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Archives of Sexual Behavior, Vol. 26, No. 5, 1997

Sexual Orientation Differences in Cerebral Asymmetry and in the Performance of Sexually Dimorphic Cognitive and Motor Tasks Geoff Sanders, Ph.D.12 and Marian Wright, B.Sc.1

With each of the tasks in the present studies we expected to find the reported sex difference between heterosexual women and heterosexual men and we predicted a sexual orientation effect with the performance of homosexual men being similar to that of heterosexual women and different from that of heterosexual men. Study I aimed to replicate earlier findings by recording the performance of a group of homosexual men on a visuospatial task, the Vincent Mechanical Diagrams Test (VMDT), a dot detection divided visual field measure of functional cerebral asymmetry, and on five subtexts of the Wechsler Adult Intelligence Scale (WAIS). For each task the profile of scores obtained for the homosexual men was similar to that of heterosexual women in that they scored lower than heterosexual men on the VMDT, they showed less asymmetry, and they recorded a higher Verbal than Performance IQ on the WAIS. In Study 2, a male-biased targeted throwing task favored heterosexual men while, in contrast, on the female-biased Purdue Pegboard single peg condition heterosexual men were outperformed by heterosexual women and homosexual men. On neither of these two tasks did the performances of homosexual men and heterosexual women differ. One task, manual speed, yielded neither sex nor sexual orientation differences. Another, the Purdue Pegboard assemblies condition, revealed a sex difference but no sexual orientation difference. Failure to obtain a sexual orientation difference in the Some data reported in this paper were presented in preliminary form as pan of the Symposium on Sex Differences in Cognition: Biological Influences, at the International Congress of Psychology, Brussels, July 1992 and at the 19th and 20th Annual Meetings of the International Academy of Sex Research, June 1993 and 1994. 1Department of Psychology, London Guildhall University, Old Castle Street, London, El TNT, England. 2To whom correspondence should be addressed.

463 0004-0002/97/10004463$12.50/0 c 1997 Plenum Publishing Corporation

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presence of a sex difference suggests that the sexual orientation effect may be restricted to a subset of sexually dimorphic tasks. KEY WORDS: sex differences; male homosexuality; sexual orientation; cognitive abilities; motor tasks; cerebral asymmetry.

INTRODUCTION The existence of sex differences in two related areas of psychological interest, cognitive abilities and functional cerebral asymmetry, has been widely investigated and much debated. Maccoby and Jacklin (1974) reviewed the evidence for sex differences in cognitive abilities and concluded that, on average, women scored higher than men on verbal tasks whereas men scored higher than women on mathematical reasoning and spatial tasks. In a review of sex differences in cerebral asymmetry, McGlone (1980) concluded that men were more lateralized than women. Levy (1969) used ideas concerning the presumed availability of processing capacity in men and women to support a causal relationship between sex differences in cerebral asymmetry and those reported for cognitive abilities. She argued that male superiority in spatial ability resulted from the marked lateralization in men of verbal abilities to the left and spatial abilities to the right hemisphere. The presence of some verbal ability in the right hemisphere of women was said to account for both their superior verbal ability (a result of the additional verbal capacity in the right hemisphere) and their inferior spatial abilities (a result of reduced spatial processing capacity in the right hemisphere). Other investigators have argued against the existence of sex differences in both cognitive abilities (verbal: Hyde and Linn, 1988; spatial: Caplan et al., 1985) and in functional cerebral asymmetry (Fairweather, 1982; Hahn, 1987). The arguments these investigators present depend on the high proportion of studies that have failed to find significant sex differences. Two points are important here. First, a study may fail to reject the null hypothesis for reasons other than the absence of a sex difference, e.g., because the tasks employed are insensitive or the sample size too small. Second, if reports of significant sex differences are chance occurrences among a wealth of nonsignificant findings then the significant effects should split 50:50 in favor of women and men. Halpern (1992) made both of these points in her criticism of the conclusions drawn by Hyde and Linn (1988) from their meta-analysis of 165 studies of sex differences in verbal abilities. Although it is true that 109 (66%) of the studies analyzed failed to find significant effects, of the 56 that reported significant sex differences in verbal abilities, 44 (79%) found that women scored higher than men. A

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similar picture emerges from studies of functional cerebral asymmetry as measured by auditory, visual, and tactual procedures. For example, Hahn (1987) reviewed 41 such studies of children (ages 1-15 years) that yielded a total of 178 same-age paired comparisons. Although 142 (80%) of these comparisons failed to find significant sex differences, of the 36 that did, 30 (83%) found males to be more lateralized than females. Effect sizes for sex differences in the performance of cognitive tasks range widely from large, through moderate, to small (Halpern, 1992). Clearly, some tasks better than others tap the elements of cognitive processing that differ between the sexes and of the many tasks that have been investigated, some are sexually dimorphic, favoring women or men, and others are neutral, favoring neither sex. Indeed, some tasks appear anomalous: solving anagrams (a verbal task) is performed faster by men than women (Hyde and Linn, 1988) while location memory for objects (a spatial task) is performed better by women than men (Eals and Silverman, 1994; Silverman and Eals, 1992). In the investigation of sex-related differences task selection is critical. Such considerations are equally important when we consider an associated area of interest that has emerged in the last decade, the possibility that differences in cognitive abilities and cerebral asymmetry exist between sexual orientation groups (Sanders and Ross-Field, 1987). Using three male-biased spatial tasks, two versions of the Piagetian water level task and the Vincent Mechanical Diagrams Test (VMDT), Sanders and Ross-Field (1986a) found that heterosexual men performed better than both heterosexual women and homosexual men whose scores did not differ. Levy's (1969) view, that sex differences in task performance may be related to differences in functional cerebral asymmetry, was supported by the outcome of a related study (Sanders and Ross-Field, 1986b) in which heterosexual men showed the male-typical left visual field advantage for a dot detection task, whereas homosexual men and heterosexual women showed no visual field advantages. Early support for the existence of sexual orientation differences in cognitive performance was provided by Willmott and Brierley (1984) who administered five subtests of the WAIS to homosexual men, heterosexual men, and an undifferentiated but predominantly heterosexual group of women. They reported no differences in prorated Full-scale IQ but a higher Verbal IQ for the homosexual men than for the heterosexual men and a higher Performance IQ for the heterosexual men than for the homosexual men and the women. Following a review of possible biological influences on cognition, cerebral lateralization, and sexual orientation, Sanders and Ross-Field (1987) suggested that the influence of prenatal hormonal events may give rise to concordant patterns of cognitive abilities, cerebral asymmetries, and sexual

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orientation. Evidence for an effect of prenatal hormones on adult sexual behavior comes primarily from work on rodents and there may be problems in applying the model to human sexuality (Meyer-Bahlburg, 1984). However, a recent study of women prenatally exposed to the synthetic estrogen, diethylstilbestrol (DBS), found that they were more likely than controls to be rated bisexual or homosexual (Meyer-Bahlburg et al, 1995). It is unlikely, as those investigators conclude, that a single biological factor could determine human sexual orientation but the evidence is persuasive that prenatal hormones contribute to this process. If so, sexual orientation differences in cognition and cerebral asymmetry may reflect the organizational activity of prenatal hormones. Evidence for sexual orientation differences in cognition has emerged from other studies that employed tasks reported to generate sex differences. With spatial tasks at which men excel, some, but not all, investigations have obtained results that are concordant with the earlier findings. Similar patterns of sexual orientation group differences were found (i) with the water level task by Gladue et al (1990) and McCormick and Witelson (1991), but not by Tkachuk and Zucker (1991) or Gladue and Bailey (1995) who found no group differences, and (ii) with the Vandenburg Mental Rotations Test by Gladue et al. (1990) and Tkachuk and Zucker (1991), who found group differences, but not by Gladue and Bailey (1995). In other spatial tests, homosexual men obtained intermediate scores on the Primary Mental Abilities Test but performed like heterosexual men rather than like heterosexual women on the Differential Aptitude Test (McCormick and Witelson, 1991). Investigators who have used tasks that women perform better than men have failed to find sexual orientation differences (Gladue et al, 1990; McCormick and Witelson, 1991), however, these investigators used tests of verbal fluency for which sex differences are often small. Here we present two studies, the first aimed to replicate earlier reports and the second to extend the investigation by including sexually dimorphic motor tasks that had not previously been used in this context. STUDY 1

Study 1 set out to replicate Sanders and Ross-Field (1986a, 1986b) and to provide prorated verbal and performance IQ scores from a group of homosexual men for comparison with the data presented by Willmott and Brierley (1984). A group of homosexual men completed the VMDT, a divided visual field dot detection task and five subtests of the WAIS. On the basis of the previous studies we predicted that, in all these tasks, the performance of homosexual men would be similar to that of heterosexual

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women and that both groups would obtain scores that differed significantly from those of heterosexual men. Methods Subjects Subjects comparable with those who participated in the studies of Sanders and Ross-Field (1986a, 1986b) were recruited from the local population by personal contact or referral by those already participating in the study. The 13 subjects were of comparable age (Table I) and all were classified right-handed having completed seven items selected from the Harris Test of Lateral Dominance (Harris, 1974) and scored a minimum of five right dominant responses, including writing with the right hand. The homosexual men were self-declared, lifelong homosexuals who were satisfied with their sexual orientation and had no history of seeking treatment. Scores obtained on the Sexual Orientation Method (SOM), as modified by Sambrooks and MacCulloch (1973), indicate that the new group of homosexual men were comparable to the original group in terms of their homohetero-erotic arousal. A lesbian group was not included because volunteers proved difficult to recruit. Measures Vincent Mechanical Diagrams Test. The VMDT forms part of the National Institute of Industrial Psychology Engineering Test Battery (NFER, 1980). It tests visuospatial ability and typically generates a marked male Table I. Age Range and Mean Sexual Orientation Method (SOM) Scores: New Group of Homosexual Men (nHmM) Compared with the Homosexual Men (HmM), Heterosexual Men (HtM), and Heterosexual Women (HtW) from the Original Studies by Sanders and Ross-Field (1986a, 1986b) New group

Original Sanders and Ross-Field groups

nHmM

HmM

HtM

HtW

13

13

13

13

Age range (years)

19-41

22-43

20-43

20-40

SOM score (min 6; max 48) Homosexual scale Heterosexual scale

47.85 18.35

46.92 13.50

10.61 47 .56

15.00 45.50

Variable No. of subjects

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advantage. Subjects are required to deduce the mechanical relationships between elements in two-dimensional space. Each test item is a drawing composed of either levers, cogs, or pulleys. For each item subjects must select from four examples the one that illustrates the movement that would be produced by the mechanism. The test was administered according to the standard instructions and the proportion of correct responses recorded within the time allowed used as a measure of performance accuracy. Divided Visual Field Dot Detection Task. The divided visual field paradigm has been widely used to investigate functional cerebral asymmetry. A performance advantage for stimuli presented in one visual field is interpreted as superior performance by the contralateral cerebral hemisphere. The simple detection of a black dot on a white ground does not generate a visual field advantage but the use of a range of contrast levels revealed a left visual field (right hemisphere) advantage which was greater in men than women (Davidoff, 1977). The present study employed a similar procedure. A 1-cm2 dot of light was projected briefly, at one of four contrast levels, 2° of visual angle to the left or right of a central fixation spot. An opaque slide was used for blank trials when no stimulus was presented. Subjects were required to indicate whether they had seen a dot of light appear on the screen. During practice trials tandem Polaroid lenses were adjusted to obtain a light level for each subject which, with a constant exposure duration of 11 msec, produced correct dot detections on about 70% of the trials. Experimental trials were presented in eight blocks of 12 trials within which dots at each of the four contrast levels appeared randomly once in each visual field together with four blank trials. The number of correct detections was calculated separately for the left and right visual fields. Further details are given in Sanders and Ross-Field (1986b). Wechsler Adult Intelligence Scale. The five WAIS subtests used were those originally chosen by Willmott and Brierley (1984) because they loaded highest for pure factors (Maxwell, 1960). Verbal IQ, Performance IQ, and Full-scale IQ scores were obtained by prorating. Comprehension, similarities, and vocabulary were used for the verbal scale plus block design and object assembly for the performance scale. Each subtest was administered and scored according to the standard instructions.

Procedure The subjects completed the SOM in their own time and all the other tasks in a single laboratory session. On arrival, subjects provided biographical details and then completed the handedness inventory, VMDT, WAIS, and dot detection task in that order. At the end of data collection the

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subjects were debriefed and paid a fixed sum to cover local travel expenses. Statistical analyses were conducted as follows: a Kruskal-Wallis one-way ANOVA and Mann-Whitney U tests for the VMDT, parametric ANOVA with Newman Keuls for the dot detection task and a related groups t test for the prorated Verbal IQ and Performance IQ scores. Results

Table II shows the proportion of correct responses recorded on the VMDT spatial task. A significant main effect of sexual orientation was revealed when the new group of homosexual men was compared with the original data for the heterosexual men and women (H = 19.41 p < 0.001). The scores for the new group of homosexual men, like those for the original group, were significantly lower than those recorded by the heterosexual men, U(13,13) = 34.5, p < 0.02), but not significantly different from the scores of the heterosexual women, U(13,13) = 48.5, p > 0.05. Table II also shows the number of correct dot detections made by each of the sexual orientation groups in the left and right visual fields. Separate two-way ANOVAs were used to compare the original and new group of homosexual men with the original data for the heterosexual men Table II. Visuospatial Ability and Cerebral Asymmetry: Mean Scores Obtained by the New Group of Homosexual Men (nHmM) Compared with Data from Homosexual Men (HmM), Heterosexual Men (HtM), and Heterosexual Women (HtW) Obtained in the Original Studies by Sanders and Ross-Field (1986a, 1986b) Sexual orientation (SOR) New group

Vincent Mechanical Diagramsa x proportion correct responses SD Dot detection taskb Left visual field (max. score 32) x correct dot detections

SD Right visual field (max. score 32) x correct dot detections

SD aSOR:

Original Sanders and Ross-Field groups

nHmM

HmM

HtM

HtW

0.65 0.22

0.65 0.22

0.85 0.08

0.50 0.09

23.62 2.06

20.38 3.90

24.38 5.52

22.15 3.36

21.92 2.36

21.38 3.52

19.31 3.15

23.08 3.28

nHmM/HtM/HtW,p < 0.001; HmM/HtM/HtW,p < 0.001. nHmM vs. HtM,p < 0.02; nHmM vs. HtW, ns. bSOR x Visual Field: nHmM/HtM/HtW,p < 0.01; HmM/HtM/HtW,p < 0.01. Left vs. Right Visual Field: nHmM, ns; HmM, ns, HtM.p < 0.01; HtW, ns.

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and women. Both analyses revealed significant interactions between sexual orientation and visual field, original group F(2,36) = 8.22 p < 0.01; new group F(2,36) = 6.37, p < 0.01. For the new group of homosexual men the difference between the left and right visual field scores was not significant, W(1,36) = 1.70 p, > 0.05. This finding agrees with those in the original study where the visual field difference was significant for heterosexual men, W(1,36) = 5.07, p < 0.01, but not for the homosexual men or the heterosexual women, W(1,36) = 1.00 and 0.93, respectively, p > 0.05. Table III compares the prorated IQ scores for the new group of homosexual men with those reported by Willmott and Brierley (1984) for homosexual men, heterosexual men, and an undifferentiated but predominantly heterosexual group of women. The Full-scale IQ scores are similar for all four groups. The new group of homosexual men have higher Verbal than Performance IQ scores, t(12) = 23.31, p < 0.001, as did the homosexual men and the women in the original study and in contrast to the heterosexual men who had marginally higher Performance than Verbal IQ scores. In the Willmott and Brierley study there were no significant differences in Full-scale IQ scores, however, the homosexual men scored higher on Verbal IQ but lower on Performance IQ than the heterosexual men.

STUDY 2 In the light of the above findings, Study 2 was designed to investigate further the existence of sexual orientation differences using male- and feTable III. Prorated Full-Scale, Verbal, and Performance IQ Scores Obtained by the New Group of Homosexual Men (nHmM) Compared with Data for Homosexual Men (HmM), Heterosexual Men (HtM), and Women from Willmott and Brierley (1984) New groupa IQ scores

Original Willmott and Brierley groups

nHmM

HmM

HtM

Women

125.9 11.06

128.15 8.22

127.60 7.05

122.40 9.37

134.85 10.42

133.50 8.30

124.20 6.65

130.25 10.18

110.92 14.52

117.40 11.22

128.50 12.63

110.30 12.79

Prorated Full scale IQ X

SD Prorated Verbal IQ X

SD Prorated Performance IQ X

SD anHrnM:

VIQ vs. PIQ, p < 0.001.

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male-biased tasks known to generate substantial sex differences and which had not been employed previously in this context. Watson and Kimura (1991) argued that more ecologically valid tasks may yield larger sex differences. They suggested that sex differences in the performance of motor tasks may be related to the spatial sphere towards which the behavior is directed, with female advantages for behaviors performed close to the body and male advantages for behaviors directed at distant objects. Watson and Kimura found robust sex differences, favoring men, for targeted throwing and an interception task. Despite the similarity of these tasks to a number of sports, partialling out physique and sports experience had little effect on the sex differences indicating that they could not be explained by differences in physique and sports history. We selected the male-biased targeted throwing task for the present study. For the female-biased tasks we avoided verbal fluency in favor of motor tasks performed close to the body. Hampson and Kimura (1988) reported reciprocal changes in the performance of male-biased spatial and female-biased articulatory-motor tasks between different phases of the menstrual cycle with the female-biased tasks performed better during the midluteal phase than at menses. From their battery we selected the manual speed and Purdue Pegboard tasks. Our predictions were (i) that all the selected tasks would generate the reported sex differences between heterosexual women and heterosexual men; (ii) that the performances of the heterosexual women and the homosexual men would not differ on any of the tasks; (iii) that heterosexual women and the homosexual men would outperform heterosexual men on the female-biased tasks while the heterosexual men would perform better than the heterosexual women and the homosexual men on the male-biased tasks. Methods

Subjects The 45 subjects, ages 19-31 years, were recruited from a student population. All gave informed consent and, on the basis of their self-reported sexual preference, 15 subjects were allocated to each of three sexual orientation groups: heterosexual women, heterosexual men, and homosexual men. A lesbian group was not included because volunteers proved difficult to recruit. Handedness was defined by the preferred writing hand. All but four of the subjects were right-handed by this criterion and used this hand for all the unimanual tasks. The exceptions were one left-handed heterosexual man and three heterosexual women who wrote with their left

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hand although they used their right for throwing. All three women preferred to use their left hand for the manual speed task and Purdue Pegboard single peg condition and performed consistently better with that hand than with their right on these tasks. Measures Manual Speed. This finger tapping task formed part of a battery of female-biased tasks used by Hampson and Kimura (1988) to investigate changes in performance across the menstrual cycle. In common with other female-biased tasks, manual speed was faster during the midluteal phase than it was during menses with an effect size of about 0.4 standard deviation units. Subjects were required to operate a telegraph key with their index finger as fast as possible. Two 10-second trials were completed with each hand and the mean number of taps was recorded separately for the preferred and nonpreferred hands. Purdue Pegboard Single Peg and Assembly Conditions. These tasks, which are reported to favor women with an effect size of about 0.6, were administered according to the standard instructions (Tiffin, 1968). The unimanual single peg condition allows subjects 30 sec to insert as many individual pegs as possible into holes on a board. The test was performed twice with each hand and the score for the preferred and nonpreferred hands was calculated as the mean number of pegs correctly placed on two successive trials. The bimanual assembly condition requires subjects to complete four-component assemblies by inserting a peg followed by a washer, a collar, and a second washer in that order. The task is performed by the coordinated use of both hands with the preferred hand placing the peg and the collar while the nonpreferred hand places the washers. The score was calculated as the mean number of items (pegs, washers, and collars) correctly placed on two successive 60 sec trials. Targeted Throwing. Watson and Kimura (1991) described a marked male advantage with an effect size of 1.3 for this task. In the present study, subjects used an overhand throw with their preferred hand in an attempt to hit the center of a 45-cm diam board with a 21-g dart from a distance of 300 cm. The center of the board was positioned 150 cm above the floor. Radial error was measured to an accuracy of 0.5 cm. Any throw that failed to hit the board was recorded as an error of 22.5 cm. The score for each subject was the mean radial error for 20 throws. Since this task is very similar to the social and competitive game of darts that is more widely played in the United Kingdom than in Northern America, we should compare the requirements for the task and the game. The regulations for the

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game of darts stipulate that players throw from a distance of 93.25 inches (237 cm) and that the center of the target be 68 inches (173 cm) from the floor. Thus, for the targeted throwing task employed in the present study the throwing distance was 20% greater and the target height 15% less than that used in the game of darts.

Procedure The motor tasks were completed in the same order by all subjects: first the manual speed task; second the Purdue Pegboard single peg followed by the assembly condition; and finally the targeted throwing task. A detailed sports history questionnaire was distributed for return with postage charges prepaid. Data from each of the four tasks were analyzed separately by ANOVA with appropriate simple main effects. Results Manual Speed. Mean scores and standard deviations are shown in Table IV for the preferred and nonpreferred hands of the three sexual orientation groups. The rate of unimanual tapping showed no interaction between sexual orientation and the hand used, F(2, 42) = 1.79, p > 0.1, and no difference between the sexual orientation groups, F(2, 42) = 0.46, p > 0.5. As would be expected, higher tapping scores were achieved with the preferred hand, F(l, 42) = 63.51, p < 0.0001. Purdue Pegboard Single Peg Condition. Mean scores and standard deviations are shown in Table IV for the preferred and nonpreferred hands of the three sexual orientation groups. For this unimanual task there was a significant interaction between group and hand, F(2, 42) = 11.49, p < 0.0001. Significant sexual orientation group effects were present for the preferred hand, F(2, 84) = 13.28, p < 0.0001, but not for the nonpreferred hand,F(2,84) = 2.37, p > 0.05. With the preferred hand, both heterosexual women, F(l, 84) = 26.11, p < 0.0001, and homosexual men, F(l, 84) = 9.80, p < 0.005, placed more pegs correctly than heterosexual men. Homosexual men tended to place fewer pegs than heterosexual women, their mean scores were 17.17 and 18.20, respectively, but the difference failed to reach significance at the 5% level, F(l, 84) = 3.92, p > 0.05. Purdue Pegboard Assembly Condition. Mean scores and standard deviations for the three sexual orientation groups are shown in Table IV. There was no overall sexual orientation group effect for this bimanual task, F(2, 42) = 2.47, p > 0.05, but paired comparisons revealed the predicted sex difference with heterosexual women scoring higher than heterosexual

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men, F(l, 42) = 4.94, p < 0.05. The homosexual men obtained intermediate scores and were not significantly different from either the heterosexual men, F(l, 42) = 1.20, p > 0.1, or the heterosexual women, F(l, 42) = 1.27, p > 0.1). Targeted Throwing. The mean radial error scores and standard deviations for each of the sexual orientation groups are shown in Table IV. There was a significant effect of sexual orientation, F(2, 42) = 5.67, p < 0.01. The error scores of the heterosexual women and homosexual men did not differ, F(l, 42) = 1.05, p > 0.3, but both heterosexual women, F(l, 42) = 10.83, p < 0.005, and homosexual men, F(l, 42) = 5.13, p < 0.05, threw less accurately than heterosexual men.

DISCUSSION Performance differences between sexual orientation groups are of interest because they may reveal differential organizational effects of hormones acting during critical prenatal periods (Sanders and Ross-Field, 1987; Gladue and Bailey, 1995). With each of the tasks in the present studies we expected to find the reported sex difference between heterosexual women and heterosexual men and we predicted a sexual orientation effect with the performance of homosexual men being similar to that of heterosexual women and different from that of heterosexual men. These outcomes were obtained in five of the seven tasks used. The present data from the VMDT (Table II), the WAIS Performance IQ (Table III), and the targeted throwing task (Table IV), confirm our previous findings (Sanders and Ross-Field, 1986a) that, on tasks favoring men, homosexual men and heterosexual women obtain similar scores which are lower than the scores obtained by heterosexual men. Data from the WAIS Verbal IQ (Table III) and Purdue Pegboard single peg condition with preferred hand (Table IV)) extend the generality of this relationship to tasks favoring women where the scores of homosexual men and heterosexual women were similar and both performed better than heterosexual men. As far as we are aware the single peg task and prorated Verbal IQ are the only tasks favoring women that have been reported to show a sexual orientation effect. The dot detection data from Study I (Table II) confirm our earlier finding (Sanders and Ross-Field, 1986b) that homosexual men, like heterosexual women, are less lateralized than heterosexual men. Overall, a concordant pattern of results emerges from these tasks with homosexual men matching heterosexual women in their pattern of performance (verbal better than spatial) and in their lack of marked functional cerebral asymmetry. The performance of both groups contrasts with the pattern of

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task performance (better spatial than verbal) and marked functional cerebral asymmetry shown by heterosexual men. These sexual orientation differences, like the sex difference studies on which they are based, support Levy's (1969) view that patterns of cognitive ability are related to patterns of cerebral asymmetry such that better verbal ability is associated with reduced lateralization while better spatial ability is associated with marked lateralization. Although these findings are compatible with a biological influence on brain organization and task performance, an environmental influence cannot be ruled out. Our targeted throwing task provides a good example. If heterosexual men play darts more than heterosexual women and homosexual men, this practice in the required motor movements and spatial judgments may contribute to, or even account for, their superior skill. However, a higher participation rate in the game of darts could be the result of, rather than the reason for, their greater skill because individuals might be expected to play games at which they enjoy a reasonable level of success. Too few of our sports history questionnaires were returned for us to be able to establish that the groups in Study 2 had similar dart-throwing experience, however, we have some data that are relevant to the question of practice effects. Table V shows the performance of 13 women who threw 12 darts with each hand at a target three times per week over a period of 5 weeks. The size of the target and the height of its center from the ground were the same as in Study 2 but the throwing distance was reduced from 300 cm to 250 cm. Over the 5 week period there was no significant change in preferred hand performance but, compared with Week 1, throwing with the nonpreferred hand became increasingly more accurate from Week 3 to Week 5 (Table V). Given that there was no significant improvement in preferred hand performance these data suggest that it is the motor rather Table V. Radial Error Scores Obtained by Women in a Target-Directed Throwing Task Showing the Effects of Practice Over a Period of Five Weeks Preferred hand Radial error (cm)

.

Nonpreferred hand

Difference from Week 1

Radial error (cm)

Difference from Week 1

Week

X

SD

(p)

X

SD

(p)

1 2 3 4 5

10.81 10.31 9.69 9.40 9.39

4.77 3.96 3.55 2.63 3.54

ns ns ns ns

16.68 15.40 14.32 13.68 12.33

4.90 5.53 4.75 4.40 4.84

< 0.05 < 0.01 < 0.001

ns

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than the spatial judgment component of the task that improves with practice. Further support for the conclusion that heterosexual men are more accurate at targeted throwing than both heterosexual women and homosexual men has recently been provided by Hall and Kimura (1995). They employed a task that was dissimilar from the game of darts because it required an underarm throw with Velcro-covered balls at a carpet-covered target. As in the present study, they also found that heterosexual men were more accurate than heterosexual women and homosexual men. Relevant practice as revealed by sports history and the physical factors of hand strength and finger size did not account for these effects. However, even in the absence of practice and physical advantage, psychosocial factors, such as expectation based on gender stereotypes (Signorella and Jamison, 1986), may have influenced performance on the targeted throwing and it seems likely that adult patterns of abilities reflect an interaction between nature and nurture. The present findings indicate that sexual orientation differences may be more likely to emerge in male-biased tasks where the sex differences tend to be larger. This view is supported by other studies of sexual orientation differences as noted in the Introduction. A failure to find sexual orientation differences in the absence of sex differences may indicate a lack of sensitivity in the task. However, the failure to find a sexual orientation difference in the presence of a sex difference demands closer attention, especially if sexual orientation differences are found with the same subject groups on concurrent tasks. Such was the case here in Study 2 (see Table IV) where the assembly condition failed to generate a sexual orientation difference although the expected sex difference did appear. We cannot use a lack of sensitivity in the task to explain the absence of a sexual orientation effect here. Other studies have also reported the absence of a sexual orientation effect in the presence of a sex effect. Hall and Kimura (1995) failed to find a sexual orientation difference with a Purdue Pegboard task. However, they used a bimanual condition requiring subjects to insert pairs of pegs, one peg with each hand, a procedure that is a simpler version of the bimanual assembly condition for which no sexual orientation differences were found in Study 2 (Table IV). Again, contrary to the outcome of Study 1 and the data reported by Willmott and Brierley (1984), Tuttle and Pillard (1991) found no sexual orientation differences on subtests of the WAIS; however, there are two differences between the studies which could account for the different findings. First, Tuttle and Pillard used a different selection of subtests from those employed here and by Willmott and Brierley. Second, they compared their sexual orientation groups on the scores obtained

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for each individual subtest and not on the basis of prorated IQ scores for the performance and verbal scales. Two other studies have failed to find a sexual orientation effect in the presence of a sex difference. First, McCormick and Witelson (1991) found that homosexual men obtained intermediate scores on the Primary Mental Abilities Test but performed like heterosexual men rather than like heterosexual women on the Differential Aptitude Test. Second, Gladue and Bailey (1995) found sex but no sexual orientation differences with Mental Rotation and the Water Level Task. Outcomes such as these, where a sex difference between heterosexual men and heterosexual women occurs in the absence of a sexual orientation difference between heterosexual men and homosexual men, suggest that the sexual orientation effect may exist for a subset of tasks only. Studies of a wider variety of sexually dimorphic tasks are required before we can draw firm conclusions regarding the relationship between patterns of cognitive/motor abilities and sexual orientation. It would be valuable to have more data from a range of sexually dimorphic tasks in order to identify task demands that do and do not generate sexual orientation differences. As a guide, it has been suggested that ecologically valid, rather than pencil and paper, tasks may be more likely to show these differences (Kimura, 1996). Ultimately, clarification of the crucial task demands could point to brain regions that may differ between sex and sexual orientation groups. The influence of prenatal hormones on cognitive abilities is presumably exerted through organizational effects on the brain which may be revealed by different patterns of cerebral asymmetry in sex and sexual orientation groups (Sanders and Ross-Field, 1987). Given the recent support for a prenatal hormonal influence on human sexual orientation (Meyer-Bahlburg et al., 1995) it is notable that the divided visual field dot detection task in Study 1 of the present paper replicates the finding of reduced functional cerebral asymmetry in homosexual men originally reported by Sanders and Ross-Field (1986b). Further support for reduced asymmetry in homosexual men has appeared in a recent magnetoencephalographic (MEG) study (Reite et al., 1995). Sex differences in cerebral laterality of the MEG-based source location estimates for the 100-msec latency auditory evoked field component (M100) have been reported by Reite et al. (1989, 1995). In women the sources are symmetrically located in the superior temporal gyri whereas in men the hemispheric locations are asymmetrical with the right anterior to the left. Reite et al. (1995) found the M100 source locations to be symmetrically located in the left and right hemispheres of homosexual men. Thus the relationship between cerebral organization and sexual orientation demonstrated by this MEG study is similar to that revealed by the divided visual field data from Study 1 and from Sanders and Ross-Field (1986b): In both cases homosexual men and

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heterosexual women exhibit a similar pattern that differs from that shown by heterosexual men. A recent brain imaging study (Shaywitz et al., 1995), which found unilateral left hemisphere activity in men but bilateral activity in women during the performance of the phonological component of a verbal task, is compatible with a sex difference in cerebral asymmetry and suggests another avenue for future sexual orientation research.

REFERENCES Caplan, P. J., MacPherson, G. M., and Tobin, P. (1985). Do sex-related differences in spatial abilities exist? Am. Psychol. 40: 786-799. Davidoff, J. B. (1977). Hemispheric differences in dot detection. Cortex 13: 434-444. Eals, M., and Silverman, T. (1994). The hunter-gatherer theory of spatial sex differences: Proximate factors mediating the female advantage in the recall of object arrays. Ethol. Sociobiol. 15: 95-105. Fairweather, H. (1982). Sex differences. In Beaumont, J. G. (ed.), Divided Visual Field Studies of Cerebral Organization, Academic Press, London. Gladue, B. A., and Bailey, M J. (1995). Spatial ability, handedness, and human sexual orientation. Psychoneuroendocrinology 20: 487-497. Gladue, B. A., Beatty, W. W., Larson, J., and Staton, R. D. (1990). Sexual orientation and spatial ability in men and women. Psychobiology 18: 101-108. Hahn, W. K. (1987). Cerebral lateralization of function: From infancy through childhood. Psychol. Bull. 101: 376-392. Hall, J. A. Y., and Kimura, D. (1995). Sexual orientation and performance on sexually dimorphic motor tasks. Arch. Sex. Behav. 24: 395-407. Halpern, D. F. (1992). Sex Differences in Cognitive Abilities, 2nd ed., Erlbaum, Hillsdale, NJ. Hampson, E., and Kimura, D. (1988). Reciprocal effects of hormonal fluctuations on human motor and perceptual-spatial skills. Behav. Neurosci. 102: 456-459. Harris, A. J. (1974). Harris Tests of Lateral Dominance, 3rd ed., Psychological Corp., New York. Hyde, J. S. and Linn, M. C. (1988). Gender differences in verbal ability: A meta-analysis. Psychol. Bull. 104: 53-69. Kimura, D. (1996). Sex, sexual orientation and sex hormones influence human cognitive function. Cur. Opinion Neurobiol. 6: 259-263. Levy, J. (1969). Possible basis for the evolution of lateral specialization of the human brain. Nature 224: 612-615. Maccoby, E. E., and Jacklin, C. N. (1974). The Psychology of Sex Differences, Stanford University Press, Stanford, CA. McConnick, C. M., and Witelson, S. F. (1991). A cognitive profile of homosexual men compared to heterosexual men and women. Psychoneuroendocrinology 16: 459-473. McGlone, J. (1980). Sex differences in human brain asymmetry: A critical survey. Behav. Brain Sci. 3: 215-263. Maxwell, A. E. (1960). Obtaining factor scores on the WAIS. J. Ment Sci. 160: 1060-1062. Meyer-Bahlburg, H. F. L. (1984). Psychoendocrine research on sexual orientation. Current status and future options. Prog. Brain Res. 61: 375-398. Meyer-Bahlburg, H. F. L., Ehrhardt, A. A., Rosen, L. R., Gruen, R. S., Veridiano, N. P., Vann, F. H., and Neuwalder, H. F. (1995). Prenatal estrogens and the development of homosexual orientation. Dev. Psychol. 31: 12-21. NFER. (1980). National Institute of Industrial Psychology Engineering Test Battery, Nelson, Windsor, U.K.

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Reite, M., Sheeder, J., Richardson, D., and Teale, P. (1995) Cerebral laterality in homosexual males: Preliminary communication using magnetoencephalography. Arch. Sex. Behav. 24: 585-593. Reite, M., Sheeder, J., Teale, P., Richardson, D., Adams, M., and Simon, J. (1995). MEG-based laterality: Sex differences in normal adults. Neuropsycholagia 33: 1607-1616. Reite, M, Teale, P., Goldstein, L., Whalen, J., and Linnville, S. (1989). Late auditory sources may differ in the left hemisphere of schizophrenic patients: A preliminary report. Arch. Gen. Psychiat. 46: 565-572. Sambrooks, J. E., and MacCulloch, M. J. (1973). A modification of the sexual orientation method and an automated technique for presentation and scoring. Br. J. Soc. Clin. Psychol 12: 163-174. Sanders, G., and Ross-Field, L. (1986a). Sexual orientation and visuospatial ability. Brain Cognit. 5: 280-290. Sanders, G., and Ross-Field, L. (1986b). Sexual orientation, cognitive abilities and cerebral asymmetry: A review and a hypothesis tested. Ital J. Zool. 20: 459-470. Sanders, G., and Ross-Field, L. (1987). Neuropsychological development of cognitive abilities: A new research strategy and some preliminary evidence for a sexual orientation model. Int. J. Neurosci. 36: 1-16. Shaywitz, B. A., Shaywitz, S. E., Pugh, K. R., Constable, R. T., Skudlarski, P., Fulbright, R. K., Bronen, R. A., Fletcher, J. M., Shankweiller, D. P., Katz, L., and Gore, J. C. (1995). Sex differences in the functional organization of the brain for language. Nature 373: 607-609. Signorella, M., and Jamison, W. (1986). Masculinity, femininity, androgeny, and cognitive performance: A meta-analysis. Psychol Bull. 100: 207-228. Silverman, I., and Eals, M. (1992). Sex differences in spatial abilities: evolutionary theory and data. In Barlow, J. H., Cosmides, L., and Tooby, J. (eds.), The Adapted Mind, Oxford University Press, Oxford, pp. 533-549. Tiffin, T. (1968). Purdue Pegboard Examiner Manual, Science Research Associates, Chicago. Tkachuk, J., and Zucker, K. J. (1991, June). The relation among sexual orientation, spatial ability, handedness, and recalled childhood gender identity in women and men. Poster presented at the annual meeting of the International Academy for Sex Research. Tuttle, G. E., and Pillard, R. C. (1991). Sexual orientation and cognitive abilities. Arch. Sex. Behav. 20: 307-318. Watson, N. V., and Kimura, D. (1991). Nontrivial sex differences in throwing and intercepting: relation to psychometrically-defined spatial functions. Pen. Indiv. Diff. 12: 375-385. Wilmott, M., and Brierley, H. (1984). Cognitive characteristics and homosexuality. Arch, Sex. Behav. 13: 311-319.

Archives of Sexual Behavior, Vol. 26, No. 5, 1997

Understanding Sexual Coercion Among Young Adolescents: Communicative Clarity, Pressure, and Acceptance Doreen A. Rosenthal, Ph.D.1,2

Young people's understanding of sexual coercion was studied. Boys and girls (N = 191) were asked to rate scenarios depicting sexual situations according to their perceptions of communicative clarity, the extent of pressure being applied to one partner, and the acceptability of the behaviors. Judgments of communicative clarity were given more readily when there was consent rather than dissent to sex. Clear communication was readily inferred even when there were no cues that this was the case. Boundaries of behaviors that were defined as constituting "pressure" were influenced by the outcome, that is whether sex did or did not occur, as well as the behavior itself. Ratings of acceptability closely followed those of pressure, although the relationships between perceptions of pressure and acceptability were stronger for girls than for boys. In general, there were few gender differences in perceptions of pressure and communicative clarity. Of concern was the finding that, for some respondents, pressure and acceptability were unrelated to the use of either physical or emotional force. KEY WORDS: sexual coercion; adolescents; communication; sexual roles.

INTRODUCTION

We examined the understanding that young people have of sexual situations in which the possibility exists for the behavior of one partner to This study was supported by a grant from the Australian Research Council and by funding from the Victorian Health Promotion Foundation. 1Centre

for the Study of Sexually Transmissible Diseases, La Trobe University, Locked Bag

12, Carlton South 3053, Victoria, Australia. 2To whom correspondence should be addressed.

481 0004-0002/97/1000-0481$12.50/0 c 1997 Plenum Publishing Corporation

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be interpreted as exerting pressure on the other partner to engage in unwanted sex. Coercive sexual behavior among university or college students, labeled variously as courtship violence, date (or acquaintance) rape, sexual harassment, and unwanted sex play, has been a focus of interest among researchers for decades. It is clear that many young people (the overwhelmingly majority of whom are women) experience unwanted sexual intercourse (Craig, 1990; Erikson and Rapkin, 1991; Gavey, 1991; Koss et al, 1987; Koss and Oris, 1982; Muehlenhard, 1988; Muehlenhard et al, 1991; Muehlenhard and Linton, 1987; Patton and Mannison, 1995; Richardson and Hammock, 1991), however it seems that men are reluctant to admit to these behaviors (Craig, 1990; Patton and Mannison, 1995). In the context of concerns about young people's sexual well-being, in part as a result of HIV/AIDS and other sexually transmitted diseases which can have long-term serious consequences, it has become increasingly important to understand more about the ways in which young people negotiate a sexual encounter. This includes understanding the nature and meaning of sexual coercion and identification of possible antecedents and correlates of unwanted sexual behaviors (Gavey, 1992; Holland et al, 1991a). There have been several theoretical explanations of coercive sexual behaviors among heterosexuals. These include Craig's (1990) situational model in which it is proposed that individual personal characteristics, the situational context, and cognitive processes interact to produce coercive behavior on the part of men. Thus the personal dispositions of young men, such as their arousal patterns or their attitudes towards women, interact with the situational context. For example, opportunities may be perceived to manipulate a social situation to their sexual advantage such as use of alcohol or emotional threats, or to interpret messages in accordance with their own intent. As Patton and Mannison (1995) noted, the model has limited explanatory power for women. There is little room for the complex sexual socialization experienced by young men and women and the proscriptions, based on gender, which apply to sexuality. An analysis of sexually coercive practices and experiences in terms of understandings of heterosexuality and male/female relationships is provided by writers such as Gavey (1992), Holland et al. (1991a, 1991b, 1992), Hollway (1984), and others. Gavey wrote of the "technologies of heterosexual coercion" in which young women themselves take part of the responsibility for enduring coercive practices because these are part of "normal" heterosexual relationships. Holland et al. (1991a) argued that the sexual pressure experienced by young women results from the patriarchal power enjoyed by young men and women's subordination by men. This is expressed along a continuum of sexual violence, encompassing gentle persuasion as well as

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aggression and forceful rape (Kelly, 1987; Koss et al, 1987). These latter approaches suggest that, in order to understand sexual coercion, we need to take account of how young people interpret and understand sexual encounters which range from those where overt and explicit pressure is applied, such as forced rape, to those in which pressure is subtle or implied. To date, the sexual encounters studied in most American literature fall into the category of "date rape" among college students. The date rape literature deals with situations in which some men perceive sexual coercion as justifiable, and resistance by the woman to a sexual encounter is merely viewed as a hurdle to overcome (see, e.g., Feltey et al., 1991; Muehlenhard and Linton, 1987; Shotland and Goodstein, 1992). In other research, dispositional features of coercive males such as "hypermasculinity" or attention to selective interpretation of women's cues have been identified (Beaver et al, 1992; Craig Shea, 1993). Several studies (e.g., Abbey 1982, 1987; Abbey and Melby, 1986; Craig Shea, 1993) have demonstrated that men interpret women's cues as more sexually motivated than do the women themselves. This "misinterpretation" of women's responses may be a contributing factor in men's coercive behavior and, taken together with the widespread belief of some men that women often say no when they mean yes (Muehlenhard and Linton, 1987), suggests that the role of clarity in communications about sexual events needs to be addressed. Most studies of sexual coercion have sampled college students. This population, while important, is only one subset of populations that need study. In particular, we need research on younger adolescents because of their sexual vulnerability. These younger boys and girls may have more difficulty in communicating about sex, may be less sensitive to partners' needs, and may be more likely to respond to their immediate desires. Furthermore, it is at the early stages of the development of sexual relationships that particular patterns of behavior are laid down and are likely to be continued in later interactions. In one study of high schoolers (Davis et al., 1993), a majority of boys (60%) reported that it was acceptable for a boy to force sex on a girl in one or more situations. Of interest is that some girls agreed, especially in situations where the girl had "led him on," or where the couple had had sex before. This raises the question of the extent to which understandings of pressure and the acceptability of behaviors are gender-related. Although it is clear that many expectations about sexual practices are strongly gender-determined (Moore and Rosenthal, 1993), there is some evidence from respondents of both sexes that the same rules (e.g., how to encourage or discourage a sexual encounter) guide the sexual behaviors of boys and girls (Rosenthal and Peart, 1996). Whether boys and girls share the same ideas about definitions of sexual practices as coercive and/or acceptable, and

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whether the biased reading of communications evident among college students extends to younger respondents are the focus of the research reported here. The study was designed to examine a range of sexual encounters, some of which we believed could be defined a priori as coercive. We used scenarios to manipulate the level of pressure being exerted by one partner over the other (ranging from overt physical force through indirect pressure to no pressure) and the clarity of the communicative response by the other partner (ranging from statements of desire for, or rejection of, sex through indirect communication to no communication). We were interested in the extent to which sexual coercion was influenced by communicative clarity and perceptions of consent as well as the boundaries of behaviors defined as constituting pressure and thus coercive and unacceptable.

METHOD Subjects The sample consisted of 191 young people (98 boys and 93 gals), ages 15-17 years (x = 16.3), 81% of whom were living with their parents. Respondents were attending recreational youth groups in metropolitan Melbourne. The majority (71%) were still at school and the sample was predominantly working class. Most of the respondents (87%) were born in Australia. Of the remainder, 10 (5%) were Asian-born and the others were European or of English-speaking descent. Measures As part of a study of young people's understandings of sexual coercion, respondents were administered a questionnaire that contained scenarios depicting 16 situations with two protagonists where sex may or not ensue. The scenarios were designed to vary in the extent to which the desire to have or not have sex was clearly articulated, whether sex did or did not occur, and whether pressure was exerted by one individual on the other. In all cases, items and their wording were chosen following discussions with young people of the same age and from similar backgrounds as the respondents. These young people were in agreement that neither heterosexuality nor male coercion of female partners should be assumed in the scenarios. Thus, all scenarios were worded so that responses could refer to same or different sex partners, and to males or females. Subsequent

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pilot testing in focus groups confirmed that the scenarios depicted situations that would be familiar and relevant to the respondents and that they would be able to understand both the instructions and the scenarios. Respondents were asked to rate, on a 4-point scale, the clarity of the communication ranging from 1 (not at all clear) to 4 (perfectly clear). They were then asked to rate, for the same scenarios, the amount of pressure applied from 1 (no pressure) to 4 (a lot of pressure). Finally, respondents rated how acceptable the situation in each of the scenarios would be to them from 1 (not at all acceptable) to 4 (perfectly acceptable). The following instructions and scenarios were presented to the adolescents: 1. Please rate how CLEAR it is to Person X what Person Y wants in each situation. In each case the encounter is new and begins with the couple X and Y kissing intimately. 2. Now we would like you to read the stories again and rate in your opinion, how much PRESSURE is being applied by X on Y. Remember, in each case the encounter is new and begins with the couple X and Y kissing intimately. 3. We are interested in what you consider to be ACCEPTABLE. Please read the stories again and rate how ACCEPTABLE each situation would be to YOU.

Scenarios 1. X and Y discuss whether sex is possible. Y says he/she does not want to have sex. X then threatens to leave. 2. X kisses Y, then suggests a walk. 3. X and Y try to excite each other. Both agree to sex and sex then occurs. 4. X and Y discuss whether sex is possible. Y says he/she does not want to have sex, but X holds Y down so he/she cannot get away and sex occurs. 5. X feels really excited and continues to kiss Y. Sex doesn't occur. 6. Before increasing excitement, X asks Y if he/she would like to have sex. Y agrees. 7. In order to encourage sex, X tells Y that he/she may be in love. Without further discussion, sex occurs. 8. X "pretends" to hold Y down, playfully removing his/her clothes and kissing Y until, without discussion, sex occurs. 9. X and Y discuss whether sex is possible. Y says he/she does not want to have sex. X then threatens to end the relationship.

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10. X asks repeatedly for sex. Y says he/she does not want to have sex. X keeps asking and sex occurs. 11. X tries to excite Y until, just before sex, X asks if sex would be okay. Y agrees. 12. X presumes that sex is going to occur. X removes Y's clothes and tries to excite him/her until, without discussion, they have sex. 13. X tries to excite Y. Sex doesn't occur. 14. Y passes out from drinking too much alcohol. X then proceeds to remove Y's clothing and to kiss and touch him/her, until Y wakes up, still drunk, and sex occurs. 15. Before increasing excitement, X tells Y that he/she would like to have sex. Y agrees. 16. X finds him/herself too embarrassed to suggest sex with Y, so sex doesn't occur. Procedure Following clearance from the University Ethics Committee, respondents were recruited through youth workers at various locations in metropolitan Melbourne and in the country. The questionnaire was administered to groups of volunteer respondents at each location. Informed consent was obtained from all respondents prior to administration of the questionnaire which was completed anonymously.

RESULTS Table I shows the number of respondents who believed that communication was quite or perfectly clear, that there was no or hardly any pressure, and that the situation described was quite or perfectly acceptable. Sex differences in perceptions of communicative clarity, pressure, and acceptability were examined by MANOVA (with some slight loss of respondents because of missing data). Communication Of interest is the finding that for all but two of the scenarios (14 and 16) the majority of respondents reported that Y clearly communicated his/her wishes, although only three of the scenarios (3, 6, and 15) attracted this response from more than three quarters of the boys and girls. It appears that agreeing to have sex (Scenarios 3,6,11, and 15) was more readily

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Table I. Number (Percentage) of Adolescents Responding Positivelya Communication

Pressure

Situation

Boys

Girls

Boys

Girls

1 2 3 4 5 6 7 8 9 10 11 12 13

59 (60.2) 59 (60.2) 79 (83.2) 47 (48.0) 55 (56.1) 75 (78.2) 68 (70.1) 68 (70.1) 50 (52.1) 43 (44.4) 75 (78.2) 55 (56.1) 59 (60.2) 34 (34.7) 77 (79.3) 41 (42.2)

63 (67.7) 49 (52.6) 77 (82.8) 61 (66.3) 53 (57.6) 74 (80.5) 47 (51.7) 48 (52.2) 53 (58.3) 47 (51.7) 61 (66.3) 46 (49.5) 51 (54.9) 36 (39.2) 76 (82.6) 37 (39.8)

19 (19.4) 62 (63.3) 69 (70.4) 21 (21.4) 52 (54.1) 66 (68.0) 48 (50.0) 42 (43.3) 16 (16.5) 20 (20.6) 54 (55.6) 53 (54.6) 59 (60.8) 34 (35.4) 65 (66.3) 51 (52.0)

18 (19.4) 63 (68.5) 75 (83.3) 15 (16.2) 67 (73.7) 73 (79.3) 39 (42.4) 42 (46.2) 12 (13.1) 12 (13.1) 52 (57.2) 50 (53.8) 61 (66.3) 29 (31.2) 77 (82.8) 69 (74.2)

14 15

16

Acceptability Boys 24 62 74 24 65 78 62 48 29 24 70 52 61 17 76 62

(24.5) (63.9) (76.31) (24.5) (66.3) (80.5) (63.9) (50.0) (29.9) (25.1) (73.7) (54.2) (63.6) (17.7) (78.4) (63.9)

Girls 11 (11.8) 68 (73.1) 73 (79.4) 19 (20.7) 61 (65.6) 71 (76.4) 42 (45.6) 44 (47.3) 21 (22.9) 19 (20.7) 64 (68.8) 34 (36.6) 68 (73.1) 15 (16.5) 72 (77.4) 66 (71.7)

aCommunication

response: quite/perfectly clear; pressure response: no/hardly any pressure; acceptability response: quite/perfectly acceptable.

recognized as clear communication than was saying no (1, 4, 9. and 10), while the absence of discussion (2, 5, 7, 8, 12, 13) was, nevertheless, interpreted by many respondents as clear communication. There were significant univariate effects of sex of respondent for Scenarios 4,F(1, 173) = 6.40, p < .05, and 7, F(l, 173) = 4.46, p < .05. In the former, girls were more likely than boys to report communication as clear (Boys' x = 2.49; Girls' x = 2.93) while the converse held for the latter scenario (Boys' x = 2.86; Girls' x = 2.58). Pressure The scenarios elicited more varied responses in ratings of the pressure applied to Y than in judgments of clarity. The majority of respondents reported that significant pressure was applied to Y in six scenarios (1, 4, 7, 8,9,14). Scenarios rated as using least pressure were those where Y agreed to sex which subsequently occurred (3, 6, 11, 15), or where there was no discussion but no sex followed (2,5,11,16). In those situations where there was no discussion and sex occurred, ratings of pressure were moderate when there was no overt threat by X but, rather, a gradual buildup of excitement in order to encourage Y's acquiescence. Those cases where Y

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explicitly stated that he/she did not want sex (and which were accompanied by physical or psychological threats on the part of X) were regarded as instances of pressure on Y by over 80% of respondents. There were significant univariate effects of sex of respondent for five scenarios: 3, F(l, 174) = 8.42, p < .01; 5, F(l, 174) = 10.11, p < .01; 10, F(l, 174) = 5.53, p < .05; 15, F(l, 174) = 10.25, p .01; and 16, F(l, 174) = 11.15, p < .001. There was also a nonsignificant trend for scenario 4, F(l, 174) = 3.43, p = .06. Girls reported that greater pressure was being applied by X in scenarios 4 (Boys' x = 3.32; Girls' x = 3.57) and 10 (Boys' x = 3.13; Girls' x = 3.44). Boys reported more pressure being applied for scenarios 3 (Boys' x = 2.02; Girls' x = 1.61), 5 (Boys' x = 2.38; Girls' x = 1.92), 15 (Boys' x = 2.13; Girls' x = 1.67), and 16 (Boys' x = 2.40; Girls' x = 1.87). Acceptability

Ratings of acceptability closely followed those of pressure. Scenarios in which high levels of pressure were reported (1, 4, 9, 10, 14) were rated as unacceptable by the large majority of respondents whereas those scenarios that described consensual sex (3, 6, 11, 15) or where sex did not occur (2, 5,13,16) were rated as acceptable by a majority of boys and girls. Falling between these were the scenarios where sex occurred without discussion but without perceived pressure. There were significant sex differences for Scenarios 1, F(l, 174) = 3.89, p < .05; 7, F(l, 174) = 10.43, p < .01; and 12, F(l, 174) = 7.81, p < .01. In all cases, boys reported the situation to be more acceptable than did girls (Boys' x scores: 1.75, 2.87, and 2.63; Girls' x scores: 1.47, 2.39, and 2.20 for Scenarios 1, 7, and 12, respectively). Relationships Between Communication, Pressure, and Acceptability

Rank-order correlations were calculated from the rankings of scenarios as shown in Table I. Although the rankings of scenarios according to absence of pressure and acceptability were remarkably similar (p = .87 for boys and .91 for girls) they were less so for communication and acceptability (p = .62 for boys and .43 for girls). It was not clear, however, whether these reflected significant relationships between the measures. Correlations between communication and acceptability and between pressure and acceptability were calculated for each of the 16 scenarios using, for each measure, respondents' scores on the rating scales (from 1 to 4). Correlations are reported separately for boys and girls in Table II.

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Table II. Correlations of Communication and Pressure with Acceptability Communication/acceptability Scenario

Boys

Girls

1 2 3 4 5

.06 .22

6

7 8 9 10 11 12 13 14 15 16 ap

bp

.33a

.19 .15 .36a .24 .16 .04 .22 .24 .38b

.12 .28a .41b

.00

Pressure/acceptability Boys

Girls

.11

-.11

.07 .37* -.14 .24 .34a .13

-.15 -.14

-.14 -.35" -.15 -.18 -.24 -.16 -.37b

.34a -.02

.05 .17

-.30° -.11 -.07 .07 -.23 -.27a -.03 -.16

.34°

.14

.00 .10 .13 .00

-.10 -.16 -.19 .03

-.34"

-.26" -.28a -.52b -.17 -.10 -.28a -.28a -.10

< 0.01. < 0.001.

In general, correlations were modest with similar patterns emerging for girls and boys in terms of the relationships between acceptability and communicative clarity but not pressure. For both boys and girls, correlations between communication and acceptability exceeded .30 for only 4 of the 16 scenarios. In three cases (Scenarios 3 and 6 for both sexes and Scenario 15 for boys only), communication was clear and positive. As might be expected, the relationship between pressure and acceptability appeared to be stronger for girls than for boys, with girls' perceptions of greater pressure correlating significantly with lower ratings of acceptability in 8 scenarios, compared with 2 in the case of boys. DISCUSSION This study sought to shed light on the understandings that young people have of communicative clarity and pressure in situations where sex may or may not result, and the acceptability of the protagonists' behavior. A surprising finding is the divergence of young people's views about what constitutes clear communication, pressure, and acceptability. There was wide variability in the responses of these 16-year-olds and few scenarios

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received positive or negative endorsement on any of the three measures by at least four fifths of the respondents. Even in the most extreme situations (e.g., Y explicitly saying yes to sex or X virtually raping Y as in Scenario 4), there was a substantial minority who held an unexpected view (unclear communication, little or no pressure). This suggests that we need to be careful in imposing normative views of communicative clarity and/or pressure on young people. It appears that communication was judged as clearer when that message was yes to sex rather than no, suggesting some support for the cultural norm that, in sexual situations, no can be interpreted as meaning yes. Of some concern was the finding that girls as well as boys held this view. There were few differences between girls and boys in reports of the clarity of the messages being conveyed. This calls into question the assumption that boys continue to pressure girls into having unwanted sex because they misunderstand girls' messages. If it is true that some boys failed to understand the message, it is also true that girls had difficulty in this regard. Given the brief and straightforward nature of our scenarios, it is unlikely that the failure of our respondents to report clear messages was due to actual inability to decode the communication. Rather, it appears that boys and girls were responding to social rules about sexual encounters in which communication, however explicit, is only part of the whole. These findings suggest that efforts to encourage young people to accept, at face value, the positive or negative messages that they receive requires disentangling communication from context. In part, this means that we need to ensure that young people of both sexes recognize that no means no and that relying on nonverbal messages of consent or otherwise is a risky practice. As might be expected, young people were more likely to report that pressure was being exerted in situations where explicit pressure tactics, either physical or emotional, were used (holding someone down, threatening to leave a relationship), especially if unwanted sex followed. Most (but not all) of these young people appeared to recognize that having sex after one of the partners has stated that he/she did not want to do so involved pressure. On the other hand, a situation in which there was a nonsexual endpoint was less likely to be regarded as involving pressure even when there was a persistent attempt at persuasion on the part of one protagonist. Again, there were more similarities than differences between boys and girls. It is difficult to detect a pattern in the differences that were observed, but there is a hint that girls were more likely to report pressure when hassled until sex occurs (Scenarios 4 and 10), and less likely than boys to report pressure when there was a sense of mutuality about proceedings (Scenarios 3, 15, and 16) whether or not sex occurred. These findings are consistent with those reported by Davis et al (1993) in which their female high school-

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ers were more likely to report that it was acceptable for a boy to force a girl to have sex with him in situations where it could be inferred that the girl had played a role in the buildup of sexual arousal. Acceptability of the sexual scenarios appeared to be determined primarily by the existence or otherwise of pressure. Both boys and girls agreed that scenarios depicting consensual sex were the most acceptable, followed by those in which no sex occurred. Sex without discussion but with goodhumored pressure was moderately acceptable but nonconsensual sex (or ambiguous situations where sex may or may not occur) was not. This rank ordering of acceptability levels is interesting since it indicates that the large majority of these young people agreed that sex between willing partners was a highly acceptable activity, a belief that appears to be borne out in practice (Moore and Rosenthal, 1993). Again, fitting with findings from other studies (Buzwell, 1996; Buzwell et al., 1992), boys had a somewhat higher threshold of acceptability for situations in which pressure was more overt. The patterns of correlations between acceptability and pressure or communication point to the complexity of the process that young people engage in when making decisions about sexual situations. A key finding is that for girls but not boys acceptability is related to perceived pressure. Clarity of communication, on the other hand, yields some puzzling and inconsistent correlations. For example, saying yes related to acceptability, but not in all cases and not for both sexes. Because in the scenarios communication and pressure were confounded, it may be a more useful strategy to examine the content of those scenarios deemed to be acceptable or unacceptable. Nevertheless, there are lessons to be learned about the impact of perceived pressure on the ways in which young people assess sexual situations as acceptable or otherwise. Finally, our finding that, on the whole, there are few sex differences agrees with other research which suggests that boys and girls are equally aware of the rules of sexual encounters (Rosenthal and Peart, 1996). However, when it comes to acting out these rules, we know that boys and girls behave differently (e.g., Holland et al, 1991a, 1991b, 1992; Moore and Rosenthal, 1993). The task for educators is to discover why there is a gap between knowledge and practice. The present study used written scenarios which, although pilot tested with young people, may not have been realistic enough to reflect real life experiences. Moreover, responses to these scenarios do not tell us what happens in real life as young people find themselves in a variety of sexual situations. To judge a scenario as unacceptable does not mean that it will not occur. While it is not possible to obtain real-life data, in situ, one strategy we are adopting is to conduct in-depth

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interviews with young people, to document what their own experiences and their reactions to these have been. From the present study, though, we can assert that sexual coercion has many forms, and that what one person may report as coercive behavior may be viewed as gentle persuasion by another. Of concern is that what appears to us as a clear example of coercion, even rape, can be regarded as acceptable behavior by a worrying number of these 16-year-old boys and girls. We need to know more about the characteristics of those whose judgments of scenarios such as these are at odds with those of the majority of young people and with our norms about acceptable sexual practices. Finally, the research suggests that if we are to reduce the number of unwanted sexual encounters between young people and increase their ability to negotiate so that the sexual needs and wishes of both boys and girls are met, then we must clarify the meaning of pressure and teach young people to be more effective communicators.

ACKNOWLEDGMENTS

The author thanks Rachel Peart and Anne Mitchell for their contributions to the study.

REFERENCES Abbey, A. (1982). Sex differences in attributions for friendly behavior: Do males misperceive females' friendliness? /. Pers. Soc. Psychol 42: 830-838. Abbey, A. (1987). Misperceptions of friendly behavior as sexual interest: A survey of naturally occurring incidents. Psychol. Women Quart. 11: 173-194. Abbey, A., and Melby, C. (1986). The effects of nonverbal cues on gender differences in perceptions of sexual intent. Sex Roles 15: 283-298. Beaver, E. D., Gold, S. R., and Prisko, A. G. (1992). Priming macho attitudes and emotions. J. Interpers. Violence. 7: 321-333. Buzwell, S. (1996). Constructing a sexual self. Doctoral dissertation, La Trobe University, Melbourne, Australia. Buzwell, S., Rosenthal, D. A, and Moore, S. M. (1992). Idealising the sexual experience. Youth Stud. Aust. 3: 10 Craig, M. E. (1990). Coercive sexuality in dating relationships: A situational model. Gin. Psychol. Rev. 10: 395-423. Craig Shea, M. E. (1993). The effects of selective evaluation on the perception of female cues in sexually coercive and noncoercive males. Arch. Sex. Behav. 22: 415-433. Davis, T. C, Peck, G. Q., and Storment, J. M. (1993). Acquaintance rape and the high school student. J. Adolescent Health Care 12: 220-224. Erikson, P., and Rapkin, A. (1991). Unwanted sexual experiences among middle and high school youth. J. Adolescent Health 12: 319-325. Feltey, K. M., Ainstie, J. J., and Gibb, A. (1991). Sexual coercion attitudes among high schools students: The influence of gender and rape education. Youth Soc. 23: 229-250.

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Gavey, N. J. (1991). Sexual victimization among New Zealand university students. /. Consult. Clin. Psychol. 59: 464-466. Gavey. N. J. (1992). Technologies and effects of heterosexual coercion. Fem. Psychol. 2: 325-351. Holland, J., Ramazanoglu, C, Sharpe, S., and Thomson, R. (1991a). Pressured Pleasure: Young Women and the Negotiation of Sexual Boundaries, The Women's Risk AIDS Project, Paper No. 7, Tufnell Press, London. Holland, J., Ramazanoglu, C, Scott, S., Sharpe, S., and Thomson, R. (1991b). Presure, Resistance and Empowerment: Young Women and the Negotiation of Safer Sex, The Women's Risk AIDS Project, Paper No. 6, Tufnell Press, London. Holland, J., Ramazanoglu, C, Scott, S., Sharpe, S., and Thomson, R. (1992). Risk, power and the possibility of pleasure: Young women and safer sex. AIDS Care 4: 273-283. Hollway W. (1984). Gender difference and the production of subjectivity. In Henriquwa, J., Hollway, W., Urwin, C. Venn, C, and Walkerdine, V. (eds.), Changing the Subject: Psychology, Social Regulation and Subjectivity, Methuen, London, pp. 227-263. Kelly, L. (1987). The continuum of sexual violence. In Hammer, J., and Maynard, M. (eds.), Women, Violence and Social Control, Macmillan, London, pp. 46-60. Koss, M. P., Gidycz, C. A., and Wisniewski, N. (1987). The scope of rape: Incidence and prevalence of sexual aggression and victimization. J. Consult. Clin. Psychol. 50: 455-457. Koss, M. P., and Oris, C. J. (1982). The Sexual Experience Survey: A research instrument investigating sexual aggression and victimization. J. Consult. Clin. Psychol. 57: 455-457. Moore, S. M., and Rosenthal, D. A. (1993). Sexuality in Adolescence, Routledge, London. Muehlenhard, C. L. (1988). Misinterpreted dating behaviors and the risk of date rape. J. Soc. Clin. Psychol. 6: 20-37. Muehlenhard, C. L., Goggins, M. F., Jones, J. M., and Satterfield, A. T. (1991). Sexual violence and coercion in close relationships. In McKinney, K., and Sprecher, S. (eds.), Sexuality in Close Relationships, Erlbaum, Hillsdale, NJ, pp. 155-175. Muehlenhard, C. L. and Linton, M. A. (1987). Date rape and sexual aggression in dating situations: Incidence and risk factors. J. Counsel. Psychol. 34: 186-196. Patton, W., and Mannison, M. (1995). Sexual coercion in dating situations among university students: Preliminary Australian data. Aust. J. Psychol. 47: 66-72. Richardson, D. R., and Hammock, G. S. (1991). Alcohol and acquaintance rape. In Parrot, A., and Bechhofer, L. (eds.), Acquaintance Rape: The Hidden Crime, Wiley, New York, pp. 83-95. Rosenthal, D. A., and Peart, R. (1996). The rules of the game: Teenagers communicating about sex. J. Adolescence 19: 321-332. Shotland, R. L., and Goodstein, L. (1992). Sexual precedence reduces the perceived legitimacy of sexual refusal: An examination of attributions concerning date rape and consensual sex. Pen. Soc. Psychol. Bull. 18: 755-764.

Archives of Sexual Behavior, Vol. 26, No. 5, 1997

Testosterone Treatment in Men with Erectile Disorder and Low Levels of Total Testosterone in Serum Zoran Rakic, M.D., Ph.D.,1,3 Vladan Starcevic, M.D., Ph.D.,2 Vesna P. Starcevic, M.D., Ph.D.,2 and Jelena Marinkovic, Ph.D.2

Since decreased serum levels of testosterone (T) do not necessarily predict good outcome of testosterone treatment for erectile disorder, the purpose,of this study was to determine which men with erectile disorder and decreased serum levels might benefit from treatment. From a sample of 31 men (\ age = 39 years), 15 (48%) with erectile disorder and decreased serum levels of T responded well after 8 weeks of testosterone treatment (100 mg of testosterone propionate in the sustained-release form given im once a week). Good treatment outcome was associated with several variables, but only high levels of luteinizing hormone (LH) and low values of the T/LH (testosterone/LH) ratio consistently emerged as significant correlates and/or predictors of effective treatment. Levels ofLH above 7.5 IU/L or the values of the T/LH ratio equal to or below 0.87 nmol/IU in patients with erectile disorder and decreased serum levels of T suggest that testosterone treatment may be effective. KEY WORDS: erectile disorder; impotence; testosterone; luteinizing hormone; testosterone/Iuteinizing hormone ratio.

NTRODUCTION Decreased levels of serum testosterone may cause a decrease in men's sexual desire, which may subsequently impair their sexual arousal and cause erectile disorder. Such sexual dysfunction may respond to treatment with 1Department

of Psychiatry, Clinical and Hospital Center "Dr. Dragisa Misovic," Bulear JNA 84,11000 Belgrade, Yugoslavia. 2Belgrade University School of Medicine, Belgrade, Yugoslavia. 3To whom correspondence should be addressed. 495 00044M02f97/1000-049S$12.50/0 C 1997 Plenum Publishing Corporation

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testosterone (Benson, 1994; Carani et al., 1990; Gooren and Rubens, 1987; Kwan et al., 1983; National Institutes of Health [NIH], 1992; O'Carroll et al., 1985). Men with a decreased sexual desire are usually not aware of it in the beginning and are more likely to be troubled by a gradually developing erectile disorder. In middle-aged men who develop such a dysfunction, it is particularly important to determine whether its cause is hormonal. Therefore, testosterone serum levels should be measured in such individuals, even though most men who seek help in sexual disorder clinics do not have a hormonal origin of their erectile disorder (Benson, 1994; NIH, 1992). In view of the clinical observation that some men with erectile disorder respond to testosterone treatment, while others do not, the purpose of this study was to determine which men with erectile disorder and decreased serum levels of total testosterone might benefit from this treatment. We sought to elucidate those factors that are associated with good outcome of testosterone treatment for erectile disorder.

METHODS Thirty-one men with erectile disorder and low serum levels of testosterone (T) participated in the study. They all sought help in the Sexual Disorders Clinic of the Clinical and Hospital Center "Dr. Dragisa Misovic" in Belgrade over a 3-year period (1990-1993) and were evaluated by one of us (Z.R.). The mean age of these patients was 39.25 years (SD = 7.57; range = 24-56). The majority (64.5%) were educated at the secondary school level. Erectile disorder was diagnosed on the basis of the DSM-III-R criteria (American Psychiatric Association, 1987). An intact capacity for penile erection was verified by the Prostin VR test (Upjohn Co.), so that it was not necessary to verify it additionally by measuring nocturnal erections. Moreover, to exclude other causes of erectile disorder, patients were selected on the basis of normal findings on the following: general physical examination, routine laboratory analyses, laboratory analyses of liver and renal function, assessment of hormonal status (thyroid, pituitary, and adrenal function tests), urological examination, examination of penile blood vessels, and analysis of chromosomes (karyotype). These procedures were performed by clinicians who did not participate in other stages of the study. Information was collected about any medications the patients might have been taking before the onset of erectile disorder and in the course of it. Those patients who were taking medications that are known to cause sexual dysfunction were excluded.

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To monitor and assess the patients' sexual activity, only those subjects were included in the study who maintained the same sexual partner throughout the duration of the erectile disorder, including the treatment period. A comparison (control) group consisted of 16 male volunteers, most of them hospital employees. They were subjected to the same evaluation procedures (physical examinations, laboratory analyses and assessments) as patients. Their mean age was 42.37 years (SD = 7.65; range = 31-59). The majority of these individuals (56.25%) also had a secondary education. There were no significant differences between patients and controls in terms of the basic demographic variables. Procedures The serum levels of T and luteinizing hormone (LH) were determined in the morning (at 8 AM) for 3 consecutive days in all patients and control group subjects. Results of these three measurements were expressed as mean levels. The T serum levels were measured by the means of the RIA method, according to a modification with extraction, provided by Biodata (Italy). Serum LH levels were also measured by the RIA method, in accordance with the modification provided by INEP-Zemun (Belgrade). The mean value for intra-assay variability for LH was 7.15 IU/L (SD = 0.36) and the coefficient of variability (CV) = 4.99%. The mean value for interassay variability for LH was 7.45 IU/L (SD = 1.24, CV = 9.86%). For intra-assay variability for testosterone, 3c = 1.160 ng/ml (3.944 nmol/L), SD = 0.031 ng/ml (0.103 nmol/L), and CV = 2.7%. Finally, for interassay variability for testosterone, x = 0.506 ng/ml (1.520 nmol/L), SD = 0.033 ng/ml (0.112 nmol/L), and CV = 6.5%. Normal T levels in the serum ranged from 12 to 35 nmol/L, while normal serum LH levels ranged from 1.05 to 10.5 IU/L. We have used the T/LH ratio to obtain a measure that would take into account variations in the levels of T and LH. Thirty-one patients with low testosterone levels in serum were treated with testosterone propionate in the sustained-release form. The dosage was 100 mg im once a week for 8 weeks. The main indicator of sexual activity was frequency of sexual intercourse, because information on that could be reliably obtained from both the patients and their sexual partners. Likewise, the key parameter of improvement in the treatment of erectile disorder was frequency of successful sexual intercourse (with normal erection), as reported by both partners. Information was also obtained on levels of sexual interest, sexual dreams

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and fantasies, and spontaneous and nocturnal erections, but these were considered less objective for the purpose of rating sexual activity. Sexual activity in the course of the treatment was continuously monitored by the second author (V.S.), who did not perform initial patient evaluations. He assessed sexual activity and outcome of an 8-week testosterone treatment using a 3-point scale based on the frequency of successful sexual intercourse, as reported by both partners. The following rating system was used: 0 = No improvement in sexual activity (no successful sexual intercourse, with persistence of erectile disorder); 1 = slight improvement in sexual activity (at least one successful sexual intercourse in the 15-day period preceding the assessment); 2 = obvious improvement in sexual activity (the frequency of successful sexual intercourse returns to that which was usual for the couple before the onset of erectile disorder). Statistical Analyses Student's t test for independent groups and the chi-square test were used for comparisons of independent variables between patients and controls. Pearson's correlation coefficient was used to examine the relationships between all variables within the group of patients and the control group. Stepwise discriminant analysis (Afifi and Clark, 1984) was performed with the aim of identifying variables that are significantly associated with good outcome of the testosterone treatment. The sensitivity analysis (Weinstein and Fineberg, 1990) was used for the purpose of determining the levels of hormones that might distinguish between responders and nonresponders to the testosterone treatment. RESULTS Good outcome of the testosterone treatment (defined as "obvious improvement in sexual activity") after 60 days of treatment was demonstrated in 15 (48.4%) patients. Poor outcome (defined as "no improvement in sexual activity, with persistence of erectile disorder") was found in 16 (51.6%) patients. There were no patients with slight improvement in sexual activity at the end of the treatment. The mean age of patients with good outcome of treatment was 41.00 years (SD = 6.46); the mean age of patients with poor outcome of treatment was 37.63 years (SD = 8.35). Table I compares several variables between the patients and the control group. In comparison with the control group, the mean level of T was significantly lower and the mean level of LH was significantly higher in the

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patients. As a result, the mean T/LH ratio was significantly lower in the patients. Patients were significantly younger at the age they married. In the control group, the Pearson correlation coefficient suggested a significant linear relationship between the levels of T and age at which the persons married (r = -.519). In the patients group, the following linear relationships (based on the Pearson correlation coefficients) were significant: Between higher levels of LH and good outcome of treatment (r = .796), between lower values of the T/LH ratio and good outcome of treatment (r = -.629), between gradual onset of erectile disorder and higher levels of LH (r = .455), between gradual onset of erectile disorder and onset of the disorder at a later age (r = .378), and between gradual onset of erectile disorder and good outcome of treatment (r = .571). Using the Pearson correlation coefficient, the same (repeated) relationships between T and LH were not found in both the patient group and the control group. Table II shows the results of the first discriminant analysis. It included all variables except for the T/LH ratio, which is not an independent variable. Variables associated with good outcome of treatment were higher levels of LH, greater number of children, older age (at the time when the hormone levels were determined), and gradual onset of erectile disorder. The correct classification index with such combination of variables was maximal: 100%. Table III shows the results of the second discriminant analysis, which excluded the levels of T and LH, but included the T/LH ratio along with other variables. In descending order of significance, variables associated with good outcome of treatment were lower values of the T/LH ratio, older age (at the time when the hormone levels were determined), lower educational level, younger age at marriage, and younger age at the onset of masturbation. Poor outcome of treatment was associated with shorter duration of erectile disorder and onset of sexual activity at a later age. The correct classification index with this combination of variables was somewhat less informative: 96.15%. Different results of the two discriminant analyses may be accounted for by the relationships between variables (as determined by the Pearson correlation coefficients), differences in the correct classification indexes, and greater prognostic value of the LH level than the T/LH ratio. The sensitivity analysis showed that good outcome of treatment was associated with levels of LH higher than 7.5 IU/L and T/LH ratio equal to or lower than 0.87 nmol/IU. Therefore, it is reasonable to expect good outcome of the testosterone treatment in patients with decreased levels of T if their levels of LH are above 7.5 IU/L and their T/LH ratios are below the corresponding value.

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Table II. Significant Variables in Predicting Outcome of Testosterone Treatment— Results of the First Discriminant Analysis Variables (by order of entrance) LH levels No of children Age Mode of onset of erectile disorder (1 = abrupt, 2 = gradual) aLevel

Good outcome of treatment

Wilks's Xa

SCDF coefficientsb

.31 .26 .23

1.057 0.525 0.332

10.8 1.85 41.9

.218

0.266

2

X

Poor outcome of treatment

SD

X

SD

2.57

1.57

6.25

4.68 1.61 37.9

0

1.54

0.5

0.7

0.5 8.2

of significance for all lambdas is < .001. Canonical Discriminant Function.

bStandardized

Table III. Significant Variables in Predicting Outcome of Testosterone Treatment— Results of the Second Discriminant Analysis Variables (by order of entrance) T/LH ratio

Age Level of education Age at marriage Duration of erectile disorder Age at onset of partner sexual activity Age at onset of masturbation

SCDF Wilks's Ja coefficientsb

1.3

Good outcome of treatment

Poor outcome of treatment

x

SD

X

.585 .458 .419 .388 .367

0.69 41.9 2.08 23.54 4.31

0.16

0.669 0.656 0.611 -0.597

0.49 2.57 4.98

1.89 37.9 2.38 25.31 3.76

.33 .3

-0.45 0.437

18.9 14.0

2.39 2.00

19.2 15.0

6.2

SD 1.03

8.2 0.65 4.90 3.00 3.78 1.73

aLevel

of significance for all lambdas is < .001. ''Standardized Canonical Discriminant Function.

DISCUSSION Even though levels of LH were higher in the group of patients as a whole (which was expected because patients had low levels of T), LH values showed prominent variability, ranging from 1.6 IU/L to 18.7 IU/L. In contrast, LH values in the control group were far more consistent, ranging from 4 IU/L to 8.6 IU/L. This indicates that in terms of LH levels, the group of patients was quite heterogeneous. Levels of free testosterone, which is a biologically active form of the hormone (Carani et al., 1990; Davidson et al., 1983; Gooren and Rubens,

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1987; Vermeulen et al., 1972), were not determined in our laboratory. Some studies (Carani et al., 1990) suggest that a decrease in the level of total testosterone does not automatically imply a decrease in the level of free testosterone. This might help account for the observation that increased levels of LH were not found in some of our patients with low levels of T, and that these patients did not respond to the testosterone treatment. Discriminant analyses suggest that higher levels of LH and lower values of the T/LH ratio are most significantly associated with good outcome of testosterone treatment, and therefore they might predict good response. The same variables were identified as significant on the basis of the Pearson correlation coefficients. A significant correlation was found between gradual onset of erectile disorder on one hand, and higher LH levels, somewhat older age, and good outcome of testosterone treatment, on the other. This finding suggests that patients with gradual onset of erectile disorder tend to have idiopathic hypogonadism and, therefore, they may be more likely to respond to testosterone treatment. However, our results also show that such a relationship is not the rule. In men over 40 with gradual onset of erectile disorder and good outcome of testosterone treatment, which suggests a hormonal origin of erectile disorder (idiopathic hypogonadism), there may be an unusually early onset of andropause. Such a condition had been described more than 50 years ago in a few men in their early 40s (Werner, 1939). Although some authors disagree that it exists (Skolnick, 1992), it may reflect a genetically determined process of premature aging. Good outcome of testosterone treatment was also associated with greater number of children in the first discriminant analysis. This was probably an artifact, because most patients with good treatment outcome had one or two children; there was only one patient with seven children. Likewise, the second discriminant analysis identified lower educational level and earlier age at which patients married as variables associated with good treatment outcome. It appears that these two variables are related, since persons with less education tend to marry earlier. However, it is difficult to conceptualize a meaningful relationship between lower educational level and erectile disorder with decreased levels of testosterone; therefore, the association of this variable with good outcome of treatment in a relatively small number of patients does not appear convincing. The association of good treatment outcome with an earlier age of onset of masturbation does not appear to be clinically significant. Although an earlier age of onset of masturbation points to a stronger sexual drive (Kinsey et al., 1948), the latter seems unrelated to the development of idiopathic hypogonadism later in life.

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Poor outcome of testosterone treatment does not point with certainty to any particular cause of erectile disorder, and its etiology then requires further investigation. In conclusion, the diagnostic workup of all middle-aged men who develop erectile disorder should include measurement of the serum levels of T and LH. The decision to start testosterone treatment should be based on the levels of LH and values of the T/LH ratio, because decreased levels of serum testosterone per so may not be the cause of erectile disorder and do not necessarily predict good outcome of treatment. According to the results from our laboratory, levels of LH above 7.5 IU/L or the values of the T/LH ratio equal to or below 0.87 nmol/IU in patients with erectile disorder and decreased levels of serum testosterone, suggest that the testosterone treatment is more likely to be effective and should therefore be attempted.

REFERENCES Afifi, A. A., and Clark, V. (1984). Computer-Aided Muttivariate Analysis, Lifetime Learning Publications, Belmont, CA. American Psychiatric Association (1987). Diagnostic and Statistical Manual of Mental Disorders, 3rd ed., rev., American Psychiatric Association, Washington, DC. Benson, G. S. (1994). Endocrine factors related to impotence. In Bennett, A. H. (ed.), Impotence. Diagnosis and Management of Erectile Dysfunction, W. B. Saunders, Philadelphia, pp. 31-41. Carani, C., Zini, D., Baldini, A., Delia Casa, L., Ghizzani, A., and Manama, P. (1990). Effects of androgen treatment in impotent men with normal and low levels of free testosterone. Arch Sex. Behav. 19: 223-234. Davidson, J. M., Chen, J. J., Crapo, L., Gray, G. D., Greenleaf, W. J., and Catania, J. A. (1983). Hormonal changes and sexual function in aging men. J. Gin. Endocrinol. Metab. 57. 71-77. Gooren, L., and Rubens, R. (1987). Overview of the concept of andropause. In Zichella, L., Whitehead, M., and Van Keep, P. A. (eds.), The Climacteric and Beyond: The Proceedings of the Fifth International Congress on the Menopause, Parthenon Publishing Group, Sorrento, pp. 85-93. Kinsey, A. C, Pomeroy, W. B., and Martin, C. E. (1948). Sexual Behavior in the Human Male. W. B. Saunders, Philadelphia. Kwan, M., Greenleaf, W. J., Mann, J., Crapo, Z., and Davidson, J. M. (1983). The nature of androgen action on male sexuality: A combined laboratory-self-report study in hypogonadal men. J. Gin. Endocrinol. Metab. 57: 557-562. National Institutes of Health. (1992, Dec. 7-9). Impotence. NIH Consensus Statement. 10(4):l-31. O'Carroll, R., Shapiro, C, and Bancroft, J. (1985). Androgens, behavior and nocturnal erection in hypogonadal men: The effects of varying the replacement dose. Clin. Endocrinol. 23: 527-538. Skolnick, A. A. (1992). Is "male menopause" real or just an excuse? J. Am. Med. Assoc. 268: 2486. Vermeulen, A., Rubens, R., and Verdonck, L. (1972). Testosterone secretion and metabolism in male senescence. J. Clin. Endocrinol. Metab. 34: 730-735.

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Weinstein, M. C., and Fineberg, H. V. (1990). Structuring clinical decisions under uncertainty. In Weinstein, M. C., and Fineberg, H. V. (eds.), Clinical Decision Analysis, W. B. Saunders, Philadelphia, pp. 61-62. Werner, A. A. (1939). Male climacteric. J. Am. Med. Assoc. 112: 1441-1443.

Archives of Sexual Behavior, Vol. 26, No. 5, 1997

Hypersexual Desire in Males: An Operational Definition and Clinical Implications for Males with Paraphilias and Paraphilia-Related Disorders Martin P. Kafka, M.D.1,2

The longitudinal history and temporal stability of total sexual outlet (TSO) in a group of outpatient males with paraphilias (PA) and paraphilia-related disorders (PRD) was assessed. Based on extant normative data from contemporary population-based surveys of sexual behavior, it was hypothesized that a persistent TSO of 7 or more orgasms/week for a minimum duration of 6 months be considered as the lower boundary for hypersexual desire in males. In almost all statistical analyses, the PA (n = 65) and PRD (n = 35) groups were not statistically different. The mean current TSO (PA, 7.4 ± 5.7; PRD, 8.0 + 4.2) as well as the current average time consumed in all unconventional sexual behaviors (1-2 hr/day) were not statistically different. Unconventional sexual behaviors (i.e., related to PAs or PRDs) leading to orgasm constituted 77% of current TSO. In the combined group (n = 100), 72% (n = 72) reported a hypersexual TSO of 7 or greater. Age of onset of hypersexual TSO in the PAs (19.2 ± 6.8 years; range 10-43) and the PRDs (21.0 ± 8.6; range 10-46) and the duration of hypersexual TSO (PA, 11.1 ± 11.2 years; PRD, 10.5 ± 9.1) were not significantly different. Fifty-seven males (57%) reported a TSO of 7 or more for a minimum duration of 5 years. Clinical implications of reconceptualizing PAs and PRD as sexual desire disorders are discussed. KEY WORDS: paraphilia; paraphilia-related disorder, hypersexuality; total sexual outlet; psychosexual disorder.

Presented by poster at the International Academy of Sex Research, Provincetown, Massachusetts, September 20-24, 1995; and at a symposium of the Association for the Treatment of Sexual Abusers (ATSA), October 12-15, 1995, in New Orleans, Louisiana. 1Harvard Medical School, Boston, Massachusetts. 2To whom all correspondence should be sent at McLean Hospital, 115 Mill Street, Belmont, Massachusetts 02178.

505 0004-0002/97/1000-0505JlZ50/0 C 1997 Plenum Publishing Corporation

506

Kafka

INTRODUCTION Although the clinical constructs for some increased human appetitive behaviors and psychiatric disorders characterized by these appetitive dysregulations (e.g., eating, sleep, and psychoactive substance-use disorders) are well established in psychiatric nosology, there has been very little empirical data to describe or operationalize a clinical construct for increased appetitive sexual behavior. The term "hypersexuality" has been utilized to describe acute changes in sexual behavior usually induced by an organic agent, for example, in illness (Blumer, 1970; Huws et al., 1991; Jensen, 1989; Van Reeth et al., 1958), brain injury (Epstein, 1973; Miller et al., 1986; Monga et al., 1986; Zencius et al., 1990), or a medication effect (Boffum et al., 1988; Uitti et al., 1989; Vogel and Schiffter, 1983). Hypersexuality has also been a clinical descriptor for sexual impulsivity disorders (SIDs), the paraphilias (PAs) and paraphilia-related disorders (PRDs) (Brotherton, 1974; Cooper, 1981; Davies, 1974; Kaplan, 1995; Orford, 1978). In men with SIDs, however, there are almost no data to characterize the prevalence of an appetitive dimension of sexual impulsivity disorders and, if present, whether hypersexuality represents an acute, episodic, or chronic condition. Paraphilias are socially deviant, repetitive, highly arousing sexual fantasies, urges, and activities enduring at least 6 months and accompanied by clinically significant distress or social impairment (American Psychiatric Association [APA], 1994). The most common paraphilias described in the DSM-IV include exhibitionism, pedophilia, voyeurism, fetishism, transvestic-fetishism, sexual sadism, sexual masochism, and frotteurism. Paraphilias are predominantly male sexuality disorders with an estimated sex differences ratio of 20:1. Kafka (1994a; Kafka and Prentky, 1992a; 1992b) operationally defined PRDs as intensely sexually arousing fantasies, urges, and sexual activities that are culturally sanctioned aspects of normative sexual arousal and behavior. These activities, however, increase in frequency or intensity (for at least 6 months duration) so as to produce significant distress or social impairment, including interference with the capacity for reciprocal affectionate activity. This definition was intended to suggest that the major distinction between paraphilias and paraphilia-related disorders is the cultural boundary distinguishing "normal" from "deviant" social preference behavior (Kafka, 1994a; Marmor, 1971). Commonly reported PRDs include compulsive masturbation (Carnes, 1989; Earle and Crow, 1989; Krafft-Ebbing, 1886/1965; Marmor, 1971), protracted promiscuity (APA, 1987, p. 296; Hirshfeld, 1948; Krafft-Ebbing, 1886/1965; Money, 1986), dependence on pornography (Carnes, 1989; Earle and Crow, 1989; Reinisch, 1990), phone sex dependence (Carnes, 1989; Earle and Crow, 1989- Kafka, 1991; Kafka and Prentky,

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1992a), dependence on sexual accessories such as drugs (Boffum et al., 1988) (e.g., amyl nitrate, cocaine) or foreign objects (e.g., dildoes) (Agnew, 1986), and severe sexual desire incompatibility (Friedman, 1977; Hirshfeld, 1948; Kafka and Prentky, 1992a; Krafft-Ebbing, 1886/1965). An operational definition for male hypersexualiry should include dimensional criteria distinguishing the frequency of specific sexual behaviors as well as the time consumed by those behaviors in comparison to a "normal" male sample. Kinsey et al. (1948) reported that in a large sample of males (N = 5300), the total sexual outlet (TSO) could be represented by a continuous frequency distribution curve skewed to the right (the high frequency end of the curve). Kinsey et al. defined TSO as the total number of orgasms achieved by any combination of sexual outlets (e.g., masturbation, sexual intercourse, oral sex) during a designated week. In such a skewed distribution curve, the median best described the "average" individual. Kinsey et al. reported that the median TSO/week of males ages adolescence-30 was 2.14, whereas in the total population, ages adolescence-85, the median TSO was 1.99. Unfortunately, most recent population-weighted sample surveys of sexual behavior have neglected the TSO concept and have focused on the incidence, prevalence, and frequency of specific sexual behaviors primarily believed to be vectors for the transmission of sexually transmitted diseases, especially the human immunodeficiency virus. In these surveys, sexual intercourse, the most common human sexual behavior, often occurs one-three times per week and declines with age and duration of marital status (Bachrach and Horn, 1987; Billy et al., 1993; Hunt 1974; Laumann et al., 1994; Leigh et al., 1993; Seidman and Reider, 1995). It is noteworthy that these surveys have generally neglected to quantify the frequency/week of masturbation, the total sexual outlet, and the total tune spent in all sexual behaviors. Regarding the high frequency end of the distribution curve, Janus and Janus (1993, p. 25) reported that 15% of men between ages 18 and 50 (n = 1,860) reported daily sexual activity (i.e., TSO of 7 or more) and 7.5% of men ages 18-50 (n = 887; p. 31) reported daily masturbation. Other contemporary investigators, however, have reported that a substantially smaller proportion of the male population report a TSO of at least 7/week. Kinsey et al. (1948, p. 197) reported that 7.6% of American males (adolescence-age 30) had a mean TSO of 7 or more for at least 5 years. In that subsample of males, masturbation was the primary sexual outlet. Atwood and Gagnon (1987) reported that 5% of high school and 3% of college age white males (n = 1,077) masturbated on a daily basis, i.e., had a TSO of at least 7 per week. Laumann et al. (1994), in the most recent sexuality survey of American males and females, reported that only 33.6% of the male population (n = 1320; ages 18-59) reported masturbation

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once/week, 14.5% masturbated 2-6 times/week, 1.9% masturbated daily, and an additional 1.2% masturbated more than once/day during the past year (S. Michaels, personal communication, October 18, 1995). This study was designed to examine the temporal stability and longitudinal history of total sexual outlet in a group of outpatient males presenting to this clinician for evaluation/treatment of paraphilias and paraphilia-related disorders. SIDS refers to the combined total of PAs and PRDs. Hypersexual TSO refers to the maximum sustained average TSO for a defined minimum period of 26 weeks (6 months) after the age of 15 years. The duration of months was selected to conform to the duration criterion for paraphilias in DSM-III, DSM-III-R, and DSM-IV (APA, 1980, 1987, 1994, respectively) as well as the duration criterion suggested for paraphilia-related disorders (Kafka, 1994a; Kafka and Prentky, 1992a, 1992b). In this report, hypersexual desire refers to males who reported a hypersexual TSO of >7. The following questions are addressed in this report, (i) Do men with PAs and PRDs self-report extended periods of persistent TSO of at least seven or more sexual behaviors leading to orgasm per week? (ii) Do PA and PRD groups differ in the prevalence or frequency of high frequency sexual behavior? (iii) Do sex offender paraphiliacs differ in their lifetime pattern of TSO in comparison with nonoffender paraphiliacs or men with PRDs? (iv) Can an operational definition for hypersexual desire in men be described utilizing the dimensions of weekly TSO as well as mean duration of a maximum average TSO?

METHODS Demographic Data The subjects were 100 consecutively evaluated outpatient males seeking treatment with this investigator for paraphilias (n = 65) or paraphiliarelated disorders (n = 35). Data were obtained during three initial evaluation visits utilizing an Intake Questionnaire and Sexual Inventories previously reported (Kafka, 1991,1994a; Kafka and Prentky, 1992a, 1992b, 1994). All demographic and sexual data were individually reviewed with the study subjects to determine PA/PRD status. Study subjects were obtained through advertisement, or self-, therapist-, or forensic referral. Men included in this investigation had to report repetitive PA or PRD behaviors in the 6 months preceding the evaluation.

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Sexual Diagnoses Paraphilias were diagnosed utilizing DSM-III-R criteria. Rape of an adult, however, was diagnosed as a parapbiiia based on the reported presence of that behavior regardless of its persistence. Paraphilia-related disorders were diagnosed using Kafka's criteria (Kafka, 1991,1994; Kafka and Prentky, 1992a). Although men with PAs could report lifetime PRDs, men with PRDs could not report any lifetime PAs to be included in the PRO group. This was done to insure that PA men were "socially deviant" with regard to sexual preference when compared to "nonparaphilic" PRD subjects. All males were rated on the Kinsey 7-point scale for sexual orientation (Kinsey et al., 1948) to determine heterosexual (Kinsey scores 0, 1), bisexual (Kinsey scores 2, 3, 4), or homosexual orientation (Kinsey scores 5,6). Exclusionary Criteria

Men receiving any psychotropic medications or reporting medical or neurological conditions that could affect current sexual behavior or self-report were excluded, as were those men whose sexual behavior occurred only during periods of general psychoactive substance abuse. None of the PA/PRD males were involved in concurrent behavioral therapies that would have artificially increased TSO, e.g., masturbatory satiation therapy (Marshall, 1979), during the baseline week or prior 6 months. Measurement of Current Sexual Behavior

The Sexual Outlet Inventory (SOI; Kafka, 1991, 1994a; Kafka and Prentky, 1992a, 1992b, 1994) is a clinician-administered rating scale that documents the incidence and frequency of sexual fantasies, urges, and activities of sexually impulsive males and females during a current or baseline week. In the SOI, sexual behaviors are divided into two broad subcategories, conventional and unconventional. Conventional sexual behaviors are intended to reflect the culturally normative concept of nonparaphilic "reciprocal affectionate sexual activity" (APA, 1980, 1987). Conventional sexual behavior does not require the presence of a stable affiliation, but merely that the intent of a sexual behavior contained a mutually consenting, relational context. Unconventional sexual behaviors generally corresponded to PA and PRD activities, including the primary use of PA/PRD fantasy dur-

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ing sexual activities, either alone or with a partner, All study participants defined their own sexual behaviors according to the dimensional guidelines proposed by the aforementioned definitions. In this study data derived from the SOI were used to code the following variables during the course of a specific baseline week: (i) the ISO of both conventional and unconventional sexual behaviors, (ii) a measure of the average period of time per day/week spent in all unconventional sexual activities, e.g., fantasies, urges, and genital activities. Sexual fantasy was defined as thoughts or visual imagery with sexual content or intention. For example, time spent fantasizing about an ongoing or wished for sexual/romantic relationship was rated as conventional sexual fantasy while time spent in fantasizing about problematic exhibitionism or promiscuity was rated as unconventional sexual fantasy. Sexual urge corresponded to an action with sexual intention but without genital activity because of selfcontrol or situational constraints. For example, unsuccessful pursuit of a partner for sexual activity could be either a conventional urge (e.g., the objective involved a romantic alliance) or an unconventional urge (e.g., a repetitive pattern of seeking a prostitute for a promiscuous liaison, cruising for an opportunity for exhibitionism). Sexual activity was defined as direct genital stimulation including but not limited to orgasm. Sexual activity was subdivided into two categories: masturbation utilizing internally generated fantasy, and "other" sexual activities. The distinction between internally and externally generated sexual imagery derives from my clinical experience with the treatment of these disorders as well as research that supports this distinction (Everitt and Bancroft, 1991; Jones and Barlow, 1990). Masturbation with conventional internally generated fantasy could include sexual fantasies of past, current, or anticipated partners, whereas unconventional masturbation involved the primary use of internally generated PA/PRD-related fantasies during masturbation. The "other" conventional sexual activities category included sexual intercourse, oral sex, anal sex, or mutual masturbation in a reciprocal sexual relationship as representative outlets. Masturbation with an externally assisted fantasy or activity (e.g., phone sex, pornography), mutual masturbation, oral sex, anal sex, or sexual intercourse as part of a PA/PRD ritual were exemplary "other" unconventional sexual behaviors. For example, sexual masochism, a PA accompanied by bondage, spanking, or humiliation, was self-rated as an unconventional sexual behavior, whereas masturbation accompanied by these masochistic fantasies but without the explicit behavioral enactment of the fantasy was rated as unconventional masturbation. The average time per day spent in current unconventional sexual fantasies, urges, and activities was measured in intervals designated in minutes

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as 0-1, 1-5, 5-15, 15-30, 30-60, 60-120, 120-240, 240-480, and 480-960

min. Determination of Temporal Patterns of Total Sexual Outlet Several questions in the Sexual Inventories specifically inquired about temporal patterns of TSO. In the 6 months immediately preceding the diagnostic evaluation, the maximum TSO/day and the average TSO/week and per month were determined. The maximum TSO/day in the past 6 months was assessed on a scale from 0 to >4, which was rated as 5. The lifetime maximum TSO/week and TSO/month since the age of 15 was determined using a scale of overlapping ranges: 0-5, 5-10, 10-15, etc. The lifetime highest TSO/week scale was scored up to 25-30 and >30. For statistical purposes, men were scored by the midpoint in their range scale. Those men reporting a week with more than 30 orgasms were rated as 32.5, considered the midpoint of the last defined range. The lifetime maximum TSO/month scale also utilized overlapping ranges but these went from 0-5 to 40-45. Any subject rating >45 was rated as 47.5. Determination of a "hypersexual TSO," i.e., the highest TSO that lasted at least 26 consecutive weeks after the age of 15 years, was made on a scale ranging from 0 to >7. The uppermost scores of the scales maximum TSO/day in the past 6 months, lifetime (since age 15) maximum TSO/week, lifetime maximum TSO/month, and hypersexual TSO lasting 26 weeks were truncated to improve self-report accuracy since it seemed reasonable to infer that subjects would be less accurate at recalling the specific number of orgasms at their highest extremes. A TSO of >7 was not necessarily the equivalent of daily sex leading to orgasm.

Statistics Means are accompanied by standard deviations. Categorical variables were examined by the chi-square statistic. Continuous variables were compared utilizing unpaired, two-tailed Student t tests and analysis of variance (ANOVA). The Scheffe F test for multiple comparisons was utilized to distinguish significant differences between subgroups in ANOVA. Pearson correlation coefficients are included when indicated. Alpha values of <.05 were considered statistically significant.

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RESULTS Demographics The demographic characteristics of the PA and PRD groups are summarized in Table I. The modal male in both groups was a married 36-year-

Table I. Demographic Variables of 100 Males with Paraphilias (PA) and/or Paraphilia-Related Disorders (PRD) Demographic variable Age (x years ± SD) Income (x $1000)

PA group (n = 65)

36.4 ± 10.2 51.3 ± 59.6 n

PRD group (n = 35)

%

37.1 ± 8.9 56.6 ± 55.4 n

%

25 40

38.4 61.5

1 28

20.0 80.0

23

35.3 58.4

17 13 2 3

48.5 37.1

74.2

Education (years)

<,12

13-23a Marital status'' Single Married Divorced Remarried

38 1 2

1.5 3.0

Sexual orientation Heterosexual Bisexual Homosexual

52 9

80.0 13.8

26

3

8.5

4

6.1

6

17.1

Religion Catholic Protestant Jewish Other

40 16 3 5

62.5 25.0

17 9 5 2

51.5 27.2 15.1

Ethnic group White Black Other

62 1 2

95.3

34 0 1

97.1

1.5 3.0

Ascertainment Advertisement Self Forensicc Therapist

7 14 34 10

10.7 21.5 52.3 15.3

8 17 1 9

22.8 48.5

4.6 7.8

5.7

8.5

6.0

0.0

2.8

2.8 25.7

V(l) = 3.56, p = 0.05. X (1) = 1-64, P = 0.19, comparing the ever-married group of PA vs. PRD. CX2(3) = 24.75, p 2 0.0001.

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old white heterosexual, Catholic, and was earning $40,000-60,000 American during the most recent year. The modal PA was a married high school graduate referred by a forensic source while the modal PRD was single, self-referred male with more than a high school education. Prevalence of Paraphilias and Paraphilia-Reiated Disorders The lifetime prevalence of paraphilias and paraphilia-reiated disorders (Table II) indicate that the most commonly reported sexual disorders in both groups were PRDs, especially compulsive masturbation (67/100; 67%), protracted promiscuity (56/100; 56%), and pornography dependence (54/100; 54%). In the PA sample, 86.1% (56/65) had at least 1 lifetime PRD. Protracted promiscuity was the only PRD reported more frequently by the PRD group x2(l) = 12.58, p = 0.0004. The most prevalent paraphilias were exhibitionism (23/65; 35.3%), voyeurism (17/65; 26.5%), and pedophilia (16/65; 24.6%). Men with PAs reported 1.8 ± 1.0 lifetime paraphilias and 1.9 ± 1.2 PRDs. Men with only PRDs reported 2.6 ± 1.0 lifetime PRDs. The combined sample reported 3.3 ± 1.6 total sexual impulse disorders (SIDS = PAs + PRDs). The PA group (x = 3.7 ± 1.8) reported significantly more lifetime SIDS than the PRD group, t(98) = 3.0, p = 0.002, but the PRD group reported more PRDs compared to the PA sample, t(98) = 3.0, p = 0.002. Recent Sexual Behavior During the 6 months preceding the evaluation, both the PA and PRD groups reported a modal maximum frequency of 2 orgasms in any single day with 72.4% of the combined sample reporting at least 1 day with 2 or more orgasms and 13.8% (9/65) PAs and 8.5% (6/35) of the PRD group reporting a maximum frequency of more than 4 orgasms in any single day. The PA and PRD groups did not differ in the mean TSO/week (PAs, 7.0 ± 5.0; PRDs, 8.2 ± 5.0), t(98) = -1.0, p = 0.27, or median TSO/week (PA and PRD = 7) during the 6 months prior to the evaluation. In addition, there was a robust correlation between the mean weekly and monthly TSO during the 6-month period that preceded evaluation (PA, r = .98; PRD, r = .99). In the 6 months preceding the evaluation, 54 men (54%) reported an average TSO of 7 or more. Data from the Sexual Outlet Inventory measured sexual behavior during a current week. In comparing the PA and PRD groups, the mean current TSO (PA, 7.4 ± 5.7; range 0-28: PRD, 8.0 ± 4.2; range 0-19), t(98) = -0.53, p = 0.59, as well as the mean frequencies of weekly masturbation

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Kafka Table II. Lifetime Prevalence of Paraphilias (PA) and Paraphilia-Related Disorders (PRD) in 100 Males PA group (n = 65) Disorder

Paraphilia Exhibitionism Voyeurism Pedophilia, any Nonincestuous Incestuous Transvestism Masochism Sadism Telephone scatologia Fetishism Frotteurism Paraphilia NOS Rape Autogynephilia Coprophilia Troilism Zoophilia Necrophilia Paraphilia-related disorder Masturbation Promiscuity, anyb Heterosexual Homosexual Pornography Phone sex Incompatibility Accessories

PRD group (n = 35)

Total (N = 100)

n

%

n

%

n

%

23 17 16 9 7 13 13 9 8 7 2 12 5 2 2 2 1 1

35.3 26.5 24.6 13.8 10.7 20.0 20.0 13.8 12.5 10.7

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

23 17 16 9 7 13 13 9 8 7 2 12 5 2 2 2 1 1

23.0 17.0 16.0

41 28a 22

63.0 43.0 33.8 13.8 46.1 20.0

26 28a 19 10 24 9 4 3

74.2 80.0 54.2 28.5 68.5 25.7 11.4

67 56 41 19 54 22 10 9

67 56 41 19 54 22 10 9

9 30 13 6 6

3.0 18.4

7.6 3.0 3.0 3.0 1.5 1.5

9.2 9.2

8.5

9.0 7.0 13.0 13.0

9.0 8.0 7.0 2.0 12.0

5.0 2.0 2.0 2.0 1.0 1.0

a3 PAs and 1 PRD reported both hetero- and homosexual promiscuity. Y(l) = 12-58, p 0.0004.

utilizing unconventional fantasy (PA, 3.0 ± 3.6; PRD, 3.0 ± 3.4), masturbation utilizing conventional fantasy (PA, .67 ± 1.4; PRD, .31 ± .71), other unconventional sexual activities (PA, 2.7 ± 4.0; PRD, 3.0 ± 3.0), and other conventional sexual activities (PA, 1.0 ± 1.4; PRD, 1.6 ± 2.4) as well as the modal time/day spent in all unconventional sexual behaviors (60-120 min) were not statistically different. Partnered heterosexual intercourse was, by far, the predominant reported sexual behavior in the "other conventional" sexual activities category while masturbation with an external stimulus (e.g., phone sex, pornography, while exposing, peeping) was the predominant

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"other unconventional" sexual outlet. Unconventional sexual behaviors leading to orgasm constituted 77% of the current TSO in the total sample. When the groups were divided by referral source, there were no differences in current weekly TSO, F(3) = 2.2, p = 0.30, unconventional masturbation, F(3, 96) = 0.012, p = 0.99, conventional masturbation, F(3, 96) = 1.9, p = 0.12, other unconventional sexual activities, F(3, 96) = 2.3, p = 0.07, other conventional sexual activities, F(3, 96) = 1.4, p = 0.24, or average time/day spent in total unconventional sexual activities, F(3, 96) = 2.22, p = 0.08. The correlation coefficient comparing average TSO in the past 6 months and current week TSO as determined by the SOI was 0.66. Lifetime Measures of Total Sexual Outlet When examining the highest TSO/week reported since the age of 15 years, there were no differences between the PRDs (jc = 16.9 ± 8.8) in comparison with the PA group (x = 14.3 ± 8.7), t(9S) = 1.4, p = 0.16. In addition, the modal maximum TSO/month in both groups was the maximum indicated (>45, rated as 47.5). The frequency distribution of the maximum monthly TSO after age 15 reported by the total sample was as follows: 12 men reported a maximum TSO/month of 32.5 (i.e., 7/week), 16 men reported 37.5 (8/week), 9 reported a TSO/month of 42.5 (9/week), and 38 men 35.3% (23/65) of PAs and 42.8% (15/35) of PRDs, reported a TSO/month of 47.5 (>10/week). In the combined sample, 75% (75/100) of the men reported 1 month (i.e., 4 weeks), with an average TSO of 7 or more/week and 38% (38/100) reported a TSO of at least 10/month after the age of 15. Hypersexual TSO: Onset and Duration The frequency distribution of hypersexual TSO is reported in Table III. The modal hypersexual TSO for both groups was 7 or more. In the combined group, 86% of the men reported a cumulative prevalence of hypersexual TSO of 5 or more for at least 26 weeks duration, 78% of men reported a hypersexual TSO of 6 or greater and 72% reported a hypersexual TSO of 7 or greater. The age of onset of hypersexual TSOs in the PAs (19.2 ± 6.8 years; Mdn = 17; range = 10-43) and the PRDs (21.6 ± 9.3; Mdn = 19; range = 10-46) and the duration of hypersexual TSO (PA, 11.2 ± 11.1 years, Mdn = 9; PRO, 10.6 ± 9.,; Mdn = 10 years) were not statistically different. Fifty-seven males (57%) reported a TSO of 7 or more for a minimum duration of 5 years.

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Kafka Table III. Hypersexual Lifetime TSO of At Least Six Months Duration in Males with Paraphilias (PA) and Paraphilia-Rdated Disorders (PRD) No. hypersexual TSO

2 3 4 5 6 7 or more

PA group (« = 65)

PRD grouo (n = 35)

n

%

n

%

1 3 7 6 3

1.5 4.6 10.7

2.8 5.7 0.0 5.7 8.5

45

69.2

1 2 0 2 3 27

9.2 4.6

77.1

ANOVA was utilized to examine whether there was a statistical relationship between the lifetime total SIDs and parameters of hypersexuality, including maximum TSO in a single week and month since age 15, hypersexual TSO, and age of onset and duration of hypersexual TSO. To further delineate any differences between the groups for these variables, the lifetime total SIDS category was divided into three subcategories: low, 1-2 lifetime SIDs, n = 33, PA = 17 (26.1%), PRD = 16 (45%); medium, 3-4 lifetime SIDs, n = 43, PA = 26 (40%), PRD = 17 (48%); and high, 5-8 lifetime SIDs, n = 24, PA = 22 (33.8%), PRD = 2 (5.7%). The high group was predominantly paraphiliacs and the predominant subgroup were forensically referred paraphiliacs (10/24; 41.6%). These subcategories were not statistically different in mean current age, F(2, 97) = 0.98, p = 0.37, or referral source, %2(6) = 5.67, p = 0.46. ANOVA comparing lifetime SIDs with maximum TSO in a single week revealed no statistical difference between the groups, F(2,97) = 1.08, p = 0.34. ANOVA comparing lifetime total SIDs and maximum TSO/month revealed a statistical difference between the low vs. the high group, F(2, 97) = 3.28, p = 0.04; Scheffe F = 3.12, p < 0.05. In addition, there was a statistically significant difference between the groups in mean hypersexual TSO, F(2,97) = 7.55, p = 0.0009, with the low group reporting a lower mean hypersexual TSO (5.6 + 1.7) in comparison with both the medium group, 6.3 ± 1.0 (Scheffe F = 3.39, p = <: 0.05, and the high group, 6.9 ± 0.4 (Scheffe" F = 7.18; p < 0.05). Although ANOVA comparing the mean age of onset, F(2, 97) = 1.97, p = 0.14, and the mean duration, F(2, 97) = 1.68, p = 0.19, of hypersexual TSO did not distinguish the subgroups, the subgroups did report stair-step differences in age of onset (low SIDS group, 21.6 ± 8.7 years; medium SIDS group, 20.3 + 7.7; high SIDS group, 17.5 ± 6.2) and mean duration

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(low, 8.5 ± 9.8 years; medium, 11.5 ± 10.1; high, 13.5 ± 11.2) in the expected direction. Additional analysis of variance was applied to distinguish whether referral source, especially forensically referred sex offender paraphiliacs, differed from the other groups in measures of hypersexuality, including maximum TSO/week, F(3, 96) = 2.2, p = 0.09, hypersexual TSO, F(3, 96) = 1.72, p = 0.16, hypersexual TSO onset, F(3, 96) = 3.24, p = 0.02, and duration, F(3, 96) = 0.93, p = 0.42. The statistical differences found between the groups reflected that the therapist-referred group reporting an earlier age of onset in comparison to the self-referred group (Scheffe F 2.73, p < 0.05). Thus, sex offender paraphiliacs (forensic referrals) per se did not report an earlier onset of hypersexual desire compared to other paraphiliacs. DISCUSSION In this sample of 100 consecutively evaluated nonmedicated white male outpatients with paraphilias and paraphilia-related disorders, the most common SIDs were paraphilia-related disorders, especially compulsive masturbation, protracted promiscuity, and dependence on pornography. As reported by other investigators, PRDs occur either accompanied by PAs (Breitner, 1973; Longo and Groth, 1983; Prentky et al., 1989) or as distinct nondeviant sexual impulsivity disorders. Inasmuch as it is common for males to report multiple paraphilias over their lifetime (Abel et al., 1988; Bradford et al., 1992), from these data the same conclusion can be applied to males with paraphilia-related disorders who seek treatment. Men with PRDs were not statistically different from paraphilic males in both current and past indices of the frequency and duration of sexual behavior as determined by TSO and time consumed by those behaviors. Either during the prior 6 months, continuously over the course of their postadolescent lifetime, or during some previous time after age 15, it was common for these men to engage in sexual behavior for at least 6 months duration leading to orgasm at least 7 times per week. It is clinically noteworthy that in males with this proposed operational definition for hypersexual desire, approximately one fifth (18%) are not currently reporting that TSO (during the 6 months preceding the current evaluation) equivalent to their prior hypersexual average. In addition, although population sample studies have suggested that heterosexual intercourse is the preeminent adult sexual outlet across cultures (Ford and Beach, 1951; Seidman and Reider, 1994), in these predominantly married men with PAs and PRDs, masturbation was the predominant sexual outlet behavior. Kinsey

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et al. (1948) also reported that men with the highest consistent TSO utilized masturbation as their primary sexual outlet. Although men with PAs and PRDs were currently engaging in sexual intercourse approximately once/week, conventional sexual outlets represented only 23% of current TSO in this study sample. Since the age of 15, 86% of the males with PAs and PRDs reported a mean sustained TSO of at least 5 and 72% reported a minimum sustained TSO/week of >7 for a minimum duration of 26 consecutive weeks. The modal male reported an average minimal TSO/week of 10 for at least 1 month and only 25% of the sample reported a lifetime maximum TSO/month of less than 30. The mean age of onset of hypersexual TSO in this sample of sexually impulsive males began in late adolescence (x age 19) and was continuous for an average of over a decade, a pattern correlated with the increased incidence of paraphilic arousal and sex offending in males reported during those decades as well (Abel and Rouleau, 1990). Men with only one or two lifetime SIDS were statistically less likely to report a hypersexual TSO of 7 or more whereas men with 5 or more lifetime SIDs almost always reported a hypersexual TSO of at least 7. Although the findings did not reach statistical significance, men who reported more lifetime sexual impulsivity disorders, predominantly paraphiliacs, were more likely to report an earlier age of onset and longer duration of TSO >7 especially in comparison with men who reported only 1-2 lifetime SIDs. While it could be argued that there is insufficient normative data from cross-sectional population samples to distinguish between population norms for the frequency of male sexual behaviors and the parameters that would define hypersexuality, data presented in the Introduction can be utilized to suggest a boundary for these distinctions. If the most commonly observed range of TSO/week in the male population is 1-3 (Bachrach and Horn, 1987; Billy et al., 1993; Hunt, 1974; Kinsey et al., 1948; Laumann et al., 1994; Leigh et al., 1993; Seidman and Reider, 1995), then this study sample of men currently report a TSO that is two or three times greater than a contemporary representative cross-sectional sample population. At a mean age of 36 years, predominantly married males from this sample are, on the average, currently masturbating more times per week than single males age puberty-20 years (Gebhard and Johnson, 1979; Laumann et al., 1994). Although only 7.6% of Kinsey et al.'s (1948) male sample reported a TSO of 7 or more during a 5-years period in their lifetime, 57% of subjects with SIDs in this sample reported a comparable TSO of at least 5-year duration. In other studies, increased sex drive is correlated with aspects of sexual aggression in college students (Malamuth et al., 1991) as well as in sex offenders (Malamuth et al., 1995). In sex offenders, high sex drive ascertained as TSO is robustly associated with the total number of paraphilias,

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use of pornography, expressed aggression, and sadism (personal communication, R. Knight, October 13, 1995) as ascertained by a structured inventory assessment (Knight et al., 1994). These findings appear to complement the data presented from this sample as well. While I could not find any comparable normative data, it is noteworthy that these middle-aged men with SIDs report currently spending 1-2 hours/day in sexual fantasies, urges, and sexual outlet behaviors related exclusively to their unconventional sexual proclivities. This is consistent with previous studies reporting a positive correlation between the frequency of sexual fantasizing, masturbation, sexual intercourse, number of lifetime sexual partners, and self-rated sex drive (Giambra and Martin, 1977; Laumann et al.., 1994; Wilson and Lang, 1981). Operationally defined male hypersexual desire in clinical practice has both clinical and theoretical applications. First, although persistently amplified sexual desire and associated behaviors are not inherently pathological (Kaplan, 1995), temporally stable patterns of heightened sexual appetitive behavior could predispose to clinical conditions accompanied by volitional impairment. Analogous examples of appetitive psychopathology include eating disorders, sleep disorders, and psychoactive substance-abuse disorders. For example, all males imbibing six or more alcoholic beverages daily for an extended period of time may not develop a psychoactive substance-use disorder; it would be expected, however, that males in that subset are at much greater risk to develop such syndromes in comparison with others who consistently drink less alcohol. Second, the persistence of an elevated and sustained TSO accompanied by highly arousing sexual fantasies over the course of a decade or more may help to explain why terms such as "sexual addiction" (Games, 1983,1989), "sexual compulsivity" (Coleman, 1986,1987; Quadland, 1985), and "sexual impulsivity" (APA, 1994; Barth and Kinder, 1987) are utilized as clinical descriptors for PAs and PRDs. Male hypersexuality, as operationally defined here, is proposed as an alternative nosological construct to the former, clinical descriptors that had been criticized because they have not been empirically validated (Wise and Schmidt, 1996). Hypersexual desire, rather than emphasizing the nature of volitional impairment that accompanies PAs and PRDs, is a categorical term to describe men with a persistent high frequency of sexual outlet. In a subset of these men hypersexual desire apparently either accompanies or predisposes to a spectrum of clinically significant disorders that include time consuming, highly arousing sexual fantasies, urges, and activities with volitional impairment, distress, or significant role dysfunction. By suggesting that PAs and PRDs are sexual desire disorders, one can look at the opposite end of the continuous frequency distribution curve

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of sexual behavior to the clinical parameters for hypoactive sexual desire disorder. The latter, a commonly reported psychosexual dysfunction, has been criticized in part because it lacks more precise parameters based on normative TSO data for sexual intercourse (Schiavi, 1996). Several prominent sex researchers have suggested an operationally defined dimension to the latter disorder as characterized by sexual intercourse less than once every 2 weeks before age 55 (Schiavi et al., 1988; Schover and LoPiccolo, 1982; Schreiner-Engel and Schiavi, 1986) accompanied by other features of low sexual desire, including a paucity of spontaneous sexual fantasies and urges. Thus, while not inherently pathologizing all males and females with either low or high frequency of sexual outlet, frequency-based operational criteria derived from available large-scale surveys in comparison with clinical samples can serve as objective guideposts for clinical inquiry and diagnosis. Third, operational criteria for male hypersexuality could serve as dimensional criteria of PAs and PRDs, such that social convention vs. social deviancy is a less necessary determinant for sexual psychopathology. The distinction of normal from deviant sexual arousal and behavior is embedded in cultural and historical context and is a permeable dimension (Kafka, 1994a; Marmor, 1971). Masturbation, for example, while currently considered a concomitant of sexual health and psychological adjustment, was socially deviant in American culture less than 80 years ago (Hare, 1962). Hypersexual desire disorders can include any repetitive sexual behaviors that are accompanied by volitional impairment and/or adverse psychosocial consequences. The persistence of increased sexual appetite and associated arousal is a dimension that is distinct from, but apparently may be related to, altered sexual preference and sexual preoccupation. Fourth, increased sex appetite may be associated with other forms of comorbid psychopathology, e.g., a depressive diathesis (Kafka and Prentky, 1994; Mathew et al., 1979; Mathew and Weinman, 1982; Nofzinger et al., 1993), or other forms of impulsivity and aggression (Malamuth et al., 1991, 1995). In the latter case, Kinsey et al. (1948) reported that nearly half of those in the occupational class "underworld" reported a persistent TSO/week of 7 or more. In the former case, depressive disorders, especially major depression and dysthymia, may be prevalent in persons with either diminished (Lieblum and Rosen, 1991; Schreiner-Engel, 1989; Schreiner-Engel and Schiavi, 1986) or increased sexual appetite (Kafka and Prentky, 1994; Mathew et al., 1979; Mathew and Weinman, 1982; Nofzinger et al., 1993). Last, recent clinical reports suggest the efficacy of serotonin reuptake inhibitors in mitigating PAs and PRDs in males (Bradford, 1995; Kafka, 1991,1994b; Kafka and Prentky, 1992b; Kruesi et al., 1992). There is ample mammalian research literature reporting that diminished central serotonin

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and other monoamines as well are associated with enhanced or disinhibited male sexual appetitive behavior (Baum and Starr, 1980; Blackburn et al., 1992; Everitt, 1990; Everitt and Bancroft, 1991; Gorzalka et al., 1990; Tucker and File, 1983) as well as human psychopathologic disorders that include depression, impulsivity, and disinhibited aggression. These data suggest that hypersexual desire disorders and comorbidly related forms of psychopathology in humans could be associated with perturbations of brain monoaminergic neuroregulation (Kafka, 1997). There are several methodological limitations to this study. First, a larger clinical sample would permit examination of more differentiated subgroups of men with clinical hypersexual desire disorders. Such a sample might help to clarify whether men with more lifetime SIDs (>5), could be further distinguished from men with a low (1-2) lifetime SIDs and, in particular, whether sex offender paraphiliacs are most likely to have multiple SIDs and a higher hypersexual TSO for a longer duration in comparison with nonoffender paraphiliacs and males with paraphilia-related disorders. Second, this study depended on retrospective data to define both the strength of sexual appetite as measured by TSO and its temporal stability. The veridicality of retrospective data reporting the frequency of sexual behaviors among a group of sexually impulsive men is unknown. We do know however, that these men might underreport their TSO history as part of the denial, minimization, shame, and guilt that frequently accompany these socially admonished behaviors (Anderson et al., 1979; Grossman and Cavanaugh, 1990; Rogers and Dickey, 1991). On the other hand, it is possible that some men exaggerated their sexual histories either to please the examiner or to enhance their self-esteem. Most of the men, however, reported temporally stable patterns of sexual outlet of considerable duration in a lifestyle where sexual arousal and behavior is often a central priority. In fact, the great majority of the men were still currently hypersexual by the standard of the definition suggested in this manuscript. In addition, the rating scales utilized to gather both retrospective and recent data were deliberately truncated at the higher frequencies of weekly sexual outlet so as to minimize exaggeration and to improve self-report accuracy. In fact, since the modal subject in this study reported the maximum measured values for lifetime maximum TSO/month (>45) and sustained hypersexual TSO (>7), meaningful statistical distinctions between PAs and PRDs, as well as intragroup differences among the PAs and PRDs, may have been obscured. Third, ascertainment bias may limit the conclusion that, as a group, men with SIDs are as likely to report heightened sexual arousal and concomitant behaviors in comparison with population-based norms for sexual behavior. These men, after all, have either been apprehended for sexual misconduct or are voluntarily help-seeking for ego-dystonic patterns of sex-

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ual behavior. Nonclinical samples of men with SIDs may not report elevated and persistent patterns of TSO or such samples may contain greater numbers of men with a low incidence of cumulative lifetime SIDs and/or a lower mean hypersexual TSO. Last, the determination of base rates for unusual sexual proclivities and even prevalent sexual behaviors such as masturbation is confounded by social censure and stigmatization. Recent studies, while utilizing modern survey methodologies for data collection to ascertain the incidence and prevalence of sexual behaviors and attitudes, do not sample for unconventional sexual proclivities and have not adequately delineated the spectrum of the frequency of masturbation or TSO. Masturbation, despite its near universal prevalence, remains one of the most sensitive areas of inquiry in social research surveys (Bradburn et al., 1978; Catania et al., 1986; Laumann et al., 1994) and has been particularly overlooked in recent epidemiological surveys because it is not an etiologic factor for the spread of sexually transmitted diseases. Thus, the TSO results derived from this white, predominantly middle class, married, clinical sample must be interpreted with caution when compared to population-based surveys utilizing other clinical instruments to ascertain the incidence, prevalence, and frequency of specific sexual behaviors.

ACKNOWLEDGMENTS

The author thanks Robert Prentky, Ph.D., for his critical review of the manuscript and Ann Hunt, Sc.D., for her statistical consultation.

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Archives of Sexual Behavior, Vol. 26, No. 5, 1997

Treatment Outcome of Brief Couple Therapy in Psychogenic Male Erectile Disorder Kevan R. Wylie, M.B., Ch.B., M.Med.Sc., M.R.C.Psych.1

Treatment outcome was studied in 37 couples who entered brief combined sex and relationship therapy for male erectile disorder in a specialized clinic. Treatment was completed by nearly two thirds of the couples. Significant improvements in target symptoms, questionnaire scores, including the Golombok Rust Inventory of Sexual Satisfaction, and frequency of attempts at sexual activity were recorded. Results suggest that behavioral-systems couple therapy and modified modern sex therapy offer a brief, flexible, and reproducible treatment option for men with psychogenic factors associated with erectile disorder. KEY WORDS: erectile dysfunction; impotence; sex therapy outcome; marital therapy outcome; prognostic factors.

INTRODUCTION Research into psychotherapy outcome requires diagnostic criteria to be stated, treatment process to be described, reproducible outcome criteria to be established and, where possible, attention paid to prognostic factors influencing dropout or outcome. Male erectile disorder (MED) is the most frequent problem in men presenting to sexual dysfunction clinics (Warner et al., 1987). With advances in diagnostic procedures, organic factors have been found to contribute more frequently to erectile problems than previously thought (Melman et al., 1988). This is in part determined by the agency where the patient is assessed. Buvat et al. (1990) have proposed factors within the sexual history 1Community

Health Sheffield National Health Service Trust, Porterbrook Clinic and Whiteley Wood Clinic, Woofindin Road, Sheffield S10 3TL, United Kingdom.

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suggestive of psychogenic etiology. Increasingly, cases where both psychogenie and organic factors are operative are being seen and on occasion one may exacerbate the other. Problems within the relationship, as well as the effect the partner may have on male sexual functioning, have been reviewed by Speckens et al. (1993). Behavioral marital therapy is well researched in marital conflict (e.g., Gurman, 1973; Wilson et al., 1988) and systemic marital therapy has been found helpful in similar conflict (Boelens et al., 1980). There have been attempts to integrate relationship and sexual therapy and these have often incorporated a systems interactional perspective (e.g., Verhulst and Heimen, 1979; Crowe and Ridley, 1986; Hof and Berman, 1986; Weeks and Hof, 1987; Nichols, 1988; Sanders and Tom, 1989; Woody, 1992). Leiblum and Rosen (1992) identified four major facets of a couple's relationship that are often implicated in the development or maintenance of erectile dysfunction. The role that sexual dysfunction plays in the maintenance of homeostasis in the area of emotional relationship between partners has been described by LoPiccolo (1992). In general, multimodel interventions used in clinical practice do not allow specification of the relative benefits of the various components within the treatment package. These typically include behavioral, cognitive, interpersonal, and systemic interventions (Mohr and Beutler, 1990). Although Crowe and Ridley (1990) did not state that behavioral-systems couple therapy (BSCT) could be combined with sex therapy for men suffering from MED, it is recognized that BSCT in combination with sex therapy may be advantageous in cases of sexual dysfunction in general. Nearly two thirds of couples have been reported to derive significant benefits at the end of a course of sex therapy (Bancroft and Coles, 1976; Heinman and LoPiccolo, 1983; Hawton and Catalan, 1986; Hawton et al., 1986). However, the assessment of outcome is problematic (Schover and Leiblum, 1994). Guidelines recommended by Kuriansky and Sharpe (1976) have only recently been considered in detail (e.g., careful specification of treatment technique, assessment of psychosocial as well as sexual functioning, clearly defined diagnostic and outcome criteria, and follow-up contacts). When assessing outcome of therapy, multiple outcome measures are probably more beneficial than single measures (Jacobson et al., 1984; Bancroft, 1989). Follow-up of sexual and marital therapy should not focus entirely on the presenting problems (d'Ardenne and Riley, 1993), and should take into account relationship satisfaction and general quality of life. Follow-up studies have usually suggested maintenance of gains during the first few months following sex therapy (Crowe et al., 1981; Hawton, 1982; Heinman and LoPiccolo, 1983). There has been limited review of maintenance of gains after a more prolonged period from the cessation of therapy.

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On reviewing the outcome of therapy for MED, Masters and Johnson (1970) reported only 26.3% of treated cases of secondary erectile dysfunction having treatment failure at the end of therapy; with the relapse rate 5 years later (among nonfailures) at 11.1%. Levine and Agle (1978) found 11 of 16 treated couples had a positive end-of-treatment outcome, but a year later, all but one had instability of erectile functioning. De Amicis et al. (1985) found that initial improvements in target problems by the end of therapy were not always sustained 3 years after therapy, although improved satisfaction tended to be maintained despite any deterioration in specific sexual problems. Men with erectile difficulty reported significant improvements in their ability to maintain erections during intercourse but not in their ability to achieve erections prior to intercourse. LoPiccolo et al. (1985) reported that greater gains tend to be seen in global ratings of satisfaction and psychometric measures of adjustment rather than actual symptom remission. Couples were not found to be affected by the sex of the single therapist. Hawton et al. (1986) also found good long-term outcome for erectile dysfunction, but that the improvement in the couple's general relationship resulting from treatment was more sustained despite some recurrence of some sexual difficulties. As recurrence was most commonly during the first 6 months after therapy was completed, many couples were able to overcome recurrence of symptoms by using coping strategies identified during therapy. Xueqian and Heqin (1990) reported a remission rate of 61.8% in a study of 21 couples in China, where cognitive behavioral therapy was used for MED over a mean number of sessions of 5.5. The authors noted improvement on the GRISS male score questionnaire. By identifying important prognostic factors, efficiency in clinical practice should improve with clinicians becoming more adept with couples most likely to respond to a particular type of sex therapy. Bancroft (1989) argued that couples respond to different treatments with great variability and that the variability in outcome is likely to be at least as great if not greater than the differences between a "good and bad" treatment method. Further, if more numbers are involved in controlled outcome studies it is of crucial importance to identify and control for the key prognostic variables. Mohr and Beutler (1990) have suggested that prognosis, not diagnosis, must be the deciding factor of the choice of treatment in MED. Attempts to identify prognostic variables in sex therapy for many years had been limited and confined to post hoc by-products of treatment outcome studies (Matthews et al., 1976; Whitehead and Matthews, 1977) or retrospective case notes studies (Glover, 1983). The number of adequately controlled studies of sex therapy is small and there is a lack of any convincing demonstrated superiority of one method over another with trends, when they occur, tending to be weak and not always in the same

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direction (Everade and Dekker, 1982). Basoglu et al. (1986) and Hawton and Catalan (1986) attempted to identify prognostic factors in sex therapy in a systemic manner. The prognostic importance of the general relationship had been noted in previous studies (e.g., Snyder and Berg, 1983). Hawton et al. (1992) reported positive treatment outcomes in 69.4% of couples attending for sex therapy for erectile dysfunction, with positive outcome associated with good pretreatment communication and general sexual adjustment, especially the female partner's interest in and enjoyment of sex, and also with absence of a positive psychiatric history in the female partner, and a couple's early engagement in homework assignments. LoPiccolo (1992) suggested that the best prognosis for successful psychotherapy occurs in cases manifesting clear behavioral deficits or a maladaptive thinking pattern that contributes towards lack of erection.

METHOD Recruitment of Patients Patients were referred by general practitioners, psychiatrists, and urologists who received posted information publicizing the specialist clinic offering an assessment and treatment service for male patients with erectile disorder. Initial screening criteria excluded patients under 18 and over 70 years of age, those with erectile failure on less than 50% of coital attempts or of less than 3-months duration; where organic etiology was considered to be greater than concurrent psychogenic factors; or those with major psychiatric disorder in the male or primary female partner sexual disorder; and those with couples requesting or requiring physical treatments or where the partner refused to attend therapy sessions. Inclusion of Patients The definition of MED employed was a failure to achieve or maintain an erection that would enable penile penetration or loss of erection very shortly after intromission (not due to ejaculation), i.e., fulfilling the criteria for male erectile disorder (DSM-III-R) and failure of genital response (ICD-10 FS2.2). This was subdivided according to etiology into organic, psychogenic, and combined. Criteria for psychogenic etiology included presence of morning erections, erections in other situations outside of foreplay with partner, and loss of erection immediately before or during sexual in-

Couple Therapy in Psychogenic Male Erectile Disorder

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tercourse (not due to premature ejaculation). An abrupt onset, typically over weeks, was considered suggestive of psychogenic etiology. The presence of one or more of the factors was recorded for each patient. Assessment of Patients Patients were assessed using a standardized comprehensive medical, psychiatric, and psychosexual history. This included collecting details about their current and previous relationships. A physical examination was carried out and blood sampling of glucose, testosterone, and prolactin carried out. Patients and their partners were also invited to complete a set of questionnaires. Measures Relationship satisfaction was assessed using the Golombok Rust Inventory of Marital State (GRIMS; Rust et al., 1988). Measures of sexual satisfaction were recorded using the Golombok Rust Inventory of Sexual Satisfaction (GRISS; Rust and Golombok, 1986) and the Pleasant/Unpleasant Feelings questionnaire (Carney et al., 1978). The latter includes ten 5-point scales concerning both pleasant and unpleasant feelings, currently invoked by five sexual situations, and has been used in outcome research for sex therapy (Hawton and Catalan, 1986). Target problems were identified and change their from the point of entry into therapy to the end of therapy (worse, no change, slightly better, moderately better, much better) was measured. Two target problems were described and rated by the patient on a 12-point scale. Target symptom A was "difficulty in attaining or maintaining an erection."and target symptom B was "lack of enjoyment from our sexual relationship." The emotional state of the patient was evaluated using the Hospital Anxiety and Depression scale (HAD; Zigmond & Snaith, 1983). The investigator rated his opinion of global change in the couples' sexual and general relationship upon completing therapy. Assignment to Treatment A range of treatments was offered to patients who were considered to have a psychogenic or combined etiology. Sex therapy (individual or couple), oral medications including yohimbine or an investigational drug, in-

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tracavernous injections or vacuum constriction devices were available. All patients accepting couple therapy were entered into a prospective interventional study and treatment began approximately 3 weeks after the initial assessment. During the wait period, the male completed a diary for 14 consecutive days. This recorded sexual interest, presence of erections, and attempts at sexual activity each day. A graded response set of several statements about each situation was used for each measure. The treatment package included Modified Modern Sex Therapy (MMST; Matthews et al., 1983) and Behavioral Systems Couple Therapy (BSCT; Crowe and Ridley, 1990). Written instructions were provided to guide couples through sensate focus exercises. Failure to progress in relationship therapy or noncompletion of sex therapy homework assignments by the third session resulted in systemic interventions being used from the hierarchy described by Crowe and Ridley. The maximum number of sessions provided was six. Sessions occurred fortnightly. Supervision of the work of the therapist was provided by an experienced relationship and sexual therapist accustomed to using the BSCT approach. Outcome Outcome was classified using both self-report (using target symptoms) and the investigator's opinion of change. An excellent outcome was recorded where the following three criteria were met: (i) Target symptom A (male) changed from 6 or greater pretreatment to 5 or less posttreatment. (ii) The perceived change in target symptom A (male) was 3 or greater, (iii) The investigator report recorded a global rating improvement of 3 or greater. A moderate outcome was reported if 2 of the above criteria were met. A mild outcome was recorded if either the patient or investigator reported a positive change at the end of therapy, i.e., (ii) or (iii) above was 1 or more. Outcome was therefore classified as excellent, moderate, mild, no change, or worse. For evaluation of prognostic factors, patients who scored excellent or moderate were considered to have a favorable outcome. Analysis The Mann Whitney U Test was used to test differences in continuous variable measures between those who completed couple therapy and those that dropped out of therapy or failed to start. For categorical variable measures the chi-square test with Yates correction was used except where the minimum established expected value was low, in which case the Fisher Exact Test (two-tailed) was used. In the 23 couples who completed ther-

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apy, the Wilcoxon Test was applied to detect any differences from the pretreatment to posttreatment state. Spearman rank correlation was used to monitor movement between the two measurement points. It was also used to detect correlations between outcome scores and various other measures. Logistic regression was performed using the outcome variable (favorable or not) and various explanatory factors, including those previously reported (LoPiccolo, 1992; Hawton et al., 1992) and new indicators under investigation such as questionnaire scores. The chi-square test was used. The small sample limited the number of factors considered for logistic regression analysis. RESULTS Characteristics of Couples The characteristics of the 37 couples are summarized in Table I. The age range for the men was 21-64 years and for the partners 22-59 years. The mean age difference between partner and patient was the female being 3.7 years younger than her partner. A combined diagnosis (i.e., current

Table L Demographic Characteristics of Men with MED Variable Age of onset (years) Current age (years) Age of partner (years) Duration of MED (years) Age difference between partner and patient (years) Length of relationship (years) No. of psychological factors (0-4) Serum testosterone (total level nmol/l) Observed frequencies of SEG

SD

38.7 44.3 40.6

13.9 11.9

5.6 -3.7 10.2

2.1 16.9

Consenting men

I II III

rv&v a Other

All a

X

Includes students and unemployed.

9 13 9 4 2 37

9.7 6.7 6.1 9.7 0.9 4.6

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physical disorder felt to be contributing towards the problem) was present in 5 individuals. Psychological Scores The pretreatment assessment rating scores are shown in Table II. No significant differences were found between scores on the questionnaires for couples who completed therapy and those who dropped out. An absence of any scores in the midrange of the GRIMS total scale was noted for those men in the dropout group. Treatment and Interventions The number of therapy sessions of all those couples consenting to couple therapy is shown in Table III. It can be seen that two thirds of couples required systemic interventions as well as behavioral interventions within therapy. Of the noncompleters in therapy the majority had not yet progressed to systemic interventions. Table II. Initial Rating Scale Scores Dropouts

GRIMS total score Male Female GRISS total score Male Female HAD score (male) Depression Anxiety Pleasant/unpleasant score Male pleasant Male unpleasant Female pleasant Female unpleasant Target score A Male Female Target score B Male Female

Completers

X

Range

X

Range

26.1 26.5

9-50 7-40

24.3 30.5

3-49 2-49

36.6 24.7

15-51 12-55

36.6 25.3

6-70 3-49

5.0 8.8

1-10 1-15

3.7 6.7

0-12 2-14

12.5

12.9

13.1

0-20 0-12 0-17

12.7

4-19 0-14 5-18

2.0

0-5

2.0

0-8

9 5.6

0-12 0-12

8.8 7.0

3-12 0-12

7.5 4.8

0-12

6.6 6.4

0-12 0-12

2.5

0-9

2.2

Couple Therapy in Psychogenic Male Erectile Disorder

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Table III. Number of Sessions Per Couple in Therapy Group

No. of sessions

n

1*1, 7*4 3*3, 6*4, 2*5, 4*6 3*1, 3*2, 1*3

X

Mdn

8 15

3.6 4.5

4

7 2 5

1.7 3.0

2 3

Completed therapy

B BS

4

Non-completers of therapy

B BS FTR

2*3

a

B = Behavioral interventions; BS = behavioral-systems interventions; FTR = failed to return after assessment. *In no. of sessions *separates the number of couples (first no.) from number of sessions each completed.

Pre- to Posttherapy Changes of Psychological Scores

The pretreatment and posttreatment questionnaire scores of couples completing couple therapy are shown in Table IV. Some of the subjects refused to complete all of the end-of-therapy questionnaires. The results presented show only the analysis of questionnaire scores where both a preand posttherapy measure is available. Considering relationship satisfaction, the first analysis considers conventional changes in the mean score before and after therapy, i.e., a decrease in the score is an improvement. No significant changes were seen for the GRIMS although a convergence of scores for the couple is seen on the GRIMS (Dirt) score which measures the difference between male and female scores. Where improvement in the GRIMS score is defined in an alternative way, namely, as movement towards the central region (away from the ideal or distressed range), three men moved in this direction while another three moved away from the central region. The number of patients are shown in Table V. A statistically significant decrease in the total GRISS score for men was recorded, and a decrease in the difference of the couples' GRISS scores was noted. Some of these changes may be influenced by the statistically significant reduction in the impotence subscore. This is not the only GRISS subscale to show significant change. Both partners report reductions in infrequency of sexual activity although this is statistically significant only in men. It appears that opinions diverged about infrequency of intercourse even though both partners felt it became less of a problem. Similarly, both partners report a reduction in noncommunication but only in men does this reach statistical significance. Men also reported a significant reduction in avoidance of sexual activity.

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Table IV. Changes in Psychological Scores in Couples Completing Couple Therapy

GRIMS total Male Female Couple (sum) Couple (diff) GRISS total score Male Female Couple (sum) Couple (diff) GRISS Impotence Male GRISS Premature ejaculation Male GRISS Nonsensuality Male Female GRISS Avoidance Male Female GRISS Infrequency Male Female Couple (sum) Couple (diff) GRISS Noncommunication Male Female Couple (sum) Couple (diff) GRISS Dissatisfaction Male Female Couple (sum) Couple (diff) HAD score Male Depression Male Anxiety Pleasant/unpleasant questionnaire Male pleasant Male unpleasant Female pleasant Female unpleasant

PKX

Post*

Change

Wilcoxon p

Spearman r

24.6 30.0 54.6 -5.4

27.1 29.0 55.6 -2.5

-2.5

0.13 0.72 0.61 0.14

.77 .85 .88 .5

36.0 25.7 62.1 10.8

30.1 25.1 55.1

4.9

5.9 0.6 7.0 5.9

0.02 0.94 0.11 0.006

.67 .57 .61 .82

9.7

7.5

2.1

0.0005

.59

5.9

5.2

0.7

0.79

.24

1.8 2.6

2.5 2.5

-0.7

0.23

0.1

1.0

.34 .51

4.8 2.8

3.2 2.8

1.6 0.0

0.006 0.61

.82 .73

5.4 5.9

4.0 5.1 9.3

1.3 0.8 2.2 0.7

0.02

.32 .44 .4 .28

0.9 0.6 1.8 0.6

0.02 0.35 0.02

0.6

.56 .28 .36 .54

0.10 0.26 0.12 0.71

.39 .41 .43 .42

0.44 0.16

.35 .67

0.004 0.34 0.69 0.26

.81 .39 .6 .52

11.5 -0.3

3.4 3.5 7.1 0.05

-1.0

2.5 2.9 5.3 -0.6

1.0 -1.0 -2.9

6.4 7.3

4.9 5.9

13.8 -0.8

10.8 -1.0

1.5 1.4 3.0 0.2

3.4 6.7

3.0 6.4

0.4 0.3

13.1

14.9

2.3

1.8

12.8

12.6

2.2

1.5

-1.8

0.5 0.2 0.7

0.1 0.02 0.05

Significant reductions are reported for target complaints A and B in the patient and target complaint A in the partner (Table VI). There is a

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537

Table V. Posttherapy GRIMS Score Where Improvement is Defined as Movement Towards Central Range Female Male

Worse

Same

Better

Total

Worse

0

2

1

3

Same

4

11

2

17

Better

0

3

0

3

Total

4

16

3

23

Table VI. Changes in Psychological Scores in Couples Completing Couple Therapy and at Six-Month Follow-Up Target Complaint

Pre x

Male A Male B Female A Female B

8.8 6.6 6.7 6.1

6-month x

Change

Wilcoxon p

Spearman r

Pre- to posttherapy (n = 23)

4.4 3.0 4.5 4.8

4.4 3.6 2.2 1.4

0.0006 0.001 0.01 0.07

.1 .18 .41 .69 .18 .05 .02 .07

Pretherapy to 6-month follow-up (n = 15) Male A Male B Female A Female B

8.27 6.97 6.62 6.46

4.86

4.4 6.0

3.41 2.07 0.62

0.02 0.07 0.33

5.76

0.7

0.4

Posttherapy to 6-month follow-up (n = 15) Male A Male B Female A Female B

3.53 2.27 3.92 3.92

4.86

4.4 6.0 5.76

-1.33 -2.13 -2.08 -1.84

0.02 0.02 0.08 0.13

.03 .006

.02 .06

nonsignificant reduction in target complaint B in the partner. Men reported a significant increase in pleasant sexual feelings and a nonsignificant reduction in unpleasant feelings which were already low at the time of initial assessment. All men completed the 14-day diary prior to entering therapy, 20 completed them after therapy and only 3 agreed to complete them at the 6-month follow-up. The changes in diary score in couples completing therapy is shown in Table VII. There was a significant increase in the active

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Wylie Table VII. Changes in Diary Scores in Couples Completing Couple Therapy

Variablea

SI POE SE AE AAS

Preic

Post*

Change

Wilcoxon p

Spearman r

32.0

5.7

32.4

0.4

5.3

-0.4

16.9 16.6 14.9

1.2 2.6 4.8

0.71 0.55 0.74 0.05 0.004

.55 .71 .65 .81 .63

15.7 14.0 10.1

aSi-sexual

interest; POE-presence of erections; SE-spontaneous erections; AE-active erections; AAS-attempts at sexual activity.

erection score and in attempts at sexual activity, but no change in reported interest in sex, number of days with erection, or spontaneous erections. Outcome Of the 23 couples completing therapy, 10 were considered to have had an excellent outcome, 4 a moderate outcome, and 6 a mild outcome; 3 were considered to show no change or were worse than at the time of assessment. Of the 23 couples completing therapy, 6 couples chose the second treatment option immediately; these couples included all 3 from a no change or worse outcome and 3 of the mild outcome group. A further 2 chose another treatment option at 6-month follow-up; both these couples were considered to have had an excellent outcome posttherapy. The dropout group included 5 couples who never returned after the assessment session and 9 other couples who had started into therapy. Of the 9, only 2 had received systemic interventions. Six-Month Follow-Up Scores At the 6-month follow-up, 15 of the 23 couples completing therapy returned target symptom ratings. Six of the 23 had chosen a second treatment immediately after couple therapy. Two couples failed to return thenfollow-up questionnaire after a second mailing and telephone call. Of the 15 returning target symptom ratings, 4 also agreed to complete the GRISS and GRIMS questionnaire. Target symptom scores pre- and posttherapy (n = 23), before therapy and 6 months after therapy (n = 15), and posttherapy and 6 months after therapy (n - 15) are shown in Table VI. The number of couples returning the GRIMS and GRISS questionnaires is too small for statistical analysis. There was no evidence to suggest that those

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539

men who showed an increase in their target score at 6 months differed as a result of having either behavioral or behavior-systems therapy interventions. Correlation of Variables Associated with Outcome

The correlation coefficient between male-reported change and actual difference from pre- to posttherapy was 0.67 in target symptom A and for target complaint B was 0.73. Consistency was reduced in women for both target complaint A (0.43) and target complaint B (0.40). The correlation between the difference in the male pre- and posttherapy GRISS impotence score and target symptom A post therapy was greater in the partner (0.76) than in the man (0.55). The therapist's end-of-therapy opinion of global change showed a good correlation with both partners' measures of target symptom change. This was particularly so with both female scores correlating highly (male: A, .77; B, .66; female: A, .84; B, .88). However, a lesser correlation was seen between the therapist's score and the couple's measures of target complaints when the actual difference was calculated (male: A, .36; B, .44; female: A, .41; B, .41) suggesting the therapist was more influenced by current feelings expressed by the couple. Comparisons of Initial Measures Between Groups Receiving Behavioral and Behavioral-Systems Interventions

Significant differences were seen between the two groups for the male GRIMS total score (Mann-Whitney = 23.5, p = 0.02) but no other scores reached a significance level. Prognostic Variables

Several factors were considered in the comparison of couples who consented to couple therapy with those that refused. These are shown in Table VIII. No significant findings were found. All 37 men and 36 women considering therapy completed the GRIMS and GRISS. However, of those refusing couple therapy, SO of 55 completed questionnaires but only 32 o 55 women completed the GRIMS and 31 women completed the GRISS. Missing data from the refusers did not allow this to be included in the statistical model in a meaningful way. A logistic regression model was applied to the factors considered but no significant results obtained. Again,

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Table VIII. Factors Considered As Possible Predictors for Whether Or Not a Couple Would Consent to Couple Therapy Consenting

Refused

Mann Whitney P

Min

Max

X

Min

Max

21 1

64 31

44.3 5.62

18 1

64 30

48.9 4.13

0.06 0.86

GRIMS Total score M Total score F

3 2

50 49

25 29.03

2 3

45 50

24.3 26.6

0.94 0.44

GRISS Total score M Total score F Imp. M

9 3 5

55 55 15

27.05 25.06 9.54

0 5 4

55 63 60

23.5 22.1 10.8

0.35 0.21 0.58

Factor

Age Duration of problem

X

no results of significance were found. No evidence was found that the male GRIMS score at enrollment had any influence on determining completion (p = 0.65). Factors found to be significant in predicting dropout from therapy were the initial GRIMS score for both the male and female. Couples were more likely to drop out if either the initial male GRIMS score suggested problems (i.e., was within the "undefined" or "distressed" range) (x2 = 6.25, p - 0.01) or where the initial female GRIMS score was good (i.e., midrange) (x2 = 4.03, p = 0.04). There was a trend to remain in therapy where both partners attended the assessment interview (x2 = 3.32, p — 0.07). The only factor that was found to predict outcome of therapy was a history of psychiatric illness in the male, which was predictive of a poor outcome (x2 = 6.35, p = 0.01).

DISCUSSION

This study attempts to provide evidence for effectiveness of specific clinical interventions in psychogenic MED. In this specific subgroup of patients presenting with MED the importance of considering the relationship and not just the penis in isolation, resulted in two thirds of couples having brief systemic therapy in addition to the standard MMST. While all couples had couple therapy from the first session, it might be argued that behavioral interventions of communication training and reciprocity negotiation are re-

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ally just a formalization of the work conducted within competent sex therapy. There is no clear agreement of what constitutes a favorable outcome of therapy. Hawton et al. (1992) relied entirely on the therapists' opinion of improvement, while Xueqian and Hequin (1990) used the GRISS scale. In this study, it can be seen that significant improvements were seen on several of the rating scales employed. Some of the improvements on the GRISS are encouraging, not just in symptom resolution but in more global areas of sexual activity (GRISS total score). Specifically, increased frequency of sexual activity and sexual communication are reported (GRISS subscales). Although these changes are of statistical significance in men, it was only a trend in women. Men also appear to be attempting sexual activity with increased confidence, with both a significant increase in attempts of sexual activity (diary score) and significant decrease in avoidance of sexual activity (GRISS subscore). Sexual activity is associated with more pleasant and less unpleasant feelings (pleasant/unpleasant feelings questionnaire and rating of target symptom B). Actual symptom improvement is evident from both the GRISS impotence subscale and the reduction of target symptom A rating. Erections within active situations (i.e., in foreplay and during intercourse with their partners) also increased significantly (diary score). The evaluation of the partner and her feelings needs to be considered and it is reassuring that partners reported a similar significant reduction in target symptom A, as well as improvements (sometimes more as trends than statistically significant) in many of the other areas considered. The finding that, overall, there were no significant changes within the relationship is not surprising. At the onset, many of the couples did not consider their relationship a problem in any way (GRIMS score and target symptom B were both midrange). This was the case in both completers of therapy and those who dropped out. It is difficult to use the GRIMS to show improvement from a favorable position at onset. There was some movement for couples from favorable to unfavorable score values, but an equal number moved in the other direction. What appears more encouraging is looking at the disparity between a couples' rating on the GRIMS questionnaire, which appeared to be reduced at the end of therapy, though not statistically significantly, which may reflect increased awareness and understanding within the couple. Many sex therapies have involved a protracted number of sessions which is difficult to accept when behavioral theories have been employed. In many cases a more eclectic approach has had to be adopted because of failure to progress. It is encouraging that in this study few couples dropped out of therapy as a result of systemic relationship work that was constructed

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alongside a progressing program of MMST. Failure to progress in MMST was dealt with at a systemic level on the assumption that it was something within the relationship and not something from sex therapy per se which was causing the "stuckness." The number of couples progressing to systemic therapy might appear higher than expected when the GRIMS scores are reviewed. It cannot be concluded that this was necessary for the outcome as there was no control group receiving MMST alone to compare these couples with. Yet, according to Crowe and Ridley (1990), the failure to progress at a behavioral level implies a need to step-up the type of intervention, i.e., it is implicit that two thirds of the couples were in need of a degree of relationship therapy. In previous studies if relationship dysfunction—however that be defined—was detected, it was often considered necessary to either postpone sex therapy and offer marital therapy first, or the couple became involved in protracted joint therapy, often with two cotherapists. If this study is correct in the assumption that relationship therapy is a necessary consideration for so many couples, it also provides reassurance that this can be offered by a single therapist. Despite the brevity of this combined approach, clinicians are offered a rich orientation of interventions to use within therapy, although clinical experience in both BSCT and MMST is encouraged before proceeding with the approach described. This is the first study to look at prognostic factors prospectively during the assessment of men presenting with MED. Strict criteria were set from the outset. The majority (20 of the 23 couples) were found to have some improvement at the end of therapy. When minimal improvement was excluded from the evaluation, 14 couples were considered to have a moderate or excellent outcome. These couples were considered to have a favorable outcome when assessing prognostic factors affecting outcome. The study by Hawton et al. (1992) was retrospective but involved a similar sample size, although there is a need for larger multicentered studies to increase total sample size. Attempts were made to predict favorable outcome of therapy by looking at various factors for the 37 couples entering into therapy. Analysis found only one factor of significance. In MED, a history of psychiatric illness in the female was found to be related to noncompletion of therapy by Hawton et al. (1992). It was felt that it represented somehow the psychological adjustment of the partner. The finding in the current study that a history of psychiatric illness in the male is likely to result in poor treatment outcome in brief couple therapy for MED suggests that an alternative intervention—perhaps individual therapy—is more suited to such patients. There remains a need to evaluate the effect of current psychiatric disorder

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on outcome. It was an exclusion factor in this study, although previous results have shown conflicting evidence of the influence of such on sex therapy in general (Hawton et al., 1992; Sungur, 1994). Relationship factors reflected by the initial GRIMS score helped predict dropout from therapy. Prior to this study, sex therapy in general produced conflicting results with regard to relationship adjustment and dropout from therapy. In this study, dropout was more likely if the male reported poor adjustment or the female reported good adjustment (but not within the same couple). This suggests that where the female does not see the general relationship as a problem, she is more likely to encourage her partner to seek help alone for the problem. The female may be satisfied with the relationship and sexual activity might play a less important role in her "needs" from her partner. If this is the case the "perceived" need for her to attend therapy is lessened. Likewise, if a male perceives the relationship as poor, he may feel that there is little point in trying to persevere with sex therapy while the relationship is unfavorable, even though combined therapy may be well suited to deal with the problem. In summary, this study demonstrates the beneficial outcome of brief couple therapy combining BSCT and MMST for psychogenic MED. Current opinion suggests that comparative studies should now compare treatments shown to be effective rather than contrive to compare an active treatment against placebo therapies. It is proposed that this should now be undertaken with attempts to conduct the study across several investigational sites, but with each site using the same reproducible therapy.

ACKNOWLEDGMENT

Statistical analysis was carried out by Andy Vail (Institute of Epidemiology and Health Services Research), University of Leeds.

REFERENCES Bancroft, J. (1989). Human Sexuality and its Problems, Churchill Livingstone, Edinburgh. Bancroft, J., and Coles, L. (1976). Three years experience in a sexual dysfunction clinic. Br. Med. J. 1: 1575-1577. Basoglu, M, Yetkin, N., Sercan, M., and Karaduman, B. (1986). Patterns of attrition for psychological and pharmacological treatment of male sexual dysfunction: Implications for sex therapy, research and cross cultural perspectives. Sex. Marital Ther. 1: 179-189. Boelens, W., Ennelknap, P., MacGillarvry, D., and Markvoort, M. (1980). A clinical evaluation of marital treatment: Reciprocity counselling vs. system-theoretic counselling. Behav. Anal Mod. 4: 85-%.

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Buvat J., Buvat-Herbart, M., Lemaire, A., Marcolin, G., and Quittelier, E. (1990). Recent developments in the clinical assessment and diagnosis of erectile dysfunction. Ann. Rev. Sex Res. 1: 265-308. Carney, A., Bancroft, J., and Mathews, A. (1978). Combination of hormonal and psychological treatment for female sexual unresponssveness: A comparative study. Br. J. Psychiat. 133: 339-346. Crowe, M. J., Gillan, P., and Golombok, S. (1981). Form and content in the conjoint treatment of sexual dysfunction: A controlled study. Behav. Res. Ther. 19, 47-54. Crowe, M. J., and Ridley, J. (1986). The negotiated timetable: A new approach to marital conflicts involving male demands and female reluctance for sex. Sex. Marital Ther. 1: 157-174. Crowe, M. J., and Ridley, J. (1990). Therapy with Couples, Blackwell, London. d'Ardenne, P., and Riley, A. J. (1993). Editorial. Sex. Marital Ther. 8: 211-212. De Amicis, L. A., Goldberg, D. C., LoPiccolo, J., Friedman, J., and Davis, L. (1985). Clinical follow-up of couples treated for sexual dysfunction. Arch. Sex. Behav. 14: 467-489. Everade, W., and Dekker, J. (1982). Treatment of secondary orgasmic dysfunction. A comparison of symptomatic de-sensitization and sex therapy. Behav. Res. Ther. 20: 269-274. Glover, I. (1983). Factors affecting the outcome of treatment of sexual problems. Br. J. Sex. Med. 10: 28-31. Gurman, A. S. (1973). The effects and effectiveness of marital therapy: A review of outcome. Res. Fam. Proc. 12: 145-170. Hawton, K. (1982). The behavioral treatment of sexual dysfunction. Br. J. Psychiat. 140: 94-101. Hawton, K., and Catalan, J. (1986). Prognostic factors in sex therapy. Behav. Res. Ther. 24: 377-385. Hawton, K., Catalan, J., Martin, P., and Fagg, J. (1986). Long term outcome of sex therapy. Behav. Res. Ther. 24: 377-385. Hawton, K., Catalan, I., and Fagg, J. (1992). Sex therapy for erectile dysfunction: Characteristics of couples, treatment outcome and prognostic factors. Arch. Sex. Behav. 21: 161-172. Heinman, J. R., and LoPiccolo, J. (1983). Clinical outcome of sex therapy. Arch. Gen. Psychiat. 40: 443-449. Hof, L., and Herman, E. M. (1986). The sexual genogram. J. Marr. Font. Ther. 12: 39-47. Jacobson, N. S., Follette, W. C, and Revenstorf, D. (1984). Psychotherapy outcome research: Methods for reporting variability and evaluating clinical significance. Behav. Ther. 15: 336-352. Kuriansky, J. B., and Sharpe, L. (1976). Guidelines for evaluating sex therapy. J. Sex Marital Ther. 2: 303-308. Leiblum, S. R., and Rosen, R. C. (1992). Couples therapy for erectile disorders: Observations, obstacles and outcomes. In Rosen, R. C, and Leiblum, S. R. (eds.). Erectile Disorders: Assessment and Treatment, Guilford, New York. Levine, S. B., and Agle, D. (1978). The effectiveness of sex therapy for chronic secondary impotence. J. Sex Marital Ther. 4: 235-238. LoPiccolo, J. (1992). Post modern sex therapy for erectile failure. In Rosen, R. C, and Leiblum, S. R. (eds.), Erectile Disorders: Assessment and Treatment, Guilford, New York. LoPiccolo, J., Heinman, J. R., Hogan, D. R., and Roberst, C. W. (1985). Effectiveness of single therapist versus co-therapy teams in sex therapy. J. Consult. Clin. Psychol. 53: 287-294. Masters, W. H., and Johnson, V. E. (1970). Human Sexual Inadequacy, Little Brown, Boston. Matthews, A., Bancroft, J., Whitehead, A., Hackmann, A., Julier, D., Gath, D., and Shaw, P. (1976). The behavioural treatment of sexual inadequacy: A comparative study. Behav. Res. Ther. 14: 427-436. Matthews, A., Whitehead, A., and Kellett, J. (1983). Psychology and hormonal factors in the treatment of female sexual dysfunction. Psychol Med. 13: 83-93. Melman, A., Tiefer, L., and Pederson, R. (1988). Evaluation of first 406 patients in urology department based center for male sexual dysfunction. Urology 32: 6-10.

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Mohr, D. C., and Beutler, L. E. (1990). Erectile dysfunction: A review of diagnostic and treatment procedures, din. Psychol. Rev. 10: 123-130. Nichols, W. C. (1988). Marital Therapy: An Integrate Approach, Guilford, New York. Rust, J., Bennun, I, Crowe, M., and Golombok, S. (1988). The Galombok Rust Inventory of Marital State, NFER-NELSON, Windsor, Ontario. Rust, J., and Golombok, S. (1986). The Golombok Rust Inventory of Sexual Satisfaction, NFER-NELSON, Windsor, Ontario. Sanders, G., and Tom, K. (1989). A cybernetic-systemic approach to problems in sexual functioning. In Kantor, D., and Okun, B. F. (eds.), Intimate Environments: Sex, Intimacy and Gender in Families, Guilford, New York. Schover, L. R., and Leiblum, S. R. (1994). Commentary: The stagnation of sex therapy. J. Psychol. Hum. Sex. 6: 5-30. Snyder, D. K., and Berg, P. (1983). Predicting couples' response to brief directive sex therapy. J. Sex Marital Ther. 9: 114-120. Speckens, A. E. M., Hengeveld, M. W., Lycklama, A., Nijeholt, G. A., van Hemert, A. N., and Hawton, K. E. (1993). Discrimination between psychogenic and organic erectile dysfunction. J. Psychosom. Res. 37: 135-145. Sungur, M. (1994). Evaluation of couples referred to a sexual dysfunction unit and prognostic factors in sexual and marital therapy. Sec Marital Ther. 9: 251-265. Verhulst, J., and Heiman, J. R. (1979). An interactional approach to sexual dysfunction. Am. J. Font. Ther. 7: 19-136. Warner, P., Bancroft, J., and Members of the Edinburgh Human Sexuality Group. (1987). A regional clinical service for sexual problems: A three year survey, Sex. Marital Ther. 2: 115-126. Weeks, G. R., and Hof, L. (1987). Integrating Sex and Marital Therapy, Brunner/Mazel, New York. Whitehead, A., and Matthews, A. (1977). Attitude change during behavioural treatment of sexual inadequacy. Br. J. Soc. Clin. Psychol. 16: 275-281. Wilson, G. L., Bornstein, P. H., and Wilson, L. J. (1988). Treatment of relationship dysfunction: An empirical evaluation of group and conjoint behavioural marital therapy. J. Consult, Clin. Psychol 56: 929-931. Woody, J. D. (1992). Treating Sexual Distress:IntegrativeSystems Therapy, Sage, Newbury Park, CA. Xueqian, L., and Hequin, Y. (1990). Cognitive behavioural therapy for erectile disorder. A study from the People's Republic of China. Sex Marital Ther. 5: 105-114. Zigmond, A. S., and Snaith, R. P. (1983). The Hospital Anxiety and Depression Scale. Ada Psychiat. Scand. 67: 361-370.

Archives of Sexual Behavior, Vol. 26, No. 5, 1997

Coming Out by South Asian Gay Men in the United Kingdom Dinesh Bhugra, M.Sc., M.B.B.S., F.R.C.Psych., M.Phil.1

The process of coming out among Western gay men and women is well described. The present study is the first to explore the experiences of coming out among gay men of South Asian origin in the U.K. South Asian is defined here as originating from the Indian subcontinent. Members of a homophile organization were given a questionnaire designed to assess the experiences of coming out to family and friends and the degree of compartmentalization in their lives. Information obtained from 52 questionnaires was supplemented by detailed interviews with 9 respondents. Families and religion played important roles in the process of coming out. Sisters were most likely to be told first. Some degree of dissonance between cultural and sexual identity was noted. In addition, each step taken in revealing one's sexual orientation to friends, family, and colleagues was dictated by the strength of the relationships and the desire for intimacy. Further areas of research are highlighted. KEY WORDS: homosexuality; gay men; coming out; South Asian.

INTRODUCTION Over the last 15-20 years "coining out" has become commonplace in the gay and lesbian community. This process has been described as an active process which involves a complex interaction of intra- and interpersonal transformations spread over a period of time. Identity formation is an interactive process between the individual and society and is highly influenced by the norms and values of family and society at large (Erikson, 1946). Cohen and Stein (1986) defined the process of coming out as "a complicated developmental process which involves at a psychological level a per1Institute

of Psychiatry, De Crespigny Park, London SE5 8AF, England. 547 0004-002/97/1000-0547$12,50W C 1997 Plenum Publishing Corporation

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son's awareness and acknowledgement of homosexual thoughts and feelings .... Various factors will affect the relative positive or negative meaning the individual places on the identity which emerges as a result of the coming out process." Various authors have described several stages of this process (Table I). The process of coming out is not staged and remains a fluid one. Although some authors (e.g., Coleman, 1985) have argued that each stage needs to be resolved prior to moving on to the next, it is not always possible and a degree of overlap between various stages is inevitable. The first stage of coming out has been called signification (Lee, 1977), awareness (Hencken and O'Dowd, 1977), acknowledgment or identification (Dank, 1971). Median age for this process is reported to be from 13 to 18 (Jay and Young, 1979; Weinberg and Williams, 1973). At this stage acceptance from a close friend means much more than acceptance from a stranger. Dank (1971) used coming out and bringing out interchangeably and argued that following the stage of coming out: there occurred a cognitive reshaping of one's experiences that was related to a great sense of relief and freedom. The development of homosexual identity has been described as occurring in six stages with relevant arbitrary stages in the model proposed by Isaac and McKendrick (1992). They suggest that after identity challenge in the early teens, identity exploration occurs in the late teens when a testing out phase may occur, with accompanying anxiety, turmoil, and self-esteem jeopardized. In the early 20s, the beginning of identity achievement occurs with commitment occurring over most of the adult life. In their survey of gay organization members in South Africa they found that 67% of the sample had come out between the ages of 15 and 24. Nearly half (46%) had experienced crisis in coming out which included psychiatric treatment, panic, anxiety, loss of self-esteem, rejection, and disapproval. Coleman (1982) suggested that some individuals begin tasks at higher levels of development before focusing on the task of an earlier stage. Thus, the fluidity of the process and parallel development of more than one stage are useful paradigms. Friends are often the first persons to be told (Trenchard and Warren, 1984) and the next step is making contact with other gay men and lesbians through a variety of outlets. The parents may be the last in the individual's circle to be told. This is related to the fear of precipitating a family crisis (Wirth, 1978; Cramer and Roach, 1988). However, little information is available on experiences of gay men from other cultures and societies, particular those in South Asia and on especially those on the Indian subcontinent (Bhugra, 1990). From South Asia several anecdotal reports on homosexual cruising (Sultan, 1990); homosexual prostitution (Seabrook, 1990) homosexuality among eunuchs (Dalrymple, 1990), and some data on

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homosexuality among prisoners (Srivastva, 1973, 1974a, 1974b), have appeared. Some studies have looked at homosexual experiences among university students (Dwivedi et al., 1979) in the context of general sexual behavior though often it is the attitudes of the teenagers that have been studied rather than the behavior itself (Bali, 1980, Bhugra and King, 1989). In a small sample of "immigrants" in Canada, Tremble et al. (1989) reported that all youngsters in their sample reported conflict in coming out. This conflict was variously with themselves, with original and/or adopted culture and with their families. The families' responses varied from embarrassment, shock, self-blame, blaming the adopted culture, and seeing it as a white disease. The three issues these authors raise were pursued in the present study: (i) particular difficulties in coming out to family; (ii) finding a niche in the gay and lesbian community in the face of discrimination; and (iii) difficulties in reconciling sexual orientation and ethnic or racial identity.

METHOD Sample Selection Common to all studies of homosexual people is the problem of ascertainment, in that most samples are unlikely to be truly representative of the homosexual community. It is even uncertain whether there is such a thing as a representative sample of a group of people who live life-styles of varying openness. Thus, to study this population, it is necessary to resort to available social or political groups or pools of people who may be prepared to take part. In 1988, a new social group exclusively for South Asian gay men and women was set up in London (Khan, 1989a, 1989b). From an initial membership of 4 the membership at the time of the study stood at over 100. The membership is far larger than the number of people who attend on any one social occasion or meeting. Thus, subjects were approached both at meetings and by post. All were asked to complete an anonymous questionnaire. In addition a different group of individuals who had not filled in the questionnaire were asked to take part in an interview. No refusals were met within this group. Questionnaire Design An open-ended questionnaire was designed using the item selection from Western studies on coming out, e.g., Cass (1979), Coleman (1985),

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and Lee (1977). In addition to basic demographic questions, i.e., sex, marital status, religion, and occupation, the questionnaire asked the respondents to describe the experiences of coming out—how they did so; who did they come out to; in which order; their own reactions and others' reactions; and attempts at hiding their own sexuality. These respondents are hereafter referred to as QRs. A small pilot study confirmed that the questions were acceptable and understandable. Interview A separate sample of 9 male respondents was recruited for the interview in which open-ended questions were asked. All these respondents were at one of the meetings of the group. There was no random selection. It is possible that those who agreed would have felt more comfortable in talking about their coming out than those who did not, but no respondent who was approached refused to take part. The aim of the interview was to ascertain the difficulties of coming out. Each interview lasted between 45-75 min and was recorded and transcribed. These are referred to as IRs hereafter. Only the interviewer was aware of the identity of the interviewees. Total confidentiality and anonymity was observed in analysis of the data. The interviewees were asked a set of questions about whether they were out to anybody—at work, at family, with friends, relatives, or others; how they decided to come out; and social pressures, role of marriage, expectations of parents, and the reactions of individuals.

RESULTS Demographic Details A total of 52 usable questionnaires (out of a total of 89 circulated to both sexes, a response rate of around 58%) was obtained. In this group the age range was 16-61 and 30 were less than 25 years. The majority of QRs were single (47 of 52), two were married, and 1 divorced. In this group, 8 were Hindu, 14 Muslims, 3 Sikhs, 2 Catholics, and 13 did not respond to the question of religion. Employment status is shown in Table II. All the students were in full-time education. Of 47 who responded to the question, 13 were in a gay relationship, 9 described it as closed monogamous and the rest reported having one regular partner and others. Of the 50 who defined their sexuality, 39 saw it as gay/homosexual, whereas 11 described it as bisexual. Among the 9 IRs, 5 were Hindu and 4 Muslim.

552

Bhugra TableIII.Employment Status Employment Pharmacist/solicitor/accountant/consultant/engineer Adm. officer/computer/retail management Self-employed/business/sales Students Unemployed Not known

QR

IR

12 15 7 6 6 6

2 2 3 2

Table III. People to Be Told of QR's Sexual Orientationa

Friends Female friend Gay friend Cousins Parents Workmate Sister Brother Teacher Doctor Others

First people to be told

First Asians to be told

21 8 5 4 3 3 3 2 2 2 4

18 3 9 3 2* 6 2 3

a

Numbers do not match up because individuals gave more than one reply. b ln one case parents "found out."

Five were below 25 years (age ranging from 21). Of this group 3 were students, 2 unemployed and the remainder employed. Not all respondents answered all questions, hence number of responses to various questions varies. Communication of Sexual Orientation Table III shows the range of the first two people the QRs had come out to. It also shows the relationship of the first two Asian people QRs had come out to. Among this group of 9 gay friends 6 belonged to the said homophile organization. Of 45 who responded to the question, 14 said

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that they would take a pill if it would make them completely and permanently heterosexual. A similar proportion, 14, acknowledged a degree of regret in being homosexual. Thirty-two QRs would make specific attempts to hide their sexuality compared to 12 who would not. Since the numbers are small, especially in terms of religious denomination, this, in general, as a factor has not been taken into account.

DISCUSSION This is the first study of the processes of coming out among Asian gay men and has some methodological problems in its sample selection. No acculturation or assimilation measures were used and there is no comparison group. The duration of their stay in the U.K. was not ascertained. The present work is only exploratory and gives expression to the authentic voices of Asian gay men and should, therefore, be seen as a first step towards understanding of issues of psychological health in Asian gay men. Another problem is with the use of open-ended questionnaires with a postal survey which produced somewhat incomplete responses. The responses to this study may not be representative of the total Asian gay population, but for purposes of determining attitudes it is representative of the gay Asian group that is "out." The overall age distribution is towards the younger and a majority were born in the U.K. Their experiences therefore are different from the older Asian males who may have been born in the Indian subcontinent. Another note of caution involves the use of the term "coming out." Issues Pertaining to the Self An interesting observation was that 11 of SO (22%) saw themselves as bisexual and yet were attending a gay group. This may suggest that this concept allows people to come to terms with their sexuality slowly. Coming Out Among the QRs the most usual group of people to be told of their sexual orientation was friends followed by cousins. Parents and work colleagues were the last to be informed. The most common reason for coming out to friends was that they were close and this was another step in maintaining this closeness. Although 3 IRs felt that their sexual orientation was important, it was seen as only a minor part of their life. All 9 IRs knew

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from an early age that they were different. However, they did not give this behavior/attraction any name. As one of them put it: "I think I was about 12 and realized because most of my friends were talking about girls and I wasn't . . . . It occurred to me that I was different but quite what it was I didn't know at that stage." Others expressed similar views. Others around the individuals noted this "strangeness" and reacted. Thus a process of "signification" begins to occur (Plummer, 1975). The step of acknowledgment of being gay to the self was seen as a feeling of relief as well as introducing a new set of anxieties. As part of the individual growth the next steps are homosexual identity acceptance, commitment to such an identity, and integration of such identity (Minton and McDonald, 1985). All the QRs by being in the social group have overcome this first stage though only a few had reached the third stage of integration of self-identity. This social support was seen as extremely valuable. Among the QRs, in response to the question whether they would take a pill that would make them completely and permanently heterosexual, the most common explanation for doing so was that being heterosexual could lead to a secure relationship. As one respondent said: "I'll take a pill that'll make me only stick to my boyfriend and lead a life like a happy heterosexual," This may be a reflection of the South Asian model of arranged marriage where by and large, divorce is a rare phenomenon. A similar proportion of respondents regretted being homosexual (compared to 25 who did not and 3 who did so sometimes). The most common explanation for this regret was not having children and going against the Asian culture. This would need to be correlated with the values and the jointness of the family and the impact of closeness of relationships. Thus, cultural assimilation and being valued within one's own culture became important features. In the U.K. sample, when individuals decided to come out to other Asians a similar picture emerged, i.e., coming out to friends followed by distant family and then leading onto immediate family and work colleagues. Positive gay images within the social group were appreciated by all the respondents who commented on it. One response says it for all of the individuals, I value (the group) a lot because I'm surrounded by people who understand me completely in both a sexual and a cultural context. Whereas if I go to a white group, they would only understand half the story I define as really alleviating the pressures from Asian gays and lesbians which other communities don't have and I think it does alleviate those pressures if not at a conscious level then at least at the subconscious level because you know there are people there if you need them which reduces the burden and also provides a kind of space away.

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Friends were also least likely be unaware of the individual's sexual orientation. On the other hand only 7 sets of parents knew compared to 20 who did not. Brown (1989) observed patterns of being closeted and juggling the processes of coming out, i.e., rigid geographical and emotional distance from the family of origin; patterns of denial—where everyone knows but nobody talks about it. The "don't tell your father" scenario was present in both these samples. Religion

Within the family system, religion plays an important role. Among the IRs three of the five Hindus described themselves as quite religious to the extent of performing regular rituals and prayers. Even though the Muslims did not describe themselves as religious three out of four IRs found it difficult to relate their religion with their sexual orientation. Similar feelings were expressed among the QRs as well. It would be useful to ascertain levels of religious involvement with perceptions of sexual orientation. As the numbers are small, this should be seen as preliminary observation. Ethnicity

In the present sample there appeared to be a clear dissonance between culture and sexual orientation. The ethnic homosexual thus has a foot in each culture without feeling a complete sense of belonging in either. Although the Asian gay community is a sexual minority within a racial minority, it may not necessarily align itself easily with blacks and other minority groups and it does not fit well with the "majority" gay community either. As one of the IRs remarked, "in a sense I have experienced it on the scene itself, because gay society is a microcosm of society at large so you're going to get people on the left and the right and in the middle, and also wherever, so you are going to get bigots there as well. Just because they're gay doesn't mean (that) they have to be friendly towards other minorities." The respondents identified Asian insularity as an important factor within the gay community. Further research needs to look at self-esteem and self-acceptance among gays who are ethnic minorities. Compartmentalization

A majority of the respondents would make specific attempts to hide their sexuality. They would try largely to hide from colleagues more than

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family. Very often they would "act straight," talk about girls, ask female friends to ring them at work, and use other smoke screens. Only 5 (from to 29 among QRs who answered the question) were advised to seek treatment or counseling for their sexual orientation. In two cases therapists advised them: "You'll grow out of it" and "You're straight." If these approaches are upheld by other studies, the training of therapists will become a major issue. The notion of self-acceptance is weak in a small group of the respondents. Feelings of regret, self-deprecation, and self-hatred are obvious. The discrepancy between being Asian and gay is quite traumatic for some. The Asian gay man faces the problem of creating a coherent sense of self from the two identities he seeks to attain: Asian and gay. Both these identities are stigmatized but possible choices are (i) to be Asian and gay and (ii) to be Asian and not gay. He cannot choose not to be Asian although he can easily reject the Indian/Pakistani/Ceylonese etc., cultures. This degree of conflict as well as assimilation within the culture needs to be studied further.

CONCLUSIONS Although the notions and stages of coming out among Asian gay men are fairly similar to those experienced by Western gay men, their ethnic identity plays an important role. External influences and pressures are culturally different and need to be studied in greater depth. An attempt should also be made to understand the "fit" of sexual orientation in the components of self-identity and self-esteem. Future research should also describe the range of solutions Asian gay males employ including compartmentalization to fend off pressures from family and community in order to cope with being gay. Although these strategies are employed by white gay men, here the concepts of cultural identity are vital in dealing with one's own sexual orientation.

ACKNOWLEDGMENTS I am grateful to all the respondents who were generous with their time and information. Thanks are also due to Drs. P. Davies and M. King for their comments on earlier drafts of this paper.

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REFERENCES Bali, P. (1980). Contraceptive and sexual knowledge in Indian children I & II. Br. J. Sex. Med. 5: 26-28, 30. Bhugra, D. (1990). Negotiating the process of coming out in Asian gay men. Unpublished M.Sc. thesis for South Bank University, London. Bhugra, D., and King, M. B. (1989). Attitudes of Indian adolescents. Br. J. Sex. Med. 16: 458-461. Brown, L. S. (1989). Lesbians, gay men and their families: common clinical issues. J. Gay Lesbian Psychother. 1: 65-77. Cass, V. C. (1979). Homosexual identity formation. /. Homosex. 4: 219-235. Cohen, C., and Stein, T. (1986). Reconceptualizing individual psychotherapy with gay men and, lesbians. In Gonsiorek, J. (ed.), A Guide to Psychotherapy with Gay and Lesbian Clients, Plenum Press, New York. Coleman, E. (1981). The Development Stages of Coming Out Process. J. Homosex. 7: 31-43. Coleman, E. (1982). Developmental stages of the coming out process. In Gonsiorek, J. C. (ed.), A Guide to Psychotherapy with Gay and Lesbian Clients, Haworth Press, New York. Coleman, E. (1985). Developmental stages of the coming out process. In Paul, W. et al. (eds.), Homosexuality: Social, Psychological and Biological Issues, Sage, Beverley Hills, CA. Cramer, D. W., and Roach, A. J. (1988). Coming out to Mum and Dad. J. Homosex. 15: 79-91. Dalrymple, W. (1990). The hidden world of India's eunuchs. The Sunday Correspondent, March 4. Dank, B. M. (1971). Coming out in the gay world. Psychiatry 34: 180-197. Dwivedi, K. N. et al. (1979). Psychosexual attitudes of resident students in an Indian University. Br. J. Sex. Med. 6: 34-40. Erikson, E. (1946). Ego development and historical change. Psychoanal. Stud. Child 2:359-396. Fong, S. L. M. (1973). Assimilation and changing social roles in Chinese Americans. J. Soc. Issues 29: 115-127. Hencken, J. D., and O'Dowd, W. T. (1977). Coming out as an aspect of identity formation. Gay Acad. Union J. 1: 18-22. Isaac, G., and McKendrick, B. (1992). Male Homosexuality in South Africa, Cape Town. Jay, K., and Young, A. (1979). The Gay Report, Summit Books, New York. Khan, S. (1989a). Shakti. Square Peg, No. 26. Khan, S. (1989b). Shakti: One year on. Bazaar 9: 2-3. Lee, J. A. (1977). Going public: A study in the sociology of homosexual liberation. J. Homosex. 3: 49-78. Minton, H., and McDonald, G. (1984). Homosexual identity formation as a development process. /. Homosex. 9: 91-104. Plummer, K. (1975). Homosexual categories. In Plummer, K. (ed.), The Making of a Modem Homosexual, Hutchinson, London, pp. 53-75. Seabrook, J. (1990). Indian take away. New Statesman and Society, Feb 2, No. 86. Srivastva, S. P. (1973). Social profile of homosexuals in an Indian male prison. Eastern AnthropoL 26: 313-322. Srivastva, S. P. (1974a). Sex life in an Indian male prison. Ind. J. Soc. Work 35: 21-33. Srivastva, S. P. (1974b). The feel of imprisonment. Ind. J. Criminal 2: 46-54. Sultan (1990). Breaking Free. Bombay Dost 1(1): 2. Trenchard, L., and Warren, H. (1984). Something to Tell You, London Gay Teenage Group, London. Tremble, B., Schneider, M., and Appathurai, C. (1989). Growing up gay or lesbian in a multicultural context. Gay Lesbian Youth 253-266. Troiden, R. (1979). Becoming homosexual: a model of gay identity acquisition. Psychiatry 42: 362-373. Weinberg, M. S., and Williams, C. J. (1973). Male Homosexuals: Their Problems and Adaption, O.U.P., Oxford. Wirth, S. (1978). Coming out close to home: Principles for psychotherapy with families of lesbians and gay men. Catalyst 6-22.

Archives of Sexual Behavior, Vol. 26, No. 5, 1997

Book Reviews Modern Homosexualities: Fragments of Lesbian and Gay Experience. Edited by Ken Plummer. Routledge, London, 1992,281 pp., $49.95 (cloth); $15.95 (paper). Reviewed by Scott L. Hershberger, Ph.D.1

As I understand it, "homosexuality" involves the experience of feeling sexually attracted to people of the same sex. A "homosexual" is a person who has these sexual feelings. Sometimes these sexual feelings are translated into overt sexual behavior, sometimes not. In my opinion, most people would readily recognize this definition. It does not deviate in any demonstrable way from the standard definition found in dictionaries. Defining homosexuality is not difficult; explaining why it occurs has proven to be much more so. Why then does there still exist a core group of scholars who insist on denying the very legitimacy of this definition? They like to go by the name "social constructionist," but their basic message is individual deconstruction—you are only a homosexual if society has defined you to be one. Never mind what the person himself or herself feels towards a person of the same sex. In answer to the proverbial inquiry, if a tree (homosexual) falls in a forest (culture), and nobody (society's members) is around to hear it, does the tree make a noise? Social constructionists would emphatically say "no." However, the tree is torn all the same. The contributors to this volume represent the social constructionist school of thought and all of them, to a greater or lesser degree, assume homosexuality, unlike gravity, is not a time or culturally invariant phenomenon. Rather, as the editor writes so eloquently in the preface, "All that is solid melts into air" (p. xvii). That homosexuality, when given behavioral expression, involves same-sex sexual behavior, is considered almost irrelevant. What is considered relevant is how the sexual behavior is interpreted by the participants (of lesser importance) and by society (of greater im1Department

of Psychology, University of Kansas, Lawrence, Kansas 66045.

559 0004-0002/97/1000-0559$12.50/0 c 1997 Plenum Publishing Corporation

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portance). This point of view is expressed frequently throughout the book. Here is one typical example: Alternative models of homosexuality are constituted on the basis of the meanings attached to same-gender erctic behaviour; and both the schema of penetration and the gender role each individual participant assumes are the decisive criteria in the conception of homosexuality. The former serves as the initial step in the cultural definition of homosexuality in the sense that the very occurrence or non-occurrence of penetrative sex sets a boundary between homosexualization and dehomosexualization of conduct, (p. 47)

Please excuse the length of the above quote. Any other quotations taken from the book illustrating the point that sexual behavior removed from interpretation is irrelevant would have been equally, if not more, prolix. Prolixity is another hallmark of the social constructionist school. The difficulty with social constructionism is that it impedes science and the collection of knowledge. To understand why something occurs, we need to have a consistent definition of it. Social constructionists deny the possibility of a constant definition of homosexuality or of the homosexual. But according to the constructionists, this does not really create a problem. The very attempt to explain homosexuality is considered bogus. Of course, this causes great problems for those researchers who believe biology is of some relevance to sexual behavior—just try drawing a family pedigree under the rules of social constructionist analysis. The constructionist school has essentially appropriated a set of behaviors and feelings that can be identified consistently across time and space, and has chosen to obfuscate those feelings and behaviors with a lot of cultural and legal artifacts. What everyone understands by homosexuality does not really differ; what does differ is the extent that societies allow the open expression of homosexuality, and how much subterfuge is required to mask its expression. Peel away the culturally (and legally) required subterfuge, and what we all see is the same—homosexuality. Social constructionist analysis, as applied to homosexuality (or sexual behavior in general), is really the documentation of to what lengths cultures will go to try to impede the expression of homosexual behavior. It sounds better to say that social constructionists study how different cultures and epochs define homosexuality, rather than to say it studies how homosexuality is compromised by legal and societal restrictions. Then social constructionism might sound like a branch of jurisprudence. According to the editor, a main goal of this book is the prediction of what the homosexual experience will be like in the future. In reality, predicting what homosexual experience will be like in the future is an exercise in predicting the spread or constriction of conservative ideologies in the population. Whether Modem Homosexualities is considered a "good" book depends on how one feels about the social constructionist perspective. If one

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feels sympathetic to this ideology, then it most certainly is good. If one does not feel sympathetic, enthusiasm for the book will be muted. If ideology is left aside, there are in fact a number of praiseworthy aspects to Modem Homosexualities. The chapters cover a broad range of topics of interest to anyone involved in homophile studies. These topics include the development of gay and lesbian studies, homosexuality in different cultures, the coming out process, parenthood, nonbiological families, nonheterosexual marriage, and AIDS activism, to mention only a few. In this respect, the book is informative and up-to-date on its treatment of these issues, and would be an excellent supplementary text for a gay and lesbian studies class. One problem frequently encountered in edited books, but fortunately missing here, is inconsistency in both the quality and style of writing. Most of the contributors write very well and clearly (if sometimes verbosely). It is obvious the editor has attempted to gather together a group of scholars and in-the-field workers with various perspectives on several issues, so leaving aside the constant shadow of social constructionism, there is some diversity of thought expressed. For example, authors take different positions on the wisdom of Queer Nation-style AIDS activism. Indeed, although the editor states that the inclusion of AIDS-related chapters is necessary to understand the modern lesbian and gay experience, one chapter warns against the frequent hegemony that AIDS is given in defining that experience by some activists and researchers. Ordinarily, when a book has "fragment"or "fragments" in its title, this may be taken as a warning that the book is discursive, disorganized, or incomplete. Modem Homosexualities is not discursive, disorganized, or incomplete in its presentation of the modern homosexual experience. On the contrary, given the diversity of the issues addressed, it is well organized and valuable as a reference. One really does not have to acknowledge the existence of a social constructionist perspective, as the editor and contributors unfortunately do, in order to appreciate the knowledge and ideas imparted by each chapter. Each chapter stands on its own and all are worth reading, and all cohere together to give the reader an accurate account of what life is like for homosexuals in today's world.

Lesbians and Psychoanalysis: Revolutions in Theory and Practice. Edited by Judith M. Glassgold and Suzanne Iasenza. Free Press, New York, 1995, 385 pp., $34.95. Reviewed by Mary C. Lamia, PH.D.2 21030

Sir Francis Drake Boulevard, Kentfield, California 94904.

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Psychoanalysis is broadly defined by the editors of this volume as "a range of therapies based on psychoanalytic theory and practice, attempting to include a wide number of approaches that reflect the diversity of the field." This definition is important to keep in mind with regard to the clinical work presented in this text. A number of the approaches diverge considerably from the basic tenets of psychoanalytic theory and practice and, in some instances, the psychoanalytically informed basis of the clinical work is imperceptible. There are three dominant themes in the 18 contributions. The first theme has to do with challenges to classical psychoanalytic ideas regarding the etiology of homosexuality and the methods of treatment that evolve from these views. The second involves the experience of shame in the lesbian patient. This painful affect becomes intertwined with the perceived or imagined opinions of the therapist and is manifested in aspects of the transference, countertransference, and resistance. Thus a third theme, the issue of self-disclosure on the part of the clinician, is discussed by a number of contributors to this volume, particularly as a means of relieving the shame and severe self-criticism of the lesbian patient. In the first section of the book, "Past to Present: Rethinking Theory," various authors bring to our attention the hazards of reductionistic thinking in psychoanalysis, particularly the assumption of the primary etiologic role of preoedipal pathology in female homosexuality. At the same time, they disagree with an approach that treats homosexuality as an issue to be explored like any other. They consider the former approach to be homophobic whereas the latter represents a denial of homophobia. The repetitive assertion in the book that psychoanalysts suffer from homophobia or denial of homophobia is itself reductionistic and short-sighted. Pathologizing prevails in psychoanalytic discourse, whether or not the subject matter has to do with homosexuality. One of the limitations of psychoanalytic thinking has been the tendency to infer that a certain behavior is a manifestation of a particular underlying pathology which negates both the individual's characteristic adaptation to the environment and other intrapsychic possibilities. Many of the contributors illuminate this limitation of psychoanalysis as it involves theory, practice, and supervision regarding the lesbian patient. The view of homosexuality as a variant of normal development vs. a developmental deviation is a critical determinant of the approach taken by the therapist. The authors of several chapters point out the detrimental effects of the therapist's view of lesbian object choice as a pathological one. They bring to our attention the hazards of therapists thinking in terms of "changing" the lesbian patient. What must change, according to these authors, are the attitudes on the part of therapists. As a reader, one questions whether or not psychoanalytically oriented clinicians choose to be en-

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lightened. Recently, Macintosh (1995) surveyed 285 psychoanalysts who reported having analyzed 1215 homosexual patients. The idea that a homosexual patient in analysis "can and should" change to heterosexuality was rejected by 97.6% of the respondents, although one third of this group of analysts believed that most other psychoanalysts hold this opinion. Nevertheless, a classical psychoanalytic perspective regarding the female homosexual continues to be upheld in recent psychoanalytic literature, where the etiology of female homosexuality is seen as faulty early feminine identifications and maternal, followed by paternal, pathology (cf. Socarides and Volkan, 1991). Homosexuality, like heterosexuality, can encompass all levels of psychopathology. Olesker (1995), for example, discussed homosexual object choice in females as representing a compromise formation of oedipal dynamics with contributions from drive derivatives at all levels of development. A significant theme in the clinical contributions to this volume concerns the shame of the lesbian patient. The authors alert therapists to potential feelings in the lesbian patient that she is a shameful disappointment, or that she must change in order to be acceptable. Therefore, traditional neutrality and analytic anonymity are experienced as negativity or judgment. The lesbian patient, because of her battle with culture and her sense of unacceptability, requires an empathic, nonjudgmental, therapist. In any patient where shame and guilt are predominant affects, neutrality and anonymity on the part of the therapist may be counterproductive. This volume makes a strong case for psychoanalysis to examine the detrimental effects of neutrality and anonymity. It is only recently that these issues have been subjected to serious reconsideration by psychoanalysts. Renik (1995), for example, considers the technique of analytic anonymity to be unconsciously motivated by the analyst's desire to be idealized. He believes that Whereas an analyst's effort to be anonymous is supposed to allow the patient greater freedom to associate, the opposite is the case in my experience. Far from diminishing the analyst's presence, a stance of non-self-disclosure tends to place the analyst center stage. It makes the analyst into a mystery, and paves the way for regarding the analyst as an omniscient sphinx whose ways cannot be known and whose authority, therefore, cannot be questioned, (p. 482)

The concept of analytic neutrality, particularly as it concerns non-selfdisclosure on the part of the therapist, is challenged in a number of chapters in this book. In question is how the therapist should respond to inquiry by the patient about the therapist's sexual orientation, or regarding attitudes of the therapist concerning the patient's sexual object choice. The usefulness of self-disclosure, when the therapist is herself a lesbian, is considered by a number of the authors. Many of the contributors to this volume sensitively and methodically discuss the use of self-disclosure as an instru-

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ment and subject of treatment with the lesbian patient. In doing so, they scrutinize its motives and repercussions and illustrate the benefits to treatment that self-disclosure may provide. The contributors expose the limitations of traditional psychoanalysis. At the same time, they illustrate how psychoanalytic ideas can be modified to fit the particular needs of the lesbian patient.

REFERENCES Macintosh, H. (1994). Attitudes and experiences of psychoanalysts in analyzing homosexual patients. J. Am. Psychoanal. Assoc. 42: 1183-1208. Olesker, W. (1995). Unconscious fantasy and compromise formation in a case of adolescent female homosexuality. J. Clin. Psychoanal. 4: 361-382. Renik, O. (1995). The ideal of the anonymous analyst and the problem of self-disclosure. Psychoanal. Q. 64: 466-495. Socarides, C, and Volkan, V. (eds.). (1991). The Homosexualities and the Therapeutic Process, International Universities Press, Madison, CT.

Identity Politics: Lesbian Feminism and the Limits of Community. By Shane Phelan. Temple University Press, Philadelphia, 1989, 206 pp., $29.95. Reviewed by Paula C. Rust, Ph.D.3

Opening with the claim that "Lesbian feminism began with and has fueled itself by the rejection of liberalism," Phelan proceeds to discuss a number of topics pertaining to liberalism, feminism, and lesbian feminism. The strengths of the book include its unusual combination of Phelan's extensive knowledge of philosophical literature with a theoretically contemporary political analysis, and the use of pornography and sadomasochism as examples to illustrate the philosophical dilemmas facing identity-based movements as they grapple with liberal understandings of the self and the political. Pornography and sadomasochism are indeed controversial issues for feminism and lesbian feminism, and Phelan clearly outlines these controversies, locating their sources in philosophically based ideological dilemmas contained within feminism and sadomasochism. In particular, Phelan argues that liberalism, by advancing a particular concept of the rational individual and a distinction between the public and the private, privatizes and thereby conceals certain forms of constructive power. These very forms of power are the ones that are most oppressive 3Department

of Sociology, Hamilton College, 198 College Hill Rd., Clinton, New York 13323.

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to lesbians. Thus, liberalism fails to provide the basis for an analysis of lesbian oppression, much less a program for naming and relieving this oppression. Phelan also argues that movements to build alternative communities (e.g., lesbian separatism) produce a false unity that relies on the denial of difference within these communities. Arguing that "otherness is a constant, harassing presence that will not vanish under any political or discursive regime in modernity," Phelan asserts that communitarian movements cannot solve the problem of otherness any more effectively than reform movements. In fact, communitarian projects are of necessity more restrictive of difference because they are under pressure to justify themselves, and these restrictions weigh more heavily on their members because "excommunication" from a small insular community is more socially and personally destructive for the individual than exclusion from a larger society. Also arguing that the identities provided by a reform movement might be more "resilient" than those "offered by alternative communities, because it is broader based," Phelan comes down on the side of reform politics. The weakness of the book is its lack of coherence. The arguments regarding the inadequacy of liberalism and communitarian movements are made most convincingly in the first and last chapters, respectively, but these chapters fail to cohere around these arguments. For example, following the opening sentence quoted above from chapter 1, Phelan engages in a discussion of liberalism, its tenets, branches, and conceptions of the self and the social. This discussion is implicitly justified by the premise that it serves as necessary groundwork for a more in-depth discussion of the inadequacy of liberal thinking to the needs and purposes of lesbians in later chapters. I enjoyed reading this chapter—it exercised a mental muscle that I have not exercised since reading Foucault and provided me with a needed review of liberal philosophy. Some of the characteristics of liberalism as presented in this chapter are indeed used in an enlightening fashion in later chapters. But in hindsight, this first chapter contains many tangential discussions that provide no building blocks for the rest of the text. The argument regarding the inadequacy of liberalism as made within the first chapter relies on only a small part of this review of liberal philosophy and provides only a thread of coherence throughout the rest of the book. I concluded, therefore, that the first chapter provided a forum for Phelan to demonstrate and organize her knowledge of the intricacies of liberal traditions and dilemmas, rather than the groundwork for a discussion of the problems of liberal thought as applied to lesbian oppression. In some cases, Phelan seems to thwart her own argument. After criticizing liberalism for privatizing and thereby concealing certain forms of power, in a later chapter she critically examines the role of "confession"

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in lesbian feminism, and, finally, exhorts us to respect one another's privacy and refrain from demanding confession. Although these are not necessarily contradictory criticisms, the route by which a coherent argument could pass from the former to conclude with the latter needs greater illumination. Perhaps more problematic is the fact that insofar as liberalism plays a role in illuminating the controversial nature of sadomasochism within lesbian feminism as described by Phelan, it is via liberal tendencies within lesbian feminism (e.g., the privileging of individual choice); this seems to call into question Phelan's initial assertion that lesbian feminism was fueled by the rejection of liberalism. The problem does not defy resolution, and Phelan does label the individualism of the two sides in the debate "paradoxical" and asserts that certain advocates of sadomasochism "take individualism beyond the bounds that liberalism usually sets." In the absence of further discussion on this exact point, however, these comments recognize the problem but do not resolve the inconsistency of the argument. Despite the fact that chapters 5 and 6 focus on pornography and sadomasochism as illuminating examples of the controversies and sites of difference among feminists and lesbians, these are not the types of difference ultimately used to argue in favor of reform politics over communitarian movements in the last chapter. Instead, racial and ethnic differences are introduced partway through the book and, in the end, serve as the compelling examples of types of differences that are suppressed in communitarian movements. I found the intermediate chapters interesting reading, with relationships to the first and last chapters consisting of an occasional identification of liberal strains of thought or dilemmas. For example, in the second chapter Phelan critiques the medicalization of lesbianism. One of the many enlightening points made in this chapter regards the effect of the interplay of medicalization and liberalism on the construction of the lesbian individual. Phelan notes that applying a medical label to an individual implies that that individual cannot control her behavior. Within the context of a society also steeped in liberalism, with a liberal concept of the individual as an autonomous and rational agent, the implication that one cannot control one's own behavior amounts to a construction of that person as less than a full agent or social citizen by reason of immaturity or lack of rationality. In making this point, Phelan relies on the liberal concept of the individual as presented in the first chapter, but the point made does not itself build on the argument of the first chapter nor serve as a building block for arguments made in later chapters. While reading this volume, I was plagued by the sincere suspicion that the lack of coherence I observed was in the eye of the beholder. I am neither a political scientist, as is Phelan, nor a philosopher. Perhaps if I

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were, Phelan's overall argument would be clearer to me because I would be more familiar with the philosophical traditions on whose concepts and connections she relies, however thorough her outlining of these concepts and connections. If, however, a lesbian sociologist who matured intellectually and politically during the heyday of lesbian feminism and who specializes in the study of sexual identity-based sociopolitical movements from a social constructionist perspective is not a member of Phelan's intended audience, then that audience must be very specialized.

Diverse Communities: The Evolution of Lesbian and Gay Politics in Ireland. By Kieran Rose. Cork University Press, Cork, 1994,84 pp., £3.95. Reviewed by Harry Oosterhuis, Ph.D.4

The Irish nation has a reputation for being conservative, even reactionary in sexual matters. Contraception, abortion, divorce, feminism, and homosexuality, more or less accepted in other Western European countries, still raise strong opposition, primarily because of the notable presence of the Catholic Church (in Northern Ireland also the Protestant Church). Nevertheless, radical changes have taken place in recent years, especially in government policies and law. In this volume, Rose, a prominent Irish gay activist, describes how male homosexuality ("buggery") was decriminalized in Northern Ireland in 1982 and in the Irish Republic in 1993. He argues that the Irish progress in sexual reform and equality legislation can be explained by the impact of international developments—by the new social, cultural, and economic forces of the 1960s onwards; and, ironically, by certain traditional Irish values that are rooted in the nationalist, anticolonial struggle against British domination. Among the new social and cultural forces, Rose focuses especially on the lesbian and gay movement in the Irish Republic; in fact, its 20-year history is the main subject of this book. According to Rose, the strength of this movement was that it connected sexual reform with the struggle for social equality and civil rights in general. In this way, links were forged with other social movements, the women's movement and trade unions in particular. Although in the 1980s law reform was delayed by the Church and lay New Right groups, they were not able to halt change. Rose offers a detailed account of the law reform campaigns in which the homosexual movement successfully challenged the Victorian (originally British) antiho4Department

Netherlands.

of History, University of Maastricht, Postbus 616, 6200 MD Maastricht, The

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mosexual laws, first at the European Court of Human Rights and then in the Irish government and parliament. As a participant in this history, Rose highlights the role of homosexual activists and politicians, such as Mary Robinson who became President of Ireland in the early 1990s. However, social and cultural developments which favored sexual reform are underexposed, as is the part played by the Church. Rose leaves the impression that the attitude of the Catholic Church had become more moderate in the early 1990s, notwithstanding the uncompromising homophobic teachings of Pope John Paul II. But why did Irish clerics, just like Irish politicians, become more tolerant of homosexuality in a relatively short period? Was the new policy facilitated by European integration, by the overall modernization of Irish society, or by the growing influence of science (medicine, psychology, and sociology) visa-vis traditional religion? Rose does not really provide sound answers to these questions. His interpretation tends to emphasize the impact of homosexual activism and the force of moral arguments. His contention that gay rights were a sign of renewed commitment to older Irish ideals that inspired the freedom struggle against Britain does not provide the reader with a satisfactory explanation. Rose's commitment to equality and emancipation is admirable, but it prevents him from keeping a proper balance between objectivity and activism. As Rose himself acknowledges, the first scholarly and social history of homosexuality in Ireland has still to be written. The questions that he raises, though, suggest that such historical research is likely to be rewarding.

Families We Choose: Lesbians, Gays, Kinship. By Kath Weston. New York, Columbia University Press, 1991, 261 pp., $13.95. Reviewed by Miriam Kaufman, BScN, M.D. FRCP5

This book is about kinship relations among a group of people who have been defined by their sexual behavior; however, one of the book's strengths is that it underscores the absurdity of seeing gay and lesbian issues as always being sexuality issues. The writing in this book is variable. Some of it is easily readable and is clear in its meaning and intent, but I got bogged down in some of the writing that could have been written in simpler words without a loss of content. An example is a sentence on p. 28: "The chart below recapitulates 5Department

of Paediatrics, Division of Adolescent Medicine, Hospital for Sick Children, 555 University Ave., Toronto, Ontario M5G 1X8 Canada.

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the ideological transformation generated as lesbians and gay men began to inscribe themselves within the domain of kinship." Unlike more recent books (e.g., Arnup, 1995; Benkov, 1994), this work examines families of choice—kinship groups formed by lesbians and gay men, groups that may include "blood" relatives, but that go beyond biology. It clearly comes out of the intense debate of the 1980s within both the feminist and the gay and lesbian communities regarding the meaning and importance of the family. The religious right has also portrayed "the family" as the only legitimate social unit of our culture, and sees it as being highly vulnerable to erosion by homosexuals. The heart of this book is contained in the introductory chapter and two others, one entitled "Families We Choose," the other "The Politics of Gay Families." Another chapter, "Exiles from Kinship," explores how gay people have been excluded from traditional family relations. This chapter includes discussion of changes in the way anthropologists are viewing the family. Much work has been done with the assumption that all cultures recognize kinship as a unified construct, an idea that has been challenged in the past 20 years. The arguments, stories, and theories of the three crucial chapters lead to the development of an idea of families of choice. Within these overlapping families, there is the "ability to weather conflict," an "exchange of material and emotional assistance," "co-parenting arrangements," shared holiday celebrations, and "support for persons with AIDS." Weston feels that unlike nuclear families, these families are "not intrinsically stratified by age or gender" and often include former lovers. At no point in the book does Weston define the criteria for family. Weston argues that seeing these as familial relationships introduces "a new basis for rendering heterosexuality and lesbian and gay identity commensurable," i.e., allowing them to be compared. This can be done without any value judgments or by imagining them to be alike. Where this all breaks down for me is in the basic thesis, which (usually implicitly) equates the nuclear family with heterosexuality and families of choice with homosexuality. Weston even states, when referring to children raised in gay families: "the kind of families these children establish should depend on their own sexual identities." During my reading of this book, I ran into numerous examples of families of choice primarily consisting of heterosexuals. I started reading the book at a cottage. We (my partner, our kids, and me) were there with two straight couples and their children. The men have known each other for over 20 years. The relationship between these families (and one other one that was not present) would have been counted as a kinship relation by Weston had they been gay and in her study. They cared for each others'

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children during times of family crisis, had mutual rituals and shared celebrations, and when asked, said that they felt like kin. All of these people had close biological family nearby. A coworker made a speech at a party to celebrate her upcoming marriage. She said that we were "like family" to her. Another heterosexual coworker told me that her family has celebrated major holidays with the same group of people for years. One of these people had just come by on the weekend to say good-bye before going off to university. "She wouldn't have just gone without seeing us first. It would be like not saying good-bye to her aunt." I was also reminded of two (straight) friends who have died in the past 10 years. Both had, in addition to biological family support, a strong group of people who cooked, took phone messages, ran errands, talked, listened, and did anything that was needed. One of the women in the second group was the daughter of the first woman who died. These families were similar to those forming around people dying of AIDS. Even Weston's insistence that the including of one's ex-lovers in a family is a gay phenomenon can be questioned. My brother and his expartner actively coparent and live a block apart. She is included in our family gatherings, and my mother told her that if she did not come to my father's 80th birthday party (in another city) there would be dire consequences. She came. While the inclusion of ex-lovers as family may be more common among gays and lesbians, it is not a characteristic only of gay families. All this is not to say that I think that gays and lesbians are "just like" heterosexuals, because I do not. I think that gays and lesbians see these kinship groups as having more meaning because of group perception of being, as Weston says, exiles from kinship. Even those of us with loving, supportive biological families feel the pain of other people who have been rejected because of their sexual orientation. It is this meaning, not the existence of nonbiological kinship, that creates the difference. My second problem with this book is that much of it is extraneous to the topic of kinship among gays and lesbians. I think Weston collected quite a bit of interesting information during her interviews and wanted to share it; however, she should have either written another book, or included kinship as an issue for one or two chapters in a more broadly based book. The two chapters on coming out were especially interesting, but irrelevant. Despite my general enjoyment of these chapters, I was annoyed by her bafflement (stated at least twice) at the negative nature of the stories she heard. Informants glossed over positive stories and emphasized negative ones. But these are not coming out stories, they are Coming Out Stories. Their drama is the point of their existence. A positive story is only dramatic

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in the context of an expectation of a negative one, such as telling one's fundamentalist preacher parents and having them say, "Oh, that's just fine dear. We'll tell all our friends." Another chapter that seemed at best peripherally related to the book's topic was "Lovers Through the Looking Glass." This explored the metaphor of the mirror in gay and lesbian relationships. This dealt with gendered difference as a cornerstone of heterosexual relationships and societal belief that a gay relationship is one of two people who are the same, and therefore not compatible. She sees this as leading to the "merging theories" of the mid-1980s, in which alleged blurring of ego boundaries was considered the major malfunction of gay and lesbian relationships. Weston also feels it is this type of imagery that led to gays being portrayed as narcissistic. I thought this chapter would have made an interesting paper, but wondered at its inclusion in this work. I also wondered about the wisdom of collecting this information from personal contacts in the community in which Weston lives. To me, one of the differences between sociology and anthropology is that one does sociology within one's culture and anthropology in a different one. Even going to a gay community outside of the Bay Area might have given Weston the ability to pull back and see it from an observer's perspective. Then I ask myself, is this just the bias of Western medicine (my academic background), that our research subjects must be somehow alien to us, that to identify with them invalidates our findings? I have always been uncomfortable referring to human beings as subjects. What better way to humanize our research than to perform it on people we know or whom we contact through friends? Clearly, this work stimulated me to think about the process of research and our relationship to those we study. It also led to interesting discussions with friends, both gay and straight, about the nature of kinship. If your library has a copy, I think it is worth perusing. REFERENCES Arnup, K. (1995). Lesbian Parenting: Living With Pride and Prejudice, gynergy books,

Charlottetown, Prince Edward Island. Benkov, L. (1994). Reinventing the Family: The Emerging Story of Lesbian and Gay Parenting, Crown, New York.

8 REVIEWS Lesbians & Psychoanalysis - Revolutions in Theory & Practice

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9 REVIEWS Identity Politics - Lesbian Feminism & the Limits of Community

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10 REVIEWS Diverse Communities - The Evolution of Lesbian & Gay Politics in Ireland

file:///D|/...S%20Diverse%20Communities%20-%20The%20Evolution%20of%20Lesbian%20&%20Gay%20Politics%20in%20Ireland.txt[28/10/2011 11:41:59 AM]

11 REVIEWS Families We Choose - Lesbians, Gays, Kinship

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Archives of Sexual Behavior, Vol. 26, No. 5, 1997

Letters to the Editor

To the Editor; A considerable bulk of research suggests that the sex ratio (proportion male) of siblings of some samples of male homosexuals may be high. (Blanchard et al, 1996). However, it is suspected that such elevated sex ratios may be confined only to some samples of homosexuals. So it is important to specify the most accurate estimate of the sex ratio expected on the null hypothesis. Blanchard and Bogaert (1996) cited me (James, 1987) to substantiate the sentence: "In white populations, the ratio of male live births to female live births is close to 106:100." They continue: "The ratio of brothers to sisters reported by any group of men drawn at random from the general population should therefore approach 106 (brothers per 100 sisters)." This inference is invalid because couples vary between one another in their probability of producing a boy: So a random group of men would be expected to have a slightly higher proportion of brothers than a random group of people. Similarly a random group of women would be expected to have a slightly lower proportion of brothers. The most abundant data known to me on this point were published by Malinvaud (1955) and reproduced in James (1975). They suggested that the expected sex ratio of a newborn when the existing sibs number n boys and m girls is 0.5145 + 0.003 n - 0.005 m. Thus, if we ascertain at random a man (born in France 1946-1950) and are informed that he has one younger sib, then the expected sex ratio of that sib is 0.5175. The corresponding estimate for a woman is 0.5095. In the present context, one may propose a further refinement. Overall population live birth sex ratios move slowly up and down in time apparently under stabilizing influences (James, 1995). So the value 0.5145 above should be considered a parameter rather than a constant. For practical purposes it may be estimated from the sex ratio of first births of the relevant population. However, it may be assumed that the variance of the distribution (as reflected in the values of +0.003 and -0.005) may be taken as constant in the absence of further data. Further adjustments may be envisaged to take account of whether the sibs are older or younger than the proband; and of their numbers. But such adjustments would be comparatively small. 573 0004-0002/97/1000-0573$12.50/0 c 1997 Plenum Publishing Corporation

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William H. James The Gallon Laboratory University College London Wolfson House 4 Stephenson Way London NW1 2HE, England

REFERENCES Blanchard, R., Zucker, K. J., Cohen-Kettenis, P. T., Gooren, L. J. G., and Bailey, J. M. (1996). Birth order and sibling sex ratio in two samples of gender-dysphoric homosexual males. Arch. Sex. Behav. 25: 495-514. Blanchard, R., and Bogaert, A. F. (1996). Biodemographic comparisons of homosexual and heterosexual men in the Kinsey interview data. Arch. Sex. Behav. 25: 551-579. James, W. H. (1975). Sex ratio and the sex composition of the existing sibs.Ann. Hum. Genet. 38: 371-378. James, W. H. (1987). The human sex ratio. Part 1: A review of the literature. Hum. Biol. 59: 721-752. James, W. H. (1995). What stabilizes the sex ratio? Ann. Hum. Genet. 59: 243-249. Malinvaud, E. (1955). Relations entre la composition des families et le taux de masculinite. J. Soc. Statist. Paris 96: 49.

To the Editor As an obstetrician and sexologist (Black, 1994) I was interested in the Blanchard and Bogaert (1996) article, especially in terms of the discussion concerning maternal testosterone levels in pregnancy, the effects of raised levels on maternal sexual behavior in pregnancy, and the predictability especially of male offspring as a result where the levels are found to be raised. This prompts me to voice a hitherto unasked question I have borne for many years, and is a project worthy of further research. In pregnancies I have managed in which the woman's face is festooned with acne instead of the traditional "peaches and cream" complexion; in whom bodily hair such as on arms, legs, pubes, and in axillae flourishes; in whom scalp hair becomes oily and additionally maybe affected by dandruff; and in whom the libido and sexual responsiveness may be lifted to heights previously uncharted, and, corroborated by the partner, I have made a confident prediction of a male offspring. After all, these are all androgen effects. I am right more often than in cases where the opposite physiological effects are present which lead me to predict a female infant. Occasionally, the gender of the baby is the exact opposite, i.e., a female infant born to a markedly androgenized mother, or a male infant born to a woman with clear skin, little hair, and reduced or absent libido.

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I wonder what the gender identity and sexual orientation of these particular neonates will prove to be one day? Worth a study, don't you think? Jules S. Black

Bondi Junction New South Wales, Australia REFERENCES Black, J. S. (1994). Sexuality and pregnancy. An interview study. Aust. N.Z. J. Obstet. Gynaecol. 34:1-2. Blanchard, R., and Bogaert, A. F. (1996). Biodemographic comparisons of homosexual and heterosexual men in the Kinsey interview. Arch. Sex. Behav. 25: 551-579.

Archives of Sexual Behavior, Vol. 26, No. 5, 1997

Evelyn Hooker—In Memoriam (1907-1996) In every generation there are a few extraordinary people whose accomplishments, like the light of distant stars, continue to illuminate our lives after the stars themselves have gone out of existence. Evelyn Hooker was one of those extraordinary people. Born Evelyn Gentry in North Platte, Nebraska, Hooker grew up in Northeast Colorado and attended a succession of one-room schoolhouses. On completing an honors program in high school, she entered the University of Colorado, and supported herself doing housework—one of the few jobs available for women in those days. After receiving her baccalaureate and Master's degrees (in psychology) at Colorado, she attended Johns Hopkins University where she received her Ph.D. Following a succession of short-term positions at other colleges, she came to the University of California, Los Angeles, where she taught psychology from 1939 to 1970. It was there that she met her second husband, English literature Professor Edward Hooker. He died in 1957—a major loss in her life. She did not remarry. It was my good fortune to get to know Evelyn in the 1950s when she was still in the early phase of her memorable studies of male homosexuality. Her subsequent classic 1957 report on "The Adjustment of the Male Homosexual" impressed me enormously and confirmed my own long-standing conviction that the traditional views of psychiatrists and psychoanalysts that homosexuality in and of itself was a mental illness were totally unwarranted. In the years that followed, we crossed paths more frequently, and she generously contributed an extremely important chapter on "Male Homosexuals and Their Worlds" to my 1965 book on homosexuality. A year later, when Evelyn obtained her grant to organize the 1967-1969 President's Task Force on Homosexuality under the auspices of The National Institute of Mental Health, I was honored to be invited to join that task force. In the years of its existence, we worked very closely together, although the final year was unhappily complicated by her developing a severe depressive illness that necessitated her being hospitalized. Fortunately, however, as Chief of Psychiatry at the Cedars-Sinai Medical Center at that time, I was 577 0004-0002/97/1000-0577$12.50/0 c 1997 Plenum Publishing Corporation

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able to ensure that she received first-rate treatment, and was in contact with her almost daily. At her request I assumed the pro-tern chairmanship of the Task Force and the maintenance of the work on its report until she recovered and was able to take over again. Evelyn was extremely grateful for what I had been able to do, and thereafter, with her typical exuberance, kept insisting that I had "saved her life." Clearly that was more than my intervention deserved. Far more important, in my eyes, was the degree to which knowing and working with Evelyn enriched my own life. In the hectic years of struggle that finally resulted in the American Psychiatric Association's historic 1973 decision to remove homosexuality from the categories of mental illness, Evelyn's unwavering encouragement lent important support to my own efforts. In 1985 I had the privilege of writing a letter on Evelyn's behalf, supporting her nomination for the award of Distinguished Contribution to Psychology in the Public Interest. Among the things that I said in that letter was that "she, more than any individual in our time, can be credited for having altered the consciousness of the scientific community, as well as that of large sections of the public, on the issue of normality versus pathology in homosexuality . . . and with having contributed significantly to making life more bearable for many thousands [today I would have said millions!] of gay men and women in America [today I would have added, and throughout the world]." In 1992 the American Psychological Association also awarded her its Lifetime Achievement award, its highest honor. Evelyn will be sorely missed, not only for her professional contributions but also for her personal warmth, her contagious laughter, and her courageous spirit. Not only those who are gay, but also those who, as she loved to put it, are "hopelessly heterosexual" will remain forever in her debt for moving us one step closer to a world in which people who differ from the majority in sexual orientation will no longer be stigmatized or discriminated against. Judd Marmor, M.D. Franz Alexander Professor of Psychiatry Emeritus University of Southern California School of Medicine Adjunct Professor of Psychiatry Emeritus University of California, Los Angeles, School of Medicine