CASE REPORT
A Female Sex Offender with Multiple Paraphilias: A Psychologic, Physiologic (Laboratory Sexual Arousal) and Endocrine Case Study* A.J. COOPER, M.D.', S. SWAMINATH, M.B. 2, D. BAXTER, Ph.D. 3 AND C. POULIN, B.A. 4 A 20 year old female pedophile exhibiting multiple paraphilias and who had been both a victim of incest and an active participant, undertook extensive clinical, psychometric, endocrine and laboratory sexual arousal studies. Her psychiatric, psychometric and physiologic arousal profiles showed similarities to those of a sizable proportion of male child molesters, especially incestors. It is suggested that laboratory arousal tests (using the vaginal photoplethysmograph) may have a role in the assessment of some female sex offenders.
female. According to Groth (I) the true incidence of sexual offenses committed by female adults against children is much higher than would be suspected from published crime statistics. Nevertheless the phenomenon remains singularly rare in comparison to males. There are very few detailed reports of female sexual offenders in the literature. In some cases there were one or more male accomplices, and it was not always clear whether the woman's role was that of an initiator/active participant or whether she simply assisted passively. Other offenders suffered from a psychosis at the time of the incident. Illustratively, of the eight female offenders described in the Badgely report, five were accomplices to acts perpetrated by a spouse or boyfriend and only one appeared to have been the "active abuser." Another offender had manic depressive psychosis and one seduced a 14 year old boy while involved in a consensual relationship (she had no prior or subsequent history of sexual misconduct). Only one of the eight was clearly a nonpsychotic active child molester; she abused her two sons, and was herself the victim of parental incest over several years. This case report is of interest for several reasons. We describe a young woman who was both a victim of sexual abuse and a hypersexual child molester. She acted alone and was not suffering from a psychosis during the offenses. In addition to detailed clinical examinations, she undertook extensive psychometric, endocrinologic, electroencephalographic, and vaginal photoplethysmographic evaluations. It is considered that this type of multi measure protocol (which closely parallels that recommended for male offenders) (7) could be employed in female offenders. Much potentially useful data might be generated.
F
emale sexual offenders are seen rarely in clinical practice (1,2). Groth (1), who examined 253 child molesters, found only three cases (1.1 %). Sarel and Masters (2) whose combined results span 21 years, unearthed only 11 men who complained of being sexually abused by a woman in over 4,000 cases (700 men and 3,500 couples) attending sexuality clinics in New Haven and St. Louis. In Canada, the Badgely Commission (3), which surveyed 727 convicted sexual offenders, found only eight (1.1 %) examples of males abused by females. However, other estimates referred to in this report point to a somewhat higher figure in the order of 1.8% to 2.8%, but even this may be too low. Davis and Leitenberg (4) and Fehrenbach et al (5) suggested that for adolescent sexual offenders, females account for approximately two percent of forceable assaults and five to seven percent of other types. Halliday (6) reported that some 13% of her cases "involved" females, the majority of whom transgressed while babysitting, counseling, or mothering the victim. However, many colluded with, or were provoked by a male who was actively involved in the offense. Groth (1), in a retrospective study of 348 male sexual offenders found, that as children, 8.3% had been sexually molested by a female adult and 4.3% by a peer age group
Case History Miss K was an unmarried caucasian woman aged 20 who was referred for a pretrial examination having been charged with two counts of sexual assault on two sisters, aged four and five. Sexual contact had occurred repeatedly over several months, during babysitting. Abusive acts included slapping the children, inserting pencils and other objects into their vaginas and performing oral sex on them. During these activities she usually felt angry, although not always with the victims. She had become increasingly preoccupied with violent sexual fantasies involving the children and was
*Manuscript received November 1988; revised May 1989. I Professor of Psychiatry, University of Western Ontario, London, Ontario; Director of Research, 51. Thomas Psychiatric Hospital, St. Thomas, Ontario. 2Assistant Professor of Psychiatry, University of Western Ontario, London, Ontario; Director Forensic Services. 51. Thomas Psychiatric Hospital, 51. Thomas, Ontario. ]Department of Psychology, Rideau Treatment Centre. Burritts Rapids, Ontario. 4Dcpartment of Psychology, Queen's University, Kingston, Qntario.
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becoming more apprehensive about possibly acting these out. Miss K also admitted that she had sexually molested several other young boys and girls over the previous two or three years, again while babysitting. However, these incidents had not come to police attention, and at the time of her assessment she had no known prior criminal record.
sexual sadism 302.84, and zoophilia 302.90) with hypersexuality and somatization disorder (seizures 300.81). Her main complaints were almost continuous preoccupation with often violent sexual fantasies involving adults and children of both sexes, unremitting sexual tension and prolonged compulsive masturbation.
Developmental' History
Psychometric Testing
Miss K was the youngest of four children and the only daughter. She was born six weeks premature, weighing Sibs 6 oz, and required blood transfusions as a result of Rhesus factor incompatibility. As a preschooler, she had frequent temper tantrums, which she attributed to parental overprotection and lack of consistent discipline. In addition, she was an obese child, and was still obese as an adult. The family moved frequently and the children were not encouraged to socialize outside the home. School grades were generally good despite the many moves. For these reasons, she had few friends during her childhood. She reached puberty at age 12.
Miss K completed the Wechsler Adult Intelligence Scale - Revised (WAIS-R), the MMPI, the Derogatis Sexual Functioning Inventory (DSFI) and the Luria-Nebraska Neurospychological Battery (LNNB). She was cooperative throughout testing, which was uneventful. On the WAIS-R she scored in the average range of intelligence (verbal IQ=96, performance IQ = 88, full scale IQ=92). There was no suggestion of defective memory or attention, although some slight impairment of visuo-motor coordination was evident. All of her scores on the LNNB were within the normal range. However, consistent with the findings in the W AISR she exhibited some mild difficulties in motor coordination and rhythm. Overall, neither of the above tests showed any evidence of significant cerebral dysfunction. The MMPI showed several markedly elevated clinical scales indicating depression, anxiety, somatic preoccupation, chronic hostility and resentment, and social alienation and isolation. Indivuduals with this type of profile are typically naive, immature and egocentric with very poor impulse controls. They tend to be distrustful, interpersonally sensitive and emotionally labile with inner conflicts about sexuality and dependency, deep feelings of insecurity and inadequacy, and exaggerated needs for affection and attention. They often respond to stress with increased somatic preoccupation or withdrawal into fantasy and daydreams. These psychometric findings are congruent with the clinical diagnosis of borderline personality disorder. Similar profiles have been reported as typical of adolescent and adult incest survivors (8-10) and some male child molesters (11,12). The DSFI scores revealed limited sex knowledge, low selfesteem, negative-conservative attitudes towards sex, and extreme dissatisfaction with her physical appearance (for example, body image). This was coupled with high sex drive and an extremely high sexual fantasy score. Taken together with the MMPI, the findings indicate an obsessive preoccupation with sex.
Sexual History Miss K alleged that she was repeatedly sexually molested by a maternal uncle when aged three. He was later imprisoned for assaulting his' own child. When she was 12, a 14 year old brother began to engage her in a variety of sexual activities. These included mutual genital fondling, oral genital stimulation and later, sexual intercourse. On the one hand she viewed her involvement as "wrong" and "not normal"; at the same time she derived considerable gratification from the emotional closeness and physical pleasure and recognized she had intense sexual cravings. At age 14, a second brother then 16 also began sexually abusing her, but in a much more aggressive manner. They began to experiment with sadomasochistic practices such as bondage, which she found particularly exhilarating. Her sexual fantasies took on more and more sadomasochistic and violent themes. The sexual abuse by her brothers continued until she left home at 17. Since then there have been two incidents of unwanted sexual advances by older men. During her childhood Miss K admitted initiating manual-genital and oral genital stimulation with a dog and a cat, both male family pets. Sex with animals was and is a frequent fantasy for her.
Significant Medical and Psychiatric History At age 15 Miss K had been diagnosed as suffering from grand mal epilepsy. However, as a result of more recent extensive evaluation (including serial waking and sleeping EEGs over two years), this diagnosis had been revised to "hysterical seizures." Miss K had an extensive psychiatric history. Since early adolescence she had complained of frequent depression with suicidal ideation. She had attended many crisis centres usually following suicidal gestures, and she had twice been hospitalized for the same reasons. At the time of this assessment her DSM-III-R diagnosis was borderline personality disorder (301.83), multiple paraphilias (notably pedophilia 302.20,
Sexual Arousal Studies Arousal studies were carried out in a standard sexual laboratory, using the vaginal photoplethysmograph (13-15), and a Grass model 8 polygraph. The system allows four arousal-dependent measures: vaginal blood volume (YBY), vaginal pulse rate (YPR), vaginal pulse amplitude (YPA) and response duration. Miss K was shown a battery of sexual slides comprising nude males and females of different ages, and adults and children engaging in a variety of sexual activities. The essential slide contents are shown in Figure 1. Testing commenced after five minutes of baseline recording, during which there was minimal fluctuation
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Figure 1. Peak vaginal pulse amplitude (VPA) to erotic slides.
(baseline= 0.0 cm of pen deflection, Figure 1). Each slide was exhibited for 30 seconds, and the interval between successive stimuli was as long as it took Miss K to return to baseline. The peak responses (ern of pen deflection) occurring during the presentation of each slide and in the 30 seconds immediately following (post-stimulus response) are seen in Figure 1. There were some initial difficulties with movement artifacts. Nevertheless, Miss K showed substantial levels of relatively undifferentiated "physiological" sexual arousal (for example, up to 2.5 em of pen deflection to an adult nude male). This was consistent with both her subjective experiences reported throughout the testing and her admitted sexual fantasies. During the assessment Miss K frequently responded to the point of orgasm. Overall, the data suggest polymorphous eroticism, with sadistic, masochistic and pedophiliac elements together with a considerable degree of hostility and aggression. They are congruent with the earlier and present clinical histories. Interestingly, Miss K admitted feeling angry at the models in some of the slides shown during testing. She felt that her anger enhanced rather than interferred with her subjective sexual arousal to those slides.
Endocrinologic Studies Serum levels of testosterone, progesterone, 17 B-estrodiol, follicle stimulating hormone, luteinizing hormone and prolactin were assayed on four occasions during the assessment period. Thyroid function was assessed twice. For the most part all test results remained within the normal range. Comment There are marked similarities between Miss K and some male sexual offenders in their developmental characteristics (for example, extensive family sexual abuse) and psychiatric diagnosis (for example, borderline personality disorder) (15-19). However" this does not imply that all individuals with such features will become sexual offenders, neither will all sexual offenders possess these stigmata. In the majority of instances there are likelyto be overlapping and dynamic elements including genetic, experiential, eNS (for example, epilepsy, mental retardation, dementia), hormonal (for example, androgens) and psychiatric (for example, mania) (7). For male offenders there is a correlation (weak) between elevated serum testosterone and "physical" aggression, with or without a sexual component (20). In females, the
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relationship between androgens and physical and sexual aggression is more tenuous. However, females fetuses exposed in utero to progestins taken by their mothers during pregnancy to reduce the likelihood of miscarriage, or who after birth or later in childhood develop adrenal hyperplasia, and excessive secretion of corticosteroids (including testosterone), have been shown to be more aggressive physically and more' active sexually (7). Moreover, the antiandrogen drug cyproterone acetate has been used successfully as a treatment for hypersexuality in women (2). Hyperthyroidism may also be associated with increased libido but Miss K's thyroid function tests were within normal limits. Her serum testosterone levels were also normal, but it has recently been hypothesized that female hypersexuality may be more a function of "super-sensitive" androgen receptors, or receptor proliferation than testosterone levels per se (22). In addition to the personality and psychiatric parallels between Miss K and some male sexual offenders, her undifferentiated physiologic sexual arousal pattern was similar to that of 40 % "Of male incestuous child molesters (23); Miss K was both a victim and (later) a perpetrator of incestuous sexual exchanges. Whether or not victims of incest who do not themselves become sexual offenders may show similar arousal profiles is a provocative research question. To date, vaginal photoplethysmography, unlike penile plethysmography or phallometry (in male offenders), has hardly been used in the assessment of female sexual offenders. However, since the physiologic mechanisms of arousal are homologous for both sexes, perhaps it could be employed more often. Female offenders, like male offenders, are likely to be heterogenous and show variable arousal profiles. Nevertheless in the individual case, photoplethysmography may assist in confirming a sexual preference (for example, for child or adult, male or female; a predilection for violent rather than than nonviolent sex) and strength of "sex drive" etc. Providing certain precautions are observed the procedure may generate useful information on those who deny or understate a problem. It may also furnish baseline data against which the effects of any treatment (for example, drugs) could be evaluated longitudinally.
7. Cooper AJ. The treatment of sexual offenders with antiandrogens. Todays Therapeutic Trends 1988; 6(1): 15-34. 8. Meiselman KC. Personality characteristics of incest history psychotherapy patients: a research note. Arch Sex Behav 1980; 9: 195-197. 9. Scott RL, Stone DA. MMPI profile constellations in incest families. J Consult Clin Psychol 1986; 54: 364-368. 10. Scott RL, Stone DA. MMPI measures of psychological disturbance in adolescent and adult victims of father-daughter incest. J Clin Psycho) 1986; 42: 251-259. II. Hall GCN, Maiuro RD, Vitaliano PP, et al. The utility of the MMPI with men who have sexually assaulted children. J Consult Clin Psychol 1986; 54: 493-496. 12. Panton JH. MMPI profile configurations associated with incestuous and nonincestuous child molesting. Psychol Rep 1979; 45: 335-338. 13. Henson C, Rubin HB, Henson DE. Woman's sexual arousal concurrently assessed by three genital measures. Arch Sex Behav 1979; 8: 459-469. 14. Wincze JP, Hoon EF, Hoon PW. Physiological responsivity of normal and sexually dysfunctional women during erotic stimulus exposure. J Psychosom Res 1976; 20: 445-451. IS. MorokoffPJ, Heiman JR. Effects of erotic stimuli on sexually functional and dysfunctional women. Behav Res Ther 1980; 18: 127-137. 16. Mills TL, Rieker PP, Carmen EH. Hospitalizationexperiences of victims of abuse. Victimology 1984; 9: 436-449. 17. Steele BF. Notes on the lasting effects of early child abuse throughout the life cycle. Child Abuse Negl 1986; 10: 283-291. 18. Browne A, Finkelhor D. Impactof child sexual abuse: a review. Psychol Bull 1986; 99: 66-77. 19. Carmen E, Rieker PP, Mills T. Victims of violence and psychiatric illness. Am J Psychiatry 1984; 141: 378-383. 20. Bradford JW, McLean D. Sexual offenders, violence and testosterone: a clinical study. Can J Psychiatry 1984: 29(4): 335-343. 21. Mellor CS, Farid NR, Craig DF. Female hypersexuality treated with cyproterone acetate. Am J Psychiatry 1988; 145(8): 1037. 22. Goodman JD. The behaviour of hypersexual delinquent girls. Am J Psychiatry 1976; 133(6): 662-668. 23. Barbaree HE, Marshal WL. Erectile responses amongst heterosexual child molesters: father-daughter incest offenders, and matched non-offenders - five distinct age preference profiles. Can J Behav Sci 1989; 21(1): 70-82.
References I. Groth AN. Sexual trauma in the life histories of rapists and child molesters. Victimology: An International Journal 1979; 4: 10-16. 2. Sarel PM, Masters WHo Sexual molestation of men by women. Arch Sex Behav 1982; II: 117-131. 3. Badgely R (Chairman). Sexual offences againstchildren, volume 2. Report of the Committee on Sexual Offences Against Children and Youths to the Government of Canada, August 1984. 4. Davis GE, Leitenberg H. Adolescent sex offenders. Psychol Bull 1987; 101(3): 417-427. 5. Fehrenbach PA, Smith W, Monastersky C, et al. Adolescent sexual offenders: offenders and offence characteristics. Am J Orthopsychiatry 1986; 56(2): 225-233. 6. Halliday L. Sexual abuse: interviewing techniques for police and other professionals. Campbell River, BC: Ptarmigan Press, 1986.
Resume Vne pedophile de 20 ans, qui manifestait plusieurs perversions sexuelles et avait ett! victime d 'inceste, mais y avait aussi pris part activement, a subi une vaste gamme d 'examens cliniques, psychometriques et endocriniens ainsi que des tests d'excitation sexuelle en laboratoire approfondis. Les profils psychiatrique, psychometrique et d'excitation physiologique de la malade ressemblent ii ceux d'un grand nombre de pedophiles males, particulierement ceux coupables d'inceste. Les resultats donnent a penser que les tests d'excitation sexuelle en laboratoire (au moyen du photoplethysmographe vaginal) pourraient etre utiles lorsqu '011 evalue des delinquantes sexuelles.
A Female Sex Offender with Multiple Paraphilias: A Psychologic, Physiologic (Laboratory Sexual Arousal) and Endocrine Case Study* A.J. COOPER, M.D.', S. SWAMINATH, M.B. 2, D. BAXTER, Ph.D. 3 AND C. POULIN, B.A. 4 A 20 year old female pedophile exhibiting multiple paraphilias and who had been both a victim of incest and an active participant, undertook extensive clinical, psychometric, endocrine and laboratory sexual arousal studies. Her psychiatric, psychometric and physiologic arousal profiles showed similarities to those of a sizable proportion of male child molesters, especially incestors. It is suggested that laboratory arousal tests (using the vaginal photoplethysmograph) may have a role in the assessment of some female sex offenders.
female. According to Groth (I) the true incidence of sexual offenses committed by female adults against children is much higher than would be suspected from published crime statistics. Nevertheless the phenomenon remains singularly rare in comparison to males. There are very few detailed reports of female sexual offenders in the literature. In some cases there were one or more male accomplices, and it was not always clear whether the woman's role was that of an initiator/active participant or whether she simply assisted passively. Other offenders suffered from a psychosis at the time of the incident. Illustratively, of the eight female offenders described in the Badgely report, five were accomplices to acts perpetrated by a spouse or boyfriend and only one appeared to have been the "active abuser." Another offender had manic depressive psychosis and one seduced a 14 year old boy while involved in a consensual relationship (she had no prior or subsequent history of sexual misconduct). Only one of the eight was clearly a nonpsychotic active child molester; she abused her two sons, and was herself the victim of parental incest over several years. This case report is of interest for several reasons. We describe a young woman who was both a victim of sexual abuse and a hypersexual child molester. She acted alone and was not suffering from a psychosis during the offenses. In addition to detailed clinical examinations, she undertook extensive psychometric, endocrinologic, electroencephalographic, and vaginal photoplethysmographic evaluations. It is considered that this type of multi measure protocol (which closely parallels that recommended for male offenders) (7) could be employed in female offenders. Much potentially useful data might be generated.
F
emale sexual offenders are seen rarely in clinical practice (1,2). Groth (1), who examined 253 child molesters, found only three cases (1.1 %). Sarel and Masters (2) whose combined results span 21 years, unearthed only 11 men who complained of being sexually abused by a woman in over 4,000 cases (700 men and 3,500 couples) attending sexuality clinics in New Haven and St. Louis. In Canada, the Badgely Commission (3), which surveyed 727 convicted sexual offenders, found only eight (1.1 %) examples of males abused by females. However, other estimates referred to in this report point to a somewhat higher figure in the order of 1.8% to 2.8%, but even this may be too low. Davis and Leitenberg (4) and Fehrenbach et al (5) suggested that for adolescent sexual offenders, females account for approximately two percent of forceable assaults and five to seven percent of other types. Halliday (6) reported that some 13% of her cases "involved" females, the majority of whom transgressed while babysitting, counseling, or mothering the victim. However, many colluded with, or were provoked by a male who was actively involved in the offense. Groth (1), in a retrospective study of 348 male sexual offenders found, that as children, 8.3% had been sexually molested by a female adult and 4.3% by a peer age group
Case History Miss K was an unmarried caucasian woman aged 20 who was referred for a pretrial examination having been charged with two counts of sexual assault on two sisters, aged four and five. Sexual contact had occurred repeatedly over several months, during babysitting. Abusive acts included slapping the children, inserting pencils and other objects into their vaginas and performing oral sex on them. During these activities she usually felt angry, although not always with the victims. She had become increasingly preoccupied with violent sexual fantasies involving the children and was
*Manuscript received November 1988; revised May 1989. I Professor of Psychiatry, University of Western Ontario, London, Ontario; Director of Research, 51. Thomas Psychiatric Hospital, St. Thomas, Ontario. 2Assistant Professor of Psychiatry, University of Western Ontario, London, Ontario; Director Forensic Services. 51. Thomas Psychiatric Hospital, 51. Thomas, Ontario. ]Department of Psychology, Rideau Treatment Centre. Burritts Rapids, Ontario. 4Dcpartment of Psychology, Queen's University, Kingston, Qntario.
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becoming more apprehensive about possibly acting these out. Miss K also admitted that she had sexually molested several other young boys and girls over the previous two or three years, again while babysitting. However, these incidents had not come to police attention, and at the time of her assessment she had no known prior criminal record.
sexual sadism 302.84, and zoophilia 302.90) with hypersexuality and somatization disorder (seizures 300.81). Her main complaints were almost continuous preoccupation with often violent sexual fantasies involving adults and children of both sexes, unremitting sexual tension and prolonged compulsive masturbation.
Developmental' History
Psychometric Testing
Miss K was the youngest of four children and the only daughter. She was born six weeks premature, weighing Sibs 6 oz, and required blood transfusions as a result of Rhesus factor incompatibility. As a preschooler, she had frequent temper tantrums, which she attributed to parental overprotection and lack of consistent discipline. In addition, she was an obese child, and was still obese as an adult. The family moved frequently and the children were not encouraged to socialize outside the home. School grades were generally good despite the many moves. For these reasons, she had few friends during her childhood. She reached puberty at age 12.
Miss K completed the Wechsler Adult Intelligence Scale - Revised (WAIS-R), the MMPI, the Derogatis Sexual Functioning Inventory (DSFI) and the Luria-Nebraska Neurospychological Battery (LNNB). She was cooperative throughout testing, which was uneventful. On the WAIS-R she scored in the average range of intelligence (verbal IQ=96, performance IQ = 88, full scale IQ=92). There was no suggestion of defective memory or attention, although some slight impairment of visuo-motor coordination was evident. All of her scores on the LNNB were within the normal range. However, consistent with the findings in the W AISR she exhibited some mild difficulties in motor coordination and rhythm. Overall, neither of the above tests showed any evidence of significant cerebral dysfunction. The MMPI showed several markedly elevated clinical scales indicating depression, anxiety, somatic preoccupation, chronic hostility and resentment, and social alienation and isolation. Indivuduals with this type of profile are typically naive, immature and egocentric with very poor impulse controls. They tend to be distrustful, interpersonally sensitive and emotionally labile with inner conflicts about sexuality and dependency, deep feelings of insecurity and inadequacy, and exaggerated needs for affection and attention. They often respond to stress with increased somatic preoccupation or withdrawal into fantasy and daydreams. These psychometric findings are congruent with the clinical diagnosis of borderline personality disorder. Similar profiles have been reported as typical of adolescent and adult incest survivors (8-10) and some male child molesters (11,12). The DSFI scores revealed limited sex knowledge, low selfesteem, negative-conservative attitudes towards sex, and extreme dissatisfaction with her physical appearance (for example, body image). This was coupled with high sex drive and an extremely high sexual fantasy score. Taken together with the MMPI, the findings indicate an obsessive preoccupation with sex.
Sexual History Miss K alleged that she was repeatedly sexually molested by a maternal uncle when aged three. He was later imprisoned for assaulting his' own child. When she was 12, a 14 year old brother began to engage her in a variety of sexual activities. These included mutual genital fondling, oral genital stimulation and later, sexual intercourse. On the one hand she viewed her involvement as "wrong" and "not normal"; at the same time she derived considerable gratification from the emotional closeness and physical pleasure and recognized she had intense sexual cravings. At age 14, a second brother then 16 also began sexually abusing her, but in a much more aggressive manner. They began to experiment with sadomasochistic practices such as bondage, which she found particularly exhilarating. Her sexual fantasies took on more and more sadomasochistic and violent themes. The sexual abuse by her brothers continued until she left home at 17. Since then there have been two incidents of unwanted sexual advances by older men. During her childhood Miss K admitted initiating manual-genital and oral genital stimulation with a dog and a cat, both male family pets. Sex with animals was and is a frequent fantasy for her.
Significant Medical and Psychiatric History At age 15 Miss K had been diagnosed as suffering from grand mal epilepsy. However, as a result of more recent extensive evaluation (including serial waking and sleeping EEGs over two years), this diagnosis had been revised to "hysterical seizures." Miss K had an extensive psychiatric history. Since early adolescence she had complained of frequent depression with suicidal ideation. She had attended many crisis centres usually following suicidal gestures, and she had twice been hospitalized for the same reasons. At the time of this assessment her DSM-III-R diagnosis was borderline personality disorder (301.83), multiple paraphilias (notably pedophilia 302.20,
Sexual Arousal Studies Arousal studies were carried out in a standard sexual laboratory, using the vaginal photoplethysmograph (13-15), and a Grass model 8 polygraph. The system allows four arousal-dependent measures: vaginal blood volume (YBY), vaginal pulse rate (YPR), vaginal pulse amplitude (YPA) and response duration. Miss K was shown a battery of sexual slides comprising nude males and females of different ages, and adults and children engaging in a variety of sexual activities. The essential slide contents are shown in Figure 1. Testing commenced after five minutes of baseline recording, during which there was minimal fluctuation
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Figure 1. Peak vaginal pulse amplitude (VPA) to erotic slides.
(baseline= 0.0 cm of pen deflection, Figure 1). Each slide was exhibited for 30 seconds, and the interval between successive stimuli was as long as it took Miss K to return to baseline. The peak responses (ern of pen deflection) occurring during the presentation of each slide and in the 30 seconds immediately following (post-stimulus response) are seen in Figure 1. There were some initial difficulties with movement artifacts. Nevertheless, Miss K showed substantial levels of relatively undifferentiated "physiological" sexual arousal (for example, up to 2.5 em of pen deflection to an adult nude male). This was consistent with both her subjective experiences reported throughout the testing and her admitted sexual fantasies. During the assessment Miss K frequently responded to the point of orgasm. Overall, the data suggest polymorphous eroticism, with sadistic, masochistic and pedophiliac elements together with a considerable degree of hostility and aggression. They are congruent with the earlier and present clinical histories. Interestingly, Miss K admitted feeling angry at the models in some of the slides shown during testing. She felt that her anger enhanced rather than interferred with her subjective sexual arousal to those slides.
Endocrinologic Studies Serum levels of testosterone, progesterone, 17 B-estrodiol, follicle stimulating hormone, luteinizing hormone and prolactin were assayed on four occasions during the assessment period. Thyroid function was assessed twice. For the most part all test results remained within the normal range. Comment There are marked similarities between Miss K and some male sexual offenders in their developmental characteristics (for example, extensive family sexual abuse) and psychiatric diagnosis (for example, borderline personality disorder) (15-19). However" this does not imply that all individuals with such features will become sexual offenders, neither will all sexual offenders possess these stigmata. In the majority of instances there are likelyto be overlapping and dynamic elements including genetic, experiential, eNS (for example, epilepsy, mental retardation, dementia), hormonal (for example, androgens) and psychiatric (for example, mania) (7). For male offenders there is a correlation (weak) between elevated serum testosterone and "physical" aggression, with or without a sexual component (20). In females, the
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A FEMALE SEX OFFENDER
relationship between androgens and physical and sexual aggression is more tenuous. However, females fetuses exposed in utero to progestins taken by their mothers during pregnancy to reduce the likelihood of miscarriage, or who after birth or later in childhood develop adrenal hyperplasia, and excessive secretion of corticosteroids (including testosterone), have been shown to be more aggressive physically and more' active sexually (7). Moreover, the antiandrogen drug cyproterone acetate has been used successfully as a treatment for hypersexuality in women (2). Hyperthyroidism may also be associated with increased libido but Miss K's thyroid function tests were within normal limits. Her serum testosterone levels were also normal, but it has recently been hypothesized that female hypersexuality may be more a function of "super-sensitive" androgen receptors, or receptor proliferation than testosterone levels per se (22). In addition to the personality and psychiatric parallels between Miss K and some male sexual offenders, her undifferentiated physiologic sexual arousal pattern was similar to that of 40 % "Of male incestuous child molesters (23); Miss K was both a victim and (later) a perpetrator of incestuous sexual exchanges. Whether or not victims of incest who do not themselves become sexual offenders may show similar arousal profiles is a provocative research question. To date, vaginal photoplethysmography, unlike penile plethysmography or phallometry (in male offenders), has hardly been used in the assessment of female sexual offenders. However, since the physiologic mechanisms of arousal are homologous for both sexes, perhaps it could be employed more often. Female offenders, like male offenders, are likely to be heterogenous and show variable arousal profiles. Nevertheless in the individual case, photoplethysmography may assist in confirming a sexual preference (for example, for child or adult, male or female; a predilection for violent rather than than nonviolent sex) and strength of "sex drive" etc. Providing certain precautions are observed the procedure may generate useful information on those who deny or understate a problem. It may also furnish baseline data against which the effects of any treatment (for example, drugs) could be evaluated longitudinally.
7. Cooper AJ. The treatment of sexual offenders with antiandrogens. Todays Therapeutic Trends 1988; 6(1): 15-34. 8. Meiselman KC. Personality characteristics of incest history psychotherapy patients: a research note. Arch Sex Behav 1980; 9: 195-197. 9. Scott RL, Stone DA. MMPI profile constellations in incest families. J Consult Clin Psychol 1986; 54: 364-368. 10. Scott RL, Stone DA. MMPI measures of psychological disturbance in adolescent and adult victims of father-daughter incest. J Clin Psycho) 1986; 42: 251-259. II. Hall GCN, Maiuro RD, Vitaliano PP, et al. The utility of the MMPI with men who have sexually assaulted children. J Consult Clin Psychol 1986; 54: 493-496. 12. Panton JH. MMPI profile configurations associated with incestuous and nonincestuous child molesting. Psychol Rep 1979; 45: 335-338. 13. Henson C, Rubin HB, Henson DE. Woman's sexual arousal concurrently assessed by three genital measures. Arch Sex Behav 1979; 8: 459-469. 14. Wincze JP, Hoon EF, Hoon PW. Physiological responsivity of normal and sexually dysfunctional women during erotic stimulus exposure. J Psychosom Res 1976; 20: 445-451. IS. MorokoffPJ, Heiman JR. Effects of erotic stimuli on sexually functional and dysfunctional women. Behav Res Ther 1980; 18: 127-137. 16. Mills TL, Rieker PP, Carmen EH. Hospitalizationexperiences of victims of abuse. Victimology 1984; 9: 436-449. 17. Steele BF. Notes on the lasting effects of early child abuse throughout the life cycle. Child Abuse Negl 1986; 10: 283-291. 18. Browne A, Finkelhor D. Impactof child sexual abuse: a review. Psychol Bull 1986; 99: 66-77. 19. Carmen E, Rieker PP, Mills T. Victims of violence and psychiatric illness. Am J Psychiatry 1984; 141: 378-383. 20. Bradford JW, McLean D. Sexual offenders, violence and testosterone: a clinical study. Can J Psychiatry 1984: 29(4): 335-343. 21. Mellor CS, Farid NR, Craig DF. Female hypersexuality treated with cyproterone acetate. Am J Psychiatry 1988; 145(8): 1037. 22. Goodman JD. The behaviour of hypersexual delinquent girls. Am J Psychiatry 1976; 133(6): 662-668. 23. Barbaree HE, Marshal WL. Erectile responses amongst heterosexual child molesters: father-daughter incest offenders, and matched non-offenders - five distinct age preference profiles. Can J Behav Sci 1989; 21(1): 70-82.
References I. Groth AN. Sexual trauma in the life histories of rapists and child molesters. Victimology: An International Journal 1979; 4: 10-16. 2. Sarel PM, Masters WHo Sexual molestation of men by women. Arch Sex Behav 1982; II: 117-131. 3. Badgely R (Chairman). Sexual offences againstchildren, volume 2. Report of the Committee on Sexual Offences Against Children and Youths to the Government of Canada, August 1984. 4. Davis GE, Leitenberg H. Adolescent sex offenders. Psychol Bull 1987; 101(3): 417-427. 5. Fehrenbach PA, Smith W, Monastersky C, et al. Adolescent sexual offenders: offenders and offence characteristics. Am J Orthopsychiatry 1986; 56(2): 225-233. 6. Halliday L. Sexual abuse: interviewing techniques for police and other professionals. Campbell River, BC: Ptarmigan Press, 1986.
Resume Vne pedophile de 20 ans, qui manifestait plusieurs perversions sexuelles et avait ett! victime d 'inceste, mais y avait aussi pris part activement, a subi une vaste gamme d 'examens cliniques, psychometriques et endocriniens ainsi que des tests d'excitation sexuelle en laboratoire approfondis. Les profils psychiatrique, psychometrique et d'excitation physiologique de la malade ressemblent ii ceux d'un grand nombre de pedophiles males, particulierement ceux coupables d'inceste. Les resultats donnent a penser que les tests d'excitation sexuelle en laboratoire (au moyen du photoplethysmographe vaginal) pourraient etre utiles lorsqu '011 evalue des delinquantes sexuelles.
