- Excerpt from Chapter 23, Sexual and Gender Identity Disorders,
by Dorothy Griffiths, Ph.D., J. Paul Fedoroff, M.D., Deborah
Richards, B.A., C.H.M.H., Diane Cox-Lindenbaum, A.C.S.W., Ron
Langevin, Ph.D., William R. Lindsay, Ph.D., Stephen Hucker, M.D., and
Marc Goldman, M.S.
Etiology and Pathogenesis
Risk Factors
Vulnerability influences represent personal (biomedical and
psychological) and socioenvironmental features that can place the
individual at risk to engage in Paraphilia behaviors when confronted
by specific instigating features. Vulnerability influences can be
psychological (for example, deficit anger control skills, deficit
social skills, or a lack of empathy skills), biomedical (for example,
mental illness, neurological problems, physical problems, or a
behavioral phenotype), or socioenvironmental (for example, a
restricted opportunity for sexual expression). These risk factors,
though not instigating the behavior, can serve to create a
vulnerability that will influence how an individual will respond when
instigating conditions are present. Knowledge of such vulnerabilities
that contribute to the behavior not only can assist in differential
diagnosis but also can be critical for designing intervention
approaches for reducing the vulnerabilities.
Biological Factors
Individuals with Paraphilia show a higher rate of neurological
abnormality, biological differences as sex hormone abnormality,
substance abuse, and problems in socialization, as well as a history
of violence that has been noted by Langevin (1992) (Strength of
evidence: IV). Mental illness is present in about 10% of forensic
cases, and that is also true of sex offenders. There is disagreement
in the field, however, with regard to the relative influence of
various factors in the development of a Paraphilia. This
determination becomes even more complicated when examining the
etiology of sexual offending in people with ID. A Paraphilia might
reflect the interactive effect of biomedical influences (that is,
physical, neurological, biochemical, sensory, or mental health
influences), psychological characteristics (in other words,
cognitions, motivational features, communication skills, emotional
expressions, anger management skills, or coping skills), and
socioenvironmental influences (for example, physical environmental
features and social interactions).
The brain pathology of individuals who are sexually aggressive is
complicated by the fact that they represent such a heterogeneous
group relative to their preference of sex, age, sexual acts, and the
context of the offense. Due to the heterogeneity of the population,
it is questionable whether brain pathology is present in all
offenders (Langevin, Wortzman, Wright, & Hardy, 1988) (Strength
of evidence: IV). It appears that the presence of brain damage and
dysfunction in some sex offenders can serve as an underlying
vulnerability that interferes with psychological and biological
functioning. The exact nature of the influence, however, is still
speculative and under investigation.
There is evidence that certain mental disorders are more prevalent
among sex offenders; it has similarly been suggested that people with
ID are as likely or more likely than the nondisabled population to
develop emotional or mental health problems.
Psychosocial Factors
Risk factors that are associated with the development of a
Paraphilia, such as a lack of attachment, neurological challenges,
and a lack of prosocial skills, are also highly associated with ID.
People who develop sexually offensive behavior have been found to
have poorer attachment bonds and family relationships, suffer from
low self-esteem, experience greater emotional loneliness, have
difficulty with social skills, enjoy fewer friendships and intimate
relationships, and have difficulty with issues of power and
inhibition (Marshall, Hudson, & Hodkinson, 1993) (Strength of
evidence: V). Individuals with ID are more vulnerable than are
nondisabled people to such psychological factors, which might be
associated with counterfeit deviance.
The psychological factors that can contribute to counterfeit deviance
include, but are not limited to, a lack of social skills or
sociosexual knowledge, institutionalized sexual learning, and
communication problems. Moreover, the lack of typical sexual learning
and the nature of sexual and relationship experiences generally
afforded by society to individuals with ID has also been found to
correlate to expressions of sexuality that were inappropriate and
sometimes labeled deviant. Individuals with ID are more likely to
experience repressive, abusive, and culturally distorted sexual
learning, which can contribute to inappropriate expressions of their sexuality.
The cognitive challenges of the person with ID can also play a role
in the presentation of a behavior that might appear as a Paraphilia.
For example, Griffiths and Fedoroff (in press) (Strength of evidence: V) described
a young man who repeatedly masturbated in the living room. He was
redirected to his bedroom and instructed that the bedroom was the
appropriate location for such behavior; he immediately returned to
the living room and began to engage in the behavior again. One
conclusion would be that he was sexually aroused from the reaction he
received from the female staff and residents. On the other hand, an
alternate hypothesis was tested to see if it was that he needed the
presence of some visual aid (for example, the presence of the women)
to gain arousal. Testing the rival hypothesis by providing him access
within his bedroom to posters of women in bathing suits and the
swimsuit edition of Sports Illustrated resulted in the
elimination of the behavior problem. Instruction was also provided so
that he understood why his previous behavior was considered
inappropriate and offensive to the women. To summarize, a simple
testing of an alternative hypothesis quickly allowed the
determination of a Paraphilia to be put aside.
The sexual abuse of people with ID is extremely prevalent in our
society. It has been suggested that 88% of people with ID have been
sexually exploited (Hill, 1987) (Strength of evidence: V). Although
exact prevalence is difficult to determine due to differences in the
methodology used, Doucette (1986) (Strength of evidence: V) suggested
that people with ID are at least one and a half times more at risk
for sexual abuse than are other members of society.
Early sexual abuse might condition some individuals to respond
sexually to the presence of certain individuals or when confronted
with specific situations reminiscent of early experiences of abuse.
The relationship between childhood violence and trauma and the
development of sexual offending behavior is called the traumagenic model.
Finkelhor (1986) (Strength of evidence: V) has suggested that
some sexual offenders might be motivated to recapitulate their own
sexual victimization and that the content of the sexual fantasies of
repeat offenders could be the result of “protracted sexually
deviant and pathological experience first sustained at a young
age” (Prentky & Burgess, 1991, p. 241) (Strength of
evidence: V). According to the traumagenic model, for some sex
offenders there is a correlation between the age of onset of fantasy-driven
sexual aggression and the age of their own abuse, the duration of
their abuse, and the level of invasiveness of the abuse (Pithers,
1993) (Strength of evidence: V). As noted, however, the correlation
between the age of the victim and that of the victimizer is not high.
Griffiths (as cited in G. Allan Roeher Institute, 1988) in a survey
of a sample of individuals participating in a clinic for sexual
offenders with ID, reported that all the individuals receiving
treatment at a specific point in time had childhood experiences of
abuse. Although this 100% rate was not present in subsequent samples,
the high rates of abuse experienced by individuals with ID who had
been referred for sexual offending behavior did continue. Similarly,
Hingsburger (1987) (Strength of evidence: V) reported that
individuals with ID with histories of institutionalization had
experienced molestation or coercive sexual activity while in the
institution, and that many of these individuals later committed
similar acts against individuals who were younger and more vulnerable.
In a rare empirical study on this topic, Lindsay, Law, Quinn, Smart,
and Smith (2001) (Strength of evidence: V) reviewed the patterns of
physical and sexual abuse in offenders with ID, comparing those who
offended sexually (46) with those who offended nonsexually (48).
After conducting comprehensive assessments over a period of a year of
their experiences of childhood sexual and physical abuse, they found
that 37% of the sexual offenders and 12.7% of the nonsexual offenders
had been sexually abused, whereas 13% of the sexual offenders and 33%
of the nonsexual offenders had experienced nonsexual physical abuse.
They concluded that sexual abuse in childhood was a significant
variable in the history of sexual offenders, whereas nonsexual
physical abuse was more prevalent in the history of nonsexual
offenders; nonetheless, they concluded, a history of abuse does not
invariably lead to offending behavior, nor is it sufficient as an
explanation of the abuse--offense cycle.
Most individuals who have experienced childhood sexual abuse do not
develop Pedophilia; conversely, most individuals who sexually offend
against children were not themselves sexually abused. Nonetheless,
data do indicate that for some individuals the traumagenic experience
might have conditioned certain stimuli to be sexually arousing (that
is, children of a certain age or in specific situations). People with
ID might be more likely to relive the traumagenic experience because:
(1) their abuse is often repeated, (2) it is often not addressed nor
treated, (3) the individual is often unlikely to escape the
conditions or environment or victimizer associated with the event,
and (4) there are less likely to be prosocial sexual experiences that
replace the initial experience. Therefore, to the extent that the
abuse is currently affecting the sexually inappropriate behavior, it
can be said that the abuse is affecting the current issues.
People with ID might lack appropriate sociosexual knowledge. This
could be directly related to behavioral phenotypes (Griffiths,
Richards, Fedoroff, & Watson, 2002) (Strength of evidence: V),
the lack of sociosexual education or social skills training
(Griffiths et al., 1989) (Strength of evidence: V) or the
result of exposure to environments where the sociosexual culture has
promoted behaviors that might be inappropriate (Hingsburger, 1992)
(Strength of evidence: V). For example, a young man who has always
lived in an institutional environment where privacy was not respected
nor taught is now living in the community. He drops his pants when he
needs to go to the bathroom to signal his discomfort; however he does
so whether in private or public. This behavior could be
misinterpreted as a Paraphilia rather than simply a lack of prosocial learning.
These psychological risks can be even more apparent in individuals
with more severe levels of ID, who might lack traditional
communication skills or language to explain various types of distress
or needs. This lack of communication could also lead to a
misinterpretation of Paraphilia. For example, a woman with Severe ID
is experiencing distress due to vaginitus or a yeast infection.
Without a means to communicate this distress to someone else, she
attempts to insert an object to scratch the itch, or she rubs up
against objects or people. This could easily be misinterpreted as a Paraphilia.
The impulsive and aggressive sexual acting out of some individuals
with Sexual Disorders can be associated with
Attention-Deficit/Hyperactivity Disorder (ADHD). It is important to
assess ADHD in individuals with Sexual Disorders generally, because
the disorder can occur at any level of intellectual functioning,
although it is not specifically associated with ID (Wender, 2000).
Learning disabilities occur in about half of all ADHD cases, and
intellectual development is often uneven, with strengths in some
areas and deficits and delays in others. Tasks requiring sustained
attention can be especially impaired without treatment of the ADHD,
and lower overall scores on standard tests of intelligence result.
The sexual acting out of some individuals can be reduced with
treatment of the ADHD.
Genetic Syndromes
Some syndromes that either cause ID or are frequently seen in
individuals with ID carry behavioral phenotypes that could appear
topographically as Paraphilia. Griffiths et al. (2002) (Strength
of evidence: V) reported that individuals with ID are more
likely to experience physical and medical challenges that interfere
with their sexual experience. Some of these syndromes are genetically
determined, and some are unknown. The expression of the inappropriate
behavior, however, might not be directly related to the disability
but to an aspect of the behavioral pheonotype. For example,
clinicians have reported that inappropriate sexual behavior with
Asperger’s Disorder might be related to Tourette’s Disorder
because of some complex motor tics involving the touching of the
genitalia of the self or of others and with Williams syndrome because
of increased sociability.
Smith-Magenis syndrome is associated with polyembolokoilamania (the
inserting of objects into orifices, such as ears or mouth as well as
anus or vagina). These latter expressions of orifice stuffing are
typically interpreted to be a sexual act rather than as a behavior
associated with the syndrome, although the exact function this serves
the individual is obscure. There is no apparent evidence to date to
indicate that this behavior is sexual (Griffiths et al., 2002)
(Strength of evidence: V). It should be noted, however, that research
on the syndromic relationship to sexual problems is lacking.
Hypotheses have been based on clinical opinions.
Socioenvironmental Factors
Edgerton (1973) (Strength of evidence: V) has suggested that
people with ID do not tend to demonstrate any more sexually
inappropriate behavior than do nondisabled people if they are
provided a normative learning experience. In a discursive summary of
the research literature on sexual aggression and people with ID,
Griffiths (2002) (Strength of evidence: V) presented research
both from the disability field and the sex offender field to
demonstrate the potential relationship between known vulnerabilities
for the development of sexual offending behavior and the life
experiences that are afforded most people with ID.
In many environments that support people with ID, sexual activity of
an appropriate nature might never have been taught, made available,
or permitted to these individuals. In the environments in which most
people with ID live, sexual activity is generally severely restricted
or punished. Day (1997) (Strength of evidence: V) has suggested that
the high rates of sexual offense behavior committed by people with ID
are a reflection of the generally repressive and restrictive
attitudes toward the sexuality of people with disabilities.
The restrictive nature of the environment can directly influence the
development of inappropriate sexual behavior in the form of either
erotophobia or functional institutionalized sexual behavior.
n Erotophobia
As explained earlier, Hingsburger (1992) (Strength of evidence: V) suggested
that the sexual experiences of individuals with ID have been so
suppressed, controlled, or punished that the individuals could be
conditioned to a negative reaction tendency to anything sexual. This
conditioning can alter their response to the instigating factors for
normal sexual experiences. In some cases, the person might shift to
response patterns that appear abnormal. In addition, the erotophobia
might alter an individual’s response to interviewing and
phallometric testing, which could account for the differential
patterns of some people with ID that were observed by Murphy et al.
(1983a) (Strength of evidence: V).
n Institutionalized sexual behavior:
Many agencies still hold written or unwritten policies that fail to
recognize the sexuality of the people they serve or that prohibit and
even punish sexual expression, appropriate or inappropriate,
consenting or not. Consequently, there is no differential response
for individuals who engage in consenting appropriate sexual
expression from those who engage in coercive nonconsensual
expression. The only difference pragmatically is that inappropriate
or nonconsenting sexual behavior might have less of a probability of
being detected by staff.
Adaptation of Diagnostic Criteria
All forms of Paraphilias have been noted to occur in people with ID.
Some people with ID, however, might present behaviors that
topographically appear as a Paraphilia yet not include recurrent and
intense sexually arousing fantasies or sexual urges. Differential
diagnosis of Paraphilia or counterfeit deviance is required.
Clinicians should rule out the rival hypothesis of counterfeit
deviance, erotophobia or behaviors that are syndrome-related rather
then sexually related.
