Chapter 15 Oyedeji Ayonrinde1 and Dinesh Bhugra2 1 Consultant Psychiatrist, South London and Maudsley NHS Foundation Trust, London, UK 2 Professor of Mental Health and Cultural Diversity, Institute of Psychiatry, King’s College London, London, UK Sexual activity is a universal phenomenon, strongly influenced by sexual orientation and fantasy. Attitudes to sex, sexuality, sexual orientation, and procreation are strongly influenced by individual cultures. Cultures also determine child-rearing patterns as well as our thought processes. Our cultural identities also influence our inner and external world views and it is inevitable that attitudes will be coloured by the manner in which we think and how our attitudes develop. Societies and cultures also decide what is seen as deviant and abnormal. In this chapter we propose to highlight some of the key issues related to diagnosis and management of paraphilias. Until relatively recently, paraphilias were known as sexual deviance or aberrations. The Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-5) [1] defines paraphilia as: Any intense and persistent sexual interest other than sexual interest in genital stimulation or preparatory fondling with phenotypically normal, physically mature, consenting human partners. This interest is seen as any sexual interest greater than or equal to normophilic sexual interests. Preferential sexual interests affect sexual activity and these can be seen as erotic activities as well as erotic targets. Paraphilias come to the attention of psychiatrists or other mental health professionals if there are legal complications. As long as two consenting adults in privacy of their home perform these acts they are not likely to be brought to clinical settings. Excess of distress or illegal nature of certain activities may lead to referral to legal or medical pathways. 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. There are a large number and variety of paraphilic disorders and we do not propose a comprehensive list but only an illustrative one (see Table 15.1). Table 15.1 Specific paraphilic disorders. The DSM-5 stresses the importance of culture-related diagnostic issues: “knowledge of and appropriate consideration for normative aspects of sexual behaviour are important factors to explore to establish a clinical diagnosis and to distinguish a clinical diagnosis from socially acceptable behaviour” [1]. This highlights the need for an awareness of cultural context and cultural values of the group to which the individual belongs in the assessment and understanding of these patterns of behaviour. Individual patients’ cultural identities and values will need to be explored and their significance confirmed with others from the same culture. The role of sexual activity is fundamental to the preservation of the human race. However, the non-procreational role of sexual activity will be influenced by a range of factors such as available sexual partners, opportunities, and individual fantasies. These individual factors are set against a backdrop of culture, norms, taboos, religion, mores, and values of the society. Society and culture have a significant impact on the recognition and acceptance of behaviours as normal or deviance. This relationship involves a complex interplay of factors, as culture determines “normality and abnormality” by defining norms of acceptable behaviour and permissible variants. In essence, the recognition of abnormal behaviour, the label ascribed, and explanatory model are culturally influenced. Furthermore, the etiological role of culture in some disorders can be illustrated by considering the societal role and expectations of body image in anorexia nervosa, thereby influencing clinical presentation and its interpretation. The rates and distribution of disorders can also be culturally influenced, as is the case with culture-bound syndromes or alcohol-related health problems. It therefore stands to reason that culture influences the seeking, provision of treatment options, and care pathways within a society. Through these expectations of what constitutes treatment, culture influences the satisfaction or outcome of treatment interventions. Within both normal and abnormal practice, a substantial range of behaviours exist. For instance, a man may dress in women’s clothes for a fancy dress party, or may occasionally dress in such clothes for sexual pleasure and gratification, or actively pursue a change to the female gender role and the desire to wear women’s clothes all the time. A snapshot of each situation would describe cross-dressing in a man, but the context is different in each scenario. The transitional role of uniforms as symbols that traverse fashion, fantasy, and fetish was highlighted by Bhugra and de Silva [2] In some situations, the absence of opportunities for heterosexual activity may lead individuals to engage in homosexual activity, for example in prisons, boarding schools, and other settings where opportunities for heterosexual activity are limited. It is possible for a person with heterosexual orientation to maintain heterosexual fantasies while engaged in homosexual acts. In light of this, it is worth emphasising that manifest sexual behaviour may not be a true measure of sexual preference or fantasy as circumstances determine. On the other hand, the perception of some deviant behaviour may be influenced by culturally determined norms such as the number of sexual partners and frequency of sexual activity in sexual addiction. Help-seeking is likely to be determined by: While paraphilias are universal phenomena across all cultures, the prevalence, distribution, and legal status may vary in individual societies. This chapter explores the impact and influence of culture on sexual behaviours and paraphilias. In addition, the controversies associated with defining these disorders and the range of sexual behaviour or deviance are considered. Culture constitutes the symbolic and learned non-biological features of human society, including customs, conventions, and language, by which human behaviour can be distinguished. It influences the way individuals live, their values, and belief systems, as well as how they communicate. Culture may be explicit or implicit in presentation and is a non-static heterogeneous phenomenon with dynamic boundaries. In societies, there is an interplay between the community and the individual. Through acculturation, for instance, the individual may retain core values while adopting visible values such as clothing or dress code. The rate of growth or change of an individual within a culture is influenced by fluid differences between the individual and the overall societal values, duration in the culture, and individual and family factors, to mention a few. Cultures have been broadly described by Hofstede [3, 4] into sociocentric (collectivist) or egocentric (individualistic). Collectivist cultures believe in “we-ness” and the different stages of the lifecycle promote social cohesiveness and in-group loyalty. Sociocentrism promotes a collective identity, group solidarity, and emotional interdependence and shared obligations toward the wellbeing of the community. These cultures promote stable friendships and encourage decision making by kin or the group. Individualistic cultures, on the other hand, believe in “I-ness” with loose ties between individuals and members of the society to promote the wellbeing of themselves and their immediate families. Egocentric cultures focus on emotional independence, individual initiative, autonomy, and the right to privacy. In addition, the “I-conscious” nature of these cultures encourages specific friendships and need for financial security. Sociocentric and egocentric cultures have important differences. Cultural determinants of relationships influence social expectations as well as attitudes and behaviours. Personal relationships are salient in collectivist societies and trump some behaviours, such as seeking personal reward or pleasure-based sexual activity. Collective cultures have an influence on moral and sexual values and therefore on expression of sexuality, sex, and sexual behaviours. Hofstede [3, 4] also described the dimensions of “masculinity-femininity.” Gender roles vary in different cultures. In some societies men and women have equal rights and opportunities, while in others there is greater male dominance. In high masculinity societies women have restricted opportunities in vocation or societal hierarchy and there are higher degrees of individualism, financial reward, and limited support for the weaker in society. Conversely, feminine societies are relationship oriented and do not focus on emotional or social differentiation. Other features of societies include power distance (a measure of interpersonal power or the degree of influence between a subordinate and his or her senior). Power distance reflects the degree of inequality. Uncertainty avoidance, on the other hand, is a measure of how tolerable the anxiety of the unknown plays in the society. Societies with low uncertainty avoidance tolerate challenges such as unemployment or work stress better because there are means of tapping on shared happiness. The final dimension is related to long-versus short-term orientation. Long-term orientation involves the preparation for the future and goals such as career planning. These five dimensions rank differently in different societies and cultures. It has been suggested [5] that cultures that are masculine and individualistic, with low power distance and with low short-term orientation as well as low uncertainty avoidance, may have a greater expression of paraphilias. Cultural analysis and awareness of dimensions give insight into the variability of paraphilias and problem sexual behaviours. Sexual practices are associated with the societal kinship structures and power gradients. Reiss [6] asserted that these sexual practices follow prescribed and shared cultural scripts, which both promote and discourage different types of sexual behaviour. Sociocultural scripts of sexual behaviour may be innate (hence biological or nature) or may be learned (nurture and environmental) through cultural transmission. Culture may further define scripted roles on the basis of age, gender, social position, and religious faith. Such cultural transmission of sexual roles and behaviours may include folklore, song, dance, or depiction in artwork. Others may limit or promote behaviour through rites of passage into manhood or the expectation of blood-stained white sheets of the bride after the consummation of marriage to affirm the wife’s virginity. Kinship-based social roles promote long-term relationships between genders and with childrearing practice while providing support mechanisms. This may be more visible in Hofstede’s sociocentric or collectivist cultures. Sexual scripts also determine gender roles, with the reinforced promotion of the often male position as being more dominant in many spheres of life—for example, head of the household, leading organisations, and the expectation to provide and ensure the wellbeing of others. Reiss’s description of this bears some similarity to Hofstede’s concepts and cultural dimensions of masculinity and femininity. Arguing the role of nature (biology), Segall, Dasen, Berry, and Poortinga [7] indicate that the processes of sexual attraction and arousal are biological, for instance, in men involving a mental process, nerve transmission, and changes in blood supply to achieve penile erection. In essence, regardless of the culture and whether the underlying outlook is sociocentric or egocentric, these important biological mechanisms play a role in the process and manifestation of paraphilic behaviours. Table 15.2 presents types of paraphilias on the strength of unusually sexually attracting stimuli for the purpose of sexual arousal. Evidence supports the role of biological, cultural and individual factors in the development of paraphilias. The weight given to each component remains uncertain and will be explored further in this chapter. Table 15.2 Types of deviance and cultural-biological influences. Adapted from Bhugra et al. [5]. + = positive correlation present. ? = unknown correlation. Standards of what constitutes the normal range of sexually attractive, arousing experiences and behaviours are difficult to define. This may range from body size, skin tone, eye colour, hair, and fragrances, to mention but a few. These subjective individual experiences are influenced by yet transcend cultures and geographical borders Bullough [8] described societies and cultures as either sex-positive or sex-negative. Elaborating on this, it was viewed that sex-negative cultures see semen loss and even intercourse as a weakness and sexual asceticism is encouraged. Sex-positive cultures, on the other hand, emphasise the pleasurable, gratifying, rewarding, and non-reproductive aspects of sex. A Western historical overview highlights the attitudinal changes over centuries as well as the changes in religious values. Early Greeks and Romans acknowledged and accepted alternative sexual behaviours with changes in attitudes toward sexuality. Religion and faith transmission of attitudes were promoted by religious doctrines and teaching. Procreation was essential to the sustenance of society and maintenance of a labour (farming) and military workforce. The non-procreative loss of semen was associated with loss of potent vital energy and the reproductive resource of the individual as well as the society. Early Christianity generally disapproved of non-procreative sex. In addition, it condemned sex outside marriage, which was subsequently embedded into one of the Ten Commandments. Bullough [8] indicated that in the midst of competing and parallel religious systems, there were different interpretations to doctrines. Marriage did not automatically endorse the right to sexual activity and was expressed more as a duty and not a source of pleasure. Islam, in contrast [8] (p. 205), appeared to lean more toward being sex-positive, with the historical understanding that the sexual traditions of pre-Islamic Arabs were more accommodating of sex. Women were sought for wedlock and not debauchery and reference is made to both transvestism and transexualism in historic documents (p. 234). However, a contradiction to the sex-positive view was that women were seen as inferior and subservient to men.
Paraphilias and culture
Introduction
Definitions
Paraphilic disorder
Type of paraphilia
Description
Voyeuristic Disorder
Urge or practice of observing an unsuspecting person who is naked, undressing, or engaging in sexual activity, or in activity deemed to be private
Exhibitionistic Disorder
Exposing one’s genitals to an unsuspecting person or performing sexual acts that can be observed by others
Frotteuristic Disorder
Touching or rubbing against a non-consenting person
Sexual Masochism Disorder
A desire to be humiliated, beaten, bound, or made to suffer for sexual pleasure
Sexual Sadism Disorder
Sexual pleasure through the infliction of pain or humiliation on another person
Pedophilic Disorder
Sexual preference for prepubescent children
Fetishistic Disorder
Use of inanimate objects to gain sexual excitement
Transvestic Disorder
Arousal from clothing associated with members of the opposite sex
Other specified paraphilic disorders:
Zoophilia
Scatologia
Necrophilia
Urophilia
Culture and the individual
Types of cultures
Sociocultural aspects of human sexuality
Deviance
Type
Cultural influences
Biological influences
Normal
Masturbation
+++
+
Oral sex
+++
?
Premarital sex
+++
?
Subcultural
Fetishism
+
?
Sadomasochism
+
?
Transsexualism
+
++
Transvestism
++
?
Individual
Exhibitionist
+
?
Rape
?
?
Incest
?
?
Sexual behaviours, attitudes, and culture
Sex positive and negative cultures
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