1996; Carter et al., 1999). For women in the present study, the categories “will not get pregnant,” “will not get a sexually transmitted disease,” and “desire for love/intimacy” (the fourth most common category for women) are consistent with these findings, as is the finding that young men and women are less likely to use condoms to prevent sexually transmitted diseases than to prevent pregnancy (Cooper et al., 1999). For men in the present study, the category “lack of spontaneity/no condom available” accounted for fewer than 14% of all responses. Discrepancies in results could be due to differences in the survey questions, as prior studies asked students why they personally did not use condoms. Not everyone who does not use condoms has attempted to dissuade a partner, and among those who have, the reasons used to dissuade a partner may not be the same as their own reason for not wanting to use one. There was disagreement about the success of lines used to dissuade partners from the couple using condoms. Persons who had attempted to dissuade a partner reported that those attempts were successful by about a 2-to-1 margin, and consistent with this, according to their self-reports they were also less likely to have used condoms consistently. However, those students whose partners had attempted to dissuade them from using condoms reported the attempts to be unsuccessful by about a 2-to-1 margin. This was true for both men and women, and again may reflect a bias in self-reports. However, according to these self-reports, women were moderately more successful than men in dissuading partners from the couple using condoms, and moderately more successful in resisting attempts to dissuade. This is consistent with other recent findings that women play a more active role, and men tend to be more reactive, in the negotiation of condom use (Carter et al., 1999). To practice safer sex, one must be able to talk with partners about using condoms, but as one researcher acknowledged, most college students do not know “how to engage in the interpersonal negotiations that have to occur in order for a condom to be used” (Morrison, quoted in Gladwell, 1992). Many studies have found that young people who have these communication skills are much more likely to practice safer sex (e.g., Catania et al., 1989; Fisher and Fisher, 1992; Lear, 1995; Polit-O’Hara and Kahn, 1985; Wight, 1992; Wingood and DiClemente, 1998). Echoing a point of view held by many, one group of researchers recently stated that “encouraging adolescents to communicate with prospective partners about sex is potentially an effective strategy for preventing STDs . . . and teenage pregnancy” (Whitaker et al., 1999). However, the results of the present study indicate that a


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sizable minority of college students uses their verbal communication skills to try to dissuade partners from the couple using condoms. Several studies have found that condom use is more likely among women who are assertive (e.g., Fisher and Fisher, 1992; Wingood and DiClemente, 1998; Yesmont, 1992), but what happens when a woman does not want her partner to use condoms because she does not like the way they feel? Among females who had attempted to convince a partner to engage in sex without condoms, the high percentage (nearly 50%) that used the line “sex feels better without a condom” is notable. Many men say that reduced pleasure is a major reason for them not using condoms (e.g., Murphy and Boggess, 1998), and many women do not bring up the subject of condoms during sex because they perceive condoms to be less enjoyable for their partners (Libbus, 1995). However, in the present study the lines used by women in the category “sex feels better without a condom” did not refer to their partners’ reduced pleasure, but to their own (e.g., “I don’t like the way it feels,” “The condom is too dry and uncomfortable,” Table III). Previous studies had not found this to be a major reason why women do not use condoms (Browne and Minichiello, 1996; Carter et al., 1999; Cooper et al., 1999). In general, men in the present study reported a moderate success in overcoming partners’ desires for the men not to use condoms, but what if men also do not like the way they feel? Obviously, sex educators are going to have to address the physical gratification aspect of condoms, and not just their role in STD and pregnancy prevention. The use of condoms is less likely in committed relationships (e.g., Bankole et al., 1999), and the present study did not address the relationship status of the subjects, but only whether they had ever attempted to convince a (any) partner not to use a condom during sexual intercourse. The study was also conducted with college students from a predominantly Catholic population (although religious affiliation was not a significant factor). Although specific conclusions must be limited to this group, the proportion of participants who had actively attempted to dissuade partners from the couple using condoms during sexual intercourse was substantial enough to warrant concern by sex educators and should be addressed in future research. REFERENCES Afifi, W. A. (1999). Harming the ones we love: Relational attachment and perceived consequences as predictors of safe-sex behavior. J. Sex Res. 36: 198–206. Bankole, A., Darroch, J. E., and Singh, S. (1999). Determinants of trends in condom use in the United States, 1988–1995. Fam. Plann. Perspect. 31: 264–271. Browne, J., and Minichiello, V. (1996). Condoms: Dilemmas of caring and autonomy in heterosexual safe sex practices. Venereology 9: 24–33. Buysse, A., and Van Oost, P. (1997). Appropriate male and female safer sexual behavior in heterosexual relationships. AIDS Care 9: 549–561.


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Carter, J. A., McNair, L. D., Corbin, W. R., and Williams, M. (1999). Gender differences related to heterosexual condom use: The influence of negotiation styles. J. Sex Marital Ther. 25: 217–225. Catania, J. A., Binson, D., Docini, M. M., Stall, R., Choi, K. H., Pollack, L. M., Hudes, E. S., Canchola, J., Phillips, K., and Moskowitz, J. T. (1995). Risk factors for HIV and other sexually transmitted diseases and prevention practices among US heterosexual adults: Changes from 1990 to 1992. Am. J. Public Health 85: 1492–1499. Catania, J. A., Dolcini, M. M., Coates, T. J., Kegeles, S. M., Greenbaum, R. M., Puckett, S., Corman, M., and Miller, J. (1989). Predictors of condom use and multiple partnered sex among sexually active adolescent women: Implications for AIDS-related health interventions. J. Sex Res. 26: 514– 524. Centers for Disease Control and Prevention. (1992). Selected behaviors that increase risk for HIV infection among high school students—United States, 1990. MMWR 41: 236–240. Centers for Disease Control and Prevention. (1998). Trends in sexual risk behavior among high school students—United States, 1991–1997. MMWR 47: 749–752. Choi, K.-H., Rickman, R., and Catania, J. A. (1994). What heterosexual adults believe about condoms. New Engl. J. Med. 331: 406, 407. Clement, U. (1990). Surveys of heterosexual behavior. Annu. Rev. Sex Res. 1: 45–74. Cooper, M. L., Agocha, V. B., and Powers, A. M. (1999). Motivations for condom use: Do pregnancy prevention goals undermine disease prevention among heterosexual young adults? Health Psychol. 18: 1–11. DiClemente, R. J., Forrest, K. A., and Mickler, S. (1990). College students’ knowledge and attitudes about AIDS and changes in HIV-preventive behaviors. AIDS Educ. Prev. 2: 201–212. Fisher, J. D., and Fisher, W. A. (1992). Changing AIDS-risk behavior. Psychol. Bull. 11: 455–474. Franzini, L. R., and Sideman, L. M. (1994). Personality characteristics of condom users. J. Sex Educ. Ther. 20: 110–118. Gladwell, M. (1992, May 16). “Safe-sex” campaign said to be missing the mark. The Washington Post, pp. A1, A11. Gray, L. A., and Saracino, M. (1989). AIDS on campus: A preliminary study of college students’ knowledge and behaviors. J. Couns. Dev. 68: 199–202. Hillier, L., Harrison, L., and Warr, D. (1998). “When you carry condoms all the boys think you want it”: Negotiating competing discourses about safe sex. J. Adolesc. 21: 15–29. Ku, L. C., Sonenstein, F. L., and Pleck, J. H. (1992). The association of AIDS education and sex education with sexual behavior and condom use among teenage men. Fam. Plann. Perspect. 24: 100–106. Ku, L. C., Sonenstein, F. L., and Pleck, J. H. (1994). The dynamics of young men’s condom use during and across relationships. Fam. Plann. Perspect. 24: 100–106. Lear, D. (1995). Sexual communication in the age of AIDS: The construction of risk and trust among young adults. Soc. Sci. Med. 41: 1311–1323. Libbus, K. (1995). Women’s beliefs concerning condom acquisition and use. Public Health Nurs. 12: 341–347. Meston, C. M., Heiman, J. R., Trapnell, P. D., and Paulhus, D. L. (1998). Socially desirable responding and sexuality self-reports. J. Sex Res. 35: 148–157. Metts, S., and Fitzpatrick, M. A. (1992). Thinking about safer sex: The risky business of “know your partner” advice. In Edgar, T., Fitzpatrick, M. A., and Freimuth, V. S. (eds.), AIDS: A Communication Perspective, Erlbaum, Hillsdale, NJ. Murphy, J. J., and Boggess, S. (1998). Increased condom use among teenage males, 1988–1995: The role of attitudes. Fam. Plann. Perspect. 30: 276–280, 303. Piccinino, L. J., and Mosher, W. D. (1998). Trends in contraceptive use in the United States: 1982–1995. Fam. Plann. Perspect. 30: 4–10, 46. Polit-O’Hara, D., and Kahn, J. (1985). Communication and contraceptive practices in adolescent couples. Adolescence 20: 33–42. Public Health Service. (1991). Healthy People 2000: National Health Promotion and Disease Prevention Objectives, U.S. Department of Health and Human Services, Washington, DC. DHHS publication PHS 91-50212. Sonenstein, F. L., Ku, L., Lindberg, L. D., Turner, C. F., and Pleck, J. H. (1998). Changes in sexual behavior and condom use among teenaged males: 1988 to 1995. Am. J. Public Health 88: 956–959.


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Whitaker, D. J., Miller, K. S., May, D. C., and Levin, M. L. (1999). Teenage partners’ communication about sexual risk and condom use: The importance of parent–teenager discussions. Fam. Plann. Perspect. 31: 117–121. Wight, D. (1992). Impediments to safer heterosexual sex: A review of research with young people. AIDS Care 4: 11–23. Wingood, G. M., and DiClemente, R. J. (1998). Gender-related correlates and predictors of consistent condom use among young adult African-American women: A prospective analysis. Int. J. STD AIDS 9: 139–145. Yesmont, G. A. (1992). The relationship of assertiveness to college students’ safer sex behaviors. Adolescence 27: 253–272.

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Sexual and Emotional Variables Influencing Sexual Response to Erotica: A Psychophysiological Investigation Eric Koukounas, PhD,1,2 and Marita P. McCabe, PhD1

The relative contribution of attentional and emotional factors to the physiological and subjective sexual arousal elicited by erotic film was evaluated. Sexual arousal, attentional, and emotional responses were measured while 30 men were presented with a series of erotic film segments. Levels of physiological and subjective sexual arousal were higher when subjects became absorbed in the activities portrayed in the film and when they experienced the depicted erotic encounters as appetitive, than when they were distracted and perceived the encounters as aversive. The erotic film elicited a diminished startle response to a sudden burst of white noise presented during stimulation relative to the nature film, suggesting that at a physiological level the erotic segments of film were processed as more appetitive in valence. The level of sexual arousal elicited by the erotic segments was related to the extent to which subjects were entertained by the film, even though there was considerable anxiety generated by the portrayed sexual scenarios. Sexual response was not significantly correlated with trait measures of absorption (as indexed by the Tellegen Absorption Scale) nor with vividness of imagery (as assessed by the Betts Questionnaire upon Mental Imagery). Arousal was related to state-assessed attentional and emotional variables, and physiological measures of emotional response, demonstrating the multidimensional nature of the sexual response. Future directions for comparing male sexual response patterns with female response patterns are suggested. KEY WORDS: sexual; emotional; erotica; psychophysiology; startle.

1 School

of Psychology, Deakin University, Burwood, Victoria, Australia.

2 To whom correspondence should be addressed at School of Psychology, Deakin University, Burwood

Road, Burwood, Victoria, Australia 3125. 393 C 2001 Plenum Publishing Corporation 0004-0002/01/0800-0393$19.50/0 °

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The psychophysiological approach to sexual response emphasizes the interaction between the physiological component of arousal, the subjective experience of arousal, and the emotional processing of the sexual situation (Bancroft, 1989; Rosen and Beck, 1988; Talmadge and Talmadge, 1990). The present study is concerned with the physiological assessment of sexual arousal in males in response to a sexual stimulus, with a concurrent evaluation of the degree to which respondents actively attend to and become immersed in the situation without distraction (absorption), and experience pleasant (appetitive) emotions. Subjective self-reports of sexual arousal, attention, and emotional response to the sexual stimulus are then compared and contrasted to their physiological equivalents. The role of attentional and emotional variables in mediating subjective sexual response has been highlighted in previous research by Koukounas and McCabe (1997). In this study, self-reported sexual arousal, attention, and emotional responses were measured while male subjects viewed a series of erotic film segments. Greater sexual arousal to erotica was reported when the men became absorbed in the activities portrayed in the film and when they experienced the depicted erotic encounters as appetitive, than when they were distracted and perceived the encounters as aversive. Subjective sexual arousal also correlated positively with the degree to which subjects experienced entertainment and curiosity to the erotic film segments, but negatively with boredom. Other research has identified the complex interaction between subjective sexual arousal, attentional processes, and other psychological variables such as emotional arousal (Jansen and Frijda, 1994), anxiety (Bruce and Barlow, 1990; Hale and Strassberg, 1900; Seto, 1992), disgust (Vonderheide and Mosher, 1988), anger (Bozman and Beck, 1991), and sexual curiosity (Hatano, 1993). Dekker and Everaerd (1988, 1989) found that subjective sexual arousal was greater to erotic text, slides, and sexual fantasy if the subjects attended to both the sexual situations and the sexual feelings associated with the events (emotion focus) than when they only attended to the sexual situations (stimulus focus). This interaction between attentional and emotional variables in eliciting sexual arousal to erotica was significant in both male and female subjects. The magnitude of self-reported positive and negative emotional arousal to sexual stimulation has also been found to differentiate sexually functional men from dysfunctional men (Rowland et al., 1995; Rowland and Slob, 1995). Although investigations of responses to erotica have highlighted the role of attentional and emotional factors, findings are inconsistent and difficult to reconcile between studies because of methodological differences relating to conceptualization and operationalization of the variables, and characteristics and size of the samples under investigation (Rosen and Beck, 1988). With respect to the variables under investigation, comparing studies becomes difficult because of the subjective nature of assessment. The validity of directly asking subjects to provide ratings of their sexual arousal and emotions is questionable since self-report is open to social acquiescence bias (telling the experimenter what the subjects believe the

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experimenter wants to hear), and the experimenter is never quite sure what criteria the subjects use to estimate their subjective response. Thus, the current research will investigate physiological measures of sexual arousal, attention, and emotional response as well as subjective indices of these variables. Erection of the penis is the most accurate physiological index of sexual arousal in functional males (Bancroft, 1989). A high level of concordance between subjective sexual arousal and physiological indices of sexual response has been demonstrated in men exposed to erotic materials (Sakheim et al., 1984). Koukounas and Over (1993) assessed attentional focus in conjunction with penile erection and subjective sexual arousal during erotic stimulation among male participants. They found that shifts in sexual response with repeated stimulation were closely paralleled by changes in attentional processing. This pattern was true of attentional focus, indexed by self-report, and by objective measurement through a secondarytask reaction time paradigm (Koukounas and Over, 1999). The latter method is based on the assumption that an individual has limited information-processing capacity, and that the amount of attention allocated to an erotic stimulus (primary task) can be indexed by the time taken to respond to a secondary task presented concurrently with the primary task (Dawson, 1990). Koukounas and Over (1999) found that as the erotic material was repeatedly presented, respondents found the erotic material harder to attend to, as indexed by a faster response to the secondary task presented during stimulation. A further factor that may influence sexual response is the emotional processing of the stimuli. A relatively new physiological measure for assessing the nature of this emotional processing during erotic stimulation is the startle reflex response. Koukounas and Over (2000) assessed the emotional processing of an erotic stimulus (primary task) by evaluating the magnitude of the eyeblink startle response to an unexpected intense auditory stimulus (secondary task probe) presented during stimulation. Lang et al. (1990) demonstrated that the magnitude of the startle response reflected the match in emotional content between the stimulus and the unexpected probe presented during that stimulation. Lang et al. classified emotional content as either appetitive (pleasant) or aversive (unpleasant). The eyeblink startle response is augmented when the attended to stimulus and the unexpected probe match in affective content, and diminished when they differ in emotional content. Since startle stimuli are aversive in nature, one would expect the startle response to be diminished when the unexpected probe is presented while the subject is attending to pleasant stimulation, but augmented when the probe is presented while the subject is attending to unpleasant stimulation. Koukounas and Over (2000) found that with repeated erotic stimulation, as the material became boring and aversive, the magnitude of the eyeblink startle response increased across repeated erotic trials. The current study will further assess the utility of the eyeblink startle response as a measure of emotional information processing. The aim of the current research is to examine the variables influencing sexual response to erotica among male subjects. Both physiological and subjective

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sexual arousal will be assessed, in conjunction with both self-reported and physiological measures of attentional focus and emotional response. Since anxiety is frequently correlated with sexual arousal (and its dysfunction) (see Barlow, 1986), self-reported levels of anxiety will also be assessed. The startle reflex paradigm will be used to objectively assess the emotional processing of an erotic stimulus. Subjective reports of sexual arousal, absorption, and emotional reactions to erotic film (positive feelings, entertainment, curiosity, anxiety, anger, boredom, disgust) will be explored as they were in Koukounas and McCabe (1997), but the novelty of the present research is that it will investigate the relationship of these subjective variables with physiological evaluations of sexual arousal, attention, and emotional response. The study will also determine the extent to which both subjective and physiological sexual arousal to erotica are associated with trait levels of arousability, absorption, and vividness of imagery formation. Koukounas and Over (1993) found a significant positive relationship between subjective sexual arousal and absorbed attention as indexed by the Tellegen Absorption Scale (Tellegen and Atkinson, 1974). The experience of sexual fantasy and the ability to form erotic mental images has also been found to correlate with sexual arousal. Koukounas and Over (1993), Harris et al. (1980), and Smith and Over (1987) found a significant relationship between subjective sexual arousal and the capacity to form vivid images during fantasy as assessed by the Betts Questionnaire upon Mental Imagery (QMI) (see Sheehan, 1967). However, Koukounas and Over (1993) concluded that state measures of attentional and emotional information processing were better predictors of sexual arousal to erotic film than were trait measures. The aim of the current study is to evaluate the relative contribution of state and trait measures of absorption and vividness of imagery to subjective sexual arousal in response to erotica, as suggested by Koukounas and Over (1993), and also to determine their relationship with physiological variables of sexual arousal, attention, and emotion in response to erotica. In summary, the present research adopts the information-processing approach to sexual arousal elicited by erotica in its focus on concurrent measurement of physiological, attentional, and emotional responses to the erotic stimulation. The magnitude of penile erection (to assess sexual arousal), reaction time (to assess attentional focus), and eyeblink startle response (to assess emotional responses) to erotica will be measured. Participants will also be asked to provide a rating of the extent to which they become sexually aroused and absorbed, and experience various emotions (positive feelings, anxiety, disgust, entertainment, boredom, anger, and curiosity) while viewing the erotica. The primary aim is to determine the relationship between the magnitude of the physiological and the self-reported variables described above. A further aim is to determine whether individual differences in the sexual response relate more to state or trait measures of attentional and emotional processes.

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METHOD Subjects A sample of 30 men (mean age 29.5 years, SD 5.5) was recruited through advertisements placed on noticeboards at a large metropolitan university and in student newspaper publications. The sample had a high level of sexual experience; 90.0% had experienced sexual intercourse, and 56.7% had a current sexual partner. Potential subjects were screened prior to testing using a sexual background sheet. Participants selected reported that they were exclusively heterosexual, had no history of sexual dysfunction or sexually transmitted diseases, and had not used medication in the previous 3 months likely to affect capacity for sexual arousal. Participation was by informed consent, and all subjects were paid $20 on completion of the test session. Materials and Procedure At the beginning of the test session, participants were asked to complete a battery of questionnaires that included the following: (1) a sexual information checklist, identifying background information such as age, sexual status, availability of a current partner, and experience with sexual fantasy, that is, the frequency of sexual thoughts and the level of enjoyment one experiences from these sexual thoughts (Smith, 1986); (2) a modified version of the Sexual Behavior InventoryMale (Bentler, 1968). Respondents were presented with 14 sexual encounters such as masturbation and oral, vaginal, and anal intercourse, and asked their experience of the activity and how they felt about the behavior; (3) the Tellegen Absorption Scale, a 34-item trait measure of the ability to immerse oneself into daily activities (Tellegen and Atkinson, 1974); (4) the Arousability Scale, a 20-item index of the general level of emotional arousal to everyday phenomena (Mehrabian, 1976); and (5) the revised Betts Questionnaire upon Mental Imagery, a measure of the vividness of self-generated fantasy, where respondents are asked to imagine 35 items and rate how vivid they appear (Sheehan, 1967). Respondents viewed ten two-minute segments of film: five erotic and five neutral stimuli. The film excerpts were taken from commercially available video film and were separated by two-minutes of blank tape. The excerpts represented material judged by subjects in a previous study (see Koukounas and McCabe, 1997) to be sexual and neutral in content. The sexual stimuli included three depictions of a man and a woman engaging in vaginal intercourse and two scenarios in which a man and a woman engaged in various combinations of oral sex. The actors were different for all five erotic scenarios. The neutral film segments include video of a country scene depicting flowers and trees. The neutral film served as a control for the erotic film since both materials were presented in the same modality (film),

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and since the neutral film material was unlikely to elicit strong positive or negative emotions, it provided a baseline against which to compare responses to the erotic film. It would have been difficult to attempt to match the erotic film with a control of equal emotional valency (but no sexual content) since not everyone reacts to erotica with equivalent emotional valency – some find it appetitive, some find it aversive. All film segments were presented without sound. To reduce anticipatory effects of stimulus presentation, subjects were informed that the erotic and neutral film segments would be interspersed. The films were presented in the following order: erotic 1, neutral1, neutral2, erotic2, neutral3, erotic3, erotic4, neutral4, erotic5, neutral5. The film segments were presented in the same order for all subjects. The order was not counterbalanced between subjects because the focus of the research was not to compare between the five film stimuli within each category but to create a composite score representing an averaged response level across the five stimuli. Respondents viewed the materials on a comfortable recliner chair. All contact between subjects and the experimenter was through an intercom system. After each erotic and neutral film segment, respondents were asked to verbally rate the material on a scale from 1 (not at all) to 5 (extremely) with respect to the following nine variables: subjective sexual arousal, absorption, positive feelings, anxiety, disgust, entertainment, boredom, anger, and curiosity. Participants were also asked to identify what it was about the film material that produced their particular responses. Physiological sexual arousal was assessed continuously electrophysiologically, and scored on Australian-design MacLab biomedical equipment. Penile tumescence was measured by a Parkes electronic mercury-in-rubber strain gauge described (and designed) by Julien and Over (1984). The gauge was fitted along the penile shaft so that changes in penile circumference were recorded as electrical signals on the MacLab recorder. Physiological sexual arousal was indexed by the difference between the maximum and minimum levels of penile circumference recorded during each erotic and nature film stimulation. This led to a measure of physiological sexual arousal for each film segment. The secondary-probe reaction time task involved the subject pressing a handheld microswitch as soon as they heard a tone through the headphones. The reaction time signal was then passed to a digital counter that calculated the time from tone onset to the respondent pressing the response switch, and then displayed the time in ms for recording. Thirty practice trials (with the tone presented without film segments) were given at the start of the session to familiarize the subject with test procedures and to provide practice, so that reaction time reached an asymptotic level. The probe signal was a 70-dB auditory tone of 1000-Hz frequency and 500-ms duration and was presented through stereophonic headphones. The eyeblink startle response was evoked by a 50-ms burst of 95 dB white noise with instantaneous rise time presented to the subjects through stereophonic headphones. The eyeblink component of the startle response was measured by

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399

recording electromyography (EMG) activity from the orbicularis oculi muscle directly above and below the left eye. The raw EMG signal was amplified and integrated using MacLab equipment. The magnitude of the startle eyeblink was indexed by the difference in EMG response level immediately prior to and following the white noise burst (startle stimulus). Both the reaction time and startle probes are described in detail in Koukounas and Over (1993). The respondents were informed at the beginning of the test session that although they will sometimes hear an intense but brief burst of white noise through the headphones, they were to disregard this noise and to continue attending to the film. Similarly, respondents were informed that although they were to respond to the presentation of the secondary tone as rapidly as possible, their primary task was to watch the erotic film. All respondents heard both sounds before the experiment commenced so that they knew how to respond. The white noise and the tone were quite different in pitch and duration and so respondents were not confused regarding their expected response. The white noise and the tone were administered separately at a point during each of the 2-min sequences of film. The timing of these stimuli were the same for all subjects and they were presented either early, middle, or late in the film sequence for each of the two types of stimuli, so that there was consistency in the timing of these stimuli for all sequences across subjects but an unpredictability about their onset for each individual subject.

RESULTS Sexual Arousal in Relation to Erotica Table I depicts descriptive data and mean levels of physiological sexual arousal, reaction time, startle magnitude, and subjective levels of sexual arousal, absorption, positive emotions, anxiety, disgust, entertainment, boredom, anger, and curiosity for the film segments. Total mean scores were obtained for the five erotic film segments and the five nature film segments. An independent-measures MANOVA with these dependent variables was conducted with film content (erotic versus neutral) as an independent variable. The sexual response and attentional and emotional processing of the erotic material was significantly different from that allocated to the nonerotic material [multivariate: F(11, 118) = 220.15, p < .01]. Univariate tests demonstrated that in comparison to the nature segments, the erotic film generated greater physiological sexual arousal [F(1, 12) = 509.97, p < .001], subjective sexual arousal [F(1, 12) = 67.50, p < .001], absorption [F(1, 12) = 17.11, p < .01], positive emotions [F(1, 12) = 6.00, p < .05], and entertainment [F(1, 12) = 11.70, p < .01]. The nature film induced more boredom than the erotic segments [F(1, 12) = 8.96, p < .01] and elicited an augmented startle response to white noise [F(1, 12) = 10.97, p < .01].

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Table I. Descriptive Data and Mean Physiological and Subjective Response to Erotic and Neutral Film Film content Demographics Age (years) Frequency of sexual thoughts: ratings from 1 (never) to 5 (daily) Frequency of sexual activity: ratings from 1 (never) to 5 (daily) Trait variablesa Sexual behaviour (range 14–70) Sexual attitudes (range 14–70) Absorption (range 34–170) Arousability (range 20–180) Vividness of imagery (range 35–245) Physiological variables Physiological sexual arousal (mm)∗∗∗ Reaction time (ms) Startle (µV)∗∗ State variables: ratings from 1 (not at all) to 5 (extremely) Subjective sexual arousal∗∗∗ Absorption∗∗ Positive feelings∗ Anxiety Disgust Entertainment∗∗ Boredom∗∗ Anger Curiosity

Mean

SD

29.47 3.73

5.46 1.28

2.15

.76

43.33 52.57 78.73 98.60 96.97

13.81 11.40 21.97 17.47 21.96

Erotic Neutral Erotic Neutral Erotic Neutral

2.95 .02 300.8 295.3 1.22 2.16

.56 .08 59.17 58.36 .45 .59

Erotic Neutral Erotic Neutral Erotic Neutral Erotic Neutral Erotic Neutral Erotic Neutral Erotic Neutral Erotic Neutral Erotic Neutral

3.00 1.00 2.57 1.54 2.26 1.38 1.23 1.00 1.30 1.00 2.55 1.18 1.24 2.24 1.28 1.00 1.43 1.00

.82 .00 .73 .46 1.02 .48 .40 .00 .80 .00 .80 .36 .36 .96 .48 .00 1.00 .00

a Lower

scores on the trait variables indicate lower values for the variables. With respect to the sexual trait variables, lower scores for sexual behavior indicate that the individual has engaged in less sexual behaviors, whereas lower scores for sexual attitudes indicate that the individual feels less positive about the sexual behaviors in question. ∗∗∗p < .001; ∗∗p < .01; ∗p < .05 (significance levels for comparisons between erotic and neutral film).

Attentional and Emotional Factors as Correlates of Physiological and Subjective Sexual Arousal Given the relatively large number of experimental variables present that could be used in a correlational analysis, and given the degree of familywise error rate

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that would be introduced if each variable was tested, the correlations were restricted to those central to the aims of the study, that is, those of a priori importance, and the required significance level was increased to p < .01, as suggested by Keppel (1991). Table II reports the extent to which physiological sexual arousal, subjective sexual arousal, self-rated absorption, and positive feelings correlated with the physiological, trait and state measures of arousal, absorption, and emotional response. Significant correlations at p < .01 will now be highlighted. Physiological sexual response to the erotic film correlated with subjective sexual arousal, self-reported absorption, positive feelings, level of entertainment, and boredom. Subjective sexual response to the erotic film correlated with self-reported absorption, positive feelings, anxiety, level of entertainment, curiosity, and boredom. Self-reported absorption in the erotic stimulation correlated with level of entertainment, positive feelings, curiosity, anxiety, disgust, anger, and boredom. Positive emotions generated by the erotic film correlated with the amount of entertainment experienced Table II. Intercorrelations Between Physiological Sexual Arousal, Subjective Sexual Arousal, State Absorption, and Positive Feelings, and the Demographic, Trait, Physiological, and Subjective Measured Variables Measured variables

Physiological sexual Subjective sexual Absorption Positive arousal arousal (state) feelings

Demographic variables Age Marital status Sexual partner Trait variables Sexual thoughts: Frequency Feelings about Sexual behavior Sexual attitudes Absorption (trait) Arousability Imagery vividness Physiological variables Physiological sexual arousal Reaction time Startle response Subjective variables Subjective sexual arousal Absorption (state) Positive feelings Anxiety Disgust Entertainment Boredom Anger Curiosity ∗p

< .01 (significance of correlations)

−.11 .26 .03

.25 .19 .15

−.13 −.01 −.07 −.17 .06 .10 −.02

.22 .20 .28

.06 .30 .32

.31 .61∗ −.11 .29 −.04 −.02 −.13

.39 .52 −.02 .32 −.08 .09 .12

.44 .41 .25 .29 −.11 .02 .15

— .22 −.65

.83∗ −.01 −.68∗

.61∗ −.04 −.64

.48∗ .06 −.67∗

.83∗ .61∗ .48∗ .38 .26 .69∗ −.58∗ .39 .25

— .84∗ .64∗ .48∗ .37 .84∗ −.54∗ .37 .40∗

.84∗ — .74∗ .48∗ .54∗ .74∗ −.48∗ .41∗ .58∗

.64∗ .74∗ — .31 .56∗ .64∗ −.26∗ .55∗ .62∗

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viewing the film, curiosity, disgust, anger, and startle response. Physiological sexual response did not correlate significantly with any of the trait measures, while subjective sexual arousal correlated significantly with the extent to which one engaged in sexual fantasy and felt positive about this fantasizing.

DISCUSSION Within the framework of psychophysiology, the present study assessed the relative contribution of attentional and emotional factors in the sexual response of males to erotic film. It was found that the attentional and emotional processes allocated to erotic film were different from those utilized in the processing of non-erotic (nature) material. The erotic film was more sexually arousing (both physiologically and subjectively), absorbing, pleasing, and entertaining than the non-erotic material, with the latter being identified as particularly boring in content. The erotic film elicited a diminished startle response to a sudden burst of white noise presented during the film relative to the nature film, suggesting that at a physiological level the erotic segments of film were emotionally perceived to be more appetitive. There were no significant differences between the two film types with respect to the reported levels of anxiety, disgust, and anger. Greater physiological and subjective sexual arousal was demonstrated to erotica than nature scenes. This increase in arousal to erotica correlated with subjects becoming absorbed in the activities portrayed in the erotic film and experiencing the depicted erotic encounters as appetitive, as opposed to subjects experiencing higher levels of distraction and aversion during the nature segments. These findings are in accordance with those of Koukounas and McCabe (1997), who examined these interrelationships with subjective but not physiological sexual arousal. Both physiological and subjective sexual arousal also correlated positively with the degree to which subjects experienced entertainment and curiosity to the erotic film segments, but negatively with boredom to the erotica. The degree to which subjects became absorbed in the erotic scenarios depicted in the film was associated with the appetitive emotions generated by the film and the extent to which participants found the material entertaining. Similarly, positive feelings were demonstrated toward the erotica, and this might be due to the finding that the sexual content entertained rather than bored the male respondents. Further, subjective sexual arousal was positively correlated with anxiety. Thus it would appear that subjects were aroused by the very film segments that caused them considerable anxiety. Perhaps anxiety increased general arousal levels and so enhanced sexual arousal (Barlow, 1986). Anxiety may augment physiological sexual arousal to erotica in men (Barlow et al., 1983), although the heightened sexual arousal following anxiety may be the result of an anxiety-relief, or positive-contrast, effect (Wolpe, 1978). Postexperimental inquiry suggested that the anxiety elicited by the erotica

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was directed at the attitude of indifference demonstrated by the male actor toward the female protagonist in the film, and by the highly graphic nature of the stimulation. Of course, it is also possible that the sexual arousal to erotica produced general physiological arousal, which was subsequently cognitively labelled or interpreted as anxiety, as predicted by a cognitive arousal model of sexual response (see Rosen and Beck, 1988). In accordance with Koukounas and Over (1993) and Koukounas and McCabe (1997), it was found that state measures of attentional and emotional information processing predict sexual arousal to erotic film whereas trait measures do not. Thus, contrary to the findings of Harris et al. (1980) and Smith and Over (1987), the level of sexual arousal reported by subjects did not correlate significantly with trait measures of absorption (as indexed by the Tellegen Absorption Scale) nor with vividness of imagery (as assessed by the Betts Questionnaire upon Mental Imagery). No significant relationship was identified between physiological and subjective sexual arousal and general level of emotional arousal (indexed by the Arousability Scale) suggesting, as Rosen and Beck (1988) have pointed out, that sexual arousal may be a specific form of generalized arousal with its own unique psychological processes. The magnitude of the sexual response generated by the erotic film was not related to the age of the respondent, nor to the individual’s extent of experience with a range of heterosexual activities. Unlike the findings of Koukounas and McCabe (1997) with males and females, sexual arousal was not augmented in persons who had engaged in sexual fantasy either during masturbation or to supplement their repertoire during heterosexual intercourse, but arousal was enhanced if subjects found their fantasies to be pleasantly engaging. These findings indicate that the emotional processing of one’s sexual fantasies is a better predictor of one’s sexual arousal to erotic film than the frequency with which one fantasizes during autoerotic activities or sexual intercourse. As Leitenberg and Henning (1995) have suggested, the experience of sexual fantasy in itself appears to be a pleasurable nonthreatening form of sexual experience in which the individual feels safe enough to explore their sexuality. When Koukounas and Over (1993, 1999) assessed attentional focus in conjunction with physiological and subjective sexual arousal during erotic stimulation in males, they found that shifts in sexual response with repeated stimulation were closely paralleled by changes in attentional processing. This pattern was true of attentional focus, indexed by self-report and by objective measurement through a secondary-task reaction time paradigm. To examine the proposition that absorbed attention and positive emotions influence the extent to which one becomes sexually aroused, objective and subjective measures of these phenomena were introduced in the present study. The secondary-task reaction time paradigm was presented as a method of indexing attentional processes allocated to the film material. The data did not, however, support the contention that reaction time was an index of absorbed attention to the erotic stimuli. It is likely that absorption in erotic film is

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made up of several components, especially emotional valence, and that attentional resources addressed by the reaction time technique are only a small component. This suggestion is supported by the finding that subjective levels of absorption were strongly correlated with both physiological and subjective levels of sexual arousal. Koukounas and Over (2000) also identified a relatively new tool for measuring the nature of emotional processing during erotic stimulation, namely, the startle reflex response. Since startle stimuli are aversive in nature, Koukounas and Over found that with repeated erotic stimulation, as the material became boring and aversive, the magnitude of the eyeblink startle response increased across repeated erotic trials. The current study also found that the startle magnitude paralleled the emotional processing of the ongoing stimulus. The startle to white noise was diminished when respondents were watching erotica, but it was augmented during presentation of the nature segments that were rated as boring and repetitive (and were experienced as less appetitive stimuli). This finding is in accordance with the research conducted by Lang et al. (1990), and also in accordance with the study by Jansen and Frijda (1994) that compared the startle response to white noise presented during film stimuli depicting negative (fearful) and positive (sexual) contents and found that eyeblink magnitude was diminished during the sexual stimuli relative to the fearful stimuli. The startle response was also strongly negatively correlated with the subjective report of positive emotional response to the film segments, suggesting that positive physiological response was associated with a positive subjective response. This would suggest that the eyeblink startle response represents a valid tool in the investigation of the emotional processing of a stimulus. The startle response did not significantly correlate with the experience of disgust to the erotica. This contrasts with the findings of Kaviani et al. (1999), who found that sometimes film clips which are found to be repulsive can actually inhibit the startle reflex rather than augment it, and suggested that film stimuli that are experienced as repulsive may produce perceptual and emotional “blunting” that reduces startle amplitude. These findings, however, were determined with respect to aversive film clips depicting surgery, whereas the current findings with respect to erotica suggest that these films are reported to be both simultaneously appetitive and eliciting negative emotions, but are still experienced physiologically as appetitive. As an extension to the findings of Koukounas and McCabe (1997), the multidimensional (and complex) nature of the sexual response was demonstrated by the fact that the magnitude of physiological sexual arousal was related to state-assessed appetitive attentional and emotional variables, such as absorption, pleasure, and entertainment, and aversive variables, such as boredom. The magnitude of subjective sexual arousal was related to these same state variables (along with curiosity and anxiety), and also to physiological factors (magnitude of startle response) and a trait variable (whether or not one engaged in sexual fantasies and found these to be pleasantly engaging). The inclusion of anxiety in the state-assessed variables

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related to subjective sexual arousal is in accordance with the findings of Bozman and Beck (1991). The fact that respondents experienced anxiety to the erotic film, yet were sexually aroused by their curiosity to the material, suggests that socialization factors play a role in the information processing of erotica. We are socialized and educated to identify the aversive qualities of pornography by religious, moral, or even legal restrictions, but remain curious and sexually aroused to the same material by the very nature of our biological predisposition toward the sexually salient. That the magnitude of subjective sexual arousal is related to state-assessed attentional and emotional variables, along with physiological and trait variables, highlights the importance of multiple sexual factors in one’s estimations of their sexual arousal to erotica. The current investigation has highlighted the role played by attentional and emotional processing of erotic film in physiological and subjective sexual arousal. In this instance, the salience of absorbed attention and positive emotions allocated to an erotic stimulus were demonstrated, and the significance of the positive emotions was supported by the measurement of the eyeblink startle response during the film presentation. The order of film segment presentation was not counterbalanced between subjects given that the focus of the present research was to create a composite score representing an averaged response level across the five erotic stimuli. It is unlikely that the sequence of films had an effect on subjects’ responses, since within each subject, there was little or no variation in magnitude of sexual response to the erotic film stimuli. However, the results still need to be treated with some caution because of the possibility of order effects, and future research can address if lack of counterbalancing film order could have resulted in the inadvertent selection of a sequence that produced unique effects. Further, the film segments were each separated by two minutes of blank tape, and this blank space was put in place to ensure that arousal returned to prestimulation levels between film segments. During postexperimental inquiry, respondents reported a lack of sexual thoughts during blank tape presentation, but since arousal levels were not measured between stimulus presentations, it is possible that arousal levels had not returned to baseline between stimuli and that this had a contaminating effect on the next film presentation. Future research might examine physiological and subjective responses during and between film presentations. This investigation focussed on male participants, and a relatively high degree of concordance was found between physiological and subjective measures of sexual arousal as has been found previously (Koukounas and Over, 1993, 1997, 1999, 2000) (see Rosen and Beck, 1988, for an overview of sexual response concordance). Psychophysiological research with women, however, has found a general discordance between sexual response measures (Heiman, 1977, 1980), suggesting that women may not be using their physiological arousal to estimate their subjective sexual response levels. It has been suggested that women are more likely to use indices such as subjective affective states as criteria when estimating magnitude

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of subjective sexual arousal (Korff and Geer, 1983). The prediction from this hypothesis is that, relative to males, females would demonstrate a higher degree of concordance between subjective sexual arousal and positive emotions assessed both through self-report and through eyeblink startle response. What is clearly needed in subsequent research is to examine female psychophysiological response patterns and compare these with those of men using the eyeblink startle response as a measure of emotional information processing during erotic stimulation. The current study was conducted with a group of men who did not experience sexual dysfunction. Future research should also evaluate whether or not the nature of response to erotic stimuli is similar among sexually dysfunctional men and women, and whether the interrelationship between subjective and physiological measures, as well as among absorption, emotion and sexual response, are replicated. REFERENCES American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders, 4th edn., American Psychiatric Press, Washington. Anthony, B. J. (1985). In the blink of an eye: Implications of reflex modification for information processing. Adv. Psychophysiol. 1: 167–218. Bancroft, J. (1989). Human Sexuality and its Problems, 2nd edn., Churchill Livingstone, Edinburgh. Barlow, D. H. (1986). Causes of sexual dysfunction: The role of anxiety and cognitive interference. J. Consult. Clin. Psychol. 54: 140–157. Barlow, D. H., Sakheim, D. K., and Beck, J. G. (1983). Anxiety increases sexual arousal. J. Abnorm. Psychol. 92: 49–54. Beck, J. G., and Barlow, D. H. (1986a). The effects of anxiety and attentional focus on sexual responding: I. Physiological patterns in erectile dysfunction. Behav. Res. Ther. 24: 9–17. Beck, J. G., and Barlow, D. H. (1986b). The effects of anxiety and attentional focus on sexual responding: II. Cognitive and affective patterns in erectile dysfunction. Behav. Res. Ther. 24: 19–26. Bentler, P. M. (1968). Heterosexual behaviour assessment-I. Males. Behav. Res. Ther. 6: 21–25. Bozman, A. W., and Beck, J. G. (1991). Covariation of sexual desire and sexual arousal: The effects of anger and anxiety. Arch. Sex. Behav. 20: 47–60. Bruce, T. J., and Barlow, D. H. (1990). The nature and role of performance anxiety in sexual dysfunction. In Harold Leitenberg (ed.), Handbook of Social and Evaluation Anxiety, Plenum Press, New York. 357–384. Dawson, M. E. (1990). Psychophysiology at the interface of clinical science, cognitive science, and neuroscience. Psychophysiology 27: 243–255. Dekker, J., and Everaerd, W. (1988). Attentional effects on sexual arousal. Psychophysiology 25: 45–54. Dekker, J., and Everaerd, W. (1989). A study suggesting two kinds of information processing of the sexual response. Arch. Sex. Behav. 18: 435–447. Fiorito, E. R., and Simons, R. F. (1994). Emotional imagery and physical anhedonia. Psychophysiology 31: 513–521. Gold, S. R., and Chick, D. A. (1988) Sexual fantasy patterns as related to sexual attitude, experience, guilt and sex. J. Sex Educ. Ther. 14: 18–23. Hale, V. E., and Strassberg, D. S. (1990) The role of anxiety on sexual arousal. Arch. Sex. Behav. 19: 569–581. Harris, R., Yulis, S., and Lacoste, D. (1980). Relationships among sexual arousability, imagery ability, and introversion-extraversion. J. Sex Res. 16: 72–86. Hatano, Y. (1993) Sexual activities of Japanese youth. J. Sex Educ. Ther. 19: 131–144. Heiman, J. R. (1977). A psychophysiological exploration of sexual arousal patterns in females and males. Psychophysiology 14: 266–274.

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Heiman, J. R. (1980). Female sexual response patterns: Interactions of physiological, affective, and contextual cues. Arch. Gen. Psychiatry 37: 1311–1316. Hsu, B., Kling, A., Kessler, C., Knapke, K., Diefenbach, P., and Elias, J. E. (1994) Gender differences in sexual fantasy and behavior in a college population: A ten-year replication. J. Sex Marital Ther. 20: 103–118. Jansen, D. M., and Frijda, N. H. (1994) Modulation of the acoustic startle response by film induced fear and sexual arousal. Psychophysiology 31: 565–571. Julien, E., and Over, R. (1988). Male sexual arousal across five modes of erotic stimulation. Arch. of Sex Behav. 17: 131–143. Kaplan, H. S. (1974). The New Sex Therapy. Brunner/Mazel New York. Kaviani, H., Gray, J. A., Checkley, S. A., Kumari, V., and Wilson, G. D. (1999). Modulation of the acoustic startle reflex by emotionally-toned film-clips. Int. J. Psychophysiol. 32: 47–54. Keppel, G. (1991). Design and Analysis: A Researcher’s Handbook, 3rd edn., Prentice Hall, New Jersey. Korff, J., and Gear, J. H. (1983). The relationship between sexual arousal experience and genital response. Psychophysiology 20: 121–127. Koukounas, E., and McCabe, M. (1997) Sexual and emotional variables influencing sexual response to erotica. Behav. Res. Ther. 35: 221–231. Koukounas, E., and Over, R. (1993). Habituation and dishabituation of male sexual arousal. Behav. Res. Ther. 31: 575–586. Koukounas, E., and Over, R. (1997). Male sexual arousal elicited by film and fantasy matched in content. Aust. J. Psychol. 49: 1–5. Koukounas, E., and Over, R. (1999). Allocation of attentional resources during habituation and dishabituation of male sexual arousal. Arch. Sex. Behav. 28: 539–552. Koukounas, E., and Over, R. (2000). Changes in the magnitude of the eyeblink startle response during habituation of male sexual arousal. Behav. Res. Ther. 38: 573–584. Laan, E., Everaerd, W., van Bellen, G., and Hanewald, G. (1994). Women’s sexual and emotional responses to male- and female-produced erotica. Arch. Sex. Behav. 23: 153–172. Lang, P. J., Bradley, M. M., and Cuthbert, B. N. (1990). Emotion, attention and the startle reflex. Psychol. Rev. 97: 377–395. Leitenberg, H., and Henning, K. (1995). Sexual fantasy. Psychol. Bull. 117: 469–496. Lopez, P. A., and Geotge, W. H. (1995) Men’s enjoyment of explicit erotica: Effects of person-specific attitudes and gender-specific norms. J. Sex Res. 32: 275–288. Mehrabian, A. (1976). Manual for the Questionnaire Measure of Stimulus Screening and Arousability. University of California Press, Los Angeles, California. Morokoff, P. J., and Heiman, J. R. (1980). Effects of erotic stimuli on sexually functional and dysfunctional women: Multiple measures before and after sex therapy. Behav. Res. Ther. 18: 127–137. Mosher, D. L., and Maclan, P. (1994) College men and women respond to X-rated videos intended for male or female audiences: Gender and sexual scripts. J. Sex Res. 31: 99–113. Patrick, C. J. (1994). Emotion and psychopathy: Startling new insights. Psychophysiology 31: 319–330. Rosen, R. C., and Beck, J. G. (1988). Patterns of Sexual Arousal:Psychophysiological Processes and Clinical Applications. Guilford, New York. Rowland, D. L., Cooper, S. E., and Heiman, J. R. (1995). A preliminary investigation of affective and cognitive responses to erotic stimulation in men before and after sex therapy. J. Sex Marital Ther. 21: 3–20. Rowland, D. L., and Slob, A. K. (1995). Understanding and diagnosing sexual dysfunction: Recent progress through psychophysiological and psychological methods. Neurosci. Biobehav. Rev. 19: 201–209. Sakheim, D. K., Barlow, D. H., Beck. J. G., and Abrahamson, D. J. (1984). The effect of an increased awarencess of erectile cues on sexual arousal. Behav. Res. Ther. 22: 151–8. Seto, M. C. (1992). A review of anxiety and sexual arousal in human sexual dysfunction. Ann. Sex Res. 5: 33–43. Sheehan, P. W. (1967). A shortened form of the Betts Questionnaire upon Mental Imagery (QMI). J. Clin. Psychol. 23: 386–389. Smith (1986). Imagery and male sexual arousal. Unpublished doctoral dissertation, Borchardt Library, La Trobe University, Australia.

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Smith, D., and Over, R. (1987). Correlates of fantasy-induced and film-induced male sexual arousal. Arch. Sex. Behav. 16: 395–409. Talmadge, L. D., and Talmadge, W. C. (1990) Sexuality assessment measures for clinical use: A review. Special Issue: Marital and family measurements. Am. J. Fam. Ther. 18: 80–105. Tellegen, A., and Atkinson, G. (1974). Openness to absorbing and self-altering experiences (“absorption”), a trait related to hypnotic suggestibility. J. Abnorm. Psychol. 83: 268–277. Vonderheide, S., and Mosher, D. L. (1988) Should I put in my diaphragm? Sex guilt and turn offs. J. Psychol. Hum. Sex. 1: 97–111. Wolpe, J. (1978). Comments on “A test of reciprocal inhibition” by Hoon, Wincze, and Hoon. J. Abnorm. Psychol. 87: 452–454.

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Depot-Leuprolide Acetate for Treatment of Paraphilias: A Report of Twelve Cases Richard B. Krueger, MD,1,2 and Meg S. Kaplan, PhD1

A new class of antiandrogen medications, gonadotropin-releasing hormone agonists, offers promise in the treatment of the paraphilias, with substantially less side effects than medroxyprogesterone acetate or cyproterone acetate. This paper reports the results of treatment using a depot suspension of leuprolide acetate on 12 patients with paraphilic disorders or with sexual disorders not otherwise specified to suppress or help these individuals control their deviant sexual behavior or impulses. The method involved uncontrolled observations of individuals treated with depot-leuprolide acetate for various lengths of time, from 6 months to 5 years, with the follow-up intervals ranging from 6 months to 6 years. Leuprolide acetate resulted in a significant suppression of deviant sexual interests and behavior as measured by self-report and was well tolerated. However, the three patients who were on long-term therapy developed bone demineralization, suggesting that this is a significant side effect of prolonged therapy. Leuprolide acetate shows promise as a treatment for the paraphilias. KEY WORDS: sex offenders; paraphilia; leuprolide acetate; antiandrogens; LHRH agonists.

INTRODUCTION The paraphilias are a significant source of social costs (Bradford, 1998) and victimization (Rosler and Witztum, 1998), as well as personal distress for individuals with these disorders. Surgical castration and antiandrogen agents have been used to treat these disorders (Bradford, 1985, 1988), but have substantial adverse side effects (Gijs and Gooren, 1996). Recently, a number of reports have detailed the use of gonadotropin-releasing hormone agonists to treat the paraphilias. Although several 1 Department

of Psychiatry, College of Physicians and Surgeons, Columbia University, New York,

New York. 2 To whom correspondence should be addressed at Sexual Behavior Clinic, New York State Psychiatric

Institute, 1051 Riverside Drive, Unit #45, New York, New York 10032-2695. 409 C 2001 Plenum Publishing Corporation 0004-0002/01/0800-0409$19.50/0 °


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of these agents have been synthesized and are available, their actions are similar (Ascoli and Segaloff, 1996). Three groups have reported on the use of triptorelin (Rosler and Witztum, 1998; Thibaut et al., 1993, 1996). Rousseau et al. (1990) reported on the use of LHRH ethylamide. Single case-reports of use of leuprolide acetate for the treatment of a patient with exhibitionism and Huntington’s Disease (Rich and Ovsiew, 1994), and of patients with pedophilia (Cooper and Cernovsky, 1994, Dickey, 1992) have been described. We present herein the use of leuprolide acetate to treat 12 individuals with paraphilic disorders or with sexual disorders not otherwise specified.

METHODS Patients were obtained through consultation with a state hospital system or from a private practice with a specialty of treatment of individuals with paraphilias. The decision to administer depot-leuprolide acetate was made on a case-by-case basis after appropriate treatment options were presented to individual patients or to those designated to consent for them. Informed consent was obtained for all patients treated. All individuals consented to the depot-leuprolide acetate without any court or legal mandate for this specific treatment, and all individuals had clinically identified problems of a paraphilia or of a sexual disorder not otherwise specified. Baseline physical and laboratory examinations that included testosterone, follicle-stimulating hormone, and lutenizing hormone levels, and blood chemistries were obtained prior to inception of leuprolide acetate treatment except as indicated, and at variable intervals thereafter. Standard radioimmune assay techniques were used by the commercial laboratories performing the laboratory evaluations. Patients were referred to their attending medical physicians for an evaluation to assess and address the risks of leuprolide acetate treatment. Beginning in 1999, baseline bone density evaluations were additionally obtained as part of a baseline examination to assess for the development of osteopenia and osteoporosis, both side effects of prolonged antiandrogen therapy. Three patients treated for 3, 4, and 4.5 years had a bone density evaluation to assess for osteoporosis; only one of these had a baseline bone density evaluation prior to the inception of therapy. To counteract a surge of follicle-stimulating hormone and lutenizing hormone, and thus testosterone, each patient was treated with flutamide, 250 mg by mouth three times per day for 30 days, beginning on the day of inception of depotleuprolide acetate treatment. The flutamide was then discontinued. Leuprolide acetate was administered at a dose of 7.5 or 3.75 mg intramuscularly at monthly intervals. All initial clinical assessments and ratings were based on direct clinical interviews; subsequent assessments were based on either direct interview or on


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consultation with the patients attending psychiatrist or other caregivers. All diagnoses were made according to DSM-IV (American Psychiatric Association, 1994). Some individuals received other treatments for their paraphilias, including weekly cognitive–behavioral group therapy or individual supportive therapy and monthly relapse-prevention therapy, and received treatment for other medical and mental disorders as was indicated.

RESULTS All baseline medical examinations and laboratory assessments, which were obtained were reported as being within normal limits; in some instances baseline endocrine or laboratory measurements were not obtained or exact values were not recorded. Normal limits for reported laboratory measurements varied because different laboratories were used for various patients. The cases are summarized in the accompanying table (Table I). Patient #1 was a 40-year-old male with diagnoses of borderline personality disorder, alcohol dependence, and in the distant past cocaine and opiate dependence, recurrent major depression, and dysthymia, with eight psychiatric hospitalizations. He had had a history of pedophilia since his early teens, with a specific interest in pubescent males; he also had a self-reported homosexual orientation with a lesser interest in adult males. He reported recurrent sadistic sexual fantasies involving pubescent males, which had been present for more than 20 years. He had a history of phenytoin-induced liver failure and of hepatitis B and hepatitis C, with normal liver function tests. He had previously been on fluoxetine, 60 mg/day, for a 1-year period without effect on his deviant sexual fantasies; this had been discontinued a year prior to his presentation. He received depot-leuprolide acetate, 7.5 mg, for a 10-month period. He was also assessed as being depressed and was treated concomitantly with fluoxetine 60 mg/day and trazodone 200 mg/day. He continued in weekly cognitive–behavioral group therapy for a year and in a monthly relapse prevention group for a second year. The patient reported that with the combination of leuprolide acetate, fluoxetine, trazodone, and group therapy he had a suppression of all sexual fantasy and functioning, and, in particular, of all sadistic sexual interest and sexual and masturbatory fantasy involving boys. This suppression continued (1) after the leuprolide acetate was discontinued, at his request because of his dislike of the loss of sexual functioning, (2) after his fluoxetine and trazodone were stopped 3 months later, and (3) after the group therapy was discontinued a year later. On cessation of leuprolide acetate treatment, the patient required 4 months before restoration of sexual and ejaculatory functioning. On interviews annually thereafter over a 4-year period, the patient reported that his deviant sexual interests remained absent, although he had had a return to normal sexual functioning and consensual sexual relationships with adult males.

Age 40

31

48

28

20

42

39

Patient

1

2

3

4

5

6

7

1. Sexual disorder NOS 2. Severe mental retardation 3. Psychotic disorder NOS

57

Cessation of aggressive sexual behavior

Markedly reduced sexual arousal and sadistic sexual fantasy Markedly reduced sexual arousal and interest

Mild gynecomastia; loss of ability to ejaculate and have erections; developed depression after leuprolide initiated Mild gynecomastia; loss of ability to ejaculate and have erections; mild to moderate demineralization

Loss of ability to ejaculate; ability to have erections maintained

412

11

11

Loss of ability to ejaculate and have erections; mild to moderate demineralization

11:10

1. Pedophilia 2. XYY karyotype 3. Conduct disorder NOS 1. Sexual masochistic disorder 2. Alcohol abuse 3. Recurrent major depression

Markedly reduced sexual arousal

Loss of ability to ejaculate and have erections, mild nausea, and vomiting

April 18, 2001

57

Markedly reduced sexual arousal

Loss of ability to ejaculate and have erections; 4 months until sexual function returned after depotleuprolide was discontinued Loss of ability to ejaculate and have erections

PP125-301060

6

Markedly reduced deviant sexual arousal 2 years after leuprolide was discontinued

Markedly reduced deviant sexual arousal 4 years after leuprolide was discontinued

Side effects noted P2: FTK/GCY

1. Exhibitionism 2. Voyeurism 3. Bipolar Type II 4. Alcohol dependence 1. Pedophilia 2. Borderline intellectual functioning 3. Borderline Personality disorder

10

10

Outcome


1. Pedophilia 2. Recurrent major depression 3. Alcohol, cocaine, opiate dependence 4. Borderline personality disorder 1. Exhibitionism 2. Sexual disorder NOS 3. Recurrent major depression 4. Alcohol dependence 5. ADHD

Principal diagnoses

Duration (in months) of 7.5 mg of leuprolide

Table I. Depot-Leuprolide Acetate for the Treatment of the Paraphilias: A Report of 12 Cases

P1: FQS/GDX/GDW/LOV/GGT Tally: FTK Style file version Nov. 19th, 1999

Krueger and Kaplan

36

33

47

37

25

8

9

10

11

12

1. Pedophilia 2. Alcohol dependence 3. Recurrent major depression 1. Pedophilia 2. Voyeurism 3. S/P closed head trauma 4. Depressive disorder NOS 1. Exhibitionism 2. Frotteurism 3. Voyeurism

1. Public masturbation 2. Exhibitionism 3. S/P closed head injury with left frontal lobectomy 1. Exhibitionism 2. Pedophilia

PP125-301060

Patient and staff reported decreased sexual interest

Loss of ability to ejaculate and have erections; statistically significant demineralization compared with baseline bone density evaluation Unilateral gynecomastia; loss of ability to ejaculate and have erections; 3 months until sex functioning returned

Loss of ability to ejaculate and have erections

Loss of ability to ejaculate and have erections

Decreased ability to ejaculate and have erections; however ability to have both was maintained

P2: FTK/GCY

12

Patient and staff reported decreased sexual arousal and preoccupation

Reported loss of sexual arousal and interest

Reduced sexual arousal, exhibitionism, and frotteurism

Reduced sexual arousal; cessation of exhibitionism and public masturbation


35

16 and 11

9, 5 at 7.5 mg/ month; 3 at 3.75 mg/month

9, 6, 4 at 7.5 mg/ month; 9 with 3.75 mg/month

P1: FQS/GDX/GDW/LOV/GGT Tally: FTK April 18, 2001


11:10 Style file version Nov. 19th, 1999

413


414

P2: FTK/GCY PP125-301060


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Krueger and Kaplan

Patient #2 was a 31-year-old male diagnosed with exhibitionism, public masturbation, voyeurism, and compulsive use of prostitutes and peep shows. In addition, he had diagnoses of alcohol dependence and marijuana dependence, with abstinence and the use of 12-step programs for 7 years prior to his initial evaluation, and of recurrent major depression. Two years of weekly treatment with a cognitive–behavioral therapist had failed to control his deviant sexual impulses. He could not tolerate sertraline at a dose of 50 mg/day because of gastrointestinal side effects. He was started on oral medroxyprogesterone acetate tablets, preferring oral medication to intramuscular injections, 40 mg/day, while increased to 120 mg/day, with his wife observing his daily ingestion of medication; he remained on this medication for a 3-month period with his testosterone level going from a baseline of 233 ng/dl (normal being 194–833 ng/dl) to 178 ng/dl after 1 month of medroxyprogesterone acetate, 40 mg/day, and 148 ng/dl after 2 additional months of 120 mg/day. He was arrested for exhibitionism after 3 months of treatment with the medroxyprogesterone acetate and ultimately sentenced to 3 years of probation. After the 3 months of medroxyprogesterone acetate therapy and his arrest, he was started on depot-leuprolide acetate, 7.5 mg intramuscularly monthly, which he remained on for 10 months. His testosterone lowered to 27 ng/dl 2 months after the leuprolide acetate was started. During the course of these antiandrogen treatments he was involved in a weekly cognitive–behavioral group during which he learned techniques of masturbatory satiation and covert sensitization. After he discontinued the depot-leuprolide acetate, he reported having more control over all aspects of his deviant sexual behavior. He has continued for 2.5 years in a monthly relapse prevention group with markedly reduced deviant fantasies and reported deviant behavior and with otherwise normal heterosexual interest and functioning. Patient #3 was a 48-year-old male with exhibitionism and voyeurism who also had a history of alcohol, marijuana, and cocaine dependence, and a bipolar type II disorder. He had been abstinent from all drugs and alcohol for 4 years at the time of evaluation. He had been maintained for several years on clomipramine 150 mg/day, valproic acid 1500 mg/day, paroxetine 60 mg/day, and naltrexone 50 mg/day. He had been previously treated with depot-medroxyprogesterone acetate, 200 mg intramuscularly weekly, for several years, which had been discontinued 3 years prior to the initial evaluation during a transition of psychiatrists. For 8 years prior to the initial evaluation he had also continued in a weekly supportive and cognitive– behavioral group for individuals with paraphilias. He began impulsively exposing himself after the medroxyprogesterone acetate was discontinued and was ultimately arrested. He was treated with depot-leuprolide acetate, 7.5 mg monthly, added to the regimen mentioned earlier, with a report of cessation of exhibitionistic impulses, which has continued for 6 months. His testosterone level dropped from a baseline of 950 ng/dl (normal being 260–1000 ng/dl) to 34 ng/dl. The patient said that his control of his exhibitionistic impulses on the leuprolide acetate was far


P2: FTK/GCY PP125-301060



11:10


415

better than on the previous regimen, which relied on depo-medroxyprogesterone acetate instead of depot-leuprolide acetate, in addition to the other medications. Patient #4 was a 28-year-old male who had been institutionalized in a state mental health system for 5 years at the time of initial evaluation. He had diagnoses of borderline personality disorder, cerebral palsy, and borderline intellectual functioning. He had had a history of pedophilia since his teens with numerous arrests and probation. He persisted with this deviant arousal despite masturbation satiation therapy, lithium, and sertraline. He initiated a lawsuit against the state government to permit him to have antiandrogen treatment and after assessment was started on depot-leuprolide acetate, 7.5 mg monthly. He reported the disappearance of all sexual functioning and fantasies, including those involving children. He remained on 7.5 mg of leuprolide acetate for 4.5 years, and was transitioned into a halfway house on the grounds of the state hospital where he was cared for. The patient was transferred back to a locked unit because of suicidal ideation, but he continued to report no sexual interest or arousal toward children and plans were continually being made to place him in a supervised community residence. The patient’s baseline testosterone was 399 ng/dl (normal was 225–900 ng/dl); 3 weeks after his initial injection of leuprolide acetate his testosterone was 38 ng/dl; at 2 years his testosterone was 55 ng/dl; and at 3 years it was 27 ng/dl. The patient did not have a bone density evaluation until 4.5 years of therapy had elapsed; this showed mild to moderate osteopenia. The patient elected to continue with the depotleuprolide treatment, calcium supplementation, and bone density evaluations every 6 months. Patient #5 was a 20-year-old male with the XYY karyotype, conduct disorder not otherwise specified, and depressive disorder not otherwise specified and who had been a resident for several years in a residential treatment facility. He had a history, for many years, of recurrent sadistic pedophilic fantasies involving young males, without any overt behavior. His history of sadistic fantasy interfered with placement of the patient in a less-restrictive facility. A trial of sertraline up to 200 mg/day had no effect on this fantasy. A trial of depot-leuprolide acetate, 7.5 mg monthly, resulted in the suppression of such fantasy, and indeed, of all sexual fantasies, such that a transfer from the intensive residential treatment facility into a community program was effectuated. The patient was able to be involved in a sex-offender-specific outpatient program that previously would not accept him. After 11 months of depot-leuprolide acetate therapy, he retained an ability to have an erection, but not to ejaculate. The patient’s testosterone dropped from a pretreatment baseline of 541 ng/dl (normal 241–827 ng/dl) to 53 ng/dl at 1 month and 18 ng/dl at 2 months postinception of the depot-leuprolide acetate. Patient #6 was a 42-year-old male with a history of recurrent major depression, alcohol abuse, exhibitionism, public masturbation, sexual masochism, and recurrent visits to prostitutes. He was a married heterosexual male and his sexual masochism and other disorders had been severely interfering with his relationship


416

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with his wife. He could not tolerate sertraline and requested for depot-leuprolide acetate that he was started on at a dose of 7.5 mg monthly, and which resulted in the cessation of all deviant sexual interest or activity. The patient’s pretreatment testosterone was 525 ng/dl (normal being 194–833 ng/dl); and his testosterone 2 months after leuprolide acetate inception was

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