G208 E BOOK Clinical Sexuality Handbook 2022 1

Filodiritto Editore – Proceedings
CLINICAL SEXUALITY
HANDBOOK FOR SEXUAL
HEALTH PROFESSIONALS
Editors
Cristian DELCEA PhD & Costel SISERMAN MD, PhD
FILODIRITTO
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LIST OF AUTHORS
CRISTIAN DELCEA
Department of Advanced Studies in Sexology, Sexology Institute of Romania, Cluj-Napoca,
Romania; “Iuliu Hațieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania.
RAFAELA ANGELESCU
University of Medicine and Pharmacy of Craiova, Romania.
ILINCA BARUCH
Babeș-Bolyai University, Faculty of Psychology and Educational Sciences, Cluj-Napoca,
Romania.
SORINA MIHAELA BĂLAN
Dimitrie Cantemir University, Targu Mures, Romania.
MARIA MĂDĂLINA BOGDAN
Romania.
AMALIA BONDREA
Department of Advanced Studies in Sexology, Sexology Institute of Romania.
KATALIN BORBÁTH
University of Sciences, Pécs, Hungary Doctoral School of Education and Society.
VLAD-IOAN CHIRILĂ
Romania.
LARISA-MARIA COSTRACHEVICI
Department of Advanced Studies in Sexology, Sexology Institute of Romania & Iuliu
Hațieganu University of Medicine and Pharmacy of Romania
EUGENIA COȘCODAN
“Alexandru Ioan Cuza” University, Faculty of Psychology and Educational Sciences, Iași,
Romania.
DIANA DRAGU
Ecological University of Bucharest, Psychology Faculty, Romania.
DORINA EUSEI
Iuliu Hațieganu University of Medicine and Pharmacy of Romania; Department of Advanced
Studies in Sexology, Sexology Institute of Romania.
FERIDE FEJZA
Institute LIBIDO – Institute for Health and Sexual Research, Prishtina, Kosova.
HAJRULLAH FEJZA
UBT – University for Business and Technology, Prishtina, Kosova; Institute LIBIDO –
Institute for Health and Sexual Research, Prishtina, Kosova.
COSMIN GIREDEA
Romania.
GABRIELA L. GROZA
Department of Psychology, Babeș-Bolyai University, Cluj-Napoca, Romania.
HAJNALKA GYŐRFY
Transilvania University of Brașov, Romania.
EJONA ICKA
Institute LIBIDO – Institute for Health and Sexual Research, Prishtina, Kosova; Universal
Peace Federation, Prishtina, Kosova.
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DOMNIȚA MIHAELA KABIRY

Faculty of Psychology, Hyperion University, Bucharest, Romania.
ALEXANDRA KOCSIS
Romania.
EMILIA FLORENTINA LESCAI
Romania.
JOKE VAN LILLEGRAVEN
University of Amsterdam, The Netherlands.
MARIA MAGDALENA LUPA
Spiru Haret University, Faculty of Sociology-Psychology, Bucharest, Romania.
DENISA MARIA MARCHIȘ
Romania.
IOANA F. MARINA
Department of Psychology, Babeș-Bolyai University, Cluj-Napoca, Romania.
IASMINA ALIDEEA MATIREL
Tibiscus University, Timișoara, Romania.
IOANA MOTOGNA
“Tibiscus” University, Timișoara, Romania.
ANDREA MÜLLER-FABIAN
Babeș-Bolyai University, Romania
DIANA NEMEȘ
Tibiscus University Timișoara, Faculty of Psychology, 4-6 Lascăr Catargiu S treet, 300559,
Timișoara, Romania.
EMIL-GRUIA NOVAC
“Tibiscus” University, Timișoara, Romania.
AVI OHRY
Tel Aviv University, Israel.
MARICICA PALADE
Romania.
ROXANA ALEXANDRA PANĂ
Faculty of Psychology, Spiru Haret University, Bucharest, Romania.
MĂDĂLINA LILIANA POP
Babeș-Bolyai University, Romania.
CORINA-MIHAELA (TUDOSE) POPA
Faculty of Psychology of Titu Maiorescu University, Bucharest, Romania.
TUDOR POPA
ADELINA PUREC
RAMONA RĂDUCAN
1 Decembrie 1918 University of Alba Iulia, Faculty of Law and Social Sciences, 5 Gabriel
Bethlen Street, 510009, Alba Iulia, Romania.
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ȘERBAN ROȘU
Victor Babeș University of Medicine and Pharmacy Timișoara, Piata E. Murgu 2, 300041,
ADRIANA ROȘU SILAGHI
Stomatologist, MA 1st year Tibiscus University Timișoara, Str. Lascăr Catargiu 4-6, 300559,
JÚLIA SIMON
Kátai Gábor Hospital, Karcag, Hungary.
COSTEL VASILE SISERMAN
“Iuliu Hațieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania.
IRINA CRISTIANA STAN
Sexology Institute of Romania, Cluj-Napoca, Romania.
CAMELIA STANCIU
Dimitrie Cantemir University, Târgu Mureș, Romania.
CRISTINA STUPARU
Hyperion University, Psychology Faculty, Bucharest, Romania.
EMILIA CLAUDIA TODORUTI
“Tibiscus” University, Timisoara, Romania.
ALEXANDRA TUDOR
The Sexology Institute of Romania, Cluj-Napoca, Romania.
ANDREI TULHINĂ
West University of Timişoara, Romania.
ADRIAN-GEORGE VLAICU
“Carol Davila” University of Medicine and Pharmacy in Bucharest, Romania.
MĂDĂLINA MARIA VOINEA
Romania.
RODICA WEIHMANN
Petrosani University, Faculty of Science, Psychosociology, Petrosani, Romania.
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CONTENTS
Preface 9
FIRST SECTION. SEXUAL DYSFUNCTIONS 10
A. MALE SEXUAL DISFUNCTIONS 10
1.1 Ejaculation disorders 10

1.1.1 Premature ejaculation 10
Sex therapy in the treatment of premature ejaculation 10
Early ejaculation 15
Ejaculation disorders 21
1.2 Erectile dysfunction 25
Erectile disorders 25
1.3 Sexual desire disorder 30
Sexual desire disorder in men 30
B. FEMALE SEXUAL DYSFUNCTIONS 34
1.4 Orgasm disorder 34

Orgasmic disorder in women 34
The female orgasm disorder. An individual psychology approaches 50
Female orgasm disorder 54
Female orgasm disorder. Anorgasmia 59
1.5 Arousal disorder 64
Arousal disorder in women 64
Dyspareunia in women 71
1.6 Desire disorder 76
Inhibited/diminished sexual desire and loss of orgasm in women 76
Disorder of sexual desire or arousal in women and the history of sexual abuse
as a predictor of it 80
1.7 Sexual pain disorders 83
Dyspareunia 83
Vaginismus 86
SECOND SECTION. PARAPHILIC DISORDERS 89
A. EXTERNALIZATION PARAPHILIC DISORDERS 89
2.1 Voyeurism disorder 89

Voyeurism and scopophilia 89
Telephone scatology 92
2.2 Exhibitionism disorder 95
Exhibitionism 95
2.3 Frotteurism disorder 97
Frotteurism 97
Frotteuristic disorder 99
Frotteurism disorder – 1 104
Frotteurism disorder – 2 108
Public masturbation 115
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2.4 Pedophilia disorder 117

Sexual deviations. Considerations regarding pedophilia – mith and reality 117
Hebephilia 122
2.5 Sadism disorder 124
Sexual deviance. The sexual sadism 124
Sexual sadism disorder 129
Sexual sadism 131
Psychodynamic formulations of paraphilias 138
Zoophilia – 1 142
Zoophilia – 2 145
Klismaphilia 150
Coprophilia 152
B. INTERNALIZATION PARAPHILIC DISORDERS 154
2.6 Fetishism and transvestism disorders 154

2.6.1 Fetishism disorder 154
Fetishistic disorder 154
Fetishism 160
2.6.2 Transvestism disorders 162
The transvestic disorder 162
THIRD SECTION. MISCELLANEOUS 169
Clinical comorbidity 169

Sexual aversion 171
Objectum sexuality or objectophilia 177
Etiological factors of psychological nature in sexual dysfunctions 182
Non-paraphilic hypersexual disorder – compulsive sexual behavior disorder
or sexual addiction 193
Paraphilic disorders 200
Forensic evaluations of sexual offenders 205
Evaluation, diagnostic and management of recidive to sexual infractors
in the virtual media 213
Vaginismus as a hidden problem: our case series 220
Can manage the security and online reputation in sexting and cyberbullying? 225
Breaking (old) news: a veterinary surgeon became a sexologist-psychoannalist.
A historical reflection of sexology 232
Justifications of rape. Comparative analysis between rapists and students.
Gender differences 235
Gender stereotypes and steam education 246
Research on Hungarian female teachers’ mental hygiene state with special regard
to the development of their professional and female identity 252
Let’s talk about sexual health education 264
3RT intervention on cognitive distorsions regarding the justification of sexual offenders 270
Symptomatology of reconstitution of trauma in adults with a history of childhood sexual abuse.
An approach from the perspective of SONapp application 284
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PREFACE
The book, Clinical Sexuality Handbook For Sexual Health Professionals. Research, theory
and practical applications include a transtheoretical approach, from the perspective of
contemporary theoretical-experimental models in the humanities, medical and
pharmacological sciences and with robust clinical applicability in the field of sexology, such
as: treating sexual problems in adolescents, people with intellectual disabilities, in the elderly,
in cancer survivors, and in lesbian, gay, bisexual, transgender, queer, intersex, and asexual
people.
This handbook critically discusses the most important theoretical foundations in the field as
well as new research directions for specific populations with sexual needs and problems.
Moreover, online and digital clinical and psychotherapeutic interventions are highlighted
for a better and more robust specialized intervention.
Sexual and paraphilic disorders are debated both categorically, from the perspective of
academic societies and international fora, and dimensionally, from the perspective of the
humanities and medical sciences, in order to draw a clinical picture, on the one hand, and on
the other, for the intervention to be as targeted as possible.
Professor Camelia Stanciu PhD
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FIRST SECTION
SEXUAL DYSFUNCTIONS
A. MALE SEXUAL DISFUNCTIONS
1.1 Ejaculation disorders
1.1.1 Premature ejaculation
SEX THERAPY IN THE TREATMENT OF PREMATURE EJACULATION
Abstract
Premature (rapid or early) ejaculation is a disorder that creates great personal distress in all
aspects of the men’s life suffering from this condition, and also for their partners and for the
relationship in general. The present article aims to create a general description of the known
information for this sexual disorder and especially sex therapy techniques and methods used in
the treatment of premature ejaculation.
Keywords: premature ejaculation, psycho-behavioral treatment, behavioral techniques, cognitive approaches,
affective approaches, relational approaches
INTRODUCTION
Premature ejaculation is a frequent sexual dysfunction with a prevalence in the general

population of men anywhere between 20% and 30%, but the real percentage may be higher
because of under diagnosis and men’s withholding of the truth and medical avoidance.
Premature ejaculation creates significant torment for men, their partner and their
relationship. [1, 2]
Definition and sub-types of premature ejaculation

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)
identifies premature ejaculation as a persistent or recurrent pattern during partnered sexual
activity which implies ejaculation within approximately 1 minute following vaginal penetration
and before the individual wishes it. In addition, the pattern must have been present for at least
6 months and must have been experienced on almost all or all occasions of sexual activity. The
sexual dysfunction causes clinically significant distress in the individual, is not explained by a
nonsexual mental disorder or as a consequence of severe relationship distress and is not
attributable to the effects of a substance, medication or another medical condition. [4, 5]
The International Society for Sexual Medicine (ISSM) developed a consensus in the
definition for lifelong premature ejaculation which implies that the disturbance has been
present since the individual became sexually active, while acquired premature ejaculation
means that the disturbance began after a period of relatively normal sexual function.
Also, premature ejaculation can be subtyped as generalized (not limited to certain types of
stimulation, situations, or partners) or situational (only occurs with certain types of stimulation,
situations or partners).
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Premature ejaculation can be mild (ejaculation occurs within approximately 30 seconds to

1 minute of vaginal penetration), moderate (15-30 seconds), or severe (ejaculation occurring
prior, at the start or within 15 seconds of vaginal penetration). [3, 5]
Risk factors and etiology of premature ejaculation

Ongoing clinical and empirical research of premature ejaculation suggests two distinct
etiologies (organic and psychogenic) that intertwine. Risk factors of premature ejaculation
include physiological or pathophysiological, psychological, relationship factors, cultural and
other socio-demographic factors. Physiological and pathophysiological risk factors include
lower urinary tract symptoms (LUTS), thyroid function problems, medication, recreational
drugs and aging. Psychological risk factors incorporate anxiety, guilt pertaining to partner
interactions, as well as man’s own low performance expectations, lower self-confidence, low
sexual self-efficacy and relationship efficacy. Premature ejaculation can be caused by the
negative impact of the couple’s relationship problems. Furthermore, cultural and socio-
demographic factors may place an additional burden on the man, variables such as religion,
socioeconomic status, nationality, geographical region, age, race, ethnicity, sexual orientation
and degree of physical and emotional ability may affect an individual’s sexual performance
and can cause premature ejaculation. [1, 2, 3]
Assessment and diagnosis of premature ejaculation

A correct assessment of premature ejaculation is an essential part in understanding the
individual’s personal struggle with this sexual dysfunction and it should begin with an analysis
of the man’s medical, psycho-social and sexual history. It is of great benefit if the man’s partner
is also investigated on the same criteria. Medical history should include organic disorders,
prescribed or recreational medications taken, the exact dose, and the duration of administration.
Referral to a urologist is necessary for a physical examination, specialized tests and blood
studies. Psycho-social history includes the complete assessment of cognitions, behaviors and
relational problems. It is also important to assess the levels of sexual awareness and
performance anxiety. It is essential to look for a lack of sexual knowledge, unrealistic sexual
expectations, the feeling of emasculation resulted from an unsuccessful sexual interaction,
anxiety about the size and function of the penis and general physical attractiveness. A complete
sexual history should include past and present levels of sexual activity and a history of abuse
or trauma. [1, 6, 7]
In addition to the assessment, there are a multitude of diagnostic instruments for premature
ejaculation which can be used for a comprehensive understanding of the individual’s disorder.
These include the “Index of Premature Ejaculation” (IPE); “Premature Ejaculation
Diagnostic Tool” (PEDT); “Premature Ejaculation Prevalence & Attitude” (PEPA); “Male
Sexual Health Questionnaire” (MSHQ). Relational assessment tools can also be useful:
“Dyadic Adjustment Scale” (DAS); “Golombok-Rust Incentory of Sexual Satisfaction”
(GRISS) and “Self-Esteem and Relationship Questionnaire” (SEAR). [1, 4, 5]
Treatment of premature ejaculation

The approach in treating premature ejaculation is typically either a biomedical option, a
psycho-behavioral treatment option or a combined therapy.
Biomedical treatment of premature ejaculation incorporates multiple drugs with various
results. The usage of local anesthetic and topical creams, gels or sprays are frequently
encountered in the treatment of premature ejaculation. The role of local anesthetics is to
diminish local sensitivity at the penis glans. The primary active substance in topical local
anesthetics is lidocaine. However, too much application can cause an exaggerated drop in the
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man’s local sensitivity and the transfer of the substances to the partner can create vaginal
numbness. To avoid the transfer, it is recommended the use of a condom. [4, 5, 9]
The use of selective serotonin reuptake inhibitors (SSRIs) is another medical option for
treating premature ejaculation. This class of medication is used primarily for its antidepressant
use but it has been shown to have a positive effect on delaying the ejaculatory response. Until
now, this type of medication was used daily, but recent studies have shown increased
effectiveness in on demand use, meaning the man administrates the medication several hours
before the initiation of sexual activity. Dapoxetine (Priligy®) has emerged as one of the most
effective oral treatments for premature ejaculation because of its very strong inhibition of
serotonin reuptake transporter and also a small half-life, resulting in a better on demand usage.
Patients should be informed not to discontinue the selective serotonin reuptake inhibitor
medication abruptly because of the discontinuation syndrome that is characterized by
symptoms of tremor, nausea and dizziness. The discontinuation should be carried out slowly
within 2 to 3 months. [5, 6, 7]
Another treatment option is the combination of anti-ejaculatory and pro-erectile drugs,
because approximately a third of men with premature ejaculation also report erectile problems.
These men are good candidates for treatment with both selective serotonin reuptake
inhibitors (SSRIs) and a phosphodiesterase – 5 (PDE-5) inhibitor such as sildenafil (Viagra®).
Other studies indicate that on demand use of clomiapramine or on demand use of tramadol
can be useful in the treatment of premature ejaculation but further studies need to be performed
to assess long term effectiveness. [1, 5, 8]
Psycho-behavioral treatment options

Psycho-behavioral treatment options include behavioral, cognitive, affective and relational
approaches. Men with premature ejaculation describe as having two moments during sexual
activity: no excitement and the point of ejaculatory inevitability. One of the roles of psycho-
behavioral treatment is to focus the man’s sexual experience on perceiving and staying in the
mid-range sexual excitement and to concentrate on their sexual arousal. [1]
Behavioral techniques
Behavioral techniques, which were first popularized by Seman, Kaplan and Masters and
Johnson, continue to play an important role in the treatment of premature ejaculation. These
are sometimes called premature ejaculation exercises. The aim of this exercises is to help men
learn to tolerate increasing levels of stimulation while being in control of their ejaculatory
reflex. These exercises or techniques are as follows: the new sensate focus technique, stop-start
technique, slow-fast technique, squeeze technique and quiet vagina technique. There are
multiple variations and applications of these techniques but the main principles remain the
same. [1, 2, 9]
The new sensate focus technique has two goals: reducing performance anxiety and
improving communication between partners. The exercises are designed for the partners to
focus on the sensual aspects of intimacy rather than on sexual performance. The goals of
sensate focus techniques are to help each partner to become more aware of his or her own
sensations, to focus on one’s own needs for pleasure, not worry about the partner’s problems,
communicate sensual and sexual needs, wishes and desires, increase awareness, expand the
repertoire of intimate sensual behaviors, learn to appreciate foreplay as a goal rather than a
means to an end. Other goals are to create positive relational experiences, build sexual desire,
enhance the level of love, caring, commitment, intimacy, cooperation and sexual interest in the
relationship. [1, 3, 10]
The start-stop technique or method implies that the man, or his partner, strokes his penis
while he is paying attention to the sensation and when he is near the point of ejaculatory
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inevitability, the man is asked to stop stroking and concentrate on the dissipation of the
sensation of near orgasm, but not long enough to lose erection. Variations on the method imply
modification of frequency, using dry or water-based lubricant for stroking the penis, and also
the usage of Kegel exercises (which are contractions of the pelvic floor muscles) at the moment
of ejaculatory inevitability that may help in achieving a better ejaculatory control. (1), (3), (8)
Another exercise is the slow-fast penile stimulation in which the man strokes the penis until
he reaches a high level of sexual excitement and then slows down rather than stopping
completely. Variations on the technique can be with the female partner in the superior position
using the man’s penis to touch the vagina without penetration and slowing down or stopping
before the point of ejaculatory inevitability. [1, 6, 9]
The squeeze technique is also a form of controlling ejaculation in which the man begins
stimulating himself or begins normal sexual activity with a partner and when he reaches the
point of ejaculatory inevitability the man or his partner can squeeze the end of the penis with
firm pressure until the sensation dissipates. Then the sexual activity can be continued and the
technique repeated as desired. [1, 2, 10]
The quiet vagina technique is an exercise where the partner is on top and inserts the man’s
penis in the vagina but doesn’t move, standing still or at most minimal movement, while the
man concentrates on the level of stimulation and controlling the ejaculatory reflex. This
technique is also known as non-demand coitus. [1, 4, 7]
Cognitive approaches
The cognitive approach implies the correct and thorough analysis of the man’s mental
process towards previous unsuccessful sexual interactions.
These negative preconceptions and ideas can help maintain and exacerbate the dysfunction,
while also creating anticipatory anxiety towards future sexual activity.
Rosen, Leiblum and Spector (1994), have identified multiple forms of cognitive distortions
which appear in men with premature ejaculation and include the following: all or nothing
thinking, overgeneralization, disqualifying the positive, mind reading, fortune telling,
emotional reasoning, categorical imperatives and catastrophizing. All or nothing thinking
implies that the man’s cognitions towards premature ejaculation are inflexible, firm and
unyielding, thinking that he is a complete failure because of his disorder.
Overgeneralization suggests that the man’s rationalization towards premature ejaculation is
that if he had trouble controlling ejaculation in the past it will surely appear in the future.
Disqualifying the positive signifies that the man thinks that good sexual reinforcements from
the partner are only to not hurt his feelings. Mind reading attitude and fortune telling underlines
a lack of communication in the couple, while emotional reasoning, categorical imperatives and
catastrophizing imply the man’s low self-esteem derived from the existence of the disorder. [1,
3, 10]
Affective approaches
The aim of affective approaches in the treatment of premature ejaculation is to understand
the underlying emotional problems the man developed as a result of the disorder and work
towards reducing the emotional anxiety surrounding sexual interactions. The purpose is to
create a balance between expressing suppressed emotions and regulating emotions if these are
overexpressed. [1, 6, 8]
Relational approaches
The relationship approach in treating patients with rapid ejaculation targets the man’s
relationship with his partner and is better managed with the inclusion of the partner.
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Couples counseling techniques focus on improving communication between partners’

sexual needs, reinforcing positive behaviors within the couple’s sexual interactions, observing
the interactional style between partners and looking for patterns representing conflicts that may
be responsible for their sexual disorder.
The intent is to shift the couple beyond an impasse that sometimes occurs when the partners
adapt to a sexually dysfunctional interaction and to work towards change as a team. [1, 2, 9]
CONCLUSION
Although premature ejaculation is a disorder that has been studied for many years, and a
great amount of information can be found on this subject, no treatment has been shown to be
fully efficient.
Combination of pharmacological and psycho-therapy has proven the most promising results
in treating premature ejaculation, offering superior efficacy to drug treatment alone.
REFERENCES
[1] Zoë D. Peterson – The Wiley Handbook of Sex Therapy (2017, Wiley Blackwell), pp. 72-97.
[2] Sandra R. Leiblum PhD – Principles and Practice of Sex Therapy, Fourth Edition (2006, The Guilford
Press), pp. 212-240.
[3] Katherine M. Hertlein, Gerald R. Weeks, Nancy Gambescia – Systemic Sex Therapy-(Routledge 2020),
pp. 77-91.
[4] Yitzchak M. Binik, Kathryn S.K. Hall, Joseph L. Wetchler – Principles and Practice of Sex Therapy,
Fifth Edition (The Guilford Press 2014), pp. 111-134.
[5] Waguih William IsHak – The Textbook of Clinical Sexual Medicine (Springer International Publishing
AG 2017), pp. 271-288.
[6] Katherine Milew Hertlein, Gerald Weeks, Nancy Gambescia - Systemic Sex Therapy (Routledge 2008),
pp. 108-126.
[7] Eric C. Krohne PhD- Sex Therapy Handbook a Clinical Manual for the Diagnosis and Treatment of
Sexual Disorders (1982, Springer Netherlands), pp. 53-60.
[8] Einat S. Metzl – When Art Therapy Meets Sex Therapy Creative Explorations of Sex, Gender, and
Relationships (2016, Routledge), pp. 72-96.
[9] Ross Morrow – Sex Research and Sex Therapy a Sociological Analysis of Masters and Johnson (2007,
Routledge), pp. 75-96.
[10] Joseph LoPiccolo, Leslie LoPiccolo – Handbook of Sex Therapy (1978 Plenum Press, New York), pp.
271-286.
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EARLY EJACULATION
Abstract
Information on the epidemiology, etiology and treatment of premature ejaculation is

reviewed. Evidence of the prevalence of premature ejaculation indicates that subjective
concern about rapid ejaculation is a common concern worldwide. The hypotheses regarding
the pathogenesis of premature ejaculation include: 1) that it is a learned model of ejaculation
maintained by interpersonal anxiety and 2) that it is a dysfunctional result of the central or
peripheral mechanisms that regulate ejaculatory thresholds and 3) that it is a normal variant in
latency ejaculation. Current evidence-based treatment interventions include behavioral
psychotherapy and the use of pharmacological agents, including topical anesthetics and
selective serotonin reuptake inhibitors. The purpose of this paper is to review the existing
knowledge base on the definition, prevalence, etiology and treatment of premature ejaculation.
American Psychiatric Association (2013).
Keywords: premature ejaculation, psycho-behavioral treatment, behavioral techniques, cognitive approaches,
affective approaches, relational approaches
INTRODUCTION
The definition and treatment of premature ejaculation has evolved considerably in recent
decades. It was initially considered a learned behavior that could have been treated with
behavioral therapy. Then, once it was recognized that serotonergic drugs could delay
ejaculation, clinicians began to assume that physiological mechanisms rather than
psychological ones could be primary in the etiology and maintenance of rapid ejaculation. To
date, there is no definitive evidence on the etiology, and there is minimal evidence to dictate
whether behavioral treatment or a combination of these should be used in treatment. Wiliam
Masters & Virginia E. Johnson (2010).
Premature ejaculation is considered one of the most common male sexual dysfunctions.
Some doctors have even suggested that the term premature ejaculation involves pathology
and that it should be replaced with the term rapid ejaculation, which is simply descriptive.
Vlaicu A. G., & Delcea C., (2020).
Officially accepted definitions are inaccurate. There is a lack of agreement on the
operational definitions used in clinical research and there is also a lack of agreement on the
threshold value of ejaculatory latency, which delimits a pathological condition of normality.
Coșcodan E., (2020).
Masters and Johnson defined premature ejaculation as the man’s inability to delay
ejaculation long enough for his partner to reach orgasm in 50% of coital encounters. This
definition has a major defect, namely, it is conditioned by the partner’s orgasm. Because, if a
woman was anorgasmic, then her partner would have been diagnosed with premature
ejaculation. Helen Singer Kaplan defined ejaculation as the absence of voluntary control over
ejaculation. However, many men would not consider their ejaculatory latency to be under
voluntary control. There are two official definitions. Manual of Diagnosis and Statistics of
Mental Disorders (DSM V) and International Classification of Diseases and Related Health
Problems (ICD-10). DSM V defined premature ejaculation as persistent or recurrent
ejaculation with minimal stimulation before or immediately after penetration and before the
person desires it. ICD-10 has a definition that requires an inability to delay ejaculation, enough
to enjoy sexual activity. Ejaculation should occur before or very soon after penetration.
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DSM-V makes a distinction between lifelong and acquired premature ejaculation, as well
as worldwide premature ejaculation and the premature situation. There is minimal evidence
that such distinctions have clinical correlations or treatment implications. In general, it is
assumed that global premature ejaculation may also show a constitutional predisposition to
rapid ejaculation, while premature ejaculation in one sexual situation and not another would be
more likely to be related to psychological problems. DSM also recommends distinguishing
between organic and psychological etiologies.
Diagnostic criteria
According to DSM V, the diagnostic criteria refer to a persistent or recurrent pattern of
ejaculation during sexual intercourse with a partner, approximately one minute after vaginal
penetration and before the individual so desires. This symptom must be present for at least 6
months and manifest in all or almost all (75-100%) of sexual activities. It must cause clinical
discomfort. It is also not better explained by a mental disorder without a sexual component or
as a consequence of serious problems in the couple, or other stressors, nor can it be considered
as a side effect when using certain substances or drugs. Depending on the severity of the
symptom, it is: mild, moderate and severe.
The light one occurs 30 seconds to one minute after penetration. In the moderate one,
ejaculation occurs 15-30 seconds later vaginal penetration and in severe ejaculation occurs
either before, or at the beginning, or in the first 15 seconds after penetration.
Debut and evolution

Permanent premature ejaculation begins in the first sexual experiences and persists
throughout life. But there are men who, even if they have problems at the beginning, start to
control the duration of ejaculation and there is the other category in which men, after a normal
ejaculation in the first period of life, develop this problem and then we talk about acquired
premature ejaculation. There is less information about the acquired ejaculation compared to the
permanent one, because the acquired ejaculation appears late, usually after the second decade
of life, while the permanent one is more stable, appearing, as we mentioned in the first sexual
experiences and is maintained on throughout life.
The elements of cultural or gender diagnosis can be imported into the diagnosis, because
the latency time in ejaculation can be different in many cultures, taking into account both
religion and genetic variations between populations. Also, the way in which modern society
sees a woman’s sexual activity has made people have different opinions regarding the latency
of ejaculation, women becoming more concerned lately with the couple’s sexual activity.
Diagnostic markers
The latency time of ejaculation is usually measured in the centers, by the sexual partner, by
using a timing device, although this method is not suitable in real life. In the case of vaginal
intercourse, the time from penetration to ejaculation is measured.
Differential diagnosis
If premature ejaculation occurs due to substance use, intoxication or discontinuation of
substance use, the diagnosis of sexual dysfunction induced by substance use or medication
should be established.
Ejaculation disorders that do not meet the diagnostic criteria: Men who have normal latency
time and who want to increase it and those who have episodic premature ejaculation (during
the first sexual intercourse with a new partner, in which case short latency is normal and often
encountered) should be identified. Neither of these should lead to the diagnosis of premature
ejaculation, even if both situations bring discomfort to men.
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Comorbidities
Premature ejaculation may be associated with erectile dysfunctions. It is difficult to establish
who preceded the other. Permanent premature ejaculation may be associated with the anxious
disorder, while acquired premature ejaculation may be associated with prostate, thyroid disease
or substance use.
Epidemiology
The largest study conducted in America was the National Health and Social Survey and
included a sample of 18-59-year-olds. About 28% reported premature ejaculation problems.
It was the largest complaint reported, in the oldest study group, never married and with a
minimum education. Another study conducted in the UK used anonymous questionnaires and
the prevalence was 31%. There was a significant association of the presence of premature
ejaculation and anxiety, measured on the scale of anxiety and depression. The global study of
sexual attitudes and behaviors provided data on 27,500 subjects aged 40-80 in 29 countries,
using a standard questionnaire, in-person or telephone interview.
Sampling methods from North America, Australia, South Africa and New Zealand consisted
of telephone interviews chosen by numerical dialing. In this population, approximately 28%
complained of rapid ejaculation. The prevalence was over 20% in Europe, Asia and South
America, while in The Middle East was about 13%. It should be noted that none of these studies
assessed ejaculatory latency or the level of interpersonal suffering.
DSM requires the presence of personal or interpersonal distraction to diagnose any sexual
disorder. There may be large differences between the prevalence of stress in men compared to
their partner. Haavio-Mannila and Kontula reported data on the survey of the population of
Sweden, Finland, Estonia, St. Petersburg, Russia and the conclusion was that 2/3 of the men
said that their partners have too long to reach orgasm. This is given that 18-20% of women
complained of premature ejaculation of their partners, while only 2-3% of men reported having
premature ejaculation problems. This proves once again that social change has raised
expectations among women.
Given that there is no agreement on the definition, it is not surprising that there are different
theories of etiology. These theories are related to different approaches to treatment and there is
minimal evidence to support one theory over the others. They fall into two major classes:
psychological and biological. The psychological ones fall into two groups based on
psychodynamic theory and learning.
The psychodynamic ones they are rarely accepted by clinicians, making unconscious anger
towards a partner a major etiological factor and this is because it is assumed that he may have
unconscious sadistic feelings towards women, emotional immaturity, denying women’s
pleasure through this premature ejaculation. The treatment consists of individual
psychotherapy. There is minimal evidence, both in support and in rejecting this theory. The
most accepted hypothesis is that of Master and Johnson, namely, that it is a learned model of
rapid ejaculation, maintained by anxiety. Anxiety regarding sexual insufficiency can interfere
with a man’s ability to monitor his arousal and ejaculation. This theory has a simplicity of
common sense, although there is minimal evidence to support and reject it. Other clinicians
argue that including relationship factors, such as the partner not encouraging, or even
sabotaging her partner’s learning control, and the situation in which the couple would need a
“symptom” to draw attention to other issues. This hypothesis is promoted by a small number
of clinics. Laboratory studies have failed to demonstrate a difference between men with
premature ejaculation and sexual arousal or sensory sensitivity. Although there is minimal
evidence to support a relationship between the laboratory measures of performance anxiety and
rapid ejaculation, there is some evidence to support the relationship between premature
ejaculation and anxiety as a general trait or psychiatric disorder. Sexual function was examined
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in patients with panic disorder and social anxiety and it was found that 47% of patients with
social phobia suffer from premature ejaculation. Studies that show a shorter latency of
ejaculation in penetration activities than masturbating ones in men with premature ejaculation
compared to men who have better ejaculation control could be interpreted as claiming that
cognitive and biological factors play a role in genesis and maintenance of rapid ejaculation.
Biological theories regarding the etiology can be separated into two major groups: those that
emphasize peripheral or spinal mechanisms as opposed to those that emphasize brain
mechanisms. It is possible that the two are correlated, because the mechanisms of the brain can
influence peripheral ejaculatory thresholds and sensory sensitivity. The main theoretical
formula for the brain mechanisms that underlie premature ejaculation throughout life was
formulated by Dutch psychiatrist Waldinger. He argues that rapid ejaculation patterns are
genetically determined and that men with hyposensitivity to the 5HT2c receptor and
hypersensitivity to 5HT1a receptor, have ejaculatory thresholds set at a lower point.
Serotonin is a neurotransmitter with the function of a neuromodulator synthesized from the
amino acid tryptophan. Tryptophan is an amino acid found in the proteins we take from our
diet. Once in the body, proteins turn into 5-HTP, which in turn turns into serotonin. 5-HT1
receptors have been implicated in producing the antidepressant effect of new antidepressant
drugs, which selectively inhibit serotonin reuptake. 5-HT2 receptors are represented in the
cortex, in the extrapyramidal system and have been involved in the mechanism of
hallucinations, by some hallucinogenic substances, as well as in anxiety phenomena. Voinea
M. M., & Delcea C., (2020).
The hypothesis of different effects on ejaculation by stimulating serotonergic receptors is
mainly based on data that serotonergic drugs that activate the 5HT2 receptor (e.g., paroxetine)
delay ejaculation and that this can be reversed by drugs that stimulate the 5HT1 receptor (e.g.,
buspirone). Although this theory seems appealing, there is little evidence to support it.
Waldinger reported a higher family incidence of premature ejaculation based on a small
sample of men with fast ejaculation. Intrinsic to Waldinger’s theory is that rapid ejaculation is
a normal variation of ejaculatory speed and as such is not a psychiatric disorder. This is similar
to the hypothesis that rapid ejaculation can probably have adaptive value. We can note that the
hypothesis of the genetic difference in the ejaculatory threshold does not exclude the fact that
men with a tendency to ejaculate quickly have the opportunity to learn ways to compensate for
their hereditary tendencies. In conclusion, there is minimal evidence to support any of the
current theories regarding the etiology of premature ejaculation throughout life. It would seem
reasonable to assume that there are inherited differences in the ejaculatory threshold, so that
the tendency to rapid ejaculation can be compensated to some extent by social learning and
that interpersonal anxiety could interfere with this learning. Although, this statement is
compatible with the available data, there is minimal evidence to support it. Delcea C. (2019).
There is isolated evidence of possible factors contributing to premature ejaculation. Several
clinical series have reported a high prevalence of premature ejaculation in men with chronic
prostate and there is a case report of normalization of ejaculatory time with prostate treatment.
There are also reports regarding the high incidence in patients who suffered traumatic brain
injuries, spinal cord injury, in men with diabetes, in hemodialysis patients None of these studies
had a comparison group. Delcea C. (2019).
Due to the fact that in the case of the studies, the sample was small and also the absence of
a uniform definition, these findings should be considered only generators of hypotheses. Delcea
C. (2019).
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Treatment
Three major treatment approaches are known: behavioral therapy procedures, topical
anesthetic ointments, and oral agents, especially those with serotonergic effects. All three
approaches have been shown to be effective. Delcea C. (2019).
The technique of manual stimulation of the penis by the partner, which was stopped when
he signaled orgasm can also be useful. Repeating this technique at least twice a week for 5-6
weeks while giving up intercourse reported an increase in ejaculatory control, probably because
the man became more aware of the level of arousal. This technique was modified by adding
brake squeezing, when the man signaled to his partner that ejaculation was imminent.
Numerous clinicians have reported high success rates with these techniques, and better
combined with couple therapy. Delcea C. (2019).
The use of local anesthetic creams and sprays has been reported to be effective in delaying
ejaculation. The side effect is penis hypoanesthesia. Vaginal absorption may occur if a condom
is not used. Delcea C. (2019).
Pharmacological treatments originate in the fact that some psychiatric drugs have been
found to have a side effect, delayed ejaculation. For example, clomipramide, used in the
treatment of obsessive-compulsive disorder in 1987, found that 96% of patients had an inability
to ejaculate or severe delayed ejaculation. Studies have shown that chronic doses of
clomipramide, paroxetine, sertraline, fluoxetine and citalopram delayed ejaculation in men
with rapid ejaculation. Delcea C. (2019).
CONCLUSIONS
It is obvious that complaints about premature ejaculation are quite common, globally.
Absence of an accepted and precise definition limits the conclusions we can draw on the
epidemiology of this disorder.
There is evidence that men with premature ejaculation are more likely to take questionnaires
that indicate anxiety and there is also evidence that may indicate certain changes in social
norms that have made women have other expectations about sexual activity.
The available data suggest that both behavioral therapy and pharmacotherapy may be
effective. Among the pharmacotherapeutic approaches, evidence supports the efficacy of
antidepressants (paroxetine and clomipramide) and the use of topical anesthetics agents. There
is no evidence as to when we should use psychotherapy as opposed to pharmacological
products, or when they both should be used at the same time.
REFERENCES
[1] American Psychiatric Association. (2013). DSM 5; pp. 698-700. Editura Callistro.
[2] Wiliam Masters & Virginia E. Johnson. (2010). Human Sexual Inadequacy. Ishi Press Publisher.
[3] Osmo Kontula & Elina Haavio-Mannila, Wiliam Sexual Pleasures Enhancement of Sex Life in Finland,
1971-1992, Aldershot: Dartmouth 1995.
[4] Vlaicu A. G., & Delcea C., (2020). Sex Therapy in the Treatment of Premature Ejaculation. Int J
Advanced Studies in Sexology. Vol. 2, Issue 2, pp. 80-84. Sexology Institute of Romania. DOI:
10.46388/ijass.2020.13.23
[5] Coșcodan E., (2020). Ejaculation disorders. Int J Advanced Studies in Sexology. Vol. 2, Issue 2, pp. 85-
88. Sexology Institute of Romania. DOI: 10.46388/ijass.2020.13.24.
[6] Voinea M. M., & Delcea C., (2020). Painful intercourse. Dyspareunia and Vaginismus. An Individual
Psychology Approach. Int J Advanced Studies in Sexology. Vol. 2, Issue 1, pp. 38-48. Sexology Institute
of Romania. DOI: 10.46388/ijass.2020.13.17.
[7] Delcea C. (2019). Erectile dysfunction. Int J Advanced Studies in Sexology. Vol. 1, Issue 1, pp. 15-22.
Sexology Institute of Romania. DOI: 10.46388/ijass.2019.12.113.
[8] Delcea C. (2019). Orgasmic disorder in men. Int J Advanced Studies in Sexology. Vol. 1, Issue 1, pp.
28-32. Sexology Institute of Romania. DOI: 10.46388/ijass.2019.12.115.
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[9] Delcea C. (2019). Sexual desire disorder in men. Int J Advanced Studies in Sexology. Vol. 1, Issue 1,
pp. 33-35. Sexology Institute of Romania. DOI: 10.46388/ijass.2019.12.116.
[10] Delcea C. (2019). Ejaculation disorder. Int J Advanced Studies in Sexology. Vol. 1, Issue 1, pp. 39-43.
[11] Delcea C. (2019). Dyspareunia in men. Int J Advanced Studies in Sexology. Vol. 1, Issue 1, pp. 48-52.
Sexology Institute of Romania. DOI: 10.46388/ijass.2019.12.11.120.
[12] Delcea C. (2019). Orgasmic disorder in women. Int J Advanced Studies in Sexology. Vol. 1, Issue 1, pp.
56-67. Sexology Institute of Romania. DOI: 10.46388/ijass.2019.12.11.122.
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EJACULATION DISORDERS
Abstract
Ejaculation disorders are one of the sexual problems faced by the male population. These
are common and are often associated with other comorbidities. This article aims to present
conclusive information in the identification of ejaculation disorders, together with the
psychological factors directly involved in their onset and evolution.
Keywords: sexual impulse, sexual behavior, ejaculation disorders, premature ejaculation sexual dysfunction,
delayed ejaculation, physiological factors, psychological factors
INTRODUCTION
Since ancient times, sexuality has played an important role in the development and evolution
of mankind. Each society, depending on the culture, religion, values, traditions, customs,
specific to each geographical area, presents certain rules in order to adapt, both to the
community they belong to and to the relationships between individuals. These rules also apply
to sexual behavior. The natural expression of natural sexual impulses was often limited by
formal and informal education. In the study “Demonstration of fetal penile erection in utero”,
conducted in 1980 by Hitchcock DA, Sutphen JH, Scholly TA., it is certified that the impulses
that are part of sexual behavior, appear from the first months after birth, in the form of
“erection”.
Parents’ reactions, education, and attitudes toward sexuality, in terms of these sexual
impulses, contribute to and influence the evolution and development of future adult sexual
behavior. Also, another important factor in terms of the evolution of sexuality, may be the
surprise of the parents by the child, in the middle of the love act, an action interpreted, in most
cases by the child, as an aggression.
Thus, people who receive a rigid and severe education may develop sooner or later: deviant
sexual behaviors, sexual dysfunctions, paraphilias, gender identity disorders, ejaculation
disorders and others. In the following, we will address ejaculation disorders that are specific to
men.
Theoretical approach
According to the “Pocket Clinical Psychiatry Handbook” by Kaplan & Sadock, 2015,
ejaculation disorders refer to sexual dysfunctions that are affected by a number of factors, such
as: biological, psychological and sociological factors. “The expression of sexuality can be
affected by internal and external genitals, hormones and neurohormones, intrapsychic
dynamics, interpersonal relationships, socio-economic status and prevalent cultural morals.”
When multiple episodes of ejaculation disorder occur, “sexual performance anxiety”
inevitably occurs, and it “aggravates the disorder and tends to perpetuate it.”
In the literature, ejaculation disorders include the following sexual dysfunctions: premature
ejaculation, delayed ejaculation, retrograde ejaculation, anejaculation.
Premature ejaculation (PE) is also called premature ejaculation. Before defining this
disorder, it is important to know the definition of the duration of sexual intercourse. The answer
to this question can be found in the paper entitled: “Male sexual dysfunctions. Erectile
dysfunction and ejaculation disorders”, by Ion Dumbrăveanu, namely: “... as long as both
partners feel good”.
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In the same vein, the author encourages us to differentiate between sexual intercourse and
latent intravaginal time. To begin with, it is important to know that a fulfilling sexual act
consists of at least three components, namely: foreplay, play and postplay.
The prelude, for some younger, inexperienced people, is often missing, or done in a hurry.
However, in some works of sexology, the foreplay is mentioned as a significant component,
given the quality of a fulfilling act of love. The recommendation to perform this step is about
30 minutes, during which the man explores by caressing, gently touching the woman’s
erogenous zones.
In this way, the woman relaxes and adjusts to her boyfriend, who prepares her for the next
stage, namely play. In the above-mentioned paper, the definition of premature ejaculation is
also mentioned, which “is characterized by the occurrence of ejaculation at an interval of less
than 2-3 minutes from the intrusion or at least 25-30 frictions.” In other words, it refers to the
situation in which the man reaches orgasm and ejaculation before he wants to.
This disorder is “more prevalent in young men, men with a new partner and those with
higher education,” compared to those without higher education. According to Kaplan &
Sadock, 2015, “it is considered to be related to partner satisfaction”.
Premature ejaculation can be occasional, accidental and can occur in the presence of strong
emotions or at the other pole, when he does not feel any emotion towards his girlfriend. Also,
this disorder can occur after a long period of abstinence or early onset of sexual activity, being
conditioned by the absence of sex education, when the body is not fully matured.
The physiological factors involved in this disorder are:
• drug use;
• prostate surgery;
• chronic prostatitis;
• thyroid disorders;
• urogenital inflammation caused by sexually transmitted infections.
Premature ejaculation disorder is most often associated with several psychological factors,
such as:
• unconscious fear of the vagina;
• couple or family relationship problems;
• depression;
• anxiety related to sexual performance.
Delayed ejaculation is also found in psychology works with the name of late ejaculation,
and refers to the situation in which the man is facing a significant delay in ejaculation. The
causes of this disorder can be both physical and psychological.
Physiological factors include:
• age;
• the presence of diabetes;
• spinal cord injuries;
• multiple sclerosis;
• the presence of a drug treatment (this can be antidepressants, antipsychotics, strong
anesthetics, drugs that treat high blood pressure or those that relax muscles,
tranquilizers or inhibitors of serotonin uptake).
And the psychological factors include:
• untreated sexual traumas from childhood;
• alcohol consumption;
• drugs;
• late secondary hypergonadism;
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• stress;
• couple or family relationship problems.
Another disorder included in ejaculation disorders is anejaculation (it is when it is
impossible to ejaculate, regardless of the duration of sexual intercourse, even if there may be
the presence of orgasm). Physiological factors can be:
• the consequence of neurological diseases;
• traumas to the spine;
• surgery;
• multiple sclerosis;
• diabetes.
The psychological factors in this disorder may be similar to late ejaculation disorder.
Retrograde ejaculation or “dry ejaculation” (is when semen is directed to the bladder,
instead of through the urethral canal). This is considered to be a disorder, even if the man
reaches orgasm. Under such conditions, normal ejaculation is completely absent, or only a very
small amount of semen may be expelled. This phenomenon can be easily observed immediately
after orgasm, when it can be seen that the urine is “cloudy”, being mixed with semen. We must
also mention that this disorder can affect the quality of semen, in the case of the man who wants
to have children.
The physiological factors involved in the occurrence of retrograde ejaculation can be:
• surgery on the prostate or bladder;
• neurological diseases;
• diabetes;
• damage to the nerves located near the bladder;
• multiple sclerosis.
The psychological factors associated with this disorder are:
• tiredness;
• stress;
• consumption of hallucinogenic substances;
• low self-image;
• anticipatory anxiety;
• inhibition of sexual impulses.
In the same formula, we can mention that at the level of psychological factors, in addition
to those mentioned, are added: limiting beliefs, prejudices, dysfunctional thoughts, feelings of
shame and guilt accumulated from childhood.
CONCLUSION
In conclusion, it is important to mention that in the psychotherapy of sexual dynamics

disorders, the diagnosis is made by an authorized specialist in ejaculation disorders. If drug
treatment is recommended, it is applied in conjunction with psychotherapy sessions.
With the help of a complex approach, in order to solve psychological and emotional
problems, both consciously and unconsciously they are approached through psychotherapy:
automatic thoughts, erroneous conclusions, sexual traumas related to sexuality acquired in
childhood and adolescence. Numerous studies (Delcea C, 2019; Delcea C, 2019; Voinea M.
M., & Delcea C., 2020; Delcea C., Perju-Dumbrava D., Kovacs, M. I., et al., 201) confirm our
results.
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For effectiveness in treating ejaculation disorders, it is recommended to look beyond the act
of treating sexual dysfunction itself, which is the correct relationship to sexuality, taking into
account both the sexual component and the emotional component.
REFERENCES
[1] Kaplan & Sadock. Clinical Psychiatry Pocket Handbook, 2015.

[2] Florin Tudose, Cătălina Tudose, Letitia Dobrănici. Treatise on psychopathology and psychiatry for
psychologists, 2011.
[3] The National Health Service (NHS) – https:// www.nhs.uk/conditions/ejaculation-problems/
[4] Accuracy of fetal sex demonstration by ultrasound https://obgyn.onlinelibrary.wiley.
com/doi/pdf/10.1046/j.0960-7692.2001. 00477.x
[5] American Pregnancy Association – http:// americanpregnancy.org/infertility/maleinfertility/
[6] Delcea C. Ejaculation disorder. Int J Advanced Studies in Sexology. Vol. 1, Issue 1, pp. 39-43. Sexology
Institute of Romania, 2019. DOI: 10.46388/ijass.2019.12.118.
[7] Delcea C. Erectile dysfunction. Int J Advanced Studies in Sexology. Vol. 1, Issue 1, pp. 15-22. Sexology
Institute of Romania, 2019. DOI: 10.46388/ijass.2019.12.113.
[8] Voinea M. M., & Delcea C. Painful intercourse. Dyspareunia and Vaginismus. An Individual
of Romania, 2020. DOI: 10.46388/ ijass.2020.13.17.
[9] Vlaicu A. G., & Delcea C. Sex Therapy in the Treatment of Premature Ejaculation. Int J Advanced
Studies in Sexology. Vol. 2, Issue 1, pp. 72-76. Sexology Institute of Romania, 2020. DOI:
10.46388/ijass.2020.13.23.
[10] Delcea C., Perju-Dumbrava D., Kovacs, M. I., et al., S plus X-Sextherapy Software. Proceedings of 1st
International Conference Supervision in Psychotherapy. Pp. 65-68, 2018. Filodiritto Publisher.
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1.2 Erectile dysfunction
ERECTILE DISORDERS
Abstract
Erectile dysfunction occurs in individuals who have a constant or repeated marked difficulty
in obtaining or maintaining the necessary erection to allow sexual intercourse. This paper aims
to present the clinical picture of the disorder, diagnostic elements and differential diagnosis
and to present a new perspective of the situation.
Keywords: erectile, DSM-5, ICD-10, prevalence, risk factors, diagnosis
INTRODUCTION
Permanent erectile dysfunction compared to the prevalence of the acquired one is unknown.
There is a significant increase in both the prevalence and incidence of erectile problems with
age, especially after 50 years. Statistics show that 13-21% of men aged 40-80 face this problem
occasionally. About 2% of men under the age of 40 report frequent erectile problems, while
40-50% of men over the age of 60-70 may have significant erectile difficulties. About 20% of
men fear the possibility of an erectile problem during the first sexual experience, while about
8% had erectile dysfunction that prevented penetration during their first sexual experience. [1]
Definitions
From the DSM-5 perspective, 4 major diagnostic criteria are presented:
• at least one of three symptoms must be present in all or about 75-100% of sexual
intercourse:
o constantly marked or repeated difficulty in obtaining the necessary erection to
perform an act sexual
o constantly marked or repeated marked difficulty in maintaining the necessary
erection to allow sexual intercourse. a marked decrease in erectile stiffness
• the symptoms are present for a period of at least 6 months.
• symptoms cause significant discomfort to the individual.
Sexual dysfunction is not explained by a mental disorder without a sexual component or as
a consequence of a severe relationship problem or other stressors and cannot be attributed to
the effects of a substance or medicine or a medical condition.
It is important to specify the type of erectile dysfunction:
• permanent – the disorder has been present since the individual became sexually active,
• acquired – the disorder began after a period of relatively normal sexual function or,
• generalized – is not limited to certain types of stimulation, situations or partners,
• situational – occurs only in the case of certain types of stimulation, situations or
partners.
From the point of view of the current severity it can be:
• mild – if there are signs of mild suffering caused by symptoms;
• moderate – if there are signs of moderate suffering caused by symptoms;
• severe – if there are signs of severe suffering caused by symptoms; [1]
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In ICD-10, the definition of erectile dysfunction is short and to the point, summarizing the
main problem of men who have difficulty developing or maintaining an adequate erection for
satisfactory sexual intercourse. [9]
ICD-10 the erectile response is coded as insufficiency of the genital response. [1]
RISK FACTORS AND FORECAST
Temperament factors. Neurotic personality disorders may be associated with erectile

dysfunction in students, and personality traits may be associated with erectile dysfunction in
men over 40-years of age. Alexithymia (deficiencies in cognitive processing of emotions) is
common in men diagnosed with psychogenic erectile dysfunction. Men with depression and
post-traumatic stress disorder may have erectile problems.
Factors that change evolution. Risk factors for erectile dysfunction are: age, smoking, lack
of exercise, diabetes and reduced sexual desire. [1]
According to multinational studies, erectile dysfunction in young men is an increasingly
common condition. Careful diagnostic evaluation should focus on identifying any underlying
etiology to ensure adequate management for the patients before proceeding with potentially
costly and invasive treatment options. [5]
DIAGNOSIS AND TREATMENT
Diagnostic elements
• The essential diagnostic element of erectile dysfunction is the repeated inability to get
or maintain an erection during sexual intercourse with a partner. (Criterion A).
• The history of sexual activity is important to determine whether the problem has been
present for a significant period of time (at least for 6 months) and occurs in most sexual
acts (at least 75% of the time).
• Symptoms may only occur in certain situations involving certain types of stimulation
or partners or may occur in all types of situations, stimuli or partners. [1]
Associated elements that support the diagnosis

In the process of evaluating and establishing the diagnosis of erectile dysfunction, other
factors that may be relevant to the etiology and treatment must be considered:
• factors related to the partner (e.g., sexual problems of the partner or his state of health);
• sexual activity;
• factors related to the individual’s vulnerability (negative image of one’s own body,
history of sexual or emotional abuse, depression, anxiety, stressors);
• cultural/religious factors (inhibitions related to the prohibition of sexual activity,
attitude towards sexuality;
• medical factors relevant to prognosis, evolution and treatment. [1]
Debut and evolution

Failure to get an erection during the first sexual experience is related to:
• unknown partner until the act of intercourse;
• drug or alcohol use;
• lack of desire to have sex.
These problems resolve spontaneously without specialized intervention, but some men may
experience episodic symptoms. [1]
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Acquired erectile dysfunction is often associated with biological factors such as diabetes
and cardiovascular disease and tends to persist. The natural history of permanent erectile
dysfunction is unknown, and the clinical examination associates the symptoms with self-
limited psychological factors or those that respond to psychological interventions, as opposed
to the acquired one which is still persistent but associated with biological factors. [1]
Through its connection with self-image and sexual problems, erectile dysfunction can cause
psychological damage. [8]
Diagnostic elements dependent on the cultural environment

The symptoms of erectile dysfunction vary in different countries. It is not clear to what
extent these differences represent differences resulting from cultural expectations, or real
differences in the frequency of inability to obtain an erection. [1]
Sexual dysfunction in older men is a dynamic disorder whose incidence and remission are
predicted by a number of modifiable risk factors.
The incidence of erectile dysfunction in relation to biopsychosocial factors,
sociodemographic factors, with lifestyle and of health was described. The highest incidence of
erectile dysfunction was observed in men with: older age, lower income, higher mass of
abdominal adipose tissue, reduced alcohol consumption, higher risk of obstructive sleep apnea,
lower urinary tract symptoms, depression and diabetes. The lower incidence was observed in
younger men who have work and the absence of other diseases such as ischemic heart disease,
diabetes and dyslipidemia. [3]
About one in three men in New Zealand, aged between 40 and 70, has erectile dysfunction.
Although it is comparable to populations in neighboring geographical areas, this prevalence is
high. [7]
Premature ejaculation is higher than erectile dysfunction in Asia-Pacific countries. 45% of
men diagnosed with premature ejaculation and erectile dysfunction were dissatisfied with the
duration of sexual intercourse before ejaculation, their control over ejaculation and,
respectively, sexual intercourse. [6]
Diagnostic markers
Useful methods in differentiating organic erectile problems from psychogenic ones are:
testing nocturnal penile intumescence and measuring erectile turgor during sleep. At the base
of this differentiation is the theory that adequate erections during sleep with rapid eye
movements indicate a psychological etiology of the problem.
Depending on the doctor’s decision, other diagnostic procedures can be performed:
• Doppler ultrasonography,
• intravascular injection of vasoactive drugs,
• cavernosonography with dynamic injection,
• studies of impulse conduction at the level of the shameful nerve,
• serum bioavailability of free testosterone,
• investigation of thyroid function,
• determining the existence of diabetes by determining fasting blood glucose,
• measuring the concentration of plasma lipids. [1]
Mental disorders without sexual component.
Major depressive disorder and erectile dysfunction are closely associated and there are cases
where erectile dysfunction coexists with major depressive disorder.
Normal erectile function should be considered in men with exaggerated expectations.
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Substance and drug use – has a specific onset of the disorder that coincides with the
beginning of the administration of the substance or drug and disappears upon discontinuation
or reduction of dose.
Medical conditions. The difference between erectile dysfunction as a mental disorder and
erectile dysfunction as a result of a medical condition is usually unclear and many cases have
complex psychological and psychiatric etiologies that influence each other. If the individual is
over 40-50 years old and/or has concomitant medical problems, the differential diagnosis
should include medical etiologies such as diabetes. Age under 40 is suggestive of the
psychological etiology of the disorder.
Other sexual dysfunctions. Erectile dysfunction can coexist with premature ejaculation and
hypoactive sexual desire disorder in men. [1]
Comorbidities
- Premature ejaculation Disorder of hypoactive sexual desire in men,
- Anxiety and depressive disorder, Prostate hypertrophy with lower urinary tract
symptoms,
- Dyslipidemia,
- Cardiovascular disease Hypogonadism Multiple sclerosis Diabetes mellitus [1].
Erectile dysfunction and premature ejaculation are reported by one in six infertile patients.
Erectile dysfunction is mainly associated with depressive symptoms and with symptoms and
signs of prostatitis, phobic anxiety. [2]
Treatment of erectile dysfunction

The treatment of erectile dysfunction has evolved with scientific research involving from
psychotherapy and treatments based on plant extracts, to more complex surgical and drug
therapies, even studying treatments based on genetic transformations, which are still in the
research stage. The treatment consists of:
• administration of medicinal preparations,
• surgical treatment – performing surgical interventions,
• family counseling,
• changing lifestyle and often the psycho-emotional relationship with the partner,
• exclusion of risk factors,
• treatment of associated diseases. [4]
CONCLUSION
Erectile dysfunction mainly affects men aged 50-59 years, and their number increases with
age. However, erectile dysfunction is not a normal part of the aging process and can occur even
in young men. In most cases, the dysfunction does not occur suddenly, but gradually sets in.
Various studies on the health and habits of the subjects managed to identify several factors
that increase the risk of erectile dysfunction. Most often, these factors risk acts simultaneously.
Mainly through its connection with self-image and sexual problems, erectile dysfunction
can cause major psychological damage.
REFERENCES
[1] American Psychiatric Association. (2013). DSM 5, pp. 426-429. Editura Callistro.
[2] Lotti F, Corona G, Rastrelli G, Forti G, Jannini EA și Maggi M. Clinical Correlates of Erectile
Dysfunction and Premature Ejaculation in Men with Couple Infertility. The Journal of Sexual Medicine,
Volume 9, Issue 10, October 2012, pp. 2698-2707 https://pubmed.ncbi.nlm.nih. gov/228977 16/
28
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[3] Martin SA, Atlantis E, Lange K, Taylor AW, O’Loughlin P, Wittert GA, and members of the Florey
Adelaide Male Ageing Study (FAMAS). Predictors of sexual dysfunction incidence and remission in
men. The Journal of Sexual Medicine, 2014; 11: pp. 1136-1147. https://
onlinelibrary.wiley.com/doi/abs/1 0.1111/ jsm.12483
[4] Ministerul Sănătății al Republicii Moldova. Disfuncţia erectile Protocol clinic naţional PCN-261
http://msmps.gov.md/wpcontent/ uploads/2020/06/15250-PCN-261.pdf
[5] Nguyen HMT, Gabrielson AT, Hellstrom WJG. Erectile Dysfunction in Young Men – A Review of the
Prevalence and Risk Factors. The Journal of Sexual Medicine, Rev 2017; 5: pp. 508-520.
https://pubmed.ncbi.nlm.nih.gov/28642047/
[6] Park JK, and Adaikan PG. Premature ejaculation and erectile dysfunction prevalence and attitudes in the
Asia‐Pacific region. The Journal ofSexual Medicine, 2012; 9: pp. 454-465.
https://pubmed.ncbi.nlm.nih.gov/22023395/
[7] Quilter M, Hodges L, von Hurst P și colab. Male Sexual Function in New Zealand: A Population-Based
Cross-Sectional Survey of the Prevalence of Erectile Dysfunction in Men Aged 40-70 Years. The Journal
of Sexual Medicine, 2017; 14: pp. 928-936.
[8] https://pubmed.ncbi.nlm.nih.gov/28673435/
[9] Wikipedia https://en.wikipedia.org/wiki/Erectile_dysf unction
[10] World Health Organization. (2019). ICD 10 – F52.2.
[11] Delcea C., Siserman C., 2020: Validation and Standardization of the Questionnaire for Evaluation of
Paraphilic Disorders. Rom J Leg Med28 (1) pp. 14-20 (2020) DOI:10.4323/ rjlm.2020.14Romanian
Society of Legal Medicine
[12] Siserman C., Delcea C., Vladi Matei H., Vică L. M. 2019: Major Affective Distres in Testing Forensic
Paternity. 2019. – Rom J Leg Med 27(3) pp. 292-296 (2019) DOI:10.4323/ rjlm.2019.292 © Romanian
Society of Legal Medicine.
[13] Delcea C., Rusu O. D., Matei V. H., Vica M. L., Siserman C., (2020). The EvidenceBased Practice
Paradigm Applied to Judicial Psychological Assessment in The Context of Forensic Medicine. Rom J
Leg Med [28] pp. 257-262 [2020] DOI: 10.4323/rjlm.2020.257.
[14] Siserman C., Giredea C., Delcea C., (2020). The Comorbidity of Paraphilic Disorders and Rape in
Individuals Incarcerated for Sexual Offences. Rom J Leg Med [28] pp. 278-282 [2020] DOI:
10.4323/rjlm.2020.278.
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1.3 Sexual desire disorder
SEXUAL DESIRE DISORDER IN MEN
Abstract
Hypoactive sexual desire disorder in men may occur in the context of poor sexual
functioning, secondary to sexual dysfunction or a state of sexual dissatisfaction, or may may
correspond to poor functioning of the couple. Thus, these multiple factors can generate a
hypoactive sexual desire issue. The disorder of desire may also mean cognitions and/or
persistently or recurrently reduced(absent) sexual/ erotic fantasies. Worldwide prevalence of
sexual desire disorder in men is occasionally 6% for those 8-24 years old; significantly 41%
for those 66-74 years old, and persistently 1,8% for those 16-44 years old. The disorder may
emerge from the beginning of the sexual life or begin after a period of relatively normal sexual
function.
Keywords: hypoactive sexual desire disorder, s-on, therapy, testing, evaluation, sexual disorders
INTRODUCTION
One can book an appointment online, by phone, sms. You will receive confirmation of the
appointment date and you will be asked to pay for the first intervention, after which you will
take the necessary steps for the chosen activity. After payment and proof of payment you will
go through each step below.
There will be a complex evaluation and testing with the S-ON Test© Clinical Sexual
Assessment System.
After testing, you will complete the 7 standardized S-ON Sextherapy© protocols to address
sexual and/or couple issues.
The next step is using S-ON Monitoring© for monitoring and feedback throughout the entire
period of interventions to improve sexual desire disorder in men as well as S-ON
Optimization© to optimize sexual performance and couple’s relationship.
You will receive more details during our interventions.
How do I pay for the service and how much does it cost?
The payment is made online into the account of Institute of Sexology: bank account:
RO45BTRL06701205M34615XX opened at Banca Transilvania. And the cost for each
intervention (evaluation, testing, intervention protocol) is 100 euro at the NBR (National Bank
of Romania) exchange rate.
Let’s start!
Testing, S-ON Test©;
Protocols, S-ON Sextherapy©;
Monitoring, S-ON Monitoring©;
Optimizing, S-ON Optimization©.
• Testing, S-ON Test© MEN

Screening-DSM/Do (S-DSM/Do)
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INSTRUCTIONS. You will find below a checklist of 8 questions that describe the actions
that men take in various sexual intercourses. For each question, check the option that best suits
you.
1/8 You have a reduced or absent sexual desire

Not at all
A little
A lot
Very much
Extremely
2/8 6 or 7 out of 10 sexual intercourses happened without sexual fantasies or wish for
having sex
Not at all
A little
A lot
Very much
Extremely
3/8 You had pleasant thoughts/cognitions to have sex during sexual intercourse
Not at all
A little
A lot
Very much
Extremely
4/8 It appared after a long time, reported to the beginning of your sexual life
Not at all
A little
A lot
Very much
Extremely
5/8 Sexual desire disorder occur with your stable long-term partner
Not at all
A little
A lot
Very much
Extremely
6/8 Sexual desire is diminushed/absent irrespective of the partener

Not at all
A little
A lot
Very much
Extremely
7/8 There an anticipatory fear of a new sexual failure

Not at all
A little
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A lot
Very much
Extremely
8/8 You have couple issues regarding sexual intercourses

Not at all
A little
A lot
Very much
Extremely
Answers
- Not at all, 0 percentages.
- A little, 10 percentages, MILD sexual desire disorder is confirmed. This means that
you have signs and symptoms regarding the reduction of interest in sexual activity,
erotic thoughts and fantasies as well as the initiative to have sex.
- A lot, 20 percentages, MODERATE sexual desire disorder is confirmed. This means
that you have signs and symptoms regarding the reduction or absence of interest in
sexual activity, erotic thoughts and fantasies as well as the initiative to have sex.
- Very much, 30 percentages, SEVERE sexual desire disorder is confirmed. This means
that you have signs and symptoms regarding the total absence of interest in sexual
activity, erotic thoughts and fantasies as well as the initiative to have sex.
- Extremely, 40 percentages, EXTREMELY SEVERE sexual desire disorder is
confirmed. This means that you have signs and symptoms regarding the total absence
of interest in sexual activity, erotic thoughts and fantasies as well as the initiative to
have sex.
Funding Sources: This research did not receive any specific grant from funding agencies
in the public, commercial, or not-for-profit sectors.
REFERENCES
[1] Abel, G. G., Becker, J. B., CunninghamRathner, J., Mittelman, M., & Rouleau, J. L., 1988. Multiple
paraphilic diagnoses among sex offenders. Bulletin of the American Academy of Psychiatry and the
Law, 16, pp. 153-168.
[2] Abel, G. G., Becker, J. B., Mittelman, M., Cunningham-Rathner, J., Rouleau, J. L., & Murphy, W.
D.,1987. Self-reported sex crimes of nonincarcerated paraphiliacs. Journal of Interpersonal Violence, 2,
pp. 3-25.
[3] Bain, J., Langevin, R., Dickey, R., & Ben-Aron, M., 1987. Sex hormones in murderers and assaulters.
Behavioral Sciences and the Law, 5, pp. 95-101.
[4] Breslow, N., Evans, N., & Langley, J., 1985. On the prevalence and roles of females in sadomasochistic
sub-culture: Report of an empirical study. Archives of Sexual Medicine, 14, pp. 303-317.
[5] Dietz, P., Hazelwood, R. R., & Warren, J., 1990. The sexually sadistic criminal and his offenses. Bulletin
of the American Academy of Psychiatry and the Law, 18, pp. 163-178.
[6] Fedora, O., Reddon, J. R., Morrison, J. W., Fedora, S. K., Pascoe, H., & Yeudall, C. T., 1992. Sadism
and other paraphilias in normal controls and aggressive and nonaggressive sex offenders. Archives of
Sexual Behavior, 21, pp. 1-15.
[7] Freud, S., 1961. On sexuality. Markham, ON: Penguin.
[8] Fromm, E., 1977. The anatomy of human destructiveness. Markham, ON: Penguin.
[9] Graber, B., Hartmann, K., Coffman, J., Huey, C., & Golden, C., 1982. Brain damage among mentally
disordered sex offenders. Journal of Forensic Sciences, 27, pp. 127-134.
[10] Gratzer, T., & Bradford, J., 1995. Offender and offense characteristics of sexual sadists: A comparative
study. Journal of Forensic Sciences, 40, pp. 450-455.
32
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[11] Holmes, R. M., & Holmes, S. T., 1994. Murder in America. Thousand Oaks, CA: Sage.
[12] Hucker, S. J., 1990. Necrophilia and other unusual paraphilias. In R. Bluglass & P. Bowden (Eds.),
Principles and practice of forensic psychiatry (pp. 723-728). London: Churchill Livingstone.
[13] Hucker, S. J., Langevin, R., Wortzman, G., Dickey, R., Bain, J., Jandy, L., et al., 1988. Cerebral damage
and dysfunction in sexually aggressive men. Annals of Sex Research, 1, pp. 33-47.
[14] Knight, R., Prentky, R. A., & Cerce, D. D., 1994. The development, reliability, and validity of an
inventory for the multidimensional assessment of sex and aggression. Criminal Justice and Behavior,
21, pp. 72-94.
[15] Laws, D. R., & O’Donohue, W., 1997. Fundamental issues in sexual deviance. In D. R. Laws & W.
O’Donohue (Eds.), Sexual deviance: Theory, assessment, and treatment (pp. 1-21). New York: Guilford
Press.
[16] Malamuth, N. M., 1989. The attraction to sexual aggression: Part One. Journal of Sex Research, 26, pp.
26-49.
[17] McGuire, R. J., Carlisle, J. M., & Young, B. G., 1965. Sexual deviation as a conditioned behavior: A
hypothesis. Behavior Research and Therapy, 2, pp. 185-190.
[18] Money, J., 1984, Paraphilias: Phenomenology and classification, American Journal of Psychotherapy,
38(2), pp. 164-179.
[19] Paulauskas, R., 2013. Is causal attribution of sexual deviance the source of thinking errors? International
Education Studies, Vol. 6(4).
[20] Saleh, F.M. & Berlin, F.S., 2008. Sexual deviancy: diagnostic and neurobiological considerations,
Journal of Child Sexual Abuse, 12: pp. 3-4, pp. 53-76.
[21] Sbraga, T. P., 2003. Sexual deviance and forensic psychology: a primer, Handbook of Rorensic
Psychology, pp. 429-470.
[22] Scott, G. G., 1983. Dominant women, submissive men. New York: Praeger.
[23] Simon, W. and J. Gagnon, 1967. ‘Homosexuality: The Formulation of a Sociological Perspective’,
Journal of Health and Social Behavior 8(3): pp. 177-85.
[24] Spengler, A., 1977. Manifest sadomasochism of males: Results of an empirical study. Archives of Sexual
Behavior, 6, pp. 441-456. 25. Thornton, D., 1993. Sexual deviancy. Current Opinion in Psychiatry, 6,
pp. 786-789.
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B. FEMALE SEXUAL DYSFUNCTIONS
1.4 Orgasm disorder
ORGASMIC DISORDER IN WOMEN
Abstract
Significant delay or absence of orgasm or reduced frequency during sexual intercourse with
or without penetration/stimulation and/or after penetration. Markedly reduced intensity of
orgasmic sensations and individual psychological discomfort. Women with orgasm disorder
have never had a clitoral or vaginal orgasm (penetration) regardless situation or stimulation.
Worldwide prevalence of orgasmic disorder in women is 42% and can be maintained
depending on partner, stimulation, situation or regardless partner, stimulation, situation etc.
The disorder may emerge from the beginning of the sexual life or begin after a period of
relatively normal sexual function.
Keywords: orgasmic disorder in women, s-on, therapy, testing, evaluation, sexual disorders
INTRODUCTION
Assessment System.
period of interventions to improve orgasmic disorder in women as well as S-ON Optimization©
to optimize sexual performance and couple’s relationship.
Let’s start!
Applications
• Testing, S-ON Test© WOMEN
Screening-DSM/Of (S-DSM/Of)
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that women take in various sexual intercourses. For each question, check the option that best
suits you.
1/8 Do you have difficulties in reaching an orgasm or you are unable to have an orgasm
after adequate sexual stimulation and penetration?
Not at all
A little
A lot
Very much
Extremely
2/8 6 or 7 out of 10 sexual intercourses have a reduced intensity of orgasmic sensations?

Not at all
A little
A lot
Very much
Extremely
3/8 Has the orgasmic disorder occurred since the beginning of your sexual life?
Not at all
A little
A lot
Very much
Extremely
4/8 Has orgasmic disorder appeared after a long time, reported to the beginning of sexual
life?
Not at all
A little
A lot
Very much
Extremely
5/8 Does orgasmic disorder occur when you are with your stable long-term partner?
Not at all
A little
A lot
Very much
Extremely
6/8 Does it appear irrespective of the partner?

Not at all
A little
A lot
Very much
Extremely
7/8 Is there an anticipatory fear of a new sexual failure?

Not at all
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A little
A lot
Very much
Extremely
8/8 Do you have couple issues regarding sexual intercourses?

Not at all
A little
A lot
Very much
Extremely
Answers
- Not at all, 0 percentages.
- A little, 10 percentages, MILD orgasm disorder is confirmed. This means you have
signs and symptoms of marked difficulty in obtaining orgasm.
- A lot, 20 percentages, MODERATE orgasm disorder is confirmed. This means you
have signs and symptoms of marked difficulty in obtaining orgasm or the absence of
it.
- Very much, 30 percentages, SEVERE orgasm disorder is confirmed. This means you
have signs and symptoms of marked difficulty in obtaining orgasm or total absence of
it.
- Extremely, 40 percentages, EXTREMELY SEVERE orgasm disorder is confirmed.
This means you have signs and symptoms of marked difficulty in obtaining orgasm or total
absence of it.

General clinical sexual screening GSCS-w
that men take in various sexual intercourses. For each question, check the option that best suits
you.
1/33 Is there a significant delay in orgasm in approximately 75-100% of sexual intercourses

occasions?
Yes No
2/33 Is there a reduced intensity of orgasmic sensations in approximately 75-100% of sexual

intercourses?
Yes No
3/33 Is there a significant reduction of sexual arousal in approximately 75-100% of sexual

intercourses?
Yes No
4/33 Is there a significant reduction of sexual arousal in response to any erotic stimuli in
approximately 75-100% of sexual intercourses?
Yes No
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5/33 Is there a significant reduction of genital sensations or erogenous zones in

approximately 75-100% of sexual intercourses?
Yes No
6/33 Is there a significant lack of sexual desire?

Yes No
7/33 Is there a significant lack of arousal and sexual orgasm?

Yes No
8/33 Is there a significant reduced interest in sexual activity?

Yes No
9/33 Is there a significant reduction in erotic thoughts/fantasies?

Yes No
10/33 Is there a persistent/recurrent discomfort with penetration?

Yes No
11/33 Is there a persistent/recurrent pain with penetration?

Yes No
12/33 Is there an intense fear/anxiety related to pain/discomfort occurence with penetration?

Yes No
13/33 Is there a significant strain/contraction of the pelvic floor muscles with penetration?
Yes No
14/33 Your partner doesn’t sexually satisfy you?

Yes No
15/33 Is there a personality incompatibility with your partner?

Yes No
16/33 You and your partner argue over sexual matters?

Yes No
17/33 You and your partner don’t share the same level of sexual interest?
Yes No
18/33 Do you feel uncomfortable engaging in some sexual activities that your partner wants
Yes No
19/33 When it comes to sex, you have different ideas and values from your partner?
Yes No
20/33 Do you think you don’t meet the sexual needs of your partner?
Yes No
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21/33 Do you and think that you and your partner don’t enjoy the same sexual activities
Yes No
22/33 When it comes to sex, you and your partner don’t get along well?
Yes No
23/33 Do you find it’s difficult for you to accept your partner’s perspective on sex?
Yes No
24/33 You and your partner don’t agree on how often you should have sex?
Yes No
25/33 You and your partner don’t share similar sexual fantasies?
Yes No
26/33 When it comes to sex, your partner your partner isn’t willing to do certain things that
you would like to do?
Yes No
27/33 You and your partner don’t share the same level of sexual desire?
Yes No
28/33 Do you think that your partner doesn’t understand you from sexual point of view?
Yes No
29/33 You and your partner share the same sexual preferences?
Yes No
30/33 Isn’t your partner willing to do certain sexual things that you would like to do
Yes No
31/33 Do you feel comfortable during sex with your partner?

Yes No
32/33 Do you consider yourself sexually inhibited by your partner?

Yes No
33/33 You and your partner aren’t sexually attracted to each other?
Yes No
Answers
- Orgasmic disorder is confirmed (1, 2, 7)
- Arousal disorder is confirmed (3, 4, 5)
- Desire disorder is confirmed (6, 8, 9)
- Dyspareunia is confirmed (10, 11, 12, 13)
- Couple issues are confirmed (14-33)

Couple satisfaction scale CSSw
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suits you.
1/30 Spending free time together is beneficial for your relationship

A little
A lot
Very much
2/30 Emotional support is sufficiently adaptive

A little
A lot
Very much
3/30 Your partner hardly ever responds when you want to discuss your sex life
A little
A lot
Very much
4/30 Your sexual life is satisfied

A little
A lot
Very much
5/30 Some sexual issues are too uncomfortable to discuss with your partner
A little
A lot
Very much
6/30 You and your partner don’t seem to resolve your misunderstandings on sexual
matters A little
A little
A lot
Very much
7/30 There is enough time invested in the relationship

A little
A lot
Very much
8/30 There are sexual issues in your relationship that you have never discussed
A little
A lot
Very much
9/30 Making important decisions together is satisfactory

A little
A lot
Very much
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10/30 When you and your partner talk about sex, you feel he is criticizing you
A little
A lot
Very much
11/30 You have shared hobbies, interests, activities

A little
A lot
Very much
12/30 You have common activities or interests outside the couple/family

A little
A lot
Very much
13/30 Your partner often complains that you’re not clear enough about what you want
from a sexual point of view
A little
A lot
Very much
14/30 You laugh and smile together

A little
A lot
Very much
15/30 You work together to project, business, etc.

A little
A lot
Very much
16/30 You show your love and you say you love each other
A little
A lot
Very much
17/30 Your partner has no difficulty talking to you about his feelings or desires
A little
A lot
Very much
18/30 Even when he is furious with you, your partner is able to appreciate your
perspectives on sexuality
A little
A lot
Very much
19/30 You and your partner have never had an open discussion about your sex life
A little
A lot
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Very much
20/30 You have common friends

A little
A lot
Very much
21/30 You know each other well enough

A little
A lot
Very much
22/30 You tolerate each other’s little/big naughty things

A little
A lot
Very much
23/30 You have secrets

A little
A lot
Very much
24/30 You are independent in your couple relationship

A little
A lot
Very much
25/30 Talking about sex is a satisfying experience for both of you

A little
A lot
Very much
26/30 You and your partner can usually talk calmly about your sex life
A little
A lot
Very much
27/30 You have a slight difficulty in telling your partner what you’re doing and what
you’re not doing from sexual point of view
A little
A lot
Very much
28/30 You rarely feel ashamed when discussing details about your sex life
A little
A lot
Very much
29/30 You are dependent on one another

A little
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A lot
Very much
30/30 How attached you are to each other

A little
A lot
Very much
Answers
- A little, 10 percentages: You obtained a low level with regard to your couple tolerance
to vital factors for relationship, such as time spent together, your money, hobbies,
friendships, sex life, common interests, shared activities, individual satisfaction
towards expressing affection and relationship intimate life as well as your commitment
to continuing the relationship;
- A lot, 20 percentages: You obtained a low level with regard to your couple tolerance
to vital factors for relationship, such as time spent together, your money, hobbies,
friendships, sex life, common interests, shared activities, individual satisfaction
towards expressing affection and relationship intimate life as well as your commitment
to continuing the relationship;
- Very much, 30 percentages: You obtained a low level with regard to your couple
tolerance to vital factors for relationship, such as time spent together, your money,
hobbies, friendships, sex life, common interests, shared activities, individual
satisfaction towards expressing affection and relationship intimate life as well as your
commitment to continuing the relationship.

Cognito-sexual questionnaire CSQ-w
of women in various sexual intercourse. For each question, check the option that best suits you.
1/15 What do you THINK of during intercourse regarding what you hear?
1. Sounds of your partner’s hyperventilation (inhalation and exhalation acceleration), the
sound of movements and other auditory sensations;
2. Your partner verbalizing words with sexual connotations;
3. A part of the first two options above;
4. You don’t give too much importance to auditory sensations.
2/15 What do you THINK of during intercourse regarding what you see
1. Intimate positions that will allow you to see your partner during intercourse and your
partner’s body;
2. Your partner’s body;
3. A part of the first two options above,
4. You don’t give too much importance to visual sensations.
3/15 What do you THINK of during intercourse regarding what you smell
1. Your partner’s body;
2. On some parts of your partner’s body;
4. You don’t give too much importance to smell and taste sensations.
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4/15 What do you THINK of during intercourse regarding what you touch
1. You focus on details when touching your partner (focus on face, neck, breasts,
abdomen, penis, buttocks, legs, back, arms);
2. You focus on overall caresses (you focus only on some parts of your partner’s body);
4. You don’t give too much importance to tactile sensations.
5/15 What do you THINK of during intercourse regarding your moves

1. You practice more positions (classic missionary, cowgirl, doggy-style, etc.) in a sexual
intercourse;
2. You practice 1 or maximum two positions (classic missionary, cowgirl, doggy-style,
etc.) in a sexual intercourse;
3. Your sexual activity is more dinamic and with few moves;
4. You don’t give too much importance to your moves during intercourse.
6/15 What do you FEEL during intercorse regarding what you hear
1. Hearing sensations that produce well-being, pleasure and excitement;
2. Hearing sensations that produce excitement and pleasure;
3. Hearing sensations that produce pleasure;
4. Hearing sensations that don’t produce well-being, pleasure and excitement.
7/15 What do you FEEL during intercorse regarding what you see
1. Visual sensations that produce well-being, pleasure and excitement;
2. Visual sensations that produce excitement and pleasure;
3. Visual sensations that produce pleasure;
4. Visual sensations that don’t produce well-being, pleasure and excitement.
8/15 What do you FEEL during intercorse regarding what you touch
1. Tactile sensations that produce well-being, pleasure and excitement;
2. Tactile sensations that produce excitement and pleasure;
3. Tactile sensations that produce pleasure;
4. Tactile sensations that don’t produce well-being, pleasure and excitement.
9/15 What do you FEEL during intercorse regarding what you smell
1. Taste and smell sensations that produce well-being, pleasure and excitement;
2. Taste and smell sensations that produce excitement and pleasure;
3. Taste and smell sensations that produce pleasure;
4. Taste and smell sensations that don’t produce well-being, pleasure and excitement.
10/15 What do you FEEL during intercorse regarding your moves

1. Motion sensations that produce well-being, pleasure and excitement;
2. Motion sensations that produce excitement and pleasure;
3. Motion sensations that produce pleasure;
4. Motion sensations that don’t produce well-being, pleasure and excitement.
11/15 What do you DO during intercorse regarding what you see

1. You insist on watching your partner and you use your imagination when you can’t see
parts of the body;
2. You prefer positions that will allow you to see your partner during intercourse, to the
detriment of those that don’t allow you to do this;
43
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3. Your eyes are guided only by sensations;

4. You don’t use too much visual senses during intercourse.
12/15 What do you DO during intercorse regarding what you hear

1. You prefer to communicate during sexual intercourse for sexual dynamics
2. You are involved in communication during intercourse
3. You let yourself being driven by erotic words during intercourse
4. You are involved in what you hear
13/15 What do you DO during intercorse regarding what you touch

1. Your touches are made in successive steps (you touch all the body parts even the
insignificant ones);
2. Your touches are short and frequent (meaning “more quickly”, “in a hurry”, “on the
run”);
3. Your touches are only made on parts of the body with maximum excitement;
4. You don’t touch too much during intercourse.
14/15 What do you DO during intercorse regarding what you smell

1. You insist to smell parts of your partner’s body (all parts of the body with erotic
significance);
2. Sometimes you can smell parts of your partner’s body (some parts of the body with
erotic significance);
3. You stimulate olfactory and gustative senses during intercourse;
4. You usually do-nothing regarding smell.
15/15 What do you DO during intercorse regarding your moves

1. Your movements are acurate and consistent (good management of movements during
intercourse);
2. Your movements are balanced (a good style of having sex);
3. You have no control over movements (you can’t find the “place” and “the right time”
to have sex);
4. You are passive during intercourse (you prefer man in dominant role).
Answers
- Mild: Your cognitive-behavioral involvement in excitatory stimuli is maladaptive.
Your thinking, sensation and behavioral process is not well-managed/adaptively used.
- Moderate: Your cognitive-behavioral involvement in excitatory stimuli is maladaptive.
Your thinking, sensation and behavioral process is not sufficiently managed/adaptively
used.
- Severe: Your cognitive-behavioral involvement in excitatory stimuli is maladaptive.
Your thinking, sensation and behavioral process is insufficient concerning the adaptive
management.
• Testing, S-ON Test© MEN

Sexual stimuli genogram SSG-m
INSTRUCTIONS. You will find below a set of 3 questions that describe the actions that
men do in various sexual acts. For each question, check the option that best suits you. Choose
the answer you think is most appropriate. You must tick from 1-10 the intensity of pleasure
(sexual attraction), relaxation (sexual disposition) and arousal (sexual stimulation). These
44
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ticked grades, in terms of pleasure, relaxation and arousal are the category of stimuli that you
work with during the sexual intercourse. You have to think carefully about what you choose to
identify your real answer.
1. PLEASURE (the extent to which you feel attracted by stimuli below)
Face
1 2 3 4 5 6 7 8 9 10
Neck
1 2 3 4 5 6 7 8 9 10
Chest
1 2 3 4 5 6 7 8 9 10
Abdomen
1 2 3 4 5 6 7 8 9 10
Arms
1 2 3 4 5 6 7 8 9 10
Penis
1 2 3 4 5 6 7 8 9 10
Buttocks
1 2 3 4 5 6 7 8 9 10
Legs
1 2 3 4 5 6 7 8 9 10
Back
1 2 3 4 5 6 7 8 9 10
2. RELAXATION (the extent to which you enjoy the stimuli below)
Face
1 2 3 4 5 6 7 8 9 10
Neck
1 2 3 4 5 6 7 8 9 10
Chest
1 2 3 4 5 6 7 8 9 10
Abdomen
1 2 3 4 5 6 7 8 9 10
Arms
1 2 3 4 5 6 7 8 9 10
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Penis
1 2 3 4 5 6 7 8 9 10
Buttocks
1 2 3 4 5 6 7 8 9 10
Legs
1 2 3 4 5 6 7 8 9 10
Back
1 2 3 4 5 6 7 8 9 10
3. AROUSAL (the extent to which you are stimulated/ aroused by stimuli below)
Face
1 2 3 4 5 6 7 8 9 10
Neck
1 2 3 4 5 6 7 8 9 10
Chest
1 2 3 4 5 6 7 8 9 10
Abdomen
1 2 3 4 5 6 7 8 9 10
Arms
1 2 3 4 5 6 7 8 9 10
Penis
1 2 3 4 5 6 7 8 9 10
Buttocks
1 2 3 4 5 6 7 8 9 10
Legs
1 2 3 4 5 6 7 8 9 10
Back
1 2 3 4 5 6 7 8 9 10
Answers
- 5-7 percentages, Mild: Your cognitive involvement and utilization of excitatory,
pleasure and relaxation stimuli are maladaptive. The number of excitatory stimuli is
reduced (you are focused only on two or four excitatory stimuli maximum) and your
sexual behavior is guided only towards those unrepresentative stimuli, failing control
sexual intercourse.
- 3-5 percentages, Moderate: Your cognitive involvement and utilization of excitatory,
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very reduced (you are focused only on one or maximum three excitatory stimuli) and
your sexual behavior is guided only towards those unrepresentative stimuli, failing
control sexual intercourse.
- 1-3 percentages, Severe: Your cognitive involvement and utilization of excitatory,
extremely reduced (you are focused only on one or maximum two excitatory stimuli)
and your sexual behavior is guided only towards those unrepresentative stimuli, failing
control sexual intercourse.
• Interventions, S-ON Sextherapy© Women

Protocol of sexual cognitive scenario, S-ONo cognitive©
Orgasm
General consideration
The protocol of S-ONd cognitive© sexual cognitive scenario was scientifically validated
with the purpose of helping women to develop a cognitive-behavioural participation by
insisting on sexual stimulus, thus controlling and maintaining the orgasm. This technique uses
cognitive scenarios and several steps to help women rediscover how to be involved at a
cognitive-behavioural level by using relevant sexual stimulus for orgasm. In fact, it is a self
guidance in how to participate at the cognitivebehavioural level only to the excitation stimulus
by using descriptions and following certain rules: What am I doing? How am I doing it? and
What am I going to do? Or What am I doing simultaneously? so that you can pay attention to
the maximum excitation/relevant stimulus.
Focus
This technique helps men to relearn how to think using all relevant sexual stimulus and how
to manage the orgasm sensations. In fact, this protocol helps men to think „analytically” in
order to identify the excitation stimulus which help achieving and maintaining the orgasm.
Specialist advice
Are you familiar with a flight deck? If the answer is no, then ask the co-pilot! Substituting
your attention on what you do rather than what you feel together with multitasking on several
sexual stimulus, will help you to become an expert in sexual activity and to increase and
maintain your sexual desire. This is what happens with an airplane pilot. Are you the pilot of
the bed?
Applications
Make a description using internal monologue in order to cover step by step your partner’s
body by following these rules: What am I doing? How am I doing it? and What am I going to
do? Or What am I doing simultaneously? and thus you can pay attention to what you do instead
of how you feel.
Rule. You have the following exercises. First step, arousal (kisses), make a silent
description of WHAT YOU DO (for instance, describe using internal monologue: “I start
kissing the lips”). Then, carry on with the description, HOW YOU DO THAT (for instance,
describe using internal monologue: “I kiss the lower lip, the upper lip, I touch her tongue and
feel her tongue in my mouth”). Then, continue describing, WHAT YOU DO NEXT or WHAT
YOU DO SIMULTANEOUSLY (for instance, describe using internal monologue: “I start
kissing down the neck and both sides of the neck while I am playing with his penis”). Carry on
in that way with the description for all stimulus/areas of your partner!
Follow the example from the Table 1.
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Table 1. Description for all stimulus/areas of your partner

FACE I start kissing the face, gently touching it with my lips, then I touch it, and
then..., etc., ...
NECK I start kissing the neck, gently touching it with my lips, then I touch it, and
then..., etc., …
BREASTS I start kissing the breasts, gently touching them with my lips, then I touch
and slowly pull them, rubb and pinch them, and then..., etc., ...
ABDOMEN I start kissing the abdomen, gently touching it with my lips, then I touch it,
rubb it, slowly pinch it, and then..., etc., ...
BACK I start kissing the back, gently touching it with my lips, then I touch it, rubb
it, slowly pinch it, then..., etc., ...
ARMS I start kissing the arms, gently touching them with my lips, then I touch them,
slowly pull them, rubb and pinch them, and then..., etc., ...
VAGINA I start kissing the vagina, gently touching it with my lips, slowly pull it, I
insert my finger into vagina, I rubb it and pinch the labia, etc., ...
BUTTOCKS I start kissing the buttocks, gently touching them with my lips, then I touch
them and slowly pull them, rubb and pinch them, and then..., etc., ...
LEGS I start kissing the legs, then I touch them and slowly, pull them, rubb and
pinch them, and then..., etc...
Well done!
You have succeeded to complete the Protocol of sexual cognitive scenario S-ONo
cognitive©. I know that this was something new for you and I hope that you have learnt how to
“analytically” think in order to manage the excitation stimulus and to achieve and maintain the
orgasm.
Feedback
Was the Protocol of sexual cognitive scenario S-ONo cognitive© useful for you? Please
express your content by crossing one of the statements bellow:
1. Unsatisfactory;
2. Satisfactory;
3. Good;
4. Very good;
5. Excellent.
REFERENCES
Law, 16, pp. 153-168.
[2] Abel, G. G., Becker, J. B., Mittelman, M., Cunningham-Rathner, J., Rouleau, J. L., & Murphy, W. D.,
1987. Self-reported sex crimes of nonincarcerated paraphiliacs. Journal of Interpersonal Violence, 2, pp.
3-25.
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21, pp. 72-94.
Press.
26-49.
38(2), pp. 164-179.
Journal of Health and Social Behavior 8(3): 177- 85.
Behavior, 6, pp. 441-456.
[25] Thornton, D., 1993. Sexual deviancy. Current Opinion in Psychiatry, 6, pp. 786-789.
49
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THE FEMALE ORGASM DISORDER. AN INDIVIDUAL PSYCHOLOGY

APPROACH
Abstract
The Individual Psychology of Alfred Adler sees the couple and the intimacy as life tasks,
and the couple as a social relation. The individuals of a couple are two personalities that share
their early childhood cooperation model based on private logic. As intimacy and sex are a
representation of one’s convictions put together with another human being, the female orgasm
disorder is closely related to one’s’ life believes and distorted convictions. This article tries to
explain the link between the early life experiences and subconscious beliefs and the female
orgasm disorder.
Keywords: private logic, early recollections, social interest, life convictions, organ jargon, inferiority complex, holistic
INTRODUCTION
Alfred Adler (1870-1937) world renowned medical doctor and psychotherapist, founder of
the Individual Psychology, considered the human being as an individual whole. He has a
different approach upon sex, than his contemporary colleague, Sigmund Freud, understanding
human sexuality and aggressiveness as two different instincts that would merge later during
life.
Adler understood man as a social being and looked at man’s problems in relation to the tasks
of life: occupation/work, society/friendship, and love/sexuality. If the main theoretical systems
are the systems of Freud and Jung, however, Adler developed his science in a completely
different direction from theirs. The couple is itself a social system, and intimacy and sexuality
are directly related with the early beliefs, family patterns and the order of birth.
The female orgasm disorder may be the effect of various reasons, but if the reason is a
psychological one, Individual Psychology can help reducing the symptoms, improving the
couple’s sexual dynamics and treat the subconscious convictions that led to the orgasm
disorder.
Theoretical aspects
Adlerian psychotherapy focuses on the treatment of psychological and emotional suffering
manifested in depression, anxiety disorders, trauma, etc., a holistic approach stimulating
development and healing, observing the harmonious relationships between the ways we
experience the self and the world around – thinking, feeling, verbalizing and action.
Adlerian psychology is interpretive, dynamic and profound, essentially, being an attempt to
understand human behavior. Some of Adler’s principles are not exclusive to the psychology he
studied or are not his originals. Similar ideas, for example, were expressed either in philosophy,
centuries ago, or even in psychology, shortly before the publication of his major works. Rather,
the totality of Adler’s principles, brought together in a functional system, is what provides a
key to understanding human behavior and the ability to change it. This is his great contribution,
and his full acceptance of the system, which makes it possible for an Adlerian psychotherapist
to approach the case holistically.
In all fields such as psychology, anthropology, sociology, criminology, psychiatry or where
efforts are made to change behavior, either individually or in groups, as in education or
psychotherapy, Adlerian psychology is applicable. All the concepts of his system are
interdependent.
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According to Alfred Adler’s Individual Psychology, each individual forms, from the first
years of life, an opinion about the world, an opinion through which one can observe his basic
beliefs, feelings and choices throughout life.
When it comes to female orgasm, we need to differentiate a physiological cause from a
psychological one, and also, if the problem occurs both in the couple or by itself. When there
is no evidence of a physiological cause, we can assume there must be a psychological one. It
is also important to clarify some personal aspects as it follows: if the orgasm disorder occurs
with or without arousal, if the person never had an orgasm or it’s a contextual problem.
Depending on the case, the therapeutic approach may differ, sometimes including sex
education or even prescribed medication. But if the orgasm disorder doesn’t affect the arousal,
we need to work on the subjective perceptions about the topic.
In Adlerian terms we could consider the female orgasm disorder as an organ jargon, meaning
that the disorder is nothing but a symptom that can reveal hidden convictions that interfere with
the normal sexual life of the person. The hidden and distorted life convictions can be extracted
during the therapeuticl process from the early recollections from the patient himself. They can
be modified through a cognitive manner so the client can change her belief about the trigger
that caused her the orgasm dysfunction.
When talking about orgasm female disorder from an Adlerian perspective we also need to
consider trauma that could be the reason for the current problem. During the therapeutical
intervention the therapist needs to discover the causes of the problem, the private logic of the
person and the unconscious beliefs about one’s own sexuality.
Individual Psychology also focuses on the individual perception about the relation with the
self and the other person. We need to explore the 4 Adlerian C’s in order to establish the relation
of the person with it’s own body, sexuality, and the relation with the partner.
Connection – If both partners feel connected to each other the feeling of belonging gives
them security and makes them feel trustworthy. When one is connected with itself has more
control over his body and mind, and the orgasmic response is present. When the partners feel
connected, they are more willing to cooperate and to offer each other pleasure. When they are
not sure of the connection between them, they question the involvement of the partner and may
feel disconnected.
Capability – When both partners feel capable, they can collaborate without feeling
dependent on each other, and can rely on themselves, because they can be responsible on their
side of the relation, and each other’s pleasure and orgasm. But when they don’t feel capable
enough, they can enter into power struggles with the other one to compensate for the feeling of
inadequacy, described by Adler as the Inferiority Complex.
To Count – When both partners feel valued and that they are important to each other, that
their opinion and actions matter, and that they can bring something important between them,
they are more likely to want to contribute. People who feel that they don’t matter may feel hurt
and for this reason they may want to hurt others to show them how they feel.
To have Courage – When both partners develop the courage to discover themselves, and
take responsibility for their own behavior, their own body and pleasure, they contribute to the
well-being of the relationship. When they have the courage to be responsible, they can enjoy
the good moments together but also manage to get through the difficult situations. Discouraged
people feel that there is no hope that things will get better, avoiding difficult situations and
giving up easily.
Cognitive Behavioral Therapy (CBT) and Individual Psychology (IP)

A conceptual discrimination could be made between CBT and IP, both through the different
concepts that build the approaches and mostly through the therapeutic methods involved in
treating the female orgasm disorder. CBT works by changing people’s attitudes and their
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behavior by focusing on the thoughts, images, beliefs and attitudes, and how these processes
relate to the way a person behaves, as a way of dealing with emotional problems and developing
personal coping strategies. The orgasm disorder may be the effect of certain mental health
problems, as neurosis and anxiety. CBT can help lower the anxious response through
desensitization and relaxation exercises.
The CBT techniques for treating female orgasm dysfunction involve using mindfulness,
relaxing techniques, dispelling myths and limited beliefs and behaviors, identifying the factors
that sabotage the relation with the self and the partner, dealing with anxiety and conflict,
creating intimacy. CBT has a direct impact upon the orgasm disorder as it offers more specific
techniques and exercises that affect the behavior and the attitude directly, from a session to
another. It offers a “here and now” solution so the client can understand it and apply it
immediately. This is beneficial because CBT works in a specific and conscious manner.
IP on the other hand, being a neopsychoanalytic therapy can be used for treating trauma,
sexual abuse and subconscious beliefs and conclusions through specific techniques. The IP
techniques involve early recollections, life style inventory, birth order, identifying early limited
convictions, private logic regarding sexuality, female/male roles and models, and the fictional
final goals of one’s dysfunctional behavior.
The fictional final goal refers to an unconscious maladaptive behavior that represents a
coping solution to compensating the inferiority complex, “an attempt at a planned final
compensation and a (secret) life plan” [Adler, quoted in Eric Berne, What Do You Say After
You Say Hello? (1974) p. 58].
CONCLUSIONS
The female orgasm is a subjective state, and depends on various factors to be achieved. Both
CBT and Individual Psychology can help on reducing the symptoms and improving
satisfaction. The benefit of Individual Psychology is that, if there is a subconscious cause of
the dysfunction this can be treated in a psychodynamic way, from the roots of the problem,
mostly through an early childhood therapeutic intervention. Numerous studies Delcea C,
Enache A, Stanciu C, [9], Delcea C, Enache A, Siserman C. [10], Gherman C, Enache A,
Delcea C. [11], Delcea C, Fabian A. M, Radu C. C, Dumbravă D. P. [12], Rus M, Delcea C,
Siserman C, [13], Siserman C, Delcea C, Matei H. V, Vică M. L. [14], Gherman C, Enache A,
Delcea C, Siserman C, [15], Delcea C, Siserman C, [16] confirm our results. Also, if the
symptoms are associated with trauma or abuse, Individual Psychology can be useful in
exploring and overcoming trauma.
REFERENCES
[1] Adler, A. The Practice and Theory of Individual Psychology (1 ed.). London: Kegan Paul, Trench,
Trubner & Co, 1924.
[2] Adler, A. et al., Superiority and Social Interest: A Collection of Later Writings, 1964.
[3] Ansbacher, L. H., et al., (eds), The Individual Psychology of Alfred Adler, New York: Basic Books,
1956.
[4] Bettner, B. L., et al., Raising kids who can, Newton Centre, MA: Connexions Press, (1989, 2005).
Costantini, E. et al., (eds.), Female Sexual Function and Dysfunction, Springer International Publishing
Switzerland, 2017.
[5] Dreikurs, R. Psychodynamics, psychotherapy and counseling. Chicago: Alfred Adler Institute, 1967.
[6] Dreikurs, R. Holistic medicine and the function of neurosis. Journal of Individual Psychology, 1977.
[7] Peterson, Z. D. The Wiley Handbook of Sex Therapy, First Edition. John Wiley & Sons Ltd. Published
by John Wiley & Sons Ltd., 2017.
[8] Vernon, A, (ed.). Cognitive and Rational-Emotive Behavior Therapy with Couples. Theory and Practice,
New York, 2012.
[9] Delcea C, Enache A. Individual Differences in Personality and Reasoning Traits between Individuals
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Accused of Murder and those who have not Committed Murder. Int J MentHealthPsychiatry 3:1. 2017.
doi: 10.4172/2471-4372.1000140.
[10] Delcea C, Enache A, Stanciu C, Assessing Maladaptive Cognitive Schemas as Predictors of Murder. Int
J MentHealthPsychiatry 3:1. 2017. doi: 10.4172/2471-4372.1000142.
[11] Delcea C, Enache A, Siserman C. The Reasoning Involved in the Decision-Making Process of
Individuals Who have Committed Murder. Int J MentHealthPsychiatry 4:1. 2018. doi: 10.4172/2471-
4372.1000160.
[12] Gherman C, Enache A, Delcea C. The multifactorial determinism of forensic expertise regarding
sentince interruption on medical grounds and decision. Journal of Forensicand Legal Medicine. Elsevier.
2019.Vol. 61, pp. 45-55. DOI 10.1016/j.jflm.2018.10.005.
[13] Delcea C., Fabian, A. M., Radu, C. C, Dumbravă D. P. Juvenile delinquency within the forensic context.
Rom J Leg Med27(4) pp. 366-372 (2019). DOI: 10.4323/rjlm.2019.366.
[14] Rus, M., Delcea C., Siserman C. The relationship between emotional distress and neuroticism at the
operational personnel of ambulance services. Rom J Leg Med27(3) pp. 279-284 (2019). DOI:
10.4323/rjlm.2019.279
[15] Siserman, C., Delcea C., Matei, H. V., Vică M. L. Major affective distress in testing forensic paternity.
Rom J Leg Med27(3) pp. 292-296 (2019). DOI: 10.4323/rjlm.2019.292.
[16] Gherman, C., Enache, A., Delcea C., Siserman C., An observational study on the parameters influencing
the duration of forensic medicine expert reports in assessment of inmates’ health status in view of
sentence interruption on medical grounds – conducted at the Cluj-Napoca Legal Medicine Institute
between 2014 and 2018. Rom J Leg Med27(2) pp. 156-162 (2019). DOI:10.4323/ rjlm.2019.156.
[17] Delcea C., Siserman C. Validation and Standardization of the Questionnaire for Evaluation of Paraphilic
Disorders. Rom J Leg Med 28 (1) pp. 14-20 (2020). DOI: 10.4323/rjlm.2020.14.
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FEMALE ORGASM DISORDER
Abstract
Female orgasm disorder is a very common condition affecting a large part of population,
women directly and men indirectly leading to multiple consequences. It is also one of the most
frequent disorders coming to a sex therapist’s clinic. This paper is a summary of causes,
symptoms and options of therapy.
Keywords: female orgasm disorder, orgasm dysfunction, anorgasmia, couple therapy, CBT
INTRODUCTION
This paper is only about female anorgasmia, although orgasm disorder is present in men
also, but it is different pathology.
Orgasm disorder or dysfunction prevalence is unknown, but incidence may vary between
10-42% depending on study and population.
There are multiple physiological and psychological causes that may lead to it: medical
conditions as diabetes, post hysterectomy status, post cultural amputation of clitoris, older age
as hormonal status changes, medication, alcohol, stress, depression, mental disorders; cultural,
religious beliefs, abuse or trauma, feelings of guilt or shyness, relationship problems, conflicts.
Also, tiredness, poor self esteem, environmental and family dynamics changes, as well as
partner performance or lack of partner may contribute to it. After giving birth, some women
experience low drive and sometimes anorgasmia, but it becomes a condition when it lasts more
than 6 months.
Patients who make it to a therapist’s clinic complains of other secondary effects that affects
life quality. They tend to avoid sex or shorten the sessions that reflects on the partner’s
wellbeing and self esteem. Dyspareunia may or may not be accompanying the intercourse and
when present it needs to be discriminated between cause or effect. Patient have lower levels of
satisfaction, depression, anxiety, other mental disorder, sleep and self esteem may be afflicted.
As it takes a lot for a person to seek professional help and is even more difficult to bring
partner to counselling, sometimes there is no constant partner. Depending on individual
assessment and therapist’s experience and training there are few techniques that might be
approached: talk therapy, CBT, couple therapy, sensory enhancement via sensate focus.
Theoretical background Orgasm disorder must be differentiated from sexual interest arousal
disorder, genital pelvic pain/penetration disorder, substance induced sexual dysfunction. After
all other conditions are excluded, also length of symptoms and level of distress causing have
to be significant. As per DSM 5, anorgasmia has to persist for 6 months or more in order to be
classified as a disorder. Arousal dysfunction is a separate entity, the drive itself it is a factor
but not all that is needed. Orgasm disorder implies that woman has difficulty or inability to
have orgasm or the intensity of sensations is decreased to a point where it causes marked
distress. Some women seek therapy for low intensity of sensations, they can say they had an
orgasm but levels of pleasure or frequency are significantly decreased compared to before.
Therapist has to investigate if dysfunction is primary or secondary. In primary anorgasmia,
woman has never experience orgasm in her life, in secondary or acquired anorgasmia the
disorder settled in after a triggering event or slowly in time, but after she has previously
experienced climax. The causes and options of therapy are very different in these 2 forms, as
the first one may be related also to anatomical variant or pathology in area and is harder to
treat.
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Before the start of psychological therapies, patient should have a medical/gynaecological

assessment to rule out any organic causes. If detected, they need to be treated first to ensure
best chance for therapy. Also, neurological and psychiatric conditions must be identified and
medication revised as serotonin inhibitors are famous for interfering on orgasm’s pathway.
Different classification is about when the disorder arises: situational anorgasmia and
generalised anorgasmia. The most common is situational anorgasmia when she can experience
orgasm in some conditions either environmental, or depending of type of sex performed (oral
vs vaginal), or partner dependant. Patient may experience orgasm with a partner or by
masturbation and not with a different one. Generalised anorgasmia means person doesn’t reach
climax no matter of circumstances. In generalised form, usually apart from possible
physiological circumstances, the psychological roots of the problem run deeper. Either is
cultural, or there is a trauma in the background.
Image from https://www.researchgate.net/figure/Four-Nerve-Six-Pathway-Theory-of-Female-Orgasm-Atleast-

six-pathway-orgasmic-reflex-arch_fig7_298463859
A woman that was sexually abused or who saw her mother or sister’s being abused may be
afraid of sex and can not associate it with pleasure. In presence of strong cultural beliefs, the
inhibition is stronger than the sensation and the orgasm perception doesn’t take place. Some
patients don’t get to relax and trust enough the partner and internal blockages as so profound
that any type of pleasure including masturbation are forbidden.
Environmental factors as level of intimacy, crowded accommodation, new born kids or
dependants in the vicinity may lead to higher levels of stress and impossibility to arouse or
have orgasm. Couple unresolved issues may carry a burden in the bedroom, infidelity, quarrels,
financial difficulties, different views in children education or extended family, physical abuse
or partner’s health related issues and many more can contribute to anorgasmia.
Sexual dysfunction is not an easy topic for most women. It may take time until they are able
to talk freely or at least clearly about their issues or disorder. Therapist should not assume to
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know from the beginning what her problem is. More than one condition or partner’s disorder
are common in practice.
After initial assessment is performed and organic causes ruled out, while looking into the
causes of the disorder, may help to bring partner to assessment, if deemed as compliant and
cooperant. Some patients may not be interested in bringing in the sexual partner they have
difficulties with as they have other relationships sexually satisfactory.
If a trigger factor is identified, then it is easier to go for a targeted therapy. Sometimes it
takes few sessions until possible causes are exposed. A primary, generalised anorgasmia has
smaller chances for a good outcome.
One of the therapies implies moving sensory focus and increasing sensitivity to other areas
of the body. It is about retraining the body and mind of what it is felt. Usually, couples
complaining about anorgasmia try to achieve orgasm through intercourse, sometimes +/- oral
sex. These persons can be taught massage techniques and to delay penetration until an increased
level of arousal and a more relaxed status is achieved.
If the women have orgasm with oral sex, but not with penetrative sex, clitoridian stimulation
may be increased and associated with penetration in different degrees. If woman only has
orgasm by masturbation, she can start practicing masturbation with her partner, slowly learning
together what makes it work.
If woman never had orgasm, it is advisable to start with masturbation as this gives her full
control and privacy. As different techniques or toys can be used, both for penetrative and non-
penetrative masturbation, including non-self-touch with remote controlled devices, the mental
barriers of inhibitions can be by-passed. If woman had orgasm, then she can be retrained to
experience it again while treating the cause of secondary anorgasmia. If the cause cannot be
reversed, then it can be emphasised on costs of maintaining the harmful thoughts and
behaviours. Sometimes, the woman has to learn how to live and overcome some loss that
cannot be brought back. Couple issues need to be addressed at the same time as environmental
factors. Many young couples live in the parents’ home and they are shamed or afraid others
might hear or see something private. These can be temporary changed if they go for a holyday.
Talk therapy is used in the first sessions, either separate or as couple. It is the part when
therapist recognises the dysfunction or dysfunctions and sets the goals. It is not about right or
wrong, taking sides or finding culprits as some patients might expect coming in. it is about
identifying the condition and the triggering factors and also looking for best way to approach
therapy. Some women find efficient talk therapy alone. Some need further input and other
therapies.
CBT – cognitive behavioural therapy has a wide range of applications. The principle is of
educating patient and setting goals regarding his/her condition. In sex therapy of orgasmic
disorder one of the goals is reducing stress, rising awareness of cost full beliefs like shame,
guilt, low self-esteem. The situation can be easily explained in terms of costs and benefits. First
the basic beliefs and the cultural background need to be identified. Then patient is educated to
recognize and understand what are the triggers and the pathway that leads to same repeated
unsuccessful actions.
Then next step is to work on changing both the beliefs and the way of action. Patient should
see the connection between the mental blockages and the inhibited way of reacting and
participating to the sexual performance. Woman need to learn new ways of doing it differently
to what didn’t work before. Numerous studies Delcea C, Enache A, Stanciu C; Delcea C,
Enache A, Siserman C, Gherman C, Enache A, Delcea C, Delcea C, Fabian A. M, Radu C. C,
Dumbravă D. P, Rus M, Delcea C, Siserman C, Siserman C, Delcea C, Matei H. V, Vică M.
L., Gherman C, Enache A, Delcea C, Siserman C, Delcea C, Siserman C, confirm our results.
If orgasm is the only goal, performance anxiety might affect both partners and instead of
enjoying all the time they have sex, they are focused on female orgasm, ignoring rest of
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pleasure and sometimes leading to pain as they might think the intercourse has to take longer
or to be repeated regardless of levels of arousal, intimacy or satisfaction. Indeed, in some cases
the anorgasmia is related to the partner’s performance or comorbid disorders like premature
ejaculation or anatomical details that turn into real problems of compatibility.
Then therapist has to work with both, together and separate, to help them solve individual
and couple issues. And sometimes, in that combination it will simply not work and then patient
has to decide how to balance personal needs and couple needs and if relation itself is worth the
hassle. The CBT targets improving skills, in areas like communication, self-awareness, sexual
performance. In some cases, hormonal therapy may be added, locally for conditions like post
oophorectomy or hysterectomy status, or systemic in very low levels of testosterone. When
determined low levels of testosterone are considered significant, there is usually an arousal
disorder associated. Length of treatment must be balanced considering side effects as hirsutism
(facial hair), aggression and irritability levels and fertility problems. Testosterone therapy is
more of benefit at the beginning of a CBT when new patterns of sexual activity are learnt,
rather than a secondary approach later. Many women never experience vaginal-only orgasm
and for them of most benefit is including clitoridian stimulation in sexual activities and during
intercourse. They need to learn what is of benefit to them and get rid of harmful beliefs and
social/media induced standards. What works for some may not be what is advertised in porn
media or may be forbidden in religious or cultural limits. One has to learn what is best for her,
regardless of what she thought is good for her as per education.
CONCLUSIONS
Female orgasm disorder is a very common condition, affecting temporary or permanent a

significant number of women during their sexually active life. This frequently leads to couple
dysfunctions and family conflicts. Sometimes is hard to know which the cause is and which
the effect is.
Therapeutical approach is best set after classification, evaluation of comorbid conditions
and couple evaluation. Medical conditions or substance use must be dealt first otherwise it will
lead to early recurrence.
Multiple therapies can be used, singular or combined, depending on patient and therapist
specific circumstances. Few of the options are: CBT, talk therapy, massage and sensory focus,
couple and family therapy. Outcome depends on factors like compliance, motivation,
frequency of sexual activities vs therapy sessions, patient-therapist compatibility as some may
consider inappropriate the psychologist’s methods and suggestions. Hormonal therapy may be
of some benefit in selected cases and needs constant monitoring. Rate of success of therapies
differs on study between 50-85%, but most studies don’t include patients that drop at the very
beginning. Favourable indicators are young age, lack of comorbid mental conditions,
supportive partner and no medical conditions.
REFERENCES
[1] https://www.healthline.com/health/orgasmicdysfunction
[2] https://www.medicalnewstoday.com/ articles/324112#what-is-orgasmic-dysfunction
[3] DSM 5 American Psychiatric Association
[4] https://beckinstitute.org/%D1%81ondition/ sexual-dysfunctions/
[5] https://beckinstitute.org/%D1%81ondition/ sexual-dysfunctions/
[6] https://www.healthline.com/health/sextherapy
doi: 10.4172/2471-4372.1000140.
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4372.1000160.
2019. Vol. 61, pp. 45-55. DOI 10.1016/j.jflm.2018.10.005.
Rom J Leg Med 27(4) pp. 366-372 (2019). DOI:10.4323/rjlm.2019.366.
operational personnel of ambulance services. Rom J Leg Med 27(3) pp. 279-284 (2019).
DOI:10.4323/rjlm.2019.279.
sentence interruption on medical grounds – conducted at the ClujNapoca Legal Medicine Institute
between 2014 and 2018. Rom J Leg Med 27(2) pp. 156-162 (2019). DOI:10.4323/rjlm.2019.156.
Disorders. Rom J Leg Med 28(1) pp. 14-20 (2020). DOI: 10.4323/ rjlm.2020.14.
58
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FEMALE ORGASM DISORDER. ANORGASMIA
Abstract
Orgasm disorder in women has become an increasingly common reason to consult a doctor,
psychotherapist, but especially a sexologist. In this paper we will try to define the concept of
anorgasmia, but first we should clarify the terminology. In women, anorgasmia can be caused
by various physical and psychological factors that influence the pelvic floor area, having
certain associations with other symptoms of sexual dysfunction, such as vulvodynia,
dyspareunia, and loss of sexual desire or libido. We will address female orgasm disorder by
integrating some elements of psychosexual history and its characteristics. We shall explain the
onset, manifestation of this disorder, the causes, the clinical approach, the treatment, and we
shall explore the physiological and psychological factors involved in this female orgasm
disorder.
Keywords: orgasm disorder, anorgasmia, sexual dysfunction, physiological factors, psychological factors, pelvic area
INTRODUCTION
Nowadays, there are a variety of terms that can be used to discuss orgasm disorders in
women, mainly because the authors in the field do not unanimously agree with the choice of a
particular, formal and specific terminology.
The sexologists have begun to pay a special attention to the sexual needs of women. They
noticed that there are much rarer the cases where orgasms are not experienced by men, and on
the contrary, there are many women who fail to reach a sexual orgasm. Each of these
sexologists conceptualises and defines the sexual disorder according to the results of their own
research. The results can vary from one researcher to another and, therefore, there are also
differences in accepting the terminological meaning of all existing sexual dysfunctions.
Orgasm disorder in women belongs to the category of female sexual dysfunctions and it is
commonly seen.
We believe women are more reluctant to talk about the ways to achieve orgasm, about its
total absence, or certain disorders related to orgasm, due to the feelings of shame and guilt they
feel, and especially because of the prejudices they have to face.
Indeed, in our current society, despite a relative sexual liberation, a woman who has multiple
adventures wanting to experience certain forms of pleasure, in search of orgasm with different
partners, is often perceived negatively as an immoral woman. She is thus judged by others
because she does not correspond to the role, she “should have” in society, according to their
vision. Regardless of this standard, it has been found that many women multiply the number
of their sexual adventures as a result of the difficulties they have in reaching orgasm. They
believe that they necessarily need an experienced partner to achieve these forms of orgasm.
Being usually very young, they consider that the best way to overcome their need for
affection would be to achieve the sexual satisfaction even though with some haste. They often
do not know of other means, or do not consider that they have sufficient resources to meet their
needs in a more appropriate way. But they quickly come to the conclusion that orgasm does
not give them the satisfaction they hoped for. After having the experience of certain unpleasant
situations, sometimes repetitive, these women end up developing sexual disorders, seeking
refuge either by frequent masturbation or by engaging in numerous sexual relationships, in
order to obtain a fulfilling, complete orgasmic satisfaction.
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This sexual dynamic is manifested through dysfunctional relationships, due to the addiction
factor, the sexual disorder. We believe that despite superficial sexual relationships, these
women are looking for orgasm through the ideal man, the prince charming who will protect
them from their problems and cancel all their shortcomings, in an ideal relationship form.
Unfortunately, most of the time, the actual partner will be unable to fulfil the needs of their
soul as well as the needs related to a sexual dynamic, as fulfilling as possible in terms of
exploring multiple forms of orgasm, especially since the man is often facing a dysfunctional
psychological dynamic as well. Always disappointed, these women embark on multiple
occasional adventures in the hope that they will no longer face suffering and anguish.
Relational failure will reactivate and intensify feelings of shame, guilt and despair. Their
self-esteem will be increasingly affected, which gradually causes countless dysfunctional,
sexual and emotional problems.
In medical terms, female orgasm disorder is also referred to as anorgasmia. It represents a
type of sexual dysfunction in which a person cannot reach orgasm, and is often found in
women, but also in men. Orgasm is a feeling of physical pleasure and tension release,
accompanied by involuntary, rhythmic contractions of the pelvic floor. Some women even feel
these pelvic or uterine contractions, others describe an electric current through the body, while
some others describe some tingling. Symptoms associated with anorgasmia are most often: the
impossibility of experiencing orgasm or delayed orgasm, heightened frustration and inhibition
of sexual desire, fear of failure, prejudices, avoidance of sexual contact for various reasons.
Anorgasmia is at the top of the list of most common sexual problems in women. Over time,
the orgasm disorder in women has undergone a number of changes. In the early twentieth
century the psychoanalysis of Sigmund Freud suggested experiencing a mature sexuality,
looking only at the vaginal orgasm during sexual intercourse, while clitoral stimulation was
considered as inappropriately reflecting femininity. Later, American researchers Alfred
Kinsey, William Masters and Virginia Johnson, contradict this hypothesis, explaining that all
types of orgasm are identical both psychologically and physiologically, regardless of the nature
of stimulation (Mantak Chia & Maneewan Chia, p. 44). Shere Hite reveals to us “how women
can reach orgasm” based on some “anecdotal” answers given by hundreds of women who
expressed their personal opinion to the extensive questionnaire proposed by her in the book
“The Hite Report” (Shere Hite, p. 27). Based on this “Hite Report”, the Federation of Feminist
Women’s Health Centers presents a new conception of the woman’s body, offering a new
approach to the female genital organs, redefining the importance of clitoral stimulation during
lovemaking and not only.
According to the definition of DSM-IV “the essential element of the woman’s orgasm
disorder is the delay or recurrent absence of orgasm after a phase of normal arousal”
(Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, p. 452). A diagnosis of
anorgasmia should be based on the clinician’s judgment to observe when exactly the woman’s
orgasmic capacity is lower than that reasonable for her age, her sexual experience and the
compatibility of the sexual stimulation that she receives, and eventually to be kept in mind
towards a number of physiological and psychological factors.
The erotic stimulation that triggers orgasm in women originates from a variety of genital
and non-genital localisations, therefore the required stimulation time is much different from
one woman to another. Although the clitoris and vagina are the most common places for
stimulation, nevertheless the stimulation of other areas (periurethral area, breasts, nipples) can
trigger an orgasm, as it can do and also help in this respect the sexual fantasies, imagination or
hypnosis.
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The absence of orgasm often signals us that it is necessary to be attentive to our body and
our emotional balance. Thus, we can say that female orgasm plays an essential role as a
barometer of our body.
Psychosexual history
There are many women who manifest a native lack of orgasm. We should turn our attention
to the primary anorgasmia that characterises a sexually active woman who has never had and
has never experienced orgasm. Those rare women who say they have never felt sexual
attraction to a man, have never felt sexy and have never had erotic dreams or sexual desires.
They feel deprived of pleasure while lovemaking.
Then there are women who previously experienced orgasm and then lost the ability to
achieve normal orgasm, due to more strange conditions related to the nature of physical and
psychological factors. These women belong to the secondary anorgasmia classification; they
manifest an inner state of inhibition, repulsion and anguish towards their body and even
towards closeness with a partner, for it is possible they have suffered some trauma or were
forced to make love against their will, maybe even raped (subjected to the “conjugal duty” that
some brutal husbands claim, and which was rightly named “domestic rape”).
It is known that orgasm is dependent, first of all on mental attitude, and here one could say
that reaching the state of orgasm is something to be learned. The first category of anorgasmia
includes women who do not know what it means to experience and have never experienced the
state of orgasm; nevertheless, they can gradually learn and experience it.
The second category includes women who can reach the state of orgasm, but not anytime
and not with anyone. They need a prior preparation, a lot of attention and a special environment;
once these conditions are fulfilled, they are able to enjoy extraordinary sexual and erotic
experiences. Young women who start their sex life with their fiancé or future husband belong
to this stage. From a statistical point of view, in order to experience the delights of orgasm
while lovemaking, a woman needs at least two years of personal exploration and self-
awareness, through an inner experience that is consciously assumed and dedicated to know her
own body, both on the physical and emotional level (Ilie T. & Gheorghe L., p. 324).
The mechanism of apparition of a female orgasm disorder has two important aspects: the
hyper-attention and the hyper-intention. It was noted that following repeated unpleasant
experiences (physical discomfort during sexual intercourse, lack of sexual satisfaction), the
woman approaches sexual activity with anticipatory anxiety (fear of a new possible failure).
While fearing, she focuses on the results (hyper-attention), so that her attention can deviate
from the partner, and stop being receptive to the stimuli received. As a result, the excitement
decreases, at which point the hyper-intention occurs – the person tries harder, and the harder
she tries the worse the results deteriorate, and the vicious circle closes (Nagosky E., p. 330-
35).
Physiological and psychological causes and factors

A certain health problem that is based on a sexual dysfunction of the partner (premature
ejaculation, erectile dysfunction) can be the cause of an orgasmic dysfunction in the woman.
An absence of orgasmic reaction in women can also depend on the wrong and erroneous
information about sexuality she has, coming from the familiar environment, regarding the fact
that men can take advantage of them, or that sex is something ugly and dirty for “good girls”.
Another common factor is the ethnic religious nature that induced the idea that sex is only
a conjugal duty related exclusively to reproduction, and that apart from this function it is a sin.
At other times the imaginary, psychological attitude can cause rejection towards the partner,
when he is not what she wants from a physical and behavioural point of view. Lubrication and
sensitivity in the genitals can be affected by certain lesions in the pelvic nerves and blood
61
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vessels. These can occur as a result of a pelvic trauma, an operation in the genital or pelvic
area: hysterectomy (removal of the uterus), oophorectomy (removal of one or both of the
ovaries), surgical intervention on the vagina or vulva. Dr. Jennifer Berman and Dr. Laura
Berman of the Female Sexual Medicine Center, University of California at Los Angeles,
UCLA, conducted innovative research in this field. Other causes of physiological nature are
breastfeeding, menopause, oral contraceptives, antihistamine drugs. Stress and anxiety
influence quite a lot the orgasmic reaction in women. Antidepressants come as well with a side
effect that affects orgasm in women. There are different levels of anxiety, and the way it
influences each person is different. For example, in some women, anxiety may be the reason
behind the difficulty of reaching an orgasm. Anxiety is what gives rise to many thoughts that
concern our minds and distract us during lovemaking, therefore the stimulation of orgasm may
be affected. For example, there are women who have an anxiety associated with their
“performance” in bed, that is, they are so worried about this aspect that they cannot relax, enjoy,
or get aroused enough. Another cause is the lack of harmonious communication in the couple,
a lack of affection or mutual respect. Depression can contribute as well to a low libido and
problems in reaching the state of orgasm.
Therapeutic methods
If anorgasmia occurs as a consequence of depression, the pharmacological treatment of the
latter can also lead to an improvement in the quality of sexual life. Nonspecific methods of
treatment have also been tried: aromatherapy, homeopathic remedies, massage with aromatic
oils – but the effectiveness of these procedures is a little difficult to evaluate from a medical
and statistical/scientific point of view.
Currently anorgasmia is commonly addressed through psychotherapy. In the
psychotherapeutic process, the partner is also involved, for improving communication and
resolving conflicts. Thus, the partners learn the self-exploration, how to solve the (unconscious)
fear of orgasm, how to reach sexual arousal or how to become aware of the erogenous
peculiarities of each other. Numerous studies (Delcea C, 2019; Delcea C, 2019; Voinea M. M.,
& Delcea C., 2020; Delcea C., PerjuDumbrava D., Kovacs, M. I., et al., 201) confirm our
results.
Other methods of psychotherapy used in the treatment of female anorgasmia are:
hypnotherapy, behavioural therapy, integrative therapy, psychodrama. The treatment of
psychological components is of significant importance. Emotional and behavioural support
from the partner is essential. Since there is no specific medication, different methods of
psychotherapy are preferable, as the obtained results are significant and satisfactory in the long
term.
CONCLUSION
We can therefore conclude that the treatment of sexual orgasm disorder can be a long-lasting
process. After giving up excessive deviant behaviour, the person undergoing therapy will
gradually gain access to an increasingly rich emotional life, and will be freed from the inner
constraints that kept her trapped in feelings of helplessness and imbalance. She will acquire
skills that will facilitate the relationship with her own person, restoring her self-esteem, and
she will be able to engage in fulfilling and orgasmic intimate relationships.
REFERENCES
[1] DSM-IV: Diagnostic and Statistical Manual of Mental Disorders, fourth edition, ‘Female Orgasmic
Disorder’ (Bucharest, 2000), p. 452.
[2] Nagoski, Emily, Arta sexualitatii, Editura Clobo, pp. 330-35, 2019.
62
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[3] Chia, Mantak, & Dr. Abrams, Rachel Carlton, Femeia multiorgasmica. Editura Venusiana, pp. 97-103,
2017.
[4] Chia, Mantak & Chia, Maneewan, Cultivarea energiei sexuale feminine, Editura Antet, pp. 44-47, 1994.
[5] Shere Hite, Raportul Hite. Noul studiu Hite despre sexualitatea feminina. Editura Nemira, pp. 27-45,
2008.
[6] Ilie, Tudor & Gheorghe, Liviu, Din tainele frumusetii feminine. Editura Kamala, p. 324, 1998.
[7] Stekel, Wilhelm, Psihologia eroticii feminine. Editura Trei, 1997.
[8] Delcea C. Orgasmic disorder in women. Int J Advanced Studies in Sexology. Vol. 1, Issue 1, pp. 56-67.
Sexology Institute of Romania, 2019. DOI: 10.46388/ijass.2019.12.11.122.
[9] Delcea C. Arousal disorder in women. Int J Advanced Studies in Sexology. Vol. 1, Issue 2, pp. 78-83.
[11] Delcea C. Dyspareunia in women. Int J Advanced Studies in Sexology. Vol. 1, Issue 2, pp. 84-88.
International Conference Supervision in Psychotherapy. Pages: 65-68, 2018. Filodiritto Publisher.
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1.5 Arousal disorder
AROUSAL DISORDER IN WOMEN
Abstract
Recurrent/persistent inability to attain/maintain until completion of the sexual activity, an

adequate lubrication-swelling response of sexual arousal. Recurrent inability to get aroused.
Your response to stimulation is physiologically/somatically maladaptive. And your
perceptions about your inability to get aroused are distorted. The disturbance causes distress.
The disturbance causes marked distress or interpersonal difficulty. Worldwide prevalence
of arousal disorder in women is 26-43% and can be maintained depending on partner,
stimulation, situation or regardless partner, stimulation, situation etc. The disorder may emerge
from the beginning of the sexual life or begin after a period of relatively normal sexual function.
Keywords: arousal disorder in women, s-on, therapy, testing, evaluation, sexual disorders
INTRODUCTION
Assessment System. After testing, you will complete the 7 standardized S-ON Sextherapy©
protocols to address sexual and/or couple issues.
period of interventions to improve arousal disorder in women as well as S-ON Optimization©
to optimize sexual performance and couple’s relationship.
Let’s start!
Applications
Screening-DSM/E (S-DSM/E)
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suits you.
1/8 After adequate stimulation and penetration do you achieve/maintain difficult or you
are inable to attain lubrication-swelling
Not at all
A little
A lot
Very much
Extremely
2/8 6 or 7 out of 10 sexual intercourses have a diminished intensity of arousal?

Not at all
A little
A lot
Very much
Extremely
3/8 Has arousal disorder occured at the beginning of your sexual life?
Not at all
A little
A lot
Very much
Extremely
4/8 Has it occured after a long period of time, reported to the beginning of sexual life?
Not at all
A little
A lot
Very much
Extremely
5/8 Arousal disorder occur with your stable long-term partner?

Not at all
A little
A lot
Very much
Extremely
6/8 It appears irrespective of the partner?

Not at all
A little
A lot
Very much
Extremely
7/8 Is there is an anticipatory fear of a new sexual failure?

Not at all
A little
65
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A lot
Very much
Extremely

Not at all
A little
A lot
Very much
Extremely
Answers
- Not at all, 0 percentages;
- A little, 10 percentages, MILD arousal disorder is confirmed. This means you have
signs and symptoms of marked difficulty in obtaining arousal and lubrication-swelling;
- A lot, 20 percentages, MODERATE arousal disorder is confirmed. This means you
have signs and symptoms of marked difficulty in obtaining or absence of arousal and
lubrication-swelling;
- Forte A lot, 30 percentages, SEVERE arousal disorder is confirmed. This means you
have signs and symptoms of marked difficulty in obtaining or total absence of arousal
sensations and lubrication-swelling;
- Extremely, 40 percentages, EXTREMELY SEVERE arousal disorder is confirmed.
This means you have signs and symptoms of marked difficulty in obtaining or total
absence of arousal sensations and lubrication-swelling.

Screening-DSM/Dof (S-DSM/Dof)
suits you.
1/8 Do you have a reduced or absent sexual desire?

Not at all
A little
A lot
Very much
Extremely
2/8 6 or 7 out of 10 sexual intercourses happened without sexual fantasies or wish for
having sex?
Not at all
A little
A lot
Very much
Extremely
3/8 Did you have pleasant thoughts/cognitions to have sex during sexual intercourse?
Not at all
A little
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A lot
Very much
Extremely
4/8 Did it appared after a long time, reported to the beginning of your sexual life?
Not at all
A little
A lot
Very much
Extremely
5/8 Sexual desire disorder occur with your stable long-term partner?
Not at all
A little
A lot
Very much
Extremely
6/8 Does it occur irrespective of the partner?

Not at all
A little
A lot
Very much
Extremely
7/8 Is there an anticipatory fear of a new sexual failure?

Not at all
A little
A lot
Very much
Extremely

Not at all
A little
A lot
Very much
Extremely
Answers
- A little, 10 percentages, MILD sexual desire disorder is confirmed. This means that
you have signs and symptoms regarding the reduction of interest in sexual activity,
erotic thoughts and fantasies as well as the initiative to have sex;
- A lot, 20 percentages, MODERATE sexual desire disorder is confirmed. This means
that you have signs and symptoms regarding the reduction or absence of interest in
sexual activity, erotic thoughts and fantasies as well as the initiative to have sex;
- Very much, 30 percentages, SEVERE sexual desire disorder is confirmed. This means
that you have signs and symptoms regarding the total absence of interest in sexual
activity, erotic thoughts and fantasies as well as the initiative to have sex;
67
©
- Extremely, 40 percentages, EXTREMELY SEVERE sexual desire disorder is

confirmed. This means that you have signs and symptoms regarding the total absence
of interest in sexual activity, erotic thoughts and fantasies as well as the initiative to
have sex.

Protocol of sexual cognitive scenario, S-ONd cognitive©
Sexual desire
The protocol of S-ONd cognitive© sexual cognitive scenario was scientifically validated
insisting on sexual stimulus, thus controlling the arousal and maintaining sexual desire. This
technique uses cognitive scenarios and several steps to help women rediscover how to be
involved at a cognitive-behavioural level by using relevant sexual stimulus of sexual desire. In
fact, it is a self guidance in how to participate at the cognitive-behavioural level only to the
excitation stimulus by using descriptions and following certain rules: What am I doing? How
am I doing it? and What am I going to do? Or What am I doing simultaneously? so that you
can pay attention to the maximum excitation/relevant stimulus.
Focus
This technique helps women to relearn how to think using all relevant sexual stimulus and
how to manage the sensations that might rise sexual desire. In fact, this protocol helps women
to think „analytically” in order to identify the excitation stimulus which contribute to the
arousal and keep your sexual libido for an increased sexual drive.
Specialist advice
sexual stimulus, will help you to become an expert in sexual activity and to increase and
the bed? They say that the more you have, the more you want. This is what happens also with
the sex.
Applications
do? Or What am I doing simultaneously? and thus you can pay attention to what you do instead
of how you feel.
in that way with the description for all of yours and your partner’s stimulus/areas! Follow the
example from the Table 1.
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then..., etc., ...
then..., etc., …
pinch them, and then..., etc., ...
Well done!
You have succeeded to complete the Protocol of sexual cognitive scenario S-ONd
“analytically” think in order to manage the excitation stimulus and to have and to keep elevated
your sexual libido.
Feedback
Was the Protocol of sexual cognitive scenario S-ONd cognitive© useful for you? Please
1. Unsatisfactory;
2. Satisfactory;
3. Good;
4. Very good;
5. Excellent.
REFERENCES
[1] Abel, G. G., Becker, J. B., Cunningham-Rathner, J., Mittelman, M., & Rouleau, J. L., 1988. Multiple
Law, 16, pp. 153-168.
[2] Abel, G. G., Becker, J. B., Mittelman, M., Cunningham-Rathner, J., Rouleau, J. L., & Murphy, W. D.,
3-25.
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21, pp. 72-94.
Press.
26-49.
38(2), pp. 164-179.
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DYSPAREUNIA IN WOMEN
Abstract
Dyspareunia is a genital pain that occurs just before, during or after intercourse. The factors
involved can be physical or psychological. Women with dyspareunia may complain of a well-
defined and localized pain or they may express a general disinterest in and dissatisfaction with
intercourse that results from the associated discomfort. Although dyspareunia is present in both
sexes, it is far more common in women, with the pain initiating in several areas, from vulvar
surfaces to deep pelvic structures. Worldwide prevalence of dyspareunia in women is 15% and
can be maintained depending on partner, stimulation, etc. or regardless partner, stimulation,
etc. The disorder may emerge from the beginning of the sexual life or begin after a period of
relatively normal sexual function.
Keywords: dyspareunia in women, s-on, therapy, testing, evaluation, sexual disorders
INTRODUCTION
Assessment System.
period of interventions to improve dyspareunia in women as well as S-ON Optimization© to
optimize sexual performance and couple’s relationship.
Let’s start!
Optimizing, S-ON Optimization© Applications.

Screening-DSM/DYf (S-DSM/DYf)
suits you.
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©
1/8 Do you feel discomfort or pain after a minimum vaginal penetration?

Not at all
A little
A lot
Very much
Extremely
2/8 Do you feel vulvovaginal/pelvic pain/discomfort during 6 or 7 out of 10 sexual

intercourses?
Not at all
A little
A lot
Very much
Extremely
3/8 Dyspareunia occurred since the beginning of your sexual life?

Not at all
A little
A lot
Very much
Extremely
4/8 It occured after a long time, reported to the beginning of sexual life?
Not at all
A little
A lot
Very much
Extremely
5/8 Orgasmic disorder occurs with your stable long-term partner?

Not at all
A little
A lot
Very much
Extremely
6/8 It happens irrespective of the partner?

Not at all
A little
A lot
Very much
Extremely
7/8 There is an anticipatory fear of a new sexual failure?

Not at all
A little
A lot
Very much
Extremely
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Not at all
A little
A lot
Very much
Extremely
Answers
- A little, 10 percentages, MILD dyspareunia is confirmed. This means you have signs
and symptoms of significant discomfort during penetration;
- A lot, 20 percentages, MODERATE dyspareunia is confirmed. This means you have
signs and symptoms of discomfort or significant pain during penetration;
- Very much, 30 percentages, SEVERE dyspareunia is confirmed. This means you have
signs and symptoms of significant, recurrent pain during penetration;
- Extremely, 40 percentages, EXTREMELY SEVERE dyspareunia is confirmed. This
means you have signs and symptoms of significant, recurrent pain during penetration.

Protocol of sexual cognitive scenario, S-ONdy cognitive©
Dyspareunia
The protocol of S-ONdy cognitive© sexual cognitive scenario was scientifically validated
insisting on sexual stimulus, thus diminishing the vaginal pain. This technique uses cognitive
scenarios and several steps to help women rediscover how to be involved at a cognitive-
behavioural level by using relevant sexual stimulus for dyspareunia. In fact, it is a self guidance
in how to participate at the cognitive-behavioural level only to the excitation/relevant stimulus
by using descriptions and following certain rules: What am I doing? How am I doing it? and
What am I going to do? Or What am I doing simultaneously? so that you can pay attention to
the maximum excitation/relevant stimulus.
Focus
This technique helps men to relearn how to think using all relevant sexual stimulus and how
to manage the sensations that might increase the pain. In fact, this protocol helps men to think
“analytically” in order to identify the relevant stimulus (relaxation, pleasure and excitation)
which relieve the pain during intercourse.
Specialist advice
relevant stimulus, will help you to become an expert in sexual activity and to increase and
the bed?
Applications
do? Or What am I doing simultaneously? and thus you can pay attention to what you feel.
73
©
in that way with the description for all stimulus/ areas of your partner!
Follow the example from the Table 1.

then..., etc., ...
then..., etc., …
pinch them, and then..., etc...
Well done!
You have succeeded to complete the Protocol of sexual cognitive scenario S-ONdy
“analytically” think in order to manage the pain stimulus and to enjoy your sex life.
Feedback
Was the Protocol of sexual cognitive scenario S-ONdy cognitive© useful for you? Please
1. Unsatisfactory;
2. Satisfactory;
3. Good;
4. Very good;
5. Excellent.
74
©
REFERENCES
Law, 16, pp. 153-168.
[2] Abel, G. G., Becker, J. B., Mittelman, M., Cunningham-Rathner, J., Rouleau, J. L., & Murphy, W.
D.,1987. Self-reported sex crimes of nonincarcerated paraphiliacs. Journal of Interpersonal Violence, 2,
pp. 3-25.
21, pp. 72-94.
Press.
26-49.
38(2), pp. 164-179.
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1.6 Desire disorder
INHIBITED/DIMINISHED SEXUAL DESIRE AND LOSS OF ORGASM IN WOMEN
Abstract
In the specialized literature, sexual desire disorder is approached as a decrease in sexual

interest, a lack of fantasies about sexual activity, decreased libido or frigidity. Gutceit believes
that “out of 10 women 4 do not feel anything during intercourse and endure it without having
the slightest pleasant sensation during friction and without having any idea about the pleasure
of ejaculation”, and Debruner even adds that 50% of women are insensitive and one cannot
speak of a proper libido.
Keywords: sexual disorder, decreased sexual desire, reduced arousal
Diagnostic
Dsm 5 says that for about 6 months there should be the following symptoms:
- reduction or absence of interest in sexual activity;
- reduction or absence of sexual or erotic thoughts and fantasies;
- lack/reduction of the initiative regarding the sexual activity, the absence of receptivity
to the partner’s initiatives;
- reduction or absence of sexual desire or arousal in response to any erotic stimulus,
every time or almost every time;
- reduction or absence of genital sensations or other erogenous zones.
Why is it so important for a woman to have an orgasm during intercourse?

Every orgasm felt by a woman is primarily clitoral. Orgasms resulting from sexual
intercourse are clitoral and vaginal which means that the penis stimulates the vagina and clitoris
simultaneously.
Another question that needs to be asked here is: whether or not a woman is able to enjoy
sexual intercourse?
Every modern woman is entitled to enjoy the fullest sensory experience available to human
beings – sexual orgasm. It is the ultimate “destination”. To deprive a woman of this experience
that rightfully belongs to her is something that no man can do deliberately. Only lack of
knowledge and misunderstanding can encourage a woman to voluntarily give up her greatest
chance of sexual happiness.
Many women who have been solemnly diagnosed as frigid simply are not sexually
stimulated enough. Under the old rules, as soon as a man sent an erect penis into her vagina,
the responsibility for reaching orgasm was transferred to the woman.
No woman deserves to be labeled sexually frigid if her partner does not give her at least
enough mechanical stimulation to trigger an orgasmic reflex.
How much stimulation does this entail?
For the typical couple, about eight minutes of actual sexual intercourse or between 75 and
80 pelvic movements. This, of course, requires a reasonable time for foreplay enough to trigger
vaginal lubrication and an emotional atmosphere of mutual affection. Under these
circumstances, the average woman should be able to reach orgasm.
What if he can’t?
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Then it is possible that she suffers to some extent from an orgasmic insufficiency due to a
fundamental emotional conflict. But if her partner gives her a quick penetration, a few
unenthusiastic movements, a quick jet of cum, and a muttered excuse, it’s more likely to be his
problem than hers.
How do hormones influence a woman’s sexual feelings?

Most modern women feel the immense force of hormones every month. Impulses may never
reach the surface in their original form.
Some women are simply starved as a wolf for a few days each month. Others become
nervous and irritable just before the start of menstruation. Some women go through a deep
depression during this period.
Many of those who are affected by these symptoms, which seem to have nothing to do with
sex, but which are related to menstruation, are women who are unwilling or unable to recognize
their sexual feelings. They manage to suppress sexual desire in response to increased hormone
production, but the emotional pressure is maintained and must be released in some form.
One of the main reasons why most women do not begin to use their true sexual potential is
the relentless and sometimes ruthless repression of their sexuality by men. Because most men
realize at least unconsciously that their sexual masculinity is microscopic compared to that of
women, they run a constant campaign to reduce and minimize female sexual capacity. This
kind of thinking may mean something to male egocentrism, but the effect on women is
devastating.
Normally, the woman who cannot reach orgasm has the same deep needs and feelings as
any other human being, sometimes even greater. Unfortunately, she still has an unconscious
emotional barrier, which prevents her from finding real sexual satisfaction.
If a woman’s orgasmic ability is only prevented from manifesting, the situation can be
remedied, but if she is cold, then she is completely frozen.
Physically and emotionally, the human female is the most complex organism on earth. It
has the potential for emotional and sexual happiness untouched by any other creature. The only
way to ever reach this potential is to understand and accept the truth about her mind, her body,
and her own unique sexuality. If the facts are presented to her in an honest way, and she is
willing to accept them in a realistic way, she will make great progress towards achieving her
own goal.
Etymology
Frigidity can be a consequence of several factors. Old age, stress, depression, anxiety, low
self-esteem, anger, fear, trauma from rape, lack of trust in the partner, quarrels in the couple
are all possible psychological causes of frigidity.
Other causes of frigidity can be:
• Hormonal imbalances that occur during menopause, during pregnancy or as a result of
oral contraceptives;
• Poor blood circulation;
• Nervous lesions in the pelvis;
• Vaginal infections (vaginitis) or bladder (cystitis);
• Vaginal dryness (vaginal atrophy);
• Some drugs (antidepressants);
• Chemotherapy/radiotherapy;
• Diabetes;
• Insufficient sexual stimulation (reduced or absent sexual foreplay);
• Insomnia;
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• Chronic fatigue;
• Mineral deficiency;
• Multiple sclerosis.
In most cases, the diagnosis of frigidity does not identify a cause of a physical nature, but a
mental one. The diagnosis is established based on the symptoms presented by the patient, but
also on her medical history. If sexual stimulation does not lead to arousal, an imaging
examination of the pelvis is most likely necessary to determine if the underlying condition may
be a medical problem (infections, nerve damage).
The doctor may also recommend a complete blood test to assess the patient’s general health.
Most of the time, however, frigidity is a consequence of lowering of the testosterone level
from blood. However, there are also situations when frigidity is caused by psychological factors
such as those mentioned above, in which case the advice of a specialist (psychologist,
psychotherapist, sexologist, specialist in couple relationships) is required, who can identify the
underlying emotional disorder. Frigidity, subsequently initiating an appropriate treatment plan.
• Psychological factors: inhibited desire is the result of self-defense as a result of
unconscious fear of sexual activity.
• Other factors on which sexual desire depends: constitutional determinants, previous
sexual experiences, attraction to the present partner, existential situation, culture, etc.
• Sexual dysfunction due to a general medical condition – the dysfunction is due
exclusively to the physiological effects of a general medical condition based on history,
laboratory data or somatic examinations.
• Substance-induced sexual dysfunction – dysfunction is due exclusively to the direct
physiological effects of a substance.
• Major depressive disorder, obsessive-compulsive disorder, post-traumatic stress –
decreased sexual desire is better explained by one of these disorders.
• Occasional sexual desire problems – not all criteria for diminished sexual desire
(duration, distress) are met.
Evolution
• Decreased sexual desire is often associated with depressive disorders.
• The disorder may have an episodic evolution (marital difficulties) or continuous.
Treatment
The treatment of frigidity depends on its cause and may consist of hormone therapy,
psychological counseling or both. If the patient is taking antidepressants that cause frigidity,
treatment may consist of simply adjusting their dose or changing them with others.
With the help of a psychotherapist specializing in couple/family relationships, the patient
can discover, together with her partner, what the basic problem is and how she can rediscover
the pleasure of sexual intercourse. In the case of a psychological trauma caused by rape or other
sexual abuse, the patient needs specialized psychological therapy to overcome this emotional
shock and to regain confidence in herself and other men.
Communication between the couple’s partners is also very important. They need to confess
their fears to each other, acknowledge the problem, and make an effort to rediscover their
sexual desire. Couples who have been together for a long time often face the loss of sexual
desire.
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CONCLUSION
Cold women have heard that sex brings pleasure but they cannot understand it and remain
cold or have at least a slight pleasure, or complain of pain and experience an unpleasant or
disgusting feeling, or may lack any sexual sensation. The woman feels neither pleasure nor
orgasm, or it is possible that the pleasure is quite great but lacks orgasm. From time to time,
the woman gets an orgasm after a long struggle. The pleasure that women want becomes
disappointment because they expect more, because they want to achieve an intensification that
can no longer be achieved.
REFERENCES
[1] American Psychiatric Association. (2013). Dsm 5. Pp. 429-437, Editura Callistro.
[2] David Reuben., (2018). Orice femeie poate. Editura Curtea Veche.
[3] Wilhelm Stekel., (1997). Psihologia eroticii feminine, Editura Trei.
[4] Delcea C. (2019). Arousal disorder in women. Int J Advanced Studies in Sexology. Vol. 1, Issue 2, pp.
[5] Delcea C. (2019). Dyspareunia in women. Int J Advanced Studies in Sexology. Vol. 1, Issue 2, pp. 84-
88. Sexology Institute of Romania. DOI: 10.46388/ijass.2019.12.11.125.
[6] Pană R. A., (2020). The Female Orgasm Disorder. An Individual Psychology Approach. Int J Advanced
Studies in Sexology. Vol. 2, Issue 1, pp. 5-8. Sexology Institute of Romania. DOI:
10.46388/ijass.2020.13.11.
[7] Hajnalka G., (2020). Painful intercourse. Dyspareunia and Vaginismus. An Individual Psychology
Approach. Int J Advanced Studies in Sexology. Vol. 2, Issue 1, pp. 32-37. Sexology Institute of
Romania. DOI: 10.46388/ ijass.2020.13.16.
[8] Voinea M. M., & Delcea C., (2020). Painful intercourse. Dyspareunia and Vaginismus. An Individual
of Romania. DOI: 10.46388/ijass.2020.13.17.
[9] Kocsis A., (2020). Female orgasm disorder. An Individual Psychology Approach. Int J Advanced
10.46388/10.46388/ijass.2020.13.18.
[10] Stuparu C., (2020). Female orgasm disorder. Anorgasmia. Int J Advanced Studies in Sexology. Vol. 2,
Issue 2, pp. 89-93. Sexology Institute of Romania. DOI: 10.46388/ijass.2020.13.25.
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DISORDER OF SEXUAL DESIRE OR AROUSAL IN WOMEN AND THE HISTORY

OF SEXUAL ABUSE AS A PREDICTOR OF IT
Abstract
The disorder of sexual desire or arousal is defined by the total or significant lack of sexual
desire or arousal, and one of the associated factors or factos that are supporting this diagnosis
is that of vulnerability of the individual, such as a history of sexual abuse. Numerous studies
have shown that women who have a history of sexual abuse are more likely to develop sexual
dysfunction.
Keywords: Disorder of desire or sexual arousal, DSM V, sexual abuse
INTRODUCTION
Disorder of desire or sexual arousal is the most common sexual disorder among women and
leads to the greatest discomfort in a relationship.
DEFINITION
DSM 5 defines this disorder by the lack or significant reduction of sexual desire/arousal. It
can be characterized by at least three of the following symptoms:
• reduction or loss of interest in sexual activity;
• absence or reduction of sexual thoughts/fantasies;
• decreased or no initiation of sexual activity or response to the partner’s attempts to
initiate sexual activity;
• reduction or absence of sexual arousal or pleasure every time or almost every time;
• reduction or absence of sexual interest or desire in the case of the majority of stimuli;
• reduction or absence of sexual genital sensations or at the level of other erogenous
zones during intercourse every time or almost every time (about 75-100%).
Diagnostic elements
A lower desire for sexual activity is not enough to diagnose the desire disorder or sexual
arousal in women. They may have different symptoms and different ways of expressing sexual
desire and arousal. When the symptoms present a persistent problem (minimum duration of
about 6 months) the diagnosis of desire disorder or sexual arousal can be expressed. Also, for
the establishment of the diagnosis requires the presence of the symptoms mentioned above,
accompanied by the presence of significant clinical discomfort.
Associated elements that support the diagnosis

In assessing and diagnosing disorder of desire or sexual arousal in women, the following
five factors should be considered: partner-related factors (e.g., partner’s health status), couple
factors (e.g., reduced communication), factors related to the vulnerability of the individual
(e.g., history of sexual abuse), cultural factors (e.g., various inhibitions) and medical factors
relevant to the prognosis.
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Prevalence
The global study on the attitudes and sexual behaviour has highlighted a prevalence of 26-
43% for the lack sexual interest in the case of women aged 40-80 in 20 countries (Laumann et
al., 2005 as cited in Delcea, 2011).
Debut and evolution

Although the definition of this disorder indicates that the lack of desire or sexual arousal is
of lifelong existence, it can be classified into two types:
Permanent – the absence of sexual desire or arousal from the first sexual experience;
Acquired – difficulties related to sexual desire and arousal have appeared along the way,
and can be consequences of some factors related to the partner, interpersonal or personal
factors.
Risk factors and prognosis

Temperament factors – negative conceptions and attitudes towards sexuality and history of
mental disorders;
Environmental factors – problems in the couple’s relationship, stress factors during
childhood, etc;
Genetic and physiological factors – medical conditions.
In general, women acknowledge that an unhappy marriage, physical or emotional abuse,
drug or alcohol addiction, and depression would influence sexual desire or arousal. However,
when they examine their own relationship, they tend to justify the lack of sexual desire or
arousal for a medical reason, never a psychological or interpersonal reason (Levine, Risen, &
Althof, 2003).
History of sexual abuse and sexual dysfunction in women

There is considerable evidence that women with a history of sexual or physical abuse often
develop various sexual dysfunctions (Fugl Meyer, 2006 as cited in Delcea, 2011). Previous
traumas compromise the feeling of security, autonomy, mutual respect, feelings that are
essential for the feeling of satisfaction and sexual pleasure (McCarthy & Breetz, 2010 as cited
in Metz, Epstein & McCarthy, 2017).
Motivated by fear of rejection or shame, sexually abused women often refuse to tell their
partners about their abuse. This attracts feelings of insecurity about the relationship, the partner
personally taking the woman’s negative attitudes and responses to sexual intercourse.
Some partners who get to know about the abuse form negative expectations and wait for
time to heal the trauma of the abuse, not being able to understand that the negative effects can
persist and take the form of sexual dysfunctions (Metz, Epstein, & McCarthy, 2017).
A study conducted in the US on the prevalence and predictors of sexual disorders found that
victims of sexual abuse have a higher prevalence of sexual dysfunctions than people without a
history of sexual abuse in childhood. The most common disorder among women is that of
sexual arousal or desire, and among men erectile dysfunction and premature ejaculation.
(Laumann, Piel & Rosen, 1999 as cited in Hall & Hall, 2011).
Cognitive-behavioural approach in sexual dysfunctions

This approach focuses primarily on same-sex or different-sex couples, but can be modified
and adapted to individual therapy and involves the formation of skills that promote functioning
and satisfaction in the couple’s relationship and sexual intercourse.
This approach also has a psycho-educational component that is necessary for couples where
partners may have a limited set of knowledge and feel embarrassed to talk about the physiology
of the sexual organs or have poor psycho-sexual skills.
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This approach focuses on the intertwining of emotional responses, behavioural interactions,

and thoughts that undermine sexual intercourse.
In desire disorder/sexual arousal, the fundamentals of the approach cognitive-behavioural
are the following:
• Establishing emotional and sexual conditions for openness, receptivity and response.
• Encouragement to create a sexual “voice”, taking responsibility for sexual desire and
“building a bridge that leads to desire” (McCarthy & Wald, 2015 as cited in Metz,
Epstein & McCarthy, 2017).
• In the case of couples in which one of the partners has been sexually abused, clinicians
ask a set of questions about the abuse as part of the sexual history. It helps the two
partners talking to them about the long-term effects of an abuse and strategies to help
the person in question heal (Metz, Epstein, & McCarthy, 2017).
CONCLUSION
Desire disorder/sexual arousal is one of the most common sexual disorders among women.
Women with a history of sexual abuse are more likely to develop a sexual dysfunction than
women who have not experienced sexual trauma. For this reason, it is very important that each
trauma is treated in time, because an untreated trauma will affect us at any time of life in
different forms. According to the studies of Siserman C., Delcea C., Vladi Matei H., Vică L.
M. (2019) and Delcea C., Siserman C., (2020) we can argue that future research must bring
new discoveries.
REFERENCES
[1] American Psychiatric Association. (2016). DSM 5 Manual de Diagnostic şi Clasificare Statistică a
Tulburărilor Mintale. Bucureşti: Callisto.
[2] Delcea, C. (2011). Psihodiagnostic și evaluare clinică în tulburările sexuale. Cluj-Napoca.
[3] Hall, M., & Hall, J. (n.d.). The Long-Term Effects of Childhood Sexual Abuse: Counseling Implications.
Retrieved from www.counseling.org: https:// www.counseling.org/docs/disaster-and-trauma_ sexual-
abuse/long-term-effects-of-childhood-se xual-abuse.pdf?sfvrsn=2
[4] Levine, S., Risen, C., & Althof, S. (2003). Handbook of Clinical Sexuality for Mental Health
Professionals. New York: Brunner Routledge.
[5] Metz, M., Epstein, N., & McCarthy, B. (2017). Cognitive-Behavioral Therapy for Sexual Dysfunction.
Routledge.
Individuals Incarcerated for Sexual Offences. Rom J Leg Med [28] pp. 278-282 [2020] DOI: 10.4323/
rjlm.2020.278.
Paraphilic Disorders. Rom J Leg Med28(1) pp. 14-20 (2020) DOI:10.4323/ rjlm.2020.14Romanian
[8] Siserman C., Delcea C., Vladi Matei H., Vică L. M. (2019). Major Affective Distres in Testing Forensic
Paternity. 2019. – Rom J Leg Med27(3) pp. 292-296 (2019) DOI:10.4323/rjlm.2019.292 © Romanian
Society of Legal Medicine
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1.7 Sexual pain disorders
DYSPAREUNIA
Abstract
Dyspareunia is also called genito-pelvic/penetration pain disorder and is characterized by

persistent or repetitive genital pain that may occur before, during or after penetrative
intercourse. Although it is present in both sexes, it is much more common in women. This
article aims to address the evolution and onset of this disorder, taking into account both
physiological and psychological factors.
Keywords: sexual disorder, dyspareunia, physiological factors, psychological factors, pelvic area
INTRODUCTION
One of the most discussed and interesting topics of all time has been and is sexuality. What
makes this topic so attractive certainly has as a point of reference the dynamics that occur
between human relationships. Among the most important ingredients that make a romantic
relationship work is the act of making love.
This action involves the interconnection of the emotional part with the sexual part. In this
direction, the knowledge of sexual development and sexual behavior has become over time an
important component for maintaining health.
In the works of sexology, it is mentioned that some sexual behaviors considered perverse in
the past are seen by contemporary society as deviant. In the same vein, sexual activity is closely
correlated with overall health and well-being.
According to a study conducted by Laumann and his colleagues in 2002, it is important to
pay special attention to sexuality and to integrate it harmoniously into our lives. Although
sexual activity relaxes and maintains our well-being, we must also take into account the fact
that it can be the source of sexual disorders in both men and women.
Sexual disorders include: female sexual dysfunction, male sexual dysfunction, paraphilias
and gender identity disorders.
The beginning of sex can be a nightmare or a real celebration. Most of the time, the first
experience becomes a point of reference for the rest of life, this being retained with the smallest
details. Usually, when a pain occurs that causes us internal discomfort, it should not be treated
superficially.
Pelvic pain can be recognized by accusations in the lower abdomen and pelvis, the area
under the abdomen and between the hips. In most cases, pain can occur when sexual intercourse
is consumed in a hurry, without taking into account a specific period of time specific to the
foreplay.
When this happens, the lubrication is insufficient, and the quality of sexual intercourse
becomes unsatisfactory.
Within the female sexual dynamics, there are several types of dyspareunia, such as:
superficial dyspareunia, deep dyspareunia, primary dyspareunia and secondary dyspareunia.
Superficial dyspareunia is characterized by pain at the beginning of penetration. The article
in the Journal de L’association Medicale Canadienne mentions that women suffering from
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superficial dyspareunia face low levels of self-esteem in terms of physical appearance,

depression and anxiety.
Deep dyspareunia can be identified by pain when penetration is complete. In the specialized
works, this disorder presents together with several comorbidities. The next type of dyspareunia
is primary dyspareunia, which is accompanied by pain from the first sexual intercourse. And
the last type of dyspareunia is secondary dyspareunia. It appears after a period of time in which
several painless sexual contacts were present, against the background of a psychological
trauma.
When referring to dyspareunia, it is good to take into account both medical and psycho-
emotional history. Sexual abuse may be present in the medical history, and in the psycho-
emotional history it can be noticed if there are mental or personality disorders. At the same
time, we can identify cultural values, religious beliefs about sex life.
Comorbidities that occur with physical dyspareunia may be: vaginal dryness, candidiasis,
thin mucosa, surgical lesions of the vagina or vulva, tumors or infections of the vagina, genital
lesions, sexually transmitted diseases, irritations or allergies to certain intimate hygiene
products or even detergents, endometriosis, cystitis, birth.
An example in this direction is postpartum dyspareunia. In this situation, it is recommended
to resume sexual intercourse at a period of 6 weeks after birth, and this will be done with a lot
of patience and gentleness.
Vaginismus that results in involuntary muscle spasm at the time of penetration can become
another trigger for dyspareunia. It can be related to a sexual trauma or the fear of not creating
genital injuries. In this sense, exercises to strengthen the pelvic floor muscles, sensory focus,
intimate touch or deep breathing are helpful.
The partner will be involved in psychotherapy and will be presented with methods of
approach. Sexual intercourse without copulation is recommended, with arousal positions that
do not obviously require penetration and physiotherapeutic treatment. Underlying causes of a
psychological nature can be anxiety, depression, concerns about physical appearance, fear of
intimacy, relationship problems and others.
In sexology work, orgasm is defined as a feminine experience that involves a change in
consciousness. Specialists in the field have sought to differentiate in terms of the intensity of
experiencing orgasm when there is emotional involvement or only physical involvement. The
quality of orgasm and well-being presupposes, besides the very good knowledge of the
erogenous zones, the clitoral stimulation, followed by the vaginal one. Current studies show
that women can experience more types of orgasms than men.
Sexuality is also an exercise in self-concentration in order to obtain a state of awareness of
orgasm. Before reaching the climax of pleasure, it must be taken into account that everyone
has a set of beliefs, but also methods by which to approach arousal. It is worth mentioning
masturbation, through which the partner experiences the preferred way of arousal or in
pathological cases, one of the few moments of orgasm.
CONCLUSION
In conclusion, it is important to keep in mind some aspects related to the prevention of

dyspareunia, namely: avoiding molded clothes, hygiene of the intimate area, wearing cotton
underwear, frequent change of underwear, urination after sexual intercourse, avoiding
unprotected sex, using a vaginal lubricant and others.
We can mention the fact that the term hygiene does not only refer to physical hygiene, but
also to a psycho-emotional hygiene. Here we can mention that personal development in this
direction is very important, by consulting a specialist psychotherapist and sexologist, who with
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the help of certain psychotherapy techniques (cognitive behavioral psychotherapy, integrative

psychotherapy, mindfulness), psychological tests, can diagnose and help treat this disorder.
Also, couple psychotherapy is very effective in identifying negative attitudes, limiting
beliefs about sex acquired and developed both in childhood and adolescence. At the same time,
in psychotherapy you can use techniques, objects related to symbolism. In some cases, after
being offered a series of objects to women in therapy, they chose sharp objects, cold, dark and
shrill colors, which reveal in the subconscious aggression, repressed trauma, the desire to
castrate the partner.
With the help of couple psychotherapy, communication between partners can also be
improved. Studies show that in couples, the communication component is a little different
compared to, communication from various social contexts. Sometimes even if we can
communicate effectively outside of the couple, we can identify a serious problem when it
comes to communicating in a relationship.
The act of communication involves not only communication through words, but also
through gestures, emotions. Often, there may be a tendency to talk more than to communicate.
Prejudice, anticipatory thinking, distorted interpretations of a subjective point of view, make
communication difficult for the couple and can lead to a tendency towards conflict. Numerous
studies (Delcea C, 2019; Delcea C, 2019; Voinea M. M., & Delcea C., 2020; Delcea C., Perju-
Dumbrava D., Kovacs, M. I., et al., 201) confirm our results.
Although the vast majority of people avoid conflicts as much as possible, they can play a
constructive role in stabilizing, maintaining and developing the relationship functionally.
In other words, communication in a couple can be the food of a healthy relationship, in terms
of not only solving the problems that may be involved in the occurrence of dyspareunia, but
problems of any kind.
REFERENCES
[1] Journal de L’association Medicale Canadienne, 01 Jun 2017, 189(24): E836.

[2] Dispareunia en mujeres despues del parto: estudios de casos y controles en un hospital de Acapulco,
Mexico, 2015.
[3] Delcea C. Orgasmic disorder in women. Int J Advanced Studies in Sexology. Vol. 1, Issue 1, pp. 56-67.
[4] Delcea C. Arousal disorder in women. Int J Advanced Studies in Sexology. Vol. 1, Issue 2, pp. 78-83.
[6] Delcea C. Dyspareunia in women. Int J Advanced Studies in Sexology. Vol. 1, Issue 2, pp. 84-88.
International Conference Supervision in Psychotherapy. Pages: 65-68, 2018. Filodiritto Publisher.
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VAGINISMUS
Abstract
Vaginismus is a relatively rare female sexual dysfunction, but with significant disabling
potential. Vaginismus can be defined as involuntary spasms of the muscles surrounding the
vaginal opening. Its severe form makes it impossible to penetrate and causes severe pain,
burning sensations. As early as 1547, when vaginismus was first described, and to this day, it
continues to be an intensely researched topic, with thousands of papers published. However,
the etiology of vaginismus remains controversial. Vaginismus has been shown to be a sexual
disorder that has phobic elements resulting from patients' actual or imagined negative sexual
experiences. Most women who suffer from vaginismus express their fear and anxiety about the
act of penetration, generally feel ashamed or disgusted with their genitals.
Keywords: vaginismus, DSM-5, sexual dysfunction
INTRODUCTION
Vaginismus is a condition that causes involuntary spasm of the vaginal muscles and pelvic
floor muscles that makes vaginal sex, the use of tampons or gynecological exams painful and
even impossible to perform.
Statistically, about 7% of women around the world suffer from vaginismus. Unfortunately,
vaginismus is often not diagnosed at all or misdiagnosed. Most often women avoid discussing
this topic. (1)
CAUSE
Vaginismus does not have a well-defined cause. It is usually due to a complex of physical
and emotional factors and is aggravated by the body’s normal reaction to avoid pain. The body
anticipates the pain and in order to avoid it, the spontaneous contraction of the vaginal muscles
is triggered. Any attempt to penetrate causes a painful sensation in the vagina and this pain
strengthens the reflex response, which has the effect of an even stronger reflex contraction of
the vaginal muscles. This generates the cycle pain from vaginismus. Once this problem arises,
the woman has no control over it, cannot provoke it and cannot stop it.
Over time, due to pain and discouragement, a woman’s sexual desire may decrease and fear
(aversion) to sexual intercourse may occur.
The causes of vaginismus can be emotional, physical or a combination of these.
The emotional causes that trigger vaginismus are quite difficult to detect and it usually takes
longer to be identified. It is important that the therapy addresses any emotional factor that could
trigger it so that at the end of the therapy the patient can have a normal sex life.
Psychological causes that can cause vaginismus:
- Childhood experiences – rigid parents, exposure to shocking sexual images, religious
teachings (“sex is bad”), inadequate sex education.
- Relationship problems – abuse, emotional detachment, mistrust, anxiety in connection
with the loss of control.
- Anxiety or stress – general anxiety, guilt, negativity about sex, or any unhealthy
emotion.
- The fear of getting pregnant, the fear of pain, the fear that a pelvic trauma has not
healed.
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- Traumatic experiences from the past such as sexual abuse, rape, physical assault,
repressed memories.
Physical causes can be:
- Changes due to age – menopause and hormonal changes, inadequate lubrication.
- Medical problems such as urinary tract infection, fungal infections, endometriosis,
STIs, pelvic inflammatory disease, cancer.
- Postpartum pain, abortion, cesarean section.
- Temporary discomfort caused by too little lubrication, insufficient prelude.
- Side effects from medications that can cause pelvic pain. (2)
TYPES OF VAGINISM
Primary vaginismus refers to the situation where there was never painless sexual intercourse
or sexual intercourse was always impossible.
Secondary vaginismus refers to the situation in which after a period of painless sexual
intercourses, pain occurs at penetration. It usually occurs after an event such as medical
problems, birth, relationship problems, etc. Vaginismus can be generalized or situational. In
the latter case, it will be limited to certain situations or certain partners.
Vaginismus can be exclusively psychogenic or it can be both psychogenic and organic. (3)
DIAGNOSTIC
The one who makes the diagnosis is the gynecologist, not everyone has experience with
vaginismus but will be able to rule out other conditions and help.
The diagnosis is made by a gynecological examination, the exclusion of other conditions
and by general and reproductive medical history and description of the problem. (4)
TREATMENT
A pelvic physiotherapist or sexologist may be contacted for treatment.

The treatment of vaginismus involves a number of conditions, including:
- Cognitive treatment
- Sex education
- Control of vaginal muscle activity
- Self-exploration of sexual anatomy
- Relaxation control training
- Sharing control with your partner
- Penis interference under the control of the woman
- Transferring the control of the partner’s interference
- Exploring phobias (if present).
The average duration of treatment is 20 sessions. The frequency of therapy sessions varies
from one to four hours per week, depending on the individual needs of the patient. Intervals
between treatment sessions are needed to get used to and integrate the changes that have taken
place. (5)
The most important variable in determining a positive evolution is, however, the support
that the woman has during the treatment in order to be able to control the anxiety produced by
the moment of penetration. The patient is in the dilemma of following a treatment that will
make her accept the thing she fears most, that is, penetration. Ideally, this anxiety should be
addressed during couple therapy so that anxiety does not lead to discontinuation of treatment
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or further refusal of women to accept possible penetration. The treatment addresses the root
causes of vaginismus and includes a combination of couple therapy, individual relaxation
exercises for women, couple exercises aimed at increasing sensitivity.
Because the causes of vaginismus are predominantly psychological, the principle of the
therapeutic approach will aim to relax the patient in order to remove anxiety. The basic
principles of treatment will be the same as for any other sexual dysfunction: mutual
responsibility, information and education, attitudinal and behavioral change, elimination of
sexual anxiety, increased level of communication, changes in the definition of sex roles and
lifestyle. (6)
The cure rate is 80-100%, and it is the psychosomatic approach that ensures this high
therapeutic success.
CONSEQUENCES OF VAGINISM
Among the consequences of vaginismus, I mention the following: marriage may remain
unconsumed (this may be grounds for divorce), the husband will be more prone to marital
infidelity, family life will be unhappy, sex will not be a source of pleasure, inability to have a
sex life will result in a couple without children.
Vaginismus makes many women feel lonely, misunderstood, scared and can affect their
relationships, emotional health and self-esteem. Some do not understand what they are going
through, others understand but still cannot get rid of guilt. (7)
CONCLUSION
The first step for any woman who suspects vaginismus is to schedule a full pelvic exam to
rule out a somatic cause. Vaginismus is most often conceptualized as a psychosomatic disorder,
a physical manifestation of deeper psychological problems.
There are several theories about the psychological causes but most of them focus on the
following three aspects: control problems in the couple, previous sexual traumas, conditional
association of pain/fear with vaginal penetration (a phobic reaction to the idea of penetration).
Regardless of the specific cause, there are two characteristic features of vaginismus: the
inability to have a vaginal penetration and emotional stress.
REFERENCES
[1] Delcea C. (2019). Orgasmic disorder in women. Int J Advanced Studies in Sexology. Vol. 1, Issue 1, pp.
[2] Pană R. A., (2020). The Female Orgasm Disorder. An Individual Psychology Approach. Int J Advanced
10.46388/ijass.2020.13.11.
[3] Hajnalka G., (2020). Painful intercourse. Dyspareunia and Vaginismus. An Individual Psychology
Romania. DOI: 10.46388/ ijass.2020.13.16.
[4] Kocsis A., (2020). Female orgasm disorder. An Individual Psychology Approach. Int J Advanced
10.46388/10.46388/ijass.2020.13.18.
[5] Stuparu C., (2020). Female orgasm disorder. Anorgasmia. Int J Advanced Studies in Sexology. Vol. 2,
Issue 2, pp. 89-93. Sexology Institute of Romania. DOI: 10.46388/ijass.2020.13.25.
[6] Lupa M. M., (2020). Dyspareunia. Int J Advanced Studies in Sexology. Vol. 2, Issue 2, pp. 98-100.
[7] Fejza H., Icka E., Fejza F., (2021). Vaginismus As a Hidden Problem: Our Case Series. Int J Advanced
10.46388/ijass.2020.13.32.
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SECOND SECTION
PARAPHILIC DISORDERS
A. EXTERNALIZATION PARAPHILIC DISORDERS
2.1 Voyeurism disorder
VOYEURISM AND SCOPOPHILIA
Abstract
Formerly known as Voyeurism in DSM-IV, this disorder refers to (for over a period of at
least 6 months) having recurrent, intense sexually arousing fantasies, sexual urges, or behaviors
involving the act of observing an unsuspecting person who is naked, in the process of disrobing,
or engaging in sexual activity. The person being considered for this disorder, in some way, has
acted on these urges towards a nonconsenting person or the sexual fantasies/urges cause
clinically significant distress or impairment in social, occupational, or other important areas of
functioning.
Keywords: voyeurism, disorder, sexual arousal, fantasies
INTRODUCTION
Voyeurism – involves the act of looking at individuals who do not realize that they are, as a
rule, strangers, who are naked, in the process of stripping or engaged in sexual activity.
Theoretical approaches
Voyeurism, sometimes called scopophilia, is the observation of the sexual activity of other
people repeatedly, as a preferred means of obtaining sexual arousal. The act of peeping is
directed at foreign persons, who do not know they are watched, who are in the bare pill (nudes),
or are stripped of or engaged in a sexual act, without being followed by the attempt to maintain
sexual relations. with these.
Voyeurism is a disorder of heterosexual individuals who have inappropriate sexual activity.
Although they hide themselves so they cannot be seen, they are often caught on the fact or
by the victim or more often by passersby. Orgasm, following sexual arousal through watching,
occurs through masturbation during voyeuristic activity or later, when he remembers what he
saw. Voyeurism is apparently more common in men, but its prevalence is not known. The onset
seems to occur before the age of 15, in adolescence, as an expression of sexual curiosity being
replaced by normal sexual intercourse. With the passage of time, this activity can be chronicled,
continuing to shoot with the eye, even if shy, especially in places where people walk naked
(e.g., beaches with nudists). A new variant of voyeurism is listening to erotic conversations,
such as sex on the phone.
The object of voyeurism is to observe unsuspecting individuals who are naked, in the
process of undressing or engaging in sexual acts. The person being observed is usually a
stranger to the observer. The act of looking or peeping is undertaken for the purpose of
achieving sexual excitement. The observer generally does not seek to have sexual contact or
activity with the person being observed. If orgasm is sought, it is usually achieved through
masturbation. This may occur during the act of observation or later, relying on the memory of
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the act that was observed. Frequently, a voyeur may have a fantasy of engaging in sexual
activity with the person being observed. In reality, this fantasy is rarely consummated.
A number of states have statutes that render voyeurism a crime. Such statutes vary widely
regarding definitions of voyeurism. Most states specifically prohibit anyone from
photographing or videotaping another person, without consent, while observing that person in
the privacy of his home or some other private place. There is no scientific consensus concerning
the basis for voyeurism. Most experts attribute the behavior to an initially random or accidental
observation of an unsuspecting person who is naked, in the process of disrobing, or engaging
in sexual activity. Successive repetitions of the act tend to reinforce and perpetuate voyeuristic
behavior.
The act of voyeurism is the observation of an unsuspecting person who is naked, in the
process of disrobing, or engaging in sexual activity that provides sexual arousal. To be
clinically diagnosed, the symptoms must include the following elements:
• recurrent, intense or sexually arousing fantasies, sexual urges, or behaviors,
• fantasies, urges, or behaviors that cause significant distress to an individual or are
disruptive of his or her daily functioning.
According to the mental health professional’s handbook, Diagnostic and Statistical Manual
of Mental Disorders, two criteria are required to make a diagnosis of voyeurism:
• Over a period of at least six months, an individual must have recurrent, intense,
sexually arousing fantasies, sexual urges, or behaviors that involve the act of observing
an unsuspecting person who is naked, in the process of disrobing, or engaging in sexual
activity,
• The fantasies, sexual urges, or behaviors must cause clinically significant distress or
impairment in social, occupational, or other important areas of functioning. In order
for a condition to be labeled “voyeurism,” the fantasies, urges, or behaviors to watch
other persons must cause significant distress in the individual or be disruptive to his or
her daily functioning.
CONCLUSIONS
For treatment to be successful, a voyeur must want to modify existing behavior patterns.
This initial step is difficult for most voyeurs to admit and then take. Most must be compelled
to accept treatment. This may often be the result of a court order. Behavioral therapy is
commonly used to try to treat voyeurism.
The voyeur must learn to control the impulse to watch non-consenting victims, and just as
important to acquire more acceptable means of sexual gratification. Outcomes of behavioral
therapy are not known. There are no direct drug treatments for voyeurism.
Voyeurism is a criminal act in many jurisdictions. It is usually classified as a misdemeanor.
As a result, legal penalties are often minor.
The possibility of exposure and embarrassment may deter some voyeurs. It is also not easy
to prosecute voyeurs as an attempt to watch is difficult to prove. In their defense statements,
they usually claim that the observation was accidental.
Most experts agree that providing guidance regarding behavior that is culturally acceptable
will prevent the development of a paraphilia such as voyeurism.
The origin of some instances of voyeurism may be accidental observation with subsequent
sexual gratification. There is no way to predict when such an event and association will occur.
Members of society at large can reduce the incidence of voyeurism by drawing curtains,
dropping blinds or closing window curtains.
Reducing opportunities for voyeurism may reduce the practice.
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The prognosis for eliminating voyeurism is poor because most voyeurs have no desire to
change their behavior pattern.
Since voyeurism involves non-consenting partners and is against the law in many
jurisdictions, the possibility of embarrassment may deter some individuals.
REFERENCES
[1] Sadock BJ, Sadock VA. Kaplan and Sadock’s Synopsis of Psychiatry: Behavioral Sciences and Clinical
Psychiatry, Ninth Edition. Philadelphia: Lippincott Williams & Wilkins; 2003. [Google Scholar]
[2] Levine SB, Althof SE, editors. Handbook of Clinical Sexuality for Mental Health Professionals. New
York: Brunner-Routledg; 2003. [Google Scholar]
[3] Levine SB, editor. Sexual disorders. In: Tasman A, Kay J, Lieberman J. Psychiatry, Second Edition.
Hoboken, NJ: Wley; 2003. [Google Scholar]
[4] Levine SB. Reexploring the concept of sexual desire. J Sex Marital Ther 20022839-51 [PubMed]
[Google Scholar]
[5] Masters WH, Johnson VE. Boston: Little, Brown & Co.; 1966. Human Sexual Response. [Google
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[6] Bechtel S The practical encyclopedia of sex and health: From aphrodisiacs and hormones to potency,
stress, vasectomy, and yeast infection. Emmaus (PA): Rodale; 1993. [Google Scholar]
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TELEPHONE SCATALOGY
Abstract
This article aims to facilitate the understanding of telephone scatology. There we present
different definitions of this paraphilic disorder, its prevalence and the difficulty in establishing
it, the comorbidities that show a strong association with other paraphilic disorders, and the
different theories that aim to better understand this disorder.
Keywords: Telephone scatology, Paraphilic disorder, voyeurism, compulsive masturbation
INTRODUCTION
There are no exhaustive descriptions of telephone scatology in the Diagnostic and Statistical
Manual of Mental Disorders (American Psychiatric Association, 2000), in the Handbook of
Forensic Sexology (Krivacska & Money, 1994), or in the International Dictionary of
Psychology (Sutherland, 1996). However, the telephone scatology (making obscene calls) is
mentioned in the DSM in the section of the specific sexual paraphilia and includes the
following criteria: recurrent sexual fantasies, which has been activated in the last 6 months and
is characterized by a pattern of sexual arousal while exposing a victim who does not suspect
any sexual and obscene material over the telephone, such as telephony, acoustic voyeurism,
verbal exhibitionism, or non-visual exposure (Dalby, 1988; Freund, Watson, & Rienzo, 1988;
Goldberg & Wise, 1985; Milner & Dopke, 1997; Price, Kafka, Commons, Gutheil, & Simpson,
2002).
Telephone scatology is defined in the Oxford Dictionary of Psychology as “a paraphilia
characterized by recurrent sexual fantasies, sexual beginnings, or behavior that includes
making obscene calls to a someone who has not agreed” (Coleman, 2003).
Comorbidities
Limited research on comorbidity of telephone scatology with other paraphilia has shown
that there are significant associations with voyeurism, compulsive masturbation and sex on the
phone (telephone sex addiction), moderate associations with exhibitionism and no significant
association with frotteurism, pedophilia, fetishism, transvestism and sadism masochism (Price
et al., 2002). It is accepted among researchers that telephone scatology does not appear as a
solitary disorder. (Abel, Becker, Cunningham-Rathner, Mittleman, & Rouleau, 1988;
Bradford, Boulet, & Pawlak, 1992; Price et al., 2002).
Prevalence
Smith and Morra (1994) warn that only 14% of sexually provocative phones are reported to
the police in Canada and only 20% are reported to phone companies, while 83% of 1990
Canadian interviewed women (ages 18-65 years) in 1992 stated that they received obscene or
threatening calls, so it is difficult to determine the prevalence. Dalby (1988) stated that in 1986
there were 636 investigations of persistent obscene calls in Calgary with a population of about
640,000, while Price et al., (2002) asserted that there were 22,000 complaints for obscene calls
in Washington DC., with a population of 570,000 (about one complaint per 26 inhabitants).
From a catatimic perspective (“in accordance with emotions”), it all starts as an ego-dystonic
(subjective) illogical thought, which becomes a fixation and eventually becomes an impulse to
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act on, followed by action and relief of mental tension. (Revitch & Schlesinger, 1989;
Schlesinger, 2004, Delcea C., 2019).
There are 4 stages in male sexual activity: the search for a partner, the interaction itself, the
tactile and genital interaction. The obscene phones would be placed in the second stage, of the
interaction, suggesting a distortion of the normal course of things (Dalby, 1988; Freund &
Blanchard, 1986).
In addition to these perspectives, there are others that could explain the telephone scatology,
such as: constructivism (Piaget), operant conditioning (Skinner), social learning (Lytton), love
maps (Money), etc. All are plausible, as they try to explain and understand the sexual
deviations.
CONCLUSION
Telephone scatology is a unique, human form of sexual interaction because it is not tactile,
but includes speech and language, but as electronic methods for communication continue to
develop, the forms of telephone scatology will certainly be altered and extended over time. It
is also important to consider that not only biological but also environmental and cognitive
factors are included in the formation of mental activity, so that each of them can contribute to
the final result (Constrachevici L, M., & Delcea C., 2019).
REFERENCES
[1] Pakhomou, S. M. (2006). Methodological aspects of telephone scatologia: A case study. International
journal of law and psychiatry, 29(3), pp. 178-185.
[2] Delcea C. (2019). Sexual deviances. Int J Advanced Studies in Sexology. Vol. 1, Issue 1, pp. 64-72.
Sexology Institute of Romania.
[3] Constrachevici L, M., & Delcea C. (2019). Sexual deviance. The Sexual sadism. Int J Advanced Studies
in Sexology. Vol. 1, Issue 1, pp. 112-121. Sexology Institute of Romania.
[4] Bondrea A., & Delcea C. (2019). Sexual deviations. Considerations regarding pedophilia – mith and
reality. Int J Advanced Studies in Sexology. Vol. 1, Issue 1, pp. 133-142. Sexology Institute of Romania.
[5] American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders (DSM-
IV-TR). Washington D. C.: American Psychiatric Association.
[6] Krivacska, J. J., & Money, J. (Eds.). (1994). The handbook of forensic psychology: Biomedical and
criminological perspectives. New York: Prometheus Books.
[7] Sutherland, N. S. (1996). The international dictionary of psychology (2nd edition). New York: The
Crossroad Publishing Company.
[8] Dalby, J. T. (1988). Is telephone scatologia a variant of exhibitionism? International Journal of Offender
and Comparative Criminology, 1, pp. 45-49.
[9] Freund, K., Watson, R., & Rienzo, D. (1988). The value of self-reports in the study of voyeurism and
exhibitionism. Annals of Sex Research, 1, pp. 243-262.
[10] Goldberg, R. L., & Wise, T. N. (1985). Psychodynamic treatment for telephone scatologia. American
Journal of Psychoanalysis, 45, pp. 291-297.
[11] Milner, J. S., & Dopke, C. A. (1997). Paraphilia not otherwise specified. In D. R. Laws &W. O’Donohue
(Eds.), Sexual deviance (pp. 404-405). New York: The Guilford Press.
[12] Price, M., Kafka, M., Commons, M. L., Gutheil, T. G., & Simpson, W. (2002). Telephone scatologia:
Comorbidity with other paraphilias and paraphilia-related disorders. International Journal of Law and
Psychiatry, 25, pp. 37-49.
[13] Coleman, A. M. (2003). Oxford dictionary of psychology. New York: Oxford University Press.
[14] Abel, G. G., Becker, J. V., Cunningham-Rathner, J., Mittlemen, M., & Rouleau, J. L. (1988). Multiple
paraphilic diagnoses among sex offenders. Bulletin of American Academy of Psychiatry and Law, 16,
pp. 153-168.
[15] Bradford, J., Boulet, J., & Pawlak, A. (1992). The paraphilias: A multiplicity of deviant behaviors.
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Canadian Journal of Psychiatry, 37, pp. 104-108.

[16] Smith, D. M., & Morra, N. N. (1994). Obscene and threatening telephone calls to women. Gender and
Society, 4, pp. 584-596.
[17] Revitch, E., & Schlesinger, L. B. (1989). Sex murder and sex aggression. Springfield, IL: Charles C.
Thomas.
[18] Schlesinger, L. B. (2004). Sexual murder: Catathymic and compulsive homicides. New York: CRC
Press.
[19] Freund, K., & Blanchard, R. (1986). The concept of courtship disorder. Journal of Sex and Marital
Therapy, 12, pp. 79-92.
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2.2 Exhibitionism disorder
EXHIBITIONISM
Abstract
In this paper we present the definition of exhibitionism and the disorder itself. We also noted
the prevalence of this disorder, in accordance with the data available, in which it is mentioned
that it is quite high (44%). The conclusion is that the prevalence would be higher but the cases
are not reported, therefore we have no concrete data.
Keywords: exhibitionism, DSM, paraphilic disorders, frotteurism
INTRODUCTION
Exhibitionism was defined in 1950 as “the act of exposing the male sexual organ”. It can be
accepted as normal or abnormal, depending on the circumstances” being considered a
compulsive, pathological condition, when the behavior is the final goal (Rickles, 1950).
Although exhibitionism is not a new phenomenon, it was not included in the Diagnostic and
Statistical Manual of Mental Disorders [DSM] until 1980.
Since then, the clinical definition of exhibitionism disorder has remained relatively
unchanged and falls into the category of paraphilic disorders along with the disorder of
voyeurism, fetishism, frotteurism, sexual masochism, social sadism, pedophilia and transvestic
(DSM-V, APA 2013) and it is considered a sexual offense, therefore illegal (Kaylor, 2019).
Exhibitionism is defined as the act of exposing in a public or semi-public context those parts
of the body that are not normally exposed – for example, the breasts, genitals, etc.
The practice may arise out of a desire or constraint to expose intimate parts to friends or
acquaintances, or to strangers for their sexual amusement or satisfaction or to shock the
passenger.
Exposure only to an intimate partner is not normally considered exhibitionism. In law, the
act of exhibitionism can be called indecent exposure, “exposure of the person” or other
expressions (Kir, 2020).
Despite indications that acts of exhibitionism are frequent events, this sexual paraphilia has
received more attention in recent years. To address this gap in our knowledge of these
paraphrases, 459 student students from a major metropolitan city completed a selfreport
measure designed to investigate the frequency and correlations of frotteurism and
exhibitionism.
The results indicate a high rate of victimization among female students for both paraphilia.
Moreover, acts of frotteurism and exhibitionism took place most often in places related to
public transport (for example, subway trains or platforms) in this urban setting. In addition,
victims reported a number of negative outcomes as a result of victimization, including feelings
of violation, behavioral changes and even long-term psychological distress. Older women were
most likely to be victimized. (Clark, 2016).
The prevalence rate is high for exhibitionism, 44% (n=203) of the sample mentioned above.
Also, a smaller but still significant percentage (15%) of the victims of exhibitionism
reported a long-term negative consequence. However, few victims reported these incidents to
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the authorities. About half of the exhibition incidents occurred on a train or subway platform
and in a crowded place.
CONCLUSIONS
These findings go along with the literature, which showed that although approximately two-
thirds of victims eventually reveal their aggression to someone on their social network, most
victims do not report the aggression to authorities (Golding, Siegel, Sorenson, Burnam, &
Stein, 1989; Koss, Money, Seibel, & Cox, 1988; Ullman & Filipas, 2001).
This reveals to us that the chances of this paraphilia being met are high, but we have no
concrete data on this.
REFERENCES
[1] American Psychiatric Association. (2013). Diagnostic and statistical manualof mental disorders (DSM-
5®). American Psychiatric Pub.
[3] Clark, S. K., Jeglic, E. L., Calkins, C., & Tatar, J. R. (2016). More Than a Nuisance: The Prevalence
and Consequences of Frotteurism and Exhibitionism. Sexual Abuse, 28(1), pp. 3-19.
https://doi.org/10.1177/1079063214525643.
[6] Golding, J. M., Siegel, J. M., Sorenson, S. B., Burnam, M. A., & Stein, J. A. (1989). Social support
sources following sexual assault. Journal of Community Psychology, 17, pp. 92-107. doi:10.1002/1520-
6629(198901).
[7] Eusei D., & Delcea C. (2019). Fetishistic disorder. Int J Advanced Studies in Sexology. Vol. 1, Issue 1,
pp. 22-30. Sexology Institute of Romania.
[8] Kaylor L.E., Jeglic E.L. (2019) Exhibitionism. In: O’Donohue W., Schewe P. (eds) Handbook of Sexual
Assault and Sexual Assault Prevention. Springer, Cham, pp. 745-760.
[9] Rickles, N. K. (1950). Exhibitionism. Lippincott.
[10] Popa T., & Delcea C. (2019) Voyeurism and Scopophilia. Int J Advanced Studies in Sexology. Vol. 1,
Issue 1, pp. 43-51. Sexology Institute of Romania.
[11] Purec A., Delcea C. (2019) Zoophilia. Int J Advanced Studies in Sexology. Vol. 1, Issue 1, pp. 85-92.
[12] Serpil Kır. (2020). New Media and Visual Communication in Social Networks. Voyeurism in Social
Networks and Changing the Perception of Privacy on the Example of Instagram. Premier References
Sources, pp. 255-269.
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2.3 Frotteurism disorder
FROTTEURISM
Abstract
Frotteurism/frotteuristic disorder seems to be a quite rare paraphylic disorder. This comes

from a relatively low prevalence (variation in the literature on this matter) and especially by
the lack of data on it in the literature. Interestingly, DSM-III did not include Frotteurism in the
8 paraphiles listed with criteria for a diagnostis. Frotteurism first appeared in DSM-III-R. The
frotteuristic disorder is included in DSM-5. The use and meaning of the word frotteurism in
sexual terms comes from a French psychiatrist Valentin Magnan in 1890. He described men
doing something that he called rubbing – rubbing their penis by women’s back without them
noticing. The word comes from “frotter” a french word, that means rubbing or putting pressure
on someone, and has no sexual connotation. Lussier P., et al., (2008).
Keywords: Frotteurism, Paraphilia, Sexology
INTRODUCTION
A frotteuristic act nowadays, means getting intense sexual arousal from touching or rubbing,
usually, the genitals (penis) or the pelvic area of another person without their consent. The
diagnostic criteria are quite vague as to what exactly it means to touch and rub. Over the years,
there has been some disagreement about the fact that frotteurism must really include rubbing
the organs of another person.
The paraphylic side of frotteurism involves the touching and rubbing of a person who does
not consent. The behavior usually occurs in crowded places; therefore, the individual can easily
escape the arrest (e.g., on crowded sidewalks or in public transport vehicles). He rubs his
genitals with the victim’s thighs or the individual is rubbing his erect penis against that person,
generall y from behind. While doing this, he usually imagines an exclusive, affectionate
relationship with the victim. However, he acknowledges that in order to avoid possible
prosecution, he must escape detection after reaching his victim. Paraphilia usually starts in
adolescence. Most rubbing acts occur when the person is between 15-25 years old, after which
a gradual decline in frequency occurs according to DSM-V (American Psychiatric Association,
2013).
Theoretical Approach
Frotteurism is not frequently reported by victims. Some of the reasons why victims do not
report frotteurism may be that they may not be fully aware of the fact, for example in a crowded
place it is difficult to be aware of what is happening or recognize the perpetrator (the meeting
may not be face to face and it may happen without an exchange of replicas). Also, the
perpetrator may claim that it was an accidental situation blaming the crowded place. (Ballon,
R. (Ed.). (2016)).
Diagnostic criteria
A. Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual
urges, or behaviors involving touching and rubbing against a non-consenting person.
B. The person has acted on these urges, or the sexual urges or fantasies cause marked distress
or interpersonal difficulty.
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Frotteurist acts by touching or rubbing another person can occur in 30% of the adult men in
the general population. Approximately 10-14% of men consulted in an ambulatory setting for
paraphylic disorders and hypersexuality, meet the criteria for frotteurism disorder. According
to DSM V the prevalence of this disorder among the population is unknown.
At the same time, a study carried out by Abel et al., (1987) on 561 non-charged sex offenders
found that the prevalence of frotteuristic behavior is 25% (Eusei D., & Delcea C., 2019).
Beginning and evolution

There is no specific age at which this disorder begins, according to DSM V (American
Psychiatric Association), the evolution of the frotteurism disorder is likely to change with age,
the men diagnosed with this disorder declare that they have become aware of the sexual interest
for rubbing other people in their late adolescence or early adulthood (Delcea C., 2019).
CONCLUSIONS
Frotteurism disorder is characterized by the rubbing of the genital organs of another person
in order to produce sexual arousal, without the other person consenting to this activity. Because
of the way this disorder is seen, it is difficult to determine whether the person has been rubbed
by another person in order to produce pleasure. It is difficult to determine the prevalence of
this disorder.
in the public, commercial, or not for profit sectors.
REFERENCES
[1] Abel GG, Becker J, Mittelman M, CunninghamRathner J, Rouleau J, Murphy W. Self-reported sex
crimes of nonincarcerated paraphiliacs. J Interpers Violence. 1987; 2: pp. 3-25.
[2] American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 3rd ed.
Washington, DC: American Psychiatric Association; 1980.
[3] American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 3 rd ed., rev.
Washington, DC: American Psychiatric Association; 1987.
[4] American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5 th ed.
Arlington: American Psychiatric Association; 2013. pp. 691-4.
[5] Balon, R. (Ed.). (2016). Practical guide to paraphilia and paraphilic disorders. Springer International
Publishing.
[6] Bondrea A., & Delcea C., (2019). Sexual deviations. Considerations regarding pedophilia – mith and
[7] Clark SK, Jeglic EL, Calkins C, Tatar JR. More than a nuisance: the prevalence and consequences of
frotteurism and exhibitionism. Sex Abuse. 2016; 28: pp. 3-19.
[9] Delcea C., (2019). Sexual deviances. Int J Advanced Studies in Sexology. Vol. 1, Issue 1, pp. 64-72.
[11] Lussier P, Piche L. Frotteurism: psychopathology and theory. In: Laws DR, O’Donohue WT, editors.
Sexual deviance. Theory, assessment, and treatment. 2nd ed. New York: Guilford; 2008. pp. 131-49.
[12] Popa T., & Delcea C., (2019) Voyeurism and Scopophilia. Int J Advanced Studies in Sexology. Vol. 1,
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FROTTEURISTIC DISORDER
Abstract
Frotteurism or frotteuristic disorder describes a behavior through which one obtains intense
sexual arousal from touching or rubbing, usually their genitals or pelvic area against a non-
consenting person. Prevalence is more common in male population. This article addresses the
characteristics, diagnosis criteria, prevalence, etiology, methods of evaluation and intervention
and explains the onset and evolution as well as the psychological factors present in this
particular paraphilic disorder.
Keywords: frotteurism, paraphilc disorder, touching, rubbing, pelvic area, diagnosis, intervention
INTRODUCTION
The term “frotteurism” was introduced in the literature for the first time in 1890 by the
French psychiatrist Valentin Magnan. It originally referred to the act in which a man touches
(rubs) with his exposed penis the buttocks or thighs of women who do not consent to this act.
“The word “frottage” comes from the French “frotter”, which means to rub or to put pressure
on someone, and has no sexual connotation” [Balon R., pp. 93-94]. Nowadays this term is
associated with obtaining intense sexual arousal as a result of touching or rubbing one’s pelvic
area against a person who does not give consent, usually an unknown woman or a person in a
crowded area. “Over the years, there has been some disagreement about whether frotteurism
has to really include rubbing genitals against an unsuspecting person. Some have argued that
frotteurism does not need to include the perpetrator’s genitals and that the act of frotteurism
should also include sexual urges to touch and acts of touching. Thus, the recent view includes
both rubbing and touching as part of a frotteuristic act. Others also argued that toucherism –
sexual arousal derived from touching, grabbing, or rubbing one’s hand against an unsuspecting
person’s areas such as crotch and breasts – should be included.” [Balon R., p. 94]. The DSM-
III-R and DSM-5 includes toucherism in the category of frotteurism.
During the act, the frotteur usually fantasizes that he is in an exclusive, affectionate, sensual
relationship with the victim. Part of the excitement from frotteurism comes from the risk of
being caught, which heightens the sexual response. Most of these cases occur with males
inappropriately touching females, although there have been cases of females touching males,
females touching females, males touching males, and adults touching children.
Aside from being considered a criminal activity because it is a form of nonconsensual sex,
frotteurism is diagnosed as a mental health disorder when the behavior continues repeatedly
for more than six months, or when the fantasies and urges cause significant distress or
dysfunction in personal relationships and daily activities of the perpetrator or those around him.
Clinical considerations
This kind of disorder is one of the least understood and studied types of paraphilic disorders.
As characteristic features of this disorder it has been noted that the deviant act usually takes
place in crowded places like subways, trains, pedestrian alleys, stairs, elevators, theaters,
shopping areas, etc. This way, the aggressor has the opportunity to disappear easily or explain
the behavior as accidental or, as well, hide in the crowd in case one should call the police, but
it is generally a type of aggression that is rarely or not at all reported to the police, mainly
because the victims simply do not feel that they are being touched or do not find or recognize
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the aggressor. Still, there are negative consequences felt by the victims, namely feelings of rape
and changes in behavior.
Frotteurism occurs in many cultures. In Japan and India especially, the problem has become
so widespread that special train cars and buses have been converted to women only spaces
since 2005, after studies revealed that over 66% of female passengers in their twenties and
thirties admitted that they had undergone acts of frotteurism (rubbing, touching, groping) on
public trains in Tokyo. In Japan this kind of behavior is called “chikan”. Women rarely file
reports of incidents of sexual harassment or assault on public transport, often because of
embarrassment, uncertainty as to whether it actually counts as a crime, or they simply accept
the issue as a fact of life. As a result, definitive frotteurism statistics can be hard to find. Still,
this type of harassment is an issue recognized all over the world. In response, female-only
public transport and taxi services had been introduced in at least 15 countries – including Brazil,
Egypt, India, and Indonesia – to protect women. [FIA Foundation Research Series, Paper 6,
2016]
The distinctive feature, as mentioned before, is the act of touching or rubbing one’s genital
area against a person who does not consent. The perpetrator manifests fantasies, impulses and
behaviors related to this typical act, in order to obtain sexual arousal. Two diagnostic criteria
must be met in order to make an accurate identification of frotteuristic disorder: the behavior
has to manifest repeatedly and last for aproximatively 6 months (Criterion A), the person upon
whom these particular sexual urges are enactd is nonconsenting, or a serious distress these
sexual impulses and fantasies generate in different areas of life for the individual or those
around him (Criterion B).
According to the DSM-5, those who do not report any suffering, meaning lack of anxiety,
obsessions, guilt or shame related to these paraphilic impulses and do not have deficits in other
important areas of functioning due to this sexual interest, and their psychiatric or criminal
history shows that they do not act under the impulse of this preference, they could be considered
to have frotteuristic sexual interest, but should not be diagnosed with frotteurism disorder.
The prevalence and incidence of paraphilic disorders is unknown. Studies are very difficult
to perform because there is a tendency for these types of sexual interests not to be reported to
researchers. The only available data are those obtained from persons detained for sexual
offense. Most authors estimate that generically, paraphilias occur in 1% of the total adult
population, especially men, with one exception - masochism. Further studies are necesarry for
clarifyng these asepcts.
The estimates of frotteuristic disorder prevalence vary widely. Based on the currently
existing data, the DSM-5 suggests that behaviors of frotteurism can occur in 30% of the adult
male population. The inclination towards this type of actions is usually manifested towards the
end of adolescence and in young adults, meaning at a relatively later stage of the development
of sexual deviance over time.
Not much is known about the etiology of frotteurism, the characteristics of persons with this
type of disorder, and the course of this disorder. Some theories about the root cause of this
disorder focus on social issues that result in a lack of consenting partners, and others on an
inability to control one’s sex drive, but eventually, what causes the disorder remains currently
unknown. Persons suffering from frotteurism are frequently involved in antisocial activities.
The course is likely to vary with time, and similar to some other paraphilic disorders, the
sexual preferences and behaviors may decline with older age.
Several theoretical models of etiology of frotteurism have been proposed. It can be attributed
to behavioral interactions associated with the searching phases for a sexual partner, namely the
finding, the affiliative, the tactile and the copulatory phases. Kurt Freund – a Czech-Canadian
physician and sexologist argued that some paraphilic behaviors, specifically voyeurism,
exhibitionism, frotteurism, obscene telephony, consensual rape can be forms of altering a
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system of social norms. They can be considered distortions of the normal courtship behavior,
meaning the interactions that precede or initiate coital behaviors, used by men. The reference
system includes 4 phases: (1) identification of a potential partner, (2) an affiliation phase –
materialized in verbal or nonverbal behaviors – looks, smiles, discussions, (3) a tactile phase –
in which physical contact occurs and (4) a copulatory phase – in which sexual contact occurs.
Therefore: voyeurism is a distortion of the identification phase, the exhibitionism of the
affiliation phase, frotterurism of the tactile phase, in which physical contact occurs, and the
consensual rape of the copulatory one. The limit of this theory is that it does not explain all
paraphilic behaviors.
Another explanation would be the hypothesis of social incompetence, manifested in
shyness, inhibition, male insecurity in the presence of a woman, or the hypothesis of sexual
impulses and the inability to manage and control them. It can also occur in individuals with co-
existing conditions which may include hypersexuality or other paraphilic disorders, most
commonly, voyeurism and exhibitionism – as well as nonsexual antisocial personality disorder,
conduct disorder, depression, anxiety, substance use disorders, intellectual disabilities of
neurological nature like autism spectrum disorders, disorders related to brain function,
Parkinson’s disease, etc., and medications being used to treat these diseases. Also, a history of
sexual abuse may play a role in the development of frotteuristic disorder, especially when signs
of the disorder appear at an early age.
The main evaluation method consists in a detailed clinical interview focusing on the sexual
experience and history of the individual – experiences or sexual behavior in childhood, sexual
experiences or lack of sexual activities in adulthood, as well as obtaining collateral information
from medical, psychiatric or judiciary documents. During the interview the clinican should be
nonjudgmental, empathic in order to develop a therapeutic relationship and an atmosphere of
trust. The therapist shoud focus on urges, fantasies, behaviors, comorbidities as well as other
paraphilic disorders, personality disorders, mental illnesses, administered treatments or
medication. There are no specific tests or scales for diagnosing frotteuristic disorder. Various
scales and tests can be used to reveal comorbidities, for example the Minnesota Multiphasic
Personality Inventory (MMPI).
Generally, in paraphilic disorders different approaches are used for therapeutic
interventions and treatment – these include: psychodynamic interventions that help identify
causes and neurotic conflicts that have led to these kind of deviant conducts, behavioral
therapy, aversive conditioning, confrontation, victim empathy, assertiveness training,
desensitization, social skills training, orgasmic reconditioning, group therapy, relapse
prevention, and/or medications. Antiandrogens are used to lower the sex drive. Selective
serotonin reuptake inhibitors (SSRIs), such as Zoloft may be prescribed to treat associated
compulsive sexual disorders and/or to gain benefit from libido-lowering sexual side effects.
Chemical castration may be achieved by shots of Leuprolide which dramatically decreases
testosterone levels. This may completely abolish deviant sexual tendencies. Numerous studies
Delcea C., Enache A., Stanciu C., Delcea C., Enache A., Siserman C., Gherman C., Enache A.,
Delcea C., Delcea C., Fabian A. M., Radu C. C., Dumbravă D. P., Rus M., Delcea C., Siserman
C., Siserman C., Delcea C., Matei H. V., Vică M. L., Gherman C., Enache A., Delcea C.,
Siserman C., Delcea C., Siserman C., confirm our results.
In any case, before any therapeutic approach it is necessary to properly inform and educate
the client, his family and partners. Once the behaviors are understood and the resistance to
these initiations is eliminated, the subject’s family and partners can provide the necessary
support and support the therapeutic process.
In the particular case of frotteurism, the prognosis for eliminating it is poor as most frotteurs
have no desire to change their behavior. They most probably will not change. It is very difficult,
if not impossible, to change a person’s sexual activity preferences. Without treatment,
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individuals with paraphilias, including frotteurism, can have a recidivism rate of 100%. In order
for treatment to be successful, a frotteur must admit that they have a problem and want to
change. Individuals with frotteuristic disorder generally do not undergo treatment on their own
and only receive help after they are arrested for sexual assault and treatment is imposed by the
courts. And since those with frotteuristic tendencies tend to act quickly in crowded, public
places, and often are able to successfully disappear or blend into a crowd without getting
caught, there is little reliable information on either prevalence or treatment success rates.
Standard treatments for frotteuristic disorder include psychotherapy and medication.
Supportive and/or cognitive behavioral therapy and relaxation training should probably be
the first line of treatment that can help manage sexual urges and redirect thoughts to more
appropriate ways of managing inappropriate sexual impulses and behaviors. Also, systematic
desensitization has a key role in reducing anxiety, aversive conditioning, group therapy is also
used and sometimes gives results. Besides these aproaches, self help texts, programs such as
Anonymous Sex Addicts are recommended as well.
Should there be no improvement, medication can be tried alongside therapy: serotonergic
antidepressants, medication for comorbidities, hormonal therapy, antiandrogenic medication
can be given to decrease sexual desire. Treatments should be prescribed only in collaboration
with a medical team of specialists, like endocrinologists, psychiatrists in case of depression,
etc.
CONCLUSION
In many cases the clinician may come across some dificulties while trying to make a
diagnosis as one individual may suffer from several types of paraphilias and diagnostics might
overlap. For example, in the case of child victims the diagnosis might be both pedophilia and
frotterurism or if the behavior involves exposure of genitals the diagnosis might be frotteurism,
exhibitionism or even fetishism.
Furthermore, one should consider that the paraphilic character in these cases of frotteuristic
acts is related to the context in which they occur – whether the involved partner is consenting
the act or not.
The diagnostic of frotteuristic disorder clearly needs to develop more rigorous research and
data in order to clarify whether it should be separated from other paraphilic disorders or not. If
frotteuristic disorder is continued to be conceptualized independently, further clarification and
more specific criteria are needed, including some specifications about the victims, like age.
REFERENCES
[1] Balon, R. – Practical Guide to Paraphilia and Paraphilic Disorders, Springer, 2016, pp. 93-105.
[2] Diagnostic and statistical manual of mental disorders. 5 th ed. Arlington: American Psychiatric
Association, 2013, pp. 691-694.
[3] Johnson, S. R., Ostermeyer B., Sikes, K. A., Nelsen, A.J., and Coverdale, J.H. – Prevalence and
Treatment of Frotteurism in the Community: A Systematic Review, Journal of the American Academy
of Psychiatry and the Law Online, 2014, 42 (4) pp. 478-483.
[4] Safe and Sound, International Research on Women’s Personal Safety on Public Transport, FIA
Foundation Research Series, Paper 6, 2016.
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4372.1000160.
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operational personnel of ambulance services. Rom J Leg Med27(3) pp. 279-284 (2019). DOI:10.4323/
rjlm.2019.279.
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between 2014 and 2018. Rom J Leg Med27(2) pp. 156-162 (2019). DOI:10.4323/ rjlm.2019.156.
Disorders. Rom J Leg Med 28 (1) pp. 14-20 (2020). DOI: 10.4323/rjlm.2020.14.
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FROTTEURISM DISORDER – 1
Abstract
Frotteurism disorder or frotteurism is one of the paraphilic disorders that cause sexual
arousal. It is the act of touching or rubbing the genitals against a person in a sexual manner,
without their consent, to obtain sexual pleasure or to reach orgasm. Those who practice
frotteurism find pleasure in having a private sexual experience in a public setting.
Keywords: frotteurism, paraphilias, frotteurism disorder, DSM-V, sexual disorder, stigma
INTRODUCTION
Although it can occur at any age, frotteurism disorder is most common in young, seemingly
shy men between the ages of 15 and 25. It has also been observed in older men, reserved and
socially withdrawn. Frotteurism is considered to be rare among women. The prevalence of the
disorder is unknown, although approximately 10-14% of adult men seen by clinicians for
paraphilic disorders meet the diagnostic criteria for frotteurism disorder. [1]
Definitions
The Manual of Diagnosis and Statistical Classification of Mental Diseases, 5th edition
(DSM-V) distinguishes between paraphilia and a paraphilic disorder.
The term paraphilia is defined as “an intense and persistent sexual interest other than sexual
interest for genital stimulation or foreplay with human partners, phenotypically normal,
physically mature and consenting.” [2]
The term disorder was specifically added to the DSM-V to indicate paraphilic behaviors.
Disorder paraphilic is “a paraphilia that causes the individual emotional distress or
dysfunction in the present or a paraphilia whose satisfaction involves self-harm or the risk of
harm to others.”
This is also true for frotteurism, which is one of the eight paraphilic disorders listed in the
DSM-V. Frotteurism is the act of touching or rubbing the genitals against a person who does
not consent sexually.
The term frottage is derived from the French word “frotter”, which means “to rub”.
KraftEbbing first described this behavior in the book Psychopathia Sexualis in 1886, while
Clifford Allen coined the term frotteurism in the 1960s.
The term toucherism is sometimes used to describe a condition closely related to
frrotteurism that involves only rubbing or stroking without rubbing, although it is generally
considered to be part of frotteurism.
A person suffering from frotteurism is known as frotteur. Most individuals with this
paraphilia are men and in most cases the victims are women. Frotters usually pick up their
victims in crowded places (e.g., public transport vehicles, crowded sidewalks), which allows
for quick escape and excuse that the touch was accidental. The frotteur rubs his genital area
against the victim’s thighs or buttocks (usually female) or the frotteur caresses a woman’s
genitals or breasts with his hands. [3]
Etiology
The exact etiology is not known, but there are many theories about the cause of frotteurism
disorder. Psychoanalysts suggest that individuals with frotteuristic behaviors may have unmet
needs to rub against the victim and cuddle, as an infant does with his mother. People who
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engage in these behaviors may imagine that they share an exclusive and close relationship with
their victims during the act. Freund and Seto argue that these individuals may also have
problems with tactile interactions that may occur during normal human erotic or sexual
interactions. [4]
There has been some research that has shown the existence of a biological mechanism,
mainly through monoamine neurotransmitters that lead to abnormal sexual behavior. [5]
Although not specific to frotteurism, paraphilias have generally been associated with the
following additional mental health diagnoses: [6] – social anxiety; – brain injuries; – the history
of sexual abuse, in general, was associated with a paraphilic disorder; – intellectual disabilities;
– substance abuse; – the presence of others or an accumulation of paraphilias, in particular
exhibitionism and frotteurism.
Diagnosis and prevalence

According to DSM-5, the criteria for frotteurism disorder are met if for a period of 6 months
a person has experienced intense sexual arousal and repeated that involves touching and
rubbing a person who does not consent, characterized by fantasies, sexual impulses or specific
behaviors. In some cases, people with frotteurism disorder reach orgasm during intercourse.
Frotteurism disorder is sometimes accompanied by other mental health disorders and
clinical problems, especially along with other paraphilic disorders, such as exhibitionism or
other combinations of paraphilic disorders. People with frotteurism may also experience
anxiety, shame, low selfimage, and other emotional problems that exacerbate behavior and
complicate treatment.
The prevalence rate of frotteurism is not yet clearly established, as it is assumed that most
people with this condition do not seek professional help voluntarily. It is difficult to assess the
prevalence of frotteurism because the studies either do not have the necessary methodological
quality or include small sample sizes or use local rather than national or international samples
and do not consistently apply DSM criteria. The prevalence rate of frotteurism can also be
uncertain because, in most cases, victims are unaware that they have been touched or rarely
report incidents to the authorities. Frotteurism is a predominantly male disorder and usually
occurs for the first time in late adolescence and decreases until the age of 25 years. It has been
estimated that 30% of adult men have engaged in frotteuristic acts, and 10% to 14% of men
diagnosed with paraphilic disorders also meet the diagnostic criteria for frotteurism disorder.
Data on the prevalence of female diagnoses of frotteurism disorder are not available. [7]
Assesment
An essential feature of the frotteurism disorder is that this behavior is repetitive.
According to DSM-V, if the individual did not act in his interest and did not present mental
discomfort or dysfunctions, it is considered that has a frotteuristic sexual interest, but not a
frotteurism disorder.
As part of establishing the diagnosis and excluding other causes, routine laboratory and
imaging tests can be obtained.
Laboratory work may include:
- metabolic panel;
- hormonal tests: tests of thyroid function, prolactin, luteinizing and folliculostimulating
hormone test, testosterone tests.
If additional deviant sexual behaviors are suspected, nocturnal penile tumescence may be
considered along with brain scans, as indicated.
Some important points to consider that can help get a diagnosis:
1. the most common form of behavior is the rubbing of an individual’s genitals against
the victim’s thighs or buttocks;
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2. the act usually takes place in a wide variety of crowded public settings, such as public
transport, subways, elevators, malls or other crowded places;
3. behaviors are usually repetitive.
Most cases are not reported. Frotters often do not face legal consequences (rarely arrested),
have a large base of casualties and are unlikely to be sentenced to long sentences. However,
there are no systematic studies to support these findings.
The initiators of frotteuristic behaviors do not seek to have any conversation with the victim
and are often surprised if they are “caught”.
Causes and risk factors

There are no scientifically proven causes or risk factors for this disorder. At the same time,
there are several theories. [8]
A person who has accidentally rubbed against someone in a crowd and, as a result of
rubbing, has been sexually aroused may want to repeat this experience. This episode could
replace more traditional means of sexual arousal.
Childhood trauma, such as sexual abuse or anxiety disorder, can prevent a person from
developing a normal psychosexual development. People with this disorder may feel contact
with a stranger as a form of foreplay and intimacy.
Another possible reason for this behavior is that a person may have problems with the
affectivity and intimacy of sexual behavior. This could be caused by the abnormal anatomy of
the brain that affects the emotional health and the control of the impulses.
The signs of paraphilia are often evident before adolescence. Someone who is very
concerned about sex may have a higher risk of rubbing.
Treatment
People with frotteurism disorder generally do not receive treatment on their own and receive
help only after they have been arrested for sexual assault and treatment is required by the courts.
And because those with frotteuristic tendencies tend to act quickly in crowded public places
and are often able to disappear or mingle in a crowd without being caught, there is little reliable
information on the prevalence or success rates of treatment. Because the literature on this topic
is rare, treatment modalities are often generalized for all paraphilic disorders.
Standard treatments for frotteurism disorder include medication and psychotherapy.
Medications such as hormones and certain antidepressants can be used to reduce sexual
desire. Behavioral or cognitive-behavioral therapy can help manage sexual needs and redirect
thoughts to more appropriate ways to control inappropriate sexual impulses and behaviors. In
many cases, people requesting a diagnosis have already been charged with a sex offense or
similar offense.
Psychotherapy focuses on identification triggers of frotteuristic behavior and the
development of strategies to redirect thoughts and feelings.
A multimodal approach is recommended, i.e., one that includes individual and family or
community participation, in addition to psychotherapeutic and pharmacological interventions.
Several different therapeutic models, including psychotherapy, cognitive behavioral
therapy, solution-oriented therapy, psychoanalysis, relaxation therapy, biofeedback, have been
explored with a certain success. In addition, the clinician must be aware of his counter-transfer
during this process.
As mentioned earlier, frotteuristic behavior has been associated with several other mental
health disorders, such as depression, anxiety, and low self-esteem. [9] Therefore, treatment
often also involves the treatment of the underlying or comorbid disorder. Regarding
pharmacological interventions, can be administered both drugs that “suppress” the sexual drive,
i.e., suppresses testosterone, as well as drugs that “reduce” the sexual drive, such as
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serotonergic antidepressants. Administration of medroxyprogesterone acetate, a female

hormone, can also help reduce sexual impulses.
Anti-androgens, especially GnRH analogues, have been used as evidencebased treatment to
reduce impulsivity and hypersexuality in severe cases. [10] Ethical challenges that require
informed consent before administering GnRH analogues must be addressed. In addition,
because impulsive hypersexuality is considered to be a factor in this disorder, certain
serotonergic antidepressants, such as Fluoxetine, Sertraline, and Paroxetine, have been
modestly successful in attenuating the increase in sexual drive, in people who may also have
comorbid conditions such as depression or obsessive-compulsive disorder (OCD). [11]
Substance abuse disorder: An intoxicated person who uses psychostimulants such as
methamphetamine or cocaine may experience an episode that may mimic frotteurism. If such
recurrent episodes continue, a diagnosis of frotteurism disorder may be considered in the
absence of acute substance poisoning.
Traumatic brain injury: Frontal and frontotemporal deficiencies resulting from traumatic
brain injury may show a similar lack of inhibition and increased sexual behaviors. However,
cognitive impairments are usually present as a result of brain damage.
Conduct disorder and antisocial personality disorder: lack of morality, non-compliance
with the law and social norms can be important to distinguish a disorder of frotteurism. The
distinction is centered on the lack of sexual interest or arousal by touching or rubbing a person
who does not consent by someone with such a disorder.
Other differential diagnoses may include:
- Obsessive-Compulsive Disorders;
- Mood Disorders;
- Other disorders of sexual dysfunction;
- Other paraphilic disorders.
Forecast
Because this is an under-studied disorder, the actual prognosis is unknown. Very few cases
are self-reported, and most offenders are discovered through legal proceedings. Largescale
studies or long-term studies based on reliable results are absent in this area. As a significant
component of treatment is based on self-reporting and the individual’s willingness to seek help,
it is safe to assume that motivated individuals, with good community support and active
involvement in the treatment, may have a better prognosis than those who do not are.
Complications
Very little is known about the long-term impact of frotteurism on the initiator or the victim.
If comorbid conditions are taken into account, this can lead to the development of a
frotteurism disorder, which can cause significant damage to the individual clinically or
functionally. These individuals may have low self-esteem, severe social anxiety, and feelings
of guilt. Untreated mental health conditions can cause a further decline in mental health. Once
time “caught”, stigma from society and obedience of rules, as well as the application of
additional legal penalties, may occur. For those with severe sexual disorders, mandatory
registration in the register of sex offenders, regular “check-ins” with the legal system or
restrictions when it comes to the access to the real estate market can further complicate the
picture. This can be similar to a traumatic experience for the victim – increased anxiety,
hypervigilance, avoidance of public transport, insecurity and a general feeling of distrust.
Discouraging and educating the patient There is no drug treatment approved by major
international agencies for frotteuristic behaviors. People should be educated and encouraged to
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seek psychotherapeutic interventions and medications when necessary. It is important to inform

the patient that the management of underlying or comorbid conditions also helps to improve
this disorder. The stigmatization of the patient is a real problem that must be recognized and
addressed by the clinician.
CONCLUSION
Frotteurism disorder can be successfully treated, although not everyone affected by this
paraphilic disorder can be completely cured. Frotteurism is considered to be in complete
remission if five years pass without another manifested episode or an uncontrolled impulse.
Many people with this condition do not think they have a problem, so it is important that
friends or family members form a support network to keep them on track. Constrachevici L,
M., & Delcea C., (2019), Delcea C., (2019), Popa T., & Delcea C., (2019), Eusei D., & Delcea
C., (2019), Dragu D., & Delcea C., Paraphilias (2019) Ongoing therapy with a therapist or
mental health counselor may also be necessary, but a forensic psychiatrist is best able to assess,
diagnose, and manage the treatment of people with frotteurism, thus improving their outcomes,
and reducing thus, future sex crimes.
REFERENCES
[1] Frotteurism. SexInfoOnline. University of California, Santa Barbara. Updated 3 Apr 2014.
[2] DSM-5. Manual de Diagnostic si Clasificare Statistica a Tulburarilor Mintale. pp. 691-694. American
Psychiatric Association (2013). Editura Callistro.
[3] Dr. Vincent Berger. Web publication. Psychologist Anywhere Anytime.
https://www.psychologistanywhereanytime.com/sexual_problems_pyschologist/psychologist_frotteuri
sm.htm
[4] Freund K, Seto MC. Preferential rape in the theory of courtship disorder. Arch Sex Behav. 1998 Oct;
27(5): pp. 433-43.
[5] Kamenskov MY, Gurina OI. [Neurotransmitter mechanisms of paraphilic disorders]. Zh Nevrol
Psikhiatr Im S S Korsakova. 2019; 119(8): pp. 61-67.
[6] Abel GG, Becker JV, Cunningham-Rathner J, Mittelman M, Rouleau JL. Multiple paraphilic diagnoses
among sex offenders. Bull Am Acad Psychiatry Law. 1988; 16(2): pp. 153-68.
[7] Mark Griffiths, PhD. Wordpress. Rubbing someone up the wrong way: A beginner’s guide to
frotteurism.
[8] James Roland, Janet Brito, Ph.D., LCSW, CST. October 26, 2017. Article. What Is Frotteurism?
https://www.healthline.com/health/frotteuri sm.
[9] Kalra G. The depressive façade in a case of compulsive sex behavior with frottage. Indian J Psychiatry.
2013 Apr; 55(2): pp. 183-5.
[10] Garcia FD, Thibaut F. Current concepts in the pharmacotherapy of paraphilias. Drugs. 2011 Apr 16;
71(6): pp. 771-90.
[11] Kafka MP, Prentky R. Fluoxetine treatment of nonparaphilic sexual addictions and paraphilias in men.
J Clin Psychiatry. 1992 Oct; 53(10): pp. 351-8.
[12] Constrachevici L, M., & Delcea C. Sexual deviance. The Sexual sadism. Int J Advanced Studies in
Sexology. Vol. 1, Issue 1, pp. 23-27. Sexology Institute of Romania. DOI: 10.46388/ ijass.2019.12.114.
[13] Delcea C., Sexual deviances. Int J Advanced Studies in Sexology. Vol. 1, Issue 1, pp. 44-47. Sexology
Institute of Romania. DOI: 10.46388/ ijass.2019.12.119.
[14] Delcea C. (2019). Zoophilia. Int J Advanced Studies in Sexology. Vol. 1, Issue 1, pp. 36-38. Sexology
Institute of Romania. DOI: 10.46388/ ijass.2019.12.117
[15] Popa T., & Delcea C., Voyeurism and Scopophilia. Int J Advanced Studies in Sexology. Vol. 1, Issue 1,
pp. 53-55. Sexology Institute of Romania. DOI: 10.46388/ijass.2019.12.11.121.
[16] Eusei D., & Delcea C., Fetishist disorder. Int J Advanced Studies in Sexology. Vol. 1, Issue 2, pp. 73-
[17] Dragu D., & Delcea C., Paraphilias and paraphilic behaviors. Voaiorismul. An Individual Psychology
Romania. DOI: 10.46388/ijass.2020.13.20.
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FROTTEURISM DISORDER – 2
Abstract
Frotteurism disorder or frotteurism is one of the paraphilic disorders that cause sexual
arousal. It is the act of touching or rubbing the genitals against a person in a sexual manner,
without their consent, to obtain sexual pleasure or to reach orgasm. Those who practice
frotteurism find pleasure in having a private sexual experience in a public setting.
Keywords: frotteurism, paraphilias, frotteurism disorder, DSM-V, sexual disorder, stigma
INTRODUCTION
Although it can occur at any age, frotteurism disorder is most common in young, seemingly
shy men between the ages of 15 and 25. It has also been observed in older men, reserved and
socially withdrawn. Frotteurism is considered to be rare among women. The prevalence of the
disorder is unknown, although approximately 10-14% of adult men seen by clinicians for
paraphilic disorders meet the diagnostic criteria for frotteurism disorder. [1]
Definitions
The Manual of Diagnosis and Statistical Classification of Mental Diseases, 5th edition
(DSM-V) distinguishes between paraphilia and a paraphilic disorder.
The term paraphilia is defined as “an intense and persistent sexual interest other than sexual
interest for genital stimulation or foreplay with human partners, phenotypically normal,
physically mature and consenting.” [2]
The term disorder was specifically added to the DSM-V to indicate paraphilic behaviors.
Disorder paraphilic is “a paraphilia that causes the individual emotional distress or
dysfunction in the present or a paraphilia whose satisfaction involves self-harm or the risk of
harm to others.”
This is also true for frotteurism, which is one of the eight paraphilic disorders listed in the
DSM-V. Frotteurism is the act of touching or rubbing the genitals against a person who does
not consent sexually.
The term frottage is derived from the French word “frotter”, which means “to rub”.
KraftEbbing first described this behavior in the book Psychopathia Sexualis in 1886, while
Clifford Allen coined the term frotteurism in the 1960s.
The term toucherism is sometimes used to describe a condition closely related to
frrotteurism that involves only rubbing or stroking without rubbing, although it is generally
considered to be part of frotteurism. A person suffering from frotteurism is known as frotteur.
Most individuals with this paraphilia are men and in most cases the victims are women.
Frotters usually pick up their victims in crowded places (e.g., public transport vehicles,
crowded sidewalks), which allows for quick escape and excuse that the touch was accidental.
The frotteur rubs his genital area against the victim’s thighs or buttocks (usually female) or
the frotteur caresses a woman’s genitals or breasts with his hands. [3]
Etiology
The exact etiology is not known, but there are many theories about the cause of frotteurism
disorder. Psychoanalysts suggest that individuals with frotteuristic behaviors may have unmet
needs to rub against the victim and cuddle, as an infant does with his mother. People who
engage in these behaviors may imagine that they share an exclusive and close relationship with
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their victims during the act. Freund and Seto argue that these individuals may also have
problems with tactile interactions that may occur during normal human erotic or sexual
interactions. [4]
There has been some research that has shown the existence of a biological mechanism,
mainly through monoamine neurotransmitters that lead to abnormal sexual behavior. [5]
Although not specific to frotteurism, paraphilias have generally been associated with the
following additional mental health diagnoses: [6]
- social anxiety;
- brain injuries;
- the history of sexual abuse, in general, was associated with a paraphilic disorder;
- intellectual disabilities;
- substance abuse;
- the presence of others or an accumulation of paraphilias, in particular exhibitionism
and frotteurism.
Diagnosis and prevalence

According to DSM-5, the criteria for frotteurism disorder are met if for a period of 6 months
a person has experienced intense sexual arousal and repeated that involves touching and
rubbing a person who does not consent, characterized by fantasies, sexual impulses or specific
behaviors. In some cases, people with frotteurism disorder reach orgasm during intercourse.
Frotteurism disorder is sometimes accompanied by other mental health disorders and
clinical problems, especially along with other paraphilic disorders, such as exhibitionism or
other combinations of paraphilic disorders. People with frotteurism may also experience
anxiety, shame, low self-image, and other emotional problems that exacerbate behavior and
complicate treatment.
The prevalence rate of frotteurism is not yet clearly established, as it is assumed that most
people with this condition do not seek professional help voluntarily. It is difficult to assess the
prevalence of frotteurism because the studies either do not have the necessary methodological
quality or include small sample sizes or use local rather than national or international samples
and do not consistently apply DSM criteria. The prevalence rate of frotteurism can also be
uncertain because, in most cases, victims are unaware that they have been touched or rarely
report incidents to the authorities. Frotteurism is a predominantly male disorder and usually
occurs for the first time in late adolescence and decreases until the age of 25 years. It has been
estimated that 30% of adult men have engaged in frotteuristic acts, and 10% to 14% of men
diagnosed with paraphilic disorders also meet the diagnostic criteria for frotteurism disorder.
Data on the prevalence of female diagnoses of frotteurism disorder are not available. [7]
Assesment
An essential feature of the frotteurism disorder is that this behavior is repetitive.
According to DSM-V, if the individual did not act in his interest and did not present mental
discomfort or dysfunctions, it is considered that has a frotteuristic sexual interest, but not a
frotteurism disorder.
As part of establishing the diagnosis and excluding other causes, routine laboratory and
imaging tests can be obtained.
Laboratory work may include:
- metabolic panel;
- hormonal tests: tests of thyroid function, prolactin, luteinizing and folliculostimulating
hormone test, testosterone tests.
If additional deviant sexual behaviors are suspected, nocturnal penile tumescence may be
considered along with brain scans, as indicated.
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Some important points to consider that can help get a diagnosis:

1. The most common form of behavior is the rubbing of an individual’s genitals against
the victim’s thighs or buttocks;
2. The act usually takes place in a wide variety of crowded public settings, such as public
transport, subways, elevators, malls or other crowded places;
3. Behaviors are usually repetitive.
Most cases are not reported. Frotters often do not face legal consequences (rarely arrested),
have a large base of casualties and are unlikely to be sentenced to long sentences. However,
there are no systematic studies to support these findings.
The initiators of frotteuristic behaviors do not seek to have any conversation with the victim
and are often surprised if they are “caught”.
Causes and risk factors

There are no scientifically proven causes or risk factors for this disorder. At the same time,
there are several theories. [8]
A person who has accidentally rubbed against someone in a crowd and, as a result of
rubbing, has been sexually aroused may want to repeat this experience. This episode could
replace more traditional means of sexual arousal.
Childhood trauma, such as sexual abuse or anxiety disorder, can prevent a person from
developing a normal psychosexual development. People with this disorder may feel contact
with a stranger as a form of foreplay and intimacy.
Another possible reason for this behavior is that a person may have problems with the
affectivity and intimacy of sexual behavior. This could be caused by the abnormal anatomy of
the brain that affects the emotional health and the control of the impulses.
The signs of paraphilia are often evident before adolescence. Someone who is very
concerned about sex may have a higher risk of rubbing.
Treatment
People with frotteurism disorder generally do not receive treatment on their own and receive
help only after they have been arrested for sexual assault and treatment is required by the courts.
And because those with frotteuristic tendencies tend to act quickly in crowded public places
and are often able to disappear or mingle in a crowd without being caught, there is little reliable
information on the prevalence or success rates of treatment. Because the literature on this topic
is rare, treatment modalities are often generalized for all paraphilic disorders.
Standard treatments for frotteurism disorder include medication and psychotherapy.
Medications such as hormones and certain antidepressants can be used to reduce sexual
desire. Behavioral or cognitive-behavioral therapy can help manage sexual needs and redirect
thoughts to more appropriate ways to control inappropriate sexual impulses and behaviors. In
many cases, people requesting a diagnosis have already been charged with a sex offense or
similar offense.
Psychotherapy focuses on identification triggers of frotteuristic behavior and the
development of strategies to redirect thoughts and feelings.
A multimodal approach is recommended, i.e., one that includes individual and family or
community participation, in addition to psychotherapeutic and pharmacological interventions.
Several different therapeutic models, including psychotherapy, cognitive behavioral
therapy, solution-oriented therapy, psychoanalysis, relaxation therapy, biofeedback, have been
explored with a certain success. In addition, the clinician must be aware of his counter-transfer
during this process.
As mentioned earlier, frotteuristic behavior has been associated with several other mental
health disorders, such as depression, anxiety, and low self-esteem. [9] Therefore, treatment
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often also involves the treatment of the underlying or comorbid disorder. Regarding
pharmacological interventions, can be administered both drugs that “suppress” the sexual drive,
i.e., suppresses testosterone, as well as drugs that “reduce” the sexual drive, such as
serotonergic antidepressants. Administration of medroxyprogesterone acetate, a female
hormone, can also help reduce sexual impulses.
Anti-androgens, especially GnRH analogues, have been used as evidence-based treatment
to reduce impulsivity and hypersexuality in severe cases. [10]
Ethical challenges that require informed consent before administering GnRH analogues
must be addressed. In addition, because impulsive hypersexuality is considered to be a factor
in this disorder, certain serotonergic antidepressants, such as Fluoxetine, Sertraline, and
Paroxetine, have been modestly successful in attenuating the increase in sexual drive, in people
who may also have comorbid conditions such as depression or obsessive-compulsive disorder
(OCD). [11]
Substance abuse disorder: An intoxicated person who uses psychostimulants such as
methamphetamine or cocaine may experience an episode that may mimic frotteurism. If such
recurrent episodes continue, a diagnosis of frotteurism disorder may be considered in the
absence of acute substance poisoning.
Traumatic brain injury: Frontal and frontotemporal deficiencies resulting from traumatic
brain injury may show a similar lack of inhibition and increased sexual behaviors. However,
cognitive impairments are usually present as a result of brain damage.
Conduct disorder and antisocial personality disorder: lack of morality, non-compliance
with the law and social norms can be important to distinguish a disorder of frotteurism. The
distinction is centered on the lack of sexual interest or arousal by touching or rubbing a person
who does not consent by someone with such a disorder.
Other differential diagnoses may include:
- Obsessive-Compulsive Disorders;
- Mood Disorders;
- Other disorders of sexual dysfunction;
- Other paraphilic disorders.
Forecast
Because this is an under-studied disorder, the actual prognosis is unknown. Very few cases
are self-reported, and most offenders are discovered through legal proceedings. Large-scale
studies or long-term studies based on reliable results are absent in this area. As a significant
component of treatment is based on self-reporting and the individual’s willingness to seek help,
it is safe to assume that motivated individuals, with good community support and active
involvement in the treatment, may have a better prognosis than those who do not are.
Complications
Very little is known about the long-term impact of frotteurism on the initiator or the victim.
If comorbid conditions are taken into account, this can lead to the development of a
frotteurism disorder, which can cause significant damage to the individual clinically or
functionally. These individuals may have low self-esteem, severe social anxiety, and feelings
of guilt. Untreated mental health conditions can cause a further decline in mental health. Once
time “caught”, stigma from society and obedience of rules, as well as the application of
additional legal penalties, may occur. For those with severe sexual disorders, mandatory
registration in the register of sex offenders, regular “check-ins” with the legal system or
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restrictions when it comes to the access to the real estate market can further complicate the
picture.
This can be similar to a traumatic experience for the victim – increased anxiety,
hypervigilance, avoidance of public transport, insecurity and a general feeling of distrust.
Discouraging and educating the patient

There is no drug treatment approved by major international agencies for frotteuristic
behaviors. People should be educated and encouraged to seek psychotherapeutic interventions
and medications when necessary. It is important to inform the patient that the management of
underlying or comorbid conditions also helps to improve this disorder. The stigmatization of
the patient is a real problem that must be recognized and addressed by the clinician.
CONCLUSION
Frotteurism disorder can be successfully treated, although not everyone affected by this
paraphilic disorder can be completely cured. Frotteurism is considered to be in complete
remission if five years pass without another manifested episode or an uncontrolled impulse.
Many people with this condition do not think they have a problem, so it is important that
friends or family members form a support network to keep them on track. Ongoing therapy
with a therapist or mental health counselor may also be necessary, but a forensic psychiatrist
is best able to assess, diagnose, and manage the treatment of people with frotteurism, thus
improving their outcomes, and reducing thus, future sex crimes.
REFERENCES
[1] Frotteurism. SexInfoOnline. University of California, Santa Barbara. Updated 3 Apr 2014.
[2] DSM-5. Manual de Diagnostic si Clasificare Statistica a Tulburarilor Mintale. pp. 691-694. American
Psychiatric Association (2013). Editura Callistro.
[3] Dr. Vincent Berger. Web publication. Psychologist Anywhere Anytime.
https://www.psychologistanywhereanytime.com/sexual_problems_pyschologist/psychologistfrotteuris
m.htm
[4] Freund K, Seto MC. Preferential rape in the theory of courtship disorder. Arch Sex Behav. 1998 Oct;
27(5): pp. 433-43.
[5] Kamenskov MY, Gurina OI. [Neurotransmitter mechanisms of paraphilic disorders]. Zh Nevrol
Psikhiatr Im S S Korsakova. 2019; 119(8): pp. 61-67.
[6] Abel GG, Becker JV, Cunningham-Rathner J, Mittelman M, Rouleau JL. Multiple paraphilic diagnoses
among sex offenders. Bull Am Acad Psychiatry Law. 1988; 16(2): pp. 153-68.
[7] Mark Griffiths, PhD. Wordpress. Rubbing someone up the wrong way: A beginner’s guide to
frotteurism.
[8] James Roland, Janet Brito, Ph.D., LCSW, CST. October 26, 2017. Article. What Is Frotteurism?
https://www.healthline.com/health/frotteurism.
[9] Kalra G. The depressive façade in a case of compulsive sex behavior with frottage. Indian J Psychiatry.
2013 Apr; 55(2): pp. 183-5.
[10] Garcia FD, Thibaut F. Current concepts in the pharmacotherapy of paraphilias. Drugs. 2011 Apr 16;
71(6): pp. 771-90.
[11] Kafka MP, Prentky R. Fluoxetine treatment of nonparaphilic sexual addictions and paraphilias in men.
J Clin Psychiatry. 1992 Oct; 53(10): pp. 351-8.
Paraphilic Disorders. Rom J Leg Med28(1) pp. 14-20 (2020) DOI:10.4323/rjlm.2020.14 Romanian
[13] Siserman C., Delcea C., Vladi Matei H., Vică L. M. 2019: Major Affective Distres in Testing Forensic
Paternity. 2019. – Rom J Leg Med27(3) pp. 292-296(2019) DOI:10.4323/rjlm.2019.292 © Romanian
[14] Delcea C., Rusu O. D., Matei V. H., Vica M. L., Siserman C., (2020). The Evidence-Based Practice
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Leg Med [28] pp. 257-262 [2020] DOI: 10.4323/ rjlm.2020.257.

Individuals Incarcerated for Sexual Offences. Rom J Leg Med [28] pp. 278-282 [2020] DOI: 10.4323/
rjlm.2020.278.
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PUBLIC MASTURBATION
Abstract
Masturbation is defined as the act of sexual self-stimulation. Moreover, it also refers to

exporing the body through personal sexual stimulation. Watson and McKee (2013) defined that
personal exploration of sexual stimulation is a positive approach to sexuality. Coleman (2002)
recognized masturbation as a healthy and natural way to achieve orgasm and an important
aspect of healthy human sexual development. To understand the benefits of masturbation, we
need to understand the benefits of orgasm.
Keywords: Public Masturbation, Paraphilia, Sexology
INTRODUCTION
Achieving an orgasm has many benefits for physical and mental health, such as increased
power of the immune system, low risk of prostate cancer due to the increased frequency of
ejaculation (Leitzmann, Platz, Stampfer, Willet and Giovannucci, 2004) and decreased
symptoms of stress (Charnetski & Brennan, 2001).
When an individual experiences high levels of stress, the body releases increased amounts
of cortisol, thus weakening the body and immune system (Charnetski & Brennan, 2001).
In this weakened state of the body, there may be an increased risk for high blood pressure,
heart disease, diabetes and stroke.
Involvement of masturbation as a means of achieving orgasm can help reduce stress levels
(Delcea C., 2019). As the organs reach the point of orgasm, the release of oxytocin and
endorphins occurs.
These chemicals create natural opioids that lower heart rate, blood pressure and reduce
physical pain (Charnetski and Brennan, 2001).
Masturbation is considered to be a normal behavior in certain conditions such as being
performed indoors and abnormal when it is performed in public places (Popa T. & Delcea C.,
2019).
As for the prevalence of public masturbation due to the lack of literature on this topic, this
was difficult to establish, especially in young children and people diagnosed with autism
spectrum disorder.
People that are diagnosed with this disorder are more likely to masturbate in public.
The majority of people gather information about sex and sexual education from social
relationships and non-formal environments through interactions with friends or close friends.
(Realmuto & Ruble, 1999).
Due to the lack of communication and the lack of social interactions, people diagnosed with
autism spectrum disorder do not benefit from this “non-formal learning”; Another explanation
for this behavior is due to the fact that these people, because of mental retardation, do not
benefit from sex education courses in schools (where sex education is taught).
Therefore, because of the the significant lack of resources and access to sex education there
is a high percentage of people with autism spectrum disorders that are at greater risk of
engaging in inappropriate sexual behaviors.
These inappropriate sexual behaviors may include inappropriate touching of the body and
removing clothing, both in public places.
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Engaging in public masturbation, touching others, without consent, and persistence in sexual
matters is very common for people that have been diagnosed with this kind of disorder. (Lawrie
& Jillings, 2004; Ray, Marks & Bray-Garretson, 2004).
According to Dewinter et al., (2013) lack of education about sexual behaviors may increase
the chances of an individual developing such behaviors (Dewinter, Vermeiren,
Vanwesenbeeck, and Nieuwenhuizen, 2013).
Dufrene et al., (2005) states that masturbation is common in young children and can occur
from the age of six months to about five years and reoccuring in puberty. Although
masturbation in young children is common and relatively acceptable (Gagnon, 1985), public
masturbation can be disturbing to parents, caretakers and teachers.
CONCLUSIONS
Therefore, the lack of education may be an important factor in the emergence of public
masturbation, as we have observed in the case of persons diagnosed with autism spectrum
disorder, as well as in the case of young children who have not yet managed to internalize the
education received from their parents.
RESOURCES
[1] Burylo, K. O. Behavioral Skills Training: Treatment for Public Masturbation Among Individuals with
Autism Spectrum Disorder (ASD). Psychiatry, 10, pp. 282-289.
[2] Dewinter, J., Vermeiren, R., Vanwesenbeeck, I., & Nieuwenhuizen, C. (2013). Autism and normative
sexual development: A narrative review. Journal of Clinical Nursing, 22, pp. 3467-3483.
[4] Dufrene, B. A., Watson, T. S., & Weaver, A. (2005). Response blocking with guided compliance and
reinforcement for a habilitative replacement behavior: Effects on public masturbation and on-task
behavior. Child & family behavior therapy, 27(4), pp. 73-84.
[6] Friedrich, W.N., Grambsch, P., Broughton, D., Kuiper, J., & Beilke, R.L. (1991). Normative sexual
behavior in Children. Pediatrics, 88, pp. 456-464.
[7] Gagnon, J.H. (1985). Attitudes and responses of parents to pre-adolescent masturbation. Archives of
[8] Lawrie, B. & Jillings, C. (2004). Assessing and addressing inappropriate sexual behavior in brain-injured
clients, Rehabilitation Nursing, 29(1), pp. 9-13.
[9] Popa T., & Delcea C. (2019). Voyeurism and Scopophilia. Int J Advanced Studies in Sexology. Vol. 1,
[10] Ray, F., Marks, C. & Bray-Garretson, H. (2004). Challenges to treating adolescents with Asperger’s
syndrome who are sexually abusive. Sexual Addiction and Compulsivity, 11, pp. 265 285.
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2.4 Pedophilia disorder
SEXUAL DEVIATIONS. CONSIDERATIONS REGARDING PEDOPHILIA – MITH

AND REALITY
Abstract
Taking to consideration the antropology venues, the medical disclosures regarding

paraphilia, centered on pedophilia, the present paper tries to make an introduction review on
the topic under discussion. However, regardless the type of studies made over the time, whether
they consisted in questionnaires and forums where people were invited to comment upon this
sexual disorder or deviation, to more complex medical research involving MRI scans and DNA
analysis, none of them proved their effectiveness, or found a real cause.
Keywords: paraphilia, pedophilia, child abuse, menthal disorder, sexual deviation
INTRODUCTION
Sexual deviation or paraphilia is primary a general term used for a menthal-sexual disorder,
accepted on a large scale as beeing used for a sexual practice not approved by the social norms,
an abnormality or a sexual perversion and characterized by getting sexual arousal from an
object, strange situation, fantasy, etc.
Among the most known sexual disorders we find voyeurism, exhibitionism, fetishism,
frotteurism, sadism and masochism, pedophilia, telephone scatologia, necrophilia, partialism,
coprophilia, klismaphilia and urophilia, etc.
Some of the sexual deviated behaviours imply the use of psychological or physical violence
(pedophilia, sadism-masochism), while others imply the use of abnormal objects or other
beings (zoophilia, necrophilia), most of them having even a criminal involvement.
From the psychiatric perspective, in the begining the paraphilias were classified as cases of
“psychopathic personality with pathologic sexuality”.
One of the most studied paraphiliac disorders is the pedophilia, as it has the most criminal
implications, the most inocent victims and is one of the most stigmatized mental disorders.
The word pedophilia comes from the Greek word παῖς, παιδός (paîs, paidós), meaning
“child”, and φιλία (philía), “friendly love” or “friendship”.
Medical perspective
Nowadays, pedophilia is a psychiatric disorder in which an adult or older adolescent (at least
5 years older than the victim), experiences a primary or exclusive sexual attraction to
prepubescent children. Infantophilia is a sub-type of pedophilia; it is used to refer to a sexual
preference for children under the age of 5 (especially infants and toddlers), other sub-type being
the hebephilia (sexual interest for children betweeen 11-14 years old) although this term is not
accepted by the DSM 5 specialists.
It is known that the pedophilia usually emerges before or during puberty and is stable over
time. Although a lot of research has been done over time, none of them has found a real
explanation for what causes it or maintains it, many specialists link it to childhood abuse.
Starting from questionnaires and forums where people were invited to comment upon this
sexual disorder or deviation, to more complex medical research involving MRI scans and DNA
analysis, none of them proved their effectiveness, or found a real cause.
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In some recent researches, based on neurological grounds, the specialists have tried to
investigate the mechanisms of sexual attraction to children, using the MRI scans but afterwards
have reported many contradictory or non-replicated findings. Additionally with the results the
specialists related the level of bilateral activation in the above-mentioned regions to be
positively correlated with ratings of perceived sexual arousal elicited by Visual perception of
explicit pictures with children. The new findings disclosed those regions as possible candidate
areas mediating sexual arousal in patients with pedophilic disorder.
Another study revealed aberrant neuroanatomy and lower intelligence as a potential core
feature underlying child sexual abuse behavior by pedophiles.
Other recent studies and researches with genetic implication have determined that the
hormonal androgen system is closely linked to sexual development and behavior. The study
revealed there are alterations of the androgen system on a prenatal and endocrine level, but the
people sample examinated were sexual child offenders, so the study cannot be specific for
pedophilia, because it is a major diference between the two terms. While the child sexual
offenders have the mental disorder of pedophilia, is not necesarry that one pedophil to sexual
abuse a child.
These findings made the connections to the theories of testosterone-linked abnormalities in
early brain development in delinquent behavior and suggested possible interactions of
testosterone receptor gene methylation and plasma testosterone with environmental factors.
Although at the begining of every study were found little differences between healthy and
paraphilia suffering people (different levels of androgen, estrogen, prolactin, corticotrophin,
serotonin, and oxytocin), after running multiple different tests No associations remained
significant, resulting that the pedophilia involves a complex of biological mechanism which
affects the adult sexual interest in children. Still there were some researchers who stated that a
very small effect sizes characterized the findings and several polymorphisms related to
different hormonal functioning were initially related to the phenotype.
But even so, a psychiatrist, Paul Fedoroff, of the University of Ottawa, recently published a
paper entitled: “Can pedophilia be changed? Yes, It can!”
Fedoroff’s perspective is that pedophilia is not a sexual orientation and he characterizes it
as a form of “sexual interest” or something that a person happens to want to have sex with. In
his opinion, sexual interest is something we gain through education, experience and
observation and, as such, “can change throughout life” and that every person can educate the
same way they educate their eating preferences – however, he does not claim that one can
change the own sexual orientation.
Fedoroff study involved analyzing 43 men whose overall arousal was assessed on two
separate occasions. At each test session, participants listened to erotic scenarios describing
children or adults, while changes in their erectile status were recorded with a penile
plethysmography (a penis ring that measures blood flow changes). If at first testing all men
indicated a pattern of pedophile arousal at the second test about half of these men (49%) showed
a change in the pattern of arousal at subsequent testing: the arousal caused by children
decreased, while that aroused by adults increased. The participants were chosen strictly based
on the fact that they were tested twice, regardless of whether or not they received any treatment.
This unique study was severlly criticised as it has no scientific grounds, moreover beeing
known that a person could imagine a non sexual thing just to be cleared from a pedophile
stigmat.
Most clinicians and researchers believe that paraphilic sexual disorder cannot be treated or
altered, but that the therapy (both psychotherapeutic and pharmacological) can reduce the
person’s discomfort with their paraphilia and limit any criminal behavior, if present.
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Sociological perspective
It is known that a pedophile most often chooses his careers that put him in direct contact
with children, beeing often a respectable person, a teacher, a coach, etc. However, despite his
jovial and friendly character he is or becomes aware that his sexual attitude, once discovered
by others, can attract the oppression and anger of the society and a stigma for the rest of his
life. To mask their vice, pedophiles often marry, to create the appearance of a normal state.
In the overwhelming majority of cases, pedophiles are recruited among men. Although the
onset of pedophilia can be at any age, most pedophiles consulted by physicians are middle-
aged men. There is no evidence that pedophiles have changed their preference, from adult
partners to children, as they grow older. The preferences seem to be established from the
beginning of the sexual life. Pedophilia, however, in rares and less scandalous cases, also
manifests itself among women.
Juridical perspective
Contrary to public perception, child sex offending and padophilia are not the same.
The romanian Criminal Code only sanctions act against minors whom the law considers
abusive, but not mere sexual inclinations. As long as a deviant sexual inclination remains only
at the level of ideas, feeling, emotion, it does not fall under the influence of the criminal law.
From a statistical point of view only half of all cases of child sex abuses are motivated by
pedophilic preference.
However, studies that investigated clinical factors accompanying and contributing to
pedophilia so far, mainly relied on pedophiles with a history of child sex abuse.
Results indicated that psychiatric comorbidities, sexual dysfunctions and adverse childhood
experiences were more common among pedophiles and child sex offenders than controls.
Offenders and non-offenders differed in age, intelligence, educational level and experience
of childhood sexual abuse, whereas pedophiles and non-pedophiles mainly differed in sexual
characteristics (e.g., additional paraphilias, onset and current level of sexual activity).
According to a recent newspaper article statistical grounds show that even now, when we,
as a society that supposed to be made up by intellectual evolved human beeings and to protect
the children, in Romania, there are judges who solved cases of child sexual abuse that
considered the acts to be consensual if the victim did not disclose the fact to a close relative.
One decision of the Apeal Court of Alba County stated: “Based on these testimonies and
the fact that the victim did not tell her parents about the alleged abuse, the court concluded that
the sexual acts were always initiated by the applicant and rejected the theory that the victim
was unable to express the will”.
Even though the Criminal Code specifies the discernment is excluded until 14 years, these
judges blatantly disregarded the legal provisions, judging only by their intimate conviction.
Moreover, even within the criminal code, some inacurracies are strained, so although it is
stipulated that until the age of 14 there is no discernment, these provisions apply only to the
perpetrators, not to the victims. In case the victims were also applied, the correct legal
classification would have been that of rape, because consent to a sexual act cannot be given if
this consent is biologically lacking.
CONCLUSION
The etiology of pedophilia remains largely unknown, but the disorder is thought to be caused
by an undetermined distribution of psychological, sociological, biological and enviromental
factors. The relationships between biochemical and psychopathological signs suggest a role of
biological mechanisms in the organization of abnormal sexual behavior.
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The prevention consisting in the prompt intervention of the judicial sistem and society, by
creating support centers for molested children would in the future diminish one of the causes
found by the specialists as being responsible for the appearance of pedophilia.
If for ethical reasons it is not possible to intervene at the DNA level, not knowing too many
details about this sexual deviance, social prevention could prove its utility on a large scale,
especially since the number related to pedophiles who sexually molested children it is directly
proportional to the abuses suffered by them in their own childhood, the deviant behavior
representing one of the victimization states to which they have evolved at present.
REFERENCES
[1] “Paraphilic Disorders”. Diagnostic and Statistical Manual of Mental Disorders (Fifth ed.). Philadelphia,
Pennsylvania: American Psychiatric Publishing. 2013. pp. 685-686.
[2] American Psychiatric Association, ed. (2013). “Other Specified Paraphilic Disorder; Unspecified
Paraphilic Disorder”. Diagnostic and Statistical Manual of Mental Disorders (Fifth ed.). American
Psychiatric Publishing. p. 705.
[3] Jahnke, S., Hoyer, J. (2013). “Stigma against people with pedophilia: A blind spot in stigma research?”.
International Journal of Sexual Health. 25 (3): pp. 169-184. doi:10.1080/19317611.2 013.795921.
[4] Liddell, H.G.; Scott, Robert (1959). Intermediate Greek-English Lexicon. Oxford, England: Oxford at
The Clarendon Press. ISBN 978-0-19-910206-8.
[5] Gavin H (2013). Criminological and Forensic Psychology. SAGE Publications. p. 155. ISBN 978-
1118510377. Retrieved July 7, 2018.
[6] Greenberg, David M.; Bradford, John; Curry, Susan (1995). “Infantophilia – a new subcategory of
pedophilia: a preliminary study”. The Bulletin of the American Academy of Psychiatry and the Law. 23
(1): pp. 63-71. PMID 7599373.
[7] Cutler, Brian L., ed. (2008). “Pedophilia”. Encyclopedia of Psychology and Law. 2. SAGE Publications,
Inc. p. 549. ISBN 978-1-4129-5189-0.
[8] Brain responses to pictures of children in men with pedophilic disorder: a functional magnetic resonance
imaging study Fadwa Cazala, Véronique Fonteille, Virginie Moulier, Mélanie Pélégrini-Issac,
Christiane De Beaurepaire, Marlène Abondo, Magali Bodon-Bruzel, Jean Cano, Florent Cochez,
Taoufik Fouli, Catherine Thevenon, Bernard Dauba, Michel Pugeat & Serge Stoléru, www.pubmed.com
https://link. springer.com/article/10.1007%2Fs00406-018-0933-z.
[9] Child sexual offenders show prenatal and epigenetic alterations of the androgen system. Kruger THC1,
Sinke C2, Kneer J2, Tenbergen G2, Khan AQ2, Burkert A2, Müller-Engling L2, Engler H3, Gerwinn
H4, von Wurmb-Schwark N5, Pohl A4, Weiß S6, Amelung T7, Mohnke S8, Massau C9, Kärgel C9,
Walter M10,11, Schiltz K12, Beier KM7, Ponseti J4, Schiffer B9, Walter H8, Jahn K2, Frieling H2.
https://www.ncbi. nlm.nih.gov/pubmed/30659171.
[10] Genetic Variants Associated with Male Pedophilic Sexual Interest. Alanko K1, Gunst A2, Mokros A3,
Santtila P4. https://www.ncbi. nlm.nih.gov/pubmed/27114195.
[11] Michael Gelder, Denis Gath, Richard Mayon, Tratat de psihiatrie OXFORD, ediţia an II-a, Asociaţia
Psihiatrilor Liberi din România şi Geneva – Initiative on Psychiatry, BucureştiAmsterdam, 1994, p. 458.
[12] https://en.wikipedia.org/wiki/Paraphilia 13. http://www.revistadesociologie.ro/pdf-uri/nr.3-4-
1999/MONICA%20%20 PATRIOARA%20art10.pdf.
[13] https://www.tolo.ro/2019/01/18/invinovatireavictimelor-12-judecatori-romani-au-consideratca-daca-
fetele-minore-violate-nu-au-spusparintilor-tacerea-reprezinta-dovada-ca-si-au-dat-consimtamantul-
pentru-sex/
[14] https://www.libertatea.ro/stiri/postarecontroverstata-a-judecatorului-cristi-daniletin-contextul-
prinderii-politistului-pedofilexplicatiile-magistratului-2100795
[15] http://theconversation.com/the-causes-ofpaedophilia-and-child-sexual-abuse-are-morecomplex-than-
the-public-believes-94915
[16] https://www.cambridge.org/core/services/aop-cambridge-
core/content/view/51AD308E2CEE6EABE06B8930BCCBFDAC/
S0924933800015480a.pdf/clinical_characteristics_associated_with_paedophilia_and_child_
sex_offending_differentiating_sexual_preference_from_offence_status.pdf
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[17] https://www.cambridge.org/core/journals/european-psychiatry/article/clinical-characteristics-
associated-with-paedophilia-and-child-sex-offending-differentiating-sexual-preference-from-offence-
status/51AD308E2CEE6EABE06B8930BCCBFDAC
[18] https://www.psychologytoday.com/intl/conditions/pedophilia
[19] https://www.totuldespremame.ro/tu-mama/lumea-in-care-traim/dragi-parinti-atentie-la-minecraft-
roblox-sau-fornite-copiii-pot-ajunge-pe-mana-
pedofililor?fbclid=IwAR0WGteh5rzTY6BvtHEuT4xzU_PhRA_0MOo8PHIKoENoZF-
IZI5BC69avXc
[20] https://www.vice.com/ro/article/mbzj5q/pedofilii-nu-pot-fi-vindecati
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HEBEPHILIA
Abstract
Franklin, K. (2010) defined Hebephilia as an obscure term, that is very rarely found in the
field of medicine, psychiatry or psychology. Moreover, it is not listed as a DSM diagnosis
(APA, 2000) neither in the ICD (World Health Organization, 2007) or any other validated
sources for diagnosis. Therefore, research in academic database show that this specific word is
very poorly used and it cannot be found not even in the Oxford English Dictionary (OED).
Keywords: Hebephilia, Paraphilia, Sexology
INTRODUCTION
Hebephilia is the sexual interest in pubescent children who are in early adolescence (Glueck,
1955). Blanchard et al., (2009) stated that those who are diagnosed with hebephilia are sexually
attracted to children who are between 11-14 years old. Pedophilia on the other hand, consists
of sexual attraction to children who are younger than 11 years old, ephebophilia is the primary
sexual interest in later adolescents, typically ages 15-19 and teleiophilia is a sexual preference
for adults.
Hebephilia is very much distinct than pedophilia because of the sexual interest in pubescent
children, more specific children who are in the first stage of development. Hebephilia is distinct
from teleiophilia as well because the second consists of the sexual interest in fully developed
people (over 19 years old).
Hebephilia is often confused with a sexual interest in teenagers, when in fact the person is
interested in physically immature children who have started to develop secondary sexual
characteristics; meanwhile teenagers who are a little bit older can appear sexually mature but
they are underage for any consent in sexual activity (Eusei D., & Delcea C., 2019).
An interest for older teenagers (aprox 15-17) has been described as “ephebophilie” but its
not considered unusual or biologically abnormal (Hames, Blachard, 2012). On the other hand,
pedophilia and hebephiliac can be viewed as atypical sexual interests (Blanchard, 2010 &
Hames & Blachard, 2012: Seto, 2016, Delcea C., 2019).
In a body of work that was led by Blanchard et al., with a goal for validating hebephilia as
a concept they used a large sample of men for the research. The aim was to show the sexual
interest that some men have in in pubescent children. Therefore, they searched for a connection
between their self-reported interest in children and the size of the penis when representations
of children were shown to them. The final conclusion was that hebephiliac does exist. (p. 347).
Moreover, another study that had the same goal, by Stephens, S (2017) proved the validity
of the concept (Constrachevici L, M., & Delcea C., 2019).
Also, some more research was made and this pattern is very stable over time. (Beier et al.,
2009, 2013; Blanchardetal., 2009; Grundmann et al., 2016). Some other results show that
hebephilia and pedo-telephony are much more frequent than pedophilia. (Studer et al., 2002).
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CONCLUSIONS
Taking into consideration that this disorder is not included in the DSM and academical
opinions are different, establishing the prevalence of the disorder was not possible, neither any
information regarding the development.
REFERENCES
[1] Beier, K. M., Neutze, J., Mundt, I. A., Ahlers, C. J., Goecker, D., Konrad, A., et al., (2009). Encouraging
self-identified pedophiles and hebephiles to seek professional help: First results of the Prevention Project
Dunkelfeld (PPD). Child Abuse and Neglect, 33, pp. 543-549.
[2] Beier, K.M., Amelung, T., Kuhle, L., Grundmann, D., Scerner, G., & Neutze, J. (2013). Hebephilia as a
sexual disorder. Fortschritte der Neurologie Psychiatrie, 81, pp. 128-137.
[3] Blanchard, R. (2009). Reply to letters regarding Pedophilia, hebephilia, and the DSM-V [Letter to the
Editor]. Archives of Sexual Behavior, 38, pp. 331-334.
[4] Blanchard, R., Lykins, A.D., Wherrett, D., Kuban, M.E., Cantor, J.M., Blak, T., et al., (2009).
Pedophilia, hebephilia, and the DSM-V. Archives of Sexual Behavior, 38, pp. 335-350.
[6] Cantor, J.M., Blanchard, R., Christensen, B. K., Dickey, R., Klassen, P. E., Beckstead, A. L., Blak, T.,
& Kuban, M. E. (2004). Intelligence, memory, and handedness in pedophilia. Neuropsychology, 18(1),
pp. 3-14.
[9] Delcea C., (2019). Sexual deviances. Int J Advanced Studies in Sexology. Vol. 1, Issue 1, pp. 64-72.
[10] Franklin, K. (2010). Hebephilia: Quintessence of diagnostic paratextuality. Behavioral sciences & the
law, 28(6), pp. 751-768.
[11] Glueck, B. C, Jr. (1955). Final report: Research project for the study and treatment of persons convicted
of crimes involving sexual aberrations. June 1952 to June 1955. New York: New York State Department
of Mental Hygiene.
[12] Grundmann, D., Krupp, J., Scherner, G., Amelung, T., & Beier, K. M. (2016). Stability of self-reported
arousal to sexual fantasies involving childrenin a clinical sample of pedophiles and hebephiles. Archives
of Sexual Behavior, 45, pp. 1153-1162.
[13] Popa T., & Delcea C. (2019) Voyeurism and Scopophilia. Int J Advanced Studies in Sexology. Vol. 1,
[14] Purec A., Delcea C. (2019) Zoophilia. Int J Advanced Studies in Sexology. Vol. 1, Issue 1, pp. 85-92.
[15] Rind, B., & Yuill, R. (2012). Hebephilia as mental disorder? A historical, cross-cultural, sociological,
cross-species, non-clinical empirical, and evolutionary review. Archives of sexual behavior, 41(4), pp.
797-829.
[16] Stephens, S., Seto, M. C., Goodwill, A. M., & Cantor, J. M. (2017). Evidence of construct validity in
the assessment of hebephilia. Archives of sexual behavior, 46(1), pp. 301-309.
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2.5 Sadism disorder
SEXUAL DEVIANCE. THE SEXUAL SADISM
Abstract
Sexual deviance is in some way a socially constructed phenomenon that shifts over time
with public opinion. The various forms of sexual deviancy are grouped and defined utilizing
the DSM-IV descriptions (American Psychitric Association, 1994), because this clasification
it is the most frequently used in forensic settings. Adult sexual assault is an essential focus of
forensic psychology, variously diagnosed as sexual sadism, paraphilia NOS (not otherwise
specified), or undiagnosed. Other forms of sexual deviance presented here include voyeurism,
exhibitionism, frotteurism, sexual sadism, rape and pedophilia. Each category is briefly
explored through its etiology, course, epidemiology, assessment and treatment (Sbraga, 2004).
Sexual sadism is said to be a disorder in which sexual satisfaction is reached and causing
another suffering, psysical or mental pain through humiliation. In this article, its about
addressing some theoretical aspects regarding the sexual deviance, but also the exemplification
of a parafilic category, namely sexual sadism.
Keywords: sexual deviance, sadism, parafilic category, sexual behaviour
INTRODUCTION
The concept of sexual deviance refers to the nature of sexual behavior that is nonconforming
whit expectations or societal norms, is of maladaptive nature and interferes with the individual
functioning (Laws and O’ Donohue, 1997; Paulauskas, 2012). Sexually deviant behaviors are
identified by one or more of the following standards: degree of consenst, the nature of the
person or object involved in the action, the actual action and body parts that are utilized, the
setting in which the bahavior is performed. In clinical literature sexual deviance is referred to
as Paraphilia and manifests itself as a disorder characterized by recurrent, intense sexually
arousing fantasies, sexual urges or behaviors involving nonhuman objects, suffering and
humiliation of oneself or one’s partner, children and other nonconsenting persons. A period of
six months lasts these fantasies, bahaviors or urges, and they cause distress or interpersonal
difficulties (DSM –IV – TR, 2000; Paulauskas, 2013).
Sexual deviance encompasses a wide spectrum of sexually aberrant behaviors and ranges
from exhibitionism, fetishism, voyeurism, pedophilia, to incest and sadistic rape at the extreme
end. Many researchers, clinicians and law enforcement representatives consider these
behaviors as a major mental health and criminal justice problem. Other terms related to sexual
deviance include: sexually abnormal behavior, sexual perversion, sexual assault, and sexual
offending; however, their meanings are not identical and the terms are often used in different
contexts (Paulauskas, 2013).
According to the classification made by J. Gagnon and W. Simon (1967), there are three
types of sexual deviance, depending on the magnitude of the deviation and the degree of
tolerance manifested by the community.
Normal sexual deviance, including behaviors, acts or preferences characterized by a low
correspondence between social rules, legal prescriptions and the behaviors of individuals (the
case of masturbation, pre-marital sexual relations, oral sex, etc.), practices that have become
permissive behaviors and tolerated, given their private character which does not come into open
conflict with moral, medical or legal requirements. Moreover, in a functionalist conception,
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such acts, are considered to have a beneficial character for the society, given that they fulfill
numerous social functions with a “sublimation” character. The “normal” sexual deviance is,
from this point of view, a kind of “neutral deviance” that does not affect either society or
individuals, having the ability to orient biological impulses to socially desirable paths.
The pathological sexual deviance takes into account those cases where there is a high
correspondence between the social norms, the legal prescriptions and the behaviors of the
individuals. Following the predominantly individual character of this form of deviance, its
labeling is based, rather, on the invocation of medical criteria rather than social or cultural
norms. For example: rape, incest and pedophilia acts.
Group sexual deviance occurs when the sexual behaviors of individuals are associated with
the norms and values of distinct subcultures, which is why it is also called “subcultural”
deviance. These subcultures are characterized by a double status: on the one hand, they are
stigmatized and marginalized in relation to the domination of the legitimate sexual culture, on
the other hand, within their individuals they acquire security and their full identity. The most
relevant examples of subcultural deviance are mentioned, prostitution and homosexuality,
which imply different or alternative forms of organization, behavior, norms and values
compared to those of “legitimate” forms of sexuality.
According to the secretive, immoral and criminal nature of most sexually deviant behaviors,
the actual extent and prevalence of this phenomenon is really unknown. Among the most
common paraphilic acts commited by sex offenders are child molestation, rape, exhibitionism
and voyeurism (Abel et al., 1987).
The deviant sexual phenomena have to be present over a period of at least six months in
order to meet criteria for one of the following nine paraphilic categories: exhibitionism;
pedophilia; fetishism; frotteurism; sexual masochism; sexual sadism, transvestic fetishism and
voyeurism (Saleh and Berlin, 2008).
John Money (1984) identified over 32 different and distinct paraphilias. Based on the
phenomenological feature, he defined six subtypes of paraphialias, such as: the sacrificial; the
predatory; the mercantile; the fetish; the eligibility and the allurement.
Sexual sadism: definition, etiology, assesment and treatment

Sexual sadism is an extracting sexual pleasure from causing pain to another living being.
From (1977), describe sadism as the drive to have absolut control over another person or
animal. Sadism is commonly seen in individuals with additional paraphilias. The study from
Abel et al., (1988), found that 18% of their sample of sex offender sadists were also
masochistic, 46% had raped, 21% had exposed themselves, 25% are engaged in voyeurism,
25% had engaged in frotteurism and 33% are engaged in pedophilia. The collected data on 30
sexual sadists by the FBI show their most interesting findings that include a percent of their
sample with a history of 43% of homosexuality, more than 50% had no prior criminal record
and 50% had a history of drug abuse after alcoholism (Dietz, Hazelwood and Warren, 1990).
Dietz and his colleagues also found these men to be profoundly narcissistic. Although some
sadists appear to stay within the realm of consensual sadomasochistic activities with a
masochistic partner (Hucker, 1990), others seem to thrive on inflicting pain on a non-
consenting person.
Etiology
Report data show a number of 75% sadistic males declarations that they have been aware of
their deviant interests prior to adulthood (Breslow, Evans and Langley, 1985; Spengler, 1977).
On the other side, according to Scott (1983), sadistic females tend to become involved in
the behaviors through adult relationships with masochistic men, discovering pleasure in sadism
through its practice.
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In the literature there are three theories regarding sexual sadism, namely: psychoanalytic,
behavioral and biological theories.
In the psychoanalytic theory, Freud (1961) affirms that sadism originates when a child
misinterprets sex as a painful by observing his parents having sexual relations. Behavioral
theory is about: conditioned sexual arousal followed by masturbation and sexual fantasies that
are reinforced encapsulates behaviorist thought on the basic origins of sadistic behavior
(McGuire, Carlisle and Young, 1965).
Biological theory: It has been hypothesized that neurological abnormalities may be
responsible for sexual sadism. Several studies have found mild associations between sadism
and temporal lobe abnormalities (Graber et al., 1982; Hucker et al., 1988; Gratzer and
Bradford, 1995). It seems possible that these abnormalities could also be the result of
physiologically and psychologically painful sex or an unidentified third variable. Other studies
have examined hormonal differences between sexual sadists and controls without finding any
significant differences (Bain et al., 1987).
Assesment
According to Holmes and Holmes (1994) to understand what elicit and maintain sexual
sadism involves assessing four major areas. These four areas include having fantasies about
inflicting pain, being attached to an inanimate object or part of the body, engaging in ritualism
that focused on the suffering of others and they feel a compulsion to act out sadistic fantasies.
Some of this information may be gathered through the self-report of the psychological
testing and the perpetrator, while plethysmography and using of the records reviews,
particularly accounts of the crimes provide a useful data (Sbraga, 2003).
Psychological tests that may have investigative or treatment utility with sexual sadists are
those that include both sexual and aggressive factors. This instrument: Sexual aggression scale
(ASA) (Malamuth, 1989) and the Multidimensional assessment of sex and aggression (MASA)
(Knight, Prentky and Cerce, 1994) have the strongest psychometric properties. The ASA was
designed to measure the appeal of sexual aggression. All scales have an internal consistency
ranging from .78 to .92 with high test-retest reliability. The MASA was designed to measure
aggressive and sexual fantasies, cognitions, and behaviors. The internal consistency is in the
acceptable range, with all scales at least .60 and 89 percent of them higher than .80. Test-retest
reliability is also acceptable (Sbraga, 2003).
Fedora, et al., (1992) found a distinctive phallometric profile for sexual sadists. Sexual
sadists in their study became sexually aroused to slides of nonsexual violence against fully
clothed women, unlike comparison participants. In addition to finding a distinct pattern of
responding that corresponds to physical violence against women, a separate sadistic profile
demonstrates deviant arousal to the domination and humiliation of women (Thornton, 1993;
Sbraga, 2003).
Treatment
Treatment objective for sexual sadists include controlling deviant sexual arousal, increasing
victim empathy, modifying cognitive distortions, and increasing social competency and
balance in the lifestyle (Sbraga, 2003).
Techniques for modifying deviant sexual arousal include electroshock, olfactory aversion,
covert sensitization, vicarious sensitization, masturbatory satiation and reconditioning, and
chemical castration (Sbraga, 2003).
Victim empathy training includes elements such as: meeting with victims of sexual
aggression, hearing audiotaped 911 calls from frantic victims, watching videos of victims
describing their experiences, writing unsent letters to victims, and discussing personal
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victimization experiences while relating one’s experience to the experience of other victims
(Sbraga, 2003).
Changing cognitive distortions involves the identification of distorted thinking and issuing
challenges to those thoughts, typically in a group therapy format. Increasing social competency
may mean different skills, training for different offenders based on individual deficits. Some
offenders may be inept in general communication. Others may have problems with
assertiveness, intimacy, or anger (Sbraga, 2003).
Lifestyle balance also implies different needs for different offenders. Some offenders have
problems with substance abuse, and others do not. Others may need treatment for other types
of unbalanced behavior that establishes or maintains their deviance, such as viewing
pornography, gambling, or isolating themselves from others. Established adjunctive treatments
may be necessary to meet the unique needs posed by a particular presentation of sexually
deviant behavior (Sbraga, 2003).
CONCLUSION
Sexual deviations are defined as sexual behavior disorders that can take many forms. These
disorders are classified into three groups: deviations regarding the partner’s choice, disorders
related to a seduction behavior and the sexual act itself. People with deviant sexual behavior
usually use sex to get rid of other problems, such as loneliness, depression, anxiety or stress.
They can continue to engage in risky sexual behaviors, despite the fact that serious
consequences can occur, such as health problems, sexually transmitted diseases or loss of
relationship. Affected persons require medication or psychological treatment, especially when
sexual disturbances harm others, such as pedophilia, sexual sadism.
in the public, commercial, or not-forprofit sectors.
REFERENCES
Law, 16, pp. 153-168.
[2] Abel, G.G., Becker, J.B., Mittelman, M., Cunningham-Rathner, J., Rouleau, J.L., & Murphy, W.D.,
3-25.
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21, pp. 72-94.
Press.
26-49.
38(2), pp. 164-179.
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SEXUAL SADISM DISORDER
Abstract
Sexual sadism is defined as intense and recurrent sexual arousal as a result of the physical
or psychological suffering of a person who does not consent to such acts. In order to meet the
SSD diagnostic criteria, the person concerned must have acted according to, or be strongly
affected by, sadistic fantasies or impulses (DSM-V, APA, 2013). Although it is one of the
paraphilia that has received the most interest in the scientific area, the disorder of sexual sadism
is a controversial subject and an underdiagnosed paraphylic disorder.
Keywords: Sexual sadism, paraphilic disorders, DSM V
INTRODUCTION
Until recently, sexual sadism was considered a strictly limited phenomenon in the criminal
field, the prevalence of SSD among the samples of sexual offenders being of 2-30%. This
phenomenon is also present in the non-criminal population (Foulkes, 2019). From a sample of
367 men aged 40-79, 21.8% reported having sadistic sexual fantasies (Ahlers, 2011). Most
people in the non-criminal population underreport such sadistic fantasies due to the high
implications from the legal and social context (Balon, 2016). However, sexual sadism is
predominant in men, being strongly associated with antisocial behaviors (Balon, 2016).
There is also a high lack of consensus regarding the components of sexual sadism (O’Meara,
Davies, Hammond, 2011). Most researchers accept that people with SSD feel pleasure from
the suffering they cause to their victims (Chester, DeWall, & Enjaian, 2018; Pfattheicher,
Keller, & Knezevic, 2019). A new line of research highlights the fact that engaging in sadistic
sexual behaviors is precipitated by dominance and power felt, the motivation being not so
strictly justified by pleasure (O’Meara et al., 2011; Plouffe, Saklofske & Smith, 2017).
SSD’s most popular indirect metasures include: The Varieties of Sadistic Tendencies
(VAST; Paulhus, Jones, Klonsky, & Dutton, 2011), The Comprehensive Assessment of
Sadistic Tendencies (CAST; Buckels, 2018), The Short Sadistic Impulse Scale (SSIS; O’Meara
et al., 2011), The Assessment of Sadistic Personality (ASP; Plouffe, Smith, & Saklofske,
2018), The Sadomasochism Checklist (Weierstall & Giebel, 2017). These tools are mainly
limited by the self-report method. In the case of direct measurements, the phalometric
evaluation (plethysmography of the penis) is used (Delcea C., 2019). This technique measures
the level of sexual arousal while the subject is presented various sexual events in which the
victim’s consent level, constraints and level of violence are manipulated (Balon, 2016). The
main objective of the treatment of sexual sadism is to control the impulses, fantasies and
associated behavioral tendencies, as well as to reduce the level of distress associated with these
symptoms (Constrachevici L, M., & Delcea C., 2019). Pharmacological intervention is the first
line of treatment in the case of severe sadistic disorders. There are three main classes of drugs
used to treat this condition: SSRI (fluoxetine; sertraline; fluvoxamine); antiandrogens
(medroxyprogesterone; cyprotonone); GNRH analogues (tryptorelin; leuprorelin). Drug
treatment is enhanced by psychotherapeutic treatment, in which the risk factors for future
criminal behavior are targeted, including relationship difficulties, poor self-regulation or
deviant sexual concerns (Balon, 2016).
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CONCLUSIONS
We can identify a number of major problems within SSD, namely: (a) the lack of a definition
that has high clinical utility; (b) poor identification of people with sexual sadism in the non-
criminal population; (c) non-specific treatment, guided by the treatment of sexual paraphilias
in general; (d) lack of consensus on SSD origins (Balon, 2016; Foulkes, 2019). To truly
understand the motivations behind TSS and to create specific treatments it is vital to consider
all of the above issues (Foulkes, 2019).
REFERENCES
[1] Ahlers, C. J., Schaefer, G. A., Mundt, I. A., Roll, S., Englert, H., Willich, S. N., & Beier, K. M. (2011).
How unusual are the contents of paraphilias? Paraphilia-associated sexual arousal patterns in a
community-based sample of men. The Journal of Sexual Medicine, 8, pp. 1362-1370. https://doi.
org/10.1111/j.1743-6109.2009.01597. x.
[2] American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-
[3] Balon, R. (Ed.). (2016). Practical guide to paraphilia and paraphilic disorders. Springer.
[5] Buckels, E. E. (2018). The psychology of everyday sadism. University of British
Columbiahttps://doi.org/10.14288/1.0369056 Retrieved from.
[6] Chester, D. S., DeWall, C. N., & Enjaian, B. (2018). Sadism and aggressive behavior: Inflicting pain to
feel pleasure. Personality and Social Psychology Bulletin014616721881632.
https://doi.org/10.1177/0146167218816327.
[9] Foulkes, L. (2019). Sadism: Review of an elusive construct. Personality and Individual Differences, 151,
109500.
[10] Joyal, C. C., & Carpentier, J. (2017). The prevalence of paraphilic interests and behaviors in the general
population: A provincial survey. Journal of Sex Research, 54, pp. 161-171. https://doi.
org/10.1080/00224499.2016.1139034.
[11] O’Meara, A., Davies, J., & Hammond, S. (2011). The psychometric properties and utility of the Short
Sadistic Impulse Scale (SSIS). Psychological assessment, 23(2), p. 523.
[12] Pfattheicher, S., Keller, J., & Knezevic, G. (2017). Sadism, the intuitive system, and antisocial
punishment in the public goods game. Personality and Social Psychology Bulletin, 43, pp. 337-346.
https://doi.org/10.1177/0146167216684134.
[13] Plouffe, R. A., Saklofske, D. H., & Smith, M. M. (2017). The assessment of sadistic personality:
Preliminary psychometric evidence for a new measure. Personality and individual differences, 104, pp.
166-171.
[14] Plouffe, R. A., Smith, M. M., & Saklofske, D. H. (2018). A psychometric investigation of the
Assessment of Sadistic Personality. Personality and Individual Differences.
https://doi.org/10.1016/j.paid.2018.01.002.
[15] Weierstall, R., & Giebel, G. (2017). The Sadomasochism Checklist: A tool for the assessment of
sadomasochistic behavior. Archives of Sexual Behavior, 46, pp. 735-745.
https://doi.org/10.1007/s10508-016-0789-0.
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SEXUAL SADISM
Abstract
However, in this review paper, I use the narrower definition of sadism – that it is the
experience of the hedonic value of cruel and antisocial acts – for three reasons. First, the
experience of pleasure appears in all definitions of sadism, while the motivation for power is
included only in some of them. Second, in works describing the Dark Tetrad (i.e., psychopathy,
Machiavellianism, narcissism, and sadism), the pleasure of cruelty is what defines sadism, not
the desire for power. Third, it is difficult to say definitively that someone who acts cruelly to
gain power over someone also does not experience pleasure. In other words, even if an
individual can report a motivation to gain power over an individual, this may be because he/she
considers power to be pleasurable – which means that the ultimate motivation could still be
pleasure.
Keywords: sadism, paraphilic disorders, forensic psychology
INTRODUCTION
Sadism is a personality trait, broadly defined as the tendency to experience pleasure because
of other people’s physical or psychological suffering (e.g., O’Meara, Davies, & Hammond,
2011). Sadistic traits are continuously distributed in both community samples (Buckels, Jones
and Paulhus, 2013) and forensics (Mokros, Schilling, Weiss, Nitschke and Eher, 2014) and
range from the pleasure of the embarrassed to the pleasure to commit torture and murder
(MacCulloch, Snowden, Wood, & Mills, 1983). It is undeniable and not surprising that people
with high levels of sadistic traits are more likely to behave antisocially. These individuals enjoy
being cruel to others, so they are more likely to behave in this way, both online and offline. In
this narrative review, I provide an overview of the key issues in sadism research to date and I
discuss the questions that remain unanswered (Cronin, Ryan, & Coughlan, 2008; Ferrari, 2015;
Green, Johnson, & Adams, 2006). I discuss about the scales that were developed to measure
sadism, the exact role it might play in antisocial behavior, and its association with other
malevolent personality traits. I consider where, if it is anywhere, sadism should appear in
Diagnostic and Statistical Manual of Mental Disorders (DSM; American Psychiatric
Association, 2013). Over time, I also discuss sexual sadism, a variant of sadism defined as
sexually aroused derived from the pain or suffering of others.
Defining and measuring sadism

Defining and measuring “everyday” sadism. Until relatively recently, sadism was
considered a forensic phenomenon. Most research on sadism has been conducted in the forensic
environment, especially focusing on sex crimes (Mokros, 2014). More recently, however, there
has been a recognition that sadistic traits exist outside this framework, a phenomenon called
“everyday sadism,” in an attempt to distinguish it from sadism in the context of sex or crime
(Buckels et al., 2013). The introduction of this concept of non-legal, non-sexual sadism has
been helpful, as these traits clearly exist in community samples (e.g., O’Meara 2011).
Researchers disagree on how everyday sadism should be defined. It is undeniable that
sadism is about deriving pleasure from the physical or psychological suffering of others
(Baumeister & Campbell, 1999; Buckels et al., 2013; Chester, DeWall and Enjaian, 2018;
Meloy, 1997; Pfattheicher, Keller and Knezevic, 2019), but some researchers suggest that
sadism does not refer exclusively to pleasure. These researchers argue that people with sadistic
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traits engage in cruel behavior either because they enjoy it or because they want to exercise
finance or power over others (O’Meara et al., 2011; Plouffe, Saklofske, & Smith, 2017).
However, in this review paper, I use the narrower definition of sadism – that it is the
experience of the hedonic value of cruel and antisocial acts – for three reasons. First, the
experience of pleasure appears in all definitions of sadism, while the motivation for power is
included only in some of them. Second, in works describing the Dark Tetrad (i.e., psychopathy,
Machiavellianism, narcissism, and sadism), the pleasure of cruelty is what defines sadism, not
the desire for power. Third, it is difficult to say definitively that someone who acts cruelly to
gain power over someone also does not experience pleasure. In other words, even if an
individual can report a motivation to gain power over an individual, this may be because he/she
considers power to be pleasurable – which means that the ultimate motivation could still be
pleasure. Therefore, in this review, I consider that sadism is characterized by the hedonic value
of being cruel to others, but I also notice the impact of the debate around this definition. A
number of scales were developed to measure daily (i.e., non-forensic, non-sexual). The
development of these measures has been useful, as they have shown that sadistic tendencies
clearly exist in the Community samples. However, some scales have not yet been evaluated by
colleagues, and others do not report all psychometric properties. In addition, these measures
differ from each other in a number of significant ways, which means that the exactly measured
phenomenon differs from one scale to another. Here I give an overview of these measures and
how they differ. The first distinction between measures is the extent to which they delimit the
subtypes of sadism. Varieties of sadistic tendencies (VAST; Paulhus, Jones, Klonsky, &
Dutton, 2011), for example, makes a distinction between indirect and direct sadism. The
comprehensive assessment of sadistic tendencies (CAST; Buckels, 2018) further divides direct
sadism into verbal (psychological) and physical sadism. In contrast, other measures contain
elements related to these different elements, but are scales with a single factor: Short scale of
sadistic impulse (SSIS; O’Meara et al., 2011), negative subscale of social potency of the social
reward questionnaire (SRQ; Foulkes, Viding, McCrory, & Neumann, 2014), the average
subscale of Short Tetrad Dark (SD4; Lance 2018).
Distinct subtypes of sadism may have significantly different associations with external
correlations, for example, direct sadism may be more clearly associated with antisocial
behavior – so this is an important issue to solve. A similar point is that everyday sadism covers
the pleasure of both physical and psychological harm, but with the exception of CAST, most
measures contain elements that do not distinguish the two (for example, “I hurt people for my
own pleasure”; O’Meara et al., 2011). The structure of CAST factors indicates that
psychological and physical sadism are distinct phenomena and this may be important: for
example, physical sadism may be relatively less common in Community samples or may have
different consequences. It would be beneficial if future scales used elements that clearly
distinguish these two types, as is done in CAST: for example, “I like to make jokes to the
detriment of others” (psychological), “I like to physically hurt people” (physically; Buckels,
2018). The second difference between the scales of sadism is the extent of the overlap with
other malicious personality traits. For example, the SRQ Negative Social Potency subscale has
only one element (“I like to be nice to someone only if I earn something from it”; Foulkes et
al., 2014), which is more characteristic of Machiavellianism than sadism. SD4, although short,
should be praised for its attempt to design elements of sadism that are deliberately less
correlated with other features of the Dark Tetrad – in others. This is probably a consequence
of the conciseness of the scale, rather than any definitive evidence that sadism is a one-
dimensional construct.
The authors deliberately tried to capture what is unique about sadism (Paulhus et al., 2018).
Sadism is clearly linked to other dark personality traits (with SD4, the correlation
coefficients between sadism and the other Dark Tetrad scales are still 0.21-0.51), so the design
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of articles without any association would be unrealistic and inaccurate. However, this attempt
to minimize at least the overlap with other features is important. A broader problem is that most
scales contain at least one ambiguous article, i.e., an element that does not clearly measure
sadism or another feature of the Dark Tetrad. For example, the Short Scale of the Sadistic
Impulse includes the element “Sometimes I get so angry that I want to hurt people.” (O’Meara
et al., 2011) It is more about regulating emotions or aggression than sadism (Buckels, 2018) In
others, the exact motivation is unclear, for example, the VAST element “I never said significant
things to my parents” (reverse score; Paulhus et al., 2011) could be approved for several
reasons unrelated to sadism. In SD4 (Paulhus et al., 2018), the article “I know how to hurt
someone with just words” could be approved by a person who knows that he/she has the ability
to upset others (as everyone else does), but who would not necessarily engage in or enjoy that
behavior.
Sadism in DSM
It has been debated for many years whether sadism and sexual sadism should appear as
psychiatric disorders in the DSM (Handbook of Diagnosis and Statistics of Mental Disorders;
American Psychiatric Association, 2013). Here I discuss the history of two such entries:
Sadistic Personality Disorder and Sexual Sadism Disorder.
Sadistic personality disorder

A Short-Term Diagnosis, A sadistic personality disorder (SPD) is not recognized as a mental
disorder in the current (fifth) version of the DSM (American Psychiatric Association, 2013),
but it briefly appeared in the previous DSM. III-R, in an appendix entitled “Proposed diagnostic
categories that require further study” (American Psychiatric Association, 1988). It was
included because forensic psychiatrists found that some patients exhibited a pattern of cruel
behavior towards others that seemed to be driven by pleasure and that this was not adequately
covered by the criteria for other personality disorders (Fiester and Gay, 1991). The focus of
their observations was not on sexual offenses, but rather on offenses such as domestic abuse,
assault, and crime (Fiester & Gay, 1991). However, there were a number of issues with the
category proposed by the SPD, which means that it never progressed beyond that version of
the DSM. First, there was concern, even if sadism was not adequately captured in existing
disorders, that SPD was not a distinct disorder in itself. This was due to high rates of
comorbidity with other disorders, especially narcissistic and antisocial personality disorders
(Fiester & Gay, 1991). From the literature to the present, it seems sadism is most likely a feature
that is sometimes present alongside other personality disorders, but it is not a distinct disorder
in itself (Fiester & Gay, 1991). Other issues related to the creation of a diagnostic category of
SPD were more about the consequences of labeling a person with SPD, with two seemingly
opposite concerns. On the one hand, critics were concerned that a diagnosis of SPD could be
unjustly stigmatizing; for example, there has been concern that patients with this label may be
more at risk of abuse by prison officers (Spitzer, Feister, Gay, & Pfohl, 1991). On the other
hand, there was concern that a diagnosis of SPD could be misused in the legal system,
improperly reducing criminal liability and allowing “The medicalization of evil” (Spitzer et
al., 1991). For all these reasons, the category proposed by the SPD has never appeared beyond
the third version of the DSM.
Sexual sadism as a paraphilic disorder

A sadistic disorder appears in DSM-5: Sexual Sadism Disorder (SSD), which is used
primarily in the forensic environment in an attempt to identify a distinct group of sex offenders.
In DSM-5, SSD appears under the category Paraphilic Disorders – disorders centered
around sexual arousal to deviant stimuli or scenarios. For a diagnosis of SSD, a person must
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have experienced recurrent and intense sexual fantasies related to the pain or suffering of others
or engaged in actual sadistic sexual behavior with a person who disagrees. Keep in mind that
for a person to qualify as having a paraphilic disorder, such as SSD, rather than just a deviant
sexual interest, the interest must have negative consequences for either the person themselves
(e.g., such intense or frequent fantasies that causes suffering or disrupts daily functioning) or
for society at large (e.g., harmful or criminal behavior; First, 2010). These criteria separate
sexual sadism as a pathology from the less frequent or more intense fantasies or consensual
behavior of sexual sadism, which should not be considered clinical problems.
The role of sadism in antisocial behavior

It is interesting to note that a sadistic behavior – acting after sadistic fantasies – is not
necessary to obtain a diagnosis of SSD. Similarly, the definitions of sexual and non-sexual
sadism center around the hedonic value of the suffering of others, rather than an individual’s
tendency to cause such suffering. However, a basic principle of psychology is that people are
likely to seek out and repeat behaviors that are rewarding for them (Berridge & Robinson,
2003) – and indeed, it could be argued that individuals can only report how much they enjoy a
behavior if they have tried it themselves. Therefore, it is obvious that people with high levels
of sadistic traits are also more likely to cause suffering to others. In the next section, we discuss
the existing evidence that sadistic traits are associated with a range of antisocial behaviors,
including harmful sexual behavior.
The role of sadism in antisocial behavior

Some questions remain about the relationship between sadism and antisocial behavior. First,
the role of sadism should be investigated in non-sexual offenses: the vast majority of forensic
sadism research has only assessed sexual offenses. Second, we need to identify the extent to
which sadism affects criminal behavior toward others known predictors. Many criminals show
no signs of sadism, so it is clear that this is not a necessary precondition for crime to take place
(Beech, Ward, & Fisher, 2006; Seto, 2017). It is also not enough: many people have sexual
fantasies about sadism, but do not adopt them with individuals who do not accept (Jozifkova,
2013). For a sadistic sexual crime to occur, sadism should be associated with other deficiencies,
such as reduced self-control, either chronic or temporary (Seto, 2017). However, up to this
date, the relationship between these risk factors and how they predict crime has not been clearly
quantified. For example, do sadistic traits and low self-control have additive or interactive
effects on the type or frequency of crimes? The relationship between anger and sadism in
motivating crime is also unclear: some research has shown that sadistic offenders have
generalized feelings of anger and resentment towards others (Beech et al., 2006), while others
have argued that sadism and anger are two distinct types of motivations that do not tend to co-
occur (Robertiello and Terry, 2007). In short, it remains unclear what defines a crime motivated
by sadism, how these crimes differ from non-sadistic crimes, and the extent to which the
presence of sadism predicts antisocial behavior above and beyond other predictors of such
behavior.
Case study
Case data
Philip, 38, is in a BDSM relationship with 25-year-old Amanda. According to Philip, their
relationship is consensual. They are very open about being in a BDSM relationship, despite the
disapproval of their families and friends.
Five months after their relationship, Philip took Amanda to the hospital where she was
hospitalized due to serious bodily injuries. The nurses reported that she had bruises on her legs
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and heavy falls on her back, as well as a minor injury to her head and swollen wrists. The nurses
also noticed that some bruises appear to be older than others, which means that they are the
result of previous incidents. Despite Amanda claiming that her injuries were the result of her
and Philip’s consensual sexual activities, the nurses reported Philip to the police because of
their suspicion of domestic violence.
During his interview with the police, Philip also claimed that his and Amanda’s sexual
activities were consensual and that Amanda’s injuries were the result of BDSM habits. Police
decided to send him to a sexologist who diagnosed him through penile plethysmography with
sexual sadism disorder.
Philip told authorities he had two similar relationships with BDSM in the past. He claims
that all his sexual experiences with these partners were consensual. Philip’s family and friends
suspected that Philip’s previous relationships had ended because Philip’s sexual habits were
“too intense” and “aggressive.” None of Philip’s previous friends were hospitalized.
In Philip’s case, I argue that his behavior is sexual sadism compared to domestic abuse and
that, despite ambiguity, he is not morally responsible for his actions.
To begin with, I believe that there are clear distinctions between domestic abuse and sexual
sadism, and that Philip’s actions clearly fall into the latter category. Domestic violence can be
defined as “a pattern of abusive behavior in any relationship that is used by a partner to gain or
maintain power and control over another intimate partner” (“Domestic Violence”, 2016). More
specifically, domestic sexual abuse in the family is defined in part by the use of coercion and
lack of consent (“Domestic Violence”, 2016).
Meanwhile, sexual sadism, at least theoretically, often involves the consent of the partner
and is done to achieve sexual arousal (although the means to do so and some pleasure can be
derived from the feeling of control over the partner) (Comer, 2014). Therefore, I see critical
differences between family abuse and Philip’s sexual sadism: his actions had the ultimate
intention of sexual arousal and, more importantly, were consensual. In addition, the fact that
Philip and Amanda are so open about their BDSM relationship with friends and family further
discourages the belief that it was domestic abuse. There is also insufficient information and
evidence to show that this was a case of domestic abuse.
Despite being diagnosed with sexual sadism disorder, Phillip is largely unclear whether or
not he is morally responsible, as defined by Joel Feinberg’s criteria in “What’s So Special
About Mental Illness?” Feinberg argues and agrees that an individual is less morally
responsible if he has uncontrollable coercion, an inability to identify motivations and irrational
in his behavior, to name the central criteria (Feinberg, 1970). Based on the limited information
provided, it is unclear whether Philip’s sadism was completely uncontrollable. An indication
that he was at least in a controllable part is that all of his BDSM sexual experiences were
consensual. Again, many people with sexual sadism disorder participate in such behavior in a
consensual relationship (Comer, 2014). More convincingly, it is possible to deduce that he was
diagnosed with a disorder indicating perhaps that his sadistic lifestyle is not on his own
initiative. This could enhance Feinberg’s argument that his behavior is more forced than freely
interpreted (Feinberg, 1970).
Although the extent of Philip’s moral responsibility according to Feinberg’s views is
generally ambiguous, the above details push his case toward the lesser end of that
responsibility.
In addition to Philip’s lower potential for moral responsibility within Feinberg’s criteria, I
believe that the fact that his and Amanda’s BDSM relationship is consensual goes beyond any
potential ambiguity and absolves Philip of moral responsibility. I trust that both Philip and
Amanda are sincere when they say that their relationship is consensual. Of course, it may not
be, but I see no evidence to prove this. As such, although I think it’s unfortunate that Amanda
was hurt so badly, I don’t think Philip should be morally responsible for such actions and results
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if Amanda agreed (and continued to claim to her detriment that she was consensual). Therefore,
I see Philip as a sexual sadist (and not as a domestic aggressor) who, because of the consensual
nature of his BDSM relationship, has no moral responsibility for the harm that has occurred.
Therapeutic techniques
The main treatment approach to behavioral therapy for paraphilias is to eliminate the pattern
of sexual arousal to deviant fantasy by assisting the patient with decreased inappropriate sexual
arousal. A variety of techniques that have been used have been reviewed by Marshall w. Laws.
Some of these will be described here: Covered Awareness: This is a method that has been
used effectively to disrupt fantasies and behaviors that are antecedents of offensive behavior.
It pairs the urges and feelings that cause a person to engage in an ant-act deviation with
aversive images that reflect the opponent’s consequences of continuing with deviant behavior.
This treatment is performed by administering the patient’s tape-recording session in private.
A therapist then reviews it and provides feedback to both people or group sessions. This
technique was used to slowly treat the exhibitors. Satiety: Masturbation satiety is a technique
that is effective in reducing deviant sexual arousal through boring deviant fantasy. This therapy
consists of making the patient masturbate at home in private to the non-deviant adult fantasies
until ejaculation has taken place. Satiety works by deviant fantasy sexual association with the
aversive task of masturbating for 55 minutes after orgasm. These sessions are audio recorded
at home and brought to therapy sessions where the cassettes are reviewed and criticized.
Several studies have supported the value of this technique. Systematic desensitization: This
is a technique that aims to reduce maladaptive anxiety by pairing relaxation with imagined
scenes that present anxiety producing situations. Therapists helped the client implement
strategies to address concerns about their negative thoughts, inhibited or hyperactive behaviors,
painful emotions, and difficulty adjusting uncomfortable physiological arousal.
Approach In my opinion the use of therapeutic methods are the best solution to help the
client in question (Philip) because they help him to cope with the traumas experienced and give
him a way to change his behavior, I think this way is the best because in combating the
problems, the human status of the person in question must be taken into account, I consider
that the use of medical methods by using different substances is not allowed to be a priority to
the therapeutic treatment because they only “solve” the “outer”, not the “inner” problem.
CONCLUSION
Most individuals enjoy seeing and provoking the happiness of others (e.g., Foulkes et al.,
2014). However, a wide body of research now demonstrates the existence of sadism: a
personality trait characterized by deriving pleasure from the pain and suffering of others.
Sadism is clearly associated with elevated levels of antisocial behavior, from cyber
aggression to rape and murder. Future research should address a number of issues relevant to
both sexual and non-sexual sadism. Hedonic pleasure that is unique to sadism must be
highlighted and isolated in a safe measure; the relationship between sadism and other
antagonistic personality traits should be examined; and the role that sadism plays in antisocial
behavior, relative to other variables, such as poor self-control, should be assessed. Finally, the
field should address where sadism comes from – its history of development and whether
anything can be done to prevent or treat it. To truly understand the motivations behind
antisocial behavior, it is vital to consider sadism and recognize that some people are actively
engaged in these behaviors because they enjoy them. According to the studies of Siserman C.,
Giredea C., Delcea C., (2020) and Delcea C., Siserman C., (2020) we can argue that future
research must bring new discoveries.
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PSYCHODYNAMIC FORMULATIONS OF PARAPHILIAS
Abstract
Therapists need to deal more and more with issues involving patients that engage in
compulsive sexual behaviour or paraphilias. For the purpose of this article, I would like to
explore the psychodynamic perspective on paraphilias or perversions as they are referred to in
the psychoanalytic literature.
Keywords: perversion, psychoanalytic formulations, voyeurism, paedophilia
INTRODUCTION
Freud’s The Three Essays on the Theory of Sexuality (1919) is a landmark in the way we
perceive sexuality. The Victorian morals of the day looked at sexuality as beginning only at
puberty and the general public refused to accept that children were anything else than innocent
and pure.
It was unthinkable that they have wishes, pleasure and fantasies and the idea that some of
these fantasies might be connected to their parents was simply unacceptable.
One hundred years later it is a fact accepted by the majority of clinicians that the root of
many of our socio-emotional and sexual problems have their origin in early childhood and in
the psycho-sexual development stages that humans so through.
There are a lot of varieties of sexual behaviours in which people engage and that they bring
into their personal therapies. The most common sexual fantasies and activities focus on a
limited range of desires and behaviours but there are also certain types of atypical sexual
preferences and behaviours. When these typical sexual behaviours become problematic, they
are referred to as perversion.
This term was changed starting with DSM – 3R in 1987 when homosexuality, oral and anal
sex were taken out from the perversion category and the name was changed from perversion to
the more stigma free paraphilia (“para” – deviant, “philia” – attraction).
Stoller, who wrote in depth about perversion, notes that the changing of the name is an
attempt to “sanitize” perversion. However, in his opinion the word perversion has more useful
connotations because it has a long history of connectedness with morality and thus with sin. In
his writing he stresses out that the feeling of transgression is key in order produce arousal and
orgasm in perverse behaviour. Both points of view have their merits so in this article I will use
the terms interchangeably.
DSM-5 classification of paraphilias

In DSM-5 the term paraphilia is defined as “any intense and persistent sexual interest other
than sexual interest in genital stimulation or preparatory fondling with phenotypically normal,
physiologically mature, consenting human partners.” Paraphilias, however, may not
necessarily classify as “intense and persistent” but rather preferential sexual interests or sexual
interests that are greater than nonparaphilic sexual interests.
The addition of the word “disorder” to the classification of paraphilias is new to DSM-5 and
is meant to indicate a paraphilia that is causing distress or impairment to the individual or a
paraphilia whereby satisfaction entailed personal harm, or risk of harm, to others. This
distinction was made in an effort to identify those sexual behaviours and interests that are of
clinical significance.
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To be diagnosed with a paraphilic disorder, DSM-5 requires that people with these interests
feel personal distress about their interest, not merely distress resulting from society’s
disapproval. Another criterion is to have a sexual desire or behaviour that involves another
person’s psychological distress, injury, or death, or a desire for sexual behaviours involving
unwilling persons or persons unable to give legal consent.
When classifying these behaviours, a distinction could be made between disorders of sexual
preference and gender identity disorders. The first group refers to sexual paraphilias and
disorders that contain fixed, repetitive behaviour, involving unusual sexual stimuli that can
involve potential harm to the self or others, and we are referring here to fetishism,
exhibitionism, voyeurism, frotteurism, masochism, sadism and paedophilia. In the category of
gender identity disorders, we are referring to transvestism and transsexualism (referred to as
gender dysphoria).
Psychoanalytic view on perversion

The Freudian view on perversion points out that there is a perverse core in all of us, and that
at the centre of perversion lies the castration anxiety that the young male needs to recognize
and negotiate if he is to have any chance of identifying with his father and arriving at a mature
heterosexual development. Stoller, in an attempt to explain the prevalence of perversions
mainly in men, postulates a developmental stage of “proto-femininity” when the boy is in a
symbiotic merger with his mother that needs to be overcome in order for him to develop a
healthy masculinity. He also postulates the idea of an “erotic form of hatred” where aggression
is sexualized and childhood trauma, hostility toward the other person, arousal and revenge all
mix up in order to convert childhood trauma into adult triumph”.
The relational schools of thought see perversion as a symptom of an unconscious conflict
or a relational issue that has later on been sexualized. Indeed, Limentani points out that “a
perversion is not an illness but only a symptom and as such it can appear at any time in the life
of an individual and for an infinite variety of reasons”.
Wood points out that, be it only a paraphilia or a paraphilic disorder, these disquieting
behaviours all have a defensive functioning to them, having the aim of protecting the individual
from mental pain or unbearable anxieties about intimacy.
Kaplan, who focuses on female perversions, talks about deception as the crucial aspect of
perversion and introduces the idea of the perverse strategy which is viewed as “a mental
strategy that uses one or another stereotype of masculinity and femininity in a way to deceive
the onlooker about the unconscious meaning of the behaviours she or he is observing.”
Psychodynamic formulations of specific perversions

Gabbard made a review of the certain common psychodynamic themes that can be
recognized in relation to sexual perversions.
Exhibitionism and voyeurism

One way of understanding exhibitionism comes from Fenichel, who believes that by putting
his genital area on display, the exhibitionist reassures himself that he is not after all castrated
and that he is very much capable of eliciting a reaction – albeit a shock one – from his victims.
This reaction gives him a feeling of power over the opposite sex and he is thus capable of
feeling a sense of value in his masculinity.
Stoller points out that another facet of exhibitionism could be connected to an identity
anxiety. In his clinical practice he talks about men that feel they cannot have any impact on the
members of their family, they thus feel invisible and they need to resort to extraordinary
measure in order to be noticed.
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Voyeurism maintains the concept of violation of a woman’s intimacy but this time it is a
secret aggressive triumph on the feminine sex. Fenichel sees it in connection to the primitive
scene when the child either sees or hears a sexual act between his parents and tries to make
sense of it. In his adult life the turns this passive rejection of being the one left out into a triumph
since he is the one that in secret is watching.
Sadism and masochism

Sadism and masochism are the only classical perversions that are present in an equal way
in both genders. Very seldom do people seek therapy for these types of sexual behaviour.
The main idea behind sadistic dynamics has to do with a role reversal of a childhood
scenario when they felt the victim of a physical or sexual abuse. As adults they change the
roles, they are now the ones with all the power and they are thus able to get their revenge. This
dynamic is the same both in cases of domestic abuse as well as in more severe cases of sadism.
The masochistic dynamics on the other hand are explained by Fenichel in the following way.
By submitting to these sadistic practices, they accept a smaller evil which is better that no
contact. If they believed that this is the only type of relationship available to them, they
willingly submit since an abusive relationship is better than no relationship. Kaplan notes that
sexual masochism can permit a man to enter a dynamic where “he can secretly identify with
the degrading position assigned to a woman but without losing face”.
The rise of the internet made more visible the BDSM clubs (Bondage, Discipline,
Sadism and Masochism) where sadism and masochism practices are very common. Most
frequently pain and humiliation are endured because they are perceived as the only viable way
of relating.
Fetishism
Fetishism can be understood both in terms of castration anxiety, when an inanimate object
is invested with restorative powers (Freud) or a transitional object that gives men the
reassurance of the integrity of his genital area. (Greenacre). These objects can be pieces of
lingerie, shoes, non-genital parts of the body. These objects stand in for the symbolic “feminine
penis”, and the underlining displacement enables both the erection and the orgasm.
Contemporary writings enlarge the spectrum of fetishist phenomena and view it as
controlling anxiety by investing objects with magical powers. The anxiety that these objects
help to calm is not necessarily an early childhood anxiety as Freud mentioned but it can be
linked to the Ego need of finding another object to calm the inner anxiety.
Paedophilia
Of all the paraphilias this one is most likely to elicit the strongest feelings of disgust and
moral judgement in therapist and psychiatrists. Through his sexual behaviours paedophile can
irreparably hurt innocent children. Psychodynamic formulations can help practitioners
maintain a certain degree of empathy and understanding for their patients.
The classical view is that of a narcissistic object choice, where the adult sees the child as a
mirror image of himself and thus, he is stuck in a child-like level of functioning, unable to fully
realize that he is hurting the child. Other view these behaviours as stemming from a very fragile
sense of self-esteem and in interactions with children they can feel better about themselves. By
idealizing the child, they can forever year for an idyllic childhood that they never had. Many
paedophiles have been themselves victims of sexual abuse. Gabbard points out that paedophile
can be either fixated at this stage or can regress to this stage. If they are fixated, they are mainly
attracted to younger boys and their attraction starts in adolescence. If they are regressed, they
mainly seek girls and most of them seek incestuous relationships with their daughters,
stepdaughters or nieces.
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In clinical practice 60% of paedophiles have severe personality disorders associated with
their sexual behaviours.
Transvestis
Transvestism, also called heterosexual cross-dressing, is viewed as a perverse strategy to
ward of castration anxiety. The patient dresses in typical manly attire and acts as a man but in
order to achieve an erection and an orgasm he needs to put on women clothes. The key concept
in the psychodynamic understanding of this perversion is the phallic mother. The boy observes
the anatomical differences in between his and his mother’s genital area. In order to overcome
his anxiety, he is fantasizing that his mother also has a penis and by dressing up he identifies
with her but at the same time maintain his penis and erection. Later revisions take into
consideration the clinical work with transvestites and report the feeling of symbiosis with an
intrapsychic maternal object. Dressing up reassures them they are in no danger of losing the
calming inner presence. These patients seldom come to seek therapy as there are no serious
consequences to their sexual behaviours that would make the distress so high as to seek
professional help.
CONCLUSION
No psychiatric disorder has more moral connotations than paraphilias. In order to establish
if a person is deviant as far as his sexuality is concerned implies being able to state criteria for
normal sexual behaviours and this an outright impossible task. Sexual paraphilias can be better
understood though using psychodynamic formulations that can shine light on the individual
significance of a paraphilia but it is very hard to establish an aetiology.
REFERENCES
[1] American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5 th ed.)
[2] Daines, B. Perret, A (2000) Psychodynamic Approaches to Sexual Problems, Buckingham, Open
University Press.
[3] Fenichel, O. (1945), The Psychoanalytical Theory of Neuroses, 50th Edition, East Sussex, Routledge &
Kegan Paul.
[4] Freud, S. Trei eseuri privind teoria sexualității, Opere esențiale, vol 10, București, Editura Trei.
[5] Gabbard, G. (2007) Tratat de Psihiatrie Psihanalitică, București, Ed. Trei.
[6] Greenacre, P. (1960) Perversions: general considerations regarding their genetical and dynamic
background, The Psychoanalytic Study of the Child, 23:1
[7] Kahn, M. (2002) Basic Freud: Psychoanalytic thought for the 21 st century, New York, Basic Books. 8.
Kaplan, L. (1991) Female perversion: The temptations of Emma Bovary, London, Jason Aronson
Printing.
[8] Limentani, A. (1989) Perversions: Treatable and Untreatable, Ch 15 in: Between Freud and Klein,
London, Free Association Books.
[9] Stoller, R. (2014) Perversiunea: forma erotica a urii, Bucuresti, Ed. Trei.
[10] Wood, H. (2014) Perspectives on Perversion. Working with problems of perversion, British Journal of
Psychotherapy, 30.
[11] Travi, S., Protter, B. (1993) Sexual Perversion: Integrative Treatment Approaches for the Clinician, New
York, Plenum Press.
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ZOOPHILIA
Abstract
Zoophilia is a paraphilia through which the perpetrator has sexual pleasure of having sex
with animals. Most countries have laws against this practice. Zoophilia can be classified in
several ways according to the criteria chosen by the author. In principle, sexual contact between
humans and animals has a lot of names such as zoophilia, bestiality and zooerasty. These terms
continue to be used in different ways by different authors, usually creating a certain amount of
confusion. Someone suggested that a mathematical classification of zoophilia, which could
group all the nuances of zoophilia into different numerical classes, could be a way to put an
end to this confusion. Parkinson’s disease (PD) is clinically defined by specific symptoms such
as bradykinesia, muscle rigidity, postural instability and resting tremor. The diagnosis is based
on the presence of these symptoms and an appropriate response to treatment with Levodopa.
However, non-motor symptoms, including sexual dysfunction, are common and least
recognized in PD patients. Zoophilia is an aberrant sexual behavior that can be found in
Parkinson’s disease. In this study, a clinical picture of this sexual perversion is described and
the possible causal relationship between this impulsive disorder and Parkinson’s disease
therapy is discussed.
Keywords: Zoophilia, Parkinson disease, Levodopa, Hypersexuality
INTRODUCTION
Zoophilia is more common in comorbidity with other paraphilia. Zoophilia is presented as

an early sign of the psychotic process, it is for us to conclude how, during the detection of such
deviant sexual behavior, it is important to pay attention to all other psychopathologies in order
to gain a perspective on the possible beginning. An increase in sexual interest and/or libido
related to antiparkinsonian therapy has been well described. Less frequent and less reported are
the occurrences of sexual deviance in combination with antiparkinsonian drugs. Such incidents
include states of hypersexuality, transvestite fetishism, zoophilia and internet pornography.
Many cases of infidelity were also reported. The reported cases indicate that a reduction or
modification of the antiparkinsonian drugs can lead to a reduction or at least a partial
improvement of the abnormal sexual behavior. We identified several cases of aberrant exual
behavior that appear to have occurred again in combination with levodopa therapy or other
drugs used in Parkinson’s disease.
Case 1:
A 63-year-old patient, married and resident of a rural area in northeastern Brazil, was
analyzed. The patient was diagnosed with Parkinson’s Disease presenting the first motor
symptoms almost 22 years ago. In a routine visit to the doctor his wife reported that on two
occasions she saw the patient trying to have sex with animals (donkeys). On the second
occasion, the patient appeared to have spatial disorientation, followed by intense feelings of
guilt, with even threats of suicide. Even before the episodes, the wife states that the patient
already had marked hypersexuality, accompanied by erectile dysfunction. Moreover, he
showed signs of sadness and insomnia, plus an episode of panic attack. His behavioral changes,
according to his wife, began many years before. Since the initial diagnosis, the patient has used
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several variants of therapy: Biperiden, Pramipexol associated with Levodopa. In time he

underwent a palidotomy. After the operation, there was a significant improvement in motor
symptoms, the patient remained without medication for six months, after which Levodopa was
reused. With the development of motor symptoms, Selegiline and Entacapone were introduced
into therapy. In the next period the patient developed episodes of hypersexuality, as well as
episodes of zoophilia.
Case 2:
A 29-year-old man began to raise his right hand at the age of 26. He later observed slowing,
stiffness and trembling of the right hand, and the patient was diagnosed with Parkinson’s
disease with young onset (PD) and was initially treated with selegiline. Subsequently the
patient developed personality disorders and mood changes. Treatment was changed and
pramipexole and ropyrinol were used. After 6 months, treatment with Levodopa was instituted.
After a while he began to develop obsessive compulsive disorder. Later he began to watch
excessive pornography on the Internet and began to show episodes of zoophilia.
Case 3:
A 77-year-old man living in a disadvantaged environment, with a very low level of
education, was diagnosed with advanced stage PD with all the symptoms specific to this
pathology. He was sent to a thorough check-up where he was diagnosed, the specific therapy
of this pathology was instituted and his progress was monitored. It was later found that he
developed hypersexuality with manifestations of zoophilia one week after starting the specific
treatment with levodopa. The treatment was changed with selegiline, the changes were
observed and it was found that hypersexuality with zoophilic manifestations disappeared.
CONCLUSIONS
Zoophilia is more common in men with low educational status, living in rural areas, as well
as in psychiatric patients with mood disorders, substance abuse and anxiety. Hypersexuality in
Parkinson’s disease occurs in about 2-6% of patients with PD related to dopaminergic
treatment. It is stressed how crucial it is to evaluate the sexuality of PD patients and to explain
these adverse effects to the families involved. The association between PD and behavioral
disorders has been very often reported. Nonmotor symptoms are an integral part of PD and
cause significant morbidity. Pharmacological therapies, also contributing to the alleviation of
the motor symptoms of the disease, also produce adverse behavioral manifestations. Klos et
al., demonstrated a close relationship between pathological hypersexuality and adjuvant
therapy with the dopamine agonist. Of the 15 patients analyzed, hypersexuality started eight
months after starting dopaminergic agonist therapy in 14 cases, including four who were on
their own. The development of hypersexuality with zoophilia may be considered a possible
complication of the established therapy, as the disappearance of symptoms was directly
associated with the discontinuation of Selegiline and the decrease of the dose of Levodopa.
However, due to the few reports in the literature on the occurrence of aberrant sexual
behaviors in PD, we cannot rule out the possibility that such symptoms are correlated with the
evolution of the disease.
in the public, commercial, or not-forprofit sectors.
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REFERENCES
[1] Journal of Forensic and Legal Medicine Volume 18, Issue 2, February 2011, Pp. 73-78.
[2] Alcoholism and psychiatry research: Journal on psychiatric research and addictions, Vol. 53 No. 1, 2017.
[3] Review of cases of zoophilia in patients with Parkinson›s disease. Campo-Arias A, CastilloTamara EE,
Herazo E.
[4] Parkinsonism & Related Disorders, Volume 19, Issue 12, December 2013, pp. 1167-1168.
[5] European Psychiatry, Volume 41, Supplement, April 2017, p. S632.
[6] Lauterbach EC. The neuropsychiatry of Parkinson’s disease and related disorders. Psychiatr Clin North
Am 2004; 27(4): pp. 801-25.
[7] Raina G, Cersosimo MG, Micheli F. Zoophilia and impulse control disorder in a patient with Parkinson
disease. J Neurol 2012; 259: pp. 969-70.
[8] Parkinsonism and Related Disorders 12 (2006) pp. 392-395.
[9] Uitti RJ, Tanner CM, Rajput AH, Goetz CG, Klawans HL, Thiessen B. Hypersexuality with anti-
parkinsonism therapy. Clin Neuropharmacol 1979; 12: pp. 375-83.
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ZOOPHILIA – 2
Abstract
Zoophilia or zooerastia (1), bestiality (2), bestiosexuality is a sexual practice that causes
pleasure to a group of people, restricted in percentage and of both sexes. During this article we
aim to clarify aspects related to the history of this disorder, the degree of spread at the
population level, forms of zoophilia, explanatory theories and therapeutic approaches.
Keywords: zoophilia, bestiality, specified paraphilic disorder, paraphilias with sexual object deformity,
sexually diverted behaviors
INTRODUCTION
Zoophilia is part of the group of paraphilias on the object of pleasure. The term – introduced
by R. Von Krafft Ebing – refers to sexual fantasies, the needs and behaviors of this type directed
at animals like, anal sex, animal masturbation and intercourse (Ebing K., 1886).
The animal usually used is one of the species with which the individual was in proximity
during his childhood.
The history of this paraphilia is very old, being documented even through cave paintings.
Many cultures contain stories and myths that refer to zoophilia.
The vast majority of these cultures, from various geographical areas, have condemned and
sanctioned various forms of zoophilia. A clear example is the religious prohibitions against
these practices mentioned in the Old Testament and Torah. Therefore, by the year 1,000, people
suspected of zoophilia were being tried. If found guilty, they were sentenced to death, along
with the animal (s) with which they interacted sexually, for their sins. In the Middle Ages, both
animals and humans were considered equally guilty. The death penalty was abolished in the
19th century and replaced. life imprisonment. In the vast majority of countries in the world,
zoophilia is considered a crime and punishable as such. In the United States there are states
that apply a small fine and a short period of detention as there are states that frame this as crime
and apply sentences of up to 50 years in prison.
The fear that bestiality could corrupt the human race through the emergence of so-called
hybrids has dominated society for a long time.
Common forms of zoophilia:

• Avisodomy/ornithophilia – consists in maintaining sexual relations with birds;
• Cynophilia/canophilia – sexual attraction to dogs, sexual intercourse with these
animals;
• Formicophilia – a subtype of zoophilia oriented towards small animals (snails, frogs,
ants, etc.) that crawl on the body, especially in the genital areas, in the perineum area
and in the nipples area;
• Ophidiophilia – sexual attraction to reptiles (snakes, lizards, etc.);
• Ponifilia – sexual attraction to ponies.
Related paraphilias are:

• Zoophilic exhibitionism that involves the pleasure gained by exposing sexual
intercourse with an animal to other people;
• Zoosadism that involves obtaining sexual arousal by causing pain and suffering to
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animals;
• Necrozoophilia or necrobestiality that involves obtaining sexual arousal by killing
animals or is related to animal carcasses;
• Mixoscopia bestialis – rather belongs to the voyeuristic paraphilia – obtaining pleasure
is done on another person who has sex with an animal;
• Mixoscopic zoophilia – also of voyeuristic type – sexual pleasure is obtained regarding
the animals that copulate.
Theoretical approach. Theoretical clarifications

For Von Krafft Ebing, zooerastia is almost similar to zoophilia with the difference that a
zooerastia prefers animals for sexual interaction even when he has the possibility of human
sexual interactions.
R. Von Krafft Ebing distinguishes between the arousal caused by domestic animals and the
act of sexual attraction.
Individuals who define themselves as zoophiles use the term bestiality/bestialist to describe
individuals who sexually use animals without having emotional affinities with those animals.
their well-being and sexual intercourse are agreed by both parties.
Research and statistical data

Studies conducted in 1948 by Kinsey, Pomerey and Martin respectively in 1953 by Kinsey,
Pomery, Martin and Gebhard showed that 8% of the total zoophilic people were men, 1.5%
pre-adolescents and 3.6% post-teen.
All of these people had at least one sexual contact with an animal. There was a much higher
incidence of cases of zoophilia in rural areas (Kinsey, Pomerey and Martin, 1948 and Kinsey,
Pomerey, Martin and Gebhard, 1953).
In a study of men’s sexual fantasies, they found that 5.3% of total respondents had sexual
fantasies with an animal (Crepault, C. and Couture, M., 1980).
The study of a sample of 561 human individuals seeking treatment for a wide range of
paraphilias revealed that all 14 identified zoophiles had more paraphilias. Moreover, as many
as 50% of zoophiles had 5 or more paraphilias in the range of pedophilia. exhibitionism,
voyeurism, frotteurism, telescopophilia, transvestite fetishism, urophilia and coprophilia (Abel,
Becker, Cunningham-Rathner, Mittelman and Rouleau, 1988).
Another study conducted in 2003 on a sample of 93 zoophilic subjects, 82 men and 11
women, the average age 30 years found that 50% had higher education and almost half were
single (had no relationship), 3 of them were married. Of these, 83% had had heterosexual sex,
76% had homosexual sex and 40.5% had sex with both sexes. The preferred animals were dogs
in the proportion of 87.2%, 80% of the horses, other preferred species being cows, sheep and
cats. The subjects were attracted, for the most part, by several species of animals. The men in
the group had also experienced genital and oral contact, having both active and Only 17% of
men confirmed that they had been sexually assaulted as children.
The subjects of this study explained their behavior through sexual attraction to animals,
various sexual fantasies related to animals and the desire to express their love for an animal
(Miletski. H, 2002).
Naturally, several hypotheses were born.
Is zoophilia associated with the lack of interpersonal relationships?
Can drunkenness favor deviant zoophilic sexual behaviors?
Can rural or farm life create a predisposition to sexual interactions with animals?
Are people with low self-esteem more likely to develop such behaviors?
Such hypotheses have given rise to theories that seek to explain this paraphilia.
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Balint in 1956, in Laws R.D. O’Donohue, W.T. 2008 states that those with zoophilic
behavior suffer from mental retardation or imbecility (Balint M., 1956).
Shenken, in 1964, considers that zoophilia is no longer found in solitude and is not
predominantly the prerogative of those with a much below average intelligence that would
replace normal relationships. He argues that zoophilia is a form of psychopathology in itself
and is closely related. with a major disorder in the clinical registry such as psychosis (Shenken
LI, 1964).
Rappaport, in 1968, finds that animals generate a feeling of envy in the child by the fact that
their instincts are not repressed. Also, children are curious and excited about the sexual
behavior of animals. According to the author, zoophilia is an abuse of an animal that represents
a conversion of feelings of hatred and anger felt in childhood towards parents who generated a
traumatic experience (Rappaport, E.A., 1968).
Traub-Werner in 1968 states that zoophilia is a very old form, historically speaking, of
perversion that manifested itself both when there were no sanctions from society and in
societies that repress it. After him, zoophilia lies in the inability to differentiate aggression
sexual impulses combined with aggression against parental symbols and the inability to
integrate body image at the genital level (Traub-Werner, D. 1986).
In 1991, Cerrone found that the factors related to the individual, the family and the socio-
cultural environment were equally important in the manifestation of zoophilia. which is
otherwise totally lacking in everyday life (Cerrone, CH 1991).
London and Caprio in 1950 and Schneck in 1974 explained zoophilic behavior through the
role of incestuous desires (London, L.S. And Caprio, F.S. 1950 & Schneck, J.M. 1974).
Meyer in 1988 linked zoophilia to borderline personality disorder and the dynamics of
attachment and separation processes (Meyer, J.K. 1988).
Kolb and Brodie in 1982 explain zoophilic behavior through extreme self-doubt (Kolb, L.C.
and Brodie, H.K.H 1982). Another theory seeks to explain zoophilic behavior through fear of
heterosexual relationships (Ebing K., 1886).
Nagaraja in 1983 observed that individuals with zoophilic tendencies are aroused at the sight
of copulating animals. These individuals, in the absence of a partner, will use an animal to
satisfy sexual needs (Nagaraja, J. 1983).
Diagnostic tools
• EPES/Erotic Preferences Examination Scheme Scale that measures the degree to which
an individual admits to having unusual erotic preference (s) (Freund, Watson and
Rienzo in 1998);
• MASS/Multidimensional Assessment of Sex and Aggression Questionnaire that
highlights a wide range of sexual and aggressive behaviors (Knight, Prentky and Cerce
in 1994);
• SFQ/Sexual Fantasy Questionnaire Scale for identifying various sexual fantasies such
as zoophilia, necrophilia and telefonoscatologia (O’Donohue, Letourneau and Dowling
in 1997).
Treatment of zoophilia
As with specific paraphilias, the essential goals of zoophilic therapy are (1) reducing the
level of distress or impairment – if any – by reducing fear of rejection or developing alternative
forms of sexuality (2) reducing the risk of possible crime – if any – by decreasing the level of
zoophilic arousal, decreasing the level of sexual impulsivity and/or sexual preoccupation, by
improving sexual self-control.
People with zoophilic behavior do not regularly attend treatment for various reasons. These
may include the specific nature of their behavior, low level of distress related to zoophilic
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behavior, lack of confidence in a positive outcome as a result of treatment. reports of effective

treatments contain case studies.
Case studies show that psychodynamic, cognitive-behavioral, behavioral and
psychopharmacological interventions have given positive results.
For rare paraphilias such as zoophilia, the relevant variables depend very much on the
individual, which makes it necessary to have an idiographic approach to evaluation and
treatment.
CONCLUSION
Zoophilia is a paraphilia that has a double classification both from the perspective of the
deformation of the sexual object and from the perspective of misappropriated sexual behaviors.
It consists in obtaining erotic pleasure through direct interaction with animals. According to
studies, only a small part of the population manifests this disorder. Most people who had sex
with animals in adolescence as adults become engaged in normal heterosexual intercourse. The
rare cases in which adults have repeated sexual contact with animals most often reflect the state
of fear and hostility towards the opposite sex. Numerous studies Delcea C, Enache A, Stanciu
C; Delcea C, Enache A, Siserman C, Gherman C, Enache A, Delcea C, Delcea C, Fabian A.
M, Radu C. C, Dumbravă D. P, Rus M, Delcea C, Siserman C, Siserman C, Delcea C, Matei
H. V, Vică M. L., Gherman C, Enache A, Delcea C, Siserman C, Delcea C, Siserman C,
confirm our results. As can be easily noticed, over time some of the characteristics of zoophiles
change. Thus, in early studies (Kinsey et al.). There is a prevalence of zoophiles in rural areas
and with a low level of education to the environment, instead of more recent studies (Miletski
H) identifies a high level of zoophiles with higher education.
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Press.
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[8] Ebings, R. (2011). Psychopatia Sexualis. The Classic Study of Deviant Sex. Arcade Publishing.
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Multipleparaphilic diagnoses among sex offenders. Bulletin of American Academy of Psychiatry and
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[10] Balint, M. (1956). Perversions and Geniality. In S. Lorand &M. Balint (Eds.), Perversions:
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Psychology, 12, pp. 29-39.
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Philadelphia: Saunders.
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Philadelphia: Saunders.
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[18] Rappaport, E.A. (1968). Zoophily and zooerasty. Psychoanalitic Quarterly, 37, pp. 565-587.
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[20] Shenken, L.I. (1964). Some clinical and psychopatological aspects of bestiality. Journal of Nervous and
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KLISMAPHILIA
Abstract
Klismaphilia (the use of enema for sexual stimulation) is a practice that causes pleasure to
a certain segment of the population, both male and female. This article attempts to explain the
evolution and explores the psychological factors regarding this paraphylic disorder.
Keywords: klismaphilia, parafilic disorder, psychological factors, physiological factors, perineum
INTRODUCTION
Klismaphlia is a specific paraphylic disorder, which describes a person who is sexually

satisfied and aroused by using the enema. The enema can produce pleasure or sexual arousal
through anal stimulation, unusual internal sensations associated with colon dilatation or
rhythmic stimulation of muscle contractions that are transmitted to genital structures and
produce sensations of a sexual nature. Some people experience extreme pleasure by practicing
this form of paraphilia to the point where they achieve orgasm. Klismafilia can be practiced
alone or with a partner of either the same or opposite sex.
Beginning and evolution

Most people with these tendencies remember about enemas received in the first part of their
life, generally between 4-8 years, but it has been reported that it can be developed later. Patients
report that often the pleasant feeling was discovered after the chance to experience an enema
in childhood. We can assume that the basic physiology was there and the early experience of
an enema for medical purposes only played a role in detecting the sensitivity. However, not all
children who were given enema developed tendencies towards anal eroticism later. (Denko, J.
D, 1977, Freytag, F. F, 1971, Delcea, C., 2017).
There are a number of predisposing factors, such as physical development (for example,
proper muscle structure) that are associated with anal stimulation (e.g., early enema) and
possibly certain unknown psychophysical or physiosexual factors in a sensitive psychological
developmental stage, leads to the development (or perhaps only discovery) of the anal
sensitivity that can be exploited later in life as part of heterosexual, homosexual or self-sexual
activities (Delcea, C., 2017).
We can establish that some people like to receive sexual stimulation from this type of anal
activity, while others find it inconceivable. Given the fact that everyone has the necessary
organs for these activities, the question arises: why is it not a pleasant activity for everyone?
This question has no concrete answer, and most of the answers are speculative and
theoretical. Most likely, both psychological and physiological factors impact on this paraphylic
disorder.
Given that there are countless physiological and psychological differences in the entire
population, not all people consider anal stimulation to be pleasant or tolerable. Thus, the nerve
of the perineum, the perineum and the muscular structure of the perineum, together with other
physiological factors are different in people, and some people don`t have any erotic sensitivity
in this area.
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The psychological aspects of negative emotions related to enema and anal activity could
revolve around the fact that the anus is related to defecation and is considered a taboo or
“unclean” topic through education and general social conventions.
Most people have psychological blockages in relation to sexual activity and conceptions
about sex in this socially unacceptable area.
Past experiences with enema will also form a basis for negative feelings about this type of
activity. Most people experience enema in a medical context, and for them enema will be
associated with the disease.
Women could associate them with activities prior to birth and pain, loss of personal space
and other real or imaginary offenses that come along with these practices.
None of these situations could be associated with eroticism or pleasurable sexual activity
(Delcea C, et al., 2017, 2018).
CONCLUSION
In conclusion, the highly sensitive nature of the anal area and perineum area make the anus
a source of intense sexual stimulation for some people. Klismafilia can be considered a form
of anal masturbation that is practiced with pleasure by both men and women.
REFERENCES
[1] Agnew, J. (2000). Klismaphilia. Venereology, 13(2), p. 75.

[2] Agnew, J. (1982). Klismaphilia – a physiological perspective. American journal of psychotherapy,
36(4), pp. 554-566.
[3] Delcea C, Enache A, Siserman C. (2018). The Reasoning Involved in the Decision-Making Process of
Individuals Who have Committed Murder. Int J Ment Health Psychiatry. 2018; 4:2. 60.
[4] Delcea C, Enache A, Stanciu C. (2017). Assessing maladaptive cognitive schemas as predictors of
murder. Int J Ment Health Psychiatry. 2017; 3:1.
[5] Delcea C, Enache A., (2017). Individual Differences in Personality and Reasoning Traits between
Individuals Accused of Murder and those who have not Committed Murder. Int J Ment Health Psychiatry
3:1.
[6] Denko, J. D. Understanding Desire for Anal Eroticism. Med. Aspects Human Sexual, 11:68, Dec. 1977.
[7] Freytag, F.F. Hypnotherapeutic Explorations of Early Enema Experience. Am. J. Clin. Hypnosis., 14:24,
1971.
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COPROPHILIA
Abstract
Coprophilia can be found in DSM IV and it is classified under 302.9 as a “Paraphilia without
other specification”. This category is included to encode paraphilia that do not meet the criteria
for any of the specific categories.
Keywords: Coprophilia, Paraphilia, Sexology
INTRODUCTION
Coprophilia can be defined as the pleasure of a person towards the use of his or her own
feces during sexual intercourse to produce sexual arousal. Depending on the person’s
preference to either smell or ingest their feces, they are divided as the following:
• Olfactory – Coprolagnia - The thought, sight or smell of excrements causes a pleasant
sexual arousal.
• Tactile – Copro/urolagnia – Sexual arousal occurs when the partner urinates or
defecates.
• Taste – Coprourophagy – Sexual arousal results from the consumption of feces and/or
urine (Di Lorenzo et al., 2018).
Morrison, J. (2014) defines coprophilia as masturbation with one’s own feces; and also
stating that it is very rare.
There are very few studies that have investigated coprophilia, which is why it is very
difficult to determine the prevalence of this disorder as well as its causes and evolution.
The evidence for estimating the prevalence, etiology and risk caused by “other paraphilic
disorders” is poor. This is demonstrated by the small number of scientific publications. In
MEDLINE (December 2015) the number of publications regarding these non-specific
disorders was as follows: telephone scatology (n=6), necrophilia (n=44), zoophilia (n=26),
coprophilia (n=6), klismaphilia (n=6), and urophilia (n=2).
Today, it is much easier to live with a particular sexual interest such as coprophilia or
urolagnia because of easier access to specific pornography and the possibility of arranging
sexual contacts or partners with similar inclinations through digital media. The existing
pornography market suggests at the same time that there is a significant number of people
interested in this kind of material (Balon, R., 2016, Delcea, C., et al., 2017, 2018).
CONCLUSION
In conclusion, coprophilia is a sexual fetish people feel when they come into contact with
feces. Coprophilia can be said to be liking the smell, taste, or feel of feces in a sexual way. The
feeling can be either through touching the skin or through rubbing the penis head against feces.
Enjoyment can also be made from the feeling of feces passing through the anus. Eating feces
is also known as coprophagia. This is bad for one’s body. A person who eats feces is at risk of
getting sick through hepatitis, infection, and AIDS.
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Those with a weak immune system should not eat feces. There are also social problems with
eating feces. It causes bad breath and is a taboo. There are people who make movies involving
coprophilia. This is called scatology.
RFERENCES
[1] American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed.
Arlington: American Psychiatric Association; 2013.
[2] Balon, R. (Ed.). (2016). Practical guide to paraphilia and paraphilic disorders. Springer International
Publishing.
[3] Delcea C, Enache A, Siserman C. (2018). The Reasoning Involved in the Decision-Making Process of
[4] Delcea C, Enache A, Stanciu C. (2017) Assessing maladaptive cognitive schemas as predictors of
murder. Int J Ment Health Psychiatry. 2017; 3:1.
[5] Delcea C, Enache A. (2017). Individual Differences in Personality and Reasoning Traits between
Individuals Accused of Murder and those who have not Committed Murder. Int J Ment Health Psychiatry
3:1. 2017.
[6] Di Lorenzo, G., Gorea, F., Longo, L., & Ribolsi, M. (2018). Paraphilia and paraphilic disorders. In
Sexual Dysfunctions in Mentally Ill Patients (pp. 193-213). Springer, Cham.
[7] Morrison, J. (2014). DSM-5 made easy: The clinician’s guide to diagnosis. Guilford Publications.
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B. INTERNALIZATION PARAPHILIC DISORDERS
2.6 Fetishism and transvestism disorders
2.6.1 Fetishism disorder
FETISHISTIC DISORDER
Abstract
Fetishism, as a technical descriptor of atypical sexual behavior, was noted in the writings of
the wellknown nineteenth century French psychologist Alfred Binet (1857-1911) (Binet, 1887)
as well as prominent European sexologists Richard von Krafft-Ebing (1840-1902) (Krafft-
Ebing, 1886), Havelock Ellis (1859-1939) (Ellis, 1906), and Magnus Hirschfeld (1868-1935)
(Hirschfeld, 1956). In their seminal writings, all of the afore mentioned sexologists used the
terms “fetish” and “fetishism” to specifically describe an intense eroticization of either non-
living objects and/or specific body parts that were symbolically associated with a person.
Fetishes could be non clinical manifestations of a normal spectrum of eroticization or
clinical disorders causing significant interpersonal difficulties. Ellis (1906) observed that body
secretions or body products could also become fetishistic expressions of “erotic symbolism”.
Freud (1928) considered both body parts (e.g., the foot) or objects associated with the body
(e.g., shoes) as fetish objects. For the purposes of this review, a “broader” historically based
core definition for Fetishism will include intense and recurrent sexual arousal to: non-living
objects, an exclusive focus on body parts or body products.
Keywords: fetishism, Paraphilia, Partialism, DSM-V
Introduction
The etymology of the word fetish derives from the French fétiche, which comes from the
Portuguese feitiço (“spell”), which in turn derives from the Latin facticius (“artificial”) and
facere (“to make”). A fetish is an object believed to have supernatural powers, or in particular,
a man-made object that has power over others. Essentially, fetishism is the attribution of
inherent value or powers to an object. Fétichisme was first used in an erotic context by Alfred
Binet in 1887.
The first recorded use of the word Fetishist to indicate an object of desire, someone who is
aroused due to a body part, or an object belonging to a person who is the object of desire was
in 1897 (Harper, 2014). There are those to whom an object or body part has the power to
captivate and enthrall. Such a focus itself is not considered a disorder, unless it is accompanied
by distress or impairment.
Fetishistic Disorder is a DSM-5 (Diagnostic and Statistical Manual of Mental Disorders,
fifth edition), diagnosis assigned to individuals who experience sexual arousal from objects or
a specific part of the body which is not typically regarded as erotic. Almost any body part or
object can be a Fetish. Examples include: clothes, shoes, stockings, gloves, hair, or latex
(Comfort, 1987). Fetishists may use the desired article for sexual gratification in the absence
of a partner, by touching, smelling, licking, or masturbating with it (Meston & Frohlich, 2013).
Fetishism is seen almost exclusively in men, and 25% of men with Fetishes are homosexual
(Meston and Frohlich, 2013). In some cases, Fetishistic Disorder is a result of Classical and
Operant Conditioning.
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One possible Scenario: A neutral stimulus, such as a pair of knee-high leather boots are
worn by a woman. Foreplay begins, and the boots are removed to the accompaniment of
growing sexual desire, which is an unconditioned response. The association between the
unconditioned response of sexual desire during foreplay turns the previously neutral stimulus
of knee-high leather boots into a conditioned stimulus. Through repeated trials, e.g., sexual
encounters, the boots produce a conditioned response of sexual arousal through the sensory
stimuli of the smell, appearance, and texture of the boots. Sex may not be as satisfying, or
erection may not even be possible unless leather boots are present. Operant Conditioning can
occur as the person will experience anticipatory pleasure or reinforcement from the process of
coming into contact with the boots.
Symptoms of Fetishistic Disorder

According to the DSM-5, there are three criteria for Fetishistic Disorder, and four specifiers
that can be applied:
A. Over a six-month period, the individual has experienced sexual urges focused on a non-
genital body part, or inanimate object, or other stimulus, and has acted out urges,
fantasies, or behaviors.
B. The fantasies, urges, or behaviors cause distress, or impairment in functioning.
C. The Fetishistic object is not an article of clothing employed in cross dressing, or a
sexual stimulation device, such as a vibrator.
• Specifiers for the diagnosis of Fetishistic Disorder include the type of stimulus which
is the focus of attention.
• Body Part(s) (non-genital or erogenous areas of the body – e.g., feet or hair). This is
also referred to as Partialism- preoccupation with a part of the body rather than the
whole person.
• Non-living Object(s) e.g., shoes or boots.
• Other- situations or activities – e.g., – smoking during sex.
Other specifiers are:
In a controlled environment where Fetishistic Disorder cannot readily be engaged in, such
as an institutional setting.
In remission: No distress or impairment of functioning for a five-year period, exclusive of
a controlled environment (American Psychiatric Association, 2013).
Causes
Paraphilias such as fetishistic disorder typically has an onset during puberty, but fetishes
can develop prior to adolescence. No cause for fetishistic disorder has been conclusively
established.
The DSM-5 notes that Fetishistic Disorder typically emerges at the onset of puberty, or less
typically, prior to adolescence. The severity of the disorder can wax and wane over the lifespan,
and is noted to appear almost exclusively in males (American Psychiatric Association, 2013).
Some theorists believe that fetishism develops from early childhood experiences, in which
an object was associated with a particularly powerful form of sexual arousal or gratification.
Other learning theorists focus on later childhood and adolescence and the conditioning
associated with masturbation and puberty.
Behavioral learning models suggest that a child who is the victim or observer of
inappropriate sexual behaviors may learn to imitate or later be reinforced for the behavior.
Compensation models suggest that these individuals may be deprived of normal social
sexual contacts, and thus seek gratification through less socially acceptable means.
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In cases involving males, some experts have suggested that fetishistic disorder may stem
from doubts about one’s own masculinity, potency, or a fear of rejection and humiliation. By
using fetishistic practices to exert control over an inanimate object, the theory goes, an
individual may safeguard himself from or compensate for feelings of inadequacy.
Prevalence
The prevalence of fetishism is not known with certainty. The majority of fetishists are male.
In a 2011 study, 30% of men reported fetishistic fantasies, and 24.5% had engaged in
fetishistic acts. Of those reporting fantasies, 45% said the fetish was intensely sexually
arousing. In a 2014 study, 26.3% of women and 27.8% of men acknowledged any fantasies
about “having sex with a fetish or non-sexual object”. A content analysis of the sample’s
favorite fantasies found that 14% of the male fantasies involved fetishism (including feet,
nonsexual objects, and specific clothing), and 4.7% focused on a specific body part other than
feet. None of the women’s favorite fantasies had fetishistic themes. Another study found that
28% of men and 11% of women reported fetishistic arousal (including feet, fabrics, and objects
“like shoes, gloves, or plush toys”). 18% of men in a 1980 study reported fetishistic fantasies.
Fetishism to the extent that it becomes a disorder appears to be rare, with less than 1% of
general psychiatric patients presenting fetishism as their primary problem. It is also uncommon
in forensic populations.
Risk Factors
The DSM-5 does not specify risk factors for the development of Fetishistic Disorder.
(American Psychiatric Association, 2013). As noted in Introduction, Fetishistic Disorder
can result from Classical and Operant Conditioning associated with an early sexual encounter.
Comorbidity
The Fetishistic Disorder can be comorbid with Hypersexuality and other paraphillias.
Fetishistic Disorder can also occur in the context of a neurological disorder, though this is
rare (American Psychiatric Association, 2013).
Treatment for Fetishistic Disorder

Fetishistic fantasies are common and, in many cases, harmless. According to the DSM
definition, they should only be treated as a disorder when they cause distress or impair a
person’s ability to function normally in day-today life.
Fetishistic disorder tends to fluctuate in intensity and frequency of urges or behavior over
the course of an individual’s life. As a result, effective treatment is usually long-term. Though
the DSM-5 does not specify particular treatments, successful approaches have included various
forms of therapy as well as medication therapy (such as SSRI’s or androgen deprivation
therapy). Some prescription medications may help to decrease the compulsive thinking
associated with fetishistic disorder. This allows a patient to concentrate on counseling with
fewer distractions.
Increasingly, evidence suggests that combining drug therapy with cognitive behavioral
therapy can be effective, although research on the outcome of these therapies remains
inconclusive. A class of drugs called antiandrogens can drastically lower testosterone levels
temporarily, and have been used in conjunction with other forms of treatment for fetishistic
disorder. This medication lowers sex drive in males and thus can reduce the frequency of
sexually arousing mental imagery.
The level of sex drive is not consistently related to the behavior of those with fetishistic
disorder, and high levels of circulating testosterone do not predispose a male to paraphilias.
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That said, hormones such as medroxyprogesterone acetate (Depo-Provera) and cyproterone

acetate help decrease the level of circulating testosterone, potentially reducing sex drive and
aggression – and, in the case of an individual with fetishistic disorder, potentially resulting in
a reduction of the frequency of erections, sexual fantasies, and initiation of sexual behaviors,
including masturbation and intercourse. Hormones are typically used in tandem with
behavioral and cognitive treatments. Antidepressants such as fluoxetine (Prozac) may also
decrease sex drive but have not been shown to effectively target sexual fantasies themselves.
Some research suggests that cognitive-behavioral models may be effective in treating people
with paraphiliac disorders. Aversive conditioning, for instance, involves using negative stimuli
to reduce or eliminate a behavior. One approach, called covert sensitization, entails the patient
relaxing and visualizing scenes of deviant behavior, followed by a visualization of a negative
event. Another approach, known as assisted aversive conditioning, is similar to covert
sensitization, except the negative event is made real (for example, a foul odor is pumped in the
air by the therapist). In both treatments, the goal is for the patient to associate the deviant
behavior with the negative event (either the visualized event, or the foul odor).
Reconditioning techniques center on immediate feedback given to the patient so that the
behavior will change right away. For example, a person might be connected to a biofeedback
machine that is linked to a light, then taught self-regulation techniques that will keep the light
within a specific range of color. They then practice doing this while being exposed to sexually
stimulating material. Masturbation training might focus on separating the pleasure of
masturbation and climax from the deviant behavior.
Impact on Functioning
Fetishistic Disorder can impact intimate relationships. If the Fetish is absent from a sexual
encounter, it can result in sexual dysfunction, such as inability to achieve or maintain an
erection (American Psychiatric Association, 2013). It is noted that paraphillias in general,
including fetishism, are correlated with general psychosocial impairment, including being
victims of physical abuse, lower educational level, inpatient admissions mental health or
substance abuse treatment, disability, unemployment, involvement with criminal justice,
increased risk of STI’s (Sexually Transmitted Infections) and comorbid mental health disorders
(Marsh, Odlaug, Thomarios, Davis, Buchanan, Meyer, & Grant, 2010). Criminal behavior may
be involved with Fetishistic Disorder, such as breaking and entering to steal articles of clothing,
or unwanted contact, such as touching a a strange woman’s feet in public. The individual with
Fetishistic Disorder may experience guilt, shame, and humiliation if they are unable to contain
their desires and act out in public.
Differential Diagnosis
There are several diagnostic rule-outs for the clinician to consider. In the DSM-5, disorders
such as transvestic Disorder, Sexual Masochism, and Fetishistic behavior without Fetishistic
Disorder (American Psychiatric Association, 2013). Tranvestic disorder specifically involves
a man dressing in typical woman’s clothing, whereas Fetishistic disorder would involve
handling, smelling, and masturbating with an article of woman’s clothing. Woman may also
wear men’s clothes with little or no social stigma. Sexual Masochism involves sexual
gratification from the infliction of pain or discomfort on another. An article used for
Masochistic behaviors, such as a ligature for restraint, may acquire independent Fetishistic
properties, but the act of restraint with a ligature during sexual activity and becoming aroused
from the discomfort of one’s partner is a Masochistic act, and a different diagnosis. There are
also individuals who use Fetishes for sexual arousal with a partner who is agreeable to the
behavior, and do not experience distress or impairment of sexual functioning, in which case
the behavior does not reach the clinical threshold of a disorder.
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Is There New Empirical Information About Partialism and Fetishism Relevant to DSM-V?
Apart from single or very small sample case reports, before 1990, the only descriptive
empirical articles or clinical samples that included more than 25 men with Fetishism were by
Krafft-Ebing (1965), Stekel (1952), Gosselin and Wilson (1980), and Chalkley and Powell
(1983). All of these investigators used the “broader” or an ambiguous definition of Fetishism.
Gosselin and Wilson’s sample (n=125) was derived from volunteers in membership
organizations such as The Mackintosh Society for rubber fetishists (n=87 and the Atomage
correspondence club for leather fetishists (n=38). Chalkey and Powell’s modestly sized clinical
sample was derived from carefully culling over 20 years of discharge diagnoses from two major
hospitals in London.
From these samples, the clinical cases described by Krafft Ebing, Ellis, Hirschfeld, and
Stekel and some additional contemporary data (Junginger, 1997; Scorolli, Ghirlanda, Enquist,
Zattoni, & Jannini, 2007; Weinberg, Williams, & Calhan, 1994, 1995), several consistent
clinical observations about Fetishism have emerged:
1. Many males who self-identify as fetishists in community or convenience samples do
not necessarily report clinical impairment in association with their fetish or fetish
associated behaviors. Thus, many “fetishists” do not meet criteria for a psychiatric
diagnosis of Fetishism that is associated with significant personal distress or
psychosocial (including sexual) role impairment.
2. Fetishes, as with other paraphilic disorders, are almost exclusively male disorders.
Clinically significant fetishes typically develop in childhood or early adolescence and
are usually persistent sexual preferences.
3. Fetishes can co-occur with other paraphilic behaviors, especially “sadomasochism”and
transvestic fetishism but are uncommon amongst sexual offender paraphiliacs.
4. Men with clinically significant fetishes may steal and collect their fetishistic objects.
5. A male with a single fetish may have multiple fetishes, including preferential sexual
arousal to both body parts and non-living objects.
6. Female undergarments, body parts especially feet, footwear including socks, shoes and
boots, and leather objects are common fetishes in contemporary community or
convenience samples of self-identified fetishists.
7. Fetishism is a multi-sensory sexual outlet as fetishists may smell, taste, touch, insert,
rub or be visually aroused by their fetishistic object or body part. In the more recent
reports, Fetishism and Partialism can co-occur, at least in communitybased or
convenience samples of males selfidentified as fetishists.
CONCLUSION
Fetishistic Disorder is classified as a Paraphilic Disorder, which requires the presence of a

paraphilia that is causing significant distress or impairment, or involve personal harm or risk
of harm to others. Fetishism is among a number of unusual attractions, known as paraphilias,
that can stray into disorder territory. Someone can cross this threshold in a number of ways –
for instance, when the attraction causes him significant distress, impairs his ability to function
or could lead him to harm others. The DSM-5 marks this transition by attaching the term
“disorder” when an unusual sexual interest crosses these boundaries. So, hypothetically,
someone who simply uses shoes to masturbate or whose partner accepts his unusual interest in
shoes could be diagnosed with fetishism, but not a fetishistic disorder – unless the fetish crosses
the threshold in one of the ways described above. The label “disorder” is akin to labeling a set
of symptoms as a mental illness, which by definition, interferes with normal functioning. Many
people would consider a sexual attraction to objects, such as shoes or underwear, abnormal or
unnatural. But is it a mental illness? It can be, but isn’t necessarily. It’s not excluded that, when
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Jago showed Othello the handkerchief of Desdemona, the effect was beyond the scope of the
crime, The husband’s jealousy was exacerbated by the idea as an intimate item of his wife got
on foreign hands.
REFERENCES
[1] The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).
[2] American Psychiatric Association, ed. (2013). “Fetishistic Disorder, 302.81 (F65.0)”. Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition. American Psychiatric Publishing. p. 700.
[3] https://www.psychologytoday.com/
[4] https://www.theravive.com/
[5] https://www.ncbi.nlm.nih.gov/
[6] https://vdocuments.site/sexual-offenderassessment-dsm-5-proposals-modifyingsexual-offender-
assessment.html
[7] https://en.wikipedia.org/wiki/Sexual_fetishism
[8] https://psychcentral.com/disorders/fetishismsymptoms/
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FETISHISM
Abstract
Using the data, we have available, in this article we present definitions of fetishism,
predominantly from DSM V. Also, we present data on fetishism between female and male
gender, including information about the prevalence of this disorder in certain clinical studies.
Keywords: fetishism, paraphilic disorders, DSM-V
INTRODUCTION
Social fetishism can be found in DSM V within the paraphilic disorders, alongside with
other disorders such as voyeurism, exhibitionism, frotteurism, sexual masochism, social
sadism, pedophilia and transvestic.
Paraphilia is defined as any sexual and persistent interest, other than the interest for genital
stimulation or having foreplay with humans that are phenotypically normal, physically mature
and consenting partners. Also, there are certain paraphilias that are better described as
preferential than intense sexual interests. (DSM-V, APA 2013)
Therefore, we call a paraphilic disorder a paraphilia that causes the individual emotional
discomfort or dysfunction at the moment, or a paraphilia whose satisfaction involves selfharm
or the risk of harming others. (DSM-V, APA 2013).
Sexual fetishism is the state of sexual arousal that a person feels about an object or situation,
for example certain parts of the body or clothing. (Jin-hai, 2013)
In a conservative society like Korea, the confession of having a fetish is equivalent to
acknowledging that you are a sexual deviant who needs psychological treatment, even if you
do no harm to anyone. (Jin-hai, 2013). However, an increasing number of people claim that
fetishism is a private inclination that does no harm to anyone and therefore should not be
incriminated.
Fetishism is not limited to men. According to Kwon Seung-jae, 31, the fetish web site he
runs has more female members than expected (Jin-hai, 2013), especially because in clinical
samples the fetish disorder is reported almost exclusively in men. What is also important is that
it may occur concomitantly with other paraphilia, as well as hypersexuality, but it may rarely
be associated with neurological disorders. (DSM-V, APA 2013, Delcea C. (2019).
Data for the true prevalence of different types of paraphilias is limited. Most published data
consist of case reports or small case series (Ventriglio et al., 2019). Weinberg et al., (2010)
found that 88% of 262 respondents who had a shoe fetish were gay and 12% declared they are
bisexual [Eusei, D., & Delcea C. (2019)].
CONCLUSIONS
Fetishism or attraction to objects for the purpose of sexual gratification is not uncommon,
although epidemiological data are not widely available, and thus evidence is rare. (Bhat, 2006)
Often these occur in a relationship setting where both parties agree and therefore no clinical
intervention is required.
Reaching a diagnosis and recognizing stress are culturally influenced values and should be
viewed as such.
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Classics need to place these behaviors in a proper context, understand them and explore
them in a social and cultural context. (Ventriglio et al., 2019)
REFERENCES
[2] Bhat PS, Gambhir J. Fetischism. Ind Psychiatr J. 2006; 15(20): p. 136.
[3] Bondrea, A., & Delcea, C. (2019). Sexual deviations. Considerations regarding pedophilia – mith and
[6] Jin-hai, Park. Fetishism: disorder or preference? The Korea Times; Seoul [Seoul] 11 June 2013.
[7] Ventriglio A, et al., Sexuality in the 21st century: Leather or rubber? Fetishism explained, Medical
Journal Armed Forces India (2018).
[8] Eusei, D., & Delcea C. (2019). Fetishistic disorder. Int J Advanced Studies in Sexology. Vol. 1, Issue 1,
[9] Popa T., & Delcea C. (2019). Voyeurism and Scopophilia. Int J Advanced Studies in Sexology. Vol. 1,
[10] Purec, A., Delcea, C. (2019). Zoophilia. Int J Advanced Studies in Sexology. Vol. 1, Issue 1, pp. 85-92.
[11] Weinberg M, Williams C, Calhan C. (1995). If the shoe fits ... exploring homosexual foot fetishism. J
Sex Res. 1995, 32: pp. 17-28.
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2.6.2 Transvestism disorders
THE TRANSVESTIC DISORDER
Abstract
According to DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth

Edition), transvestic disorder is a form of paraphilia reported almost exclusively in men. Sexual
arousal manifested in its most obvious form – as an erection of the penis – can be associated
with transvestism in various manners. The diagnosis of transvestic disorder applies to
individuals who practice transvestism and whose fantasies about disguising in clothes that are
specific to the other sex and whose associated behaviours are always or frequently
accompanied by sexual arousal, and to whom this type of behaviour causes emotional
discomfort, or a significant dysfunction manifested clinically in various areas of their life. This
paper tries to explore the onset, the evolution, the various psychological factors that emerge as
a result the paraphilic disorder, and, respectively, the criteria used to the purpose of clinical
assessment, and the specific therapeutic approaches to the disorder.
Keywords: paraphilia, transvestic disorder, transvestism, paraphilic disorder, psychological factors, sexual arousal,
hyper-sexuality.
INTRODUCTION
It is difficult to formulate a definition of paraphilia because of the fact that – up to the present
day – it has not been possible to draw a clear line between normal and pathological
manifestations when it comes to sexual behaviour. The reason behind this issue is represented
by the evolution of sexual interests over time and has to do with cultural diversity.
Paraphilias and paraphilic disorders have existed from the very dawn of human sexuality.
Currently, paraphilias are conceptualized as deviations from sexual behaviour and are
considered to be pathologies, going beyond the sphere of personal choices and the lifestyle
options of the individual.
According to DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition)
and ICD-10 (International Classification of Diseases, 10th edition), the most common forms of
paraphilia are represented by: voyeurism, exhibitionism, frotteurism, transvestic fetishism,
sadism, masochism, paedophilia and transvestic disorder.
The term ‘transvestism’ is generally associated with the adoption of a manner of dressing
up that is in contrast with the one specific to the biological gender of the individual, regardless
of purpose. In a generic sense, it can also mean assuming the behaviour of the opposite sex.
The diagnosis of transvestic disorder does not apply to all individuals who dress in clothes
specific to the opposite sex – not even to those who do so on a regular basis. However, it applies
to individuals who practice transvestism and whose fantasies about disguising in the clothes
that are specific to the other sex are always or frequently accompanied by sexual arousal and
to whom this type of behaviour causes emotional discomfort, or a significant dysfunction
clinically manifested in their social or professional life, or in other important areas of activity.
Transvestic disorder is a specific paraphilic disorder, which is associated with the presence
of intense and repeated sexual arousal obtained by trying on and wearing clothes specific to the
opposite sex (disguise), manifested in the form of fantasies, sexual impulses, or specific
behaviours, extending over a period of at least six months. According to DSM-5, this disorder
can be associated with fetishism (in which case the sexual arousal is obtained by touching
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fabrics, materials, or clothing), or with autogynephilia (a form of sexual arousal that occurs as
a result of a man imagining himself to be his female version or of his fantasies in this regard).
The presence of fetishism decreases the likelihood of gender dysphoria in men with
transvestic disorder. However, the presence of autogynephilia increases this probability. It must
also be specified whether the disorder occurs in a controlled environment (an indicator
applicable to people living in an institutional environment or in other environments where the
possibilities of transvestism are restricted), or it is in complete remission (as a result of the
manifestation of the disorder, there have been no consequences in their social or professional
life or in other areas of activity, for at least five years spent in an uncontrolled environment).
In a psychiatric or sexological sense, transvestism is defined as a way of obtaining sexual
arousal by means of adopting the manner of dressing up that is specific to the opposite sex.
However, the disorder is recognized as such when it induces significant levels of disability
and distress.
Usually, the emergence of sexual desire does not imply the existence of a real partner, but
it is stimulated by the man’s fantasy consisting in the fact that he is both himself and the woman
with whom he is going to engage in sexual intercourse. Some men only wear a certain piece of
women’s clothing, while other dress up completely in women’s clothes, fix their hair in a lady-
like fashion, and/or put on make-up. Cross-dressing would not be a problem if the person
affected by this disorder didn’t have to resort to dressing up in the clothes specific to the other
sex in order to be able to arouse his or her sexual appetite or to experience an orgasm.
If the purpose for which cross-dressing is used – the disguise or the mimicking of the
behaviour or of the physical appearance of the opposite sex – excludes obtaining sexual arousal,
then we can speak of the following categories of persons who are excluded from the category
of paraphiliacs:
• Transsexuals – persons who are dissatisfied with their biological sex, and who want to
live permanently (or to be perceived) as having the opposite sex.
• Transgender – persons who are satisfied with their biological sex, but sometimes (or
permanently) prefer the social role or the typical behaviour associated with the opposite
sex.
• Androgens – persons who are dissatisfied with their biological sex and their gender
identity, and who obtain satisfaction from trans-sexual expression.
• ‘No Gender’ – persons who are satisfied with their biological sex and gender identity,
and who imitate the opposite sex for entertainment purposes or as a job.
• Emasculated homosexuals.
Many persons who display this habit and who fantasize about it do not meet the criteria to
be included in the pathological sphere (the behaviour must extend over at least six months).
According to DSM-5, transvestic disorder is a paraphilia reported almost exclusively in
men. Sexual arousal manifested in its most obvious form – as an erection of the penis – can be
associated with transvestism in various manners. In young men, disguise often leads to
masturbation, posterior to which women’s clothes are removed. Instead, elderly men learn to
avoid masturbation or penile stimulation, because avoiding ejaculation allows them to prolong
the time dedicated to transvestism. Men with female partners sometimes end the transvestite
episode by having sex with their partners, and some have difficulty maintaining an erection
long enough to have sex with a partner in the absence of transvestism (or without intimate
fantasies about it).
The clinical evaluation of the distress and of the dysfunction associated with transvestism
and the evaluation of sexual arousal obtained as a result of transvestisms are usually based on
the individual’s statements. The ‘elimination and acquisition’ behaviour pattern often indicates
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the presence of emotional discomfort in people with a transvestic disorder. In this behavioural
pattern, an individual who has spent a considerable amount of money on women’s clothing and
on other accessories (wigs, shoes, etc.) periodically throws away these objects in an attempt to
fight back the urge to disguise and, at a later time, begins to buy this kind of items again.
The prevalence of transvestic disorder is unknown (it is rare in men, and extremely rare in
women). Less than 3% of men admit having been sexually aroused by wearing clothes of the
opposite sex at a given moment in the past. Most men with a transvestism disorder consider
themselves heterosexual, although some individuals have occasional sexual intercourse with
other men, especially when they are in disguise.
The first signs of this orientation can become manifest in childhood and are expressed as a
fascination with a particular item of women’s clothing or with women’s clothing in general.
Puberty is the period of development of the disorder in which interest in clothes of the
opposite sex acquires an explicit sexual content and can, in some cases, lead to ejaculation.
However, the fullest intensity of the excitatory interest and manifestations associated with
this type of disorder is reached at the age of young adulthood. After this threshold, the interest
in this behaviour can diminish, as people who suffer from this disorder only get to feel a state
of well-being associated with the interest in the clothes of the opposite sex. Even so, the desire
to disguise remains the same, or it can become even stronger.
In certain cases, subjects evolve into forms of gender dysphoria and grow increasingly
interested in the female gender role. Most of them view their own sexual interest as an
egodystonic one.
In some cases, the evolution of the transvestic disorder is continuous, while in others –
episodic – thus, every so often, men with a transvestic disorder lose interest in disguise when
they first fall in love with a woman and start a relationship, but this change usually turns out to
be temporary. Practising behaviours specific to transvestism can interfere with heterosexual
relationships or – on the contrary – distract the subject from them. This can be a source of
suffering for men who want to maintain conventional marriages or emotional relationships with
their partners. If the spouse does not want to accept this behaviour, the person may develop
psychological or psychiatric disorders such as guilt, anxiety, depression, or shame.
Some characteristics of people who have this preference: they are men; mostly heterosexual;
they are married, separated from their parents, they come with a homosexual history; they are
easily aroused; they consume pornography; they have a higher masturbation frequency than
the average; they like to experience pain during intercourse.
Comorbidities
Transvestism is often found in association with other paraphilias: fetishism, exhibitionism,
voyeurism, masochism. A vast part of the partners of those who suffer from this disorder know
about the existence of the behaviour. It is generally associated with hyper-sexuality. In a high
percentage of fatal cases, a special form of masochism, self-erotic asphyxia, is associated with
transvestism.
There are several theories concerning the aetiology:
• Some scholars claim the existence of psychogenic determinants: e.g., according to the
classical theory of conditioning, the source of the disorder lies in a strengthening
behaviour by means of associating accidental exposure to women’s clothing with a
pleasant experience.
• Considerations related to the family of origin (family constellations, relationships with
parents).
• The impact of sexual abuse in childhood.
• Psychoanalytic theories – concentrated around the fear of castration.
• There is no biological evidence to support such aetiology.
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Differential Diagnosis
Fetish Disorder: A distinction needs to be made in case of this disorder and that of the
transvestic disorder – to which it is similar – especially in men who display fetishism and who
wear women’s underwear while masturbating. The differentiation depends on the particular
ideation of the individual during such an activity (men who display transvestic disorder rely on
the idea that they are a woman, that they are like a woman, or that they are dressed like a
woman), and the presence of other fetishes (e.g., silky fabrics, regardless of whether they are
used as clothing, or for other purpose). As specified in the diagnostic criteria, the diagnosis of
fetish disorder does not apply if the fetish objects are limited to clothing worn exclusively
during disguise (specific to the transvestite disorder), or if the object used is a genital
stimulation device intended for this purpose (e.g., a vibrator).
Gender Dysphoria: Individuals who suffer from the transvestic disorder do not claim
inconsistency between the gender they identify with as a result of their own perception and the
socially attributed gender, nor do they have the desire to actually belong to the opposite gender.
Typically, these individuals do not have a history of childhood disguise behaviour that may
be present in people with gender dysphoria. Individuals whose clinical picture meets all criteria
for both transvestism disorder and gender dysphoria need to receive both diagnoses.
In transvestism, sexual arousal is obtained by dressing up in clothes that typically belong to
the opposite sex. Transvestites are not necessarily homosexuals. In reality, a survey organized
among the subscribers of the ‘Transvestia’ magazine, only 10% described themselves as
homosexuals. Transvestites usually report cross-dressing before puberty (Buhrich &
Beaumont, 1981). Buhrich and Beaumont also state that cross-dressing is often accompanied
by fantasies related to slavery (being bound or dominated by someone).
Both men and women can adopt clothing specific to the opposite sex, but it seems that men
only do it with a view to obtaining intense sexual sensations. Male transvestites need not
necessarily suffer from gender dysphoria. They may be perfectly happy as men, but they love
to wear the clothes specific to the opposite sex.
Defining transvestism as sexual behaviour, rather than as a manifestation of gender
dysphoria, Levine and Lothstein (1981) stated that all transvestites are men. Money (1981)
agreed. He found that women, who dress like men, whether they are heterosexual, lesbian, or
transgender, simply feel more comfortable in men’s clothing and do not feel sexually aroused
by performing this action.
Assessment: the clinical interview, focusing on the detailed description of the behaviour
related to the preferences regarding clothes, and the connection between it and the sexual
arousal. If sexual arousal does not occur during a cross-dressing experience, the clinician will
not diagnose the person as suffering from transvestic disorder. However, there is a need to
investigate elements related to gender dysphoria, transsexuality and/or gender identity issues.
Secondly, the existence of a certain level of distress associated with cross-dressing
behaviours must be clarified. The description of the sexual history of the client will include
medical information, psychiatric evaluations, family background information, the history of
the psychosexual development of the person, the history of substance abuse, his relational
history, the social evaluation of the person, his educational and occupational history, his
previous criminal problems (if applicable), his other sexual dysfunctions, comorbidities, other
paraphilias, or the history of sexual violence (if any).
There are no psycho-diagnostic tools specific to trace this disorder, but MMPI or Millon
Clinical Multiaxial Inventory intelligence tests or personality profiles can be used. Attention
must be drawn to the relationship between cross-dressing and the level of distress associated
with it. Therapy or medication may reduce the negative impact of arousal preferences on an
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individual’s relational life, but in most cases, the arousal caused by the preference for women’s
clothing cannot be inhibited completely.
Therapeutic intervention
Various therapeutic approaches can be used – relapse prevention, distress reduction,
dialectical behavioural therapy, psychoanalytic therapy (relational psychoanalysis). The
purpose of therapy may be to change the excitatory preference (the elimination of the behaviour
is not achieved, but the forms of manifestations can be improved), or to reduce the distress
associated with the behaviour. The medication that can be used for such purposes includes
SSRIs, buspirone (a serotonergic anxiolytic suitable thanks to its good tolerance), and hormone
therapy (in extreme cases).
Clinical example in Practical Guide to Paraphilia and Paraphilic Disorders (Richard
Balon), for transvestic disorder: male in his 30’, single, working as a programmer annalist. He
comes to the practice with the view ‘to get help with his «so-called behaviour problem»’, as he
puts it. He states that – as far as he can remember – he has had a preference for women’s
clothing, especially for underwear. Wearing women’s underwear excites him, causing his penis
to become erect and sometimes leads to ejaculation. He is happy that he was born as a man,
and he does not feel that his sexuality is not in order, although he has occasionally wondered
what it would be like to be a woman, and how is a sexual experience perceived from a woman’s
perspective, and what is it ‘that they feel differently’. He has never deemed his own behaviour
to be problematic. He has been able to have regular sex with several friends, ‘although
sometimes I felt more aroused by wearing women’s lingerie than in regular conditions’ –
according to his statements. Some of his sexual partners were familiar with his preferences and
tolerated them. The man said that because he was not careful enough, and he walked around
the house nonchalantly dressed in women’s clothes, some of the neighbours noticed him, and
rumours about his habits began to spread quickly in the neighbourhood. Some children called
him ‘a faggot’ during his jogging activity, and some adults asked him whether he had deviant
behaviour or not. Eventually, rumours reached the man’s employer – who wanted a
clarification about his behaviour and who began to fear for the company’s good reputation. The
man has become increasingly anxious and slightly depressed, worrying about his own safety
and job. His work performance has dropped. He said that he felt like he needed to come together
and to turn back into the person that he used to be before being faced with the public exposure
of his sexual preferences. He was more concerned about job performance than about his own
sexual preferences, claiming that the former was actually the core to his personality. He agreed
to begin a cognitive-behavioural therapeutic process and to see how he would react to the
administration of buspirone, starting with a dose of 10 mg/day and that would gradually be
increased to 30 mg/day. However, he cancelled his second appointment and decided to leave
the community. He found a new job in New York, where people are more tolerant, and where
‘the individual can remain anonymous more easily’.
The therapeutic intervention develops over the following stages: stabilization, clarification,
coping with the behaviour, respectively transfer of the behaviour. These steps complement each
other, and the approach needs to remain flexible. Depending on the client’s availability, it is
possible to switch from one objective to another and to further proceed with a temporary return
to the avoided objective, respectively to a final integration.
Stabilization: in the first phase, any intervention aims to identify and activate the client’s
resources needed for the purpose of the therapeutic work. Clinicians should prioritize signs or
risks related to (sexual) violence or self-punishing behaviours. In these cases, a risk assessment
must be made. There are situations in which psychiatric interventions may be necessary. It is a
good time to sign a written form of therapeutic commitment, and to build up situational control
techniques, and to activate the resources that may be useful to the clinical healing process
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(places, people or activities that can help the patient refrain from implementing his hypersexual
urges). In addition to activating the client’s resources, the proposed objective for the therapeutic
intervention is also very important. The premises for a therapeutic alliance are being defined
as a starting point for further therapy.
Clarification: in this second phase, a deeper understanding of the client’s behaviour must
be intended. It starts with a behavioural analysis, by identifying the factors that have generated
and maintained the problematic behaviour, followed by a functional analysis: which area is the
behaviour oriented to: the search for pleasure and sensations / the reduction of tension and
anxiety / the avoidance of negative emotions / boredom management / the reduction of social
distance or of social isolation / the need for gaining more social approval? Together with the
client, the mechanisms underpinning the manifestations of hyper-sexuality are evaluated.
Sometimes the process generates distress because it exceeds the client’s threshold of conflict
tolerance. For this reason, techniques for clarification of the reasons that lie behind the disorder
must be alternated with those for activating resources, in such a way as to avoid resistance and
the termination of therapy. At the end of the process, a sort of individual profile is obtained.
The interventions that will be applied in the next stage of therapy must be correlated with
this hypothesis. Motivational aspects must also be investigated. Usually, clients resist when it
comes to changing their hyper-sexual patterns, because certain short-term consequences are
inherent. When the client has decided that he is motivated to change, he moves on to the next
phase. Numerous studies Delcea C, Enache A, Stanciu C; Delcea C, Enache A, Siserman C,
Gherman C, Enache A, Delcea C, Delcea C, Fabian A. M, Radu C. C, Dumbravă D. P, Rus M,
Delcea C, Siserman C, Siserman C, Delcea C, Matei H. V, Vică M. L., Gherman C, Enache A,
Delcea C, Siserman C, Delcea C, Siserman C, confirm our results.
Coping with the situation: In this stage, clients learn specific skills to address their own
problems. In some cases, the focus may be on stress management, as clients learn which are
the strategies that they can apply to solve their issues. There are also clients who need to learn
to deal with negative emotions and impulsivity. In this case, approaches such as emotional
psychoeducation, mindfulness, and/or experiential methods are used. These usually involve
(also) the activation of negative emotions. Therapeutic tasks (such as beginning emotional
diaries or writing letters) can be assigned to clients. For clients who face communication
problems in relationships, communication improvement techniques are used with a view to be
increasing the level of closeness between the partners and achieving a high level of relationship
satisfaction. When necessary, sex education or relational advice can be integrated in the
approach. In these situations, it is preferable not to work with the client alone, but with his
partner as well, should both partners be willing to engage in therapy.
Transfer: Finally, we teach clients how to transfer the knowledge gained in therapy in
situations that they face in their own lives. The stressful stimuli and the elements that activate
the anxious responses are reviewed. Clients must also be prepared for failure, while avoiding
catastrophic thinking. We remind clients to contextualize each incident as a chance to learn
something important about his own inner mechanisms. Therefore, in order to be effective,
treatments aiming at managing paraphilic disorders must be performed in the long term, while
realizing that the unwillingness by the client to observe the prescribed treatment will hinder the
healing process.
CONCLUSIONS
When it comes to fulfilling sexual needs and desires, people prove to be very creative.
However, it is imperative that their materialization should be manifested within the limits
of social acceptance or based on the consent of both partners. Many people have atypical sexual
fantasies, but in the case of paraphilias, atypical sexual acts become the main form of arousal.
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As we have marked out in this paper, the diagnosis of transvestic disorder does not apply to
all people who wear clothes specific to the opposite sex, as many persons who display this
habit and who fantasize about it do not meet the criteria to be included in the pathological
sphere (the behaviour must extend over at least six months). Instead, it applies to individuals
who practice transvestism, and whose fantasies about disguising in clothes that are specific to
the other sex and whose associated behaviours are always or frequently accompanied by sexual
arousal, and to whom this type of behaviour causes emotional discomfort, or a significant
dysfunction manifested clinically in various areas of their life.
REFERENCES
[1] Balon, R. Practical Guide to Paraphilia and Paraphilic Disorders. Transvestic Disorder. Pp. 171-186,
2016.
[2] DSM-5, Manual de Diagnostic şi Clasificare Statistică a Tulburărilor Mintale. Editura Callisto, 2016.
[3] ICD-10, Clasificarea Tulburărilor Mentale şi de comportament. Bucureşti: Editura Trei, 2016.
[4] Seligman, L. Hardenburg, S. Assessment and treatment of paraphilias. Journal of Counseling and
Development: JCD; 78 (1). P. 107, 2000.
[5] Krueger, R. Kaplan, M. Paraphilic Diagnoses in DSM 5, College of Physicians & Surgeons, Department
of Psychiatry and Sexual Beshavior Clinic.
doi: 10.4172/2471-4372.1000140.
4372.1000160.
2019.Vol. 61, pp. 45-55. DOI 10.1016/j.jflm.2018.10.005.
DOI:10.4323/rjlm.2019.279.
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THIRD SECTION
MISCELLANEOUS
CLINICAL COMORBIDITY
Abstract
We have included a possible definition for clinical comorbidity, differences between

comorbidity and multimorbidity and the areas in which we can meet this concept from the
perspective of the data available to us.
Keywords: comorbidity, multimorbidity, DSM
INTRODUCTION
Comorbidity is associated with poorer health outcomes, more complex clinical

management, and increased costs for health care. However, there is no agreement on the
meaning of the term, and the related constructions, such as multimorbidity, morbidity burden
and patient complexity, are not well conceptualized. The value of a given construct lies in its
ability to explain a certain phenomenon of interest in the fields of (1) clinical care, (2)
epidemiology or (3) health care planning and financing.
Mechanisms that may underlie the coexistence of 2 or more conditions in a patient (direct
causation, associated risk factors, heterogeneity, independence) are examined and the
implications for clinical care are considered as well (Ritchie, 2007, Delcea C, et al., 2017,
2018).
Several definitions have been suggested for comorbidity based on different
conceptualizations of a basic concept: the presence of more than one distinct condition in an
individual. Therefore, 4 major types of distinctions are made: (1) the nature of the health
condition, (2) the relative importance of the conditions that appear, (3) the chronology of the
presentation of the conditions and (4) extended conceptualizations. (Fortin, 2007)
Differentiating the nature of conditions is essential for conceptualizing comorbidity,
because the simultaneous occurrence of poorly defined entities can signal a problem with their
own classification system. For example, some would argue that depression and anxiety are not
separate entities but are part of a spectrum and, if so, patients with both should not be classified
as having comorbidity. (Valderas, 2009)
CONCLUSION
In psychiatry there would be a particular example of multimorbidity, in which two distinct

disorders coexist, without any implicit ordering, for example, severe mental illness and
substance abuse.
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REFERENCES
[3] Delcea C, Enache A, Stanciu C. Assessing maladaptive cognitive schemas as predictors of murder. Int
J Ment Health Psychiatry. 2017; 3:1.
Accused of Murder and those who have not Committed Murder. Int J Ment Health Psychiatry 3:1. 2017.
[5] Fortin M, Soubhi H, Hudon C, Bayliss EA, van den Akker M. Multi-morbidity’s many challenges. BMJ.
2007; 334(7602): pp. 1016-1017.
[6] Ritchie C. Health care quality and multimorbidity: the jury is still out. Med Care. 2007; 45(6): pp. 477-
479.
[7] Valderas JM, Starfield B, Sibbald B, Salisbury C, Roland M. Defining comorbidity: implications for
understanding health and health services. Ann Fam Med. 2009; 7(4): pp. 357-363.
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SEXUAL AVERSION
Abstract
Sexual aversion is a phobic reaction often involving trauma, not necessarily related to sexual
abuse or rape. It consists of avoidance of sex related stimuli that have been associated by the
patient with distressing experiences. It leads to sexual dysfunction for either male or female,
and it can have a tremendous impact on a person’s life. This article investigates the etiology,
evolution and factors the construct implies and explores some treatment considerations.
Keywords: sexual aversion, lack of sexual interest, anxiety, sexual disgust
INTRODUCTION
Sexual aversion is the effect of past traumatic experiences involving the body: history of
physical, sexual and emotional abuse (with chronic PTSD associated symptoms), unresolved
internal conflicts concerning sex and sex related behaviors, improperly integrated gender
identity, emotional discomfort with pleasure, negative beliefs about gender role,
femininity/masculinity. It is often defined as a phobic reaction depending on its severity, or at
least it is associated with anxiety and correlated discomfort.
The notion implies the reluctance in engaging in sexual activities and an overall decrease in
sexual interest and drive. It is triggered by cognitions, actual life situations and it can vary in
severity, with extreme levels of panic, disgust and revulsion (Foley et al., 2012). It results in
either the absence of sex (eroticism and sexuality are repressed and excluded from the
individual’s conscious life) or in dissociative sex or acting outs (in the event sex cannot be
excluded entirely, the emotional experience is nevertheless numbed). The prevalence of sexual
aversion is difficult to trace because such patients avoid couple and sex therapy, unless there is
pressure by the partner (Metz et al., 2018). Once diagnosed, it is relatively difficult to address
in conventional forms of therapy.
Theoretical perspectives
When first included among the DSM dysfunctions in 1987 in DSM-III-R (American
Psychiatric Association, 1987), sexual aversion received the following definition “persistent or
recurrent extreme aversion to, and avoidance of, all or almost all, genital sexual contact with a
sexual partner”.
DSM-IV-TR (American Psychiatric Association, 2000) extended the definition and stressed
the idea that (even the perspective of) having any sexual contact was associated with fear,
anxiety, and disgust. Also, a wide range of stimuli and behaviors were meant to evoke aversion,
ranging from a very specific aspect related to sexual intercourse (e.g., genital fluid) to almost
all stimuli or behaviors that may be involved in sexual activities (kissing, touching, cuddling
included). Symptoms of (extreme) anxiety/panic and avoidance behaviors were described as
signs of severe sexual aversion. Interestingly enough, DSM-IV-TR also indexed another
dysfunction which dealt with hypoactive sexual desire (Hypoactive Sexual Desire Disorder,
HSDD), which is not limited to sex with someone else, but is also related to having less sexual
desire, fantasies, and urges to self-pleasure.
As DSM turned the page and reached its 5th edition, sexual aversion disappeared from the
list of sexual dysfunctions, which is quite interesting as it surely did not disappear from
people’s lives.
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The why might be explained by a theoretical struggle between specialists regarding the
nature of the problem. Questions arose: what is the nature of sexual aversion? And the answers
taken into consideration were phobic related, or sexual cored. Another aspect that needed to be
investigated were the differences between this construct and HSDD. Because there was not
enough evidence to support sexual aversion as a distinct category, researchers returned to
studying its roots.
Mary Kaplan in 1987 explained the phobic characteristics of sexual aversion. Consistent
with this conceptualization, individuals diagnosed with SAD (Sexual Aversion Dysfunction)
are known to avoid of all shapes and forms of sexual contact within a large spectrum. In
addition, fear, anxiety, and disgust, have been considered prominent features of aversion in the
DSM-IV-TR, which further stresses the similarities between specific phobias and SAD.
As far as research is concerned, there is one study quoted on the subject which involved
4.147 subjects. The sample is considered representative for the adult population of Netherlands,
ages 19-69. Performed online by Bakker & Vanwezenbeek, 2006, apud Borg et al., 2014 it
used a validated DSM-based questionnaire and demonstrated that over 30% of the participants
reported experiencing sexual aversion at some point in their lives, out of which 4% met the
criteria for SAD. In terms of prevalence the percentage were similar to those related to
dyspareunia (5%). Moreover, women between 15 and 40 years reported significantly more
often to have (symptoms of) sexual aversion than women above 40 years of age. This is in line
with what one would expect, as disgust responding and corresponding avoidance decreases
with exposure to unpleasant stimuli. This also means that as they age, most women tend to get
accustomed to the stimuli in question.
When investigating the possible link between disgust and sexual aversion, there is an
increased interest on the subject (de Jong, & Weijmar-Schultz, 2010 apud Borg et al., 2014).
For instance, Rosen et al., 2000 proved that low sexual functioning as measured by the
Female Sexual Functioning Index was associated with relatively high disgust for sex relevant
stimuli. The correlation did not confirm for men. A follow-up study showed that women with
vaginismus (a DSM-IV-TR based diagnosis) scored higher on sexual disgust than women
without sexual problems. On the other hand, sexual disgust was absent in women with
dyspareunia (van Overveld et al., 2013 Study 2 apud Borg et al., 2014). This may be due to the
actual focus in this particular dysfunction. Fear of pain tends to be more important than aversion
at the prospect of actual intercourse. Congruent with the idea that disgust might play a role in
vaginismus, women with such diagnose also showed relatively strong activity of the disgust-
specific facial muscle while watching adult sexual content (Borg et al., 2014).
Trauma related literature has regarded sex aversion as a direct consequence of disturbing
and highly overstimulating interpersonal experiences. There is considerable evidence that
women who experience physical and sexual abuse commonly develop sexual dysfunction.
Their sense of safety, their ability to trust a potential intimate partner, their willingness to
open up and talk about their traumatic experience is undermined by feelings of guilt, shame,
fear of rejection. As if it wouldn’t suffice, traumatic experiences are usually topping internal
conflicts regarding sex. There might be issues concerning low self-esteem, poor body image,
inaccurate or unrealistic sexual cognitions, internal ambivalence or conflict regarding the
sexual self, fear of intimacy, and discomfort with the concept of pleasure.
Another root to the problem might be the dissociative solution some people find with regard
to their sexual behavior. One possibly takes out is the isolation of the affect when it comes to
sex (the individual protects himself by distancing the consciousness from the body) or acting
out practices (for instance latent homosexuals who engage in heterosexual relationships
avoiding sex, also have a secret homosexual active life). The picture can widen when there is
an actual physical response in the body that ties sexual activities with discomfort and/or pain
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(male and female dyspareunia, vaginismus) or there is a physiological problem that needs to
be addressed with the help of the MD.
As a defense meant to word off emotional conflict regarding sexuality, many people reject
sex entirely. They don’t self pleasure, they are out of contact with their body and can prove
unexperienced and fearful when it comes to remediation of sexual skills. Guilt and shame
become of huge importance. Guilt has been of central importance to an understanding of mental
life since Freud proposed it as the precursor of conscience. Psychoanalytic writers have
emphasized that guilt plays a healthy role in shaping people’s values and capacity to love, while
also noting that an excess of guilt – particularly unconscious guilt – can contribute to problems
as diverse as depression and psychosomatic diseases.
Therapeutic challenges
As stated above, once diagnosed sexual aversion proved to be very difficult to address in
the clinical practice. There are a number of choices.
CBT, for instance which is used with positive results in the common treatment for sexual
dysfunction could be an option for both individual therapy as well as group support.
In the core interventions for sexual aversion in individual meetings a therapist can rely on
cognitive behavioral strategies adapted from anxiety and anxiety related protocols. There are
many directions to follow depending on the aim of the treatment:
1) Strategies that target a reduction in fear (of penetration, sex related anxiety):
a. CBT for fear related cognitions.
b. Exposure therapy targeting behavioral avoidance (anxiety protocols).
c. Systematic desensitization using behavioral hierarchies of sexual activities (to reduce
anxiety before addressing arousal or orgasmic issues).
d. Mindfulness-based interventions – increasing awareness of sexual responses,
decreasing judgment toward these responses, and reducing the effect of distractions (by
viewing them as mental events not necessarily needing to be attended to).
2) Avoidance behavior
Although anxiety and fear are mentioned to play a role in sexual dysfunctions, and treatment
efficacy supports the use of CBT targeting relevant fears and anxiety, it would be useful to
better understand the specific effects of anxiety on sexual avoidance to identify specific
mechanisms that can be addressed in the clinical practice. For example, reduction in coital fear
among women with vaginismus is changed through addressing avoidance behavior.
Cognitive models that incorporate individual differences with regard to beliefs about anxiety
and sexuality may be useful in explaining the diversity of situations confronted by the therapist.
A combined diagnostic approach, examining individual differences in belief systems can
help expand our understanding of the etiology of sexual dysfunction and lead to the
development of interventions that are based on established research findings rather than clinical
intuition. As far as anxiety and sex are concerned, correlational analysis suggests that anxiety
sensitivity is associated with greater sexual functioning difficulties in both women (Gerrior,
Watt, Weaver, & Gallagher, 2015) and men (Tutino, Shaughnessy, & Ouimet, 2018).
Experimental research manipulating anxiety sensitivity (by inducing beliefs about
physiological sensations and their consequences) is needed to determine whether and to what
extent anxiety sensitivity determines sexual avoidance and other aspects of sexual response.
Returning to the privacy of the therapist’s office, the patient needs to learn how to relax and
develop a sense of safety, empowerment, as well as skills to manage the phobic reaction
(mindfulness techniques). A progressive approach is using sensate focus which allows the
patient to develop a connection with his body and stay in the moment, wording off anxiety and
having a complete sense of control over the sexual encounter (Weiner & Avery-Clark, 2017).
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This way the client relies on a good base for developing a sense of safety and an increased
interpersonal connection to the partner. Awareness of pleasurable sensations is important, as
the patient needs to disconnect the brain wiring from the traumatic associations. This way, as
his mind recognizes the experience as being good, it will allow access to it, further exploration
as well as a diminished stress response.
While doing cognitive restructuring of the anxious associations to sex, behavioral strategies
help developing skills modify aversive reactions as well as build an authentic intimate
relationship with the partner.
Another approach is group CBT therapy consisting in sex education; couple sexual
intimacy-exercises; sensate focus; communication skills training; intimate communication
skills training; sexual fantasy training; cognitive restructuring; and various homework
assignments, including relevant readings. Literature also mentions orgasm consistency training
which might comprise of directed masturbation literacy; “ladies cum first” rules; and the use
of CAT (coital alignment technique) to ensure direct clitoral stimulation by the penis during
intercourse. All this can be used after the tolerance to sexual stimuli has grown and a sexual
encounter isn’t seen as threatening as initially was.
Sometimes, teaching someone how to do things right and working with cognition isn’t a
predictor for success. Usually, traumatized people understand perfectly what they need to do
in order to address their sex issues, but the traumatic affect remains unaddressed and lost in
translation. This is where individual/group trauma therapy, or talk therapy may be a more
appropriate choice, because this way the traumatic content itself can be emotionally integrated.
When overwhelming stressors occur acutely or chronically, there is a natural response of
the body and mind (both physiologically and psychologically) which implies numbing,
avoidance, amnesia and anhedonia bypassed by sporadic presences of affect and memory,
hyper reactivity to stimuli and traumatic re-experiencing (Horowitz, 1986).
The numbness is about avoidance, detachment, emotional constriction and depression.
Because of the high level of fear a traumatized person gradually revisits the event for limited
periods of time, either directly or indirectly, until it is mastered or integrated. The link between
trauma and sexuality is mediated by the phenomenon of dissociation.
Dissociation is a safety-oriented cognitive mechanism in which the individual attempts to
avoid memories or affect that alter the psychic equilibrium. With dissociation there may come
reality detachment – isolation of affect, events are perceived without emotions, the self
becomes robot-like and others are seen as emotionless objects. Thus, dissociation serves the
function of creating a distance, an empty space between the traumatized person and the rest of
the word since closeness and/or dependency may be seen as dangerous by the traumatized
person.
Also, distancing oneself allows the individual to maintain the depersonalized state, and
therefore not think or feel about past traumatic events. Braun (1988) has conceptualized
dissociation of behavior, affect, sensation and knowledge (or cognition) as the BASK model.
As far as the compulsive behavior is concerned it becomes a reenactment of the original
trauma. A part of self will revisit the experience of the abuse time and time again, to repeat the
danger and excitement, in an attempt to complete the flight, fight, freeze response cycle.
Dissociation of affect might include experiencing terror, numbness or confusion without
any apparent cause, or affect not correlated to the present situation. Dissociation of sensation
may include numbness, headaches or sickness or pain in the physical body with no medical
explanation.
The sensations of the body with sexually traumatized people are particularly subject to
dissociation because of the irrational belief that the body is responsible for their misfortune.
It’s because of my gender /sex role / body / femininity that I was abused. Other examples of
dissociation are the out-of-body experiences (while having sex the individual “leaves” the body
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and watches from above/the side, thus feeling numb). The cognitive system shuts down, and
the individual then disengages each time he or she has sex lending the “body” to the partner.
Another critical component of dissociation is fragmentation of personality and the self.
Whenever a traumatic situation occurs, the event is entrapped by the dissociative process
and separated from the rest of a person’s life. There is some exchange of information with the
external reality and memories come back as flash-backs or dreams.
Typically, when there is severe early trauma, a part of the self becomes a machine that has
endured the abusive experience, and another one holds the affect: rage, sadness which cannot
be expressed. Because of the splitting in personality, which once allowed the survival of the
individual, the here and now self might struggle among conflicting needs. These parts of self
may act autonomously encouraging selfdestructive behavior. That’s why obsessions and
compulsions provide a relief from the pain of disconnection and chronic dysphoria.
The acting-out behavior and revictimization of self is a form of masochism, known to be
one of the long-term effects of severe early abuse and neglect. Ultimately, resolution of past
trauma and integration of the split off parts of self are essential to stop the self-destructive
behavior.
CONCLUSIONS
As often the case with sexual dysfunction, the best approach to the problem is a combined
effort to develop and awaken the hidden resources of the patient asking for help. Cognitive,
behavioral, pharmacologic or talk therapy treatment options are helpful to reduce the aversive
response to sexual cues. Because sex aversion quickly becomes a relationship breaker, the full
support and engagement of the partner is a must.
Numerous studies Delcea C, Enache A, Stanciu C, [17], Delcea C, Enache A, Siserman C.
[18], Gherman C, Enache A, Delcea C. [19], Delcea C, Fabian, A. M., Radu, C. C, Dumbravă
D. P. [20], Rus M., Delcea C., Siserman C, [21], Siserman, C., Delcea, C., Matei, H. V., Vică
M. L. [22], Gherman, C., Enache, A., Delcea, C., Siserman C., [23], Delcea C, Siserman C,
[24] confirm our results. The members of the couple collaborate to engage in positive and
affectionate sexual expression, working as an intimate team to counteract conditioned
traumatic responses (Calhoun & Tedeschi, 2006).
REFERENCES
[1] American Psychiatric Association. (1987) – Diagnostic and statistical manual of mental disorders (3 rd
ed., rev.). Washington, DC: Author.
[2] American Psychiatric Association. (1994) – Diagnostic and statistical manual of mental disorders (4 th
ed.). Washington, DC: Author.
ed., text rev.). Washington, DC: Author.
ed.). Arlington, VA: Author.
[5] Borg et al., (2014) – Sexual Aversion and the DSM5: An excluded disorder with unabated relevance as
a trans-diagnostic symptom, Archives in Sexual Behavior, July, 2014.
[6] Braun, B.G., (1988) – The BASK Model of Dissociation, Dissociation 1:1, March 1988.
[7] Calhoun, L. & Tedeschi, R. (2006) – Handbook of posttraumatic growth. Mahwah, NJ: Erlbaum.
[8] Foley, S., Kope, S., Sugrue, D. (2012) – Sex matters for women (2nd Ed.), Guilford, New York.
[9] Gerrior, Watt, Weaver, & Gallagher (2015) – The role of anxiety sensitivity in the sexual functioning of
young women, Sexual and Relationship Therapy, vol. 30, 2015, issue 3.
[10] Horowitz, M.J., 1986 – Stress-response syndromes: a review of posttraumatic and adjustment disorders,
Hospital Community Psychiatry, March.
[11] Kaplan, H. S. (1987) – Sexual aversion, sexual phobias, and panic disorder. New York: Brunner-Mazel.
[12] Metz, M., Epstein, N.B., McCarthy, B. (2018) – Cognitive-behavioral therapy for sexual dysfunction,
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Routledge Ed., New York.

[13] Rosen, R., Brown, C., Heiman, J., Leiblum, S., Meston, C., Shabsigh, R., et al., (2000) – The Female
Sexual Function Index (FSFI): A multidimensional self-report instrument for the assessment of female
sexual function. Journal of Sex and Marital Therapy, 26, pp. 191-208.
[14] Tutino, Shaughnessy, & Ouimet (2018) – Looking at the bigger picture: young men’s sexual health from
a psychological perspective, Journal of Health Psychology, Volume: 23 Issues: 2, pp. 345-358.
[15] Weiner, L., Avery-Clark, C. (2017) – Sensate Focus in Sex Therapy. The illustrated manual, Routledge
Ed., New York.
doi: 10.4172/2471-4372.1000140.
4372.1000160.
[19] Gherman C, Enache A, Delcea C. The multi-factorial determinism of forensic expertise regarding
2019.Vol. 61, pp. 45-55. DOI 10.1016/j. jflm.2018.10.005.
[20] Delcea, C., Fabian, A. M., Radu, C. C, Dumbravă D. P. Juvenile delinquency within the forensic context.
[21] Rus, M., Delcea, C., Siserman C. The relationship between emotional distress and neuroticism at the
operational personnel of ambulance services. Rom J Leg Med 27(3) pp. 279-284 (2019). DOI:10.4323/
rjlm.2019.279.
[22] Siserman, C., Delcea, C., Matei, H. V., Vică M. L. Major affective distress in testing forensic paternity.
Rom J Leg Med 27(3) pp. 292-296 (2019). DOI:10.4323/ rjlm.2019.292.
[23] Gherman, C., Enache, A., Delcea, C., Siserman C., An observational study on the parameters influencing
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OBJECTUM SEXUALITY OR OBJECTOPHILIA
Abstract
“Loving Objects” a category of peoples that explores the formation of a newly named sexual
orientation, also called objectum-sexuality (OS), are the one who openly declare their desire
for objects, loving the objects not like a fetishism, like an amorous partner, even life partners.
The fallow material examines some aspects regarding OS behaviour, how they interact in
the online environment with the rest of the world, how they perceive sexual intimacy and what
rights they demand, the fact that it represents a non-specific paraphilia and that it has links with
autism and synesthesia.
Keywords: objectum-sexuality, intimacy, synecdocal marriage, autism, syneasthezia, non-specific paraphilic disease
INTRODUCTION
Objectophilia or objectum-sexuality is a form of nonspecific paraphilia. The objectophiles

are sexually and emotionally attracted to inanimate objects. But the objects must have a certain
meaning for them (a special pillow) or to have a massive structure (Turn Eiffel, Berlin Wall),
or be famous (rollercoaster “1001 Nachts”). In addition to sexual attraction, the objectophiles
or objectum-sexuality (OS) have strong feelings of love and marital commitment to certain
objects or structures of their fixation. The object-sexual individuals believe in animism (Love,
1992), and sense reciprocation based on the belief that the loved objects have souls, are
intelligent, can have feelings and even are able to communicate.
Research has shown that OS individuals were discovered with the establishment of an
Internet network (In 2002, in Germany, Oliver Arndt, created an active network called
Objektophilie) that aimed to connect all those who had this preference. But from what has been
observed the study of belletristic, in “The Hunchback of Notre Dame”, (Hugo, V., Cobb W.,
1965), Quasimodo was passionate attachment to the bell of the cathedral and spend romantic
time with the bell. That means the OS specimens exist even before internet connection appear.
But going further in the past, we find an example in the myth of Pygmalion’s love where is
shown that he loves a statue from where the “pygmalionism” (known as statuophilia,
aglamatophilia, galateism) was coming, which refers to a sexual attraction to statues, where
Pygmalion wish that statue to become his wife, which may indicate emotionally implication
more than a fetish (Love, 1992).
Objectum Sexuals are similar in that they love objects but they have a variety of responses
in these actions and the way in which they view their relationships. Some of them sense gender
in objects and the others don’t. Some have gender preferences on their objects, some don’t.
Some feel they are sensing the gender the object wants to convey, others don’t feel that way
at all. But a distinction is made between the OS individuals that are biologically female, who
call themselves “objectum sexuals” and those biologically male born natively, who call
themselves “mechasexual” (Marsh, A. 2009).
Experiences of communication, emotions and feelings in rapport with the object vary too,
that for some people feel a good communication, the object feels and answer with the same
emotions, a great deal, with reciprocity but others do not experience the same (Marsh, A. 2010).
Even the choice of a single object as monogamy or of several objects as polygamy is varied
from one to another, some of them said that they like to have multiple object relationships at
the same time, making love with more object, considering themselves poliamory, the other has
just one lover, being faithful and responsible only for that relationship.
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Some say that they have been attracted to objects since they were children, others only that
after certain events in life they have adopted this type of attraction. Objectum Sexuals become
aware of their object attraction at different stages of their lives. For many of the Objectum
Sexuals, OS the lack of proximity is the main problem, also lack of intimacy, the inability to
express freely sexually in the pubic with that public object makes intimacy quite difficult. Have
long distance relationships with public objects and also long-time relationships make the hard
moments to express love.
Amy Marsh has done some studies with those of the OS who were willing to participate and
when they were asked, “If you are in a long-distance relationship, do you feel you can
sometimes or always sense or communicate with your lover?” some peoples answered that was
not applicable to their situation, because their objects were near them always, and they could
love and communicate easily, but some of them was not sure. The rest of the answers were
affirmative, the feelings of communication is easy possible because they use a pictures and
photos, they have videos recorded, and alsoa a talisman, the small amulets and figurines in
various sizes with which they can have sex. Even if it’s a long-distance relationship, it doesn’t
stop them, they make amulets, pictures and all kinds of other souvenirs to keep the lover
around. Intimate life is not considered masturbation or self pleasuring, it is considered sexual
intercourse because the object lover is always present on the act of pleasuring like a person.
Human rights, Privacy, Problems, Proximity

Lack of social acceptance for Objectum Sexuality relationships (marriage with objects) is
the main problem, but also can appear other social difficulties. Objectum Sexuals faces a
number of hurdles in their pursuit of satisfying personal lives. The biggest problem which both
they and the rest of the world notice it is lack of acceptance by society, followed closely by
human abuse of beloved objects (of course, people come to visit those public monuments, some
even leave their mark by writing, or putting various signs announcing their passing). And other
problem is the inability to be publicly affectionate, caressing or kissing, or even pleasuring
with beloved objects. That why the physical proximity become a large problem but just for
those who love public monuments, (the Berlin Wall, the Eiffel Tower, the carousel 2001Nights,
landmarks, fairground rides, public transportation, or other structures and buildings). There are
also certain Objectum Sexuals that love small objects, that they have in the house and that do
not claim the problem of intimacy and proximity, but also for them the great problem of social
acceptance remains valid (Eiffel, E. 2015).
In Amy Marsh study in 2010 all of the Objectum Sexuals surveyed expressed satisfaction
with their love to objects, all are happy in the way they are. The unhappiness and stress for the
OS comes just from lack of understanding from others people, from society, and human
interference with their object relationships. Almost all of them expressed a depth emotion like
for the human being, and great commitment to their relationships, with all the emotions aspects.
Almost all feels that their feelings are acknowledged and reciprocated by the lovers
(objects).
People who identify as OS are just a sexual minority, even considered a nonspecific
paraphilia, also contends with additional challenges such as a high incidence of autism and
Asperger’s Syndrome within its ranks. Objectum Sexuality it is rare, but in the same time has
attracted a lot of attention, great deal of notoriety, but also controversy and ridiculity. That is
why they have not always been able to manage public opinion and ridicule, to deal with public
scorn. Under the guidance and advices of Erika Eiffel, Eija-Ritta Eklof BerlinerMauer the OS
joined forces and created a website and forum where all who wished could express their
opinions and wishes.
Thus, Objectum Sexuals are becoming more and more known and even demand their
acceptance in society as other sexual minorities. Sexologists, therapists, social workers,
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medical personnel and other helping professionals lack information and understanding that will
allow them to treat the OS person with the same respect and understanding, more of this they
are expected to extend OS to become members of other sexual minority groups.
According to the scientific report conducted in 2019 by researchers Julia Sinmer, James E.
A. Hughes and Noam Sagiv it was concluded that people who call themselves Objectum
Sexuals have a greater or lesser degree of autism and also have a complex phenomenon of
perception called synesthesia. (Julia Sinmer, James E. A. Hughes and Noam Sagiv, 2019).
The apparent link of OS to autism spectrum conditions and object personification
synesthesia should be investigated and researched more even Sinmer and co started to do that
research. That would be an important addition to the study of human sexual behavior and would
benefit the autism/Asperger’s community as well as the OS community.
Until 2009 hasn’t been much research about OS, but in that time sexologist Amy Marsh
discovered the website made by Erika Eiffel and started to investigate. 21 people who consider
themselves OS was surveyed to the research. Amy found that five of them were diagnosed with
Asperger’s Syndrome, one had been diagnosed as autistic, and four identified as having
Asperger’s Syndrome but were not diagnosed with the condition.
Was the question if OS suffered traumas or sexual abuse in childhood, due to which this
kind of paraphilia was triggered? The answer was not direct related with trauma, because the
Objectum Sexuals states that they have not suffered abuse or trauma in childhood, on the
contrary that they are very happy in the way how they are now.
When Amy Marsh was invited to ABC News she said: “I can tell you that what I’m finding
is not much history of sexual abuse, and actually not much in the way of psychiatric diagnoses
either,”. “I’m finding they’re very happy, and they don’t want to change. I am also finding out
that quite a few of them have a diagnosis of Asperger’s syndrome or autism, but not
everybody.” (Snow, K. and Brady, J., 2009). Erika Eiffel was invited to ABC News where she
told that does not have Asperger’s syndrome and even, she had stressful childhood history in
foster don’t think is the reason for her loving to objects.
Under these conditions, the problem is: is it a paraphilia or can it be a new sexual
orientation? Amy Marsh states that from the research done there are certain aspects that may
incline towards a new sexual orientation. Later in 2019 it was concluded that those who are
considering themselves OS are affected by autism, Asperger’s syndrome and synesthesia. (Julia
Sinmer, James E. A. Hughes and Noam Sagiv, 2019). The tests were applied to 122
participants, 34 were OS individuals, 18 female, 5 male, 11 other and 88 controls without OS
from which 63 are female. Because Objectum Sexuals are quite extremely rare it was possible
to analyses 20 OS participants and 50 controls, that for the ethical standards laid down in the
1964 Declaration of Helsinki it is sufficient to detect differences between that two independent
proportions.
Link with autism and Asperger’s Syndrome

Usualy the people with Asperger’s Syndrome are characterized, how Dewey describes them,
by their preoccupations and consuming special interests (Dewey, et al., 2005; Attwood, 2004).
That why the objects that attract OS may also serve as special interests for them, for the one
that been diagnosed with autism.
The research conducted in 2019, aimed at differentiating between OS and control persons
in terms of attention to details, social skills, attention switching, communication and
imagination. Conclusion was that OS individuals had significantly more diagnoses of autism
and Asperger’s Syndrome, compared to published epidemiological data from the general
population.
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In conclusion it was observed that rates of diagnosed autism were over higher in Obiectum
Sexuals individuals than otherwise expected. Most results and information about the
appearance of autistic manifestations in OS have been revealed by the scale Social Skills where
the Os find social situations difficult or unenjoyable, and that why they prefer objects over
humans. The poor inter-human relationships are the most relevant aspects that makes OS
individuals to develop relationships with objects. Although there may be a hypothesis that the
lack of social skills may be the contributing factor or a consequence of relationships of OS with
objects.
In 1992, psychologists De Silva and Pernet study an Objectum Sexuals that call himself the
mechasexual, the real name George. They described George as being shy boy, having no social
life, he still lived at home with his parents, having no friends, lacking in social skills, and he
was interest just for cars. Also, his “major preoccupation had been with children and adult
women urinating.” In Gorge’s sexual life his interest was in Austin Metro cars, and he preferred
to masturbate in or behind them. De Silva and Pernet view George as a person who shares some
of the features of Asperger’s Syndrome. It was the moment to the entry of Asperger’s
Syndrome in the DSM IV. (De Silva, P., & Pernet, A., 1992).
Link with syneasthsia Obiectum

Sexuals relationships feel natural and appropriate to those who have attraction to objects too
and considers it is obvious to have a happy marriage with the inanimate object they love: “They
are real. They are complex. They are no less and no more of value than other romantic
relationships.” (Marsh, 2010). Starting from this statement it is clear that beloved objects are
animated, are alive for the Objectum Sexuals. How can be that possible?
In 2019 researchers Julia Sinmer, James E. A. Hughes and Noam Sagiv, they investigated
by submitting to the Test for Object-personification synaesthesia, both OS individuals and
control persons. During this test, OS participants had rated the personality of their object-
partner, the controls rated the personality of their ‘most-loved or favourite object’. OS
participants were significantly more consistent over their object-personality descriptions than
controls, which led to the hypothesis that Objectum Sexuals feelings might stem from object-
personification synaesthesia. (Julia Sinmer, James E. A. Hughes and Noam Sagiv, 2019).
Object personification synesthesia is a form of synesthesia that detects personalities in
objects (Smilek, D., Malcolmson, K., Carriere, J., Eller, M., Kwan, D., & Reynolds, M. 2007).
This may be the most scientifically accessible explanation for experiences of object
personality and reciprical affection reported by some objectum sexuals. Objectum sexuality
could then be understood as an affectionate and/or eroticized response to the object
personalities detected through synesthesia.
In the research it was an observation that shown in the be that the tests for assigning the
personality of the letters or numbers OS have the same results with the controls, which could
mean that OS are not better memorisers of personalities in general, but tend to have genuine
object-personification synaesthesia for some specific objects.
In the Marsh survey was not ask questions about synesthesia, but though one OS person
reported the ability to sense temperature at a distance that might be considered a form of
synesthesia. This is the potential link between Objectum Sexuality and object personification
synesthesia.
CONCLUSION
The most mysterious aspect of Objectum Sexuality is that many of OS people sense
personality, sense also reciprocal feelings and/or energy that comes from the object or objects
they love, and that big problem is that this biggest reason that OS invoke, the society and people
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ridiculed. One respondent of survey said, “We are not freaks, nor are we fetishists. Our lovers
are living beings that communicate, and love us back. Contrary to popular belief, machines and
other objects do have souls. This is what our relationships are based off of, and they’re not
entirely sexual.” Numerous studies (Delcea C, & Siserman C,) confirm our results. While some
in the OS community will talk of animism and similar traditions, this explanation does not
seem adequate for the experts or the general public. It seems impossible for a sane person to
have a dialogue, let alone a relationship, with an “inanimate” object – therefore most people
assume there is something drastically wrong with objectum sexuals.
REFERENCES
[1] Love, B. (1992). Encyclopedia of Unusual Sex Practices. Barricade Books, NJ.
[2] Hugo, V., Cobb, W.J. (1965). The Hunchback of Notre-Dame. Puffin Classics.
[3] Marsh, A. (2009). People Who Love Objects, Love’s Outer Limits. Carnal Nation.
[4] Marsh, A. (2010) Love among the Objectum Sexuals, Electronic Journal of Human Sexuality, Volume
13, March 1, 2010.
[5] Terry, J. (2010). Loving Objects.TransHumanities. Ewha Women’s University, Seoul, Korea. In press.
[6] Eiffel, E. Objectum-sexuality Internationale. (2015). Available at: http://www.objectumsexuality.org/,
(Accessed: 20th May 2020).
[7] Julia Sinmer, James E. A. Hughes and Noam Sagiv (2019) Objectum sexuality: A sexual orientation
linked with autism and synaesthesia, Published online 2019 Dec 27, https://www.
ncbi.nlm.nih.gov/pmc/articles/PMC6934473 (Accessed: 20th May 2020).
[8] Snow, K and Brady, J (2009) article on ABC news. Woman Proves Love for Eiffel Tower with
Commitment Ceremony, https://abcnews. go.com/GMA/story?id=7283494&page=1 (Accessed: 20 th
May 2020).
[9] Dewey, M., Pylodet, L., Cutter, C., Weston, B., Brown, K., Wessells, H., Morrison, A., Mann, B., Bashe,
P. & Kirby, B. (2005). The Oasis guide to asperger syndrome. Crown.
[10] Smilek, D., Malcolmson, K., Carriere, J., Eller, M., Kwan, D., & Reynolds, M. (2007). When “3” is a
Jerk and “E” is a King: Personifying Inanimate Objects in Synesthesia. Journal of Cognitive
Neuroscience, 19:6, pp. 981-992.
[11] De Silva, P., & Pernet, A. (1992). Pollution in “Metroland”: An unusual paraphilia in a shy young man.
Sexual & Marital Therapy, https://doi.org/10.1080/02674659208404491 (Accessed: 20th May 2020).
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ETIOLOGICAL FACTORS OF PSYCHOLOGICAL NATURE IN SEXUAL

DYSFUNCTIONS
Abstract
Through this paper, we aimed to better understand the psychological factors that influence
the development and evolution of sexuality. This work that can be beneficial in the evaluation
stage of clients who come to the office with sexual dysfunctions of a psychogenic nature and
in that of conceptualization of the case as well as in following essential steps in establishing
the therapeutic objectives and strategy and, of course, in the evolution of the case.
At the same time, we wanted to draw attention to the multitude, variety, complexity and
interactions between personal, social, biological, relationship factors, etc., which influences
and enhances the appearance, maintenance and, why not, amelioration of sexual dysfunctions,
each of which can be a significant node in the therapeutic approach to sexual dysfunctions.
We also aimed to review, from a cognitive perspective, the psychogenesis factors of sexual
dysfunction, cognitive structures, the transformation of an irrational / dysfunctional thinking
style into a rational, adaptive, healthy one, (but not the only one) among the aspects that
contribute to the success of any therapy.
Keywords: sexuality, cognitive schemas, irrational cognitions, cognitive therapy, etiological factors, automatic thoughts
INTRODUCTION
Psychological development begins before birth and continues throughout our lives, through
the interaction of biological, psychological, social factors that act on the person and have a
modeling, regulatory, adaptive role.
Sexuality also develops throughout life, in the form of pleasure, sexual abilities,
interpersonal sex-role abilities, as well as in the form of sexual orientation, sexual identity and
the assumption or not of the role. Under the pressure of education and society, as well as one’s
own experiences or one’s own judgments, assessments and inferences, the axiological
framework that will circumscribe sexual conduct develops, from sexual responses, genetically
and physiologically mediated, to the motivation of sexual behavior and preferences.
Sexual difficulties/disorders (of the individual and/or the couple) occur at the intersection
between psychological factors and one or more of the biological, social, environmental,
educational factors. The general vulnerability of the person to sexual problems can be
interpreted in terms of risk factors versus individual protection factors, in the context of the
person’s general ability to effectively face and manage significant adversity and to keep the
experience to use and future events (personal resilience). A person is all the more vulnerable
to developing a number of sexual difficulties (and not only), the higher the number of risk
factors, the longer the period of exposure to them, and the lower the degree of personal
resilience. There is also the situation in which a person with effective resilience mechanisms
can develop health problems, for a longer or shorter period of time, even in the conditions of a
single event, if it is of very high intensity and the stressors are much stronger than individual
protection factors.
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THEORETICAL APPROACHES
1. Considerations on the development of human sexuality

The process of organizing sexuality is not well understood or easy to explain, and the
information is most often explanatory, ascertaining, and not proactive; as a result, in conditions
of similar bio-physiological organizations, sexuality (from the first signs of arousal and sexual
desire, to the actual sexual behaviors and the degree of satisfaction felt) develops differently,
has different ways of expression, deeply individual, precisely because of the multitude of
variables, influences and interferences.
Studies show that there are forms of pleasure from the intrauterine period, a few months
before birth, which is easier to observe in male fetuses, by the appearance of erections, both
spontaneously and when sucking fingers or swallowing various injected substances in amniotic
fluid. In girls, experiments were performed after birth, finding that lubrication of the vagina
and swelling of the clitoris occur, even at the age of one day.
Child sexuality, in the sense of pleasure in the senses, not sexuality strictly related to the
sexual organs, is quasi-present. Babies raise and touch their feet, toes, clap, shout loudly in
different ways and wait for the reactions of those around them; they like to be held in their
arms, massaged, caressed, tickled. They explore their body, including touching their genitals.
Over time, boys earlier, in the first 6-7 months, and girls at about 10 months, begin to touch
their genitals in particular. It is very likely that when the touches move to the stage of
sensuality, babies begin to associate the touches with emotions and ideas of pleasure (they will
resort throughout life to touch, from time to time, the genitals, just to rediscover the pleasure
and/or the peace they discovered in the first year of life). Up to the age of 3, children will
masturbate from time to time, especially if they have not received reactions of disapproval from
adults. They can use their fingers, palms or rhythmically rub against various objects.
Around the age of three, children tend to hide or stop the actions of self-achievement, self-
stimulation, most likely due to the reactions of adults, who are more likely to occur during this
period.
Early childhood is a stage in which sexual differentiation continues and behaviors related to
obtaining pleasure are diversified. Physical contact with others, especially caregivers, self-
exploration, peer observation, game orientation during individual exploration or after adult
guidance, will all influence in one way or another, the child’s sexual development, choices and
role-sex behaviors, expectations and beliefs about sex. Moreover, the reactions of others to the
child’s reflexes and sexual behaviors, as well as to the behaviors and interests of exploration,
in general, the information that adults provide children about sexuality, interpersonal
relationships, conduct towards the opposite sex and, especially, the model he offers in the
interaction with his partner are opportunities for early sex education, especially since early
childhood is the stage when boys imitate their fathers and have a romantic attachment to
mothers.
A balanced behavior of caregivers, with natural reactions, adapted and appropriate to the
child’s age, with explanations provided appropriately, depending on the age, the child’s ability
to understand and, especially, how much and what he wants to know, increases the chance for
a balanced development of the personality as a whole, with the understanding and acceptance
of one’s sexuality.
In preschool, boys and girls play together, there is not necessarily a differentiated preference
for boys’ games and girls’ games, even in the presence of a clear sexual identity. Girls play
with cars, with guns, just as boys can imitate household activities – washing and ironing
clothes, cooking, knitting, in general what they see in caregivers. However, there is an
apprehension of boys for a more dynamic style, even with notes of aggression and risk-taking,
while girls prefer games and static interactions, which cause an exchange of emotions and
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empathic expression. As sexual behaviors, self-exploration, touching, interest in sexual games

is maintained, but new behaviors also appear: sexual games with other children, voyeurism,
interest in nudity, exhibitionism, as a sexual language appears.
Again, inability, inhibitory interventions in adults can interfere with the natural development
specific to this stage. Manifestly expressed concerns of the father when the 4-5-year-old boy
wants a “girl’s” toy raises in the child’s mind a series of questions and ambiguities: “There is
something wrong with me, with my masculinity or the father’s”; if comments like “No, what,
are you a girl?” one’s own sense of masculinity is questioned.
In essence, we are not 100% male or female, and the “percentage” of the opposite sex in
each of us is more beneficial than suggesting potential problems: a little feminine in a boy can
mean an easier understanding of the opposite sex, greater capacity for empathic communication
with the opposite sex, etc. which leads to better communication, less conflict and, for a couple,
a better quality of life. Also, the feminine peak in a boy is more related to the paternal instinct
than to homosexuality. Much more harmful for the formation of sexual identity can be moments
of confusion generated by violent reactions to choices, preferences at one time or another or,
later, the inability of the parent to explain, to accompany the pubescent and adolescent in the
process of change, to agree with the child’s choices and preferences. I think it would be much
more disastrous for a parent for his child to be unhappy all his life (with himself, with others,
with life in general) than to have a child whose sexual life does not correspond to the generally
accepted “norms”, but through which he does not harm himself or others, for which he has a
partner with whom he can evolve and live in harmony, in a couple and in society.
The age of 7-8 is also the period in which children begin to seek and assert their
independence, and interest in sex and sexuality remains in the background (continues to
masturbate occasionally, but only to reduce anxiety, after as interest in the genitals seems to be
compared to others rather than for pleasure). Legendary heroes, fictional characters, with
special powers and qualities, but also with the unwritten laws of interaction and reporting to
the social environment, are more and more present in the child’s life. In the interaction with
adults, from the romantic love he had for the parent of the opposite sex, the child behaves
coldly and no longer accepts manifestations of this love with other children. From a sexual
point of view, they construct their sexual identity mainly by identifying with the parent of the
same sex, but also by testing behaviors observed in others or in fictional characters; boys
continue to detach themselves more and more from their mother’s influence; insufficient or
absent detachment, the mother’s perseverance in carrying out translated behaviors, most often,
through hyperprotection, often interferes negatively with the process of sexual maturation. At
the same time, the idea of the implications of the absence (non-existence or blurred play of the
sex role) of the same-sex parent in the child’s life, on sexuality and the development of rolesex
behavior can be speculated, as well as, in general, in the process of emotional maturation and
gaining autonomy. The processes of identification and count er-identification with
attachment/caregivers, social regulation both within the family of origin and in the
interpersonal environm ent, through the feedback provided by congeners, are significant factors
in human sexua l development, in the foreshadowing of sexual preferences, shaping sexual
motivation, eve n understanding and accepting sexuality.
At puberty, under the pressure generated by hormones, boys begin to perceive girls’ interest
in them and, although shy, they also begin to show interest in girls (they are more attentive to
dress, to cleanliness). It seems that, in a first phase, the pubescents return to the feelings of love
towards the parent of the opposite sex, this time with sexual notes, not only with the romance
specific to childhood. However, moral courts intervene (the child is in the conventional stage
of moral development, in which social conventions on good and evil are accepted) and, to avoid
feelings of shame, embarrassment, guilt, the preadolescent prefers to hide his increasingly
loaded desires, sexuality, in even aggressive behaviors, of opposition and revolt towards the
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parent of the opposite sex, with quarrels, disregard, blame, etc. The beginning of sexual
interests for VIPs, actors, some teachers, etc. it could be the result of shifting sexual attention
from the parent of the opposite sex. Slowly, shyly, in a longer or shorter period, they begin to
express their feelings towards colleagues, at first in a romantic manner, then in an increasingly
impetuous sexual manner. The interest in sex is more and more intense, and teenagers are
starting to have more or less skillful courtship behaviors.
Conformism towards one’s own gender or, on the contrary, ambivalence or nonconformism
can be a first indicator for homo- or heterosexual orientation, but neither sufficient nor
necessary. The content of sexual fantasies that appear in preadolescence, the convergence
between one’s own sex and behavioral drivers could have a greater consistency in anticipating
sexual orientation and preferences.
Preadolescence and adolescence are extremely sensitive and important periods in sexual
development, the person now combines the concern for the transformations that his own body
goes through, with the concern for the opposite sex or, in general, for sex. The feeling of being
psychologically compatible with one’s own, the expectations of others and the pressure to
conform to sex stereotypes, the feeling of superiority over the opposite sex are all factors that
interfere with the evolution and assumption of sexuality.
There is interest in belonging to a social group, its acceptance or rejection can influence, in
the context of emotional vulnerabilities, the evolution of the person’s personality, in terms of
self-esteem, image and self-confidence, otherwise extremely unstable at this age, with major
reverberations in the natural development of sexuality. The group provides the framework for
each to explore compatibility with their own gender, as well as the feeling of superiority of
their own gender over the other.
Often, the group is the one that opens the perspective of sexual interactions, in the sense of
facilitating the interpersonal behaviors of seduction, courtship, in general of expressing
sexuality. Group processes (establishing hierarchies, dynamics of preferences and rejections,
regulatory feedback, information flow, etc.) leave their mark, directly or indirectly, on the
person’s evolution, opening or closing doors to understanding, assuming, developing sexuality.
Also, in adolescence, boys and girls are very receptive to cultural messages about “what a
man/woman should look like” and experience all sorts of behaviors associated with the socially
promoted image (boys begin to be concerned with appearance, she had a perfect body, and girls
adopted, for example, outfits that highlighted their sexuality, often out of the ordinary and even
less to the liking of their parents).
The first sexual experience is often considered to have an impact on sexual adaptation and
subsequent sexual development. However, studies have failed to demonstrate the universality
of this, the significance given to the first sexual experience being, rather, the specificity of the
person’s cognitive-emotional structure, the person’s beliefs, attitudes and values, the attitude
of those around him, the reaction of the reference group, as well as the possible consequences
or consequences.
The challenges of the young adult pass in the sphere of consolidating the financial
independence, of assuming the responsibilities of couple and family, of the social and
professional evolution, all these being circumscribed to the socially accepted and promoted
patterns. Intrapsychic conflicts of a sexual nature, with or without impact, of longer or shorter
duration, situational or generalized, can occur at any time, at the interaction between the bio-
psycho-social reality of each of us, as it is structured in terms of beliefs, desires, personal needs,
individual mental maps through which we filter the immediate experience, etc. and sex-role
expectations, the patterns that society imposes in more or less subtle ways.
Social scripts carry “norms” of conduct, including sexual. They prescribe what, how, when
you have to feel, think, carry out a certain behavior, in order to be in the norm that prescribes
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a certain situation (what “should” you wear to the wedding, how “should” be the mother-in-
law relationship etc.).
If the person’s biological and personality do not contradict these scenarios, things can go
smoothly, and subsequent sexual evolution is self-sustaining, especially as social scenarios
contribute, through decreasing insecurity, to decreased anxiety and, consequently, gaining a
sense of confidence and self-confidence, with increasing satisfaction.
However, if there is a conflict between what is required and what the person wants / can /
consider, the evolution in terms of sexuality can register slowdowns, derailments and even
blockages.
If the person is sexually assumed, has a set of healthy cognitive beliefs about himself, etc.,
he can “resist” even in the conditions in which he intends to live his life differently from how
prescribed by social patterns, selectively, with a sporadic or total spacing.
However, if his needs and desires are grafted on a series of cognitive and emotional
vulnerabilities, the impact of the deviation from the rule can result in as varied effects as
possible, from simple recurrent depressive states, to the development of clinical symptoms
and/or structuring a personality disorder or even mental illness.
Consequently, although there are numerous thorough studies, according to all scientific
rules, the process of sexuality development is a great unknown.
2. Risk factors in the occurrence and maintenance of sexual dysfunction

Sexual dysfunctions are generated and maintained by a multitude of factors, with various
origins and strictly customized manifestations.
In general, the specialized literature classifies etiological factors according to two criteria:
• by their nature, they are exogenous factors (physical, chemical, biological and
psychosocial agents) and endogenous factors (genetic factors, responsible for causing
genetic abnormalities);
• according to the function they fulfill in the genesis/appearance of the disease, there are
triggering factors, predisposing factors, precipitating factors, maintenance factors and
contextual factors, specifying that their division has, rather, a didactic role.
Predisposing factors refer both to early life experiences as well to aspects related to the
physical constitution of the person. These factors are often insufficient to generate sexual
dysfunction, but they subsist and contribute to the general vulnerability of the person:
• constitutional predisposing factors – inherited anatomical and/or physiological
features, hormonal disorders, delayed puberty, temperamental characteristics, degree
of physical endurance, personality traits;
• predisposing factors related to development (developmental factors) – type of primary
attachment, parental style/pattern, exposure to violence (psychological, sexual,
physical), traumatic events, early sexual experiences, sexual abuse, messages,
expectations, religious constraints / (including poor sex education, inadequate
information about sex and sexuality).
We can add to the list of predisposing factors the central and intermediate cognitive
structures, coded in the form of maladaptive cognitive schemas, and the evaluative cognitive
structures – general and intermediate irrational cognitions, which we will treat separately in the
next chapter (David D., 2015).
The precipitating factors reside in any life experience, to which the person attributes,
consciously or not, an intensely negative meaning. They are what we call intensely stressors,
and the reaction (sexual dysfunction) is the body’s response to stress. The main characteristic
of precipitating factors is that they have a strictly personal character, being difficult, if not
impossible to anticipate what are the factors / moment / conditions / circumstances that
guarantee the appearance / absence of sexual dysfunctions, namely from the concrete existence
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or psyche of the person whether or not it is a trigger for sexual problems. Moreover, what for
one person is a trigger for sexual dysfunction, for another person can be a
motivating/determining and triggering factor of feelings, behaviors and attitudes generating
sexual satisfaction and fulfillment, due to its extremely particular character which filters and
transforms the trigger event.
In essence, we can consider that the pathological condition can occur in the context in which
the person’s goals, desires, expectations, hopes, expectancies contradict (cognitive
discrepancy) with various events that the person goes through, considered activating events,
and “the greater the cognitive discrepancy is, the more severe the psychological problems are”
(David D., 2012).
The ascertaining studies managed to group some factors under the title of precipitating
factors of sexual dysfunctions, in the sense that they have a higher probability of producing
sexual dysfunctions, but not obligatory; they can also cause sexual dysfunction of different
durations or even permanent:
- events generally considered to be extremely stressful: loss of any kind (death,
divorce/separation, loss of job, even change of place of residence), infidelity of the
partner, birth, menopause/andropause;
- infertility, postpartum experiences;
- humiliating sexual experiences, even a first unsuccessful or humiliating sexual
experience;
- emotional disorders, depression, anxiety;
- intramarital conflicts;
- substance abuse.
The maintenance factors are those that turn a negative sexual event, singular or episodic,
into a lasting sexual dysfunction, with great chances of chronicity. We consider that the impact
of maintenance factors is the most difficult to manage in therapy, especially since other people,
relationships, environments in which the client lives are involved. For example, any problem
of the client’s partner can become a factor in maintaining sexual dysfunction and, moreover,
the difficulties of each can become a trigger for the other.
• anxiety, depression, self-confidence/image/self-esteem; loss of self-confidence from a
sexual point of view, performance anxiety;
• aspects related to the partner: a sexual dysfunction of the partner, affective-emotional
peculiarities, disorders on axes 1 and 2;
• intrapsychic conflicts;
• prolonged interpersonal conflicts, within the family or at work;
• sustained stress, personal, occupational, emotional;
• acute or chronic health problems;
• problems associated with aging etc.
Contextual or favoring factors are those stressors that interfere with the individual’s or the
couple’s life, which act temporarily, but through the “echo” or psychological reactions,
relationships, etc. may become chronic, with longer-lasting impairment of sexual function:
• financial difficulties, unemployment;
• fatigue (raising a child, busy periods at work, caring for a sick person, etc.);
• lack of a space to ensure privacy;
• different schedules of the two partners;
• failure to get pregnant or any other health problem of one of the two partners etc.
A special set of factors with a significant role in the occurrence and maintenance of sexual
dysfunctions we consider to be local cognitive structures, in the form of irrational automatic
thoughts, which we will discuss further (David D., 2015).
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3. Cognitive structures and their role in the occurrence and maintening of sexual
dysfunctions
The central cognitive structures (cognitive schemas) are factors of general vulnerability.
Cognitive schemas are emotional patterns, referring to oneself, others and/ or life, in general,
in which emotions, physical sensations, cognitions, memories are encrypted; they appear and
develop in childhood and/or adolescence, feed throughout life and are dysfunctional, to varying
degrees. They remain as matrices with which we signify current experiences or as “abstract
cognitive maps that guide us in interpreting information and solving problems” (Young &,
2015). Unfortunately, maladaptive schemes mediate inefficient, wrong solutions and generate
self-sabotaging behaviors through the coping mechanisms it uses.
Some authors consider that there are two central cognitive schemes (Beck A.T., 1995, 2012
– the selfless/helpless scheme, in which the central belief is that he/she is a bad, worthless and
helpless person, and the self-exclusion/non-acceptance scheme – unlovable, in which the
person thinks he/she is not accepted and not appreciated by others). Other authors consider that
there are 18 such cognitive patterns, grouped in four domains/categories representative of
unmet emotional needs (Young &, 2015), as follows:
Area I – Separation and Rejection includes Abandonment/Instability, Distrust/Abuse,
Emotional Deprivation, and Deficiency/Shame.
People with cognitive patterns in this field have great difficulty in developing secure and
satisfying attachments to other people because of the belief that their needs for stability, care,
security, love, and belonging will never be met. In most cases, the family of origin was cold,
critical, abusive, unstable, socially isolated, creating the context of a traumatic childhood for
the client. In adulthood, the client will either try in vain to build a surrogate family environment
and throw himself into various and destructive relationships, or isolate himself from the rest of
the world to avoid the emotional pain of childhood.
They will live with the conviction that they cannot establish, obtain and maintain a
satisfactory emotional connection with anyone, and they will not receive affection, attention,
understanding, support, etc., no matter how hard they try (emotional deprivation).
They will live with the quasi-permanent fear that they will be abandoned by the significant
people in their lives for someone better, that they are an unsatisfactory and unpredictable
presence for the other (Abandonment/Instability scheme). Some people believe that if given
the opportunity, others will abuse, hurt, use, lie, humiliate, or deceive them (Disbelief/Abuse
scheme). Some people live with the belief that they are worthless, inferior to many, defective;
they feel ashamed and embarrassed about what they consider to be unacceptable to them
(Deficiency/Shame scheme).
Other people feel different from others and thus inadequate; as a result, they do not feel that
they are adapted to any social group, nor do they manage to integrate.
From the perspective of psycho-sexology, people who have such active schemes can
develop various disorders, from low sexual desire, vaginismus, erectile dysfunction (against
the background of avoiding intimate relationships), to sexual preferences in the BDSM register,
in which they look for abusive partners, situations in which he feels humiliated or degraded
etc.
Area 2 – Autonomy and poor performance includes Dependency/Incompetence,
Vulnerability to injury and illness, Interdependence/Childhood, Failure schemes.
People who have one or another of the schemes specific to the field grew up in a hyper
protective environment, in which they were not allowed to try, explore, differentiate and create
their own identity; the parents did everything in their place, transmitting – without intending to
do so – the idea of incapacity, undermining their self-confidence in their ability to do. There
are great chances to develop schemes in this field and children who have not been cared for at
all. People who have developed schemes in this field feel unable to do something without help
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from others, experience a general feeling of helplessness and, consequently, are passive, do not
engage in activities, do not take the slightest risk. They feel inadequate compared to people of
the same age, think of themselves as being bad, untalented, with no chance of achievement.
They tend to merge with one of the significant people, feel that I cannot live without the
other. Other people have an exaggerated fear that something bad is about to happen (the
appearance of a serious illness, a natural disaster, loss of control/madness).
In the field of psycho-sexology, they can develop a wide range of symptoms, from erectile
dysfunction and premature ejaculation to paraphilic disorders.
Area 3 – Deficient Limitations Includes Delusions of Grandeur/Feelings of Justification,
Reduced Self-Control/Reduced Self-Discipline.
People who have schemes in this field grew up in too permissive families, without limits
and rules. They tend not to respect the rules of discipline, the rights of others, do not cooperate,
and do not respect commitments; they seem selfish, narcissistic, pampered, consider that the
rules are only for others, they feel superior to everyone. Once they become adults, they restrain
their impulses too little or not at all, they have a low tolerance for frustration, they cannot
pursue long-term goals, they expect special benefits and privileges. They are demanding,
dominant, weak or not at all empathetic.
Area 4 – Orientation to the other includes the schemes Subjugation, Self-Sacrifice, Need for
Approval/Need for Recognition.
People with these active cognitive patterns grew up in families where they felt accepted only
if they met the demands of adults, if they hid/suppressed their desires, undesirable personality
traits for significant people. As an adult, they seek the approval of others and do whatever it
takes to get it; their choices are based on the reactions of others, their own needs are not realized
and, even if they appear on the threshold of consciousness, the affective reactions
corresponding to the need are not taken into account. Subjugation and Self-Sacrifice Schemes
are very frustrating; the accumulated anger is not expressed directly, but erupts through
passive-aggressive behaviors, fits of anger and/or psychosomatic symptoms. In the case of
those who have an active Need for Recognition scheme, they value the reactions of other people
rather than their own reactions, are overly concerned with accumulating money and/or success.
Area 5 – Hypervigilance and inhibition includes the schemes Negativism/Pessimism,
Emotional Inhibition, Unrealistic Standards/Hypercriticism, Punishment.
People who develop schemes in this area often come from families where they have not
been encouraged to play freely and happily, but have learned that life means a long series of
negative events that they need to be aware of. They tend to select from the surrounding reality
the negative aspects (death, disappointment, conflict, loss, suffering, etc.), they expect their life
to take a negative turn at any time and they permanently experience the fear of not making
mistakes that lead them to this (Scheme Negativism/Pessimism). Many of them do not express
their emotions so as not to be criticized or to lose control and appear to be cold, expressionless,
withdrawn (Emotional Inhibition Scheme). Other people set very high standards, followed by
constant pressure and constant and exaggerated criticism of themselves and others (Schema
Hypercriticism). “MUST!” it is quasi-permanent and governs their entire existence. For others,
the mistake must be severely punished. They feel anger and intolerance towards themselves
and others who do not meet certain standards and consider that harsh punishments are needed.
He does not forgive mistakes, does not accept imperfection, does not take into account the
way others see things and understand reality.
Cognitive patterns occur as a result of the frustration/dissatisfaction, during childhood, of
some basic, universal emotional needs, felt with more or less intensity by an individual – the
need for security, stability, to be guided, to be accepted as you are, the need for autonomy, the
feeling of being competent/able to do things and having your own identity, the freedom to
express needs and emotions, spontaneity and play, realistic limits and self-control. Reactions
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and responses of the family of origin, of the primary attachment figures, of the groups of
congeners, of the caregivers, the behavioral models, the education viewed in a general sense
etc., mediates the emergence and consolidation of these cognitive patterns.
A person in distress is a person who is not aware of the existence of this frustrated need and
who, even if he/she sensed the needs, could not satisfy them in an adaptive way, because does
not know how, and did not have adequate models the type and intensity of the need. In therapy,
he/she identifies the central cognitive schema, but is also guided to identify ways to meet these
needs in a way that meets individual expectations.
As mentioned above, cognitive patterns are factors of general vulnerability, which means
that although two people may identify in their personality structure the same cognitive pattern,
dysfunctional behaviors and associated emotions may be totally different, not only through
subtle psychological processes of identification and counter-identification with one or another
of the attachment figures, but also, mainly, through the intervention of intermediate cognitive
structures (attitudes, assumptions and rules with a compensatory role).
For example, a central scheme of deficiency (“I am bad, defective, unwanted, unlovable,
inferior”, “No one would love me if they knew my flaws”, with feelings of insecurity when in
the company of others, with feelings of shame etc.), can be expressed in intermediate cognitions
such as: It is bad not to be wanted (attitude), If I say what I think, I will be rejected or If I do
not say what I think, then others will appreciate me and accept me (assumption) or I have to be
perfect and not make mistakes (rule with a compensatory role). In interacting with others,
he/she may develop coping mechanisms of capitulation (enters into relationships with critical
partners, who reject and, in order to be accepted, degrades), avoidance (does not express real
thoughts and feelings and does not let others approaching) or overcompensating (criticizing,
rejecting, doing everything to look perfect).
Identifying the cognitive schema and coping mechanisms are essential in therapy, and their
recognition in the daily choices by the client is fundamental. An important element in therapy
is the awareness that the coping mechanism, which became maladaptive, self-sabotaging in
adulthood, was essential in childhood/adolescence and helped the client cope with aversive
events; but, once in adulthood, out of the situation of survival inherent in the child, the person
has many alternatives to choose from, alternatives that can change the quality of life for the
better.
Maladaptive cognitive schemas, as determinants, can be activated by any of the categories
of factors mentioned above. They serve as a kind of filter through which the current life
experience passes and which gives meaning to various events, transforming some of them into
etiopathogenetic factors. Adaptive cognitive patterns evolve differently. “Some people show
more psychological resilience and fail to develop strong maladaptive cognitive schemas, even
in particularly aversive situations, unlike others who are more psychologically vulnerable and
develop maladaptive cognitive schemas even if they have passed through an abuse of relatively
low severity.” (Young J., 2015).
Another set of determinants that contribute to the increase of vulnerability to the disease is
the general and intermediate evaluative cognitive structures (David, 2015). The central
irrational cognition is absolutist thinking (demandingness, for example, “I have to satisfy my
partner every time!”) accompanied by three intermediate irrational cognitions: awfulizing, for
example, “My marriage will end because of my impotence!” or “It’s awful what happens to
me!”, low frustration tolerance (e.g.: “My current condition is unacceptable”) and global
evaluation. In therapy, the goal is to transform this absolutist thinking style into a rational one,
by acquiring and practicing flexible thinking skills, expressing it in terms of preferences, not
in terms of “absolutely absolutist need,” accepting that what we wish it might not happen, non-
catastrophic (accepting that no matter how bad you feel about an event/aspect/problem,
evaluating it as the worst thing that could happen is dysfunctional and false), tolerance of
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frustration (accepting that even if we don’t like a situation and do what it takes for us to change
it, failing that doesn’t make it impossible to tolerate) and contextual assessment, rather than
global assessment (behaviors, actions of a people and their results do not label/define the
person, this being in its essence valuable and, therefore, unconditionally accepted, but there are
singular aspects that can signal the need to modify/optimize various particular aspects; for
example, a weak or non-existent erection at some point may not make you “less of a man”).
Local cognitive structures, in the form of dysfunctional automatic thoughts, are factors of
local vulnerability and are part of the clinical picture of any sexual dysfunction. Disadaptive
thoughts move easily from one role to another, and can be both precipitating and maintaining
or even predisposing factors (through the meanings that the person can give to
biophysiological/subjective reactions caused by automatic thoughts and the installation of a
new vicious circle).
Labeling (“I’m no longer a full man”, “I’m flawed”), dichotomous thinking (“If she doesn’t
have an orgasm, I’m nothing!”), overgeneralization (“I’ll never be able to satisfy her if I
couldn’t now”), maximalization (“My wife will leave me because of my problem”), selective
abstraction, “tunnel” vision, personalization are the main automatic thoughts described by A.T.
Beck in 1976.
The transformation of central, intermediate and local cognitive structures into healthy,
adaptive alternatives is the main goal in cognitive-behavioral therapy, postulating that, with
their replacement, the intensity of emotions and/or psychophysiological/subjective reactions
changes, and them in the adaptive register, the symptoms diminish. Of course, changes of a
cognitive nature are desirable to be accompanied by learning new skills in interpersonal
communication, problem-solving skills, learning relaxation techniques, etc., behavioral
optimizations strengthening management skills at the cognitive level.
CONCLUSIONS
This paper wanted to reveal once again the complexity of the human sexuality, functional
or non-functional, given that sexuality occurs at the intersection of biology, development and
individual psychology, interaction with others, culture, education, environment, in the broadest
meanings of notions. Each of these exerts a significant and consistent influence on the sexual
becoming of the person and is very difficult, if not impossible to establish a hierarchy of these
factors. Numerous studies (Delcea C, Enache A, Stanciu C); (Delcea C, Enache A, Siserman
C,); (Gherman C, Enache A, Delcea C,); (Delcea C, Fabian A. M, Radu C. C, Dumbravă D.
P,); (Rus M, Delcea C, Siserman C,); (Siserman C, Delcea C, Matei H. V, Vică M. L.);
(Gherman C, Enache A, Delcea C, Siserman C,); (Delcea C, Siserman C,) confirm our results.
In the therapeutic approach of sexual dysfunctions of a psychogenic nature, the complexity
of the phenomenon makes it all the more difficult to establish precisely the causes that led to
their occurrence. However, the thorough personal history, the most accurate identification of
the possible psychological factors that contributed to the appearance of sexual dysfunction
allow to adjust the focus in therapy, as well as to the awareness of therapeutic objectives, which
gives the client the role of active participant and the feeling of gaining control over his own
life.
Practice has shown that replacing an irrational style of thinking with a rational one,
flexibility of thinking, optimization of interpersonal communication, awareness of self-
sabotaging behaviours and the learning of healthy and adaptive behaviors, optimization of
problem-solving skills, learning healthy ways of conflict resolution, psychoeducation, etc.
increase the chances of success in overcoming sexual difficulties, not only those of a
psychogenic nature, but also those with organic/physiological substrate, and, above all,
contribute to an increase in the quality of life of the person.
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REFERENCES
[1] Beck A.T. Cognitive Therapy and The Emotional Disorders, 1976.
[2] Clark D.A., Beck A.T. Terapia cognitivă a tulburărilor de anxietate (Cognitive Therapy of Anxiety
Disorders), 2012.
[3] Young J. E., Klosko J.S., Weishaar Terapia centrată pe scheme cognitive – Manualul practicianului
(Schema therapy: A practitioner’s guide), 2015.
[4] Porst H., Reisman Y. The ESSM Syllabus of Sexual Medicine, 2012.
doi: 10.4172/2471-4372.1000140.
4372.1000160.
2019. Vol. 61, pp. 45-55. DOI 10.1016/j.jflm.2018.10.005.
DOI:10.4323/rjlm.2019.279.
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NON-PARAPHILIC HYPERSEXUAL DISORDER – COMPULSIVE SEXUAL

BEHAVIOR DISORDER OR SEXUAL ADDICTION
Abstract
The conceptualization of excessive sexual behavior has been intensely debated over the
years, and the concept of hypersexuality is still controversial. After long debates, the indexation
in ICD-11 (International Classification of Diseases, 11th Revision, World Health Organization,
2018) of excessive and problematic sexual behavior as a compulsive sexual behavior disorder
(CSBD) is welcome. There are still debates about the category of the disorder. In ICD-11,
CSBD is classified as an impulse control disorder, but this classification is controversial, as
there is evidence that CSBD has many addictive features (Kraus et al., 2016). Although the
diagnosis of hypersexual disorder, proposed by Kafka, was not included in the DSM-5
(Diagnostic and Statistical Manual of Mental Disorders, 5th edition, American Psychiatric
Association, 2013), this diagnosis was supported by both clinical contexts as well as by some
research that indicates that excessive sexual behavior can have serious consequences in an
individual’s life (Kafka, 2010; Kaplan & Krueger, 2010, Reid et al., 2012). Understanding,
defining and correctly diagnosing this disorder are important prerequisites for proper treatment,
and allow also warning of certain risk factors for the development of this disorder.
Keywords: hypersexuality, hypersexual disorder, compulsive sexual behavior disorder, compulsive online sexual behavior,
sexual addiction
INTRODUCTION
Hypersexuality, or excessive sexual behavior, has been categorized as: sexual addiction
(Carnes, 1983; Goodman, 1983, 2001; Karila, et al., 2014), sexual compulsivity (Coleman,
1987, 2002), sexual impulsivity (Barth & Kinder, 1987; Reid, Berlin & Kingston, 2015), out
of control sexual behavior (Bancroft & Vukadinovic, 2004), hypersexual disorder (Kafka,
2010; Kaplan & Krueger, 2010).
The misunderstanding of hypersexuality and the debates regarding its correct definition
have limited the research and the effective treatment of this disorder (Franque, Klein & Briken,
2014). The prevalence of this disorder varies between 3% and 6%, with a higher rate in men
(male/female prevalence ratio varies between 2:1 and 5:1) (Tripodi, et al., 2013; Briken, et al.,
2007).
There are various theoretical approaches and each term used to define problematic
hypersexual behavior corresponds to a specific approach. Overlaps or complementarities can
also be observed, the subject being still in a process of research and debate.
Problematic sexual behavior involves the presence of three general criteria: obsession
(thoughts, impulses, recurrent and persistent), compulsion (loss of the ability to choose to stop
a behavior) and the consequences of the behavior (Schneider, 1994).
Hypersexuality is a term that indicates excessive sexual behavior that can be considered
normal, when it is not accompanied by consequences, or abnormal when it significantly affects
an individual’s life or is associated with a mental disorder or medical condition (Kafka, 2010).
Barth and Kinder chose the term sexual impulsivity to refer to the inability to control strong
sexual desires or to reduce concern about sexual activity, practically the inability to stop
initiating action (Barth & Kinder, 1987).
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Sexual compulsivity indicates the inability to stop or reduce ongoing sexual behavior.
Impulsivity and compulsivity are present in obsessive-compulsive disorders (OCSD), and
are two important factors for compulsive sexual behavior (Hollander, Poskar & Gerard, 2012).
Sexual addiction defines a recurring sexual behavior that cannot be controlled and is
maintained despite the negative consequences. Related to the addiction model, the compulsive
model assumes that sexual thoughts, images or impulses become obsessive and lead to
repetitive, compulsive engagement in sexual activities in order to reduce anxiety (IsHak, 2008).
The addiction model meets the criteria present in an addiction process defined by Goodman
(2001) as a recurrent and uncontrollable behavior despite the serious consequences, which
becomes progressive over time (Carnes, 1983, Carnes 2001, Goodman, 1993).
Multiple addictions were also reported in people with sexual addiction (Carnes, 2001;
Kaplan & Krueger, 2010).
Other evidence suggests that CSBD shares many features with addictions. The data suggest
significant clinical, neurobiological, and phenomenological similarities between excessive
involvement in behaviors such as gambling, compulsive sex, compulsive shopping, and
substance dependence (Kraus et al., 2016).
Some neuroimaging studies have found, in the case of subjects with compulsive sexual
behavior, a higher reactivity in three brain regions related to rewards (ventral striatum, anterior
cingulate and amygdala), in response to explicit sexual images. The same areas are activated
in the case of substance-dependent subjects (Voon et al., 2014).
Diagnosis and Assessment

Diagnostic criteria for hypersexual disorder proposed by Kafka for DSM-5 (Kafka, 2010,
Kafka, 2013):
A. The presence for a period of at least 6 months of recurrent and intense sexual fantasies,
sexual urges and sexual behavior in association with at least 3 of the following criteria:
A.1 Sexual preoccupation or excessive time invested in sexual fantasies, impulses and
behaviors as well as in their planning, thus neglecting other areas of life.
A.2 Repetitive engagement in these fantasies, sexual urges and behaviors to cope with
negative moods (anxiety, depression, boredom and irritability).
A.3 Repetitive engagement in fantasies, starts and sexual behavior in response to stressful
life events.
A.4 Repetitive but unsuccessful efforts to control and significantly reduce these sexual
fantasies, impulses, and behaviors.
A.5 Repetitive engaging in sexual behavior without considering the risk of physical or
emotional harm to oneself or others.
B. The presence of personal distress, clinically significant, or significant impairment of
important areas of functioning of the individual (social, occupational, relational).
C. Sexual fantasies, impulses, and behaviors are not directly due to substance use (drugs or
medications), or a concomitant general medical condition or manic episodes.
D. The person is over 18 years old.
It will be specified if it regards: masturbation, pornography, consensual sexual behavior, sex
on the internet (cybersex), sex on the phone (hot line) or strip clubs, etc. (Kafka, 2010, Kafka,
2013).
Assessing hypersexuality is an essential step in diagnosis. In addition to the empathy and
support given to the patient during the interview, it is necessary for therapists to control any
possible personal reactions of rejection towards certain sexual behaviors, so as not to
accentuate patients’ feelings of guilt. It is also useful to know the different types of pornography
and sexual services accessed by users (Franque, Klein & Briken, 2016).
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The objectives of the evaluation during the interview are: symptoms, the degree of
impairment of the individual’s functionality in areas of life, family as well as relational history,
sexual (psychosexual development, history of sexual abuse, sexual behavior, sexual
dysfunction problems), medical and psychiatric history, self-image perception, problems
regarding consumption of substances or addiction to gambling, identification of risky behaviors
(self-destructive or sexual violence) (Kafka 2010, Tripodi et al., 2013, Franque, Klein &
Briken, 2016, Klein, 2015).
Practically, the evaluation considers: behavior, cognitions and emotions, as well as the
social/relational area (Grubbs et al., 2017).
Hypersexuality is a behavioral disorder, but recurrent sexual behavior or excessive
frequency is not sufficient to diagnose the disorder. Therefore, the degree in which the
functionality and quality of life is affected, is a key indicator for diagnosis (Carnes, 2001;
Kafka, 2010; Reid et al., 2012).
Sexual behavior has individual variations, and labeling as much, little or normal is subjective
and it depends to each individual. If it is seen as excessive or problematic only from the
perspective of conventional or religious norms, without causing dysfunctions in other areas of
life, it cannot be diagnosed as a disorder (Kafka, 2010). There may also be situations when
persons who have addressed the specialist, claiming to be sexually addicted, confuse the
addiction with increased sexual desire.
The cognitive and emotional components are strong in hypersexuality (Grubbs et al.,
2017).
Cognitively, the sexual thoughts and fantasies of hypersexual people become obsessive and
difficult to control when hypersexual behavior becomes compulsive.
Emotionally, negative states such as: distress, anxiety and depression are co-morbid or
represent consequences of compulsive sexual behavior (Birchard, 2018b).
Excessive sexual behavior sometimes develops as an attempt to adapt to stress and other
negative emotional states, but this way of adapting will become a vicious circle as it generates
even more negative emotional consequences that will sustain the behavior (Kafka, 2010, 2013).
This sets up anxiety, shame and depression (Gilliland et al., 2011).
The negative consequences in social, professional and relational areas can be multiple,
from dysfunctions to conflicts, thus affecting the life of the individual (Reid et al., 2012).
However, the correct diagnosis of this disorder is a challenge because hypersexual behavior
can have several etiologies.
Causes of hypersexuality
Because multiple comorbidities are reported, it is necessary to consider diseases or other
problems that may coexist with excessive sexual behavior: mental illness, organic disease,
problems regarding substance abuse (Kafka, 2010).
It is important to investigate whether hypersexuality is not directly due to other mental
disorders, medical causes, or is not the direct effect of substance use (drugs or medications)
(Kafka, 2010).
Mental disorders that may coexist with hypersexuality: anxiety, mood disorders,
paraphilias, personality disorders (especially borderline personality disorder and obsessive-
compulsive disorder), posttraumatic stress disorder, autism, bipolar disorder (in the manic
episode), schizophrenia, oligophrenia (cortical inhibitory processes are diminished), dementia,
alcohol or drug addiction (can facilitate the development of hypersexuality, as it affects sexual
and social inhibitions).
Medical conditions, endocrine or neurochemical imbalances that may be associated with
hypersexual behavior:
• Neurological or neurodegenerative diseases such as: epilepsy (cortical inhibitory
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processes are diminished), Alzheimer’s disease, Kleine-Levin syndrome (sleep

disorder-hypersomnia), Kluver-Bucy syndrome (bilateral affection of the two temporal
lobes in their medial portion; it may be the result of herpes encephalitis, trauma or
oxygen deprivation), Huntington’s disease or chronic Huntington’s chorea
(neurological, degenerative, hereditary disease);
• Brain injuries or surgeries in the frontal or temporal lobes (in the medial area);
• Encephalitis, tuberculosis (tuberculosis toxins can have a stimulating action on the
hypothalamic centers of sexual behavior);
• Endocrine disorders such as hyperestrogenism, hyperandrogenism, hyperthyroidism,
may also be accompanied by hypersexuality (but there is insufficient evidence
regarding the mechanisms);
• Imbalance in the levels of serotonin, dopamine and norepinephrine in the brain.
Hypersexuality may be linked to high levels of these neurotransmitters (Kafka, 2010);
• Some medications, such as dopaminergic agonists, used to treat Parkinson’s disease
(levodopa, ropinirole, pramipexole), or cabergoline, also a dopaminergic agonist,
indicated for the inhibition of lactation and the treatment of hyperprolactinemia, may
cause disorders related to the control of hypersexual impulses, gambling addiction,
compulsive appetite, compulsive spending or shopping.
Introduction of Compulsive Sexual Behavior Disorder (CSDB) in ICD-11

In ICD-10 the diagnosis of Excessive Sexual Activity can be found, with the code F52.7 (in
which the chapter F52 refers to “Sexual dysfunction not caused by an organic disorder or
disease”).
In 2018, the WHO announced the inclusion in ICD-11 of this disorder as Compulsive Sexual
Behavior Disorder (CSBD), thus recognizing it as a mental disorder. Compulsive involvement
and decreased control are the basic features of impulse control disorders.
The diagnosis for this disorder results from the persistent pattern of difficulty or failure in
efforts to control sexual impulses, which leads to repetitive sexual behaviors over a long period
of time (minimum 6 months), associated with negative consequences that can endanger the
individual’s or others’ life, or causes a significant impact on the areas of life of the individual
(family, relationship, professional, social, etc.).
There are still debates about the category of the disorder. In ICD-11, CSBD is classified as
an impulse control disorder, but this classification is controversial, as there is evidence that
CSBD has many addictive features (Kraus et al., 2016).
In the DSM-5, pathological gambling was reclassified as a “Substance and addiction
disorder.” A similar approach should be applied to CBS, which is currently considered to be
an impulse control disorder in ICD-11 (Kraus et al., 2018).
This diagnosis, CSBD, also includes compulsive sexual behavior on the internet that affects
the life of the individual. Over 80% of people with compulsive sexual behavior report excessive
or problematic pornography use (Kafka, 2010; Reid et al., 2012).
The development of technology and almost unlimited access to sexual material on the
internet has led to an increase in the consumption of pornography and other sexual services on
the internet in recent years.
Internet sex or cybersex includes: watching erotic or pornographic content, explicit sexual
discussions, sexual interactions on forums, video chat, searching for potential sexual partners
for offline relationships, involvement in explicit sexual acts on social networks or other means
of communication on the internet (Southern, 2008).
The number of people engaging in sexual activities on the internet is high, but many do not
complain of difficulties related to these activities (Cooper, 2000). However, users can develop
problematic sexual behaviors on the internet if they are obsessively preoccupied with accessing
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these services and persist in this sexual behavior, although they face negative consequences in
their lives (Carnes, 2001).
One study estimated the percentage of users with problematic behavior at 17% (Cooper,
2000), but another Swedish study found that their percentage is lower, at 10% (Månsson, 2003).
However, there are descriptions that show that this behavior develops as: a consequence of
the inability to adapt to certain negative states (the individual tries to use his behavior to cope
with stress, anxiety or depression – Schwartz MF, 2000), a conditioned behavior, a dissociative
relapse of lifelong trauma or a courtship disorder (Southern, 2008).
The description of compulsive sexual behavior as an adaptive attempt of the individual to
cope with stress, anxiety or depression, also emerges from the frequent association of anxiety
and mood disorders with this type of behavior.
Given these comorbidities, it would be useful, as specialists, to assess how the reduction of
social and personal interactions, imposed in the context of the Covid-19 pandemic, influences
and affects the sexual life of individuals during this period.
Clinicians reported an increase in anxiety, mood disorders and alcohol consumption in
conditions of social isolation. Pornographic sites such as PornHub and online sex-chat or video-
chat sites have reported a significant increase in user access.
We may wonder whether the current social context could represent, amid increasing stress,
anxiety and depression, a predisposing factor for the development of compulsive sexual
behavior on the internet, as an adaptive reaction to negative emotional states.
CONCLUSIONS
For the correct diagnosis of this disorder, a complex clinical interview is necessary, that
allows the evaluation of the mental and physical health state of the individual, of the
functionality in various areas of life, as well as a thorough differential diagnosis considering
the multiple causes that can promote the development of a hypersexual behavior.
Although many people who engage in sexual activities on the internet do not report
problems in their personal lives or other areas of activity, sex on the internet can become
problematic when the concern becomes obsessive and the behavior becomes compulsive and
persistent, despite the negative consequences.
The efforts of sex therapists to make prevention programs through psychoeducation and sex
education can contribute enormously to improving people’s sexual health.
Such a program could aim to inform the population about predisposing or risk factors that
may promote the development of compulsive sexual behavior on the internet, as well as the
negative consequences resulting from this behavior. Such a program would be all the more
useful in the social context of the Covid-19 pandemic.
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PARAPHILIC DISORDERS
Abstract
Paraphilic disorders are diagnosed largely in forensic settings and it is both a social and a
public health issue. In this paper we discuss about the differences between paraphilias and
paraphilic disorders and we emphasize clinical features regarding voyeuristic disorder,
pedophilia, necrophilia and rape.
Keywords: paraphilic disorders, comorbidity, prevalence, sexual offending
INTRODUCTION
It is highly important to distinguish between paraphilias and paraphilic disorders. A

paraphilia is defined as an atypical or deviant sexual interest. Paraphilic disorder is a paraphilia
that is currently causing distress or impairment to the individual or a paraphilia whose
Satisfaction has entailed personal harm, or risk of harm, to others. (APA, 2013)
DSM-V includes eight specific paraphilic disorders:
1. Voyeuristic Disorder;
2. Fetishistic Disorder,
3. Exhibitionistic Disorder;
4. Frotteuristic Disorder;
5. Sexual Masochism Disorder;
6. Sadistic Disorder;
7. Pedophilic Disorder;
8. Trasvestic Fetishism.
Other specified paraphilic disorders are: necrophilia, klismaphilia, coprophilia, urofilia,

infantilism, telephone scatalogia.
In this article there will be presented the following: voyeuristic disorder, pedophilia,
necrophilia and rape.
Voyeuristic Disorder
Urges to observe an unsuspecting person who is naked, undressing or engaging in sexual
activities, or in activities deemed to be of a private nature. Sometimes it is also called
scopophilia (skopos = viewer, filia = love, pleasure). Voyeurism is characterized as having
recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving the act of
observing an unsuspecting person who is naked, in the process of disrobing, or engaging in
sexual activity. The person being considered for this disorder, in some way, has acted on these
urges towards a non-consenting person or the sexual fantasies/urges cause clinically significant
distress or impairment in social, occupational, or other important areas of functioning.
(According to DSM-V). Also, the individual who acts after the impulses is at least 18 years
old.
Comorbidity
According to other studies, there is considerable overlap with other potentially criminal
paraphilias in clinical samples, particularly exhibitionism and sadomasochism (Abel et al.,
1988; Bradford et al., 1992; Fedora et al., 1992; Freund et al., 1997; Gebhard et al., 1965).
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Prevalence
It seems that acts of voyeurism are very common in the area of sexual behaviors that have
the potential for breaking the law (e.g., Abel et al., 1988; Bradford et al., 1992). Langstrom
and Seto (2006) studied the prevalence of the characteristic feature of this disorder, that is,
arousal caused by watching persons involved in sexual activities on a representative sample
from Sweden. The sample included 2,450 subjects between the ages of 18 and 60. 191 of them
(12% men and 4% women) reported at least one incident in which they had sexual arousal
caused by spying on other people while having sex. Despite these indications of considerable
prevalence, research has been “extremely limited” (Mann, Ainsworth, Al-Attar, & Davies,
2008).
Another study examined whether non-clinical subjects would engage in voyeurism. Rye and
Meaney (2007) asked university students about the likelihood (0-100%) that they would
secretly watch an attractive person undress or two attractive people having sex, and the results
show that non clinical subjects also have voyeuristic behaviors. According to another study
that had as a population a rural area in the United States of America, which included 60 male
students who have never been convicted, says that 42% of them looked at others in hiding
during a sexual act. Langstro and Seto (2006) also investigated a possible association between
voyeurism behaviors and possible risk factors. In the given context, it seems that being male
and having psychological problems (sexual or emotional abuse in childhood), low life
satisfaction, high substance use, multiple sexual partners, high frequency of using pornographic
materials and masturbation, are risk factors for voyeurism disorder.
Pedophilia
The term “pedophilia” comes from the Greek language, “pais” meaning “child” and “philia”
which means “friendship”. This disorder refers to the directing of fantasies and sexual
behaviors towards adolescents or pre-adolescents. The Diagnostic Manual of Mental Disorders
(DSM-V) presents three criteria for diagnosing such a disorder. First, for at least 6 months, the
individual manifests sexual fantasies and behaviors that lead to sexual arousal with one or more
children, pre-pubertal age, usually under 13 years. Secondly, the individual has acted according
to impulses or they cause discomfort both psychically and in interpersonal relationships. The
last criterion refers to age, so the individual must be 16 years of age or older and the age
difference between the individual and the child is at least 5 years. Pedophilia itself is not
punished by the law, because punished are the concrete facts and not the sensations, feelings
and desires (e.g., sexual orientation). The pedophile will only be punished if he gives in to his
primary desires and takes action.
Dimensions:
• Exclusive → attracted only by children.
• Non-exclusive: → attracted by children and adults (Studies show that the vast majority
of pedophiles are nonexclusive. This means that they often have relationships with
adults).
• Incestuous versus Non incestuos: In Abel and Osborne’s study only 1% of the victims
were relatives with the one who molested them. Although incest is less frequent, it has
very long-term costs.
• Attracted to masculine gender, attracted to feminine gender or both. (Some studies
show that there are more homosexual pedophiles than heterosexuals. In 1992, however,
Abel and Osbourne conducted a study which resulted in more than 60% having
aggression against girls and boys.
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Comorbidity
There is empirical evidence that shows the clinical implications of pedophilia, and one of
them is the presence of several paraphilia disorders in people diagnosed with pedophilia, such
as: voyeurism, exhibitionism and frottoeurism. In Raymond’s study, 53% of the subjects were
diagnosed with multiple paraphilia disorders.
Necrophilia
One of the most sensitive parts in the field of sexual fantasies is because of their deviant
side Necrophilia is the sexual attraction to corpses. The main motivation of these acts seems to
be the pleasure of dominating a body that is not showing resistance. Another motivation found
in necrophiles would be to meet a former partner with whom they had a romantic relationship.
There is also a strong desire to overcome the profound sense of isolation. It is a rare disorder
that dates back to ancient times. According to Herodotus, the ancient Egyptians took measures
against necrophilia by forbidding to send the corpses of the wives of men of rank from being
delivered immediately to the embalmers, for fear that the embalmers would violate them.
According to a legend, King Herod had sex with his wife Marianne for seven years after he
killed her. In the Diagnostic Manual of Mental Disorders (DSM V) it is included in the category
of specified paraphylactic disorders and refers to an intense excitation present for at least 6
months and which is towards corpses.
In one study, a classification was made:
• “Genuine necrophils” and “pseudo-necrophiles”.
For the first category they wrote about 3 subtypes:
- Necrophilic Homicide – those who kill to get sexual pleasure with a corpse,
- Necrophiles – those who use the corpses without killing, to obtain sexual excitement,
- Necrophilic Fantasy – those who have fantasies with corpses.
According to a body of work, a 40-year-old, single man requested psychiatric help because
he was afraid that he would carry out a repetitive fantasy he had had since he was 15. His
fantasy was to kill a woman, cut her up, remove the organs, and then masturbate while
immersing his hands in the blood of the corpse. He had always been socially isolated. He had
been caught masturbating in public places and engaging in voyeuristic activities as well.
Choking prostitutes also excited him sexually. In his late 20s, he obtained a job in a morgue
for the sole purpose of being near dead bodies. Although he denied any actual sexual contact
with the corpses, he had become sexually excited by cutting them up. He killed animals for the
purpose of carrying out a similar fantasy. He killed the animals painlessly, taking no pleasure
in the killing itself. His pleasure came from the mutilation of the warm bodies (Risen, personal
communication).
For the second category, named “pseudo-necrophiles”, they do not have as primary interest
the bodies, but prefer the sexual contact with living persons.
Regarding psychopathology, it seems that in a sample of 64 subjects, 17% were psychotic,
and half were diagnosed with personality disorders. The access to the corpses is given by
occupation, the most common being in the hospital, the cemetery or the morgue. In fact, many
necrophiles have affirmed the choice of occupation as the main way to ensure their needs and
to express their fantasies.
Motivations:
The main motivation of these acts seems to be the pleasure of having a body that does not
resist. Another motivation found in necrophiles would be to meet a former partner with whom
they had a romantic relationship.
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Rape
Sexual offenses are a major social problem. Rape is a crime, thus punished by law and refers
to a sexual act that takes place against the will of one of the partners. The social danger
generated by sex offenses is represented by the physical and mental harm caused to the victim.
The costs are very high in the long term, being affected the sexual life but also the social
one. The state of “inability to defend itself” or “inability to express its will” are also relevant
for committing the crime of rape (and for other crimes), when the perpetrator has either put the
victim in this state or profited of this pre-existing state of the victim.
Povey and Kaiza (2007) investigated the statistics of these crimes in 2006-2007. In this
context, the police recorded 57,542 sex offenses in England. Just over three quarters (43,755)
are classified as serious sexual offenses, for example rape, sexual assault and sexual intercourse
with children. The other (less serious) sexual offenses consisted of sexual wrong doing, mostly
with adults, such as prostitutes. Adult men are the most common perpetrators of sexual crimes.
Myhill and Allen (2002) suggest that women between the ages of 16 and 24 are at greatest
risk of being raped or sexually assaulted. Knight and Prentky (1990) reported three types of
rapist motivations that actually help us identify typologies: sexual, anger-driven, and sadistic.
A common psychopathology that has been found in sexual offenders is antisocial personality
disorder. Antisocial personality disorder is characterized by a pattern of disregard and violation
of the rights of others. It is the most common disorder in prison systems. According to research
by Fazel & Danesh (2002), the prevalence of the disorder among prisoners is 47% in men and
21% in women.
CONCLUSIONS
Paraphilic disorders are diagnosed largely in forensic settings and delineating what is normal
versus deviant is one of the biggest challenges when using the term paraphilia. There is
empirical evidence that shows the clinical implications, such as comorbidity and distress.
Numerous studies (Bondrea A. & Delcea C., 2019; Constrachevici L, M., & Delcea C.,
2019; Delcea C, 2019; Popa T., & Delcea C., 2019; Eusei D., & Delcea C., 2019) confirm our
results. It is highly important to distinguish between paraphilias and paraphilic disorders, in
order to reduce the stigma for those with atypical sexual interests who do not cause harm.
Paraphilic disorders represents both a social and a public health issue and further research
is needed.
REFERENCES
[1] Brown, J. M., & Campbell, E. A. (Eds.). The Cambridge handbook of forensic psychology. Cambridge
University Press, 2010.
[2] Rosman, J. P., & Resnick, P. J. Sexual attraction to corpses: A psychiatric review of necrophilia. Bulletin
of the American Academy of Psychiatry and the Law, 17(2), pp. 153-163, 1989.
[3] American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM5®).
American Psychiatric Pub, 2013.
[4] Cohen, L. J., & Galynker, I. I. Clinical features of pedophilia and implications for treatment. Journal of
Psychiatric Practice®, 8(5), pp. 276-289, 2002.
[5] Långström, N. The DSM diagnostic criteria for exhibitionism, voyeurism, and frotteurism. Archives of
sexual behavior, 39(2), pp. 317-324, 2010.
[6] Metzl, J. M. Voyeur nation? Changing definitions of voyeurism, 1950-2004. Harvard review of
psychiatry, 12(2), pp. 127-131, 2004.
[7] Moser, C. DSM-5 and the paraphilic disorders: Conceptual issues. Archives of Sexual Behavior, 45(8),
pp. 2181-2186, 2016.
[8] Bondrea A. & Delcea C. Sexual deviations. Considerations regarding pedophilia – mith and reality. Int
J Advanced Studies in Sexology. Vol. 1, Issue 1, pp. 10-14. Sexology Institute of Romania. DOI:
10.46388/ijass.2019.12.112.
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[9] Constrachevici L, M., & Delcea C. Sexual deviance. The Sexual sadism. Int J Advanced Studies in
Sexology. Vol. 1, Issue 1, pp. 23-27. Sexology Institute of Romania. DOI: 10.46388/ ijass.2019.12.114
10. Delcea C. Zoophilia. Int J Advanced Studies in Sexology. Vol. 1, Issue 1, pp. 36-38. Sexology
[10] Delcea C. Sexual deviances. Int J Advanced Studies in Sexology. Vol. 1, Issue 1, pp. 44-47. Sexology
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[12] Eusei D., & Delcea C. Fetishist disorder. Int J Advanced Studies in Sexology. Vol. 1, Issue 2, pp. 73-
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FORENSIC EVALUATIONS OF SEXUAL OFFENDERS
Abstract
In this paper, my aim is to show the paraphilic disorders described in DSM-5 by highlighting
their contribution to sex offences, the psychological profile of the sex offender, the most
frequent sex offences, how the severity of paraphilias is being assessed and the individual’s
sexual interest.
Keywords: paraphilia, voyeurism, exhibitionism, frotteurism, masochism, sadism, fetishism, tranvestism, pedophilia, sex,
offender, offence, rape, abuse, anxiety, shame, guilt, disorder, discomfort, paraphilic disorder, antisocial disorder, minors,
children
INTRODUCTION
The Romanian explanatory dictionary (DEX) (2010) describes the offence as a “violation of
a predetermined rule which represents a social danger, consisting in the culpable commission
of a violation of the criminal law and it is sanctioned by law”. Synonym: “violation”.
The offender is, also according to DEX (2010), the person committing the offence.
Synonym: “wrongdoer”.
Of course, an offence has different degrees of severity. However, when a father tells his 15-
year-old daughter, “Stop wearing these shorts around the house, they’re too short and you’re
already a young lady!”, could we say the father is an offender? That sounds like an
exaggeration! However, although they are just words, their impact on the daughter is enormous:
“how is my father bothered if my shorts are too short?”, “how did he notice that, isn’t he, my
father?!”. From that moment on, “daddy’s girl” suddenly falls in a strange adult world. The
consequences are the permanent emotional separation from her father, distrust in the friendship
of men (“what does he really want from me?”) and inhibition reflected in the sexual life. If an
offence is committed, does this mean that this father is an “offender”?
The law established the severity of an offence especially according to the severity of the act,
but what if some words have the same impact over the “victim” as an incest?
In the following pages, I will talk about paraphilias and paraphilic disorders, their diagnosis
and how they are assessed and tested, by following their criminal potential.
According to DSM-5 (2016), the paraphilia term defines “any intense and persistent sexual
interest other than sexual interest in genital stimulation or preparatory fondling with
phenotypically normal, physiologically mature, consenting human partners” (p. 685). “A
paraphilic disorder is a paraphilia that is currently causing distress or impairment to the
individual or a paraphilia whose satisfaction has entailed personal harm, or risk of harm, to
others.” (p. 685).
DSM-5 presents eight types of paraphilias, which are relatively common, in relation to other
paraphilic disorders, and some of them entail actions for their satisfaction that, because of their
noxiousness or potential harm to others, are classed as criminal offenses.
1. Voyeurism: spying on the intimate actions of nonconsenting individuals. The voyeur is
hidden, does not want to be observed, and obtains pleasure and sexual arousal from breaking
the intimacy of the individual(s) observed. Generally, he/she desires to reach orgasm through
masturbation while watching or after when fantasizing about what he/she saw. We can talk
about a voyeuristic disorder when this behaviour is repeated and persistent over a period of at
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least 6 months, it causes mental discomfort or clinically significant dysfunction in the social or
personal area or in other important areas of functioning, and the individual is of at least 18
years of age.
2. Exhibitionism: exposing the genitals by surprise to strangers with the purpose of intense
sexual arousal. Much more frequent in men, though there are cases in women too. Rarely,
exposing the genitals can be accompanied by masturbation. It is considered an exhibitionistic
disorder when the specific behaviours or fantasies related to possible reactions to this
behaviour last for a period of at least 6 months, causing mental discomfort (feelings of guilt,
shame, intense sexual frustration, loneliness) or clinically significant dysfunction in the social
or personal area or in other important areas of functioning. The subtypes for exhibitionistic
disorder are based on the age or physical maturity of the nonconsenting individuals to whom
the individual prefers to expose his/her genitals. The nonconsenting individuals can be
prepubescent children, adults, or both. The subtype is important to mention to be able to spot a
coexistent consistent pedophilic disorder.
3. Frotteurism: touching or rubbing against a nonconsenting or unconscious individual to
obtain intense sexual arousal. This paraphilia is characterized by fantasies, sexual impulses, or
specific behaviours. Frotteuristic disorder involves repeated behaviour and the presence of
frotteurism for a period of at least 6 months and the appearance of mental discomfort (feelings
of shame, guilt) in the individual or of clinically significant dysfunction in other important
areas of functioning. This disorder has a significantly higher frequency in men than in women.
4. Sexual Masochism: acts through which the individual is humiliated, beaten, tied, or made
to suffer in any other way for the purpose of obtaining intense sexual arousal. Masochism is
characterised by fantasises, sexual impulses or specific behaviours. This turns into sexual
masochism disorder when the sexual masochism, with all its characteristics, persists for at
least 6 months and when the fantasies, sexual impulses or specific behaviours cause mental
discomfort or clinically significant dysfunction in the social or professional area or in other
important areas of functioning. Other acts that cause suffering can be: burning, skin perforation,
flagellation, electric shocks, sexual acts with immobilization, etc. Other acts which pose a
higher risk to the individual’s life are those that provide sexual arousal through oxygen
deprivation, a subtype called asphyxiophilia. Asphyxiophilia (hypoxyphilia or auto-erotic
asphyxiation) consists of obtaining sexual arousal through suffocation or controlled
strangulation. This paraphilic disorder can be harder to class as offence because the negative
consequences are over the own person, not over others. There is the risk of accidental death,
especially through asphyxiation. In the sexual masochism disorder, an associated feature
sometimes appears represented by the use of pornographic material with individuals who are
beaten, tied, or made to suffer in different ways. The prevalence of the disorder in the
population is unknown, but according to existing data, no significant difference between men
and women exists.
5. Sexual sadism: involves provoking the physical or mental suffering of a nonconsenting
individual with the purpose of obtaining intense sexual arousal. It is characterized by fantasies,
sexual impulses, or specific behaviours. Sexual sadism disorder involves repeated and
persistent presence of specific behaviours, fantasies and sexual impulses or mental discomfort
or clinically significant dysfunction in the social or professional area, or in other important
areas of functioning for at least 6 months. If the partner consents (as a masochist) and sexual
sadism is moderate, it can be considered a shared sexual practice and will not be considered a
disorder. When sexual sadism is performed with nonconsenting individuals it is considered an
offence. Sexual sadism is especially severe when associated with an antisocial personality
disorder. This combination of disorders is extremely resistant to psychiatric treatment and
psychotherapy. Sex offenders with a pronounced sexual sadism disorder are capable of
atrocious crimes.
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6. Pedophilia: is represented by obtaining intense sexual arousal through sexual activity

with one or more prepubescent children (under 13 years old). Pedophilia disorder involves the
presence for at least 6 months of sexually arousing fantasies, intense and repeated sexual
impulses or behaviours leading to obtaining sexual arousal through sexual activity with one or
more children. If the individual has acted upon these sexual impulses or if these impulses or
sexual fantasies cause significant mental discomfort (feelings of shame, guilt, anxiety, intense
sexual frustration, isolation) or difficulties in interpersonal relationships, this will be classified
as pedophilic disorder. For this, the individual must be at least 16 years old and at least 5 years
older than the victim child. To abuse the child, the individual will use force or mental
manipulation, because later the child will be threatened not to reveal the abuse to someone else.
Associated elements that support diagnosis are the extensive use of pornographic material
showing prepubescent children. Pedophilia, it seems, is a disorder that lasts for the entire life,
but advancing in age has the effect of diminishing this disorder, as is the case of other paraphilic
or normal behaviours. The association between pedophilic disorder and antisocial disorder,
alcohol consumption or even obsessive-compulsive disorder (rarely) increases the possibility
for these individuals to exhibit a sexual behaviour that targets children. When an individual’s
history suggests the possible existence of pedophilic disorder but he/she denies having a strong
or preferred attraction to children, psychophysiological methods of measuring sexual interest
are used, such as visualisation time (also called visual reaction time), penile plethysmography
or vaginal photoplethysmography. These methods will be described later.
7. Fetishism: manifested through an array of fantasies, sexual impulses or specific
behaviours, consists of using inert objects, either in the very specific interest for a certain
anatomical body part (excepting the genitals) with the purpose of obtaining intense sexual
arousal. Repeated behaviour and presence for at least 6 months and mental discomfort,
associated with clinically significant dysfunction in the social or professional areas or in other
important areas of functioning shape the fetishistic disorder diagnosis. The problems of an
individual affected by fetishistic disorder are reflected especially in couples, because they
cannot orgasm if the fetishized object is unavailable. Therefore, even when in a romantic
relationship, these individuals prefer solitary sexual activity where they can freely use their
fetishized objects. Fetishistic disorder is relatively rare in sex offenders. At most, their criminal
acts are related to stealing fetishized objects.
8. Transvestism: is represented by donning and wearing clothes of the opposite sex
(transvestism) to obtain intense sexual arousal. It manifests through fantasies, sexual impulses,
or specific behaviours. When these fantasies, sexual impulses or behaviours cause emotional
discomfort or clinically significant dysfunction in the social or professional area or other
important areas of functioning or when they repeat and last for more than 6 months, we can
talk about transvestism disorder. However, in this situation, the individual’s social and cultural
environment matter, because the mental discomfort felt could be caused by not being accepted
by others. If the same individual would live in a society without negative reactions to
transvestism, the mental discomfort would disappear, or it would be significantly lowered.
Suffering and dysfunction can manifest in heterosexual couples when the man has
difficulties in maintaining penile erection and in obtaining sexual orgasm without transvestism
or without intimate fantasies about transvestism.
Causes
One of the factors that appears to catalyse most paraphilias is childhood sexual abuse. Thus,
we can conclude that pedophilia can also be cause and effect of itself and at the base of other
paraphilias. In what regards pedophilia, some proof shows that neurodevelopment disorders
during in-utero life increase the probability of pedophilia.
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Methods to evaluate the severity of paraphilias

a) Questionnaires: the fantasies, impulses or paraphilic sexual behaviours of the examined
individual are evaluated in relation to his/ her normal sexual interests and behaviours: lower,
approximately equal, or stronger than the normal sexual interests and behaviours. The
subjectivity of the answers given by a subject represents a disadvantage in questionnaires.
b) Penile plethysmography is a psychophysiological procedure that can offer more
objective measurements, standardized to evaluate the individual’s sexual interest. The subject’s
sexual arousal is measured through a ring fixed around the penis which allows measuring the
variation of the penile circumference. The ring is thin and elastic, and it stretches as the penis
circumference grows. There is also the volumetric plethysmography method, where a cylinder
is placed over the penis to measure the air movement caused by the penis erection. Some state
that volumetric measurement is more precise than circumference measurement. The stimuli
that can determine the penile volumetric or circumference growth are represented by images
and audio/video recordings (erotic slides) chosen according to the suspected disorder: nude
children in the case of pedophiles, molested children in the case of child molesters, sexual
violence in the case of those with sexual sadism disorder, etc.
Penile plethysmography allows to differentiate between sex and non-sex offenders, and for
sex offenders, between rapists and non-rapists. Therefore, penile plethysmography and other
measurements offer the most comprehensive and exact image of the sexual and non-sexual
interests of the individual, but it also predicts the success of treatment, as well as the probability
of relapse.
Marshall (1996) and British Psychological Society (2008) do not recommend penile
plethysmography as:
- Sole criteria for determining deviant sexual interests;
- Sole criteria for recommending the release of offenders in community;
- Consideration if the individual has finalized treatment;
- Conclusion if someone has or has not committed a specific sexual offense;
- Test for an individual before the remission of symptoms;
- Determination of the risks and treatment needs in the absence of other information.
Also, the prudent use of penile plethysmography is recommended in people with
developmental disabilities, major acute mental disease (National Clearinghouse on Violence
Family, 1998) or in those with difficulties in the exact perception of stimuli because of a limited
capacity of discrimination between age and sex in each example of the evaluation and who
could have trouble with understating the procedure (Haaven and Schlank, 2001).
Ethical concerns related to the use of penile plethysmography

The ethical concerns are related to the fact that penile plethysmography evokes deviant
sexual arousal and testing could be considered intrusive. The association for the treatment of
sexual abusers (2001), British Psychological Society (2008) and Marshall (1996) affirm that
the following ethical considerations should be kept in mind for penile plethysmography:
- The explicit exposure of the subjects to deviant stimuli could be seen as tacit approval
of the material;
- Exposing minors and impressionable adults to materials with explicitly deviant stimuli
could shape future patters for sexually deviant interests;
- The stimuli inherently degrade women and children;
- Exposure to explicitly deviant stimuli can induce anxiety, nervousness, depression and
other emotional disorders;
- Laboratory procedures which impose the subject to auto-stimulation to reach maximum
arousal lead to the subject’s humiliation and could go against religious beliefs.
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c) Visualisation time
It is supposed that sexual arousal is not a unitary construction, but it has three stages:
- When the response is aesthetic and the response to the sexual stimuli is hedonic (the
subject is pleased with seeing the object of attraction);
- The subject approaches the object of attraction with the desire of having body contact
with it;
- Genital response as reaction to the sexual impulses.
Visualisation time is a method to evaluate sexual interest, it involves measuring the
visualisation reaction time and is based on a heightened visual response to seeing the objects
of attraction (aesthetic or hedonic response).
Compared to penile plethysmography, which involves laboratory, equipment, hardware,
software, and training costs, the visualisation time method is a much more economical
alternative. What is more, it is less intrusive than penile plethysmography, as the subject does
not have to disrobe and have a device attached to his/her genitals.
The most known option of this method is AASI (Abel Assessment for Sexual Interest). The
subject visualises 160 slides with masculine and feminine characters, aged from 2 to adult age.
There are no nude images. The subject will indicate the degree of disgust or excitation on a
scale of 1 to 7, where 1 reflects a very low interest, even disgust, while 7 reflects the image is
sexually arousing.
d) Polygraph test
The polygraph is a device that measures and records certain physiological parameters of a
subject during a series of questions that orient the examiner in establishing the veracity of the
answers. However, three emotions which come up in the examined subjects are difficult to
differentiate:
- The fear of detection by the guilty examinee;
- The fear of possible errors in the procedure by the innocent examinee;
- The anger towards the examination of the innocent examinee.
When a question is perceived as threatening, the sympathetic nervous system reacts in a
discharge of epinephrine and norepinephrine which prepare the organism for “fight or flight”
mode. This hormonal secretion constricts small blood vessels which creates nausea, skin pallor,
cooling of the extremities caused by decreased blood supply. The salivary glands change their
secretion and saliva becomes viscous causing the feeling of “dry mouth”. Conversely, the sweat
glands accelerate secretion and sweat increases. The breathing rhythm changes, the pupils
dilate, and the anal sphincter contracts. The polygraph is composed of four basics components
that record physiological parameters:
- Pneumograph with sensors to record the parameters of the respiratory system at the
abdominal and thoracic level;
- Sensors to measure the electroconductive quality of the skin, placed on the subject’s
nondominant hand;
- Sleeve to determine blood pressure;
- Plethysmograph with photoelectrical sensor on the finger to measure cardiac rhythm.
In practice, the polygraph is used for the following types of examinations, according to
PCSOT (T. Tipton, 2007):
a) Examination of sexual history;
b) Examination of the reveal;
c) Maintenance examination (at 3-6 months);
d) Monitoring examination;
e) Examination of the incident itself.
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Sex offenders
Taking into account the complex character of personality, approaching the offender in the
context of legal psychology must target the following channels, according to T. Butoi (2004):
• Clinical research, to establish the individual’s personal and possible pathological
antecedents;
• Paraclinical examinations, to test the clinical diagnosis or to establish other possible
clauses (for example, establishing brain tumours, etc.);
• Biogenetic investigations, to identify heredity factors;
• Neurophysiopathological interpretation, to explore the causality of aggressive
manifestations with an antisocial echo related to biopsychological conditions which
heighten or trigger them;
• Sociologic research that follows, on one hand, the reconstruction of the delinquent’s
personality, and on the other hand, the possibilities of social reinsertion;
• The result of forensic and psychiatric expertise, that through psychiatric and
psychologic examination established the presence, absence, or reduction of judgement
in the subject.
Approaching the offender’s personality in this way is needed for the following reasons:
o It allows the correct appreciation of the individual’s mental state by establishing
the diagnosis and excluding simulation (through biodetection);
o The essential characteristics of the individual’s personality can be established;
o The nature and evolution of the disorders preceding or accompanying the act
can be established;
o Some appreciations can be made on the degree of danger over the individual’s
personality traits or over the existent behaviour disorders.
Sex offenders can manifest personality disorders that are oftentimes associated with
paraphilic disorders. A sex offender with the antisocial personality disorder is capable of
atrocious crimes because he/she is unable to feel empathy, remorse, guilt, or shame.
The sexual psychopath, where psychopathy is associated with one or more paraphilic
disorders: voyeurism, exhibitionism, frotteurism, masochism, sadism, paedophilia. About
sexual psychopaths, Szondi says that instinctively they are dominated by the principle of
pleasure, meaning they are stuck at a primitive-infantile stage of sexuality; from there comes
their tendency to polymorphic perversions and sexual offences.
A common element in many offenders is frustration, which results from being hindered from
or deprived of obtaining satisfaction or reaching a desired goal and is felt on the cognitive plan
as a tension affecting the individual’s activity. Depending on the degree of tolerance to
frustration, the individual can surpass the frustration state (in the case of a high tolerance to
frustration) or he/she can react aggressively and chaotically (in the case of a low tolerance to
frustration).
Sex offences
Often, men commit more sex offences than women. As a group, sex offenders rank higher
than other offenders, though they usually have a history of non-sex offences. The most common
sex offences are: rape, sex offences against children, exhibitionism. Some sex offences do not
imply violence (exhibitionism, voyeurism, etc.), while others considerably imply violence
(rape).
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Rape
Most rapists are young, sexually frustrated, inexperienced in sexual relationships and most
have criminal records. The main behavioural types are:
• Antisocial aggressive men with a history of general criminal behaviour, but without
any mental disorders (most frequent);
• Sadistic, aggressive men, who want to humiliate and harm women;
• Explosive rapists, often shy and inhibited, who premeditate the act to release their
frustration;
• Mentally ill rapists, who are often manic.
Sex offences against children

These offences vary in severity from mild indecency to severely aggressive behaviour, but
most do not imply violence:
- Indecent allusions;
- Severe indecency;
- Insistent indecent behaviour;
- Rape or rape attempt;
- Indecent exposure;
- Incest;
- Pornography;
- Illegal sexual relationship (ages lower than 16).
A recent study performed in 2001 by M. Tardif and H.V. Gijseghem in Canada, using the
Minnesota Multiphase Personality Inventory, Rorschach test, Ego Identity Scale, has made the
following conclusions: paedophiles who abuse female victims and who abuse masculine
victims have more fragile limits of their image of self and score higher on the social
introversion scale than offenders who do not commit sex offences. What is more, paedophiles
who abuse masculine victims have a weaker ego than paedophiles who abuse female victims
or than offenders who do not commit sex offences.
In a 2000 study on 462 men accused of sex offences against minors in England, of which
374 were condemned, C. Pritchard and C. Bagley made an interesting typology of those. Based
on the substantial law parameters, the authors of the study split the men in three categories:
• offenders who had only committed sex offences;
• offenders who had committed sex offences and other offences as well;
• offenders who had committed violent sex offences. Alex Thio created a psycho.
Behavioural profile of those who commit sexual abuse against children as compared to
rapists:
• the age average is over 35, rapists being under 20;
• they are sexually inhibited or less sexually aggressive; they start with masturbation and
have sexual contact later in life;
• generally, they are calm, gentle, and passive, rapists being much more aggressive;
• unable to maintain relationships with the opposite sex as they are anxious and lack the
ability of communication, as opposed to rapists;
• most commit offences against the same child, while rapists attack more victims;
• most admit guilt when accused, while rapists don’t;
• homosexuals who molest boys admit guilt much easier than heterosexuals who molest
girls.
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CONCLUSIONS
As shown, in most cases of sex offences the offender’s behaviour is based on the
manifestation of one or more paraphilic disorders often triggered by childhood sexual abuse.
This could be the psychological factor, though not the only one: recent researches have
shown that paraphilic disorders can also be determined by biological, neurobiological, and
hormonal causes. Should we know more about these processes, we could intervene with
prevention, a much more efficient method than treating these affections. Numerous studies
Delcea C, Enache A, Stanciu C, 2017; Delcea C, Enache A, 2017; Gherman C, Enache A,
Delcea C, 2018; Delcea C, Fabian A. M, Radu C. C, Dumbravă D. P, 2019; Rus M, Delcea C,
Siserman C, 2019; Siserman C, Delcea C, Matei H. V, Vică M. L., 2019; Gherman C, Enache
A, Delcea C, Siserman C, Delcea C, Siserman C., 2020 confirm our results. Paying attention
to children and their social circles, plays a key role in avoiding their exposure to any kind of
abuse, especially sexual abuse.
REFERENCES
[1] Phenix, A., Hoberman, H., Maram, W., Sexual Offending- Predisposing Antecedents, Assessments and
Management, Ed. Springer Science+Business Media, New York, 2016, pp. 1-56, pp. 331-349.
[2] Perrotta, G., Paraphilic Disorder: Definition, Contexts and Clinical Strategies, Neuro Research 1(1):4,
2019.
[3] American Psychiatric Association, DSM-5 Manual de Diagnostic și Clasificare Statistică a Tulburărilor
Mintale, Editura Medicală Callisto, București, 2016, pp. 685-705.
[4] Butoi, T., Butoi I., Psihologie judiciară, Editura Fundației România de Mâine, București, 2004, pp. 385-
389.
[5] Zamoșteanu, A., Delincvența, între etiologie și abordare trapeutică, Editura Eurobit, Timișara, 2008.
DOI: 10.4172/2471-4372.1000140.
4372.1000160.
2019. Vol. 61, p. 45. DOI 10.1016/j.jflm.2018.10.005.
DOI:10.4323/rjlm.2019.279.
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EVALUATION, DIAGNOSTIC AND MANAGEMENT OF RECIDIVE TO SEXUAL

INFRACTORS IN THE VIRTUAL MEDIA
Abstract
The paper addresses the types of sexual crimes committed with the help of virtual space,
presents two case studies and offers aspects of the situation of sexual crimes in Romania. It
details the possible risk factors of recidivism of cyber-offenders in Romania.
Keywords: cybercriminal, paraphilia, risk factors in recidivism
INTRODUCTION
Even if human behavior has always been influenced by technology, we are now witnessing
the greatest possible modeling of behaviors of all historical times. It is about the decisive impact
of the internet on communication, on impulsivity and attitudinal and relational disinhibition,
even on encouragement and stimulation in adopting behaviors that would not take place outside
virtual space.
Human relation also has undergone massive transformations, especially in the ritual
procedures of sexual closeness, evident by the emerging behaviors of sending selfie images
and sexting (sexually explicit messages).
Crimes of a sexual nature, such as rape or other sexual abuse (perversion or sexual
corruption or incest), committed on minors or adults, mark the lives of victims, leave deep
traces on a psychological level, not only physically. Research continues to look for ways to
contain these crimes, but statistics indicate that the chances of rehabilitation are unfortunately
quite low.
John Suler (apud Aiken, 2016) believes that the online disinhibition effect contributes
massively to the adoption of hostile conduct, while M. Aiken emphasizes the influence of
online escalation, through which problematic behaviors in the online space are amplified, from
excessively hostile verbal exchanges to highly challenging personal attacks on people. M.
Aiken (2016, p. 30) also observed that “whenever technology meets an adjacent predisposition
or a tendency towards a certain type of behavior, it can lead to an amplification or an escalation
of behavior. I would argue that the trends and vulnerabilities that cause the greatest difficulties
in real life could become even more aggressive online.” Mr. Aiken noted that cyber-harassers
are not limited to a single victim, as in the real world, but that they are developing an evolution
of criminal behavior by migrating, accelerating or amplifying it in the virtual environment.
If in the past unusual sexual behaviors have been classified as deviant or perverse, they are
now known as paraphiles. These behaviors are not associated with a “traditional” romantic
relationship, but with atypical behaviors that include fetishes. DSM-5 identifies 8 main types
of conditions: exhibitionist disorder, pedophile disorder, fetish disorder, erotic masochism
disorder, sexual sadism disorder, transvestic disorder, voyeuristic disorder, frotteuristic
disorder. Although dozens of other paraphilias have been identified, starting with sexual
attraction to people with amputated organs or limbs (acrotomophilia), to deceased people
(necrophilia), to pregnant women (maiesiophilia), toys (plushophilia), it seems that the most
common sexual attractions are to shoes, leather and latex items, respectively to female
underwear.
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Why are these fetishes and paraphiles important? Because there is a fine line between
behavior considered normal and disorder, i.e., between non-criminal and criminal behavior. If
it is practiced between two adults, with the explicit expression of the consent of both and which
does not cause physical or mental damage/trauma to either partner, then we may be tempted to
consider it acceptable. After all, what provokes pleasure in the privacy of adult sexual partners
does not concern society, but only themselves.
Problems arise, however, when these paraphiles become harmful, when they defy social and
legal conventions. For example, the most common association of paraphilias with social crimes
is burglary, theft, damage to public or private property, coercion or the obligation to participate
forcibly in their performance. On these coordinates, the internet and technology do nothing but
provide a fertile ground for the initiation or full manifestation of these paraphiles in the sense
of criminal behavior, especially by popularizing with a somewhat romantic, rebellious and
libertine tinge these types of behaviors.
One of the most disturbing and sad cases of amplified paraphilia after the person found
several partners on social media, occurred in 2012. It is about Ewelle O’Hara, alone, 36, a child
carer from Ireland, who was initially reported missing. Police discovered sexy latex lingerie
and images of two hunting knives in her apartment. Her history has revealed self-mutilation,
depression and suicide attempts. But the most worrying aspect was that Emaine had confessed
to her father that she had found on the internet a sexual partner who liked to tie her up and
asked her to kill her!
In 2013, Emaine’s body was discovered in the bushes of the Dublin Mountains, her mobile
phone, a rusty chain, a sex slavery mask, a rope, knives and other BDSM accessories. The text
message history showed that Elaine had been in a relationship with a man named Graham
Gwyer who had declared himself sadistic and that they had shown mutual interest in stabbing
and being stabbed in search of sexual pleasure. Interestingly, Graham had three children and
had a good job as an architect in Dublin. In 2015 he was sentenced to life in the murder of
killing Elaine.
To discover their shared history, the police noticed that both were using the FetLife website,
as well as other BDSM sites to touch their sexual fantasies. The message exchanges between
the two show a gradual increase in discussions about BDSM up to those about the killing itself.
It can be said that it was the story of the slave who was looking for a sexual master and a
master who was looking for a slave. But it can also be the tragic story of a depressed and
suicidal woman who met the man who had impulses and stabbing fantasies. In the absence of
the Internet, they may never have met!
Due to anonymity and disinhibition, reactions and behaviors atypical to the real world take
place online. As M. Aiken observes (2016, p. 35) “online syndication is not just about finding
other people who share your interests. It can start a process of regulation and socialization
which, when it comes to deviant or criminal behavior, poses an enormous threat to society if it
is not recognized or moderate.” By hyper-connecting people can socialize faster, you can
quickly start interacting with members of a community with the same interests as yours and
you are introduced to a system of beliefs, attitudes, values, principles, habits etc., which will
gradually become the norm of their lives. The feeling of finding other people “like you” are
unparalleled, and membership in such a community can end up replacing real-life social
relationships, especially when they are not gratifying enough.
Another example of paraphilia is exhibitionism, which affects men of very different age,
professional training and social statuses. One of the famous cases of Us Congressman Anthony
Weiner, who in 2011 was forced to relinquish any political office because of the sexting scandal
in which he was involved. Interestingly, nearly a third of adult men arrested in the US for sexual
offences are exhibitionists. They show or send pictures of the sexual organs of women, girls or
underage boys. The reasons are diverse: they are either looking for masculinity, they want
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attention, or they are so angry with women that they want to shock and scare them. However,
the practice of sexting has become quite common today, very close to being considered
“normal”.
Another situation is present in Romania. “Official statistics on rapes in Romania tend to
remain within constant limits in recent years. In 2005 there were 1,013 rapes, in 2006, 1116, in
2007, 1048, and in 2008, 1016. In the first 6 months of 2009 there were already 493 rapes
recorded. Rape ranks second among violent crimes against the person after robbery, the number
of which has almost halved between 2006 and 2007. We must consider that not all sexual
offences are reported, due to the shame of the victims, the lack of knowledge of the laws and
the flawed system of police reports. (Decse-Radu, Pripp, 2009, source:
http://penalreform.ro/uploads/media/reducerea_recidivei_in_abuzurile_sexuale.pdf).
The literature distinguishes two types of sexual abusers: legal and clinical, as being different,
though not mutually exclusive. The legal sex offender is the person convicted of committing
illegal sexual acts, and the clinical sexual abuser is the one who can be diagnosed as showing
a paraphilia (Burdon, Gallaghes, 2002, pp. 87-109).
In the Manual of Diagnostic and Statistics of Mental Disorders (DSM IV TR, 2000), rape is
not included in the category of paraphilias, although some authors consider it a paraphilia,
making as arguments the statements of rapists who experience recurring fantasies about the
commission of abuse as well as the association of rape with other paraphiles (exhibitionism,
frotteurism, voyeurism).
The earliest diagnosis category of rape and included in DSM IV TR (2000) is that of sexual
sadism. A clear overlap over the category of clinical sex offender is the diagnosis of pedophilia
(manifestation for a minimum of 6 months, of sexually exciting, intense, recurrent fantasies,
impulses or behaviors involving sexual activity with a child or with prepubertal children, aged
up to 13 years).
From the perspective of the legal sex offender, in our country, the legislature introduces a
number of offences relating to sexual abuse, whether committed on an adult person (according
to Article 197 from the Penal Code, rape is sexual intercourse of any kind, with a person of
different sex or is the same sex, by coercing him or taking advantage of his inability to defend
himself or express his will) or on a minor (pedophilia – sexual act of any kind , with a person
of a different sex or of the same sex, who has not reached the age of 15 or sexual corruption,
art. 198 PC – obscene acts committed on a minor or in the presence of a minor).
The process of assessing sexual abusers

The initial assessment is an essential process because, on the one hand, it must determine
the personality characteristics, the focus points, and, on the other hand, it sets the timing, format
and content of the specialized intervention. Although there is no standard evaluation procedure,
it must consider the three principles: risk, need and responsiveness. Evaluations must sum up
all conclusions regarding: criminogenic needs, risk factors (static and dynamic), risk of relapse.
Dynamic and static risk factors

“Static risk factors aim at assessing traits related to criminal history and personality, in terms
of traits that do not support major changes over time. Dynamic risk factors, on the other hand,
target daily variables susceptible to change through treatment or other interventions. In terms
of the factors that can influence rape, we also talk about distal and proximal factors. The first
category includes personality characteristics, attitudes and general life experience of the abuser
and victim. The second category refers to the current elements, which characterize the general
context that favored the occurrence of abuse. (Decse-Radu, Pripp, 2009, source:
http://penalreform.ro/uploads/media/reducerea_recidivei_in_abuzurile_ sexuale.pdf).
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Based on studies undertaken by DecseRadu and Pripp (2009, source:

http://penalreform.ro/uploads/media/reducerea_recidivei_in_abuzurile_sexuale.pdf), we will
present below the factors we consider at risk in the recidivism of online sex offenders.
Static risk factors in relation to relapse

More research has focused on establishing a relationship between risk factors and relapse.
Among them, an important role in deciding to reoffend appear to have the following static
risk factors:
• personality disorder (psychopathy),
• cognitive dysfunctions (linked to the process of learning),
• the age up till 40,
• antisocial behavior and compulsive, deviant,
• detachment, lack of secure attachments.
Dynamic risk factors associated with relapse can be:

• stereotypical, hostile attitudes towards women,
• a high level of impulsivity,
• cognitive distortions and emotional loneliness,
• low empathy towards the victim,
• emotionally impaired control,
• deficits in the sphere of privacy and problem solving,
• deviant sexual pursuits and fantasies.
There is no doubt that cognitive distortions are characteristic of sexual abusers, however,
the question arises whether they are precursors of the crime or strategies for maintaining an
appropriate self-image, strategies that have been developed post-offence. Research covers both
cognitive structures (schemes), cognitive operations (information processing strategies) and
cognitive products (beliefs, attributions, attitudes, self-statements), but tend to focus more on
the last category, the result, the most easily accessible. Cognitive distortions are most often
regarded as rationalizations developed before, during and after the sexual offence.
Denial
A special type of cognitive distortion is denial. The general purpose of therapeutic programs
aimed at sexual abusers is to reduce relapse. There is, however, resistance from the abuser to
involvement in specialized intervention, generated, in part, by the process of denial. Those who
do not take responsibility will show a lower compliance with the tasks of treatment, will be
resistant to accepting its purposes and will often fail to complete it. The fact is that at least
indirectly denial increases the relapsing potential. The Association for the Treatment of Sexual
Abusers (USA) strongly recommends that accepting responsibility for abusive behavior be a
goal of all treatments and not be considered an obstacle to treatment or a criterion for
eliminating subjects in the pre-treatment selection process.
Gender roles
Research indicates that hostility of sexual abusers is based on poor socialization, lack of
inhibitory and control factors. Hostility precedes and facilitates sexual aggression, being a good
predictor for violent crimes. A high level of hostility to women in the case of sexual abusers is
confirmed by several researches. Rigid gender attitudes towards women seem to differentiate
sexual abusers from other categories of offenders (MuresanChira, Decsei-Radu, 2007).
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Emotional dimension of sexual abusers

Research led by Pithers & et al., (1988, apud Decse-Radu and Pripp, 2009, source:
http://penalreform.ro/uploads/media/reducerea_recidivei_in_abuzurile_sexuale.pdf) indicate
that 89% of sexual abusers had experienced negative emotional states in the hours before the
crime was committed. To cope with these stressors, abusers use inappropriate coping strategies,
including deviant sexual behaviors - as well as self-denigration. In this context, anger appears
as a pre-criminal emotional state or as a means of justifying the crime and less as a feature of
it. Sexual abusers also have higher levels of anxiety relative to men in the general population.
Lack of empathy
More than 91% of psychotherapeutic programs for sexual abusers in the US have as their
key objective to increase participants’ empathy, expecting this to lead to the strengthening of
internal inhibitors that play a role in preventing relapse. It is useful to approach empathy from
the perspective of information processing. Most research identifies an even lower level of
sexual abuser empathy towards their own victim. These deficits have also been linked to sexual
arousal (a competing emotional state that can inhibit empathy) or to specific cognitive
distortions.
Parent relationship
The attachments most often identified in the case of sexual abusers are those anxious,
ambivalent or avoidant. In general, families of sexual abusers appear to be characterized by
instability and disorganization. Consequently, the adult romantic attachment style of sexual
abusers tends to be avoidant and ambivalent (Muresan-Chira, Decsei-Radu, 2007).
Intimacy and loneliness

Intimacy is, according to Erikson (apud Decse-Radu and Pripp, 2009, source:
http://penalreform.ro/uploads/media/reducerea_recidivei_in_abuzurile_sexuale.pdf) an
indicator of the quality of an adult relationship and involves closeness, openness, disclosure,
affection, warmth, self-confidence and confidence in others. Research points out that sexual
abusers are much more privacy-deficient and lonelier. Thus, the recommendation that
strengthening privacy and reducing loneliness in the case of sexual abusers must be part of the
intervention model.
Social and heterosocial competences

Sexual abuse was considered the result of the abusers’ inability to establish natural adult
relationships. Most research on the social competence of sexual abusers shows deficits at this
level and high degrees of social anxiety, especially in relation to the members of the opposite
sex.
Impulsiveness
Impulsivity is differentiated in general impulsivity – characteristic of the lifestyle of
individuals and impulsivity related to the commission of the crime. It seems that modal
impulsivity involved in the commission of the crime does not correlate with impulsiveness as
a lifestyle. Lower levels of impulsivity have been identified as a trait for sexual abusers in
relation to other categories of offenders.
Size of sexuality and sexual abuse

Sexual offences are essentially motivated by sexual desire, but also by the desire for power
and control. An important role in this context is played by the deviant sexual fantasies of sexual
abusers who generally have a rather active, impersonal, aggressive, power-oriented content,
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sadism. Although the sexual satisfaction experienced as a result of abuse appears to be

insignificant, deviant sexual fantasies reinforce and maintain the risk of recidivism.
Personality disorders
In the research that studies the presence of personality disorders, the authors identify, in the
case of sexual abusers:
• two personality profiles – anxious and dramatic (Luissier & et al., 2001, apud Decse-
Radu and Pripp, 2009, source:
http://penalreform.ro/uploads/media/reducerea_recidivei_in_abuzurile_sexuale.pdf),
• four profiles – detached, antisocial-aggressive, antisocial-passive aggressive and a
subclinical profile (Bard, Knight, apud Decse-Radu and Pripp, 2009, source:
http://penalreform. ro/uploads/media/reducerea_recidivei_in_ abuzurile_sexuale.pdf).
High scores are found at the level of characteristics: histrionic, narcissistic, compulsive,
anxious, schizoid, avoidant, passive-aggressive, schizotypal, borderline. The point of
convergence of research is the existence of high scores at the level of passive-aggressive
personality disorder.
CONCLUSIONS
Virtual space can no longer be restricted, but on the contrary, it will continue to expand and
take more and more niches of real life. It’s a place where people can become everything they
want to be, either in a positive or negative sense. And since sexual impulse is native, virtual
space is a good place for the full manifestation of the entire cortege of sexual behavioral
deviations, starting from an increasingly young age towards increasingly earth-shattering
aggressions. Numerous studies Delcea C, Enache A, Stanciu C, 2017; Delcea C, Enache A,
2017; Gherman C, Enache A, Delcea C, 2018; Delcea C, Fabian A. M, Radu C. C, Dumbravă
D. P, 2019; Rus M, Delcea C, Siserman C, 2019; Siserman C, Delcea C, Matei H. V, Vică M.
L., 2019; Gherman C, Enache A, Delcea C, Siserman C, Delcea C, Siserman C., 2020 confirm
our results. It is therefore vital that the personality aspects associated with sexual offences
online are known, properly assessed and ways of intervention are established as early as
possible. It is perfectly true that this increases social control over the online activity of
individuals, which will lead to protests about the penetration of personal privacy.
Perhaps soon we will have a choice whether to protect the privacy and freedoms of the
potential victim or potential sexual abuser.
REFERENCES
[1] Aiken, M. (2016), The Cyber Effect, Psychology of Human Behavior Online, Bucharest, Ed. Niculescu.
[2] American Psychiatric Association (2003), Diagnostic and Statistical Manual of Mental Disorders, 4 th
revised ed., Bucharest, Ed. Association of Free Psychiatrists of Romania.
[3] Burdon, W.M., Gallaghes, C.A. (2002), Coercion and sex offenders: controlling sex-offending behavior
through incapacitation and treatment, Criminal Justice & Behavior, 29.
[4] Center for sex offender management (2006), Understanding treatment for adults and juveniles who have
committed sex offences, A Project of the U.S. Department of Justice, Office of Justice Program.
[5] Decse-Radu, A.R., Pripp, C. (2009), Specific Psychosocial Assistance Program to Reduce Relapse in
Sexual Abuse, Source: http://penalreform. ro/uploads/media/reducerea_recidivei_in_
abuzurile_sexuale.pdf.
[6] Flora, R. (2001), How to work with sex offenders, a handbook for Criminal Justice, Human Service and
Mental Health Professionals.
[7] Muresan-Chira, G., Decsei-Radu, A. (2007), Incarceration between universal and individual. Sexual
abusers, Cluj – Napoca, Ed. Limes.
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DOI: 10.4172/2471-4372.1000140.
4372.1000160.
2019. Vol. 61, p. 45. DOI 10.1016/j.jflm.2018.10.005.
DOI:10.4323/rjlm.2019.279.
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VAGINISMUS AS A HIDDEN PROBLEM: OUR CASE SERIES
Abstract
Vaginismus is a hidden problem because it is not discussed enough among professionals or

inside the family. Consequently, the treatment of this problem is done secretly and by people
who are not professionals, not to mention that they do not know what vaginismus really is.
Vaginismus causes a woman’s pelvic floor muscles to contract at the attempt of vaginal
penetration, making the vagina narrower and tighter. These muscle spasms are involuntary, and
women with vaginismus often have trouble with any type of vaginal penetration, such as
vaginal intercourse, tampon insertion, and gynecological exams. Penetration, when possible, is
usually quite painful and causes great anxiety. For some women, intercourse is impossible. We
present series of three cases treated in our Institute after a long-time treatment by others. All of
them came et our Institute after a long period of time seeking alternative help and hiding the
problem. Much work needs to be done on the sex education of the population in order to make
them aware that they can discuss sexual problems freely. Physicians and other health personnel
should also include a sexual history as an equal part of the medical examination.
Keywords: vaginismus, sexuality, disorders
INTRODUCTION
In our culture and society vaginismus is a hidden problem because it is not discussed enough
among professionals or in the family. Girls and women who face this problem in most cases
do not discuss this issue with anyone until the moment when their marriage or relationship is
seriously endangered. Consequently, the treatment of this problem is done secretly and by
people who are not professionals, not to mention that they do not know what vaginismus really
is.
Vaginismus – now classified under the umbrella of genito-pelvic pain/penetration disorders
(GPPPD), causes a woman’s pelvic floor muscles to contract at the attempt of vaginal
penetration, making the vagina narrower and tighter. These muscle spasms are involuntary, and
women with vaginismus often have trouble with any type of vaginal penetration, such as
vaginal intercourse, tampon insertion, and gynecological exams. Penetration, when possible, is
usually quite painful and causes great anxiety. For some women, intercourse is impossible.
Women with vaginismus can still be sexually aroused, and many enjoy sexual activities that
don’t involve penetration, such as oral sex. However, vaginismus can be a problem for couples
who want to have vaginal sex. This condition is not well-known, and its incidence varies across
cultures. Many women can’t explain why the spasms happen. They may feel anxious or
inadequate, while partners might feel puzzled or rejected. Single women might avoid dating
altogether. [1]
Depression and anxiety levels, sexual dysfunctions, and affective temperament
characteristics of women with lifelong vaginismus (LLV) and their male partners may have
important effects on the development, maintenance, and exacerbation of vaginismus. Affective
temperaments detected in women with this problem (depressive, cyclothymic, anxious and
irritable) and their male partners (depressive and cyclothymic) have an effect on the
development, maintenance, and exacerbation of vaginismus, and affective temperaments have
an effect on both their own and partner’s sexual functions. [2]
Vaginismus seems like a common issue. It is a major problem due to less interest in the
literature because of cultural sensitivities and complexity of the definition. The worldwide
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prevalence of vaginismus varies between studies, countries, and populations. However, there
is no exact data for the prevalence of vaginismus, it is reported that the prevalence rate of
vaginismus is as high as 1-7% worldwide. Women with vaginismus tend to remain silent about
their vaginismus and, they do not easily discuss their complaint with their family or friends and
often not even with their doctor. Therefore, the true incidence of vaginismus is unknown [3].
There appears to be agreement that vaginismus is a psychosociological disorder with phobic
elements resulting from actual or imagined negative experiences with penetration attempts.
Fear and anxiety concerning penetration is expressed physiologically via the involuntary
vaginal muscle spasm that characterizes vaginismus. Women with vaginismus generally
experience shame, disgust and dislike toward their genitals. They frequently have or have had
other phobias. They are usually overprotected by their fathers and have been “good girls” since
childhood. Their sexual partners are usually kind, gentle, considerate and passive “nice guys”.
The male partner’s lack of aggressiveness can actually lead to un-consummation of the
marriage. The sexually secure husband can usually overcome mild degrees of vaginismus by
persistent but firm penile insertion. However, the real etiology of vaginismus remains
unknown. [4]
Several different treatments have been tried to treat vaginismus. Many unnecessary
procedures such as hymenotomy and surgical widening of vagina have also been performed.
In spite of an important relationship between vaginismus and infertility, there are hardly any
reports on the outcome of infertility after the management of vaginismus. “Sensate focus”, a
technique originally described by Masters and Johnson, involved counseling and active
participation of both partners in vaginal dilatation. This was later modified by Kaplan to treat
different sexual problems and enhance sexual pleasure. The technique consists of a series of
structured instructions for touching activities to help couples overcome anxiety and increase
comfort with physical intimacy. The focus is on touch rather than on performance. [5]
The study conducted in Iran show that even within a single country, the etiological causes
of vaginismus could vary significantly according to socioeconomic factors; therefore, treatment
should be individualized to each woman’s circumstances. This study also confirmed the general
consensus of other studies that a major contributing factor of vaginismus was fear of pain. [6]
Vaginismus can lead to dyspareunia, infertility and sexual dysfunction in both partners with
often secondary erectile dysfunction in the male partner and therefore has a severe impact on
the quality of the marital relationship. The treatment of vaginismus is mostly psychological,
and cognitive behavioral therapy (CBT) has proved to be effective. It consists essentially of
two techniques: sexual education and hierarchic exposure. [7]
Vaginismus results from fear of pain and fear of intercourse, making coitus impossible or
extremely difficult. This condition occurs in many unconsummated marriages. Vaginismus has
been likened to an eye blink response when a threat of touch occurs. The symptom is ego-syn-
tonic; marriages may go on for many years before some other motivation, such as desire for
childbearing, brings these women or couples in for treatment. The actual diagnosis of
vaginismus is determined in a physician’s office upon pelvic examination. Women with
vaginismus often fear gynecological exams as well as sexual penetration. They do not use
tampons and are unable to insert anything into their vaginas. [8]
Aristotelis et al., in their study with 22 women seeking psychotherapy for psychogenic
vaginismus examined them for family patterns. Nearly all of the women had domineering,
threatening fathers who were moralistic but also sexually seductive. The parents of these
women had high levels of conflict and verbal and/or physical abuse in their marriages. The
women with vaginismus were the ‘good girls’ of their families; obedient, unable to express
anger and in constant need of approval. These women tend to choose partners who appear to
be the opposite of their fathers; they seem kind, gentle and often passive. Both the women and
their partners fear aggression. Women with vaginismus see intercourse as violation or invasion.
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The symptom serves to protect against violation. Most of the women either witnessed or
experienced actual physical violation in their histories. [9]
A clinically relevant effect of systematic desensitization when compared with any of the
control interventions cannot be ruled out. None of the included trials compared other behavior
therapies (e.g., cognitive behavior therapy, sex therapy) to pharmacological interventions. The
findings are limited by the evidence available and as such conclusions about the efficacy of
interventions for the treatment of vaginismus should be drawn cautiously. [10]
The Aim
The aim of our study was therefore to draw attention to the professionals, society and
families to such a big and hidden problem - vaginismus. We present series of three cases treated
in our Institute after a long-time treatment by others. Our intention was to show through the
cases of the three couples, a whole problem which is hidden and not treated properly.
CASES PRESENTATION
Case 1
An 8 years ago married couple, she 28 and he 32 years old, came to the Institute based on
the recommendation of a psychologist with complaints about un consumed marriage having
never had penetrative sex. Her education was mainly focused on the necessity to stay virgin
until marriage, and to keep away from men. Her friends told her that first intercourse is very
painful. The first question was where were you, what have you been doing all these years?
The woman explains in detail how they have hidden this problem from their families and
from society out of shame and fear of stigmatization. After 3 years of marriage, they asked for
help first from the religious cleric and then from the gynecologist and psychiatrist, but without
any success. At the Institute they first heard the word vaginismus. To be even more tragic even
in their previous reports they did not mark it as a diagnosis at least.
Following our clarifications on what we are talking about we agreed on a long cycle of
treatments that included CBT, sensate focus techniques and other sex therapies. In the first
month we only dealt with sex education, sensate focus techniques and mindfulness, the result
has been very good. The woman was no longer afraid of being touched and did not refuse to
be touched by herself and her partner. After that we started to show them more precisely how
to treat themselves and in what position they tend to have penetrative intercourse. At the end
of the second month of therapy they came happy as they had managed to achieve penetration
into the vagina without much pain. Then, another month they were advised and guided to the
perfection of the relationship and emerged as a happy couple.
Case 2
A 25-year-old married woman with a high school education comes to our Institute with
complaints of pain and inability to have penetrative sex. After listening carefully to her sex
story, she clearly understood her problem and was introduced to the word vaginismus.
Normally, she did not discuss this with anyone and relatives, and she blamed her partner for
the fact that she was not pregnant. Her fear was so great that when you mentioned penetration
she started to tea and was terribly obsessed with just the thought that something might be
inserted into her vagina.
We explained to her what the problem is, how it will be addressed and that the presence and
cooperation of the partner is necessary. She lacked basic information about the vulva and its
reproductive system.
At the next visit together with the partner we gave them information on the anatomy and
physiology of the genitals, sex education and treatment plan. In the other visits that were every
222
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week they were treated them with Sensate focus technique, CBT and Mindfulness. Only after
a month of therapy she was ready to allow herself to be touched by her partner in the genital
area but was afraid of the hymen rupture. Although we worked hard to convince her to try
penetration, she initially insisted on the hymenotomy which we approved and then after three
weeks of counseling they performed their first penetration intercourse.
Case 3
A 33-year-old man set a date for sexual counseling. When he came, he started to show that
he did not have any specific problems for himself but his pregnant wife in the 6th month now,
does not allow him to have penetrative sex from the first night of marriage when they had first
and last penetrative which resulted in pregnancy. His concern was twofold: not allowing
penetration and approaching the delivery time. He insisted on helping without having to come
with his wife. We told him that this is impossible and that they should come together. On the
first visit it was found that the woman, 25 years old, was suffering from vaginismus and that
even the first intercourse had been almost unsatisfactory, with a lot of pain and this had been
the reason that she was not ready for another sexual penetration nor a visit to the gynecologist
being pregnant.
During the conversation it was found lack of basic information about sexual health and
sexual response. Both underwent sex therapy with Sensate Focus Technique and CBT. Progress
was slow at first but after the first month she started inserting her finger into the vagina and at
the end of the second month of therapy they performed penetrative sex. After the birth they
were again visiting more or less courtesy and thanks for solving the problem that had helped
her to have a normal birth and a satisfying sex life.
CONCLUSIONS
These are not the only cases but we have selected three of those that have been hiding
vaginismus for a long time. Based on our estimates, this problem is very present and in
countries with culture and social status like ours, there are many women and couples who keep
it hidden from the friends and family.
Much work needs to be done on the sex education of the population in order to make them
aware that they can discuss sexual problems freely. Physicians and other health personnel
should also include a sexual history as an equal part of the medical examination.
The authors declare no Conflict of Interests.
No financial support is gained for this manuscript.
The authors are fully and solely responsible for the contents of their manuscripts.
REFERENCES
[1] International Society for Sexual Medicine. “What is vaginismus”. https://www.issm.info/ sexual-health-
qa/what-is-vaginismus/
[2] Turan Ş, Usta Sağlam NG, Bakay H, et al. Levels of Depression and Anxiety, Sexual Functions, and
Affective Temperaments in Women with Lifelong Vaginismus and Their Male Partners. J Sex Med
2020; 17: pp. 2434-2445.
[3] Ayse Deliktas Demirci and Kamile Kabukcuoglu, “Being a Woman” in the Shadow of Vaginismus: The
Implications of Vaginismus for Women”, Current Psychiatry Research and Reviews (2019) 15: p. 231
[4] Jeng, C. J. (2004, March). The Pathophysiology and Etiology of Vaginismus. Taiwanese Journal of
Obstetrics and Gynecology.
[5] Jindal, U., & Jindal, S. (2010). Use by gynecologists of a modified sensate focus technique to treat
vaginismus causing infertility. Fertility and sterility, 94 6, pp. 2393-5.
[6] Farnam, F., Janghorbani, M., Merghati-khoei, E., & Raisi, F. (2014). Vaginismus and its correlates in
an Iranian clinical sample. International Journal of Impotence Research, 26, pp. 230-234.
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[7] Zgueb, Y., Ouali, U., Achour, R., Jomli, R., & Nacef, F. (2019). Cultural aspects of vaginismus therapy:
A case series of Arab-Muslim patients. The Cognitive Behaviour Therapist, 12, E3.
[8] Silverstein J, L: Origins of Psychogenic Vaginismus. Psychother Psychosom 1989; 52: pp. 197-204.
[9] Aristotelis G. Anastasiadis, Dmitry Droggin, Anne Davis, Laurent Salomon, Ridwan Shabsigh. (2004).
Male and Female Sexual Dysfunction: Epidemiology, Pathophysiology, Classifications, and Treatment.
Principles of Gender-Specific Medicine, Academic Press, pp. 573-585.
[10] Melnik T, Hawton K, McGuire H. (2012). Interventions for vaginismus. Cochrane Database of
Systematic Reviews, Issue 12. Art. No. 1.
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CAN MANAGE THE SECURITY AND ONLINE REPUTATION IN SEXTING AND

CYBERBULLYING?
Abstract
One of the most wonderful inventions is the internet. Analyzing the advantages and
disadvantages of this fantastic world, we believe that we must turn our attention to the sexual
implications of cyberbullying. In introduction can find the specific terminology, like:
cyberbullying, harassment, cyberstalking, denigration, outing and trickery and sexting. Next
part present same research in the topics, same case study from specific literature. How can
manage the security and online reputation? – the answers can guide the rider. Education in
prevention of Sexting and cyberbullying indicate also advices for parents, made reference at
parental control recommendations and ten specific messages to share with adolescents in
formal or informal. In this moment we can say that is difficult to managing the security and
online reputation in sexting and cyberbullying but is a major provocation.
Keywords: Cyberbullying, Sexual cyberbullying, Sexting, Sexting prevention
INTRODUCTION
Writing this article, I remembered a situation encountered in my teaching career, at the high
school, where I was deputy director, a few years ago. A minor student started having sex with
a boy, who filmed her and posted the pictures on Facebook. I remember the implications of all
the factors involved, but I also remember the attitude of hers coleagues, who marginalized the
girl, instead of being with her. Today, more and more cases are transposed in films, books or
articles. The speed with which the information is transmitted in the online environment is
indisputable.
But, what can we do in education to prevent the emergence of cyberbullying on the Internet,
especially regarding sex?
Specific terminology
“It is important that bullying and cyberbullying policies are implemented, not just
throughout K-12 education but in higher education as well. One of the most important policies
on UNL’s campus to address bullying is Title IX which discusses and helps to fight against
discrimination and sexual misconduct.” (Cherian). [1]
A list of most common forms of cyberbullying are:
• Flaming: Online fights using electronic messages with angry and vulgar language.
• Harassment: Repeatedly sending offensive, rude and insulting messages.
• Cyberstalking: Repeatedly sending message that include threats of harm or are highly
intimidating; engaging in other online activities that make a person afraid for his or her
safety.
• Denigration: “Dissing” someone online. Sending or posting cruel gossip or rumors
about a person to damage his or her reputation or friendships.
• Exclusion: Intentionally excluding someone from an online group, like a “buddy list”
or a game.
• Impersonation: Breaking into someone’s account, posing as that person and sending
messages to make the person look bad, get that person in trouble or danger, or damage
that person’s reputation or friendships.
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• Outing and trickery: Sharing someone’s secrets or embarrassing information online.

Tricking someone into revealing secrets or embarrassing information, which is then shared
online [2].
Sexting
Sexting is when someone takes a naked or semi-naked-explicit- picture or video of
themselves, usually using their phone, and sends it to someone else. Some teens participate in
sexting voluntary as a way to flirt or be intimate with a romantic partner, while others might
be coerced or manipulated into sharing explicit images. Due to the varying nature of sexting
incidents, care should be taken to address the behavior in a way that minimizes harm of the
person depicted, are tips to help parents deal with sexting when it occurs. [3]
Regarding sexting – sending images or videos of parts of the body with the authorization of
the sender – Sandoval addressed an important message: “Sending sexual photos and videos of
minors is child pornography and is a federal crime” [4]
MATERIAL AND METHODS
The author Cherian say that “Cyber bullying typically starts at about 9 years of age and
usually ends after 14 years of age; after 14, it becomes cyber or sexual harassment. It affects
65-85% of kids. 90% of middle school students polled had their feelings hurt online. 65% of
their students between 8-14 have been involved directly or indirectly in a cyber bullying
incident as the cyber bully, victim or friend and 50% had seen or heard of a website bashing
of another student survey of students nationwide”. [5]
Interesting is the point of view of R. deSouza & Suely reviewed studies that “show that both
victims and those who practice cyberbullying undergo negative experiences in their
psychological and behavioral health, where school dropout may also occur, along with social
isolation, depression, suicidal ideation and suicide. However, there is hardly any questioning
about cyber culture and how it establishes new socialite’s – knowledge and debate crucial to
understanding the phenomenon”. [6]
Experiences with older adolescent’s victims of cyber aggression in a rural community were
explored in the study of Reason, L., Boyd, M., & Reason. The results showed that cyber-
harassment stems in turn from jealousy of romantic relationships and cultural, religious or
sexual intolerance, sexual orientation. It turned out that:
• Cyber attackers tend to be naughtier and crueller as a result of perceived anonymity;
• Feelings of helplessness and anger were reported in response to the attacks;
• Lack of knowledge and understanding of cyberspace has led to a lack of emotional
support and protection against cyber aggression. [7]
Serrano, AR, & Catalán have made an approach to cyberbullying in the Spanish social
network Curious Cat, with more than two million users on an international scale, an analysis
of an incidental non-probabilistic sample of 1025 users was carried out. The results obtained
show that most of the aggressions were verbal or oriented to the humiliation of the victim and
often related with the personal life of the users. The victims usually felt detached with the
contents of the aggressions, and the attackers usually justified their actions sheltering behind a
Justice excuse. [8]
In Guatemala, the campaign ElegíCuidarte promotes the responsible use of connected
technologies and protects physical and emotional integrity minors, social network users and
the internet in general. To promote it, a light is given about this issue with the video “Love
Story”, which circulating on the official channel of Movistar Guatemala, in YouTube. The
main message is to prevent children and adolescents from accepting requests from strangers in
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their social networks to avoid being victims of abuse, such as sexual cyberbullying, care,
sexting, among others. [9]
The results of a survey carried out in 20 educational institutions in Asunción and the interior
of the country, on the negative impact on adolescents of the use of the Internet and social
networks, from Paraguay show signs of the vulnerability of adolescents to situations of abuse,
such as grooming (recruitment of adolescents on social networks and the Internet, for the
purposes of sexual harassment), cyberbullying, sexting, and even sexual exploitation. [10]
More and more teenagers see sexting as normal, despite the serious consequences it can
have on their well-being. Little is known about the factors that facilitate the participation of
adolescents and whether the same factors influence different types of sexting behaviors –
sending, receiving, forwarding or receiving through an intermediary – in different ways. The
authors Casas, Ojeda, Elipe & Del Rey analyzed if necessary for popularity, participation in
cyber gossip, social competence, the level of normalization of sexting and the willingness to
have sex are predicted to what extent adolescents participate in the activity, and whether gender
influences this participation. 1431 Spanish adolescents, aged between 11 and 18, participated
in a two-wave longitudinal study with a time lag of four months. For girls, the most important
factors were participation in cyber gossip and the need for popularity, while for boys, the most
important factors were levels of normalization and desire to have sex. [11]
Kopecký researching the risky behavior among Slovak children on the Internet mentioned
“sexting has been related to other phenomena such as blackmail, bullying, cyberbullying and
extortion”. At the research was participated 1466 respondents aged 1117, boys = 44.96% and
girls = 55.04%, and has motorized 2 basic form of sexting distribution – uploading of the
sexually explicit materials on the Internet (e.g., to the profile of the social network or to the
database of the photo digital storage device) and direct sending of the own sexual material to
other people (e.g., a boyfriend, girlfriend, friend, partner etc.) [12].
Case study from specific literature

A 25-year-old man from Sydney has been accused of using a transport service to threaten,
harass and prosecute crimes, he pleaded guilty to making sexual threats on social networks, in
what is seen as a case of cyber aggression testing, specifically he wrote abusive and threatening
comments on a Facebook post about a 25-yearold girl. A friend of the young man had taken a
screenshot of the victim’s Tinder profile and posted it on Facebook, where he was shared
thousands of times.
The victim spoke publicly about the abuses she suffered, for fear of provoking a new
reaction, she also said that she is worried about losing her job and about the upset of her parents.
He called the federal government to fund a campaign to discourage men from attacking
women online. The group “Sexual violence will not be silenced” was set up in the hope that
this case would set a precedent for other women to come forward. [13].
Interesting is Bateman’s article, about the investigation of a series of emails containing
sexually explicit content sent from a University de Moncton, email account and distributed to
members of an internal group email list. The first email contained an “explicit message and
photo with sexual connotation”. As soon as they got the email, that message and the image
were erased from the system, the university’s IT staff sent an email to all students and staff for
advising them of the issue and warning “not to open the email or any similar messages, and the
university is committed to providing support services to members of the university community
who are victims of sexual harassment or cyberbullying.” [14]
“She promised young teenage boys sexual favors in exchange for nude pictures of them. But
“she” turned out to be a 20-year-old man, Andrew Newman, admitted to being the online prey
of at least 1,300 boys in Ontario and Quebec in 2015.” He pleaded guilty to more than 400 of
seduction, committing and possession of child pornography and extortion charges involving
227
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more than 400 charges in Toronto and Quebec. It is believed to be the largest case of attraction
and child pornography known in Canada. Newman traded with unsuspecting teenagers –
deceiving them into providing pornographic images or videos, or sending them porn videos of
a beautiful teenage girl, or offering them sexual favors in exchange for their own images.
Pazzano & Sun says that “Sextortion and cyberbullying know no boundaries”, “From
Stouffville to Nova Scotia to Virginia Beach, Va., there have been horrific tales of cyberbullying
perpetrated by people from all walks of life”. [15]
How can manage the security and online reputation?

“Some cyberbullying crosses the line into unlawful or criminal behavior. Cyberbullying can
harm the online reputations of everyone involved – not just the person being bullied, but those
doing the bullying or participating in it. Not all negative interaction online or on social media
can be attributed to cyberbullying. Research suggests that there are also interactions online
that result in peer pressure, which can have a negative, positive, or neutral impact on those
involved.” [5]
Referring the subject Teen sexting, Hinduja, & Patchin give ten advices for the parents [4]:
• Gather information;
• Stop the bleeding;
• Talk with child;
• Be discrete;
• Camden the behavior, not the child;
• Contact other parents;
• Contact the school;
• Contact the police;
• Seek professional help;
• Offer alternatives to sexting identity, intimacy and relationships.
Rebecca Garza Bueron, an expert in internet security, urged parents to know the use and
scope of sites and electronic devices to which their children have access and thereby regain
control over the use and security settings of the cell phone, IPad, Xbox and internet sites like
Google and YouTube. She shared ways to configure YouTube, Google, Play Store, Netflix and
Xbox to have more parental control:
• Safe zones – Internet safety specialist Rebeca Garza Buerón shared with parents some
tips for setting up programs and websites.
• Youtube – Activate filters to prevent children from taking inappropriate videos or use
YouTube Kids for children under 8 years old.
• Instagram – Be aware of who follows your children and who they follow.
• Google – Activate the “Safe Search” filter in the settings.
• Netflix – Open an account for children where their age is specified so that they have
access to controlled content.
• Google Store – Activate “Parental Control” to restrict downloads and purchases. [16]
In Canada, a specific law on revenge has been created, which allows the victim to sue for
restitution. The law, called “The Privacy Act”, applies to anyone who can be identified in a
photo or video, who appears naked or engaged in sexual activity, taken in circumstances where
they would have a reasonable expectation of privacy. E.g., The case “Jane Doe 464533 v. ND”,
an Ontario Superior Court judge recognized for the first time in Canada the privacy tort of
“publication of embarrassing private facts” and the judge found for the plaintiff and awarded
approximately $142,000 in damages against a former boyfriend who posted a sexually explicit
video of victim online. [17]
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Education in prevention of sexting and cyberbullying

In this digital world, all mankind must adapt their actions in combating any cybernetic
sexual acts that harm the human being.
In Canada, an attempt by a school in Hamilton to change the curriculum, it was argued that
the 1998 Curriculum has “written in a world where cellphones, sexting, cyberbullying, and
online porn didn’t exist”, The Conservatives’ decision has named “a giant step backwards”, the
bord of school say “we know that these are realities that particularly young women face online.
That’s not being addressed, and that seriously concerns me”, “We live in a hyper-hyper-
sexualized world. The largest users of online porn are boys between 12 and 17 – is that where
we want kids to be getting their sexual education from?” [18]
“Some new dangers have arrived, like sexting, cyberbullying, and problems that I don’t
remember children bringing to us in 1986, like self-harm and eating disorders, which have
become almost an epidemic, and the really worrying thing is the number of suicidal young
people has doubled in the last five years.” [19], Kopecký recommendations is “to pay a large
attention to the prevention of this phenomenon in particular (n.a. sexting), and to introduce the
concrete consequences resulting from this behavior to the adolescents. An ideal way is to
present the concrete examples to the children, showing damage caused to the victim (victim’s
suicide in extreme cases). Public education focused on the parents or teachers presents an
integral part of the sexting prevention.” [12]
In some workshops on the sexting topics, the participants discussed different tactics that the
girl could use to divert persistent requests for nudes and unsolicited images. One suggested
tactic was to change the subject of the conversation “as fast as you can” or ignoring the
requester for a period of time. [20]
Patchin & Hinduja suggested themes encapsulated in 10 specific messages to share with
adolescents in formal or informal contexts after weighing their developmental and sexual
maturity:
1. If someone sends you a sext, do not send it todor showd anyone else;
2. If you send someone a sext, make sure you know and fully trust them;
3. Do not send images to someone who you are not certain would like to see it;
4. Consider boudoir pictures. Boudoir is a genre of photography that involves suggestion
rather than explicitness. Instead of nudes, send photos that strategically cover the most
private of private parts;
5. Never include your face;
6. Make sure the images do not include tattoos, birthmarks, scars, or other features that
could connect them to you, remove all jewelry before sharing;
7. Turn your device’s location services off for all of your social media apps, make sure
your photos are not automatically tagged with your location or username, and delete
any metadata digitally attached to the image;
8. If you are being pressured or threatened to send nude photos, collect evidence when
possible;
9. Use apps that provide the capability for sent images to be automatically and securely
deleted after a certain amount of time;
10. Be sure to promptly delete any explicit photos or videos from your device. [21]
CONCLUSIONS
Can talk about the “reciprocal relationships between the perpetration of traditional
bullying, cyberbullying, and four forms of sexting: sending, receiving, third-party forwarding,
and receiving sexts via an intermediary” because “Involvement in bullying and cyberbullying
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appears to be a vicious cycle, with engagement in either form of aggression associated with a
raised likelihood of later involvement in the other”. [22]
Efforts must be made to prevent and educate on this phenomenon, which has become
widespread in recent years, related to sexing and cyberbullying.
It is time to talk about this phenomenon and “take the skeletons out of the closet”, in 2015
Romania is otherwise ranked 2nd in Europe in the phenomenon of “sexting”. [23]
Parental involvement in children’s online activities according to the results of research
conducted by Csipkes is not associated with the phenomenon of sexting, suggesting an
“inefficiency or difficulty in educating children on virtual behavior. Nor the training courses
from during school hours does not seem to influence the phenomenon of sexting.” [24]
Phenomena such as cyber sexism, cyber misogyny and erotic messages (sexting) have in
common that they are all based on deeprooted gender stereotypes, ideas about what
women/girls and men/boys are or should be, stereotypes can be rigidly prescriptive. [25], [26],
[27], [28], [29].
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BREAKING (OLD) NEWS: A VETERINARY SURGEON BECAME A

SEXOLOGIST-PSYCHOANNALIST. A HISTORICAL REFLECTION OF
SEXOLOGY
Abstract
Theodore James Faithfull (1885-1973), the grandfather of the singer Mariann Faithfull, was
a veterinary surgeon who became a psychotherapist and sexologist. His remarkable personal
story, is an important part of the history persons who envisioned modern sociology. This article
brings a “meeting point” between history of medicine, medicine, sociology, psychology,
sexology and veterinary medicine. The names of Sir Patrick Geddes FRSE (1854-1932), Dr.
Theodore James Faithfull (1885-1973), his son, Robert Glynn Faithfull (1912-1998), and
Victor Branford (1863-1930), are listed among those who envisioned modern sociology.
Keywords: Theodore James Faithfull, historical, sexology
APPROACH
As a rehabilitation medicine physician, I regularly co-operate with the multidisciplinary

health professional team (1). Naturally, the process of a successful rehabilitation process, needs
the assistance of experts from various other fields, such as: bio-engineering, physical education,
law, and more. It occurred that we need even the assistance of veterinarian surgeon: when we
adopted electro-ejaculation apparatus developed by a veterinarian (2) and used it in spinal cord
injured patients (3), and when we trained Capuchin monkeys to assist tetraplegics (4). The
contributions of veterinarians to the history of medicine, is relatively unknown to the readers
of medical literature. Only a few historians recognize that veterinary history has a significant
place in general medical history and in the overlapping aspects of human and animal medicine.
I have reviewed some historical facts about the contributions of veterinarians to general
medicine. These are also a few examples of veterinarians, who became famous as writers,
politicians and inventors (5). I was fascinated with the fact that we use on a daily basis, terms,
signs and symptoms or eponyms from the animal world (6). “As companion animals become
more central to individuals and families, there are countless ways that veterinary medical
practice can benefit from understanding human psychology ... we focus on key areas of care
for companion animals that are integrally linked to their human caregivers‫ ׳‬psychological
reactions and behavior, including health maintenance, managing illness, and end-of-life care.”
(7)
Years after my article was published, (5), I came across the remarkable story of Dr.
Theodore James Faithfull (1885-1973), the grandfather of the singer Marianne Faithfull, a
veterinary surgeon who became a psychotherapist and sexologist, through the biographical
database of persons mentioned in “Envisioning Sociology”, which contains “notes on the
various intellectual, business and political associates of Geddes and Branford, together with
others with whom they were connected…” (8). In this list, we can find five physicians: Dr.
Arthur John Brock, (1879-1947), an Edinburgh graduate who met Sir Patrick Geddes FRSE
(1854-1932) in 1899 while still a medical student, and took up the environmental work of Pierre
Guillaume Frédéric le Play (1806-1882) who was a French engineer, sociologist and
economist. Brock worked at Craiglockhart Hospital in Edinburgh, where he treated shell shock
patients including the poet Wilfred Owen (1893-1918), poet-writer Siegfried Loraine Sassoon
CBE MC (1886-1967) and historian-author Robert Graves (1895-1985); Sir Arthur Thomson
(1861-1933), a lecturer in medicine and biology at Edinburgh University, and a Professor of
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Natural History at Aberdeen, 1899- 1930 who was also a close associate of Patrick Geddes in
his biological work; Dr. Aubrey Thomas Westlake, (1893-1985) who, in 1938 left London to
live at Sandy Balls, developing organic farming and herbal and alternative medicine. He is
known as a prominent British authority on radiesthesia, alternative medical therapies, and
holistic health; Alfred Salter (1873-1945), a medical partner of Aubrey Westlake in
Bermondsey, London. He became a Labour MP for Bermondsey West. He wrote the “Salter
Report on road and rail transport”. In 1932; and John Norman Glaister, (1883-1961) a
psychiatrist, who after First World War, became involved with the Order of Woodcraft
Chivalry. He founded Braziers Park School of Integrative Social Research in 1950.
One patient is found in that list: Frederick Victor Rubens Branford-Powell, (1892-1941),
the son of actor Mary Branford, nephew of Victor Branford. He was educated at the universities
of Edinburgh and Leiden. Serving as a captain in the Royal Naval Air Service, Branford was
badly wounded at the Battle of the Somme, when he was shot down over the sea off Cadzand
in the Netherlands coast and swam ashore, where he was interned and later, treated at
Craiglockhart Hospital and lived on a disability pension. He is known as a war poet.
“The hearts of the mountains were void,
The sea spake foreign tongues,
From the speed of the wind,
I gat me no breath,
And the temples of Time were as sepulchres.
I walked about the world in the midnight,
I stood under water, and over stars,
I cast Life from me,
I handled Death,
I walked naked into lightning,
I had so great a thirst for God.” (9).
And one veterinarian surgeon and his son. Theodore James Faithfull, (1885-1973) a Member
of the Royal College of Veterinary Surgeons and a Major in Veterinary Corps, who became a
pioneer of psychoanalytical ideas.
“He ran a ‘progressive’ school for problematic children, The Priory Gate School, which
encouraged nudity for both pupils and staff in sports and art classes and allowed swearing.
When the school, unsurprisingly, closed in the 1930s following allegations of indecency,
Faithfull moved to Hampstead and started his new career as a sex therapist. He invented a
device he called the “Frigidity machine” to unlock primal libidinal energy and had a policy of
not taking baths. Theodore was considered a pioneering influence on an ideology known as
“New Psychology”, a term used to embrace theories popularized by Sigmund Freud and
Wilhelm Reich (10). I could not find evidence about his educational training, when he shifted
veterinary medicine to human medicine.
His son, Robert Glynn Faithfull (1912-1998), was a British Army intelligence officer. With
Dr. Norman Glaister, they formed the Braziers School of Integrative Social Research after the
Second World War. He is the Father of singer Marion ‘Marianne’ Faithfull.
Theodore James Faithfull’s list of books is impressive. Some evoked much debate and
dispute:
1. A handbook of sex education. A handbook for parents and teachers. 1970.
2. Eros, Philia and Agapë. An essay on love, 1957.
3. Plato And the New Psychology, 1928.
4. The Future of Women and Other Essays, 1967.
5. Bisexuality: An Essay on Extraversion and Introversion, 1927.
6. Psychological Foundations; A Contribution to Everyman’s Knowledge of Himself,
1933.
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7. Letters to Margaret – a Simple Introduction to Psychology, 1941.

8. The Mystery of the Androgyne: three papers on the theory and practice of psycho-
analysis, 1938.
CONCLUSION
Sir Patrick Geddes FRSE (1854-1932) was a Scottish biologist, sociologist, advocate of
social reconstruction (11-12), geographer, philanthropist and pioneering town planner. In 1919,
Geddes co-operated with his son-in-law, the architect Frank Mears, on a number of projects in
Palestine. He designed a plan for the Hebrew University of Jerusalem at the request of the
British psychoanalyst, Dr. David Eder (13), who headed the Zionist Organization’s London
Branch. In 1925 he submitted the town planning in Jaffa and Tel Aviv. His associate, the
sociologist Victor Branford (1863-1930), was the founder of the Sociological Society and was
made an Honorary member of the American Sociological Society. “Together with a circle of
co-workers, they set out a distinctive vision of sociology and built the professional framework
they thought was needed for its development. Working initially in Edinburgh and then in
London, Branford was the central organizer of sociological activity in the first decades of the
twentieth century. While also following a career in finance and banking that took him to New
York and involved him in the telephone and railway systems of Cuba, and South America” (8).
REFERENCES
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Review.
[2] Shaban SF, Seager SW, Lipshultz LI. Clinical electroejaculation. Med Instrum 1988; 22(2): pp. 77-81.
[3] Heruti RJ, Katz H, Menashe Y, Weissenberg R, Raviv G, Madjar I, Ohry A. Treatment of male infertility
due to spinal cord injury using rectal probe electroejaculation: the Israeli experience. Spinal Cord 2001;
39(3): pp. 168-75. 4. An evaluation of capuchin monkeys trained to help severely disabled individuals.
The Rehabilitation R&D Evaluation Unit, Rehabilitation Research and Development Service,
Department of Veterans Affairs. J Rehabil Res Dev 1991; 28(2): pp. 91-6.
[4] Ohry A. The Hippiatros and the Iatros: historical perspectives. Isr J Veter Med 2006; 61(No. 3-4): pp.
1-6.
[5] Ohry A, The animals’ world and us. Harefuah 1996; 131(3-4): pp. 126-7.
[6] Siess S, Marziliano A, Sarma EA, Sikorski LE, Moyer A. Why Psychology Matters in Veterinary
Medicine. Top Companion Anim Med 2015; 30(2): pp. 43-7.
[7] Scott J and Bromley R, “Biographical Database”.
[8] Envisioning Sociology: Victor Branford, Patrick Geddes, and Social Reconstruction. SUNY Press, 2013,
on: https://www.johnscottcbe. com/areas-of-research/history-of-sociology/the-geddes-and-branford-
project/biographicaldatabase-of-persons-mentioned-inenvisioning-sociology/
[9] https://www.poemhunter.com/poem/return-44/
[10] Hodkinson M. Marianne Faithfull: as years go by, chapter 1, 2013 Omnibus Press, London (first ed.
1991).
[11] Renwick C. Patrick Geddes and the politics of evolution. Endeavour 2010; 34(4): pp. 151-6.
[12] Renwick C. The practice of Spencerian science: Patrick Geddes’s Biosocial.
[13] Program, 1876-1889. Isis 2009; 100(1): pp. 36-57.
[14] Thomson M. ‘The solution to his own enigma’: connecting the life of Montague.
[15] David Eder (1865-1936), socialist, psychoanalyst, Zionist and modern saint. Med Hist 2011; 55(1): pp.
61-84.
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JUSTIFICATIONS OF RAPE. COMPARATIVE ANALYSIS BETWEEN RAPISTS

AND STUDENTS. GENDER DIFFERENCES
Abstract
The rationalization used by rapists to justify their criminal behavior are a risk factor for
relapse. The modification of cognitive distortions is a therapeutic purpose for rehabilitation
(Someda, 2009). Using Rape Scale (Bumby, 1996) we evaluated the participants’ (N = 480, 57
convicted rapists, 223 students’ non-rapists) level of cognitive distortions related to rape. Using
ANOVA we identified differences between convicted rapists, psychology or law students and
polytechnic students [F (3,461) = 60,69, .000, η2p = 0.283]. In line with previous research
(Bell, Kuriloff & Lottes, 1994), men are more lenient with rapists, accept more justifications
about rape and blame the victim more. We identified differences between male and female
participants and between male students and convicted rapists [F (2,477) = 98,88, .000, η2p =
.293]. This research brings new evidence for the importance of cognitive restructuring for
implicit cognitive distortions. We discuss possible limitations and directions for future
research.
Keywords: convicted sexual offenders, rationalizations, RAPE Scale, intervention, cognitive distortions,
cognitive restructuring
INTRODUCTION
Sexual offenders are a special category of offenders because they have specific motivations
to engage in criminal behavior. The purpose of this research is to identify the rationalizations,
the cognitive distortions of convicted rapists. In order to make cognitive restructuring
interventions more efficient, we need to identify the cognitive distortions which influence
(implicit or explicit) the behavior of those who commit these acts. Just the punishment for an
undesirable behavior does not guarantee the rehabilitation of a sexual offender. An important
aspect to consider when analysing the risk of relapse is the identification of factors which have
predisposed to perpetration of rape and remained unchanged. Cognitive distortions are included
in this category. A convicted rapist, who justifies his behavior without feeling any guilt, is
predisposed to a greater risk for relapse. Therefore, is essential to make a distinction between
these two categories of sexual offenders (those who are feeling guilty vs. those who are not)
and to design different therapeutic interventions, considering these elements. Most of the
sexual offenders can’t explain their justifications related to deviant behavior. This is why is
much easier for them to recognise from a list of rationalizations, the ones they agree with. In
this research we used such a list – RAPE Scale (Bumby, 1996), which comprises the most
frequent justifications for rape; our purpose was to identify those used in a greater extend by
convicted rapists. The utility of this research consists in the fact that it is a starting point for a
cognitive restructuring intervention for cognitive distortions related to rape. After evaluating
the level of cognitive distortions, the therapist can formulate a more accurate purpose for the
intervention. Some of the implicit theories related to rape were identified in the general
population, so another purpose of this study was to identify the differences between
rationalisations of rapists’ and those accepted by the general population. We think that a
realistic therapeutic purpose is to bring, after the intervention, the sexual offender’s cognitive
distortions to a level similar to the level of the general population.
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Theoretical framework
Rape is a behavior convicted by the criminal law and is a severe violation of the sexual
freedom. In the filed literature, experts talk about “implicit theories related to rape”; these
theories include cognitive distortions related to rape. These cognitive distortions are organised
as schemas and are utilized by individuals to explain and interpret social information. These
schemas can be regarded as “implicit theories” because they are part of the process by which
offenders explain and interpret the actions of others (Ward & Beech, 2016). Greater
endorsement of cognitive distortions related to rape is associated with denial, minimization of
guilt and harm towards the victim (Nunes L.K. & Jung S., 2012). For sexual offenders, these
cognitive distortions are rationalizations and justifications for rape. The implicit theories
related to rape are used to explain other people’s actions and to make predictions about the
world (Ward, 2000). The cognitive distortions of sexual offenders are based on factors such as
attribution of responsibility to the victim, hostility toward women and accepting interpersonal
violence (Burt, 1983). These factors work to help the sexual offender to normalise his behavior.
Previous research has identified five (5) implicit theories related to rape, among sexual
offenders (rapists) (Polaschek & Ward, 2002). Next, we will present them shortly:
• “Women are unknowable”. Men believe that women are very different and can’t be
understood. This belief facilitates rape because men can’t perceive women as being
similar. The level of empathy expressed in interpersonal interactions depends on the
level of perceived similarity. Rapists who possess this implicit theory have a lower
level of empathy for the victim. The lack of empathy, together with the belief that
women are unknowable, facilitates rape. Men with this implicit theory don’t seek for
intimacy in a relationship with a woman but keep it very impersonal and superficial.
Examples of cognitions related to this theory are: “Women who say no to sexual
advances often mean yes”, “Women are usually sweet until they’ve caught a man and
then they let their true self show” (Polaschek & Ward, 2002).
• “Women as sex objects”. According to this theory, women are open all the time to
sexual cues and they need to be constantly available to meet men’s sexual needs. This
theory facilitates the interpretation of non-sexual behavior in a sexual manner and leads
men to believe that rape is not harmful if the woman is not hurt physically or beaten.
Also, they believe that a woman’s duty is to sexually satisfy her husband, no matter her
desires. These are some specific cognitions: “A woman can enjoy sex even when it is
forced upon her” “Rape is generally a misinterpretation of sexual cues”, “Only women
who are physically beaten should feel justified in reporting a rape” (Polaschek & Ward,
2002).
• “Male sex drive is uncontrollable”. Men who have this theory justify their behavior
attributing the causes to external factors: the victim or environmental conditions. The
basic idea of this theory is that male’s sexual needs are uncontrollable and women are
responsible if men lose their temper and control over their sexual behavior. The primary
reason for losing control is women’s refuse to offer sexual gratification. These men
believe that women are responsible for their lost of control and because of that woman
can’t claim rape. Specific cognitions related to this theory are: “Women have men
charged falsely with rape to protect their reputation”, “One reason women falsely report
a rape is that they frequently have a need to call attention to themselves”, “Most charges
of rape are unfounded” (Polaschek & Ward, 2002).
• “Entitlement”. According to this theory, men should have their sexual needs met any
time they want. This theory leads a man to think that once a woman allows him to take
her out on a date or to buy her diner, he is entitled to have sex with her. Women are
thought to be immature and naive, which is why men have to decide what they want
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and control them. Related cognitions are: “It would do some women good to be raped”,
“Rape serves as a way to put or keep women in their place”, “A woman who is stuck-
up and thinks she is too good to talk to guys on the street deserves to be taught a lesson”
(Polaschek & Ward, 2002).
• “Dangerous world”. The beliefs that the world is a hostile place, where people lie and
cheat to fulfil their wishes and facilitates seeing threats where evidence is absent or
ambiguous and supports hostile behavior towards others to prevent harm to the self.
One specific cognition is “She would have done the same to me, if I hadn’t got to her
first” (Polaschek & Ward, 2002).
Traumatic experiences form early childhood and hostile family environment play a major
role in their development. The “Dangerous world” theory may develop as an attempt to
understand an unforeseeable and unpredictable family enviroment. The “Entitlement” theory
may come from early parental abuse and neglect, and an insecure attachment style. This
implicit theory may also form as a result of social learning, in families that endorse very
traditional gender roles, were the child learns that some members of the family are entitled to
act superior with others (Polaschek & Ward, 2002). The implicit theories related to rape can
develop in explicit cognitive distortions.
There is empirical evidence which confirm the existence of implicit theories. The results of
a research (Polaschek & Gannon, 2004) conducted with 37 sexual offenders, show significant
empirical support for the existence of those five implicit theories related to rape, on a sample
of convicted rapists. “Women Are Unknowable implicit theory was identified in 65% of
offenders,” “Women Are Sex Objects” was found in 70% of offenders, “Male Sex Drive Is
Uncontrollable” in 16%, “Entitlement” in 68% and “Dangerous World” theory in 19% of
offenders. The most frequent implicit theories found among rapists are: “Women Are
Dangerous / “Women Are Unknowable”, “Women Are Sex Objects”, and “Entitlement”.
“Women Are Dangerous” theory was more frequent among rapists who deny their
responsibility for rape; these men believe that the victims say they were raped just to get back
on them, to get revenge. Also, “Women are sex objects” theory was more frequent among
deniers because they can’t understant the fact that a woman can see the sexual relationship as
rape. Empirical findings prove the existence of implicit cognitions in rapists (Ward, 2000).
RAPE Scale and cognitive distortions related to rape, classified on two dimensions
One of the instruments used to identify and measure implicit cognitive distortions related to
rape is “RAPE Scale” (Bumby, 1996). The items of this scale reflect cognitive distortions
defined by those five implicit theories related to rape (Polaschek & Ward, 2002). “RAPE
Scale” is a list of thirty-six (36) items which reflect cognitive distortions related to rape. “RAPE
Scale” accurately discriminates between rapists (N=25) and non-sexually offending inmate
group (N=20) (Bumby, 1996). Post-hoc analysis showed a significant relationship between
rapist’s score on the RAPE Scale and the number of victims, the number of cognitive distortions
increasing with the number of victims (Bumby, 1996). In another study, (Arkowits & Vess,
2003) the results revealed a significant correlation between RAPE Scale’s scores and the
number of victims.
There are multiple advantages of using RAPE Scale as a method to identify cognitive
distortions related to rape. Fist, this scale contains items from other questionnaires which
evaluate cognitive distortions (e.g., “Rape Myth Scale”) so is an integrative instrument.
Second, the items are not related to social desirability, which is a very important
psychometric characteristic. The validation study (Bumby, 1996) showed that “RAPE Scale”
is not related to socially desirable response bias. Also, the items are scored on a four-point
Likert scale ranging from strongly disagree (1) to strongly agree (4); this method is used to
prevent a frequent neutral response.
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The items of “RAPE Scale” reflect those five implicit theories related to rape, identified
among sexual offenders who commit rape. For “Women Are Unknowable” theory we have the
items: “If a woman does not resist strongly to sexual advances, she is probably willing to have
sex” (5), “A lot of women claim they were raped just because they want attention” (11). For
“Women are sex objects” theory correspond the items: “A lot of women who get raped had
“bad reputations” in the first place” (7), “If a man has had sex with a woman before, then he
should be able to have sex with her any time he wants” (13). For “Male sex drive
isuncontrollable” are the items: “Women often falsely accuse men of rape” (6), “When women
act like they are too good for men, most men probably think about raping the women to put
them in their place” (24). For “Entitlement” theory correspond the items: “Men who commit
rape are probably responding to a lot of stress in their lives, and raping helps to reduce that
stress” (1), “On a date, when a man spends a lot of money on a woman, the woman ought to at
least give the man something in return sexually” (22).
The validation study (Bumby, 1996) showed that “RAPE Scale” is able to make a
discrimination between rapists and non-sexual offenders (N=25, N=20). Also, the results
showed a greater number of implicit cognitive distortions among rapists, in comparison with
other categories of offenders. Other studies used “RAPE Scale” to identify cognitive distortions
related to rape among rape-prone men (Blake& Gannon, 2010) and their hypothesis was that
men with a higher predisposition to rape will have a greater number of cognitive distortions
related to rape. The sample (N=80) was composed of students and the results showed a positive
correlation (r=.42, p<.001) between predisposition to rape and cognitive distortions related to
rape. The results show that rape-prone men also have a higher number of implicit cognitive
distortions related to rape.
The RAPE Scale is widely used to identify and asses’ cognitive distortions among sexual
offenders. Recent research used it to identify the relationship between cognitive distortions and
early maladaptive schemas (Sigre-Leiros V., Carvalgo J. & Nobre P.J., 2015). The findings
show that the entitlement/grandiosity schema from impaired limits domain is a significant
predictor of cognitive distortions related to Justifying Rape factor.
Other research tries to identify if RAPE Scale measures attitudes/evaluations or cognitive
distortions (Nunes K.L, Hermann C.A., White K., Pettersen C. & Bumby K, 2018). The results
showed that evaluations of rape are distinct from cognitive distortions, and we need to take
them both into consideration when we try to understand sexual violence. It is possible that
RAPE scale assesses cognitive distortions specifically (e.g., hostility towards women), not
evaluations of rape or victimis.
Cognitive restructuring of distortions related to rape and rehabilitation A relevant research
for our purpose is the study conducted by Eastman J.B. (2004), where “RAPE Scale” was used
to evaluate the efficacy of therapeutic interventions for incarcerated rapists (N=100). During
intervention, RAPE Scale was administered both pre and post-test (M=76.08; M=52.75.,
p<.001). The results demonstrate that RAPE Scale is an instrument that can be used as a
measure of evaluation for therapeutic interventions for cognitive distortions, among
incarcerated sexual offenders. Other research tested the efficacy of cognitive restructuring from
CBT programmes of rehabilitation, and identified a positive effect. Therapeutic interventions
whose purpose was to identify and recognize cognitive distortions, to change these distortions
in socially accepted attitudes, to understand the consequences of deviant behavior and to create
self-discipline were associated with a lower rate of relapse (Someda, 2009). A meta-analysis
(Banse, Koppehele-Gossel & Kistemaker, 2013) showed that CBT intervention is efficient for
reducing pro-criminal attitudes. The major drawback of the studies included in the analysis is
the lack of a control group, so other factors may contribute to the results (prison, time, aging).
The results showed that changing pro-criminal attitudes is associated with a lower relapse
rate, so with a better rehabilitation. A meta-analysis (Helmus, Hanson, Babchishin& Mann,
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2013) revealed that cognitive distortions related to rape are significantly related to sexual
recidivism (Cohen’s d=.22). So, attitudes and cognitions supportive to rape are a risk factor for
relapse among sexual offenders.
“Excusing rape” and “Justifying rape” – dimensions of RAPE Scale An analysis of RAPE
Scale (Hermann, Babchishin, Nunes, Leth-Steensen & Cortoni, 2012) argues that seeing
implicit cognitions related to rape as a unitary construct, can leave out of sight important
information. Therefore, the authors propose a two-factor model of RAPE Scale – excusing rape
and justifying rape.
• The “Excusing rape” factor contains cognitions that reduce the feeling of guilt because
the responsibility for the rape is attributed to the victim orother uncontrollable factors
(e.g., high sexual drive, sexual deprivation, child sexual abuse). This factor includes
items such as: “If a woman gets drunk at a party, it is really her own fault if someone
takes advantage of her sexually”, “Most of the time, the only reason a man commits
rape is because he was sexually assaulted as a child” (Bumby, 1996). Having this
rationalization for rape, the rapist doesn’t feel any guilt or responsability for the
offence.
• “Justifying rape” factor contains item that minimize the wrongfully of rape by
reflecting sentiments of men’s entitlement, hostility towards victims or minimization
of harm. A relevant item for this factor is: “As long as a man does not slap or punch a
woman in the process, forcing her to have sex is not as bad” (Bumby, 1996). These
cognitions minimize the negative effects of rape, claiming that rape is not harmful.
Therefore, we observe that the „excusing rape” factor is a denial of responsibility and the
“justifying rape” factor is a denial of effects (according to classification proposed by Shields
& Whitehall, 1994 apud G. Visu-Petra, C. Borlean, and G. Groza, 2006). Thinking of “RAPE
Scale” (Bumby, 1996) as being composed of these two factors may increase precision in
measuring rape-supportive cognitions and may lead to a better understanding of the types of
rape-supportive cognition that contribute to the initiation and the maintenance of sexually
aggressive behavior (Hermann et al., 2012).
Gender differences in cognitive distortions related to rape

Research showed that there are gender differences related to rape – women reported more
egalitarian gender-role believes (Simonson & Subich, 1999) and negative attitudes towards
rape. The acceptance of traditional gender-roles influences the acceptance of rape and is a
significant predictor of the acceptance of rape myths, for both men and women (Burt, 1980).
Furthermore, women evaluate rape as being more serious and is less likely they have
justifying rape believes (Bell et al.,1994). Men are more likely to attribute blame to the victim
(Bell et al., 1994) and have a less negative attitude towards rapists (Kanekar & Nazareth, 1988).
A study with a sample of 150 students (75 men and 75 women), showed gender differences
concerning attitudes towards gender roles: female participants had more egalitarian attitudes
(M=4.2 vs. M=3.93), and male participants have a tendency to minimize the rape (Ben-David
& Schneider, 2005). The are no significant gender differences related to the perception of
victim or sexual offender. Other studies (Acock & Ireland, 1983) showed that both men and
women have a negative attitude towards rape, and this attitude is notinfluenced by gender-role
believes. The sample was composed of 399 students (201 men and 198 women) and the results
show that men have a positive attitude towards rapists and women have a positive attitude
towards the victim. The results obtained by Giacopassi and Dull (1996) are similar; they used
a questionnaire to measure the acceptance or rejection of rape myths on a sample of 499
students (181 male and 254 women). The results show that women reject more often the
following believes: “women falsely accuse men of rape”, “women have sexual fantasies about
being raped” and “victims are to blame for rape” and disagree more often with the belief:
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“normal men do not rape”. These results are an addition to previous findings (Feild, 1978; Burt,
1980), which showed that women accept to a lesser extent justifications related to rape,
comparing to men. The rape related myths analysed in this study were similar to the cognitive
distortions measured by the RAPE Scale.
More recent studies (Anderson & Quinn, 2009) identified a significant difference between
men and women when analysing the attitude towards rape (N=240 medical students; 120 male
și 120 female). The results showed that men have a more negative attitude towards rape victims,
comparing to women.
Our study
Our purpose was to analyse the differences concerning beliefs about rape, comparing
between incarcerated offenders (rapists) and students’ non-rapists from different college. We
expect to find some excuses and justifications related to rape among non-rapists (students).
Another purpose was to identify a desirable level of cognitive distortions, in order to be a
priority for cognitive restructuring therapy for rapists. Most of the research presented, used
different instruments to analyse the cognitive factors of rape (believes, attitudes, other variables
related to risk of offending), on different samples-students or convicted rapists. We didn’t
found studies which used the same questionnaire both on a population of convicted rapists and
a control group, on the same time. This kind of analysis can be useful for establishing a level
of cognitive distortions related to rape unrelated to criminal behavior.
Another purpose is to identify gender differences (men vs. women) regarding cognitive
distortions related to rape. Previous research showed differences between men and women-
men are more lenient with rapists and blame the victim more frequent. We expect to find similar
results using RAPE Scale.
Thus, our hypothesis for this research is:
1. Cognitive distortions related to rape are more frequent among incarcerated rapists
comparing to non-rapists (students).
2. Women have less cognitive distortions related to rape than men.
METHOD
Participants
The sample is composed of 480 participants. 222 are men – 57 are convicted rapists (M age:
and 165 are male students (M age: 21.6 and SD=2.93) and 258 female students (M age: 21.27
and SD: 4.02). The offenders were selected from 3 prisons from Romania (Aiud Penitentiary,
Baia Mare Penitentiary and Gherla Penitentiary). Most of the students who participated at this
research are from Faculty of Psychology (N=228, 50 male students, 178 female students),
Faculty of Law (N=63, 10 male and 53 female) and Polytechnic (N=117, 98 male and 19
female).
The RAPE Scale was not validated for Romania’s population and it was not validated for
the populations of interest either. Although, the RAPE Scale was translated according to
standard procedures.
Demographics
The age in the students’ population ranges from 18 to 43 years old and the most prevalent
ages are 18 years old (19.10%) and 20 years old (24.3%). The population is heterogeneous,
61.5% are male and 38.5% are female. When we look at the level of education, the majority of
them are highschool graduates (71.2%) and 23.6% of them graduated form a university, 38.1%
of the students are from Psychology, 30% are from Polythenic and 14.6% are from Law. The
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majority of them live in the city 81.8% and 18.2% live in a rural enviroment. For the detainees,
we do not have any demographical data.
Measures
Individual differences concerning implicit cognitions about rape were measured with
“RAPE Scale” (Bumby, 1996). RAPE Scale is a measurement of implicit cognitions about rape
and is composed of 36 items, each of them reflecting cognitive distortions about rape. Items
are scored on a four-point Likert scale, ranging from strongly disagree (1) to strongly agree (4).
The validation study (Bumby, 1996) showed that “RAPE Scale” has very good
psychometric properties, the standardized α coefficient was α=.96, indicating a good internal
consistency and measurement of a primary construct. Temporal stability of the RAPE Scale
was also very good, with a test-retest correlation of r=.86 (t7<.001), over a 2-week interval.
For RAPE Scale, the lowest score is 36 and the highest is 144. A higher score means that
there is a higher number of implicit cognitive distortions about rape. The good psychometric
properties of the RAPE Scale were demonstrated in other studies. In an evaluation study
(Arkowits & Vess, 2003) the results show a good internal consistency coefficient (α=.97).
For this research, we used the two-factor model of RAPE Scale, which separates the
cognitive distortions on two dimensions – “excusing rape” and “justifying rape” (Hermann et
al., 2012). “Excusing rape” factor contains items which attribute the responsibility for rape to
the victim or to other uncontrollably external factors. “Justifying rape” factor contains
rationalizations which deny the negative effects of rape for the victim.
Procedure
For the selection of eligible convicted rapists and information about sex and age of the
participants, we used the peniteciary’s data base. We selected all the prisoners convicted for
rape and we invited them to participate to the study, in exchange of 3 penitentiary credits
(rewards which can be used to cancel a punishment – for breaking the internal rules or to obtain
a reward – extra visits for example). All the selected convicts who agreed to participate were
included in the study. Each participant was given instructions about how to fill out the
questionnaires. The students’ sample was obtained after posting an online announcement on
the academic groups from Faculty of Psychology, Faculty of Law and Faculty of Polytechnic.
423 students responded to the announcement, 16 of them being from other college than those
three (we included them in the gender differences analysis).
Data analysis
For the comparison between convicted rapists and students, for the analysis of the
differences between students’ scores and for the measurement of gender differences between
cognitive distortions related to rape we used the analysis of variance ANOVA and post-hoc
analysis Scheffe. All the statistical analysis were ruled in SPSS program.
RESULTS
The cognitive distortions related to rape are present to a greater extent among convicted
rapists comparing to non-rapists (students)
We found higher levels of cognitive distortions related to rape among convicted rapists, in
comparison with students from different faculties; using ANOVA, we found F (3,461) = 60.69,
.000, η2p=0.283. The Scheffe test indicated significant differences between convicted rapists
(M=79.91, SD=21.92), psychology students (M=52.12, SD=11.99), law students (M=54.02,
SD=12.87) and polytechnic students (M=65.32, SD=17.70). All three students’ groups are
considerable different from the convicted rapists. There are significant differences between
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students from polytechnic and those from psychology and law and no significant differences
between psychology and law students.
“Excusing rape” beliefs are more frequent among rapists, comparing to non-rapists
Convicted rapists reported higher levels of cognitive distortions related to rape, on the
“excusing rape” dimension, in comparison with students; the analysis of variance ANOVA
revealed F (3.461) = 45.77, .000, η2p=.230. The Scheffe test indicated significant differences
between 57 convicted rapists (M=46.00, SD=12.15), psychology students (M=31.95,
SD=8.32), law students (M=33.05, SD=7.93) and polytechnic students (M=40.26, SD=10.47).
All three students’ groups are considerable different from convicted rapists’ group. We
found significant differences between polytechnic students and law and psychology students
and no significant differences between psychology and law students.
“Justifying rape” beliefs are more frequent among rapists, comparing to non-rapists
Convicted rapists reported higher levels of cognitive distortions related to rape, on the
“justifying rape” dimension, in comparison with students; the analysis of variance ANOVA
revealed F (3,461) = 73.03.000, η2p=.322. The Scheffe test indicated significant differences
between 57 convicted rapists (M=33.91, SD=10.63), psychology students (M=0.17, SD=4.20),
law students (M=20.97, SD=5.60) and polytechnic students (M=25.06, SD=7.98). All three
groups are considerable different from convicted rapists’ group. There are significant
differences between polytechnic students and law and psychology students and no differences
between psychology and law students.
Differences between convicted rapists and male and female students in order to observe
gender differences related to RAPE Scale, we conducted an Oneway ANOVA analysis, and
using the post-hoc Scheffe test, we observed differences between convicted rapists (N=57, all
men), male students (N=165) and female students (N=258). In this analysis were included
students from faculties of psychology, law and polytechnic and other groups of students (N=16)
which responded to our announcement.
The results showed differences between groups, with F (2,477) = 98.88, .000, η2p=.293.
Post-hoc Scheffe test indicated significant differences between convicted rapists, male
students and female students, on the dimension cognitive distortions related to rape (RAPE
Scale). Convicted rapists (male) have higher levels of cognitive distortions related to rape, in
comparison with male students. Women have a lower level of cognitive distortions related to
rape, considerable different from male students and convicted rapists (male). We present mean
differences on RAPE Scale in Chart 2.
The same significant differences were obtained between scores at those two factors of RAPE
Scale, excusing rape (F (2.477) = 75.53, .000, η2p=.241) and justifying rape (F (2.477) =
114.68, .000, η2p=.325). Convicted rapists have more cognitive distortions which “excuse”
rape, in comparison with male students. On the other hand, male students have a significant
greater level of cognitive distortions which excuse rape, in comparison with female students.
The same pattern was identified with the dimension justifying rape, differences being
identified between the three groups.
DISCUSSIONS AND CONCLUSIONS
The results of this research indicate significant differences for the cognitive distortions
related to rape, both between convicted rapists and students’ non-rapists, and also between
different categories of students. Previous research (Bumby, 1996) showed differences in RAPE
Scale between convicted rapists and convicted non-rapists (other type of crimes). As far as we
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know, there are no previous studies for analysing the scores on RAPE Scale comparatively
between convicted rapists and non-criminal population. We though it would be useful to
analyse the differences making a comparison between convicted rapists (M=79.91, SD=21.92)
and college students. For this purpose, we chose to compose a heterogeonus sample, with
students from 3 different faculties (law, psychology and polytechnic) and we wanted to identify
the possible differences between these categories of students. Many of the studies from
psychology use psychology students as participants. We think that psychology students might
not be a representative sample for the general population. On one side, psychology students
have a particular interest for the human psychic but in the other side, they are trained in this
particular domain (which helps them make a clear distinction between rational and irational
thoughts and cognitive distortions, analysed by this research). We made a comparison for the
level of cognitive distortions related to rape, between psychology (M=52.12, SD=11.99), law
(M=54.02, SD=12.87) and polytechnic students (M=65.32, SD=17.70). The results showed
that psychology students are similar to law students, both categories being considerable
different from polytechnic students. Therefore, the highest level of cognitive distortions was
identified among convicted rapists, the middle level among polytechnic students and the lowest
level among psychology and law students. Based on these results, we can conclude that the
level of cognitive distortions related to rape can be different, even among the control population
(non-rapists). Another thing to remember is that researchers need to be cautious when choosing
a sample composed just of psychology students. Sometimes, the profile of the psychology
student is not very representative for the general population.
In a cognitive restructuring intervention one purpose is the lowering of relapse rate and
another is the decrease of cognitive distortions related to rape. Otherwise, the study conducted
by Eastman J.B. (2004) on a sample of convicted rapists, evaluated the scores on RAPE Scale,
before and after intervention and showed a significant decrease from M=76.08 to M=52.75
(p<.001). The results of the present study showed values of cognitive distortions in the sample
of convicted rapists, comparable to those obtained by Eastman J.B. (2004), the mean values
being M=79.91 vs. M=76.08. We also can observe that after the intervention the level of
cognitive distortions among incarcerated rapists is comparable with the level identified by us,
among psychology and law students. When we analysed the two factors – “excusing rape” and
“justifying rape”, we identified the exact same pattern in the experimental groups. So, we can
conclude that those groups who make an external attribution of guilt (blaming the victim or
attributing the responsibility to external and uncontrolable factor), are the same groups which
minimize the effects of rape over the victim, justifying rape by entitlement or hostility toward
women.
Our results after analysing the gender differences (male vs. female) are similar to those of
previous research (Bell, Kuriloff & Lottes, 1994). In our study, for the dimension “cognitive
distortion related to rape”, convicted male rapists (M=79.91) are significantly different from
non-rapists’ male students (M=64.15), and male students are considerable different from
female students (M=51.31). The same pattern was identified for the two factors of RAPE Scale.
Gender differences identified for the “excusing rape” subscale findings are similar to that
obtained by Bell et al., (1994), who concluded that men are blaming more the victim for rape.
The scores on the “justifying rape” factor is similar to those obtained by Ben-David and
Schneider (2005), who showed that men have a proclivity to minimize the importance of rape.
The findings of this study are important for two reasons. First of all, the results showed us,
a result that we expected, that cognitive distortions related to rape are much more frequent
among convicted rapists compared to college students. Second of all, the comparison between
gender (college students), showed us that cognitive distortions related to rape are much more
frequent among male students, compared to female, which means men, not women too, blame
rape victims more. Pehaps the most important result concerns the sample of college students.
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We found that the level of cognitive distortions is different among students from different
universities, and the lowest level is found among psychology students. This result is important
because a lot of studies use psychology students as a sample, but this sample might not be
reprezentative for the population, especially when we talk about cognitive distortions. The
results of the present study are important and a contribution to the existing literature by finding
that there are big differences regarding cognitive distortions among convicted rapists and
college students, between male and female participants and between students for different
universities. These differences are important to be taken into consideration when we choose
the target population for research. Much more, it’s important to know the level of cognitive
distortions in normal population, so we can work with convicted rapists to bring their
pathological level of cognitive distorsion at a normal level.
Limits and future directions

We can identify some limits. First, we can observe differences related to homogenity
between the students’ sample: the sample of psychology students (N=228) is composed of 50
men and 178 women, the sample of law students (N=63) is composed of 10 men and 53 women
and that of polytechnic students (117) is composed of 98 men and 19 women. Therefore, a part
of the differences between these samples can be explained by the gender differences distributed
disproportionately inside each sample.
Another limit is related to the gender of the rapist and the victim, which was formulated
according to the RAPE Scale items. The fact that the rapist is male and the victim is female
can explain the gender differences identified for the cognitive distortions related to rape. It’s
more likely that male participants found themselves similar to the abuser and female
participants similar to the victim, a fact that can partially explain the differences between
scores. Future research should analyse gender differences with a questionnaire with items
separated for the situations when the abuser is a woman and the victim is a man or the abuser
and the victim have the same sex. In this way, it could be controled the effect of empathy
produced by the identification with the attitude/believes about rape. Another limit of this study
is the different level of education between the sample of convicted rapists and that of students.
In general, the educational level of the convicted rapists is significantly lower than college
studies.
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GENDER STEREOTYPES AND STEAM EDUCATION
Abstract
Then we talk about gender stereotypes in Steam education we can find in the societal
mentality: “Girls don’t find STEAM interesting” “Boys are more capable for STEAM”, “Boys
are oriented to achievements, girls to feelings and society”. This paper presents the results of
sensitive gender workshops, to provide illustrations of stereotypes as an input for the creation
of value-added content with gender awareness and continue sensitizing teachers about gender
stereotypes in approach to learning that uses Science, Technology, Engineering, the Arts and
Mathematics in education.
Keywords: Gender Stereotips, STEAM Education, STEM Education, Sex Segregation
INTRODUCTION
In a world with greater population, global interconnection, technological advancement, and

large-scale problems than ever before in human history, complex problems require
sophisticated problem-solving skills and innovative, complicated solutions. [1]
Perignat & Katz-Buonin examined 44 published articles (empirical, descriptive, and
pedagogical frameworks) on the topic of STEAM education from 2007 to 2018 and also
differentiate in methods for merging STEAM disciplines, described in one of five ways:
transdisciplinary, interdisciplinary, multi-disciplinary, cross-disciplinary, and arts-integration.
[2]
MATERIAL AND METHODS
1. What meens STEAM Education?

Tam, Yuk-fung Chan, & Long-hin Lai proposes to get optimal impact of STEM education
and truly prepare students for the real-world problems, a different approach of teaching where
students can offer and argue with evidence, hear different points of view and discern which
seem reasonable, interact and communicate newly created ideas is important [3].
Considering the current climate change, health disparities, food shortage, and others can say
that STEM disciplines have become of greater importance than ever.” [4]
Sex segregation seems to vary cross-nationally by socioeconomic development and gender
equity; we may find similar variation on these indicators within this rapidly industrializing
Southeast Asian nation. [5]
Students’ beliefs, teachers’ recommendation and the system of tracking are all important
factors in choosing an in-demand science career. [6]
While education levels of women have increased dramatically relative to men, womenare
still greatly underrepresented in Science, Technology, Engineering, and Mathematics (STEM)
college programmer. [7]
2. The stereotyped situations in STEAM education

Two workshops were performed in the field of STEAM Education. In first workshops
participated 9 students (just girls) from the psychology faculty attended the second year, and
in workshop 2: 16 students, including 14 girls and 2 boys, students from “Dimitrie Cantemir”
University were studying Psychology, Law, and School-teaching. Workshop facilitators were
provided with a guide to identify common and unconscious in stereotypes of gender in the most
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homogenous way as possible. The aims of sensitive gender workshops were: to provide a
framework for input to encourage local content workshops; to provide illustrations of
stereotypes as an input for the creation of value-added content with gender awareness; to
continue sensitizing teachers about gender stereotypes in STEAM education.
2.1 Breaking the ice activity

The first activity comprised of the distribution of paper slips that contained statements on
gender issues. The strips had been cut in half in various ways so that each piece could be only
matched with its original mate.
In the second activity, participants had to find the matching half to the piece of paper they
were holding. When they found the right match, they formed pairs with the person who had the
matching piece. Each person in the pair then interviewed the other and after they discuss the
sentence.
In the third activity, each person in each pair introduced his or her partner to the group after
they had introduced themselves and been talking about their interests, etc Once they had
introduced themselves, they had to say what phrase they had been touched by and what they
thought of it, if they thought it was true, why?
Even though most of students agreed that it was not something of “nature” but of learned
skills, it is worthy to remark that there is still a high percentage of students that consider that
women cannot work as hard as men.
All participants presented and expressed their opinion freely. In the first group the opinions
were homogeneous, they generally had the same opinions. In the second group, opinions were
much more divergent and each tried to reasonably support his opinion.
Some of the initial views of the students are synthesized below:
• G. began the debate stating that “There are 60,000 anatomic differences between the
body of the woman and the man: the most beautiful profession/profession is to form
life through educated sittings” (C.G., Psychology, 1st year).
• T. S. say: “There is inequality between women and men. Unfortunately for the same
thing in certain jobs even if women and men do the same job, men are better paid than
women. I do not think men are always right”.
• M.A. believes that “Women have the same rights as men” (MA-, future teacher) N.G.
disagrees, says she was credited with a Muslim family, and women are honored, but
she says, “I do not think we can be 100% equal. Men have certain qualities and women
do not have them the other way around. We are different from each other” (N.G.-
Muslimorigin third year psychology student, DPPD l).
• “In our society, geared towards democracy and equality, I believe that women use
gender inequalities as a pretext to motivate their own failures. A woman who wants her
education will be educated. A woman who wants to advance in her career will do
everything in her power to get this done. If he wants a family and obligations; is
involved, will establish a family, and if not, will not do so. Although stereotypes exist,
they can’t and must not stand in the way of a person’s goals” (B.D.M.)
• P.S.A. says that “gender inequality exists today. Women are in some devalued areas,
everything being in favor of men. They are not excluded, but only marginalized. Just
as in rural areas, women are inferior to men because they are domestic, they have to
deal with home and children in general, some of whom are denied the right to work. I
think that even small children are involuntarily imposing certain stereotypes: women
= secretary; man = army; women = sensitivity, emotion; man = force, protective. Each
of these qualities, whether male or female, must be appreciated by each of the two
parties, to complement each other.” (DPPD student, first level, 3rd year of psychology)
• G.A.M., the mother of two boys says boys are disadvantaged, they are apostrophe more
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often than girls, sometimes even beaten by teenagers and girls are forgiven, even if
they are wrong, they also conclude that “stores have more products for women than for
men, what I do not feel right, I have two boys, go abroad to shop. For supplies and
clothes, because we do not find in our country, women are more accented. I believe
that society is first guilty of inducing this state of being unequal. Men love the real part
(math-real), women’s human side (the Romanian-human language). So, they say. I say
that it depends very much on how the little child is educated, it is about temperament,
personality, character, no matter the genre.”
“Inequality is present and there will be a long time,” adds a participant, and B.V. says
“it is a controversial topic and I think most have a misconception about the role played
by woman and man in society”.
2.2 Riddle activity

The aim of activity has to get participants to re-think their first assumptions about gender.
The facilitator read the riddle to the participants and showed it either on a screen or paper
in order to let participants to read it as many times as they need. Once the group solved the
riddle, ie. Figures out that the surgeon – a woman – is the boy’s mother, facilitator leaded a
discussion about the assumptions people make concerning the professional roles of women and
men.
Riddle: “I cannot operate on this child”.
• “Deepak and his son Arjun live in one of big cities of India. One Sunday, they take the
car to go to the market. On the way, they have a serious accident and Deepak is instantly
killed. His son, injured and unconscious, is rushed to the nearest hospital.” [8] Most
participants said the surgeon is a mother, because the father got caught in the accident
although the text does not specify this, but the name suggested it. Regarding the ethics
of operating or not owning a child, she thinks that a mother cannot.
• V. believes that the surgeon “can’t operate because there is intense emotional
affection.” “Because of the emotional shock and the likelihood that you will be
mistaken for the technique, in the child’s life or success will be doubtful” (C.G).
• M.A.M says that “Mum was the surgeon and could not operate that child because he
was subjectively involved. Perhaps if the father was a surgeon, he could not”.
• To the question “Since a father could operate and a mother did not, a response was,”
the surgeon is allowed to operate the baby, but regardless of gender, whether it is
mother or child’s father, this/this will be much subjectively and because of feelings
refused surgery “(NG), while another opinion is that “mother, because of attachment
to the child, can’t emotionally detach from the situation.”
2.3 Reflection on Societal

Views about Women and Men’s Roles the Aim of this activity has to help participants clarify
their personal views and beliefs about the roles sixth reason point out that teacher have some.
For the first activity, facilitators taped a sheet of paper marked ‘agree’ on one wall of the
room and a sheet marked ‘disagree’ on the opposite wall.
Participants were said that facilitators would be reading aloud a series of statements about
the role and status of women. As each statement was read, participants had to decide whether
they agreed or disagreed with the statement and quickly move to the wall that indicated the
opinion they favor. Those grouped together under the same sign did discuss their reasons for
agreeing or disagreeing and appointed a reporter to share their reasons with the other group.
At the question “Do you think girls are better at humanity, and boys are better at science?”
same answers have:
• Yes (the woman is sociable and action-oriented; I think the woman is “built” based on
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feelings; women are predominantly rational, and men are more attached to the goal;
since primary classes, girls are interested in studying while boys on technique, skill).
• No (I think it’s about everyone’s mentality and his / her ambition; everyone is different,
so sex does not determine your abilities; they have the same qualities and defects; We
are born with the same capabilities that the menu engages or inhibits; it does not matter
sex in any field).
• There are no good men on the social side and women who are good on the logical side.
• It is not mandatory. Gender is not a determining factor in terms of knowledge, skills.
• The humanitarian and scientific side is equally developed in women.
Question: Why do you think men choose a STEAM profession?
Answers:
• Because of their natural nature, it instinctively comes to them • Somewhat encouraged
from the outside, the media.
• Yes-I think every person has his own reasons. The difference does not make it the kind.
• It’s not a special choice.
• Because of their skills, their skills have been stimulated since childhood.
• Not only men choose them, they also do not all choose those professions.
• I do not choose men specially.
• The inclinations they find.
• That’s what they want.
• Because they are based on logic in most of the time.
• Men choose these professions because they are subject to stereotypes because they are
passionate and capable. This statement does not exclude the competence and passions
of women.
• Because they are encouraged to do so.
• They have been educated; they have to turn to the right jobs.
Summing up, results show that students agree about the reasons why boys are more oriented
towards STEAM. Some of them are that boys feel more comfortable with STEAM as they have
been taught in STEAM skills.
2.4 Role Plays to identify Gender Stereotypes in scholastic situations

This exercise was designed to get from participants their personal views about different
Gender Stereotypes treatment identified in scholastic situations.
We explained to participants that they would carry out a role play activity to help them to
think about different situations in which they felt that they received different treatments due
their condition of girl or boy. As participants rehearsed and discussed their scenarios, facilitator
circulated and helped them get through rough patches. Then, they come together and shared
their scenario with the group.
Results show that teachers treat in different way boys and girls, based (and perpetuating) on
stereotypes such as that girls are more fragile and gentler (and passive) and boys ruder.
2.5 Feedback of activity’s

Following the first Workshop, the participants expressed their views:
• “The theme was real. Gender differences exist and can be overcome by will, freedom
of expression, work and education. The choices belong to us, so we have to choose
wisely”.
• “I hope that in the near future we will eliminate the prejudices and the stereotypes that
we have today. WOMAN IS BEAUTIFUL AS A MAN!”
• “I liked the subject, I think we would have a better world if we eliminate the
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stereotypes, because anything a man can do can make a woman with little exceptions.
I liked workshop and the way this subject was discussed and presented.”
• “E-STEAM is a good initiative that I hope will help the company continue to ignore
prejudices and stereotypes. Both women and men should be equal in chances to choose
a career.”
• “Inequality between women and men exists on the day of sharpening. Women are
devalued very much. Changing this cause could change in the future. This cause comes
from grandparents’ times.” (C.R.A.)
• “My opinion is that at the moment the role of the man and the role of the woman is
denaturant. First, taking into account the natural role presented in the Bible, both men
and women have predominant, special qualities, which distinguish them. Secondly, it
is obvious that from a physical point of view a woman cannot exceed a man’s strength.
Equally, at the psychic level, it is demonstrated that the woman is focused on details
and the man on the generalities, in case a problem occurs, need to be solved. Last but
not least, within a family, a woman naturally fulfills her household chores easily, while
a barbarian is difficult to cope with each of them. Returning to the special qualities, the
woman is sensitive, tender, patient and imam, while the man presents strength, strength,
self-confidence, and ease of doing business”. (B.V.A.)
• “I think that there is equality between a man and a woman, in general, that if we enter
into details things could degenerate from one person to another, and the conception of
each one is related to several factors starting from the most elementary, the family and
here many others – religion, conception, society, etc. No one stop a woman from
pursuing a career that is considered to be “destined” to men, and if she wants, she is
absolutely achievable. From a legal point of view, we are all equal, the rest are only
perceptions and indoctrinated ideas.”
• “In conclusion, inequality between sexes does not exist in the law, at least in us.
Inequality is something about your own conduct and mentality.”
• “I think this subject is very varied and it takes more time to debate it.”
CONCLUSIONS
The stereotypes identified during the workshop, regarding “personality” attributes are: girls
are more focused on appearance, are fragile, too emotive since boys are more logical and
stronger. Regarding way of behaving participants says that girls are inferior to boys in sports,
are neater and better organized, and are more passive, gentler. Regarding the way of expressing
emotions, girls are more emotional, which might impede them doing their job.
Efforts have been made in recent years to promote STEAM education, but we still live with
stereotypes that are part of the nation’s culture and the way we were raised. STEAM education
can change the thinking- students can be engaged in more activities for a better life together –
Women and men.
Professional development should include methods for modeling and fostering creativity in
the classroom. [2]
It’s interesting the point of view of authors Ho, La, Nguyen, Pha, Vuong, Vuong, Pham,
Hoang & Vuong: “In Confucian cultures, those who did not have to do handicrafts were usually
government officials, considered to be part of the intelligence. Such people with letters would
have better resources to secure their children with a scientific culture, as well as to impose strict
disciplines, manners, and labels.” [4]
Increased education may in some ways heighten and in other ways reduce women’s
vulnerability to the health effects of gender discrimination. [9], [10], [11]
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REFERENCES
[1] Margaret E. Madden, Marsha Baxter, Heather Beauchamp, Kimberley Bouchard, Derek Habermas,
Mark Huff, Brian Ladd, Jill Pearon, Gordon Plague, Rethinking STEM Education: An Interdisciplinary
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[2] Elaine Perignat, Jen Katz-Buonincontro, STEAM in practice and research: An integrative literature
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https://doi.org/10.1016/j.tsc.2018.10.002. accesed in february 2021 from
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Vuong, Hung-Hiep Pham, Anh-Duc Hoang, Quan-Hoang Vuong, An analytical view on STEM
education and outcomes: Examples of the social gap and gender disparity in Vietnam, Children and
Youth Services Review, Volume 119, 2020, 105650, ISSN 0190-7409,
https://doi.org/10.1016/j.childyouth.2020.105650. Accessed on February 2021 from
https://www.sciencedirect.com/science/article/pii/S0190740920320739
[5] Lara Perez-Felkner, John S. Felkner, Samantha Nix, Melissa Magalhães, The puzzling relationship
between international development and gender equity: The case of STEM postsecondary education in
Cambodia, International Journal of Educational Development, Volume 72, 2020, 102102, ISSN 0738-
0593, https://doi.org/10.1016/j.ijedudev.2019.102102. Accessed at 28.02.2021 from
https://www.sciencedirect.com/science/ article/pii/S0738059319300756
[6] Gheorghita M. Faitar, Silviu L. Faitar, Gender Gap and Stem Career Choices in 21st Century American
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0428, https://doi.org/10.1016/j. sbspro.2013.12.142. Accesed in 27 02 2021 from
[7] Judith M. Delaney, Paul J. Devereux, Understanding gender differences in STEM: Evidence from
college applications, Economics of Education Review, Volume 72, 2019, pp. 219-238, ISSN 0272-7757,
https://doi.org/10.1016/j. econedurev.2019.06.002 accessed in february 2021 from
[8] Gender Bias Exercise can be accesed at https://www.coursehero.com/file/21592978/GenderBias-
Exercise-1/
[9] Matthew A. Andersson, Catherine E. Harnois, Higher exposure, lower vulnerability? The curious case
of education, gender discrimination, and Women’s health, Social Science & Medicine, Volume 246,
2020, 112780, ISSN 0277-9536, https://doi.org/10.1016/j.socscimed.2019.112780. Accesed in
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RESEARCH ON HUNGARIAN FEMALE TEACHERS’ MENTAL HYGIENE STATE

WITH SPECIAL REGARD TO THE DEVELOPMENT OF THEIR PROFESSIONAL
AND FEMALE IDENTITY
Abstract
We worked with the fact that, nowadays, the majority of teachers in schools are female, so
the aim of our research became to assess the general state of mental hygiene in female teachers,
and its causal relations. In this study we presented the may-sided, diversified roots of the
research, based on positive, Jungian and personal psychology, educational researches on
teachers’ personality, gender issues in education. We also exhibited the connected studies on
stress and burn out mostly in connection to teachers and the field of education. The research
has a specific focus on female teachers' mental hygiene states in connection with their
developing professional and female identity. We pointed out some connections of our main
points of examination and the Finnish teacher training practice, too. As a main hypothesis we
presume that just a certain group of female teachers are in a state of fragile mental hygiene. In
the detailed hypotheses we are looking for evidence that the mental hygiene state shows
differences between certain groups among female teachers. The best way for examination
appeared to be by using two validated (MBI-ES, LOT-R) and two personal creating
questionnaires (BÉIK, SzSzK, only in Hungarian), as a comparative survey. On the whole, our
starting assumption has been proved, that female teachers’ mental hygiene state in our meaning
the level of burnout and psychological well-being are in connection with the level of the
elaboration of their professional and female identity.
Keywords: feminine, masculine, gender, sex
INTRODUCTION
In Hungary the statement that the teaching profession has become feminised is accepted as
and has mostly negative connotations. Interpretation of this feature as a problem is a cliche in
the pedagogical literature and practice nowadays too, although since 1989 it has been
conceptualized that it can yield positive effects and understandings (Buda, 1989, Thun, 2005,
Rédai and Sáfrány 2019). We were inspired primarily by Thun’s studies (Thun, 1996, 2012) to
work towards the theme of female teachers’ identity, and the importance of awareness of this
topic.
Problem identification: Whether feminization of the teaching profession is a real

problem?
Buda (1996) in his study has thought through the negative connotations in detail, from
psychological, educational, and social angles, concluding that there is no danger, or that the
feminization of the teaching profession may not have any significant impact. At the same time,
Buda says that women, by nature, are more sensitive and more capable of empathy than men.
In our opinion, the explanation of these features has nothing to do with the temperament of
the female, hence, in the field of pedagogy, which is dominated by women, could we notice
empathetic expressions, or expressions without empathy.
The question arises whether gender itself predisposes an individual toward certain
operational behaviour patterns, or toward a state of mental hygiene, or whether personal
disposition makes a difference? The latter arises in studies by Zsuzsa F. Lassú (F. Lassú, 2001,
2004).
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One question remains: whether the plurality of the female personality plays a role? How
much are women aware of their personality, how authentically do they live? Do they simply
adjust their personality to the expectations of society (Kovács E., 2012)? How aware are female
teachers of other questions relating to their profession? Does the measurement of awareness
make any difference in the mental hygiene state, or to the extent of burnout? In what
circumstances could they sustain a healthy personality?
Another issue further complicates the matter: how the state of teachers is influenced by the
way the topic of gender is handled in schools, and the almost complete invisibility of the topic
in everyday life.
The awareness is also a question according to how developed the professional personality
is.
Whether an individual who is aware of her place and has built her professional personality
is less vulnerable according to the controversial expectations upon women (like a teacher and
like a female)? Does an individual who is more aware choose her operational skills and
reactions, does she feel her identity as a whole, and experience greater protection in her state
of mental hygiene? It has become clear that this awareness when developing female and
professional identity is a basic point in our examination.
Another important point of view for us is that we intended to examine the female teacher’s
mental hygiene state, not just merely from the deficiency side, but from the resource’s side
also. For this reason, the approach of positive psychology found a place in the research and the
interpretation.
From this aspect, we do not focus on deficit, but psychological well-being and its elements.
Aims of the research assess the state of mental hygiene in female teachers
We worked with the fact that, nowadays, the majority of teachers in schools are female, so
the aim of the research became to assess the general state of mental hygiene in female teachers,
and its causal relations. The long-term aims of the research are to contribute to the creation of
a state of well-being with relation to teacher’s mental hygiene; and through their state of well-
being, thrive in a school climate, and indirectly help to create a less stressful, healthier climate
for the students.
Another aim of our research is to refute those theoretical pathways and practical misbeliefs
which surround the concept of the feminization of the teaching profession.
The research has a specific focus on female teachers’ mental hygiene states in connection
with their developing professional and female identity, so to provide a many-sided view which
allows us to be aware of certain nuances.
Our research examines personal and professional identity, focusing on active female
teachers’ mental hygiene state, and searches for relationships between presence of personal and
professional identity, their level of elaboration, and the state of mental hygiene. It is important
to point out, taht the survey of the mental hygiene state came from two directions. From
burnout, and from the shape of personal life orientation as a predictor of psychological well-
being.
The dissertation represents psycho-dynamical theoretical aspects of the personality, which
has roots in the possibility of continuous development, and it seeks to identify the presence of
the conscious shaping of it with the complex examination of the female teachers’ mental
hygiene state.
The most appropriate definition of the dynamic personality concept approach is the
integrated, three-leveled model of McAdams (1995), which attempts to summarize all the
personality concepts of the different psychological directions. In his model, he endeavours to
sum up the personality models: and writes that, on one level, we have found basic personality
traits; on another level there are personality concepts (attitude, motifs, beliefs, roles, etc.) which
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depend on social environment. He assumes the existence of a third level of the personality also,
which contains identities and narratives of the personality which can be organized into a
narrative identity.
Parallel thoughts with Finish teacher training practice

The actuality of the researched theme has been shown by its topic. It deals with the
educational field, which is always affected by contemporary issues. Including the topic of the
educational field, the research concentrates on the actors in the process, those who determine
the quality of the education: the teachers. In this way, it is connected to the field of teachers’
personality research, which is nowadays undergoing something of a renaissance (Göncz, 2014,
2017). Since the research (which sprang from the fact that the majority of teachers are women)
has focused on female teachers, it finds a connection with surveys on gender in school,
including teachers functioning, methods, and effects of teaching (Kovács, E., 2019). The novel
start point of the research is the examination of the female teacher’s mental hygiene state from
multi-angled ways integrated to the objects of the research, the questions of professional
identity and psychological well-being. At this point, we would like to open the readers’ eyes to
the fact that Finnish education, which is one of the most modern, up-to-date educational
models, places a huge emphasis on the creation of professional identity. It is easy to find
connections between the features of the system and the atmosphere in Finnish schools and the
teacher training model. It is not the aim of this dissertation to explain the Finnish teacher
training system, but we would like to make use of those connections which relate to teachers’
personality, identity, and professional identity. To begin with, it should be mentioned that
support of teachers’ professional identity plays a central role in the model. This importance of
this central role has been intensified by the relationship between surveys and teaching, which
makes the professional self and identity stronger during the years spent studying at university.
Orsolya Kálmán says that there aren’t special Finnish methodologies; the essence is in the
interplay of the educational effect systems (Kálmán, 2008, 3.).
The Finnish teacher training system pays extra attention to shaping the teachers’ own
identity; as they urge the creation of a personal teacher’s image (Kálmán, 2008). An important
element of the Finnish teacher training system is the preparation of teacher candidates for
continuous self-reflection and the development of critical thinking elements of which play a
part in the creation of professional identity also (Csapó, 2015). Through the influence of the
Finnish teacher training model, the educational system has started to change in some European
countries, and more and more countries emphasize research-based learning. Hungary has also
started the promotion of research-based education. One sign of this process is that the highest
qualification of the teachers’ professional pathway goes to teachers who do surveys (Csapó,
2015). The Finnish teacher training system supports candidates to form their own frames of
methodology, theory, and thinking (Kálmán, 2008). In teacher training for candidates or active
teachers equally, professional development is connected to their personal and academic way of
learning. The integration of the contents of teacher training provides research-based teacher
training and narrative biography-based, self-reflective thesis, and portfolio writing practice
(Kálmán, 2011).
Criteria which characterize the emotional life and the everyday atmosphere of Finnish
schools (natural lifestyle, calm and balanced teachers and students, well-organized systems,
trust and independence for children, an efficient system, and the openness of the learning
environment) all assume the presence of psychological well-being and teachers’ attention to it
(Kálmán, 2008). The system probably helps the well-being of the candidates, while diminishing
their level of anxiety with not giving marks also. The few administration tasks support teachers’
renewing and psychological well-being too. Also, the Finnish teachers are valued socially and
financially as well.
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It is a relevant feature of the Finnish teacher training system that candidates do not simply
become familiar with the teaching profession, but their personalities are changed by the
process. These changes are connected to the structure of the training system which is based on
self-knowledge, research, and active learning (Hercz, 2008).
Namely, we can state that the features of a successfully operating teacher training system
are the researched-based aspects, the acquisition of self-knowledge, and also skills of self-
reflection and building a personal professional identity, which is based on the previous.
By these criteria, the Finnish system creates a huge amount of awareness in teachers
(candidates) which is an essential component of the professional personality of the teachers
that we are examining.
Diversified literature roots of the research

At the background of the research, we deal with most of the main elements (except for basic
skills and capability) of the surveys of the teachers (traits of an effective teacher; pedagogical
skills; basic personality traits; detecting the basic skills; knowledge influencing effectiveness;
practical skills; pedagogical thinking; detecting traits and specialties of pedagogical decision
making; detecting beliefs and practical philosophy of teachers; defining reflective teaching;
Falus, 1998). We deal with the traits of effective teachers (as we meant it: they occupy a state
of psychological well-being) (Szebedy, 2005), the basic traits of a teacher (Göncz, 2017),
pedagogical thinking; decision-making; detecting believes; practical philosophy; and
capability of reflection of teachers.
The McKinsley report (2007) gave a new dynamism of the research approaching the
personality of the teachers by stating that the most important part of the pedagogical work is
the personality of the teacher.
The cognitive pedagogical direction, namely the reflective teaching theme has got an
emphasis in the dissertation mostly building upon the works of Szivák (2010). Before we talk
about the teacher personality surveys – which touch the territory of personal psychology – we
draw up multivarious personality concepts (McCrae and Costa, 1987, McAddams,1995).
Identity presents as a common theme of social psychology and personality psychology is
(Erikson, 1963). The theme of narrative identity fits in this row (László,2008), as does the
concept of teacher’s professional identity (Korthagen, 2004). Newsy topics among themes of
teachers’ professional identity is the balance of work-private life, or private life-work conflicts
topics, which coloured our work also. On the psychological side we deal with mostly Jungian
personality theories (Jung, 1934/1954). Among these theories, we mention the psychological
types theory, including the extraversion-introversion dimension concept (Eysenck, 1978, Hull,
2011) and the Jungian feminist psychoanalytic studies. We gave extra attention to Jean Shinoda
Bolen (Bolen, 1984/2009) Jungian psychoanalyst archetypes categories and preludes of this.
We show some thoughts from feminist pedagogy literature which focuses on female
teachers and from feminist psychoanalytic literature with a focus on the female psyche. The
critical analysis of the feminist psychoanalytic direction and its thoughts on Bolen’s typology
is also demonstrated. Furthermore, it has shown the founding of the place of female
psychoanalysis among counseling as an applied science by also Enns’s studies which we
mention shortly (Enns 1993, 1994).
The fertilization of the basics of positive psychology and some aspects of school psychology
plays a part in theoretical and practical education, which are both fundamental basements for
the dissertation. Positive psychology examines the state of the psyche from the perspective of
health (Peterson and co, 2000, Csíkszentmihályi, 1997/2001, Oláh 2005), which creates a
balance according to the theories that come from the deficit states.
Piko’s (2010) ideas also gave inspiration to the planning of the research since the theories
and practice of non-traditional mental hygienical supporting factors are important parts of the
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scientific background of our survey. The most significant positive psychological based
researches and theories on the teacher’s traits and the field of education are mentioned also
(Holecz és Molnár, 2014, Kun-Szabó, 2017).
The background literature of the survey has some roots in gender studies as well. They
mostly come from the educational sociology aspect, since important bases of the research are
the studies which pioneer the examination of female teachers’ identity (Thun, 1996, F. Lassú,
2001, Kereszthy, 2005).
Building upon these, the background literature touches on studies from mental hygiene as a
boundary scientific area, which regards the development of burnout examination as the most
important thematic element. We can follow the burnout topic through Maslach and her
colleagues’ examinations (Maslach 1981, Leiter és Maslach, 2016). Applied psychological
research on teachers’ mental hygiene are organic parts of the dissertation too. It worth
mentioning among the Hungarian researchers Petróczy and her colleagues (1999), Ónody
(2001) Paksi and her colleagues (2006, 2015), and from the international literature Seibt,
Spitzer, Druschke, Scheuch és Hinz, (2013), Antalka (2015) examinations.
Next to all of these theoretical strata, we can regard school psychological attitude (Borbáth,
2010) and institutional mental hygiene examinations (Szabó-Jagodics, 2016) as antecedents.
Hypotheses
We presume that just a certain group of female teachers are in a state of fragile mental
hygiene. And this feature refers to the fact that it is not a consequence of the feminization of
the teaching profession. The detailed hypotheses control this assumption, where we are looking
for evidence that the mental hygiene state shows differences between certain groups among
female teachers. In this survey, we measure mental hygiene by the burnout state and the attitude
of life orientation. More differentiation research is made possible by the four-aspect
examination. As we examine the problem, we set one fundamental (H.0.) and five main
hypotheses, next to them we composed some more hypothetical sub statements also.
We are convinced that with proving or disclaiming hypotheses shown hereafter, we can
draw a complex picture about female teachers’ state of professional identity, the elaboration of
their professional identity, and features of their female identity.
Our start point is H.0. We assume fundamentally that the state of female teachers’
professional identity, the elaboration of their professional identity, and features of their female
identity are in connection with their mental hygiene state. Examining our start point we
established some more hypotheses:
H.1. We presume that female teachers’ mental hygiene state is in connection with their life
orientation. We assume that the more optimistic life orientation comes along with the healthier
mental hygiene state.
H.2. Female teachers’ mental hygiene states are different according to their place of living,
/position/spending years in the teacher profession/professional field/qualification.
H.3. We assume also that female teachers with variant archetypal characterization have
different mental hygiene states, life orientation, and professional identity traits.
H.4. Female teachers’ professional identities are different according to their place of living,
/position/years spent in the teacher profession/professional field/qualification.
H.5. We presume that the female teachers’ mental hygiene state and life orientation are in
connection with their professional identity state.
Paradigm and the Framework of the Research

The chosen research paradigm is a quantitative one, based on facts, which comes from
systematic measurement and quantifiable data. The research itself is based on inductive,
conclusion-searching, partly describing strategy, which gets its starting point from the everyday
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reality of school life. Using questionnaires emerged as an adequate methodology of the

research which in the meantime gave us the opportunity for an integrative approach also. The
present survey has planned to examine the transformation of female teachers’ identity and
mental hygiene state. The most expedient way of planning this examination appeared to be by
using two validated and two personal creating questionnaires, as a comparative survey.
We have connected the main two questions of the teachers’ personality research, while we
integrated the question: “what makes a good teacher?” into the question: “how does the process
of becoming a teacher work?” We broadened this direction with the aspects of mental hygiene
and, because in the teaching profession we find mostly women, so we should examine the role
of their female identity elaboration too.
For the examination, we have done the four questionnaires of statistical analysis which
together make up a complex whole, since all of them have grabbed a part of the personality
and the psychological state relevant aspects, like mental hygiene state, life orientation, the
feature of professional personality and archetypes of female identity. For mapping the mental
hygiene state, we used to measure burnout in the validated and broadly applied Maslach
Burnout Inventory Educators Survey (Schwab, Maslach, Jackson, 1986).
For measuring life orientation, we used the also validated LOT-R test, which is a tool
developed by representatives of positive psychology (Scheier, Carver és Bridges, 1994).
To make up an image of professional identity we used an originally developed tool, called
My Professional Identity Questionnaire (SzSzK). To measure female identity type, we created
another tool, called Female Master Teachers and Goddess Within Us (BÉIK).
The statistical analysis of the data we have done by the SPSS statistical program: First we
completed the basics, describing data analysis, and after the normality examination we chose
the Kruskal-Walli’s test for group analysis. We managed post hoc pair comparisons, Chi-
square tests, and cross tables. Furthermore, we completed correlation counting’s also. The
coefficients which cause limitations in statistical analysis are demonstrated also.
Summary of Results and Conclusions

After finishing our examination and its statistical analysis we can state that our starting
assumptions are proved, that the female teachers’ mental hygiene state (by our definition it is
the togetherness of the level of burnout and psychological well-being) are connected with the
extent of elaboration of the professional identity and the female identity.
Our fundamental hypothesis, that if the feminization of the teaching profession is a problem,
then its cause is the missing of freely and authentically lived professional and female identity
– has been proved. We can conclude that for the mental health of the female teachers, they
should develop their professional identity in order to strengthen their identity and deploy their
special female identity or character combination.
Based on our survey which has formed the picture in the examined connection more
complex – we can state that it does not come through in the pedagogical discourse (Buda, 1996)
spread assumption that boys in the feminized school environment ab ovo have suffered in their
psychosocial development because of the lack of the male model in teachers’ role.
We can state that our results according to burnout and life orientation are in harmony with
the current results of national and international surveys. After the statistical analysis, it became
obvious that our detailed presumptions were proven, with some exceptions.
It has completely been proven that the predisposition for optimism and positive
life/orientation is controversially proportional to signs of burnout. We have found cooperation
by spending years in the teaching profession and professional field, but we haven’t picked it
up with qualification and position. We have got indirect affirmation to that fact by choosing
from the archetypes that there are differences in the mental hygiene state of teachers who live
in Budapest or live in the countryside.
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We have significant discrepancies in mental hygiene state among the different age groups
by spending years in the teaching profession.
We pointed out that in the beginner (0-5 yrs) group of the female teachers are the most
optimistic group, and the female teachers in the advanced (6-17 yrs) group have the weakest
mental hygiene state. There are distinctions according to professional fields also: female
teachers in preschools are in the best mental hygiene state and the ones who did not indicate
professional field are in the worst mental hygiene state. This outcome was reinforced by the
fact that preschool teachers tended to choose the mental hygienically balanced Aphrodite
archetype as their type more than another type. On the contrary, the teachers who did not
indicate professional field tended to elect a Persephone type, the archetype famous for fragile
psychological well-being.
In the case of the latter group, we assume identity problems in the background, which is
connected with the character description of the Persephone type, who are challenged with
difficult identity building. She could transform by following her inner development from an
unnamed girl into a wise, experienced woman. In our survey, this transformation was
successful for just a few of them.
Among groups by spending years in the teaching profession, we have found beginners are
in a more balanced mental hygiene state than the other groups. In the background of this
balanced state, we detected several special attitudes and features. One of the beginners’ groups’
strengths is that they do more sport, more open learning from the experienced generation, and
self-reflection is important for them.
It is important to consider that beginners are less receptive to reality than the other group,
which comes across as a mental hygiene protecting factor. There is another element for growing
self-efficiency for the beginners: they have a higher level of digital skills than the other groups
(Gyarmathy, 2012), and this fact can grow their self-confidence and counterbalance their
anxiety comes from the inexperience which is another broad scientific theme (Szivák, 1999).
Some of the outcomes of the research underline the role of the flow experience – as a central
factor – in preserving good mental hygiene and building professional personality as more time
is spent in the teaching profession. These outcomes are the facts, that with the growing years
in the teaching profession the capability for flow strengthens, and which are parallel with the
growing competency and stronger professional identity.
The beginners’ flow experiences during classes are the rarest but they are a mentally
healthier group among teachers, which seems like a contradiction. But, if we thought about that
beginners’ mental hygiene preventive habits and competencies are stronger on the whole, that
many of capabilities for good mental hygiene – such as flow, and the more developed
professional personality – of the groups of veteran teachers and those who have taught from a
long time, we would be disappointed, because the whole picture is even more complex than
this.
Since the elaboration of the professional personality and its elements such as the flow
capability at the class is a good prediction of the stronger psychological well-being. Also,
because the mental hygiene state of the groups of veteran teachers and the ones who have taught
for a long time is clearer than the advanced group’s (who have spent less time in the teaching
profession) mental hygiene state.
The research reveals that the advanced group’s members are in the weakest mental hygiene
state among the groups, according to the comparison of the amount of time spent in the teaching
profession.
We presume that the effects of the work-life balance crisis are the strongest in this group,
and because of that external pressure which becomes internal, the “internal whacker” effect is
the strongest here (Kast, 2012). Furthermore, the optimism of the beginners does not shield
them at this stage anymore. This group recognised the anomaly of the educational field already.
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In addition to this for the workload, the advanced group has the least of all possibilities for
recreational activities. For example, the number of those who take part in sporting activities
drastically decreased compared to the previous group. It is an additional specialty that
beginners are not represented in the burnouts’ group nor the group of female teachers in burnout
danger.
In parallel with this we can say that compared to the other groups, teachers dealing with
children with special needs mental hygiene are healthier. Alike then
kindergarten/preschool/teachers: among them there are none in the burnout group, neither in
the group of female teachers in burnout danger, which is in harmony with the result of Szabó,
Litke és Jagodics (2018). The most balanced values have the group of teachers dealing with
children with special needs and kindergarten/preschool/teacher, whose values originate
ability/possibility of presiding over reality and also to the less set pedagogical tasks.
The reverse can be true in these cases: teaching with less set tasks, with relatively more
freedom and creative opportunity, provides more safety according to mental hygiene and that
is why these areas attract characters with dispositional advantages, primarily the Aphrodite
type. Presumptions of ours that examine the connection between professional personality and
mental hygiene most of them are proved by the statistical analysis of the SZSzK, the MBI-ES,
and LOT-R questionnaires. This result, among several other issues, confirmed implicitly the
validity of the SzSzK questionnaire.
It has been proved, that the forms of openness (pedagogical, psychological, active, and
passive) primarily the openness to psychological themes correlates with psychological well-
being and are inverse relation and/or the marks of burnout syndrome. Our assumption has been
confirmed by analysing the openness factor of the SzSzK questionnaire.
It has been verified that teachers’ /self/ reflective mindset correlates in the other way around
with the marks of burnout and attends signs of psychological well-being.
We certified that the flow /creating/ experience in everyday pedagogical practice correlates
with psychological well-being and are at a reciprocal rate with the signs of burnout, while the
achievement-centred attitude / non-flow / creating / experience in everyday pedagogical
practice are in connection with stronger burnout signs and lower level of psychological well-
being.
Partly it has been attested that the non-traditional mental hygiene protecting factors result
in lower burnout and higher psychological well-being levels. We have got tendencies according
to the facts, that creative and relaxing activities have a protecting effect on mental hygiene. We
have not found proof for the supporting effect of the spiritual attitude.
It has become obvious that the teachers’ harmonious relationships with students and parents
provide better mental hygiene and also, we have found that the presence of pessimism is
stronger in the case of a reality-centered attitude.
We can state that the flowability which contains dispositional elements and complex
capabilities (in our examination this is the capacity to experience flow during a teaching in the
class) is one of the measures of the elaboration level of the professional personality and mental
hygiene. It has been followed by openness (we meant openness for teaching area, educational
methodology, and psychology too); furthermore, sustaining and keeping harmonious work
relations; also operating elements – as many as possible – of reflective working mode.
The child-centred attitude system, the less reality centred approach and the conscious use of
free time for supporting mental hygiene by applying well-known protection factors (sport,
relaxation, creative activities) are all present as a defence for mental hygiene, and at the same
time, they are marks of the maturity of the professional personality. However, the factors which
have been presented as approaching background are not or just loosely connected to their
mental hygiene state, except approaching reality.
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We can declare that the elaboration of the female teachers’ professional personalities is in a
strong connection with the conscious protection of mental hygiene and with psychological
well-being. According to this, we gained data by examining female archetypes and independent
variables.
On the grounds of characterology, the Aphrodite type’s strong flowability has been
presumed. It has been verified that female teachers who prefer the Aphrodite type have the
healthiest psyche, next to the Hestia type who is characterized by conscious self-knowledge
and instinctive meditative abilities. Due to their characterization, the Hera type shows
ambivalent mental health: in self-effectiveness, they are on the top however their level of
pessimism is the strongest, which is weakening the psychological well-being.
We can settle that the representatives of the fragile goddess archetypes in the Bolenian
category system (Hera, Déméter, Persephoné types) are in a lower level of health, moreover
we have found Persephone type in the most fragile mental hygiene state.
We couldn’t gain any significant data about the Demeter type. Due to the Bolenian
categorization, we could imagine Demeter traditionally in the role of the mother or supporter.
The role of the mother corresponds to the teaching area of the schoolteacher; however,
Demeter’s generously supportive side of her character would not fit into this role.
For this reason, these characters are presented among helpers, as F. Lassú és Szarvas (2010)
has found in her research. Another reason for the lack of statistical coherence is in the
organization of data, because we analyzed several groups of teaching areas, and each group has
a low element number.
Besides we have known that the Demeter type’s mental hygiene state is less weak than
Persephone types. Supposedly it is because the Demeter type has less introverted features than
Persephone has.
In the meaning of Bolenian categories, the „virgin” character (Athena, Artemis, Hestia),
means a more independent female character, and in this meaning, they have stronger mental
health which character specification has been affirmed by our examination also.
We confirm the characterization also in that meaning that, as expected, the Pallas Athene
types are the most common among teachers. We can find their representatives in all the
teaching areas. Although this type of mental health is not outstanding however seemingly they
can adjust to the educational field quite well. Adjusting to the world of school is not difficult
for them according to their features of the character, a world is still, considering its main
elements, a world that has patriarchal tradition.
We have little data about Artemis type since they have been presented in our sample with a
limited element number, and supposedly because of that, they feature less significant
connections. By all means, we have found out that the Artemis type doesn’t feel happy being
a teacher, and this reaction is understandable due to their features of the character. Also, their
low element number among teachers is concluded from the Bolenian character features of
them.
We have a mediate inference that there is a connection between mental hygiene state and
extraversion and introversion as background elements. On one hand, we drew our conclusions
from the pattern of preferences of home office work. We presumed that the preference of home
office means more introverted characters, who are in danger of burnout, or who experience less
psychological well-being. On the other hand, we think that the less a teacher is interested in
home office the more we can assume that she has balanced mental health and or she is an
extrovert type.
We presume that in the teaching profession the extroverted disposition is protection for
mental health while the introverted disposition can have a weakening effect if it is not
connected with an aware, conscious self-developing work.
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An exciting outcome of the examination, the feature we have experienced according to my

possibility answers. This answer is more often true with regard to weaker mental hygiene states,
and in the background, we presume procrastination behaviour. While analysing our results we
concluded that procrastinating as an attitude and hesitancy as a disposition attend burnout and
a lower level of optimism, and a higher level of pessimism. These correlations are waiting for
further analysis.
On the whole, our starting assumption has been proved, that female teachers’ mental hygiene
state in our meaning the level of burnout and psychological well-being are in connection with
the level of the elaboration of their professional and female identity.
Namely, female teachers need to develop their professional personality in order to gain a
solid identity, in addition to deploying more and more their special female character, or
combination of character. The fact that both of our personally developed questionnaires –
BÉIK, SzSzK – can produce valid answers has gained mediate evidence.
Further possible directions of our research

We can imagine several alternatives as to the follow-ups for our research. One of them is
following the survey by deep-interview technique in focus groups or repeating it in the school
environment nowadays. Exciting and newsy outcomes can be awaited from personality
examination among female teachers’ by combining Szebedy’s teacher’s character and Bolen’s
female archetypes typology, also validating this new research tool. The research can be the
basis for examinations that are aimed specifically at the ones who are in burnout danger and
the ones who are protected from burnout using the female identity types as a possible aspect
for it. Present research can serve as a base for vocational aptitude examination also.
The dissertation raised the role of the reflective pedagogy knowledge in the connection of
mental hygiene state and spending time in the teaching profession, which needs further
revealing to be a progression element for understanding deeper interrelations.
It would be rewarding to propose and explore the line also which deals with the outcomes
according to female teachers’ idols in the teaching profession. Due to this item of our
questionnaire, the outcome turned out to be that half of the examined female teacher population
do not know these well-known women, all of them were historical, teacher personalities. The
question of who those famous Hungarian and international teacher idols are whose life and
work path are known among female teachers has emerged.
We can suggest further researches in the following themes: the connection between burnout
and procrastination as a mark of depression; hesitancy and its role in burnout or the danger of
burnout; examinations according to extraversion and introversion topic as a possible aspect in
the field of counselling of choosing the special pedagogical area as a profession. An aim can
be raised to develop and validate both of the personally edited questionnaires (SzSzK and
BÉIK).
Finally, one more issue: while planning the research one of my motivations was writing a
specific mental hygiene handbook, supplement for female teachers and this task still has been
waiting for me.
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LET’S TALK ABOUT SEXUAL HEALTH EDUCATION
Abstract
Sexual Health Education must be is on important field of education. The purpose of our
article is to synthesize the diverse aspects founded in the literature of sexual health education.
We conducted a search of the literature on sexual health education and specific results of
subject. We synthetized their information about standards and specific skill elements, teaching
sexual health education, pedagogical, methodological and theoretical approach. During the
workshops organized with teachers, students and parents, the topic of sex education was
debated, the topic giving rise to controversy, especially due to the religious aspect. Important
is the role of parents in sexual health education and finally is important to know the perceptions
of adolescents.
Keywords: sexual health education, teaching sexual education
INTRODUCTION
In Romania, the notion “sex education” has been replaced, in law, with that of “health
education”. There were voices proposing a review of the law that produced this change, that of
having a written agreement with parents for the health education program., in the same tome
the report of Centre for Educational Research and Innovation say “The expansion of school-
based sexuality education in most countries has taken place with a strong focus on conveying
information about sexual and reproductive health.” [1]
Sexual health education the nearly two decades of research Pampati, Johns. M, Szucs, & all
synthesized information to the foundation for future programmatic and research efforts to make
sexual health education more inclusive. [2]
Sexual health education is a systematic, evidence-informed approach designed to promote
sexual health and prevent risk-related behaviors and experiences which are associated with
HIV/STD and unintended pregnancy [3].
Standards and specific skill elements

The United States federal government spent almost 80 million dollars in 2018, funding
mostly “abstinence until marriage” or sexual risk avoidance education programs (Sex
Information and Education Council of the U.S. [4].
In the Developing a scope and sequence for sexual health education, are selected standards
and specific skill expectations by grade for sexual health education from the Health Education
Curriculum Analysis Tool:
Grade 5 Standard 2: Analyze the influence of family, peers, culture, media, technology, and
other factors on health.
Grade 8 Standard 5: Use decision making skills to enhance health.
Grade 10 Standard 3: Access valid information and products and services to enhance health;
Standard 4: Use interpersonal communication skills to enhance health and avoid or reduce
health risks.
The document National Health Education Standards [5] are focused on:
• Core Concept – comprehend concepts related to health promotion and disease
prevention to enhance health.
• Analyzing Influences – analyze the influence of family, peers, culture, media,
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technology, and other factors on health behaviors.

• Accessing Information – demonstrate the ability to access valid information, products,
and services to enhance health.
• Interpersonal Communication – demonstrate the ability to use interpersonal
communication skills to enhance health and avoid or reduce health risks.
• Decision-Making – demonstrate the ability to use decision-making skills to enhance
health.
• Goal-Setting – demonstrate the ability to use goal-setting skills to enhance health.
• Self-Management – demonstrate the ability to practice health-enhancing behaviors and
avoid or reduce health risks.
• Advocacy – demonstrate the ability to advocate for personal, family, and community
health thought of it, if they thought it was true, why?
The standards are also presented by topic strand as follows: Consent and Healthy
Relationships; Anatomy and Physiology; Puberty and Adolescent Sexual Development;
Gender Identity and Expression; Sexual Orientation and Identity; Sexual Health, and
Interpersonal Violence.
The sexual medicine education defined objectives as 3 specific areas, education in all
categories should be integrated to improve retention and learner performance. This education
would involve input from different specialties, particularly by psychiatry, obstetrics and
gynecology, urology, and primary care and supplementary instruction from non-physicians,
like psychologists, public health workers, etc. This would add a diversity of perspective on
human sexuality and demonstrate the intrinsic connection with systems. [6]
Teaching sexual health education

Targeting teachers directly involved in teaching the subjects which include sexuality
education is key. Teachers in close contact with students and families, such as those in
counselling roles, could benefit extensively from training as well. [1]
Schools can use evidence-based strategies such as the provision of instructional materials to
strengthen instructional practices, that can ensure that teachers have access to accurate and age-
appropriate content as well as diverse teaching and learning strategies designed to reinforce
relevant knowledge and skills for students. [7]
Jones, Brener, & McManus have data from a national study of school health policies and
practices that indicate lead health education teachers who received PD included a large number
of general health education topics in their instruction than colleagues who did not receive
professional development. Teachers perceived the adapted curriculum and sexual health
education lessons to be beneficial to their instructional practice [8].
The authors Airtona & Koecher has maddened review of the literature on integrating gender
and sexual diversity in teacher education, 158 publications span 35 years (1982e2017) that
represent a range of genres from research articles – quantitative and qualitative – to teacher
educator reflections and descriptions of exemplars, to impassioned appeals on the need to
incorporate gender and sexual diversity in teacher education. 53 sources grounded their
research problem in studies of gender and sexual minority youth experiences in schools, but
made no substantive connections to teacher education at all. Teacher educators who actively
take up gender and sexual diversity in our courses aim to make the world more hospitable to
the many ways gender and sexuality are lived through a similar trickle-down of our practice
[9].
Pedagogical approach found in the articles are:
• Reading children’s and young adult literature;
• Inviting LGBTQ guest speakers;
• Doing fieldwork or (leading) professional development;
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• Reading LGBTQ-themed fiction and non-fiction;

• Brainstorming and gathering TC prior knowledge or assumptions about gender and
sexual diversity;
• Scenarios, role plays, or simulations (acting or analyzing);
• Guiding TCs in self-reflective writing on their own identities, memories or related
understandings;
• Screening the video, it’s Elementary.
Methodological feature a variety of research methods:
• Mixed-methods;
• Qualitative: Analyzing assignments, analyzing classroom dialogue, Analyzing TCs’
written feedback, Focus groups, Interviews with TCs, Observation, Practitioner
narrative, Self-study.
Quantitative: Measuring changes in self-reported TC attitudes or beliefs, Pre- and/or post-
surveys. Theoretical approach was observed:
• Anti-oppressive education;
• Critical pedagogy;
• Feminist theory;
• Foucault;
• Multicultural education;
• Psychoanalysis;
• Queer theory.
Workshops organized with teachers, students and parents

At “Dimitrie Cantemir” University from Tg. Mures, a series of workshops were held
throughout the university, and the subject of sex education was approached and debated, being
of interest. In this article we will highlight the workshop on-line entitled “Education for
Physical, Emotional and Spiritual WellBeingin april 2021, which attendedence of 92 people.
Mr. Dancila, T with experience in sex education (responsible behavior regarding
HIV/AIDS/STIs at the Education Center 2000+ and volunteering at Ernst-Kirchweger-Haus)
presented the paper “HOW DO WE RELATE TO SEXUAL EDUCATION?”
The paper aims that “in Romania, national policies and programs do not give due importance
to sexual health and this is very seriously reflected in the development of society. The incidence
of HIV/AIDS and STIs, lack of family planning culture and unwanted pregnancies, child abuse
– especially in the family, trafficking in human beings, intolerant and discriminatory climate,
all these problems revealed by extensive studies and statistics place Romania in an
uncomfortable position. People want sexuality education; they demand their rights but the
authorities are not able to provide it. International organizations and EU regulations are pushing
for these shortcomings, but politicians and the church often join nationalist-extremist currents,
citing the loss of Romanian charm and traditionalist identity. The costs are measured in failed
lives, communities that don’t cover their basic needs, stress, disorganization and violence.”
The material makes a foray into the most painful points and urges us to use of scientific
studies and reviews before we positioning ourselves in one way or another towards sexuality
education.
To the question “Who and why rejects sex education in Romania?” four major factors were
presented: 1. the Romanian Orthodox Church, 2. the Romanian Parliament, 3. managers and
teachers in education and 4. parents.
After the presentation the topic of sex education was debated, the topic giving rise to
controversy, especially due to the religious aspect.
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The role of parents in sexual health education

Given the absence of systematic plans to implement personal safety education into the
school systems in Iran, combined with the willingness of parents to discuss personal safety
with their children, the study of Khoori, Gholamfarkhani, Tatari & Wurtele concluded that
parents can play an important role in empowering their own children to protect themselves
either by supporting their child’s participation in a school-based program or by discussing this
topic at home. [10]
In British families, parents are the preferred source of sexual health education for young
people; playing a pivotal role in the formation of their children’s values, attitudes, and beliefs
about identity, intimacy and relationships. [11]
Adolescents and sexual health education

Using cross-comparative national results, the study of Iordanescu, Iordanescu & Draghici
emphasis that in 2006 the percentage of 15 years Romanian adolescents already having sexual
activity is lower than in Greece, Bulgaria, Denmark, but higher than in Italy, Slovenia and
Hungary. [12]
In article of Corcoran, Davies, Knight, Lanzi, Li & Ladores the adolescents offered
reasonable suggestions regarding the characteristics of a good sexual health education program;
discussed the essential characteristics of the educator, the environment, the timing, and the
education to create a good program. The factors that influenced adolescent perceptions of
school-based sexual health education programs were: age, study type, gender, and educational
content. The recommendation of authors is “the need for education systems to consult with
adolescents about their educational preferences when developing and delivering sexual health
education.” [13].
Alford, S., & Feijoo, A. S have considered that European adolescents have easier access to
birth control than U.S. adolescents, and the European society as a whole has a more normative
view of adolescent sexuality than in the U.S. [14].
CONCLUSIONS
Zhe Zhang, Alexa Solazzo, Bridget K. Gorman considered there “is much room for future
work in this area, including why education functions as a resource substitution, resource
multiplication, or neutral resource for different groups, and how a person’s specific
intersectional identity (based on gender, sexual orientation, and other social positions) may
influence education’s association with health. As women have become an increasingly large
part of the college-educated population, and sexual minority adults experience broader
acceptance, researchers should also seek to understand if education’s relationship with health
differs based on time period or region studied”, also suggests that “the relationship between
education and health may depend on the intersection of gender and sexual orientation among
U.S. adults.” [15].
Analyzing 35 papers that met the inclusion criteria: “most age at first sex, age at first
marriage, age at first pregnancy/birth, contraceptive use, fertility, and HIV status and other
sexually transmitted infections”, the authors Psaki, Chuang, Melnikas, Wilson, & Mensch
“demonstrates that, although investments in schooling may have positive ripple effects for
sexual and reproductive health in some circumstances, those effects may not be as large or
consistent as expected, nor understanding of the circumstances in which schooling is most
likely to improve sexual and reproduction health remains somewhat limited”. [16]
Education systems and schools are uniquely positioned to influence sexual health education
delivery. Schools must listen to the voices of adolescents and provide comfortable
environments for the facilitation of sexual health education and train sexual health educators
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to deliver non-biased, non-judgmental education. Education programs must acknowledge that

no one sexual health program will meet the needs of all adolescents. [17]
Among parents, teachers, and others, there is still enormous discomfort in providing
sexuality education that is truly comprehensive and contraceptive services, especially to
unmarried adolescents. [18]
Sexuality education needs to account for the views of students themselves if the aim is to be
respective of their rights and effective for their needs [19].
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3RT INTERVENTION ON COGNITIVE DISTORSIONS REGARDING THE

JUSTIFICATION OF SEXUAL OFFENDERS
Abstract
Mean-making is a very complex process, involving social, moral and psychological aspects.
When it comes to trauma or crimes, the ability to “make sense” of the events and to find
meaning in the midst of chaos is associated with greater psychological resilience (Chan et al.,
2006). However, when it comes to sexual offenders, the existence of a usual stuck-point in
mean-making. Specifically, given the many levels of the crime the offender is usually not able
to access all these levels, as some are deeper than their awareness. At that moment, the talk
therapy and cognitive behavioral therapy for developing adaptive skills are crucial, as they
have to create a safe context, in which the person can think freely and explore their inner world.
Keywords: talk therapy, CBT therapy for sexual offenders, forensic psychotherapy in forensic mental health
INTRODUCTION
Psychotherapy and the field of mental health can not be disentangled from the topic of the
human language. Specifically, the development of emotion regulation skills is very much
dependent on the verbal abilities of the subject, as scholars have suggested that they influence
each other (Cole et al., 2010). Many times, the therapy process is centered around finding the
meaning of a traumatic experience, though talking about it. More so, a useful therapeutic
technique is the verbal articulation of the patient’s inner struggles, as noticed by the therapist.
This process is not just a way of improving the therapeutic relationship through validation
and expression of empathy but is, in itself, a therapeutic tool. By naming the emotions that the
client is experiencing, the therapist shows that the emotion is nothing to fear. The patient
suddenly sees that the “entity” they have been dealing with has a name, and, therefore, it
becomes more tangible and manageable.
The question that arises then, is one of both practicality and ethics. The authors wonder
about the efficacy of the therapeutic process, when the talking aspect of it is contaminated by
doubt and fear and even lack of basic trust (i.e that the person sitting in front of you will not lie
throughout the conversation). The matter of ethics is also implied in the authors’ question “How
can we provide psychotherapy if we assume that the patient is not up for the task?”. In such
instances, one might wonder if talk therapy is, indeed, the best course of action for offenders
and the most efficient way of providing help. If such important doubts arise, it is our duty, as
academics and practitioners, to clarify the utility of those methods, before arguing in their
favour.
The first part of Chapter 11 from Forensic Psychiatry and Psychology in Europe (Goethals,
2018) deals with the aspect of language when it comes to Forensic psychotherapy. It is a well-
known fact that the outcome of therapy is dependent on the therapeutic relationship (Lambert
& Barley, 2001). This relationship is based on mutual trust, as well as unconditional acceptance
and the expression of empathy. When it comes to Forensic psychotherapy, the authors wonder
how much of that relationship can be built through talking and how easily a therapist can
develop trust when it comes to a patient that has committed crimes. Another issue that arises is
how much an offender can trust the therapist, given their negative experiences with authorities
and the possible consequences of admitting to the committed crimes. The topics addressed by
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offenders are often difficult for them to talk about. A phenomenon that may happen is the
distortion of the events by the offender (i.e., by minimizing the offence or by attributing more
fault to the victim).
In the anecdote presented by Koenraadt, McGauley, & Willemsen (2018), regarding the
psychiatrist’s bias, the misunderstanding arises from the words chosen by the offender to
describe his crime. When it comes to certain therapy protocols (i.e., for treating Post Traumatic
Stress – PTSD), an important aspect is the creation of a comprehensive, coherent and detailed
narrative of the client’s life story or trauma. In exposure therapy for PTSD (Rauch & Foa,
2006), for example, the patient is required to retell the story of the trauma over and over, as
well as to listen to tapes of them telling that story! The mechanism of change is the repeated
exposure to those stimuli that once presented themselves as so horrifying that the client would
not be able to face them. This exposure is facilitated by the “simple” act of talking. Many of
our patients have never had anyone that they could openly talk to about their feelings, no one
to help them sort their tangled ideas and make sense of them. Talking is, then, a curative process
in many therapeutic instances. Let’s take coaching for example. We ask our clients to elaborate
their goals, we ask them to specify their wishes and values in great detail, in order to create an
action plan and a path to a satisfying life. The chapter’s authors mention the importance of
stories and narratives in finding meaning and orienting ourselves in the world. The ability to
make the inner world explicit is, therefore, a crucial element of psychotherapy.
The use of narratives to create meaning is also used in Forensic psychotherapy. The stories
told by offenders are closely linked to the issue of morality. When creating a story of the crime,
the offender has to first think about what they did wrong and then analyse the causes and effects
of that wrongdoing. In order for that to happen, moral judgment plays a central role. The
authors suggest that the distortions in the stories of offenders (i.e., attributing blame to the
victim, minimizing the crime) could be a phenomenon of cognitive nature, rather than assuming
that this tendency is personalitybased. The authors imply that such distortions may represent a
defense mechanism, as studies have shown that taking full responsibility for our dysfunctional
behaviour could be detrimental to one’s mental health. In dealing with other kinds of issues
brought by our clients (besides crimes), we often encourage them “to see the bigger picture”
and to give up black-and-white thinking, in favor of a more nuanced way of viewing things.
We rarely ask clients to take full responsibility for something that has happened to them,
partly because that would be too much to tolerate! When it comes to offenders, by contrast, we
want them to suddenly and quickly give up all defense mechanisms and fully accept their fault.
That is very unlikely to happen. Talk therapy is useful in this area for analyzing moral
problems and possible solutions from perspectives other than that of sex offenders, in order to
replace attitudes and cognitive distortions about moral reasoning and justifications for crime.
When considering the motives of the crimes, the authors suggest the crime needs to be
understood in the context of the patient’s life and can not be untangled from it. Freud believed
that human behaviour is motivated by two drives: the sexual drive and the aggressive drive. He
believed that the fuel for behaviour is the wish to satisfy the sexual and aggressive instincts.
which are, for the most part, repressed into the unconscious. However, these drives are
embodied, in the sense that they are acted out in the world by the body. When it comes to
offenders, these drives usually begin to manifest early on, as the person shows aggressive
tendencies throughout their life. This culminates with the act of the crime. The authors claim
that the moment of the crime is the moment when the repressed and hidden parts of the person
express themselves clearly, surpassing the self-defence mechanisms that had repressed them.
However, since aggressive and sex drives are usually unconscious, it is very difficult for the
person to fully articulate the motive of their crime.
Regarding the history of Forensic psychotherapy, the approach used to be very rigid, at least
in the Netherlands, the authors suggest. That is until the Utrecht Dr. H. van der Hoeven hospital
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was created. The new approach was based on Maxwell Jones’ idea to practice psychotherapy
in small groups. He encouraged the hospital “to work as a therapeutic community”. That is, a
community that relies on open communication and shared leadership. Therefore, the stigma
associated with being a patient is decreased. As time passed, more hospitals embraced this idea.
The community, as a therapeutic instrument, fosters a sense of safety and encourages the
patients to disclose their experience with the staff member and other patients. Using this
approach allows the patient to interact with the demands of external reality and practice new
behaviours in a safe setting (as opposed to being institutionalized). The hospital becomes a
center for reintegration.
Although cognitive-behavioural approaches are dominant in the field of Forensic
psychotherapy, the psychoanalytic notion of the unconscious mind and its roles in the crime
act adds another dimension, thus facilitating the understanding of the offence. The authors
suggest that the inner worlds of forensic patients are often marked by fragmentation and lack
of cohesiveness.
Given the large number of sex offenders in criminal justice systems, the need to outline
effective interventions to reduce the likelihood of sexual recidivism has been emphasized
(Becker, Harris & Sales, 1993; Marshall, 2001; Pitherii, 1993). The meta-analysis by Losel and
Schmucker (2008) emphasized the positive effect of psychological treatments in reducing
sexual recidivism. This meta-analysis included 69 studies (N=22,181 sex offenders),
comparing the recurrence rates of sex offenders who received treatment (N=9,512) with those
who did not receive such programs (N=12,669). Also, the intervention programs based on
cognitive behavioral therapy had the highest levels of efficiency compared to other types of
psychosocial programs.
The main purpose of cognitive-behavioral interventions for sex offenders is to replace
maladaptive cognitions and deviant sexual behavior with maladaptive beliefs and prosocially
oriented behaviors. In this sense, it also aims to acquire new skills and specific strategies for
solving problems, improving social perspectives and managing emotional states (Yates et al.,
2000; Becker & Murphy, 1998; Marshall et al., 1999). Cognitive distortions are the main factor
that favors the appearance of sexual aggression, because they allow to reduce the cognitive
dissonance, to reduce the responsibility and the guilt felt towards the committed deed. Thus,
the main mechanism behind deviant sexual behavior is the justifications for sexual crime
(Nicholaichuk et al., 2000; Johnston, & Marshall, 1997). The main distortions identified in the
case of sex offenders are attributing the guilt of the victim, minimizing the damage caused and
rationalizing the sexual assault (Feild, 1978).
The main purpose of therapy for sexual offenses is to reduce a person’s likelihood of re-
engaging in such behavior. There is currently no “gold standard” for dealing with sex crimes.
3RT (Recidivism Risk Reduction Therapy) describes a cognitive-behavioral approach
focused on behavior in sexual crime (Wheeler & Covell, 2005, Wheeler, George, & Stephens,
2005a, Wheeler, George & Stoner, 2005b). Regarding sexual offending behavior, dynamic risk
factors appear to be associated with one of two broad categories: deviant sexual interests and
antisocial orientation (Hanson & Morton-Bourgon, 2004; Hanson & Bussière, 1998; Bakker,
& Ward, 2002; Quinsey, Lalumiere, Rice, & Harris, 1995; Roberts, Doren, & Thornton, 2002).
3RT explicitly includes dynamic risk factors (DRF) as the dominant framework for the
treatment of sexual offenses. Dynamic risk factors refer to those aspects of the client’s
environment, lifestyle or personality that are statistically associated with an increased risk of
recurrence and may change.
The main objective of the research is to investigate the effectiveness of 3RT intervention on
cognitive distorsions regarding the justification of sexual offenders.
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Hypotheses
1. The experimental group that will benefit from the 3RT intervention will have
significantly lower scores of the victim’s guilt compared to the control group (waiting
list).
significantly lower scores of minimizing the harm caused to the victim compared to the
control group (waiting list).
significantly lower scores of rationalizations of sexual assault compared to the control
group (waiting list).
Method
Design
The study design is an experimental one, being an efficiency study.
Participants
The criteria for including participants (N=64), according to Gpower, are the following: to
be sex offenders in liberty, to be over 18 years old, to participate voluntarily. They will be
randomized into two groups (the intervention group vs. the control group represented by the
waiting list).
Measures
The measured variables (pre-intervention, post-intervention, follow-up) are the score of
cognitive distortion regarding the attribution of the victim’s guilt, the score of cognitive
distortion regarding the minimization of the caused damage and the score of cognitive
distortion regarding the rationalization of sexual aggression.
Attitudes Toward Rape Victims Scale (Ward, 1988) and the Burt Rape Scales (Burt, 1980)
will be used to measure the cognitive distortion score related to attributing the victim’s guilt,
RAPE Scale(Bumby, 1996), and The Abel and Becker Cognitions Scale (Abel et al., 1984)
will be used to measure the cognitive distortion score related to minimizing the damage caused
and Rape Myth Acceptance Scale (Payne, Lonsway, 1999) and Justifications Scale of the
Multiphasic Sex Inventory (Nichols & Molinder, 1984, 2000; VRS-SO: Wong & Olver, 2010)
will be used to measure the score of cognitive distortion related to the rationalization of sexual
assault.
Procedure
The experimental group will be given the intervention Recidivism Risk Reduction Therapy
(Wheeler, George & Stoner, 2005) (3RT) for 9 months to reduce the number of cognitive
distortions regarding the justification of sexual offenses. The control group will be represented
by the waiting list for 9 months. Measurements of dependent variables will be recorded at the
beginning and end of the intervention and follow-up at 6 months. For statistical analysis,
unifactorial ANOVA with repeated measurements will be used.
Description of 3RT intervention

Recidivism Risk Reduction Therapy (Wheeler, George & Stoner, 2005) comprises three
phases: (i) pre-treatment, (ii) treatment and (iii) post-treatment. The primary mechanism of
change occurs during the treatment phase, while the pre- and post-treatment phases are
designed to prepare for effective treatment and to develop strategies to prevent recurrence.
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The “pre-treatment” phase involves an assessment period in which the client’s characteristic
dynamic risk factors are identified and conceptualized as a “cluster” of thoughts, emotions,
problem behaviors, and these problem behaviors become the focus of therapeutic change. Once
a client’s DRFs have been identified and conceptualized as problematic behaviors, the goal of
the 3RT treatment phase is to teach clients how to replace their maladaptive thoughts and
behaviors with adaptive thoughts and behaviors (skills training).
1. Pre-treatment phase
Before starting the intervention, all patients participate in the pre-treatment phase for about
4-8 weeks. The objectives of the Pre-treatment phase are: (i) obtaining the client’s informed
consent to participate in the treatment; (ii) identify the resources that should be allocated to
each client based on the recidivism assessment; (iii) assessing customers’ dynamic risk and
response needs; (iv) conceptualizing the history of customer crimes in the broader context of
their global operation; (v) formulation of the language treatment plan (to address the specific
strengths and limitations of each client); and (vi) motivating customers to content and process.
Input evaluation
Assessment of dynamic risk needs

Main purpose is identification of stable DRFs of customers. DRFs are used as a guiding
conceptual framework for describing problematic client behavior and formulating treatment
goals. There are numerous resources for assessing DRF associated with general criminal
recidivism (e.g., service inventory level – revised: Andrews & Bonta, 1995; Psychopathology
Checklist – revised, second edition: Hare, 2003; revised): American Association of Psychiatry,
2000, Scale of Risk of Violence (VRS): Wong & Gordon, 2001, IORNS: Miller, 2006) and
Sexual Recidivism (SONAR Hanson & Harris 2000b; 2007 and Acute-2007: Hanson, Harris,
Scott and Helmus, 2007; Multiphase sexual inventory: Nichols & Molinder, 1984, 2000; VRS-
SO: Wong & Olver, 2010). DRFs for recidivism of sexual offenses fall into one of two areas
that are associated with “sexual deviance” and/or “antisocial behavior”. In 3RT these two broad
areas are called erotopathic risk needs and antisocial risk. Each of these areas contains
subcategories that describe the types of thoughts, emotions, and problem behaviors that
characterize that area. Each subcategory includes many factors, each of which can be
conceptualized as DRF that can be targeted in treatment.
The need for erotopathic risk refers to any thoughts, feelings, behaviors, and relationships
that are associated with the client’s problematic, inappropriate, or otherwise maladaptive
sexual/romantic relationships. The erotopathic domain is divided into three categories. The first
deficits in sexual self-regulation include the risk needs related to the deficient expression of
sexual impulses. The second lack of intimacy refers to the ability to form and maintain close
and intimate relationships with sexual partners of the same age. The third attitude that supports
the sexual crime is the one that excuses, allows or condemns such behavior, including
justifications, rationalizations and minimizing the consequences of the crime.
Orientation sessions
3RT covers a wide range of topics to help clients understand what to expect from treatment
and why treatment will be beneficial to them. The purpose of these groups is to help clients
understand that treatment is not something that happens to them, but is a process in which they
are active participants and collaborators. These explanations lead to the active involvement in
the client’s therapeutic process, increasing the credibility of therapists and strengthening the
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therapeutic alliance. Topics in the guidance include: the history of sexual offenses treatment,
an overview of dynamic risk factors, CBT and DBT.
Orientation sessions can be conducted individually or in groups, depending on available
resources and customer response needs. Because these groups are psychoeducational in nature
and patients are not required to disclose personal information, guidance groups may be
“mixed”; that is, two or more clients could be placed together in a target group, regardless of
clinically significant differences in their history of crime, demographic characteristics,
dynamic risk factors, etc.
2. Treatment phase
The treatment phase uses CBT interventions focused on the acquisition of skills and their
generalization, in order to target dynamic risk factors. Dynamic risk factors are used in
conceptualization and the main goal of the treatment phase is to eliminate them. In other words,
by the end of the treatment phase, clients should have developed new ways of thinking and
behaving that would be expected to mitigate the risk of repeating them in the future. The
treatment phase includes two therapeutic modalities: skills training sessions and individual
therapy sessions.
Training skills in 3RT: Conceptualizing DRF as skills deficits

In some traditional approaches to the treatment of sexual offenses, emphasis has been placed
(clearly) on attracting clients to stop exposing problematic thoughts, emotions and behaviors
(eg, stop your deviant fantasies). In 3RT, the goal of all treatment interventions is to
reduce/eliminate problematic behavior and replace it with adaptive behavior. If the client does
not learn and practice a new response, it is expected that his old behavior will recur, especially
when the client is under pressure or a state of increased arousal (e.g., anger, sexual arousal).
During the treatment phase, clients participate in two rounds of training in cognitive-
behavioral skills (for European and antisocial needs). Each competency training round lasts
approximately 6 months and is organized into four problem-solving skills training modules: (i)
thoughts, (ii) emotions, (iii) behaviors and (iv) relationships. In this study, attention is paid to
the pathophysiological needs, so there will be a single round of skills training. Similar to the
orientation sessions provided in the Pre-Treatment phase, the skills training sessions are mostly
didactic, and clients do not have to disclose personal information about their history. These
sessions are practical psychoeducation rather than a therapy group. However, they are
integrated into therapies, as these sessions are a vital aspect of facilitating prosocial change
through modeling.
To facilitate this boundary between individual therapy sessions and skills training sessions,
it is very important that competency training sessions be as separate as possible from individual
sessions. This separation can be accomplished in several ways, such as using a skill trainer who
is not the individual therapist, holding competency sessions on a different day/time than
individual sessions, or holding competency training sessions on a different day. room than the
therapy office. Skills training sessions can be conducted in individual or group formats,
depending on available resources. These should be “closed” groups, so that all members of the
group start and finish each module together (because each session is based on what was covered
in the previous session). The members of the new group could join an existing group at the
beginning of each of the four modules. Training sessions can be led by a therapist, but if there
are adequate resources, it is recommended that these sessions be organized by a skills coach
(or, ideally, two competency trainers per group). 5 or 6 weeks are allocated per module, which
means that all four modules will be completed in about 6 months, assuming weekly sessions.
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Adapting DBT skills training for 3RT

A useful set of skills training techniques are those provided in the Skills Training Manual
for Dialectical Behavioral Therapy (DBT, Linehan, 1993). DBT has demonstrated empirical
success in reducing the maladaptive behaviors of people with borderline personality disorder
(Linehan et al., 1991), and with other clinical populations (Dimeff & Koerner, 2007). More
recently, increased attention has been paid to the applicability of DBT skills to the treatment of
sexual offending behavior (Hover, 1999, Hover & Packard, 1998, 1999; Wheeler et al., 2005b).
In addition, Quigley (2000) and Shingler (2004) provide a detailed analysis of the theoretical
and practical compatibility between DBT treatment and sexual offenses.
DBT models address treatment needs that are directly relevant to DRFs associated with
sexual offending behavior, including problematic thoughts (“deviant” sexual fantasies,
antisocial attitudes, attitudes that support sexual abuse, sexual rights) sex/arousal, loneliness,
anger/hostility, suspicion/mistrust), problematic behavior (sexual
dysregulation/hypersexuality, use of sex as a coping strategy, aggression/violence, impulsivity,
antisocial behavior, substance abuse, unstable/parasitic lifestyle, breaking the rules) and
problematic relationships (emotional identification with children, instability/lack of romantic
relationships, intimacy deficits, social isolation, proximal relationships with peers with the
same traits and lack of concern for others).
Specifically, it is recommended that the first round (approximately 6 months) of skills
training in 3RT involve “standard” training in DBT skills, without mentioning in particular the
specific treatment needs of sexual offenses. For clients who have difficulty discussing or
openly admitting their deviant sexual behavior, or for clients who may be resistant to
participating in sex-specific therapy, the motivational interview may be used to be willing to
make changes in their lives, but not they are still ready to solve their specific needs. It can
facilitate changes in attitudes or tolerance towards vulnerability, which allow a willingness to
explore more directly and/or address issues specific to sexual deviance and risk needs.
Sex-offense-specific skills training

Despite its theoretical and practical compatibility with the needs of this population, DBT
does not address some of the specific treatment needs of clients who have engaged in sexual
offenses. For example, DBT does not specifically include interventions to manage
problematic/antisocial sexual thoughts, emotions, and behaviors. Therefore, 3RT includes a
skills training program that is based on DBT skills training, but specifically modified to meet
customers’ dynamic risk needs. As previously described, erotopathic risk needs (i.e.,
maladaptive sexual/romantic behaviors) and ansocial risk needs (i.e., maladaptive social
behaviors and lifestyle) form the foundation of skills training sessions. Thus, skills training
sessions are taught through the Competence Handbook for Dialectical Behavior Therapy
(Linehan, 1993), aided by additional teaching notes, discussion points, and activities
specifically designed to address these types of dynamic risk factors. Clients can be assigned to
one or both types of skills training sessions.
3RT-E skills training sessions

In erotopathic 3RT (3RT-E) skills training sessions, clients learn arousal monitoring skills,
reduce problematic thinking patterns, and replace these maladaptive thoughts and behaviors
with more effective methods of self-monitoring and regulation. sexual. Clients develop skills
to develop and maintain adaptive, satisfying intimate relationships with partners of similar age.
(Hanson et al., 2007), the following stable erotopic dynamic factors were associated with an
increased risk of sexual recurrence:
• Deviant sexual interests (sexual interest in children, any paraphilic interest, sexual
concern);
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• Deviant sexual preferences (any deviant sexual preference, sexual preference for
children);
• Lack of romantic partner (no relationship or history of unstable relationships);
• Deficiencies of intimacy (loneliness/social isolation, emotional identification with
children, conflicts with intimate partners);
• Attitudes that support sexual offenses (attitudes that support rape, attitudes that support
sexual offenders, sexual rights).
When conceptualized as deficits, we need to direct the client to develop skills to maintain
satisfying and prosocial intimate/sexual relationships. The purpose of the 3RT-E competency
training groups is to help clients develop at least some of the skills described below. To improve
sexual self-monitoring skills, participants learn skills to monitor their own arousal processes
(sexual thoughts, subjective arousal, sensory perceptions and physical sensations) and
objective perception of stimuli in their environment (description of sexual stimuli without
interpretation or judgment). These skills are specifically designed to target maladaptive
patterns of sexualized thoughts and behaviors that contribute to inappropriate sexual self-
regulation of offenders and to replace them with more effective methods for sexual self-control.
To improve their sexual/emotional regulation skills, participants learn skills to identify,
label, monitor, and control their sexual impulses, as well as the emotions inherent in engaging
in romantic relationships (jealousy, insecurity, mistrust, anger). Participants learn to monitor
sexual arousal and other physiological reactions and then label them. They also learn to reduce
their vulnerability to certain emotional states, including sexual arousal as desirable. To reduce
the misuse of sexual thoughts and behaviors as a coping strategy, participants learn skills to
identify their maladaptive sexual adaptation strategies and replace them with more effective
coping techniques. In addition to developing skills for acute coping responses, 3RT-E skills
include a broader focus on how to reduce overall stress in the client’s life, by increasing the
number of behaviors (non-harmful and non-sexual) that the client engages in. finds them
enjoyable or rewards them in some other way. To diminish romantic/sexual relationships and
their interactions, clients learn and practice the skills to engage in prosocial interactions and
intimate relationships. Ideally, these skills directly target those skills needed to form and
maintain healthy romantic relationships (dating, ending relationships, building intimacy,
obtaining mutual consent). These skills are modeled and repeated in groups (in role-playing
games) and in vivo (through home missions or group trips).
3RT: Individual therapy sessions

The purpose of individual therapy sessions is to provide clients with the opportunity to
address their specific needs in terms of risk and to apply the skills they learn for their
functioning (using weekly diary books, activity diaries). In addition, individual sessions
provide a format for clients to address significant life events and crises as they occur (and
conduct functional analysis of problem behavior) and opportunities for behavioral rehearsals
and feedback (i.e., role-plays).
A therapeutic activity/intervention that actually takes place during individual sessions is a
functional analysis of a client’s problematic behavior. Specifically, the client can learn in depth
the thoughts and emotions associated with their behavior and how each one interacts. This
information is essential to help clients understand their own vulnerabilities and identify
intervention needs.
Another therapeutic activity that best suits individual sessions is the creation, assignment
and subsequent review of home practice activities (activity journals). Each week, the therapist
reviews what important competencies the client is focusing on and develops activities to
increase the client’s opportunities to practice these skills between sessions. The activity is
clearly explained to the client and is explicitly related to their treatment needs. Before
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concluding the session, the therapist and client engage in certain prevention issues to identify
possible barriers to completing assignments and how they can be minimized or completely
eliminated. Most importantly, therapists then review the client’s progress toward completing
this activity in the next therapy session, while continuing to address any barriers to completing
assignments and implementing/practicing skills outside of formal treatment sessions.
An example of practicing home skills that therapists can assign each week is an activity
card/journal. These are sheets that identify each day of the week and specific tasks to be
recorded or documented daily. For example, therapists may ask clients to keep track of the
skills they use each day, how they spend their time on an hourly basis, or to record the
frequency of their sexual thoughts and behaviors (e.g., an “arousal diary”). The purpose of
these journals should be clearly explained to the client and the journals should be reviewed
with the client in the next session. For some clients, the purpose of keeping such records may
be to help them develop a more accurate assessment of how often they engage in certain
activities, while for other clients it is possible to increase responsibility for how they engage. I
spend time. What is most important is that the therapeutic rationale for keeping the journal is
clear to the client and that the journal is reviewed after it has been completed.
3. post-treatment phase
In 3RT, the post-treatment phase can be performed in the form of weekly individual sessions
or in the form of facilitator-led groups (4 weeks). This stage may involve less time face to face
with therapists. Community transition planning applies to clients participating in community
treatment. This phase can integrate other adjuvant groups, services and interventions. The two
main objectives of clients in the post-treatment phase are: (i) to finalize a PR Plan that includes
their acute DRFs and (ii) to identify the basic logistical needs of the community (and/or away
from professional support and supervision); and their community transition plan to meet these
needs (residential, employment, financial, social/emotional). Clients should be provided with
sketches and guidelines for the completion of both the PR plan and the Community transition
plan, and the differences between each plan should be clearly explained. Creating a routine and
a structured day is a therapeutic instrument used with all kinds of patients, as it is well-known
that having a purpose is associated with well-being (Reker, 1989).
Outcomes
Following the validation of the intervention in other studies (Wheeler & Covell, 2005;
Wheeler, George, & Stephens, 2005a; Wheeler, George, & Stoner, 2005b, Tafrate & Mitchell,
2013), a priori we expect that the experimental group that benefited of 3RT intervention has
significantly lower scores of victim attribution compared to the control group. We also expect
that the experimental group that benefited from 3RT intervention has significantly lower scores
of minimizing harm to the victim compared to the control group, and that the experimental
group that benefited from 3RT intervention has significantly lower scores of rationalizing
sexual assault. compared to the control group.
Limits and future directions of research

In the case of Recidivism Risk Reduction Therapy (Wheeler & Covell, 2005) with sexual
offenses, the notion of completing treatment is complex, primarily because patients who will
be released during the program will artificially stop treatment. Terms such as graduation and
completion can be misleading, contributing to the false impression that therapy is like a “class”
with a clear beginning and end and/or that there is a fixed and terminal nature of a client’s risk
and ability/need to change so that they are no longer at risk of engaging in sexual behavior
problems.
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Indeed, clients’ progress, their change, and the nature and extent of their individual risk
needs vary and are influenced by their current circumstances. Consequently, we are aware that
changes will continue to occur with clients and that they will encounter or create situations and
circumstances that are risky for them, which may require a return to treatment.
CONCLUSIONS
When it comes to practice, an advantage of Forensic psychotherapy’s psychoanalytic

influences is the fact that it provides a framework through which practitioners can better
understand the offenders. By looking at the crimes through a psychoanalytic perspective and
talk therapy for offenders’ perspective, the practitioner can help the patient understand the
unconscious motives of the crime, as well as the way in which these unconscious drives shape
and influence the environment around the offender.
It is also known that cognitive behavioral therapy is the best scientifically validated
therapeutic approach for inmates. 3RT is a cognitive-behavioral approach to treating sexual
crimes. 3RT uses dynamic risk factors as an organizational framework for treatment planning
and delivery and draws on existing CBT techniques, such as DBT skills, to target these risk
factors. 3RT is an extremely flexible approach, which can be easily adapted to the needs of
clients, including adults and minors, men and women, in hospitals and outpatients. In this way,
3RT offers therapists a direct and empirical approach derived to reduce the risk of recurrence
in patients with a history of sexual offenses.
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SYMPTOMATOLOGY OF RECONSTITUTION OF TRAUMA IN ADULTS WITH A

HISTORY OF CHILDHOOD SEXUAL ABUSE. AN APPROACH FROM THE
PERSPECTIVE OF SONapp APPLICATION
Abstract
Adults with a history of childhood sexual abuse often experience symptoms derived from
lived traumatic experiences, which are analogous to many of the criteria of diagnosis of
Borderline-Personality-Disorder (BPD) but also with those of stress disorder post-traumatic
stress disorder (PTSD). We will briefly examine these symptoms in the context of a framework
trauma, to conclude later whether symptomatic behaviors may be indicative more accurate for
a post-traumatic response, especially in terms of behavior reconstitution or re-experience of
trauma. Recognition of self-harm behavior or masochistic tendencies in adult survivors of
sexual abuse trauma as an attempt to reconstitution of sexual trauma suffered in childhood,
rather than as a manifestation characteristic of personality disorders, serves to establish an
appropriate diagnosis, mental health professionals can continue to focus on the consequences
of trauma unresolved sexual issues rather than personality restructuring. (Standardized
intervention model SON, Delcea C., 2019) Thus, seek to We understand clients in a trauma
setting can provide a more objective treatment climate and can minimize the stigma that may
result potentially from making an inappropriate diagnosis borderline personality disorder
(BPD).
Keywords: childhood sexual abuse, sexual abuse trauma, personality disorder borderline, BPD,
Post-traumatic stress disorder, PTSD, trauma recovery, re-experiencing trauma
INTRODUCTION
In recent years, the professional literature has dealt with the similarities and differences
between BPD and post-traumatic stress disorder (PTSD) (Hodges, 2003; Murray, 1993) in an
attempt to etiologically differentiate and discover effective treatment methodologies. Miller
(1994) suggested that BPD could be misdiagnosed in survivor’s sexual abuse. Rather than a
diagnosis of BPD, the client’s symptoms could accurately reflect a diagnosis of PTSD in
particular in PTSD clients who show specific symptoms of trauma recovery. Freud (1920)
suggested that survivors of traumatic events may develop this way called traumatic neurosis,
the consequence of which is the compulsion to always repeat elements of the traumatic event.
Like Freud’s concept, Miller (1994) postulated that adult survivors of childhood sexual
trauma who engage in harmful and risky behaviors, such as sexual promiscuity, abuse of
substances, which encounter difficulties in interpersonal relationships, try to actually
reconstitute symbolic behaviors of childhood trauma.
Types of trauma reconstructions in which these individuals engage may be:
1. behavioral (harm to oneself or others);
2. self-destructive (subconscious sabotage of situations so as to lead to feelings
revictimization);
3. re-experimentation (flashbacks).
Theoretical aspects
Several theories try to explain the etiology of these recreational behaviors or reconstitution
of trauma. One of them was proposed by van der Kolk (1989). He postulated that at these
individuals developed a behavior of dependence on the traumatic experiences they suffered and
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as therefore, they might try to recreate it (for example, a victim of sexual abuse in childhood
could become a prostitute). Such individuals have reported feeling flattened, agitated and even
anxious when not experiencing some form of derived activity from their trauma. Miller (1994)
suggested that this need for arousal may be an impulse for trauma recreation behaviors. For
children who have experienced trauma, these experiences have become synonymous with
relationships and the child is often in a constant state of hyperactivity due to fear, anger,
hyperalert or anxiety. This state of hyperalert or constant hyperactivity has a major impact on
the child’s biochemistry and inhibits his recovery at initial homeostasis. Thus, as adults,
individuals may become addicted to painful emotions, however, for them it is somewhat
pleasant and comforting (for example, dependent people watching movies or soap operas with
dramatic or tragic action).
Moreover, van der Kolk (1989) reported that high levels of stress activate opioid systems in
the brain. Just as drugs can activate and create these systems a cycle of activation and
depression, as could the hyperexcitation that is created due to trauma. Self-harming behaviors
perpetuate this cycle by producing stimulation stress-related opioids.
To further support this theory, van der Kolk stressed the benefits of opioid receptor blockers
in reducing behavior self-mutilating. Miller (1994) suggested that the process of reconstructing
trauma is cyclical and includes thoughts, feelings and behaviors that can be interpreted at
different times in the cycle.
At some point, the cycle could be interpreted as feelings of anger, shame, or intense fear
which could cause an individual to self-harm. At another point, it could be interpreted that self-
harm causes disgust to others, which could lead to further punishment, or interprets that when
an interpersonal relationship becomes to intimate the individual feels the urge to detach
themselves through self-injurious behaviors. The self-abuse cycle somehow serves to
protecting the trauma survivor because it keeps others at bay. Function of Selfprotection of
self-harm behaviors is necessary because survivors are often unable to protect themselves due
to the fact that they usually maintain diffuse borders in interpersonal relationships.
Paradoxically, they really want to be saved and protected. Considered together, these
tendencies create relational instability. In the following we will discuss the impact of childhood
sexual abuse on personality development and attachment, but also about how traumatic
experiences from childhood can lead to behaviors of reconstitution of trauma in adulthood. We
will then explore the association between the symptoms of reconstitution and the diagnostic
categories in DSM 5 of BPD and PTSD. Then we will be able to see if the use of BPD diagnosis
when treats the survivors of a sexual trauma, it is the right one, because such diagnosis may
not be clinically accurate, even having an impact with potentially stigmatizing or more harmful
than beneficial.
The impact of sexual trauma on personality development

Traumatic experiences in childhood can hinder the normal developmental process. Janet
(1911) suggested that personality development is affected by experiences traumatic. As a
result, the individual is unable to adapt and assimilate new information from experiences, thus
impairing his ability to cope with future challenges. This thing eventually causes the individual
to become able to integrate the traumatic material into existing cognitive patterns. According
to Freud (1920), individuals who are not able to assimilate traumatic experiences in the
cognitive system repeats the material repressed in experiences contemporary and as van der
Kolk (1989) suggests, it is unlikely to make a connection aware of past experiences and current
reconstructions.
It has been postulated that cognitive distortions result from sexual trauma suffered in
childhood (Solomon & Heide, 2005). And Owens and Chard (2001) suggested that these
cognitive distortions have a major impact in these five areas: security, trust, strength, self-
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esteem and privacy. The culminating effect of such distortions can lead to anxiety, behaviors
avoidance, fear of betrayal, anger, passivity, feelings of helplessness (Owens & Chard, 2001)
and an exaggerated potential for a sense of danger (Briere & Runtz, 1993). Bleiberg (1994)
also suggested that sexual abuse may become part of the struggle conflicts characteristic of the
development process and can fuel fears of abandonment or feelings of self-alienation and
disconnection from others. A major problem in the pattern of trauma recovery is the absence
of a presence protective in early relationships, an absence that affects the individual’s ability
to manifest trust in others, thus impacting the attachment process and decreasing resilience of
the individual (Miller, 1994; 1996).
According to Liotti and Pasquini (2000), domestic violence, and here we refer not only to
abuse physically and sexually, but also to other traumatic conditions, such as witnessing scenes
violence, early separation and loss, neglect, all these affect the child in his relationship with the
caretaker.
Conceptualizing the implications of malformed interpersonal relationships due to
experiences traumatic disorders in early childhood, which result in reconstitution behaviors,
attachment theory is explored in connection with childhood sexual trauma.
As mentioned above, there is an empirically supported link between sexual trauma
childhood, attachment disorders and the diagnosis of BPD in adults. Because of this connection
and symptomatic similarities in BPD and PTSD, there is the distinct possibility that Early
trauma and attachment difficulties result in an inadequate diagnosis of BPD. Instead, these
manifestations may be more eloquently reflected in the reconstruction of the trauma, which has
a greater concordance with the diagnosis of PTSD.
Attachment Attachment functions serve to provide proximity and protection: proximity
between an individual and his or her caregiver and protection against sexual predators (Bowlby,
1973). In the in essence, the attachment figure becomes a safe base for children to go exploring
the world and return. A secure foundation is crucial for development as it promotes self-
confidence, autonomy, empathy and existential significance. The absence of this secure basis
may even have an impact on biological development (van der Kolk, 1989), as a highlights
psychosocial dwarfism, the phenomenon in which children in extremely stressful environments
develops aberrant behaviors and growth retardation (Powell, Brasel, & Blizzard, 1967).
Van der Kolk (1987) suggested that the earliest and possibly the most harmful trauma
psychological is the loss of a secure base. When those who should be the sources of safety and
of care becomes a source of danger at the same time, children strive to restore a certain feeling
safe and often blaming themselves instead of coming back against their caregivers (van der
Kolk, 1989). In fact, children strive to maintain their parents’ perception of being good at
coping with intense negative emotions, such as fear and anger, which often accompany sexual
abuse. It is a normal process for individuals to intensify attachment in response to a threat (van
der Kolk, 1989). We have as an example the Stockholm syndrome, in which the victims of the
situations of hostages begin to identify and empathize with their captors (Gachnochi &
Skunik,1992).
When caregivers become a source of danger and torture, children can develop strong
emotional ties with them. The traumatic connection legitimizes the behaviors and inappropriate
requests from the perpetrator and thus can give the victim a sense of reconciliation. If a
caregiver rejects and abuses them, children may become hyperactive due to it.
Conflicting negative emotions and increased attachment, and the resulting cycle of over-
excitation and reconciliation, can function as a hardener (van der Kolk, 1989). In adult
survivors of sexual abuse, hyperexcitation often interferes with their ability to be calm and
rational, and thus preventing the assimilation of traumatic material. The adult survivor then
responds to anything threats as emergencies, which require action rather than thinking (van der
Kolk, 1989).
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Childhood sexual abuse disrupts the natural process of attachment, leaving individuals with
inadequate interpersonal skills and often leading to patterns of behavior disruptive and
unhealthy (Liem & Boudewyn, 1999). Inconsistent parental care, which is characteristic of
unresolved attachment, establishes a reception and a coding in short circuit of relational stimuli
in the child. According to Koos and Gergely (2001), inconsistency demonstrated in the process
of raising the child leads to a “dissociative style of attention and behavioral organization
characteristic of the disorganized attachment of the infant”. This one Primary inconsistency in
care seems to be a logical precursor to emotional attachment, of also inconsistent, manifested
by individuals with BPD in adult interpersonal relationships (Holmes, 2004). Herman (1999)
suggested that the main difficulty for those diagnosed with BPD is their lack of confidence in
people, which may come from a lack of a cognitive pattern integrated and based on a reliable
source of trust, but which was not formed in childhood.
Liotti and Pasquini (2000) demonstrated the similarities between BPD and its subsequent
effects disorganized attachment to personality development, emphasizing that both BPD and
Disorganized attachment are characterized by an unintegrated representation of the self with
others, individuals with weak emotional drive and control and a penchant for experience
dissociative. The effect of this fragmented process is a lack of clear boundaries as well as
feelings of uncertainty about the security of relationships with others (Miller, 1994).
In individuals experiencing trauma, this is evidence of attachment inconsistent that will
influence their future relationships. Miller (1996) described the spectator unprotected as a
parental figure who ignored the occurrence of sexual abuse.
Lack of protection from the unsecured viewer has a significant impact on the attachment,
the consequences being the inability to protect oneself and to calm oneself. This inability it will
determine a fragmented personality, in which the individual is incapable of perceiving himself
as a whole person, thus relating to others in fragmented parts. Reconstruction of trauma in
adulthood once an individual has been abused, he or she will never be able to perceive himself
or herself the world in the same way as before abuse, because all future experiences will be
rebuilt through the filter of abuse (van der Kolk, 1989). This filter is connected to the cognitive
processes of assimilation and accommodation identified by Piaget.
Piaget (1970) described assimilation as the integration of experiences into cognitive
schemas existing and the adaptation with modification of the schemes by the assimilated
experiences. Van Geert (1998) later described the process of assimilation as the way the world
is understood in depending on the level of cognitive development of the individual at the time
of experience and accommodation with the way the individual adapts to the reality of the
experience. Thus, when a child experiencing sexual trauma, he or she will assimilate the
experience depending on his or her level of cognitive development and then will adjust to that
experience. Because the development of the process of assimilation and accommodation has
such an impactsignificantly on cognitive patterns, adults may continue to behave or to think in
accordance with these schemes. For example, victims of past trauma may respond to
contemporary events as if the trauma had returned and re-experienced the hyperexcitation that
accompanied the initial trauma. Van der Kolk (1989) suggested that the adult trauma survivor
seeks to erase the past through exemplary behavior, love and competence. If the individual fails
to heal his trauma, self-blame reappears along with a return to previous self-destructive coping
mechanisms.
Doob (1992) suggested that there is an apparent link between the reconstitution of trauma
through borderline pathology and the history of sexual trauma in the accommodation process.
Victims of abusechronically accepts the initial abuse as an adaptive survival strategy,
denying its existence and changing their emotional responses to abuse and thought processes
those who should have protected them, instead harmed them. Finally, these strategies result in
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the victim experiencing anger, which is redirected to himself and thus results in self-injurious
behavior.
It turns out that self-harm is essentially a behavior of reconstructing history traumatic client.
This strategy allows the abused child to stay connected with family members. However, as
adults, these accommodations, which manifest through dissociative symptoms, self-
destruction, irrational anxiety, interpersonal conflicts, behaviors and paranoid ideation,
depression and anxiety, are seen as psychopathology in mental health community, rather than
as adaptive skills.
Borderline personality disorder and childhood sexual abuse Research shows that attachment
disorders and relationships or interpersonal relationships with early childhood referrals affect
personality development and healthy interpersonal functioning as an adult, often leading to the
development of disorders personality, such as BPD (Adams, 1999; Mahler, 1971). Marked by
a pattern of instability relationship problems, identity disorders, impulsivity, suicidal ideation
or suicide attempts, reactive mood swings, chronic feelings of emptiness, inadequate anger
and/or uncontrolled and often explosive, contradictory feelings and severe dissociative
episodes (APA, 2013), people with BPD seem to be driven by a paradoxical search for close
relationships and they are constantly being sabotaged. Of course, the primary deficit in the
disorder borderline personality has been described as a “failure to achieve the constancy of the
object ... a failure to form reliable and well-integrated inner representations with trusted
people” (Herman, 1999).
A number of researchers have found that a significant number of individuals are diagnosed
with BPDs have a history of sexual and physical abuse in childhood (Goldman, D’Angelo, &
DeMaso, 1993; Herman, Perry and van der Kolk, 1989; Herman & van der Kolk), 1987;
Zanarini, Frankenburg, Reich and Marino, 2000). Sexual-physical trauma that occurs as a result
of sexual abuse childhood contributes to an interpersonal style of functioning that involves
manipulative relationships, addicted and a chronic low self-esteem. Terr (1991) suggested that
children exposed to experiences of trauma have changed their attitudes towards interpersonal
relationships, experiences of life and difficulties related to their ability to consider the effects
of this on of the future. Many individuals with these characteristics eventually end up resorting
to psychotherapy and are diagnosed with BPD.
However, although it is possible, and often likely, that the symptoms of the trauma survivor
to be somewhat similar to the diagnostic criteria for BPD, it is imperative to take into account
consider the basic motivators, represented in the symptoms, before giving a diagnosis of BPD.
These basic motivators are often the result of avoiding abuse to deal with trauma and
eventually lead to the development of strategies maladaptive adaptations. The result of
avoiding stimuli associated with childhood trauma, inclusive increased excitement and re-
experiencing trauma, are distinct behaviors that characterize victims’ responses to sexual
trauma (Morgan, Rigaud, & Taylor, 1990), and therefore, they are more in line with the
diagnostic criteria for PTSD. In addition, when Sexual boundaries are invaded during
experiences of sexual trauma, strategies of psychological adaptation of the victims helps to
suppress overwhelming emotions and thoughts related to trauma.
Repression and dissociation allow victims to cope with experiences they cannot integrate,
and when repression and dissociation begin to fail as coping mechanisms, individuals may re-
experience traumatic events (Morgan, Rigaud & Taylor, 1990). Many Victims face the
“breakdown of the avoidance response” by reexperiencing all or some aspects of their sexual
trauma. For example, people may experience intrusive flashbacks to sensations, including
sounds, smells, or tastes that were present at the time. incident of abuse. As a result of re-
experiencing the trauma, the individual may become confused and can cause intense emotions
that can lead to misdiagnosis. These answers are similar to BPD’s characteristics of emotional
instability, inappropriate anger, or ideation paranoid stress-related. If we consider these
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characteristics, it seems reasonable toWe believe that the symptoms that often lead to a
diagnosis of BPD may be more consistent with the recreation of trauma, rather than with the
reflection of personality deficits.
Post-traumatic stress disorder PTSD

Miller (1994) suggested that distinguishing symptoms of reconstitution of trauma from BPD
symptoms involve a thorough understanding of the client’s history. People who reconstruct and
relive childhood traumas often have a vast history of multiple traumas: physical, sexual or
emotional abuse, neglect and/or invasive care, chronic behavior challenging interpersonal and
intrapersonal difficulties, as well as a behavioral pattern self-destructive harm to personal
health and well-being. These behaviors, though pathological, are mechanisms of maladaptive
coping rather than symptomatology characteristic of a personality disorder. Although these
characteristics seem similar to the diagnostic criteria of BPD, the history of trauma. Childhood
sexual dysfunction is not a prerequisite for the diagnosis of BPD. However, due to traumatic
events, individuals exhibit reconstructive behaviors.
Since PTSD is one of the few situationally identified DSM-5 diagnoses, it seems reasonable
to be described in more detail.
Post-Traumatic Stress Disorder is marked by the following key areas:
1.) psychobiological changes (such as hypervigilance, predisposition to anger,
exaggerated response startle sleep disorders);
2.) traumatic memory (e.g., nightmares, relapse, imaging intrusive, dissociation);
3.) avoidance, numbness and denial (e.g., alienation and detachment, substance abuse,
emotional constraint);
4.) self-concept, ego states, personal identity and self-structure (e.g., dissemination of
identity, vulnerability, poor knowledge about oneself and the world);
5.) attachment, intimacy and interpersonal relationships (e.g., alienation, self-destructive
relationships, mistrust, borderline problems with others, impulsivity) (APA, 2013;
Wilson, Friedman and Lindy, 2001).
The diagnostic criteria in the DSM-5 listed above appear to be similar to those discussed
previously for BPD. In fact, Hodges (2003) supported the current view that suggests that BPD
is a “chronic form of PTSD that has been integrated into the personality.” The idea that PTSD
could be a chronic condition that was originally suggested two decades ago by Armsworth
(1984), who indicated that survivors of childhood sexual trauma who PTSD may have
persistent symptoms during adulthood. More recently, Banyard, Williams, and Siegel (2000)
indicated that childhood sexual trauma may have a chain reaction of psychological suffering
that begins in childhood and continues throughout life, if the trauma is not healed. Lang et al.,
(2003) found that women with a history of trauma PTSD had significantly more symptoms
than women without such sex antecedents.
In addition, their findings indicated that PTSD mediates the relationship between trauma
history and poor health behaviors, including risky sexual behaviors and substance abuse.
Thompson et al., (2003) also found significant results statistically, which suggests that
women who suffered sexual trauma in childhood had more chances of having symptoms of
PTSD than women who have not suffered such a trauma.
May much, Banyard et al., (2000) found that childhood sexual trauma is associated with
PTSD symptoms of anxiety, hyperexcitability, depression, avoidance, intrusions, self-referral,
dissociation, and sexual concerns.
Supporting the above assertions, which suggest that survivors of sexual trauma in Childhood
experiencing PTSD symptoms is important, but not the key to it understanding and treating
symptoms of reconstitution of trauma. To provide efficient services survivors of childhood
sexual trauma, the mental health community must take in consider the underlying reasons why
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some survivors experience it reconstitution behaviors, while others do not, although little is
known about this.
Banyard et al., (2000) suggested that for some, the symptoms associated with PTSD become
part of it from the structure of their personality.
If we consider the childhood sexual trauma of aframework of learning theory, it is logical
that the coping and response models that were used during the period in which the sexual
trauma took place to be the same coping and response patterns used in other life situations and
thus increase the risk of problems future psychology (Banyard et al., 2000).
A reconsideration of borderline personality disorders

While mental health professionals may disagree with the theory and origin BPD, few would
argue against the claim that BPD is one of the most difficult forms of mental illness to be
treated. People with BPD often present themselves as very manipulative and causes a certain
frustration to therapists in relation to the cycle of manipulation and rejection manifested by
these customers. Perry (1997) suggested that health professionals.
People with a diagnosis of BPD often see the therapist as imposing on the therapist
responsibility for their improvement, but at the same time rejecting the therapist’s efforts to it
helps. Some sort of stigma associated with this diagnosis has somehow become commonplace
mental health professionals globally, which is why BPD often does similar to a kind of “death
sentence” for a client (Gallop, Lancee and Garfinkel, 1989; Nehls, 1998; Reiser & Levinson,
1984). In fact, “psychological cancer” was the term used by Kernberg (1984, p. 262) to describe
the diagnosis of BPD. In a 1988 study by Lewis and Appleby, psychiatrists were found to be
pejorative, critical, and the patient with BPD claiming that they were manipulative and required
extreme attention, giving Of course, they do not deserve the same quality of care as other
patients. Reiser and Levenson (1984) indicated that the term borderline may create an
interruption of empathy between the clinician and the client.
Indeed, the diagnostic criteria for BPD are similar to many of the consequences and
longterm reactions to childhood sexual abuse. For example, some consequences on Long-term
notices of sexual abuse include affected relationships and mistrust others, concern for sexual
issues and promiscuity, sexual dysfunction, and impulsivity risky behaviors (e.g., substance
abuse, prostitution, behaviors self-destructive), suicidal ideation and depression (Murray,
1993). However, stigma derived from the diagnosis of BPD can actually lead to the re-trauma
of the adult survivor of childhood sexual abuse during therapy. Dobb (1992) suggested that
because adult survivors often continue to “blame themselves for their victimization, explaining
that they have been abused because of their essential wickedness “, the label of a personality
disorder may confirms this notion for the adult who was sexually abused as a child Moreover,
a practitioner focused on a diagnosis of such a personality disorder BPD will probably focus
on the specific features of that diagnosis and will not look beyond of character concerns, at the
sources of problems that make the client repeat patterns behavioral (Miller, 1994). However,
visualizing the client’s struggles from a trauma framework allows the therapist to see the
symptoms as coping mechanisms for the history of his trauma and allows the explanation, in a
way perceived as non-threatening by to the client, how such past experiences are reactivated
by the present choices. Therefore, this explanation may allow the client to understand how
these behaviors they have served as maladaptive coping mechanisms that maintain the status
of victim, offering however, at the same time, the opportunity to learn other more effective
coping mechanisms. This change in his thinking towards a status of survivor, without guilt or
revictimization, it is an absolutely necessary condition.
Although the diagnosis of BPD can be helpful in identifying behaviors when consult with
other mental health professionals about the stigma attached to the label can provide customer
290
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service by mislabeling behaviors as being characterological rather than adaptive behaviors

(Miller, 1994).
Miller and May suggested that a client who is recovering from childhood trauma should be
understood through exploration maladaptive behaviors (e.g., self-harm, anger, relationship
turmoil), rather than trying to silence them.
Axis I diagnosis, BPD should be considered a subclassification of PTSD. In doing so, he
indicated Hodges would reduce the stigma associated with BPD and integrate two categories
of diagnosis apparently similar.
The complexity of the implications and needs of the clients who show the symptoms of
reconstitution trauma creates the need for a comprehensive assessment, treatment planning and
psychotherapeutic intervention. Therefore, it seems necessary to take a therapeutic approach
integrate emotional, behavioral and interpersonal awareness.
It is essential to create a secure environment in which the customer can explore openly
traumatic history. Customers should be helped to make conscious connections between their
experiences past and reconstitution experiences, as the recognition of this connection will allow
coping mechanisms to be more adaptable, to fall into the category of conscious reactions to
stressful events (Miller, 1994).
In order to recreate the cyclical pattern, clients should begin to recognize the cyclical pattern
maladaptive and often destructive created when the expressed needs of a client are not fulfilled
as a result of his behaviors. For subjects facing reconstitution of trauma, expressions of need
(safety, trust, strength, esteem and privacy) in the way they are accustomed (reconstitution
behaviors) result in rejection to any attempt by others to satisfy these needs, thus catching them
in a cycle destructive. Clients who experience reconstitution of trauma often cause it
simultaneously the closeness and emotional intimacy of a protective spectator, only to reject
him in the the latter (Miller, 1994).
Therefore, creating awareness and gaining the ability to satisfying needs through other more
adaptive behaviors becomes the key to treatment clients facing trauma recreation.
From a cognitive perspective, the distortions that result from childhood trauma and which
result in anxiety, avoidant behavior, fear of betrayal, anger, and passivity feelings of
helplessness should be realized and altered (Owens & Chard, 2001). Customers who
experience the reconstitution of trauma may think that “their purpose in life” is to always relive
and be punished constantly in response to the traumatic episode. Furthermore, they can
maintain the cognitive distortion in which they feel guilty and that the perpetrator is in as a
rule, in an attempt to manage the cognitive dissonance that results when a caregiver is
simultaneously the source of safety and danger (Delcea C., Enache A., 2021). These and other
specific beliefs or distortions each individual client should be challenged and eventually
replaced with other cognitions stronger, selfaware. Miller (1994) outlines four approaches to
trauma recovery treatment.
In turn, it indicates that understanding the context surrounding the symptoms of
reconstitution Trauma is fundamental to understanding and treatment. Miller states that by
context she refers to “situations in which the person lives, interacts, thinks and experiences
itself in relation to the world”. Miller suggests that there are several contexts that support logic
ubiquitous reconstitution. Second, the symptoms should be viewed from a perspective
historical, as an adaptation and communication of the individual past. In the third line, behavior
should be seen as having many functions even when that behavior it is no longer necessary.
For trauma victims, the symptoms become a companion, much less threatening than other
new relationships or experiences and often their only source of power and control. Finally,
Miller says the victim of trauma needs recovery at least a meaningful and healthy relationship
before revisiting the traumatic event. This can be achieved most often in the therapeutic
relationship.
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In essence, the client who is experiencing symptoms of trauma abuse Childhood sexual
abuse should be treated comprehensively and systemically. It would be a disservice major to
treat separately the symptoms or behaviors that form the recreation trauma. Specifically, it
would certainly be ineffective to treat only the disorder addiction or eating disorder or
selfharming behavior, separately.
CONCLUSIONS
This summary review of the literature supports the need to adopt an attitude more cautious
and careful about the differential diagnosis between BPD and PTSD within diagnostic practices
of mental health professionals when treats adults who have experienced sexual trauma in
childhood. It seems that the expression of this trauma of abuse, which often results in
disorganized attachment, manifests itself in parallel through many symptoms of BPD and
PTSD. Although there are similarities between the diagnosis of a borderline personality
disorders and trauma reconstitution behaviors, honesty professional forces the psychotherapist
to carefully assess whether the client’s symptoms reflect more much PTSD, thus providing a
more effective treatment climate. Due to the potential of discrimination found in the global
mental health community and the implications for the environment socio-professional, it
becomes extremely important to determine whether the client’s symptoms are the result of
unresolved childhood sexual trauma or a real sexual disorder borderline personality, each with
treatment implications and protocols unique and different.
REFERENCES
[1] Delcea C., S-ON©, an online application for clinical evaluation and treating sexual dysfunctions. Int J
Advanced Studies in Sexology. Vol. 1, Issue 1, pp. 5-9. Sexology Institute of Romania. DOI: 10.46388/
ijass.2019.12.11.1
[2] Delcea C., Construction, Validation, and Standardization of the Sexual-DSMapp Application; in
„Psychiatric Research and Clinical Practice”, Volume 2, Issue 2, December 2020, pp. 70-75. Wiley
Periodicals LLC. on behalf of the American Psychiatric Association.
[3] Adams, K. M. (1999). Sexual harassment as cycles of trauma reenactment and sexual compulsivity.
Sexual Addiction and Compulsivity.
[4] American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5 th ed.).
[5] Armsworth, M.W. (1984). Post-traumatic stress responses in women who experienced incest as children
or adolescents. Dissertation Abstracts International.
[6] Banyard, V.L., Williams, L.M., & Siegel, J.A. (2000). The long-term mental health consequences of
child sexual abuse: An exploratory study of the impact of multiple traumas in a sample of women.
Journal of Traumatic Stress.
[7] Bleiberg, E. (1994). Borderline disorders in children and adolescents: The concept, the diagnosis, and
the controversy [Electronic version]. Bulletin of the Mettinger Clinic.
[8] Bowlby, J. (1973). Separation: Anxieties and anger. London: Penguin Books.
[9] Briere, J., & Runtz, M. (1993). Childhood sexual abuse: Long-term sequelae and implications for
psychological assessment. Journal of Interpersonal Violence.
[10] Diamond, R., & Factor, R. (1994). Taking issue: Treatment-resistant patients or a treatment resistant
system? Hospital and Community Psychiatry.
[11] Doob, D. (1992). Female sexual abuse survivors as patients: Avoiding retraumatization. Archives of
Psychiatric Nursing.
[12] Freud, S. (1920). Beyond the pleasure principle. In J. Starchey (Ed.) Complete Psychological Works
(3rd edition). London: Hogarth Press.
[13] Gachnochi, G., & Skunik, N. (1992). The paradoxical effects of hostage taking. International Social
Science Journal.
[14] Gallop, R., Lancee, W. J., & Garfinkel, P. (1989). How nursing staff respond to the label “Borderline
Personality Disorder.” Hospital and Community Psychiatry.
[15] Goldman, S. J., D’Angelo, E. J., & DeMaso, D. R. (1993). Psychopathology in the family of children
and adolescents with borderline personality disorder. American Journal of Psychiatry.
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[16] Herman, J. (1999). Trauma and recovery: The aftermath of violence from domestic abuse to political
terror. New York: Basic Books.
[17] Herman, J. L., Perry, C., & van der Kolk, B. A. (1989). Childhood trauma in borderline personality
disorder. American Journal of Psychiatry.
[18] Delcea C., Enache A., (2021). Personality Traits as Predictor of Crime. Rom J Leg Med [29] 2, pp. 227-
231 [2021] DOI: 10.4323/rjlm.2021.227.
[19] Herman, J. L., & van der Kolk, B. A. (1987). Traumatic antecedents of BPD. In B.A. van der Kolk (Ed.)
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Filodiritto Editore – Proceedings

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First Edition February 2022

© Copyright 2022 Filodiritto Publisher

DOMNIȚA MIHAELA KABIRY

FIRST SECTION. SEXUAL DYSFUNCTIONS 10

A. MALE SEXUAL DISFUNCTIONS 10

1.1 Ejaculation disorders 10

B. FEMALE SEXUAL DYSFUNCTIONS 34

1.4 Orgasm disorder 34

SECOND SECTION. PARAPHILIC DISORDERS 89

A. EXTERNALIZATION PARAPHILIC DISORDERS 89

2.1 Voyeurism disorder 89

2.4 Pedophilia disorder 117

B. INTERNALIZATION PARAPHILIC DISORDERS 154

2.6 Fetishism and transvestism disorders 154

THIRD SECTION. MISCELLANEOUS 169

Clinical comorbidity 169

Professor Camelia Stanciu PhD

1.1 Ejaculation disorders

1.1.1 Premature ejaculation

SEX THERAPY IN THE TREATMENT OF PREMATURE EJACULATION

Premature ejaculation is a frequent sexual dysfunction with a prevalence in the general

Definition and sub-types of premature ejaculation

Premature ejaculation can be mild (ejaculation occurs within approximately 30 seconds to

Risk factors and etiology of premature ejaculation

Assessment and diagnosis of premature ejaculation

Treatment of premature ejaculation

Psycho-behavioral treatment options

Couples counseling techniques focus on improving communication between partners’

Information on the epidemiology, etiology and treatment of premature ejaculation is

Debut and evolution

In conclusion, it is important to mention that in the psychotherapy of sexual dynamics

[1] Kaplan & Sadock. Clinical Psychiatry Pocket Handbook, 2015.

1.2 Erectile dysfunction

RISK FACTORS AND FORECAST

Temperament factors. Neurotic personality disorders may be associated with erectile

DIAGNOSIS AND TREATMENT

Associated elements that support the diagnosis

Debut and evolution

Diagnostic elements dependent on the cultural environment

Treatment of erectile dysfunction

1.3 Sexual desire disorder

SEXUAL DESIRE DISORDER IN MEN

• Testing, S-ON Test© MEN

1/8 You have a reduced or absent sexual desire

6/8 Sexual desire is diminushed/absent irrespective of the partener

7/8 There an anticipatory fear of a new sexual failure

8/8 You have couple issues regarding sexual intercourses

B. FEMALE SEXUAL DYSFUNCTIONS

1.4 Orgasm disorder

ORGASMIC DISORDER IN WOMEN

2/8 6 or 7 out of 10 sexual intercourses have a reduced intensity of orgasmic sensations?

6/8 Does it appear irrespective of the partner?

7/8 Is there an anticipatory fear of a new sexual failure?

8/8 Do you have couple issues regarding sexual intercourses?

• Testing, S-ON Test© WOMEN

1/33 Is there a significant delay in orgasm in approximately 75-100% of sexual intercourses

2/33 Is there a reduced intensity of orgasmic sensations in approximately 75-100% of sexual

3/33 Is there a significant reduction of sexual arousal in approximately 75-100% of sexual