paraphilic disorder
Explain the diagnostic criteria for the gender dysphoria, paraphilic disorder, or sexual dysfunction you selected.
Explain the evidenced-based psychotherapy and psychopharmacologic treatment for the gender dysphoria, paraphilic disorder, or sexual dysfunction you selected.
Review Article 2019; 1(1): 4 NEURO RESEARCH
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Citation: Perrotta G (2019). Paraphilic Disorder: Definition, Contexts and Clinical Strategies. Neuro Research 1(1): 4.
ISSN: 2689-3193
DOI: https://doi.org/10.35702/nrj.10004
Paraphilic Disorder: Definition, Contexts and Clinical
Strategies
Giulio Perrotta
¹Director, Department of Criminal and Investigative Psychology UNIFEDER, Italy
*Corresponding author:
Giulio Perrotta
Director, Department of Criminal and Investigative
Psychology UNIFEDER, Italy.
Received : September 4, 2019
Published : September 24, 2019
ABSTRACT
Starting from the concept of paraphilic disorder, we proceeded
to list the individual forms envisaged by the DSM-V, with
a series of focus on clinical, psychodynamic, cognitive-
behavioural and strategic profiles, focusing the analysis above
all on the resolving context of the problems analyzed.
KEYWORDS: Psychology; Neuroscience; Anxiety; Prefrontal
Cortex; Limbic System; Voyeurism; Paraphilia; Paraphilic
Disorder; Paraphiliac Disorders; Paedophilia; Rape; Sexology;
Exhibitionism; Frotteurism; Masochism; Sadism; Fetishism;
Transvestism; Psychotherapy; Psychopharmacology; Mood-
Stabilizing Drugs; Antidepressants; Anxiety; Strategic
Approach.
DEFINITION AND CLINICAL CONTEXT OF PARAPHILIAC
DISORDERS
Definitions and preliminary distinctions
The evolution of the definition of perverted or paraphilic
sexual activity reveals how psychiatric nosography reflects
the society that expresses it. In the context of a culture that
considered sexuality in relatively narrow terms, Freud (1905)
first, in a closed socio-cultural context but eager to open up,
defined perverse sexual activity according to various criteria,
such as: focusing of body regions not necessarily genitals (eg:
neck, back, …); the replacement of the usual sexual practice
exclusively focused on genital contacts with a partner of the
other sex, often for procreative purposes, according to the
religious direction; the tendency to be the exclusive practice of
the individual. From his first paper, however, cultural attitudes
relating to sexuality have changed radically, thanks to
globalization and the spread of telematics and social networks
capable of connecting individuals separated by oceans and
continents. Over the decades, from the first theorizations of
the beginning of the last century, not surprisingly, couples (in
their intimacy) have cleared a variety of sexual behaviours so
to speak “bizarre”, up to the removal of perverse behaviours
like anal penetration and homosexual orientation [1].
According to McDougall (1986), perverse fantasies are
found in all adult sexual behaviour, but cause few problems
as they are not experienced as compulsive, or at least as
loss of control (so to speak, egodistoniche concerning the
external environment). He also suggested using the term
“neo-sexuality” to refer to paraphilias, to purify the subject of
moralistic and pejorative tones, children of an obscurantist
view of reason.
Stoller (1975, 1985) suggested instead a narrower definition
of “sexual perversion”, meaning it as the erotic form of hatred.
In essence, he asserted that cruelty, the desire to humiliate
and degrade the sexual partner, and even themselves, are
crucial determinants for classifying perverse behaviour.
According to this perspective, the intention of the individual is
a critical variable in defining perversion. An individual is called
perverse, only when the erotic act is used to avoid a long-
term, emotionally intimate relationship with another person.
The definition of the paraphilias of the DSM-IV [2], in an attempt
to be non-judgmental, suggested the restriction of the term
to situations in which non-human objects are used, actual
pain is inflicted on oneself, or one’s partner or humiliation, or
non-consenting children or adults are involved. To consider
the continuum between fantasy and action, the DSM-IV has
developed a spectrum of gravity:
a) in mild forms, patients are troubled by their
2019; 1(1): 4Perrotta G.
Citation: Perrotta G (2019). Paraphilic Disorder: Definition, Contexts and Clinical Strategies. Neuro Research 1(1): 4.
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ISSN: 2689-3193
DOI: https://doi.org/10.35702/nrj.10004
paraphiliac sexual urges, but do not implement them;
b) in conditions of moderate severity, patients
translate thrust into action, but only occasionally;
c) in severe cases, patients repeatedly perform their
paraphiliac thrusts.
The genesis of the paraphilic disorder
The aetiology of paraphilias remains full mainly of mystery.
Although some studies have suggested that biological factors
contribute to the pathogenesis of perversions, the data are
currently conflicting. Even if biological factors are present
(which we will see in the paragraph dedicated to neural
correlates), it is undoubtedly the psychological reasons that
play a decisive role in the choice of paraphilia and the meaning
underlying the sexual acts.
The classical (or psychodynamic) vision [3] of perversions,
according to Freud’s (1905) drive theory, he believed that in
these disorders “instinct” and “object” were separated from
each other: “the sexual drive is probably at first independent
of its object”. Therefore, in perversions, according to this
orientation, fantasies become conscious and are expressed
directly as “pleasant” ego-syntonic activities.
Continuing on this theoretical orientation, according
to Fenichel (1945), the decisive factor that prevents the
achievement of an orgasm through the conventional genital
relationship is castration anxiety. Perversions, according to
this classical view, therefore perform the function of denying
castration.
Again, for Kohut (1971, 1977), father of the stream of self-
psychology, the perverse activity includes a desperate
attempt to restore the integrity and cohesion of the Self in
the absence of empathic responses from the Self-object by
the others. Sexual activity or fantasy can help the patient
feel alive and healthy when threatened by abandonment or
separation. A perverse behaviour in therapy can be a reaction
to failures of empathy on the part of the therapist, which lead
to a temporary disruption in the Self / object-Self matrix.
According to the scholar Stoller (1975, 1985), the essence of
perversion is the conversion “of childhood trauma into an adult
triumph”. Patients are driven by their fantasies of avenging
humiliating childhood trauma caused by their parents. Their
method of revenge is to humiliate or dehumanize the partner
during the fantasy or the perverse act.
According to Michell (1988), however, perverse sexual activity
can also be an escape from object relationality. Many people
who suffer from paraphilias have separated and individualized
incompletely from their intrapsychic representations of
the mother. The result is that they feel that their identity as
separate people are constantly threatened by a merger of
internal or external objects. Sexual expression can thus be the
only area in which they can assert their independence.
McDougall (1986), as already mentioned, proposes the use of
the term “neo-sexuality” and suggests that sexual behaviour
should evolve from a complicated array of identifications and
counter-identifications with parents. Each child is involved
in an unconscious psychological theatre that arises from
the parents’ unconscious erotic desires and conflicts. So the
obligatory nature of every neo-sexuality is programmed by
parental scripts internalized by the child. Finally, according to
the author, certain sexual practices and objects become like
a drug that the patient uses to treat a sense of internal death
and a fear of disintegration of the Self.
Finally, as regards, specifically, the study of female perversions,
Kaplan (1991) emphasizes that they imply more subtle
dynamics than the more predictable sexuality of male
perversions. The themes of separation, abandonment and
loss are part of the sexual activities that derive from female
paraphilias.
In conclusion, before examining the dynamics of each
paraphilia, we must remember that the individual preference
of a perverse fantasy rather than another remains obscure.
Therefore, the psychodynamic understanding of a patient
involved in perverse sexual activity implies a comprehensive
understanding of how perversion interacts with the underlying
characterological structure of the patient:
1) In the case of exhibitionism, for Freud (1905) and Fenichel
(1945), the exhibitionist exposes his genitals in public
because in this way he is reassured of not being castrated,
as a sort of reaffirmation of his sexual dimension and his
social role. The shock reactions that these actions cause
help him to cope with castration anxiety and give him
a sense of power over the opposite sex. Fenichel has
also associated voyeuristic tendencies with a fixation
on the first infantile scene, in which the child attends or
hears a sexual relationship between the parents. This
early traumatic experience could stimulate the child’s
castration anxiety and then lead him, once an adult, to
re-enact the scene over and over again in an attempt to
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Citation: Perrotta G (2019). Paraphilic Disorder: Definition, Contexts and Clinical Strategies. Neuro Research 1(1): 4.
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DOI: https://doi.org/10.35702/nrj.10004
master a passively experienced trauma actively. Finally,
the scholar also identified an aggressive component in
looking, conceptualizing it as a shift in the desire to be
directly destructive to women, to avoid feelings of guilt.
The scholar Stoller (1985) instead pointed out that the
typically exhibitionistic actions follow a situation in which
the person responsible felt humiliated, often by a woman.
2) Furthermore, the act of showing his genitals allows a man
to regain some sense of value and positive male identity.
Often these men reveal deep insecurity concerning
their sense of masculinity. According to Mitchell (1988),
exhibitionists often feel that they have had no impact on
any person in their family and have, therefore had to resort
to extraordinary measures to be noticed. Even the other
side of exhibitionism, voyeurism, involves the violation
of the private life of an unknown woman, an aggressive
triumph, but secret over the female sex.
3) In the case of sadism and masochism, the discourse is
more articulated. Patients afflicted with sadism are often
unconsciously attempting to overturn childhood scenarios
in which they have been victims of physical or sexual abuse.
For Fenichel (1945), inflicting on others what happened
to them when they were children, they get revenge
and a sense of mastery over childhood experiences of
abuse at the same time. Masochistic patients may be
firmly convinced that they deserve punishment for their
conflicted sadistic desires and that the acceptance of a
sadistic act is a “lesser evil” than their fear of castration.
According to the current of self psychology, masochistic
behaviour can be experienced by the patient as capable
of restructuring the Self. In this regard, a masochistic
patient wrote to her therapist “physical pain is better than
spiritual death”. In relational terms, according to Michell
(1988), sadism often develops from a particular internal
relationship in which the rejecting and distant object
needs an energetic effort to overcome its resistance to its
representation of the Self. Even masochistic patients, who
need humiliation and even pain to achieve sexual pleasure,
maybe repeating childhood experiences of abuse. The
masochistic surrender is essentially the implementation
of an internal object relationship in which the object will
respond to the Self only when it is humiliated.
4) In fetishism, to achieve sexual excitement, fetishists need
to use an inanimate object, often an article of feminine
underwear, or a shoe, or a non-genital part of the body.
Freud initially explained fetishism as derived from
castration anxiety. The object chosen as a fetish represents
the female penis, a shift that helps fetishists overcome
castration anxiety. Following the premise that the
masculine awareness of female genitalia increases man’s
fear of losing his genitals and becoming like a woman,
Freud thought that this unconscious symbolization
explained the relatively frequent presence of fetishism. The
founder of psychoanalysis used this theory to develop his
concept of splitting the ego (1938): in the fetishist’s mind,
two contradictory ideas coexist the denial of castration
and the affirmation of castration. The fetish represents
both. According to Greenacre (1979), fetishism derives
from severe problems in the mother-child relationship: the
child cannot be consoled by the mother or by transactional
objects. To experience bodily integrity, the child, therefore,
needs a fetish, a reassuring, hard, inflexible, immutable
and lasting object. These early pregenital disorders are
subsequently reactivated when the male child or adult is
concerned about genital integrity. Also, the scholar Kohut
(1977), argued for a relatively similar view of fetishism,
although expressed in terms of Self Psychology. In his view,
the fetishist, in contrast to feelings of helplessness towards
his mother, can have complete control over the non-
human version of the self-object. Therefore, what appears
to be an intense sexual need for a narcissistic object may
reflect severe anxiety about the loss of one’s sense of self.
5) In paedophilia, again for Freud (1905) and Fenichel (1945),
the paedophile sees the child as an image that represents
himself; for this reason, paedophilia is considered as a
narcissistic object choice. In clinical practice, it is found
that sexual activity with prepubertal children can affect
fragile self-esteem. On the other hand, the paedophile
often idealizes children: sexual activity with them involves
the unconscious fantasy of fusion with an ideal object or
restructuring of a young, idealized self. At a deeper level,
the union with a child represents the desire to incorporate
the mother’s breast and therefore to compensate for the
practical absence of maternal care in early childhood.
Furthermore, paedophiles have frequently been victims
of child sexual abuse. Sadistic dynamics and a sense of
triumph and power can accompany the transformation of
a passive trauma into an actively perpetrated victimization.
6) In transvestism, the male patient dresses as a woman
to create in himself a sexual excitement that leads to a
heterosexual sexual relationship or masturbation. The
patient behaves traditionally masculine when dressing as a
man, but becomes effeminate when dressing as a woman.
2019; 1(1): 4Perrotta G.
Citation: Perrotta G (2019). Paraphilic Disorder: Definition, Contexts and Clinical Strategies. Neuro Research 1(1): 4.
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ISSN: 2689-3193
DOI: https://doi.org/10.35702/nrj.10004
The classical psychoanalytic understanding of dressing
up as a woman involves the notion of a phallic mother.
Imagining that the mother has a penis, although this is not
visible, the male child overcomes his castration anxiety.
For Fenichel (1945), the act of dressing up as a woman can,
therefore, be an identification with the phallic mother. On
a more primitive level, the small child can identify with the
mother to avoid anxiety about separation. His awareness
of the sexual differences between him and his mother can
trigger the anxiety of losing her because they are separate
people.
Paraphilia and paraphilic disorder: Distinctions and
similarities
At the outset, a clear distinction must be made between
“paraphilia” and “paraphiliac disorder”. [4]
In the definition of Colombo [5], paraphilias are described
as “sexual disorders” because the objects or situations that
cause excitement deviate from those commonly found
in normality. The choice of the object or the deformation
of the act is manifested with characteristics of exclusivity,
continuity and compulsiveness. If paraphilias stabilize, they
can seriously influence the subject’s ability to establish mutual
and satisfying affectionate relationships, leading to a deviant
behaviour that is harmful to the well-being of the individual.
Conversely, those paraphilic or perverse behaviours that are
transiently manifested and remain circumscribed within
healthy sexuality and a couple of relationships are not to be
considered pathological. Not surprisingly, Colombo describes
paraphilias as behaviours marked by impulses, fantasies
or intense and recurrent sexual behaviours, which involve
unusual objects, activities or situations; in fact, among the
main diagnostic criteria we find the consequent presence of
clinically significant distress or impairment of the social, work,
or other important areas of individual functioning, for at least
a period exceeding six months.
Paraphilias involve sexual excitement for atypical objects,
situations and/or subjects (e.g., children, corpses, animals).
However, sexual activities that seem unusual to another
person or health professional do not constitute paraphilia
simply because they are unusual. People may have paraphiliac
interests even when they do not meet the criteria for a
paraphiliac disorder.
Unconventional sexual arousal patterns in paraphilias are
considered pathological disorders only when both of the
following conditions are met:
a) are intense and persistent;
b) cause significant hardship or social or occupational
impairment or in other important areas of functioning
or damage, or have the potential to damage, others
(e.g., children, non-consenting adults);
c) paraphilias can present a compromised or non-existent
ability to become attached, to experience emotional
involvement and sexual intimacy with a consenting
partner.
The disturbed modes of sexual arousal are usually well
developed before puberty, and at least 3 mechanisms are
involved:
a) anxiety or early emotional trauma interfere with healthy
psychosexual development;
b) the typical pattern of excitement is replaced by
another model, sometimes through early exposure
to significant sexual experiences that reinforce the
subject’s experience of sexual pleasure;
c) the sexual arousal mode often acquires symbolic and
conditioning objects (e.g., a fetish symbolizes the
object of sexual excitement, but it can be chosen
because it has been randomly associated with curiosity,
desire and sexual excitement).
The definition of “paraphiliac disorder” instead applies
when a paraphilia begins to cause discomfort or
impairment in the person’s daily life or even causes damage
or danger to themselves or others, becoming for the person
who lives them of ego-dystonic behaviours concerning
the environment. Concerning the diagnostic criteria for
the disorder in question, the DSM-V identifies two: A
which specifies the qualitative nature of paraphilia (e.g.
addressing sexual attention towards children) and B which
specifies the negative consequences of paraphilia, i.e.
discomfort impairment or damage to others. The diagnosis
of paraphiliac disorder should, therefore, be reserved for
individuals who satisfy both Criteria A and B; if an individual
only satisfies Criterion A but not B for a particular paraphilia,
then it could be said that the individual has a paraphilia,
but not a paraphiliac disorder.
To be diagnosed with a paraphiliac disorder, the DSM V
requires that people with this interest live it with personal
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Citation: Perrotta G (2019). Paraphilic Disorder: Definition, Contexts and Clinical Strategies. Neuro Research 1(1): 4.
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ISSN: 2689-3193
DOI: https://doi.org/10.35702/nrj.10004
anguish, not merely resulting from social disapproval; or have
a sexual desire or behavior that leads to mental distress, injury
or the death of another person; or a desire for sexual behavior
involving other people unable to give valid consent or involved
without their knowledge. To further emphasize the boundary
between an atypical sexual desire and a mental disorder, the
working group redefined, for example, “Sexual Masochism”
from DSM IV in “Sexual Masochism Disorder”. The chapter
on paraphilias includes eight conditions: exhibitionistic
disorder, fetishistic disorder, frotteurism disorder, paedophile
disorder, sexual masochism disorder, sexual sadism disorder,
transvestism disorder, and voyeuristic disorder. An essential
difference from the DSM IV-R concerns transvestism disorder,
which identifies people who are sexually excited by dressing
as the opposite sex, but who experience significant discomfort
in their social or work life due to this behaviour. The DSM IV
limited this behaviour to heterosexual men: the DSM V has no
restrictions, opening this diagnosis to women or homosexual
men. In the first criticism that this change would widen the
people interested in the diagnosis, the working group pointed
out that to enter the category, individuals must experience
considerable discomfort due to their behaviour. To date,
paraphilias can be classified according to the “act” they replace
or to the “object” to which they are addressed. A further
subdivision concerns the sensory channel that is solicited:
a) in the part of the act there is a substitution of coitus or
sexual activity, with other practices;
b) in the part of the object there is a subrogation of the
normative object or displacement of the goal:
– the normative object is constituted by the sexual partner
(heterosexual or homosexual);
– The goal is represented by the achievement of sexual
pleasure (orgasm).
c) the sensory channels involved in paraphilias:
– the visual channel, sexual excitement is sought in the
display of the body or parts of it (exhibitionism), in
the observation of other subjects engaged in sexual
activities (voyeurism, mixoscopy) or physiological
bodily functions (coprophilia, urophilia);
– acoustic/verbal channel, excitement is obtained through
the practice of foul language, listening or pronouncing
scurrilous or vulgar words related to sexuality
(telephone scatology, coprolalia, pornolalia, mixacusi);
– olfactory channel, there are neurophysiological
connections between the vomeronasal organ and
certain areas of the brain, such as the limbic system
(emotional) and the BNST nucleus (nucleus of the
terminal strip); sexual excitement is given by the
perception of odours, even unpleasant ones, such
as urine, faeces, flatulence (flatulophilia), sweat
(ospressiophilia), this can be connected to pheromones
excreted with these substances;
– taste channel, sexual excitement is pursued through the
ingestion/spraying of body excretions (coprophagia,
spermatophore, pissing);
– the practice of unusual bodily activities gives tactile
channel, sexual pleasure: stuffing (penetration with
objects), percoxophilia, spanking (spanking with
violence), climatephilia (enema practice), basophilia,
rhinolagnia, urolagnia (stimulation of parts of the
body not classically erogenous, like the nostrils or the
urethra).
Paraphilias and the concept of abnormality
Until 2012, the psychiatric classification described with
the term “paraphilias” (from the Greek παρά=”beyond” and
φιλία=”love”) all those erotic impulses characterized by
intense and recurring fantasies or impulses that imply specific
activities that concern objects, which involve suffering and/
or humiliation, or that are directed towards minors and/or
non-consenting persons. It is with this term that classification
has replaced the classic and more widespread category of
perversions, thus attempting to reduce the negative judgment
connected to these disorders. It was later, in 2013, that the new
Diagnostic and Statistical Classification of Mental Disorders
(DSM V) further normalized some preferences, distinguishing
“paraphilias” from “paraphiliac disorders” [6]. The boundary
between normality and pathology would, therefore, reside
in this distinction. According to this definition, to diagnose
a paraphiliac disorder, people with this interest should
experience it with anguish, not merely deriving from social
disapproval, or having a desire or sexual behavior that leads to
mental distress, injury or death to another person, or a desire
for sexual behavior involving other people unable to give valid
consent or involved without their knowledge.
However, how much is there anomalous in the paraphilic
interests? Towards the end of 2014, a researcher Canadian
wrote a commentary on this subject, questioning the definition
2019; 1(1): 4Perrotta G.
Citation: Perrotta G (2019). Paraphilic Disorder: Definition, Contexts and Clinical Strategies. Neuro Research 1(1): 4.
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ISSN: 2689-3193
DOI: https://doi.org/10.35702/nrj.10004
of paraphilia. In DSM V this term goes, in fact, to indicate every
intense and persistent sexual interest (fantasy or behaviour)
not included in the definition of those so-called neurotypical
ones, or genital stimulation with consenting human partners,
phenotypically normal (already understanding what is
going to mean in a way objective this attribute is somewhat
complicated), physically mature. The author, therefore,
underlines how much this type of definition depends more on
historical, political and socio-cultural factors than on medical
or scientific evidence.
In this regard, it is perhaps useful to recall that until relatively
recently, masturbation, anal sex and homosexuality were
considered “perverse” practices. Normality is therefore
continually subject to revisions and changes in time and space
and consequently also what is considered deviation from the
norm.
The distinction between paraphilias and paraphiliac disorders
is already a good step forward in the pathologization of non-
penetrative and non-criminal sexual interests such as fetishism,
masochism or consensual sadism. One could argue whether
these interests can even be considered non-paraphiliac, at
least when they are confined to sexual fantasies.
Two new diagnoses, “coercive paraphilic disorder” and
“hypersexual disorder”, have been proposed for inclusion in
the manual, but without being seriously considered.
TIPOLOGIE E CLASSIFICAZIONI DEI DISTURBI
According to the DSM V [7] Eight different types [8] of
paraphilic disorder can be identified [9]:
Voyeuristic disorder
In voyeurism, the person gets sexual excitement and
gratification from observing and watching the naked
bodies of people often not aware of being observed and
even engaged in sexual activities. A specific must be done if
the observer is aware and consenting: in this case, we speak
of troilism. Troilism consists of drawing sexual excitement
from observing-without hiding-individuals who have
sexual relations, who know they are being observed and
are therefore consenting. The real voyeur instead hides
from the sight of others and generally wants to reach
orgasm through masturbation, while it is observing or at
a later time through fantasies about what it has observed.
In action it is passive, and the pleasure derives from the
fact that it violates the intimacy of the subjects that are
observed, without having any need to get in touch with the
victims to get pleasure. In the most severe forms, voyeurism
is the particular form of sexual activity.
Exhibitionistic disorder
Exhibitionistic disorder is a paraphiliac disorder that consists
of exhibiting one’s genitals or sexual organs to people who
do not agree and are often unknown and in inappropriate
situations. Usually, exhibitionism is prevalent in the male
gender, but in more rare cases, it can also occur in women.
As in other paraphilic disorders, the exhibitionist tends to
objectify the victim towards whom he projects his desires
and sexual impulses, while the victim lives and suffers
the fact as a violent act, not sought after and unwanted.
Exhibitionist men and women usually do not seek any
physical or sexual approach with the stranger who is the
victim of this attention. In more rare cases, exhibitionist
behaviour can also be accompanied by masturbation.
Frotteurism disorder
It’s characterized by intense and recurrent sexual excitement
manifested through fantasies, desires and/or real
behaviours related to touching, or rubbing against, a non-
consenting person. To satisfy the criterion of frotteuristico
disorder, these fantasies and/or behaviours must manifest
themselves for at least 6 months (alternatively the condition
can be defined paraphilia but not paraphilic disorder).
Sexual masochism disorder
In sexual masochism disorder, sexual arousal manifests
itself recurrently and intensely through fantasies, desires
or behaviours deriving from the act of being humiliated,
beaten, bound (bondage) by other acts inducing pain
and suffering (burns, perforation of the skin, flagellation,
application of electric shocks, …). Such behaviours and
fantasies must cause clinically significant distress and must
last at least six months. Sexual masochism can often be a
form of paraphilia in most people who have masochistic
interests but do not meet the criteria for the diagnosis of
a paraphiliac disorder. Sadomasochistic sexual fantasies
and behaviours among consenting adults are persistent.
Masochistic activity tends to be ritualized and long-lasting.
The disorder can be accompanied by asphyxiation if the
subject is attracted by the practice of achieving sexual
excitation connected with the limitation of breathing
(see below the specification of asphyxia as an additional
paraphiliac disorder).
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Citation: Perrotta G (2019). Paraphilic Disorder: Definition, Contexts and Clinical Strategies. Neuro Research 1(1): 4.
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DOI: https://doi.org/10.35702/nrj.10004
Sexual sadism disorder
In sexual sadism disorder, sexual excitement manifests itself
in a recurring and intense way through desires, fantasies or
behaviours in which the physical or psychological suffering
of another person is deliberately and intentionally caused.
Most sexual sadists have persistent fantasies in which
sexual excitement is the result of suffering inflicted on
the partner, whether consenting or not. If the criteria for
sexual sadism disorder are not met, sexual sadism can be
considered a form of paraphilia; Moderate sadistic sexual
behaviour is a common sexual practice among consenting
adults, and is usually limited in scope and not harmful.
However, when such behaviour, fantasies or impulses of a
person cause clinically significant distress or behavioural
impairment and/or cause damage to others, one enters
the pathological area of the paraphiliac disorder. When
practised with non-consenting partners, sexual sadism is a
criminal activity. Sexual sadism is particularly severe when
it is associated with an antisocial personality disorder.
This combination of disorders is particularly resistant to
psychiatric and psychotherapeutic treatment.
Pedophilic disorder
Paedophilia is a form of paraphilia that causes harm to
others and is therefore considered a paraphilic disorder.
The clinical diagnosis of Pedophilic Disorder according to
DSM5 includes the following criteria: a) recurrent sexually
arousing fantasies, impulses or behaviours involving one
or more prepubertal children (usually ≤ 13 years) who
were present for ≥ 6 months; b) the person is driven by the
impulse or is firmly in difficulty or altered by impulses and
fantasies; c) the person is ≥ 16 years and ≥ 5 years older
than the child-targeted by fantasies or behaviours (but
older adults who are in continuous contact with a child of
12 or 13 must be excluded). For the diagnosis, therefore, it is
necessary to keep in mind that the subject must be at least
16 years old and his age must be at least 5 years greater
than the child (or children) towards whom the fantasies,
desires or pedophiliac behaviours manifest themselves. The
disorder can be exclusive when the patient is only attracted
to children or non-exclusive. Often subjects suffering from
paedophilia disorder can use force and physically threaten
the child if they reveal abuse.
Fetishistic disorder
The fetishist disorder consists of an intense and recurrent
sexual excitement, for at least six months, manifested
through fantasies, desires or behaviours, deriving from the
use of inanimate objects or particular interest for one or
more non-genital parts of the body. The objects must not
be limited to items of clothing used for cross-dressing (as in
transvestic disorder) or to instruments designed explicitly
for tactile stimulation of the genitals (e.g. vibrator, rubber
fouls, …). It can also be characterized as paraphilia without
the disturbance criteria being met.
Transvestism disorder
The transvestite disorder implies a recurrent and intense
sexual excitement, manifested with fantasies, desires
or behaviours, for at least six months, deviant by cross-
dressing, or by wearing clothing of the opposite sex. A
significant difference compared to the DSM IV-TR concerns
the transvestitism disorder, which identifies people who are
sexually excited by dressing like people of the opposite sex,
but who feel discomfort in their social or work life because
of this behaviour. The DSM IV considered concerning this
behaviour only heterosexual men, while the DSM 5 now
includes also homosexual men and women in this category.
There are also a series of paraphiliac disorders not
otherwise specified. For example, autoerotic asphyxia (also
called asphyxiophilia) is a paraphilia disorder not otherwise
specified associated with Sexual Masochism Disorder
(DSM V, 2013). Among the various types of atypical sexual
behaviour, probably the autoerotic asphyxia (once also
called hypoxifilia) is among the most dangerous (Prati,
2006). Erotic asphyxia (or auto-erotic) is a sexual practice
that through the deprivation of oxygen to the brain
increases sensitivity during masturbation and orgasm.
Oxygen deprivation can be implemented in various ways:
through the use of laces, plastic bags, chest compression,
suffocation instruments, the immersion of the head in
liquids, stunning by chemical inhalation, use of unique
masks (Myers et al., 2008). Focusing on the dangers of
this practice, the risk of sudden deaths is high, primarily if
implemented in solitude.
During oxygen deprivation, on the one hand, there is an
increase in pleasure sensations; on the other hand, reaction
times decrease. It often happens that the person is not
able to free himself from the grip that was created and
that he dies by suffocation. It is complicated to establish
the epidemiology of the phenomenon, both because
autoerotic asphyxia is a very private and socially little
accepted practice and because they are often mistaken for
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suicide cases. Among paraphilias not otherwise specified
may also include “devotes”. The “devotes” is a cultural
translation of the diagnostic category “acrotomophilia”,
which Money J, a psychologist and sexologist, explores
scientifically in the eighties, or the ability to experience
interest or sexual excitement only in the presence of
people who have deformations or amputations in the
limbs or as in the basophilia for aids such as wheelchairs,
plaster casts, prostheses … The pathological component
of this phenomenon resides and takes shape in the fact
that the interest is directed only towards the amputated
part or the handicap and rarely towards the person and
his human qualities. In devotees, the social, occupational
and emotional and sexual intimacy with their partner is
often compromised. This type of paraphilia comes close to
fetishism, as a sexual drive directed towards an inanimate
object. As in the fetishist, the object is indispensable and
indispensable for excitement and sexual activity.
Devotees tend to avoid the intimate relationship with their
partner and make not a boot but erotic aids that the disabled
use or the impaired limb. In devoting, people ask to be able
to touch their legs, to watch while the person eats, they ask
to be able to comb their hair or be able to accompany her
to the bathroom, and treat the person as an object. Most
devotees belong to the group of “Amplovers” or amputee
lovers. Sexual attraction can reside in the stump itself, in
prostheses, or in the imagination of what exists under it.
Other paraphilic disorders not otherwise specified include,
among many others, sexual arousal related to zoophilia
(animals), necrophilia (cadavers), coprophilia (faeces),
chlimafilia (enemas) or urophilia (urine).
The Neural Correlates in Paraphiliac Disorders
The organization [10] of the sexual brain, circuits begin
during the fetal period, and the primordial basis is the female
one. The brain in male subjects masculinizes before birth
through the secretion of testosterone and its conversion into
the hormone estrogen. Masculinization means that some
regions of the brain, especially groups of neurons within
the hypothalamus, grow the most while other areas, such as
the corpus callosum, remain smaller. A subsequent turning
point is in puberty when there is the maturation of ovarian
estrogens and progestogen steroids for female subjects and
intense production of testosterone for male subjects. These
hormones bind to various receptors in different subcortical
regions of the brain, especially in men, in the preoptic area of
the anterior hypothalamus.
Laboratory studies [11] show that male animal that loses their
testicles before sexual maturation does not develop strong
impulses to sexuality while maintaining social impulses. It
has been observed, however, that the impulse is preserved if
the testicles are lost by men who are already sexually active.
Testosterone is therefore of great importance for male libido,
above all because it activates various neuropeptides, such as
vasopressin, which in males is present in double the amount
of female subjects. Vasopressin in animals promotes courtship,
sexual ardour, territorial marking and aggressiveness among
males. Testosterone also activates nitric oxide (NO) which,
once again, promotes sexual ardour and aggression. From
these observations, it can be noted that testosterone plays an
important role both in male sexuality and in the impulse of
social dominance, even if these two systems remain, however,
distinct. In female subjects, impulses for sexual receptivity
originate in the ventromedial hypothalamus (VMH). Most of
them do not produce much testosterone and their sexuality
is controlled primarily by estrogen and progesterone. Sexual
activation is also governed by regular oestrous cycles.
Estrogens and progesterone also promote the production of
oxytocin, which would make female subjects emotionally more
receptive and more confident. This discourse is only partially
valid for human beings since sexuality in humans is much more
linked to the useful life of the mind and to the socio-cultural
aspects of what happens in other animals. Nevertheless, at
the level of primary processes, the circuits of sexual desire
are very similar. Panksepp (2012) notes that the dopamine-
driven research system, especially in the search for a sexual
partner, is also involved in the promotion of sexual desire.
Concerning the gender difference, Panksepp emphasizes that
the two hormones, oxytocin and vasopressin, are the basis of
the most marked differences. Normally oxytocin encourages
attitudes of care, translating into the expression “take care and
be friendly”, while vasopressin is more aggressive attitudes,
translating into “attack and compete”. Oxytocin has been
commonly considered, according to a simplistic view, as the
“love hormone”. Panksepp remembers, in this regard, how
oxytocin does not act alone but works with the support of
many other chemical substances and environmental stimuli,
so it is likely that it will produce intense positive affective
experiences starting from concomitant social interactions.
Animal studies show that oxytocin provides comfort when
animals are alone, promotes confidence and facilitates
positive social interactions. Furthermore, it seems that these
results can also be extended to humans. In the system of
sexual desire, the homeostatic and sensory elements play a
strong role in sexual activation, nevertheless it is configured,
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for Panksepp, as an emotional system because it presents
a very evident readiness to act and its affective state can
perturb other systems. As for sexual development, Panksepp
makes an important distinction between the gender of the
body and the genus of the mind, in fact these develop in
a way, in some respects, independent: the sex hormones
that determine the sexual organization of the brain in
development fetal are different from those that make specific
the appearance of the genital apparatus. Biologically we call
females those born with chromosome XX and males those
born with XY chromosome and normally the female brain
circuit is stronger in biological females and that male in males.
However, this does not always happen in this way, and this
happens when, for example, the fetal sexual substances of the
brain are arranged in an atypical way. From this, it follows that
gender identity is not simply learned and cannot be altered by
persuasion. Panksepp reports the results of some experiments
in the laboratory, in which some female rats were injected
with estrogen generating female offspring with a male brain.
Other studies show that if testosterone cannot be converted
into estrogen during the last months of pregnancy, there is
a good chance that a male fetus is born with a female brain.
These latter cases would occur, for example, when the mother
experiences strong prenatal stress. It is hard to say how much
these data can be generalized even to humans, although
many cases seem to confirm them. However, it should not be
forgotten that biological phenomena must be combined with
personal, social and cultural phenomena, with tendencies
that are sometimes contrary to various levels, from primary
to third. The sexual desire system has emerged to promote
reproduction and preserve the animal species. It is a system
capable of pushing to the creation of the first bonds between
organisms: when the system is active, the animal looks for a
body connection with another that is sexually receptive, so
the tension can be positive or can become a stress factor if this
junction was denied. However, this system is also at the origin
of those bonds that, as happens in different species, can also
be exclusive and last a lifetime. The system of sexual desire is,
therefore, fundamental in the development of social life.
Post-mortem and Imaging studies with mass spectrometry
[12] over the last two decades have revealed the structural
brain related to sexuality and sexual disorders, including: the
hypothalamus, the thalamus, the amygdala.
Recently, however, new studies have found the substantial (or
structural) difference, from a neural point of view, between
hetero and homosexual sexual orientation:
a) Hypothalamus: It is a portion of the brain that contains
several “nuclei” (discrete groups of cell bodies in the neuron
soma) [13]. Now, the term “nucleus” in neuroanatomy
must not be confused with the same use made of it in
cell biology: in the second case it refers to the organelles
found in eukaryotic cells that contain the genetic material
of the cell; while in the former it refers to discrete groups
of densely packed neuronal cell bodies in the central
nervous system [14]. In anatomical sections, a nucleus
appears as a region of grey substance surrounded by
white matter. It is known to be involved in sex differences
in reproductive behaviour, mediating menstrual cycle
responses: in particular, the anterior hypothalamus helps
regulate typical male sexual behaviour. In the mid-1990s,
it was also linked to gender identity and sexual orientation
[15]. Seminal research conducted by Simon LeVay
would have discovered that an interstitial nucleus of the
hypothalamus, INAH3, was dimorphic according to sexual
orientation but not according to gender. Specifically, the
INA3 of homosexual men was found to be lower in volume
than that of heterosexual men; these results were obtained
by post-mortem analysis of hypothalamic nuclei of known
homosexual subjects compared to heterosexual patients
[16]. Further research has shown that INH3 has a smaller
volume in homosexual men than in heterosexual men,
this because the former have a higher neuronal density
within it than the latter; there is no difference in the
number of the cross-sectional area of neurons in the INA3
of homosexual men compared to heterosexuals [17]. It has
also been discovered that there is no effect found from
HIV infection on the size of INAH3, i.e. it does not take into
account the difference observed in the volume between
homosexual and heterosexual men. The hypothalamus
is also linked to sexual orientation through discoveries
showing that aromatase activity-an important enzyme
that converts androgen into estrogen-is elevated in the
pre-optic hypothalamic region of the mammal during the
pre and neonatal periods. This is indeed related to sexual
differentiation and may be a basis in the structural and
functional sex differences that play a role in mediating
orientation development due to prenatal hormone
exposure. The suprachiasmatic nucleus of the anterior
hypothalamus (SCN) also refers to sexual orientation, being
larger and more elongated in homosexual males than in
heterosexual males and females. The cell sub-nucleus
containing the vasopressin of the SCN of homosexual
men is twice as large and has 2.1 times the number of cells
compared to the subgroup containing the vasopressin of
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the SCN in heterosexual men [18].
b) Thalamus: It is a symmetrical ovoid structure of the midline
within the human brain, located between the cerebral
cortex and the midbrain in both cerebral hemispheres.
A magnetic resonance imaging study compared
subcortical volumes of homosexual and heterosexual
men; found that while both groups did not differ in the
total volume of the brain, the volume of the thalamus (in
both hemispheres) was greater in heterosexual men [19].
Another study reported that the functional connectivity
involving the right thalamus and the right cuneus was
different between homosexual and heterosexual men
and also showed correlations with Kinsey scale scores
[20]; moreover the thalamus is involved in the process of
sexual excitement and reward; during the visually evoked
excitement both heterosexual men and homosexuals
activated the thalamus, but in contrast to the latter,
heterosexuals showed further activation in the lingual
gyrus [21]. The basal nucleus of the terminal stria (BNST)
is an area of the limbic system of the prosencephalon
which is involved in the control of the coupling behaviour;
it receives neuronal input from the medial amygdala and
the accessory olfactory bulb and sends projections both
to the medial preoptic area [22] and to the ventro-medial
nucleus of the hypothalamus [23]. The central part of the
BNST (the BNSTc) is greater than 44% in heterosexual men
compared to straight women and 62% in homosexual men
compared to them [24]. BNSTc is larger in homosexual men
than in straight men, although the size difference is not
statistically significant. It is therefore hypothesized that the
BNSTc of homosexual men is “hyper-masculinized” as it is
larger than the BNSTc of straight men and women.
c) Amygdala: It was discovered that both men and
homosexual women show connections with the amygdala
different from those of heterosexual men and women [25].
Specifically, the connections between homosexual men
and straight women were more widespread by the left
amygdala, while in straight men and lesbians functional
connections were more common in the right one [26].
d) Anterior commissure: It is a bundle of white matter fibers
that connects the two cerebral hemispheres. It was found
by Allen and Gorski to be significantly larger in homosexual
men and heterosexual women than in heterosexual men
[27]. This discovery provides a possible anatomical basis
for higher inter-hemispherical functional connections in
homosexuals, which explain why homosexual men and
heterosexual women show a marked functional symmetry
of the linguistic circuit in comparison with heterosexual
men performing the same verbal tests [28].
e) Corpus callosum: Like the anterior commissure, it is an
essential neuronal connection that connects the two
hemispheres; however, unlike the commissura (which
is present in all types of vertebrates), CC is present only
in placenta animals (including therefore humans) [29].
An MRI study that compared the CC of homosexual and
heterosexual men found that all parts of CC are more
significant in gay people [30]. In particular, the isthmus
(a part of the CC present between the corpus callosum
and the splenius muscle of the head) is significantly more
abundant in homosexual men than in heterosexuals;
the size of CC has a strong genetic basis, with genetic
inheritance rates ranging between 82% and 94%. This
association of sexual orientation with a highly heritable
brain structure supports the thesis of a genetic and
neurobiological basis in the origin of the same orientation.
f ) Gray substance [31]: It is an important part of the
central nervous system that is mainly composed of
neuronal cell bodies. While men generally have a greater
amount of grey and white matter than women (due to
the greater male body mass and consequently a greater
brain size), women generally have a greater grey matter-
to-substance ratio and larger layers of it in areas of the
cerebral cortex specific to men. It has been found that
homosexual women have relatively less grey matter than
straight women in the ventral cerebellum area, in the left
premotoreal cortex, in the temporal-basal cerebral cortex
and, more significantly, in the left perirhinal cortex of
the temporal lobe. No difference in the amount of grey
matter was found between straight and homosexual
men. These results are important because the perirhinal
cortex is located near the brain regions (entorhinal cortex,
hippocampus, parahippocampal gyrus and amygdala)
involved in olfactory and spatial processing, which have
been shown to determine differences in sexual orientation-
in particular, are notes in homosexual women superior
performance to straight women in spatial processing
tests. The perirhinal cortex itself is involved in functions
related to the processing of sexual stimuli such as olfactory
processing, memory coding and spatial processing itself;
it is also involved in detecting the identity of the object. It
is known that it modifies sexual attraction in humans, and
the olfactory system is able to differentiate pheromone-
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like compounds based on sexual orientation.
g) Brain asymmetry: The size of the telencephalon is a
sexually dimorphic trait in which men tend to show
asymmetry in the volumes of their hemispheres, while
women show a volumetric symmetry instead. It is also
a trait that is very unlikely to be influenced by learned
socio-environmental patterns [32]. A volumetric study
with magnetic resonance in 2008 indicated that gay
men and heterosexual women showed symmetrical
hemispheric volumes, while homosexual women and
straight men showed a right-hand asymmetry. These
results demonstrate a global neurological difference in
brain structures that show atypical sexual characteristics
associated with sexual orientation [33].
h) Cerebral cortex [34]: It is the outermost layer of the
human brain and is composed of nervous tissue. An RM
study compared the cortical thickness in various brain
regions of homosexual men, heterosexual men and
heterosexual women: he discovered that homosexual
men had thinner cortexes-compared to hetero-in the
lateral orbitolateral region of the right hemisphere, as
well as in the regions located in the visual cortex (lingual,
pericalcarin and wedge). The same regions showed a
thinner cortex in heterosexual women than straight men,
while no differences were found between heterosexual
women and homosexual men. Gay and hetero males did
not differ in total brain volumes, and it was determined
that the differences reported in cortical thickness were not
influenced by the years of education or the brain volume
of the subjects. Since the regions mentioned above show
sexual dimorphism, the authors hypothesized that the
biological processes frequently proposed to underestimate
the same, such as gene-dependent and sex-hormone-
dependent mechanisms during prenatal and postnatal
development, may interact with cortical architecture in
visual areas resulting in different cortical thicknesses in
gays compared to hetero.
i) Brodmann area 45: Homosexual men showed thinner
cortices than straight men and women both in the
triangular pars right (Brodmann area 45) and in the lower
temporal regions; this suggests that brain differences
related to male homosexuality may also be present in
regions that are not necessarily considered as sexually
dimorphic [35]. Another study showed that the cortical
thickness of the right triangular pars also differs among
MtFe transsexuals and gay men. Specifically, the pars
triangularis of MtF people (and of heterosexual men) is
thicker than that of gays; moreover, in MtF it is thicker even
than that of straight men. In particular, in both studies, the
region concerned is the pars triangularis present in the
right hemisphere) [35].
Still, other studies have found functional differences, always
from a neural point of view, between hetero and homosexual
sexual orientation:
a) Response to pheromones: Two proposed
human pheromones [the progesterone derivative
4,16-androstadienone-3-one (AND) and an ester-1,3-5
(10), 16-tetraen-3-ol (EST) (estrogen-like steroid] showed
specific responses to sexual orientation in the activation
of neural circuits of the anterior hypothalamus in both
homosexual and heterosexual subjects. The anterior
hypothalamus is involved in the processing of reproductive
functions, and recent evidence suggests that it helps to
integrate stimuli Hormonal and sensory involvement in
sexual behaviour and its preferences [36]. Recent functional
magnetic resonance imaging experiments have shown
that the presentation of AND, found in male sweating,
as an olfactory stimulus produced normal olfactory
responses in straight and lesbian men, while activating the
anterior hypothalamus in gay men and straight women
[37]. The EST proposal of the pheromone, found in the
urine of pregnant women, produces a normal activation
or olfactive in gay men and heterosexual women, while
lesbians and straight men have shown to have sexually
related hypothalamic responses. Gay men showed the
same sexually related functional responses to these
stimuli of heterosexual women, while homosexual women
responded as straight men. This research by Berglund and
Savic indicates on the whole that AND and EST induce
“specific effects of sexuality on the autonomic nervous
system” and that stimuli have produced a response path
that depended on the sexual orientation of the subject
rather than on the sex resulting from the phenotype.
b) Response to visual sexual stimuli: Sexual arousal is a
highly coordinated process that prepares a person for
reproductive behaviour; widespread changes occur in
the person’s neurophysiological state during excitement
to obtain adaptive responses. The attention, affective
and motivational systems of the individual concerned
are optimized to allow the selection and successful use
of sexual stimuli. In response to visual sexual stimuli, men
show subjective and self-reported excitement of a specific
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category; their greatest excitement is directed to those
categories of people with whom they prefer to have sex:
homosexual men experience greater genital and subjective
excitement for men than for women (and therefore prefer
male sexual stimuli), while for heterosexual men the
reverse happens. It is believed that the hormone influences
the development of neural structures that regulate sexual
behaviour in the prenatal period; therefore it is believed
that some aspects of neuro-hormonal development in
homosexuals proceed differently from heterosexuals, with
consequent psychological differences such as distinct
triggers (or “stimuli”) for sexual excitement. A 2007 study
on functional magnetic resonance imaging (fMRI) [38] that
explored the neural mechanisms of sexual arousal in gay,
and straight men showed their subjects composite sexual
interactions; have shown that both male groups activate
the same brain regions after each is exposed to a sexual
stimulus that agrees with the sexual orientation of the
subject being examined. Another fMRI study [39] showed
that by observing both hetero and gay erotic visual stimuli,
only those videos corresponding to the subject’s sexual
orientation produced patterns of activation in the areas of
the brain associated with sexual arousal. The heterosexual
response showed the same pattern of neural sexual
processing that caused gay vision while displaying images
of the opposite orientation did not elicit the same response.
A significant correlation was therefore found between
excitation and neural activation in the hypothalamus, a
key region of the human brain due to its sexual function;
self-reported sexual arousal values were also equal in both
groups. However, the extent of hypothalamic activation
was lower in gay men than in straight men, a trait that is
also shared by straight women. A further fMRI study [40]
determined patterns of cerebral activation in homosexual
and heterosexual subjects, exposing them to gay, hetero
and lesbian visual stimuli; they then found that different
neuronal circuits were active in the two male groups: brain
regions such as the left angular gyrus, the right pale globe
and the left caudate nucleus were activated exclusively
in homosexual men while the bilateral lingual gyrus, the
right parahippocampal gyrus and l right hippocampus
were activated exclusively in heterosexual men. These
results indicate that the neural circuits (related to the
processing of visual sexual stimuli) that are active during
sexual arousal in homosexual and heterosexual men are
different. New fMRI research [41] has shown heterosexual
and homosexual women and men photos of male
genitalia and female genitalia; thus limiting the visual
sexual stimulus to genital photographs, the authors have
minimized the neuronal activity related to the processing
of various stimuli such as faces, voices, body movements
and sexually exciting body parts in addition to genitals.
They found that the ventral striatum, the centromedian
thalamus and the bilateral premotoriavental cortex
showed a stronger response to the photos of the preferred
sex than those corresponding to non-preferred sex. Since
the ventral striatum and the centromedian thalamus are
known to be activated by innate preferences, the selective
response of these regions to the preferred sexual stimuli
seems to reflect a predetermined response pattern. This
notion is therefore used to support one of the tests that
want sexual orientation to be of a purely biological origin.
Another FMRI study [42] sought to verify whether subjects
responded more to faces (male or female) to whom they
were sexually-oriented and predicted this modulation in
the brain circuit of the reward system. Heterosexual and
homosexual men and women were shown photos of male
and female faces and therefore invited to evaluate their
visual attractiveness. Consistent with the hypothesis, it was
discovered that the reward circuit of homosexual males and
heterosexual females responded more to photographs of
male faces, while the reward circuits of homosexual females
and heterosexual males responded more to photographs
showing female faces. The interaction between the
subject’s gender stimulus (male or female face) and sexual
orientation (homosexual or heterosexual) was highly
significant in two brain regions: the mediodorsal nucleus
of the thalamus (MDT) and the medial orbitofrontal cortex
(OFC). The activation in the OFC is remarkable because it
is involved in the representation of the reward value of
various sensory stimuli, including attractive faces. It also
appears to play an important role in processing the facial
signals necessary for social communication, as this region
has selective neurons for the face and because patients
with OFC lesions are unable to identify emotional facial
expressions. The modulation of the response to faces
within the OFC through sexual orientation adds further
importance to its role in social behaviour; since mdT and
OFC receive neural projections from each other, the similar
activation patterns observed in these regions can be
attributed to their anatomical connections.
c) Response to serotonin: Serotonin is a neurotransmitter
found in the central nervous system that has various roles
in regulating sexual behaviour; its agonists and antagonists
have to activate or inhibiting effects depending on their
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concentration and the brain area involved. Fluoxetine
is a selective serotonin reuptake inhibitor that prolongs
its effect on neurons [43]. Kinnunen et al. administered
fluoxetine to their study subjects to see if the brain is
activated differently in homosexual and heterosexual men
through the action of serotonin [44]; after administration
of fluoroxin they measured glucose metabolism in the
brain using positron emission tomography (FDG-PET).
They found that the cerebral response to fluoxetine differs
between gay people and straight men, ie the former
show a lower reduction in glucose metabolism in the
hypothalamus than in the latter. Also, other areas of the
brain were also differentially activated: the associative
prefrontal cortex of homosexual men showed greater
activity after administration, while that of straight men
showed no change. The anterior lateral girdle and the
bilateral/parahippocampal gyrus of the straight men
showed greater activity, while a reduced one was observed
in portions of their anterior cingulate cortex. These results
suggest that homosexuals and heterosexuals may not
only differ in the total number of neurons in various areas
of their central nervous system but may also differ in the
distribution of certain types of them, such as serotonergic
and dopaminergic neurons.
CLINICAL AND THERAPEUTIC STRATEGIES
As for therapeutic interventions, the most effective
treatments for paraphiliac disorders are those that involve
the integration between psychotherapy and adequate
drug therapy (if necessary, compared to the case under
consideration). Clearly, treatments will be more effective in
those situations where the discomfort experienced by the
subject is relevant, and the subject requires help. In the case
of many paraphiliac disorders, the treatment is less effective
instead when it is ordered by the court and the motivation
for the treatment is extrinsic, even if many subjects, even
in such cases, still benefit from treatments, such as group
psychotherapy associated with antiandrogens. Among
psychotherapeutic approaches, cognitive-behavioural
therapy has proven to be a very effective treatment in
helping the subject manage impulses and sexual fantasies.
This type of therapy aims to identify and modify beliefs
and thoughts, which lead the subject to implement
dysfunctional behaviour by replacing this behaviour with
other more functional behavioural modalities. Therapeutic
approaches generally support the patient and must take
a non-judgmental attitude, promoting acceptance and
empathy. In general, the treatment is multiaxial and may
include specific cognitive-behavioural interventions to
modify dysfunctional sexual thoughts, behaviours and
emotions that are activated in front of a specific situation
training of social-relational skills and self-regulation of
impulses in the management of adult affective relationships
treatment of sexual dysfunctions to address dysfunctions
related to the sexual sphere.
With regard to pharmacological treatment, this is
considered very useful in the process of treating various
paraphiliac disorders because, for example, treatment with
antiandrogens helps to inhibit the response of sex hormones,
causing a decrease in desire and sexual excitement.
Antiandrogenic drugs, such as cyproterone acetate (CPA)
and medroxyprogesterone acetate (MPA, Depo-Provera),
and lutein hormone therapies [45], in addition to therapies
based on SSRIs (serotonin selective reuptake inhibitors) [46],
Are, therefore, common therapeutic tools, but their use is,
however, limited due to side effects on the patient’s health.
Finally, the problem of the low compliance of the products and
the fact that they do not resolve the deviation in itself is very
remarkable. If the drug is interrupted, the deviant behaviour
will reappear.
CONCLUSION
Recent discoveries in the field of neuroscience have shown that
paraphilic disorder, and emotional sexuality in general, has
not only psychological but also biological and neurobiological
roots. Future studies will necessarily have to orientate in this
direction, favouring the study of the relationships between
hormones and sexuality, emotions and sexual orientations
and sexual preferences and neuronal circuits. Also from a
therapeutic point of view, the causal link between the binomial
“psychotherapy-pharmacology” and the resolution of the
paraphiliac disorder appears clear and demonstrated, even if
the most resistant form seems to be the paraphiliac disorder
of sadistic matrix, due to its intrinsic psychological qualities
linked to the first years and the first evolutionary stages of the
subject, stratified with irrational convictions now anchored in
the personality.
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Copyright: Perrotta, et al. ©2019. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribu-
tion, and reproduction in any medium, provided the original author and source are credited.
The Influence of Childhood Trauma on Sexual Violence and Sexual
Deviance in Adulthood
Jill S. Levenson
Barry University
Melissa D. Grady
The Catholic University of America
The purpose of this study was to determine the influence of various types of childhood adversity on later
sexual deviance and sexually violent behavior. Data were collected from more than 700 convicted sexual
offenders in outpatient and confinement-based treatment programs throughout the U.S. Using the 10-item
Adverse Childhood Experiences (ACE) Scale, participants were surveyed about childhood maltreatment and
family dysfunction. For male sex offenders, factors that significantly predicted sexual deviance included
childhood sexual abuse, emotional neglect, and having unmarried parents. Factors that significantly predicted
violent sexual offending included child physical abuse, substance abuse in the childhood home, mental illness
in the home, and having an incarcerated family member. ACE scores were significantly higher for generalist
offenders than for those specializing in sexual crime. The results underscore the need for clinicians to assess
the existence of early adversity, to understand the role of traumatic events in the development of criminality
and abusive behaviors, and to utilize trauma-informed counseling practices. In terms of policy, investing in
prevention services for maltreated children and at-risk families is an important step in disrupting the cycle of
interpersonal violence and crime in our communities.
Keywords: ACE, adverse childhood experiences, sex offender, sexual deviance, sexual violence, trauma-
informed care
The largest study to examine the role of adverse childhood expe-
riences (ACE) and adult outcomes surveyed over 17,000 people and
found that at least two thirds of adults reported at least one type of
childhood maltreatment or household dysfunction, and nearly 13%
reported four or more (Centers for Disease Control & Prevention,
2013b). Though these numbers are staggering, the rates of early
trauma in poor, disadvantaged, clinical, and criminal populations are
even higher (Christensen et al., 2005; Eckenrode, Smith, McCarthy,
& Dineen, 2014; Larkin, Felitti, & Anda, 2014; Levenson, Willis, &
Prescott, 2014; Wallace, Conner, & Dass-Brailsford, 2011). As ACEs
accumulate, the risk for numerous health, mental health, and behav-
ioral problems in adulthood has been observed to increase in a
dose–response fashion (Felitti et al., 1998). Among the negative
sequelae of early trauma is increased risk for criminal behavior,
including sexual perpetration (Marshall, 2010; Mersky, Topitzes, &
Reynolds, 2012; Patterson, DeBaryshe, & Ramsey, 1989). The pur-
pose of this study is to explore the influence of different types of
childhood adversity on adult sexual violence and sexual deviance.
Developmental Theory and Criminality
Understanding the complexities of an individual’s psychosocial
history is a vital component in assessing how the seeds of criminal
behavior may be planted early in life and flourish into adulthood
(Dudley & Leonard, 2007; Guin, Noble, & Merrill, 2003). Devel-
opmental psychopathology theorists propose that emotional and
behavioral adaptations stem from a reciprocal interaction of affec-
tive and cognitive processing; individuals attach meaning to their
experiences and this is how we “establish a coherence of function-
ing as a thinking, feeling human being” (Rutter & Sroufe, 2000, p.
265). Developmental theories of antisocial behavior argue that
inept parenting, harsh or arbitrary punishment, poor supervision,
and limited positive parental involvement raise the risk for conduct
problems and delinquency (Cicchetti & Banny, 2014; Kohlberg,
Lacrosse, Ricks, & Wolman, 1972; Patterson et al., 1989; Rutter,
Kim-Cohen, & Maughan, 2006). The pathways from early adver-
sity to psychosocial problems are complex, but early toxic stress
creates hyper-arousal, increasing the production of hormones as-
sociated with fight-or-flight responses and inhibiting the growth
and connection of neurons (Anda et al., 2006; van der Kolk, 2006).
Over time, these changes in the brain can compromise emotional
regulation, social attachment, impulse control, and cognitive pro-
cessing (Anda, Butchart, Felitti, & Brown, 2010; Anda et al., 2006;
Whitfield, 1998).
This bio-psycho-social trajectory is further complicated by ac-
cumulating cascade effects by which early deficiencies in one
domain of functioning obstruct mastery of skills in other develop-
ing areas (Masten & Cicchetti, 2010; Rutter et al., 2006). For
example, traumatic childhood experiences can lead to self-
regulation deficits which then interfere with academic perfor-
mance and social competencies. Consequently, the child may elicit
negative reactions from schoolmates and teachers, increasing the
risk for delinquency when needs for acceptance are met by asso-
ciations with other nonconforming peers (Rutter et al., 2006).
This article was published Online First February 25, 2016.
Jill S. Levenson, School of Social Work, Barry University; Melissa D.
Grady, National School of Social Service, The Catholic University of
America.
Correspondence concerning this article should be addressed to Jill S.
Levenson, School of Social Work, Barry University, Miami Shores, FL
33161. E-mail: jlevenson@barry.edu
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Traumatology © 2016 American Psychological Association
2016, Vol. 22, No. 2,
94
–103 1085-9373/16/$12.00
http://dx.doi.org/10.1037/trm0000067
94
Clinicians taking psycho-social histories in justice-involved set-
tings often seek to explore the role of child maltreatment and
chaotic family environments on later criminal behavior.
Childhood adversity is very common in the histories of criminal
offenders. Prospectively collected data from the Chicago Longi-
tudinal Study (N � 1,539 low-income minority children) identified
child maltreatment as a predictor of criminal behavior for both
boys and girls (Mersky et al., 2012). In addition, child abuse and
neglect were found to be much more common among 64,000
juvenile delinquents in Florida than in the general population
(Baglivio et al., 2014). Among adult offenders, greater exposure to
early trauma is significantly associated with mental health disor-
ders, drug abuse, and serious crime (Harlow, 1999; Messina,
Grella, Burdon, & Prendergast, 2007). Although individuals vary
in their response to toxic stress, and many people exhibit resilience
following adversity, traumagenic environments may be most del-
eterious for those with negative personality traits and limited
intellectual or social resources (Patterson et al., 1989). Pathogenic
parenting and deprivational environments impede family function-
ing and model maladaptive coping, and are often exacerbated by
impoverished socioeconomic conditions (Patterson et al., 1989).
Attachment theory is helpful in conceptualizing the link be-
tween early adversity and adult psychosocial problems. Attach-
ment theory postulates that primary caregivers’ interactions with a
child must be nurturing, consistent, reliable, and responsive to
needs in order for youngsters to learn that the world is safe place
(Bowlby, 1977, 2005). Children who experience maltreatment and
family dysfunction are exposed to unpredictable parenting patterns
that compromise the development of secure attachments to care-
takers, and these youngsters often witness chaotic conditions that
fail to exemplify healthy interpersonal functioning across the life
span (Carlson & Sroufe, 1995; Cicchetti & Banny, 2014; Rutter et
al., 2006). Abused and neglected children are socialized within
relationships characterized by betrayal and invalidation, which can
then produce distorted cognitive schema, boundary violations,
disorganized attachment patterns, and emotional dysregulation
(Chakhssi, de Ruiter, & Bernstein, 2013; Loper, Mahmoodzade-
gan, & Warren, 2008; J. E. Young, Klosko, & Weishaar, 2003).
Poor quality of early attachment has been associated with a num-
ber of long-term negative effects including deficient relational
skills, self-regulation problems, and psychopathology (Bowlby,
1977; Jovev & Jackson, 2004; Loper et al., 2008). Sexually abu-
sive behaviors seem to have some roots in early attachment dis-
ruptions, whereby attempts are made to satisfy unmet emotional
needs and to connect with others through sexual or aggressive
means (Beech & Mitchell, 2005; Bushman, Baumeister, & Phil-
lips, 2001; Grady, Levenson, & Bolder, 2016; Hudson & Ward,
1997; Hudson, Ward, & McCormack, 1999; Smallbone & Dadds,
1998; Vondra, Shaw, Swearingen, Cohen, & Owens, 2001).
ACE and Sex Offenders
The ACE scale was developed by the CDC to measure child-
hood adversity and was used in the 1990s to collect normative data
from over 17,000 adults in California; it has become a useful and
well-researched tool for measuring the accumulation of traumatic
events related to child maltreatment and family dysfunction (Anda
et al., 2010). One’s ACE score (1–10) reflects the number of
dichotomous items endorsed and higher scores represent a more
pervasive and diverse history of adversities. Both male and female
sexual offenders have significantly higher ACE scores than indi-
viduals in the general population (Levenson et al., 2014; Levenson,
Willis, & Prescott, 2015; Reavis, Looman, Franco, & Rojas, 2013;
Weeks & Widom, 1998). A study of adult male sexual offenders
(N � 679) found that, compared to males in the general popula-
tion, they had more than three times the odds of child sexual abuse
(CSA), nearly twice the odds of physical abuse, 13 times the odds
of verbal abuse, and more than four times the odds of emotional
neglect or having unmarried parents (Levenson et al., 2014).
Weeks and Widom (1998) also found that the rates of child
maltreatments for male sex offenders exceeded those of males in
the general population, with 26% revealing child sexual abuse,
18% reporting neglect, and two thirds stating that they were
victims of physical abuse. Likewise, the prevalence of adverse
childhood experiences is higher for female sexual abusers than for
nonoffending women (Gannon, Rose, & Ward, 2008; Levenson et
al., 2015; Turner, Miller, & Henderson, 2008; Wijkman, Bijleveld,
& Hendriks, 2010). Emotional abuse early in life is a robust risk
factor for both sexual victimization and sexual perpetration behav-
ior, whereas physical neglect and family violence emerged as
significant risk factors for sexual victimization (Jennings, Zgoba,
Maschi, & Reingle, 2014).
It appears that many sex offenders were raised in chaotic or
disordered social environments by caregivers who were ill-
equipped to protect their children from harm (Levenson et al.,
2014, 2015). For instance, less than 16% of male sex offenders
reported no adverse experiences, compared with 38% of the males
in the CDC study, and almost half endorsed four or more (com-
pared with about 9% of the male CDC sample, Levenson et al.,
2014). In a similar analysis, 48% of male interpersonal violence
offenders (child abusers, domestic violence assaulters, sex offend-
ers, and stalkers) reported four or more adverse experiences (Rea-
vis et al., 2013).
Some scholars have hypothesized that insecure attachments
lead to intimacy deficits and that some individuals attempt to
connect with others through coercive, violent, or deviant sexual
behavior (Bushman et al., 2001; Marshall, 2010; Ward, 2014).
Sex offenders with insecure attachments demonstrate higher
levels of aggression in sexual relationships, have a higher
tolerance for violence in relationships in general, and have more
instability in their adult romantic relationships (Lyn & Burton,
2005). Furthermore, recent research suggests that there is a
positive correlation between measures of insecure attachment
and the number and severity of risk factors associated with
criminal behavior, including sexual crimes (Grady, Swett, &
Shields, under review).
It is perhaps not unexpected that early adversity is linked to
sexually abusive behavior. Incompetent parenting activates and
reinforces dysfunctional interaction styles and reduces oppor-
tunities for exposure to (and rehearsal of) effective communi-
cation and intimacy skills (Rutter et al., 2006). A lack of
healthy attachment in a childhood environment can contribute
to subsequent impersonal, selfish, combative, or adversarial
relationship patterns, including tolerant attitudes toward bound-
ary violations such as sexual abuse (Beech & Mitchell, 2005;
Hanson & Morton-Bourgon, 2005). Violent or sexually deviant
behavior may be among the coping responses that emerge from
early traumatic experiences.
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95ACE AND SEX OFFENSE PATTERNS
Additional research has revealed a relationship between early
family experiences and sex offenders’ types of offenses (Levenson
et al., 2014; Lyn & Burton, 2004; Smallbone & Dadds, 1998;
Ward, 2014). Sexualized coping may provide a way of soothing
distress and/or meeting needs for intimacy, affection, attention,
power, or control, and this may be especially true for sex offenders
with a childhood history of molestation (Seto, 2008). Sexual
deviance, as evidenced by paraphilic preference for children,
seems to be linked with early adversity; higher ACE scores were
correlated with younger victim age (Levenson et al., 2014). Sex
offenders have higher rates of child sexual abuse than nonsex
offenders (Jespersen, Lalumière, & Seto, 2009), and those with a
sexual abuse history are more likely to have younger victims and
pedophilic interests (Nunes, Hermann, Renee Malcom, & Lavoie,
2013). Higher ACE scores have also been correlated with use of
force or violence in the commission of a sex crime (Levenson et
al., 2014).
Sexual deviance and antisocial criminality are important ar-
eas to study and understand, as they are both associated
with increased risk for recidivism (Hanson & Bussiere, 1998;
Hanson & Morton-Bourgon, 2005; Quinsey, Harris, Rice, &
Cormier, 1998). The most dangerous sex offenders are those
who are afflicted not only with deviant sexual preferences, but
who also possess the capacity to act on those interests with little
regard for the consequences to others. Early meta-analyses
(Hanson & Bussiere, 1998; Hanson & Morton-Bourgon, 2005)
observed that childhood abuse was not associated with sexual
recidivism, but more recent and refined findings point to a link
between CSA and sexual recidivism for high-risk sex offenders
(Nunes et al., 2013), and to a correlation between ACE scores
and risk scores (Levenson et al., 2014). Patterns of sexual
deviance and violence are also different for generalist and
specialist sex offenders; specialists are defined as those for
whom sexual offenses constitute more than half of their total
number of arrests (Harris, Knight, Smallbone, & Dennison,
2011). For instance, child molesters are more likely to engage
only in sexual offending (specialists), whereas rapists of adults
display tendencies toward criminal diversity (generalists) (Har-
ris et al., 2011; Harris, Smallbone, Dennison, & Knight, 2009;
Lussier, LeBlanc, & Proulx, 2005). Higher ACE scores have
been associated with greater versatility and persistence of crim-
inal behavior in male sexual offenders (Levenson & Socia,
2015).
Purpose of the Current Study
The purpose of this study was to explore the influence of
adverse childhood experiences on offense characteristics in a sam-
ple of convicted sexual offenders. Based on developmental theo-
ries of criminality and sexual offending, it was hypothesized that
higher ACE scores would be associated with higher levels of
sexual deviance and sexual violence. An additional exploratory
aim was to determine the influence of various types of childhood
adversity on sexually abusive and violent behavior. This study is
the first to investigate the relationship between childhood adversity
and the two outcome variables in this particular fashion, attempt-
ing to fill a gap in knowledge about the etiology of sexual perpe-
tration patterns.
Method
Data Collection
A nonrandom convenience sample of sexual offenders was
surveyed in outpatient (72%) and civil commitment (28%) treat-
ment programs in the United States. An invitation was posted on
the e-mail list-serv of the Association for the Treatment of Sexual
Abusers (ATSA) to find treatment programs who could recruit sex
offender client participants. The data collection sites were located
in New Jersey, Illinois, Texas, Florida, Georgia, Maryland, Mon-
tana, Washington, and Maine. All clients attending treatment in the
programs (approximately 1,000) were invited to participate by
staff and therapists. Presumably because of these trusting relation-
ships between clients and staff, a strong response rate (approxi-
mately 74%) was obtained, and a total of 740 sex offenders
voluntarily agreed to complete the survey. Outpatient sex offender
treatment programs usually serve clients who have been court
ordered to treatment as part of their parole following a criminal
conviction, or as part of a family court plan related to a child
protective services investigation, and in this sample 2.9% reported
no arrest history and voluntarily sought treatment. Civilly com-
mitted sex offenders receive treatment in a secure facility follow-
ing their incarceration.
Federal guidelines for human subject protection were followed
and the project was approved by an Institutional Review Board.
Clients were invited to voluntarily complete the anonymous survey
during a regularly scheduled group therapy session at their respec-
tive participating data collection sites. Clients were instructed not
to write their names on the survey, and to place the completed
survey in a sealed box with a slot opening. Informed consent was
provided in writing and explained verbally. To further ensure
anonymity, participants were not required to sign a consent doc-
ument. Completion of the survey was considered to imply in-
formed consent to participate in the project.
Participants
The sample for the current study was comprised of 740 male
(93.5%) and female (6.5%) adult sex offenders. Sample demo-
graphics are displayed in Table 1. Most participants were white
(68%) and the majority (71%) were between 31 and 60 years of
age, with 20% age 30 or younger and 9% over age 60. Nearly two
thirds (62%) of the sample had completed high school or obtained
a Graduate Equivalency Diploma (GED) as their highest educa-
tional achievement, and one in five identified themselves as col-
lege graduates. More than half (59%) grossed less than $30,000 in
the last year they earned income. Almost half (46%) of the sex
offenders had never been married, with 16% currently married,
35% divorced or separated, and 3% widowed.
Instrumentation
The first section of the survey consisted of the Adverse Child-
hood Experiences (ACE) Scale (Centers for Disease Control &
Prevention, 2013b), a 10-item dichotomous (yes/no) scale in which
participants endorse whether or not they had experiences prior to
18 years of age that included: abuse (emotional, physical, and
sexual), neglect (emotional and physical), and household dysfunc-
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96 LEVENSON AND GRADY
tion (domestic violence, unmarried parents, and the presence of a
substance-abusing, mentally ill, or incarcerated member of the
household). One’s total ACE score is the sum of the number of
items endorsed by that individual (range � 0 –10).
The ACE categories were originally developed by adapting
items from instruments that demonstrated validity and reliability in
earlier studies: the Conflict Tactics Scale (Straus, Gelles, & Smith,
1990), the Child Trauma Questionnaire (Bernstein et al., 1994),
and questions from a survey about sexual abuse (Wyatt, 1985).
The test–retest reliability of the ACE scale has been examined by
administering the survey twice to over 600 participants, and re-
searchers found that Kappa coefficients ranged from good to
excellent, indicating that retrospective reports of early abuse and
household dysfunction are normally stable over time (Dube, Wil-
liamson, Thompson, Felitti, & Anda, 2004). Though no validity
data are available on the ACE scale itself, a review of 40 studies
assessing the validity of retrospective reports found that underre-
porting of child maltreatment was common, but false positives
were rare, and researchers should not be dissuaded from using
well-defined self-report measures of childhood adversity (Hardt &
Rutter, 2004). Finkelhor et al. (2013) attempted to improve the
ACE scale by modifying some items and adding additional do-
mains (e.g., peer victimization, community violence, illnesses and
injuries, socioeconomic status), and then testing the new version
on a nationally representative sample. They concluded that the
adjustments led to more robust effects when measuring distress by
trauma scores, but that the child maltreatment items in the original
ACE scale remained important contributors to the cumulative
stress of early adversity (Finkelhor, Shattuck, Turner, & Hamby,
2013). Noteworthy is that the ACE scale has become a widely used
measure of childhood adversity and many researchers have relied
on this brief instrument in hundreds of studies (Centers for Disease
Control & Prevention, 2013a).
The second section of the survey collected information about
offense characteristics, which were used to measure the constructs
of interest in this study (sexual deviance and sexual violence) and
can be seen in Table 4. No information that could potentially
identify offenders or victims was sought.
Variables
The primary purpose of the study was to explore the influence
of adverse childhood experiences on sexual deviance and sexual
violence, and two dependent variables were created for this pur-
pose. The Sexual Deviance Scale (possible score range � 0 – 4)
comprised four dichotomous (yes/no) items including male victim,
stranger victim, victim under 12, and multiple victims (Cronbach’s
alpha � .61). The scale was devised using known risk factors for
sex offense recidivism and indicators of paraphilic preference
patterns; a higher score (endorsement of multiple categories) in-
dicated a higher degree of sexual deviance. The other variable, the
Sexual Violence Scale, was intended to capture the use of violence
in the commission of a sexual crime, as measured by endorsement
of “yes” to questions asking whether the offender had ever used
force, weapons, or caused injury during a sexual crime (range �
0 –3; Cronbach’s alpha � .73). All of these variables were ob-
tained via self-report in the survey.
Independent variables included the 10 dichotomous ACE items
(yes/no; see Table 2) and the total ACE score, by which a higher
score reflects a wider scope of childhood maltreatment and expo-
sure to household dysfunction.
Analyses
Descriptive statistics are reported for each of the ACE items and
constructs of interest. Group comparisons (t tests and chi-square)
and bivariate correlations were used to examine relationships
between variables. Multivariate regression was used to examine
the influence of individual ACE factors in explaining sexual de-
viance and violent sexual offending.
Results
Table 2 displays the endorsements of ACE items and distribu-
tion of ACE scores for the current sample. It should be noted that
these results have been published elsewhere (Levenson, Willis, &
Prescott, 2014, 2015) but are included here for readers’ conve-
nience.
Participants answered a series of questions about victim char-
acteristics, taking into account their index offense, any prior ar-
rests, and any undetected offending, and endorsed whether they
had ever had a victim in any of the gender, age, or relationship
categories listed in Table 3. There were significant differences
between males and females in most of the categories. Importantly,
males were more likely to have stranger victims, more victims,
more sex crime arrests, and more general arrests. Males were more
likely to use force or weapons. Nearly three-quarters of the females
were specialist offenders (compared to half the males), for whom
sexual offenses constituted more than half of their total arrests.
t tests were used to test mean differences between groups in
ACE scores (see Table 4). Though males and minorities had
Table 1
Sample Demographics
Demographic categories Percent (N � 740)
Race
White 68
Minority 32
Gender
Male 93.5
Female 6.5
Age (years)
18–30 20
31–40 22
41–50 30
51–60 19
Over 60 9
Marital status
Never married 46
Married 16
Divorced/separated 35
Widowed 3
Education
Not high school graduate 18
High school graduate or GED 62
College graduate or higher 20
Income
Under $20,000 41
$20,000–$29,999 18
$30,000–$49,999 20
$50,000� 21
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97ACE AND SEX OFFENSE PATTERNS
slightly higher ACE scores than females and Whites, these differ-
ences were not significant. However, sex offenders with male,
stranger, prepubescent, and multiple victims had significantly
higher ACE scores, as did those who had used force or weapons or
caused injury during a sex offense. Specialists whose sex offenses
constituted more than half of their arrests were found to have
significantly lower ACE scores than generalist offenders.
Bivariate correlations revealed that higher ACE scores were
significantly correlated with higher scores on the scales measuring
sexual deviance, r � .30, p � .01 and sexual violence, r � .28, p �
.001. Sexual deviance and sexual violence were significantly cor-
related with each other, r � .41, p � .01.
Multiple regression techniques were used to further examine the
influence of childhood adversity on sexual deviance and sexual
violence for male offenders only (see Table 5). The decision to
exclude females was made because there is less consensus in the
conceptualization of sexual deviance for female sex offenders, and
therefore the use of factors to devise this construct would be
speculative. Paraphilic sexual deviance indicators are much more
well-established in the research literature about male sex offend-
ers. Missing data reduced the sample size in all models by case-
wise (listwise) deletion, however power analysis determined that
Table 2
ACE Item Endorsement and Score Distribution (Valid n � 689)
Measure
Total
(n � 681)
Male
(n � 635)
Female
(n � 46)
ACE item endorsement
Childhood experience with
. . . % responding ‘yes’
Chi-square
(male/female comparison)
Verbal abuse 52 53 38 3.982�
Physical abuse 42 42 34 1.209
Child sexual abuse 38 38 50 2.847
Emotional neglect 37 38 40 .150
Physical neglect 16 16 11 .942
Parents not married 54 54 47 1.003
DV in home 24 24 23 .010
Substance abuse in home 46 47 40 .706
Mental illness in home 26 26 21 .486
Incarcerated family member 23 23 17 .804
Distribution of ACE scores
Total ACE score % with ACE score Chi-square
0 15.7 16 20 ns
1 13.8 14 11 ns
2 12.8 13 15 ns
3 12.5 12 13 ns
4� 45.3 45 41 ns
Mean ACE score (SD) 3.51 (2.71) 3.54 (2.7) 3.2 (2.6) t � .816
Note. ACE Scores ranged from 0 to 10. ns � not significant.
� p � .05.
Table 3
Offense and Victim Characteristics by Gender of Offender
Characteristic
Male
%/mean
Female
%/mean
Male victim� 27% 42%
Stranger victim�� 35% 11%
Victim under 12 52% 40%
Ever used force�� 23% 4%
Ever used weapon� 9% 0%
Ever caused injury 10% 2%
Total sex crime arrests� 1.47 1.09
Total nonsex arrests�� 2.99 1.87
Multiple (2 or more) victims��� 58% 30%
Specialist�� 50% 73%
Note. Chi-Square Significant differences between groups.
� p � .05. �� p � .01. ��� p � .001.
Table 4
Group Comparisons of Mean ACE Scores
Variable
Groups
Sig.Mean ACE score
Gender Male Female ns
3.5 3.2
Race Minority White ns
3.7 3.5
Male victim Yes No .000
4.3 3.2
Stranger victim Yes No .000
4.1 3.2
Victim under 12 Yes No .000
4.2 2.9
Ever used force Yes No .000
4.9 3.1
Ever used weapon Yes No .000
5.3 3.4
Ever caused injury Yes No .000
5.4 3.3
Multiple victims Yes No .000
3.9 2.9
Specialist (versus generalist) Yes No .000
3.1 4.1
Note. ns � not significant.
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98 LEVENSON AND GRADY
to detect a medium effect size with 10 predictors, the reduced
sample size of 609 was more than sufficient (Faul, Erdfelder,
Lang, & Buchner, 2007). Preliminary analyses were conducted to
check for normality, outliers, and collinearity. Residuals were
observed in the probability plots and revealed no major deviations.
Standardized residuals were checked and few cases had values
above 3.0 or below �3.0. The maximum Cook’s Distance was
.015, indicating that outliers were not a significant problem. The
variance inflation factors were all below 10, and tolerance was
well above .10, indicating that multicollinearity was not problem-
atic.
ACE items were entered into the multiple regression model with
the sexual deviance scale score as the dependent variable. The
model explained about 15.7% of the variance in the dependent
variable, F(10, 609) � 11.150, p � .001.Within the model, child-
hood sexual abuse, emotional neglect, mental illness in the home,
and parents not married were significant (p � .05) predictors of
increased sexual deviance. The strongest contributors were child
sexual abuse and emotional neglect.
ACE items were entered into a new multiple regression model with
sexual violence as the dependent variable, explaining 9.7% of the
variance, F(10, 616) � 6.540, p � .001.Within the final model,
childhood physical abuse, substance abuse in the childhood home, and
an incarcerated family member were significant predictors of in-
creased sexual violence. Incarcerated family member was the stron-
gest contributor, followed by physical abuse and substance abuse.
Discussion
The results revealed that childhood adversity was associated
with sexual deviance and sexual violence for male sex offenders,
suggesting that the accumulation of early trauma can increase the
likelihood of sexual and general self-regulation difficulties later in
life. The regression models examining the influence of the ACE
items were statistically significant, however the effect sizes were
not substantial and explained only a minority of the variance in the
outcomes of interest. This implies that there are other factors, not
contained in these models, which provide explanatory power about
the overall etiology of sexual deviance and sexual violence. It
appears that adverse childhood experiences do contribute to these
negative adult outcomes, but obviously they do so in combination
with other variables, not available in these analyses, that mediate
risk and resilience. Consistent with developmental and attachment
theories of criminality and sexual offending, the findings sup-
ported the hypothesis that higher ACE scores would be associated
with indicators of sexual deviance and sexual violence.
The findings offer some insight into the different pathways
leading to sexually deviant and sexually violent behaviors. Predic-
tors of deviance included childhood sexual abuse, emotional ne-
glect, mental illness in the home, and unmarried parents. It is
known that children with single or unmarried parents are at higher
risk for CSA (Finkelhor & Baron, 1986) because of less attentive
supervision and exposure to multiple caretakers on whom an
unmarried parent might rely for child care assistance. At the same
time, an overwhelmed single parent might be physically absent
and/or emotionally unavailable, increasing the child’s vulnerability
to a sexually abusive adult who grooms the child by providing
attention and nurturing. Sexually abused children may grow up to
use sex to compensate for feelings of invalidation or powerless-
ness, they may replicate their own abuser’s behavior and distorted
thinking, or they may come to associate sexual arousal with
adult-child sexual activity (Seto, 2008). Sexualized coping can
offer a way of soothing distress and/or meeting needs for intimacy,
affection, attention, and control (Bushman et al., 2001; Levenson
et al., 2014). The abused or neglected child, as an adult, may tend
to seek out younger individuals whom he perceives as looking up
to him and who will not hurt him. His victim choices are “safe”
and therefore he feels less vulnerable.
On the other hand, predictors of violence included physical child
abuse, substance abuse in the home, and having an incarcerated
family member. Sexual violence in adulthood might be shaped by
earlier observations of aggression via harsh corporal punishment
or arbitrary discipline practices. The effects of physically abusive
parenting can be exacerbated when substance abuse interferes with
a parent’s anger management and further models poor self-
regulation (Dube et al., 2001). Having incarcerated family mem-
bers may reinforce criminal modeling, and may also generate
feelings of hopelessness and helplessness for children witnessing
such conditions in their own homes. Disempowerment and a view
of the world as unfair might lead to a distorted sense of entitle-
ment, and violence can become a way to seize a sense of power
and control. As well, the chaotic familial dynamics characterized
by aggression and addiction may offer few opportunities to ob-
serve and establish healthy intimate attachments, paving the way
for affective and behavioral dysregulation as well as maladaptive
coping (Ford, Chapman, Connor, & Cruise, 2012).
Deficits in interpersonal functioning and coping are commonly
found among individuals with insecure attachments. Research
shows that individuals without a secure attachment are more likely
to struggle with affect regulation (Ford et al., 2012), have a mental
health diagnosis (DeKlyen & Greenberg, 2008; Mikulincer &
Shaver, 2012), and have higher rates of violence across the life
Table 5
ACE Items Predicting Sexual Deviance and Sexual Violence
(Male Offenders)
ACE items Beta t Sig.
Model 1: ACE items predicting sexual deviance
Verbal abuse .072 1.363 .173
Physical abuse �.010 �.187 .852
Child sexual abuse .257 6.092 .000
Emotional neglect .118 2.626 .009
Physical neglect �.057 �1.295 .196
Parents not married �.095 �2.341 .020
DV in home .057 1.288 .198
Substance abuse in home .026 .606 .545
Mental illness in home .099 2.329 .020
Incarceration family member .021 .526 .599
Model 2: ACE items predicting sexual violence
Verbal abuse .022 .405 .686
Physical abuse .108 2.005 .045
Child sexual abuse .077 1.776 .076
Emotional neglect .066 1.434 .152
Physical neglect �.020 �.454 .650
Parents not married �.009 �.204 .839
DV in home .008 .177 .860
Substance Abuse in home .097 2.179 .030
Mental illness in home .009 .202 .840
Incarceration family member .126 3.073 .002
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99ACE AND SEX OFFENSE PATTERNS
span (Crittenden, 1992). It is therefore possible that sexual vio-
lence and deviance, in many cases, can be traced back to insecure
attachments that were formed through adverse childhood experi-
ences (Grady, Levenson, & Bolder, 2016). The link between child
abuse and neglect and later offending behavior is well established
(Abbiati et al., 2014; Lee, Jackson, Pattison, & Ward, 2002;
Simons, Wurtele, & Durham, 2008).
Implications for Practice and Policy
Trauma-informed practitioners recognize the prevalence of
childhood adversity in the general population, expect the majority
of clients to have experienced early trauma, and understand the
biological, social, psychological, cognitive, and relational impact
of traumatic events on adult functioning and high-risk behavior
(Larkin et al., 2014; Levenson, 2014; D. S. Young, 2014). Clini-
cians assessing and treating sex offenders should be well-versed in
knowledge related to trauma and how it contributes to problematic
sexual behaviors. Though cognitive– behavioral interventions are
the conventional treatment of choice for sex offenders, such pro-
grams can be informed by the literature on attachment, develop-
mental psychopathology, and trauma-informed care.
Trauma-informed clinicians recognize that relational patterns in
adulthood often mimic those learned early in life. That sexual
deviance was significantly associated with sexual abuse, and that
sexual violence was associated with physical abuse, reinforces the
notion of isomorphism between early victimization and later per-
petration. Isomorphism as a psychological construct refers to a
symbolic representation that generates behavior and decision-
making based on anticipated events and relations in the environ-
ment (Gallistel, 2001). In other words, expectations associated
with past encounters are triggered when similar environmental
conditions exist in the present, and thus adult perpetration patterns
may replicate victimization experiences. Helping sex offender
clients understand the impact of traumatic childhood experiences
on their adult functioning might lead to improved therapeutic
outcomes that diminish future risk (Abbiati et al., 2014; Levenson,
2014) and provide reparative opportunities for anxious and inse-
cure attachment styles (Grady, Swett, & Shields, 2016).
The therapeutic alliance itself can have a profound positive
impact on outcomes for sex offenders through exposure to trauma-
informed corrective emotional experiences that model empathy
and effective relational skills (Connors, 2011; Marshall, Burton, &
Marshall, 2013; Marshall et al., 2003; Marshall et al., 2002).
Research indicates that through the curative nature of a trauma-
informed counseling relationship, clients’ attachment styles can
shift and become more secure (Mikulincer & Shaver, 2012). Re-
cent research specifically with sex offenders demonstrated that
they can and do become more securely attached with a strong
therapeutic bond, even in a CBT-based program (Grady et al.,
2016). Furthermore, as attachment becomes more secure, dynamic
risk factors associated with criminality are reduced (Grady et al.,
under review). Clinical practitioners can advance social justice
through the application of trauma-informed service delivery (Mas-
chi & Killian, 2011; Sheehan, 2012; D. S. Young, 2014).
Moreover, it is crucial that social policies be responsive to the
lasting and substantial impacts of early adversities and their role in
the development of criminal and abusive behaviors. Adverse child-
hood experiences are now viewed as a public health crisis (Anda
et al., 2010; Felitti, 2002; Larkin et al., 2014). There is a robust
body of research documenting the significant impact of childhood
adversity on risk for poly victimization as well as pervasive and
profound posttraumatic stress symptoms (Cloitre et al., 2009;
Finkelhor, Turner, Hamby, & Ormrod, 2011). Unfortunately, pri-
mary prevention of child maltreatment has been somewhat ne-
glected in favor of American social policies focused predomi-
nantly on offender punishment and child placement (Larkin et al.,
2014; Levenson & Socia, 2015). Youth growing up in disadvan-
taged communities and society as a whole would benefit from
prioritizing preventive interventions.
Household dysfunction and chronic maltreatment put children at
a higher risk for becoming addicted to substances and committing
crimes (DeHart et al., 2009; DeHart, Lynch, Belknap, Dass-
Brailsford, & Green, 2014; Harlow, 1999; Jennings et al., 2014;
Mersky et al., 2012; Topitzes, Mersky, & Reynolds, 2012; Widom
& Maxfield, 2001). Multiple public health and primary prevention
implications are clear: we need to provide victims of all forms of
child maltreatment with immediate and appropriate therapeutic
services, to intervene early with at-risk parents to help them
develop skills that foster attachments and healthy family function-
ing, and to alter the culture of the criminal justice system to utilize
a more trauma informed approach to incarceration and reentry
(Baglivio et al., 2014; Larkin et al., 2014; Mendelson & Letour-
neau, 2015; Miller & Najavits, 2012). To halt the cycle of inter-
personal violence in communities, it is critical that the mental
health, child protective, and criminal justice systems invest in
comprehensive prevention programs for high risk families and
treatment for child victims (Anda et al., 2010; Baglivio et al.,
2014; Miller & Najavits, 2012).
Limitations
There are several limitations to this study. First, all information was
provided by offender self-report, and the design of the study did not
allow for review of official documentation to verify responses. The
responses may reflect impression management bias, a desire to hide
embarrassing behaviors or experiences, or exaggeration of early
trauma experiences in a maneuver to gain sympathy or justify behav-
ior. On the other hand, it is plausible that some offenders do not
readily recognize early adversity as pertaining to themselves, perhaps
underreporting childhood trauma. Another limitation of self-report is
that we were unable to obtain DSM diagnoses made by a clinician to
determine whether a participant met criteria for a paraphilic disorder,
which might have provided an additional and important measure of
sexual deviance. Second, the participants were all in treatment pro-
grams and therefore the findings might not generalize to the full
population of sexual offenders. Third, the ACE scale as a measure of
early adversity is imperfect. Clearly there is an array of traumatic
experiences beyond child maltreatment and family dysfunction that
shape adult behavior. Moreover, the ACE scale measures only intra-
familial experiences and its dichotomous nature does not allow for
unmeasured heterogeneity in the frequency, duration, or severity of
childhood traumas. This study does not account for extrafamilial or
environmental factors such as community violence, poverty, discrim-
ination, microaggression, death, illness, natural disasters, or bullying.
The ACE scale is not intended to be an exhaustive measure of trauma,
nor does it fully capture the scope of variables that contribute to
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100 LEVENSON AND GRADY
sexually abusive behavior. Finally, given the retrospective and cross-
sectional research design, causality cannot be inferred.
Conclusions
Adverse childhood experiences were associated with sexual
deviance and sexual violence. Clinicians should recognize the
prevalence of early trauma in the lives of clients and consider the
role of childhood adversity to inform treatment planning for both
offenders and victims. Because self-regulatory deficits are often a
consequence of ACEs and should be viewed as dynamic risk
factors for reoffending, practitioners should integrate trauma-
informed forensic counseling methods that individualize and de-
liver services in a way that is relevant to risk, criminogenic needs,
and responsivity factors (Andrews & Bonta, 2010; Hanson, Bour-
gon, Helmus, & Hodgson, 2009; Levenson, 2014). Social policies
that prioritize primary prevention programs, child protection ser-
vices, and early interventions for at-risk families and maltreated
youth can disrupt the trajectory toward criminal and sexually
abusive behavior in adulthood. Trauma-informed practitioners
must address the micro, mezzo, and macro issues that perpetuate
the cycle of sexual violence in our communities.
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Received October 3, 2015
Revision received December 30, 2015
Accepted January 18, 2016 �
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103ACE AND SEX OFFENSE PATTERNS