How Does Sexual Deviance Develop?: Document Status and Date

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How does sexual deviance develop?

Citation for published version (APA):

Schippers, E. E. (2024). How does sexual deviance develop? [Doctoral Thesis, Maastricht University].
Maastricht University. https://doi.org/10.26481/dis.20240422es

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Published: 01/01/2024

DOI:
10.26481/dis.20240422es

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Download date: 12 Oct. 2024


246 Appendix

English Summary

Chapter 1
Sexual deviance is common. It is estimated that nearly half of the people has at least
one deviant sexual interest, and about a quarter of the people has ever engaged
in deviant sexual behavior. Sexual deviance can be defined as a deviation from
various norms. It is mostly defined by social norms, in which society decides what is
nonnormative, and legal norms, in which the law determines what is nonnormative.
This thesis focuses on deviant sexual interests and uses sexual deviance as an
umbrella term encompassing interest, behavior, preference, fantasy, or urge. We
adopted a broad definition of deviant sexual interests, including sexual interest in
illegal as well as in itself “harmless” but unusual behaviors.

In essence, sexual deviance is not problematic. Sexual deviance can, however, be


problematic if it negatively affects health or quality of life, or acts as a risk factor
for sexual offenses. It is unclear how often deviant sexual interests have a negative
life impact or lead to sexual offenses. About two-thirds of the people convicted for
sexual offenses have some level of deviant sexual interests. That means that about
one-third of the sexual offenses is not associated with deviant sexual interests.

To reduce suffering or prevent sexual offenses, it can sometimes be necessary


to address sexual deviance in treatment. Treatment to prevent sexual offenses
should focus on risk factors related to the offense behavior and adopt a cognitive-
behavioral approach. This means that sexual deviance must be targeted in treatment
if it is an individually relevant risk factor for sexual reoffenses. Current treatment
may, however, not be optimal, not least because it is unclear how sexual deviance
develops. Assumptions about the development of sexual deviance shape the way
we approach it. Therefore, this thesis focuses on the question: how does sexual
deviance develop?

Chapter 2
Chapter 2 presents a systematic review to theories on the development of deviant
sexual interests. We conducted a systematic search of the databases PubMed
and APA PsycInfo (EBSCO). Studies were included when they discussed a theory
regarding the etiology or development of sexual deviance. Included studies were
assessed on quality criteria for good theories, for instance, regarding testability
or explanatory value. Common etiological themes were extracted using thematic
analysis. We included 49 theories explaining sexual deviance in general as well as
various specific deviant sexual interests, such as pedophilia (children) and sadism/
English Summary | 247

masochism (inflicting/receiving pain). Few theories (k = 7) were of acceptable


quality. These studies indicated that deviant sexual interests may develop as the
result of an interplay of various factors: excitation transfer between emotions
and sexual arousal, problems with “normative” sexuality, conditioning, and social
learning. Neurobiological findings could not be included as no acceptable quality
neurobiological theories could be retrieved. The important roles of excitation transfer
and conditioning designate that dynamic, changeable processes take part in the
etiology of sexual deviance. These same processes could potentially be deployed to
diminish unwanted deviant sexual interests.

The following chapters three through seven correspond with results from this review.
First, the mechanism of excitation transfer was explored: the transfer of arousal from
one emotion to another.

Chapter 3
Chapter 3 describes an experimental intervention to induce excitation transfer. In
this pilot study, we investigated if we could induce excitation transfer between
various emotions and sexual arousal in a lab setting with 30 male volunteers. We
induced low-level sexual arousal in response to vibrostimulation and erotic film. This
was done in four different emotional states (aggression/dominance, endearment,
fear, disgust) and a neutral state. Sexual arousal was measured genitally using penile
plethysmography, and via self-report. There was no mean group effect, possibly due
to large interindividual variations. Still, 60% of the subjects showed more sexual
arousal in at least one of the emotional states than in the neutral state. Excitation
transfer was most prominent with aggression/dominance and least prominent with
disgust. Genitally measured excitation transfer was strongly related to lower penile
reactivity and to higher self-reported erotophilia (the love of erotica). This pilot study
paves the way for further research into excitation transfer as a mechanism to increase
the salience of stimuli that otherwise would not have been sexual in nature.

Chapter 4
Chapter 4 is a protocol of a proposed follow-up study with improved methodology.
Following the prior pilot study, several adjustments were made to the study protocol,
including a stronger emotional manipulation by using 360-degree emotional film
clips with virtual reality glasses. Additionally, we aim to include a larger sample of
50 adult male volunteers with more diverse sexual interests. A
The previous chapters showed that emotions can influence sexual arousal. Following
this idea, it was investigated in the following chapters five and six if specific deviant
248 Appendix

sexual interests that often co-occur can be divided into clusters. Such clusters might
hypothetically be related to a certain emotion. Various deviant sexual interests that
evoke disgust, for example, may co-occur more often (feces, urine, vomit).

Chapter 5
In chapter 5, we aimed to identify underlying clusters in a variety of deviant
sexual interests. Participants rated 50 deviant sexual interests on a scale from 1
(very unappealing) to 7 (very appealing) in an anonymous, online survey. The 669
participants (61% female) came from various countries, mostly from the U.S.A. and the
Netherlands. Using exploratory factor analysis, we investigated which interests often
co-occurred in the total sample, and in women and men separately. Furthermore, we
assessed self-reported sex life satisfaction, sexual outlet, and psychiatric symptoms
(ADHD, depression, anxiety, and stress). Deviant sexual interests could be divided
into five clusters that were largely comparable for women and men: (1) submission/
masochism (receiving pain), (2) forbidden sexual activities, (3) dominance/sadism
(inflicting pain), (4) mysophilia (dirtiness or soiled things), and (5) fetishism (objects
or body parts). For women, having more deviant sexual interest related to more
psychiatric symptoms and higher sexual outlet, whereas this relation was less explicit
for men. Different clusters of deviant sexual interests may serve different underlying
functions or motivations, for instance related to sexual and emotional regulation.

Chapter 6
Chapter 6 describes a replication study to examine whether the findings from chapter 5
could be generalized to the general population. An online, anonymous sample of
256 men, representative of the Dutch adult male population, rated 32 deviant sexual
interests on a scale from 1 (very unappealing) to 7 (very appealing). Exploratory and
confirmatory factor analyses assessed whether similar clusters would emerge as in
the original study. Four slightly different clusters of sexual interests were found: (1)
extreme, illegal and mysophilic sexual activities, for example, with children, force,
vomit, feces; (2) light BDSM1 without real pain or suffering, for example, being
tied, blindfolding, spanking; (3) heavy BDSM that may include pain or suffering, for
example, gagging someone, seriously hurting; and (4) illegal but lower-sentenced
and fetishistic sexual activities, for example, exposing genitals, spying others
having sex, plush animals, blow-up dolls. The representative replication sample was
more sexually conservative and showed less sexual engagement than the original
convenience sample. Integrating both studies, on a fundamental level, the sexual
interest in light BDSM activities seems to be a relatively separate construct from

1
Bondage and Discipline (BD), Dominance and Submission (DS) and Sadism and Masochism (SM)
English Summary | 249

extreme, forbidden, and mysophilic activities. Different emotional needs may


underlie these clusters.

Subsequently, chapter 7 describes meta-analyses and a systematic review concerning


the “normative deficiency” hypothesis. This hypothesis states that decreased sexual
interest in normative stimuli contributes to increased sexual interest in deviant
stimuli. This can be explored using studies that measure the sexual reaction to
normative and deviant stimuli. While the normative deficiency is hypothesized
to hold for any deviant sexual interest, research almost exclusively focuses on
pedophilia, assessing sexual reactions to child and adult stimuli. Therefore, the
normative deficiency hypothesis was investigated with respect to pedophilia in
people who have committed sexual offenses.

Chapter 7
A sexual preference for children (pedophilia) is an important factor contributing
to sexual (re)offending against children. Sexual interest in children is therefore
frequently researched in people who have sexually offended against children (PSOC).
Studies usually calculate a difference score in which the sexual response to adult
stimuli is subtracted from the sexual response to child stimuli. These difference
scores have shown more discriminative value between PSOC and non-PSOC groups
than the responses to child stimuli alone. The current state of research makes it
difficult to conclude if people with pedophilia are overly interested in children, or
have lower interest in adults, or both. This is relevant knowledge in treatment for
preventing sexual (re)offenses against children.

This study aimed to systematically analyze sexual interest in both children and adults
in samples of men with pedophilia and comparison groups. We aimed to compare
the absolute sexual responses to child stimuli and adult stimuli with each other. A
total of 55 studies with 8,465 participants were included in four meta-analyses and
a systematic review. Most included studies considered PSOC and not nonoffending
pedophilic samples. About half of the included PSOC samples was presumed to be
pedophilic based on clinical information. Firstly, the results indicated that PSOC with
pedophilia did not have a clear sexual preference for children over adults: Their sexual
response to children was equal to their sexual response to adults. Secondly, PSOC’s
sexual response to children was higher than comparison groups. Thirdly, PSOC’s
sexual response to adults was lower than comparison groups (see Figure 1). A
250 Appendix

Figure 1
Schematic Representation of Sexual Responses PSOC and Comparison Groups (Schippers, Smid, Hoogsteder,
Planting, et al., 2023)

The current study circumvented the use of difference scores that are made relative to
comparison groups. As such, we were able to conclude that, besides the traditional
focus on sexual interest in children, the lack of sexual interest in adults may be a
relevant factor in PSOC with pedophilia. More studies are needed to disentangle
sexual interest in children from sexual interest in adults, while using carefully
matched comparison groups that have similar demographic characteristics.

Relative to the previous chapters with fundamental research, chapter 8 reflects


current clinical practice.

Chapter 8
Chapter 8 explored the prevalence and consideration of sexual deviance in
outpatient treatment for sexual offending behavior. Sexual deviance was assessed
in 198 adult clients with a combination of the Stable-2007 (Fernandez et al., 2014),
DSM-5 (American Psychiatric Association, 2022), or client self-report. Preliminary
treatment effects over the first year were assessed using the Stable-2007 in a
smaller subsample. Two groups of clients could be discerned with different needs:
a sexual deviance group (two-thirds of the clients) with more sexual preoccupation
and sexual coping, and a group with more impulse control disorders (about one-
third). Treatment content was similar for both groups, meaning treatment did not
specifically target the different needs in the different groups. Preliminary positive
English Summary | 251

treatment effects were found for both groups, which seemed mostly driven by
improvements in sexual self-regulation. Treatment more specialized towards the
needs of the subgroups and including more behavioral techniques might have more
pronounced effects.

Chapter 9 contains a general discussion in which the findings from this thesis
were integrated.

Chapter 9
In chapter 2, it was theorized that an interplay of dynamic, changeable factors
contributes to the development of deviant sexual interests. These include the transfer
of arousal between various emotions (“excitation transfer”), a lack of sexual response to
normative stimuli (“normative deficiency”), conditioning, and social learning. This can
be integrated into an Incentive Motivational Model, which is a common approach in
general sexology (Ågmo & Laan, 2022; Both et al., 2007; Toates, 2014). This model looks
at sexual motivation as an emotional response to a sexually relevant stimulus. These
stimuli are salient because they signal potential reward in the form of sexual arousal
and gratification. Processing emotional stimuli causes activation of the emotion
systems in the brain and prepares for behavioral action (LeDoux, 2012). Behavioral
action may, for instance, consist of approaching the stimulus, ultimately resulting in
sexual interaction, or entertaining a sexual fantasy, resulting in masturbation. Sexual
arousal, and especially sexual gratification, are strong reinforcers, causing one to
return to the sexual stimulus and strengthen its connection with sexual arousal even
further (operant conditioning). Social learning may play a role when, for instance,
approving peers reinforce certain behaviors or sexual partners introduce new sexual
stimuli. Suggested neurobiological predispositions lie in the sensitivity for reward, the
processing of visual cues, or the strength of the sexual reaction.

Smid and Wever (2019) explicitly apply the Incentive Motivational Model to sexual
deviance using the mechanisms of excitation transfer and normative deficiency.
Sexual arousal is tightly coupled with general, sympathetic arousal, which allows
overflow between emotional arousal and sexual motivation (Ågmo & Laan, 2022).
Some stimuli have strong emotional reactions, such as pain, humiliation, anger, or
disgust. Through excitation transfer, the emotional reactions of such stimuli might
overflow in sexual arousal, making the stimulus potent enough to induce sexual
arousal or even sexual gratification. Repeated coupling of that stimulus and sexual A
arousal may eventually result in a stable sexual interest. A strong emotional stimulus
to enhance sexual arousal is not necessary if the sexual motivation is already strong
enough. Therefore, the normative deficiency hypothesis suggests that excitation
252 Appendix

transfer might especially work for people who have no strong sexual motivation to
normative sexual stimuli.

From the findings in this thesis, three concluding key statements were derived:

1. Deviant sexual interests seem malleable, to some extent;


2. Emotion can increase sexual arousal to deviant stimuli;
3. A normative deficiency seems related to deviant sexual interests.

Changeable factors contribute to deviant sexual interests. If changeable factors


contribute to the development of deviant sexual interests, it does not necessarily
mean that deviant sexual interests are changeable. Changeable factors can put into
motion unchangeable processes. Despite a limited research base, there are some
indications that deviant sexual behaviors, as well as interests, are changeable to
some extent.

Emotion is one of the mechanisms to affect deviant sexual interests. Specific


emotions and general mood states have shown to be able to increase or decrease
sexual arousal. While emotions and mood may influence sexual arousal, the opposite
is also likely true: Sexual behavior might improve negative mood states. If one wishes
to reduce sexual deviance, it might be useful to look at the connection between
emotions and sex in the individual. Being able to regulate emotions seems a useful
tool to regulate sexuality.

Further research to normative deficiency as a developmental factor for sexual deviance


should focus on two aspects: causality and generalization. First, does normative
deficiency actually cause deviant sexual interests, and two, is this generalizable to
other deviant sexual interests than pedophilia. Promising interventions to improve
normative sexuality include healthy lifestyle changes, pharmacotherapy, sexological
therapy, couples therapy, and reconditioning techniques. Further research as well
as treatment efforts should take into account two things: the deviant identity and
proper assessment of sexual interests. In the example of pedophilia that means: If
people see pedophilia as part of their identity, this may obscure any residual sexual
interest in adults. Proper assessment helps to differentiate sexual interest in children
from sexual interest in adults.

A strength of this thesis is that it used various methods and samples from
various populations. Additionally, we provided a useful framework to explain the
development of sexual deviance. A limitation of the state of research in general and
English Summary | 253

some of the research in this thesis, is that it is largely limited to sexual offending
behavior. Therefore, the findings can only be generalized to nonoffending
populations with prudence.

Conclusion
Deviant sexual interests seem malleable, to some extent. The roles of excitation
transfer and normative deficiency designate that changeable processes take part in
the etiology of sexual deviance. These same processes could potentially be deployed
to diminish unwanted deviant sexual interests. This is most relevant in treatment of
people who have committed sexual offenses to reduce the risk of future reoffenses.
It might also be informative for people who suffer negative consequences from their
deviant sexual interests. More research is needed to explore which specific treatment
techniques are effective in reducing sexual deviance. Improving emotion regulation
and strengthening normative sexual interests are promising treatment options.

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