SEXUAL ABUSE AND TREATMENT

By Jurriaan Plesman BA(Psych), Post Grad Dip Clin Nutr

The community demands that men who commit horrendous crimes, such as rape and pedophilia, be brought to justice and sentenced, so as to protect all members of society against their predatory behaviour.
The question is what happens to these men after they have been placed under the control of the state. Is their any hope for their rehabilitation? If so, what prompted these men to offend against the moral and legal standards of society? What flaws in their personality brought them into conflict with civilization and if so, can these be 'treated'. More importantly, how can we prevent these crimes after having gained some insight into the contributory factors of sexual abuse? Some of these issues are discussed in this article.

Sexual assault and the treatment of sexual offenders is a controversial subject. Some authors believe sex offenders have been singled out for differential treatment by the legal and mental health systems. 1 Others maintain based on results obtained from a meta-analysis of 43 studies, that the average rate of recidivism of sexual offenders are no different from other offences which are known to have high recidivist rates. The recidivism of treated sex offenders were assessed at 12.3% compared to non-treatment 16.8 %. A similar pattern was found for general recidivism, although the overall rates were predictably higher (treatment 27.9%, comparison 39.2%, 30 studies) 2 Some of these studies show that treatment of sexual offenders is worthwhile, compared to the usual punitive approach by means of incarceration of offenders.

It will be argued in this article that the problem of recidivism in criminal behaviour is influenced by ‘treatment’ programs that generally ignore the biochemical/metabolic aspects of behaviour. This is turn may be due to the body/mind controversy so prevalent in Western academia, that finds it difficult to accept that, scientifically, there is no gap between the science of psychology and medicine. This separation of body and mind is symbolically represented in our universities where the departments of psychology and medicine are sharply demarcated. It could also reflect the economic basis of the mind/body controversy, stemming more from economic competition between the two branches of science vying for the almighty dollar in the wider community.

Whatever the rationale, there are still many ‘therapists’ that cannot see the connection between the hypoglycemic disease - a metabolic disorder - and mental illness, between nutrition and behaviour. So long this lasts the mystery of recidivism - really they should be seen as treatment failures - will baffle the pundits. For further reading see: The Serotonin Connectionand The Forgotten Factor in the Crime Debate at this web site.

There are many definitions of sexual abuse, but the broadest possible definition of sexual abuse is when a person, usually a male, forces his sexual desire upon another without the consent of that person. It is often accompanied by signs of various mood disorders, such as depression leading to unsatisfactory life-styles. It is non-consensual sex. Thus sexual abuse is often linked to aggression and often violent behaviour, although less so among child molesters. 3 The NSW Bureau of Statistics recorded an increase in the number of sexual assaults from 2272 to 2996 or an increase of 30% over the period from 1995 to 1999.

Conservative estimates of sexual assault prevalence suggest that 25 percent of American women have experienced sexual assault, including rape. Approximately one-half of those cases involve alcohol consumption by the perpetrator, victim, or both. 4 Although actual figures are difficult to obtain, there was one estimate that approximately 336,200 sexual offences are committed against children every year in the United States.5

From a definitional point of view many questions arise, such as whether marital infidelity or prostitution is a form of sexual abuse. When women are brought into prostitution against their will, this would be sexual abuse. Is fetishism sexual abuse, when a person obtains sexual gratification from masturbating in the presence of lady’s underwear? Most would agree that rape, incest, inappropriate touching, pedophilia, exhibitionism, and physical or verbal harassment, exposing children to pornographic material or using children in the production of pornography all constitutes sexual abuse.

Whatever form sexual abuse takes it arouses very powerful emotions within us, that often prevent us from looking rationally at some of the causes of this kind of behaviour. This is especially so, when children are the victims, and usually perpetrators are not even safe from fellow inmates who subscribe to their own kind of violent justice in the prison system.

If we had some understanding of human sexuality it could help us prevent getting into situations of sexual abuse and also provide some treatment for those willing to change their behaviour. Remember that most sentenced sexual offenders are ultimately released into the community.

Theoretical/philosophical model explaining sexual abuse
One way of getting an understanding of this kind of offensive behaviour is to go back to our roots in the mammalian animal kingdom. Most sexual offences can be traced to elements of sexual behaviour among our mammalian ancestors. Rape, gang-rape, stalking, sexual harassment among humans, you name it, any sexual offence appears to be a throwback to earlier genetic times. In times of war - when civilisation breaks down - these behaviours seem to emerge from just underneath the skin of our ‘culture’. It is as if some men - and let us face it, most offenders are males - behave under the influence of some mysterious genes dating back to prehistoric times. But let me emphasise that most men have their feet firmly planted in civilised society and are often equally at a loss to understand the motivation of sexual abusers.

When we study these animals we see that there are vast differences in the sexual behaviour of males and females. When we observe mammalian animals we can only come to the conclusion that there is a lot of conflict - often violent from our point of view - between males and females.

Aggression among animals is closely tied to the privilege of mating with the opposite sex. Males tend to fight one another for the domination of their herd or harem, which then seems to become part of their territorial possessions. It is no accident that in many cultures wives are regarded as part of the personal property of men. The winners of fights among prehistoric males are said to have superior genes, that can then be past on to their progeny. Thus the remark that some men tend to be more possessive and aggressive then women may well be a genetic feature of our ancestry. The production of testosterone - also associated with aggression and the hormonal source of the sexual drive - is greater in men then in women. Males have plasma concentrations of testosterone amounting to 10-30 nmol/L (290-860 ng/100 ml), whereas females have 0.8-2.8 nmol/L (23-81ng/100 ml) 6. Males have on average 13 times more testosterone floating around in their blood. Thus men have a greater sex drive than women.

One client reported to me that he felt constantly on heat. On the other hand, it has been claimed by some that a few women can live happily without any sexual activities. Studying the testosterone or other hormonal levels it must be realised that we are dealing with bell-shaped averages; some individuals (male or female) showing extremes at either ends of the distribution of measurements and some overlapping.

Looking at the ancient animal kingdom, we observe that males, lording it over the herd, tend to be promiscuous as opposed to females who tend to be monogamous. This is still very apparent among human behaviour where we see males inclined to be promiscuous compared to females. This is also evident in human male homosexual relationships, where these sex characteristics may be even more pronounced. The majority of clients of prostitutes are said to be married men, thus providing an outlet for some of the males promiscuous needs. 7 This is more fully discussed in The Sexual Desire Disorders by HS Kaplan p.37

Many psychological surveys have reported that there are vast differences in the perception, emotional and sexual reactions among human males and females, in regard to masturbation, extramarital sex or sexual fantasies. This has created according to some researchers the concept of a separate male and female cultures of beliefs, attitudes and expectations in man/woman relationships. 8Christina A Clarke writes: “Previous research has also shown that women, more so than men, associate sex, love, and marriage as belonging together (Weis, Slosnerick, Cate, & Sollie, 1986).” 9 This gender cultural separation has often resulted in physical separation between the sexes into associations, clubs and even at parties where in some societies men are aggregated in the kitchen whilst women are located in the lounge room.

In the lower echelons of animal behaviour we see that males’ sexual behaviour is triggered by certain pheromones (odours) emanating from females, indicating that they are ready to copulate. Thus the sense of smell is important in sexual behaviour of most animals. This pattern seems to have disappeared along the path of evolution when humanoid primates started to walk upright. Humanoids lost their acute sense of smell, which appeared to have been transferred to and replaced with the sense of sight. We see that among the primates - especially noticeable among the chimpanzees which are said to be our closest cousins - that the trigger for sexual behaviour appears to depend on visual cues. Thus humanoid apes and male humans appear to respond to visual stimuli to elicit a sexual response.

In one video recording it was shown that a male chimpanzee got very agitated when it watched a scene depicting a mating session between two other chimpanzees. Hence we have an explanation for the human male’s fascination with nude female bodies. The universal pornographic industry feeds on these primitive forces of visual stimulation, which leave most females rather cold.

The mechanism of sexual arousal is obviously different between males and females and in some cases this may be a cause of conflict. Thus we see how a ‘Peeping Tom’ is driven along by a puzzling inner drive to peer into windows of homes in the hope of encountering ladies in the process of undressing.

The masculine notion that the sight of sexual organs provokes a sexual response in females - as it would be in most men - drives some men to expose themselves, in the firm belief that what is sauce for the goose is sauce for the gander. Such men are called ‘flashers’ in common parlance. Technically speaking one can say that they are projecting their own feelings on to other people, believing that these feelings are normal and therefore present in the other gender. This is in line with much research findings that many sexual offenders generally suffer from “cognitive distortions”. 10, 11

Some psychologists have put forth that such men may have lacked male models in their upbringing, who could have taught them that women and men are different, or at least that being a man is alright. The inculcation of this recognition would have both inspired pride in their own sex as well as respect for the other gender. Others have pointed to the birth order of the offender in his family. 12, 13.

The belief promoted by some sections of the feminist movement - modelled on the behaviouristic model of psychology - that men and women are or should be the same in all respect may have brought about a confusion in the sexual education of young people. The fact is that there are vast sexual differences between the sexes lurking just below ‘civilised’ behaviour.

Lacking such modelling by male parents, it is often reported that rapists claim that their victim consented to their offence, because they are biologically inclined to recognise their own arousal in other people, through this process of ‘projection’, part of their ‘cognitive distortion’.

Some biologists would suggest that the role of copulation in the lower animals have made way for a more extensive function in humans. Whereas in the lower species its function is reproduction, among humans freedom from periodical pheromones has made the capacity for sex timeless, serving also as a bonding activity between the sexes. It could well be that without such bonding the long period of human nurturing of the young - sometimes reaching twenty years - may deprive the offspring the protection of the adults. Sex seems to play a similar social role among some groups of primates.

Of course, the notion of how men react to visual stimuli is no stranger to most women. The female passive sexual activities may compel them to spend an inordinate time and energy on their personal appearances. This may appear to be unconscious, but this preoccupation becomes pathological, when a young girl start to believe - despite clear evidence to the contrary - that she is ugly or “fat”. A slight tendency to obesity - caused by a possible metabolic abnormality to start off with - can graduate to a full-blown anorexia or bulimia. Therefore, is anorexia really a sexual problem? It has been proposed in this section of psychotherapy, that the combination of a metabolic disorder related to serotonin synthesis - which could also expose the sufferer to bouts of depression - together with a negative self-image can initiate this serious eating disorder.

The evolution of the mammalians into civilised humans.
It must have taken billions of years for human primates to evolve into upright creatures with a much enlarged brain through genetic mutations. But this enlarged brain enabled humans to develop languages - a learned skill of communication. The same brain enabled them to think in abstract terms, to imagine spirits, to believe in Gods, to understand rules, to organise themselves into co-operative families, tribes, societies and than nations. No doubt this evolutionary change has been brought about by the need for a long period of nurturing parenthood of the human progeny, which demands an extraordinary time to ‘socialise’ the infant. The development of the human brain may have offered an alternative to the often violent sexual life of lower mammals.

Whereas changes in the evolution in the lower animals are limited to the slow mutations in their genetic, the enlarged brain empowered humans to acquire ‘culture’, which accelerated the evolution of human behaviour by leaps and bounds, so that virtually a new species appeared on the surface of the earth out of the blue in terms of geological times. That ‘cultured’ animal appeared to behave in a totally different way from the members of his ancestry, who were locked into a rigid, instinctual predictable pattern of life.

Unfortunately, cultural evolution split the human community into different branches with often conflicting belief systems and behaviour patterns. And the genetic survival of the fittest among animals has now been converted to the struggle of fittest culture among human societies. War seems to be practically unavoidable and perhaps may be seen as a natural by-products of cultural evolution.

Thus human behaviour can be divided into genetic behaviour 14- derived from the mammalian animal kingdom - and cultured behaviour learned behaviour from the society of which we are part. Cultured behaviour includes language, acceptance of perceived values of one’s society, in short all that behaviour that has been learned from one’s culture.

Women contribute to these cultural evolution by choosing men who are ‘civilised’, gentle, understanding, supportive, stable, all attributes to protect the ‘cultural’ offspring of the new species. By choosing and preferring such men, they may well have changed already some of the genetic make-up of this new humanoid species.

If this analysis is correct it becomes sensible to ask the question why some men in our society predominantly display genetic behaviour bringing them into conflict with moral if not legal standards of his society?

Sexual behaviour is controlled by powerful sanctions of one sort or other in all societies. This discloses the near submerged genetic behaviour in all of us. Genetic behaviour is not only restricted to sexual inclinations, but also to other aspects of human behaviour; such as the drive for power over fellow humans, the exploitation of the weak, economic ‘rivalry’, the pursuit of any kind of competition in games by individuals and groups.

We have only to see the atrocities committed by ‘civilised’ humans in the 21st century Europe, to realise how shallow ‘cultured’ behaviour is. These non-sexual genetic patterns of behaviour - which among humans know no boundaries - are seldom recognised as stemming from our animal ancestry.

Treatment of sexual offenders
The above analysis suggests that unacceptable sexual behaviour is the product of a disrupted socialisation in the development of personality. So we need to look at factors - both psychological and metabolic - that have hindered this socialisation of this person into a ‘cultured’ person of his society.

Psychological Factors
The above studies show that it is difficult to separate biochemical from psychological factors and that there is much interplay. But looking at the component parts, predominantly psychological factors may be detected.

If we look at human courtship, regardless of a particular culture, it is clear that considerable social skill would be required. Most important of these would be the ability to communicate at a feeling level. A well-known handicap would be when a person suffers from the Anaclitic Reaction.

The concept of anaclytic reaction, also known as ‘anaclitic depression’, was introduced in 1946 by psychiatrist René Spitz to refer to children who became depressed after being separated from their mothers for a period of three months or longer during the second six months of life. This often happens to orphaned children or those placed in extended infant care. This could result in the child withdrawing socially from significant people - nurses, substitute parents and teachers. This withdrawal may be reflected in their language in adult life. I found that such persons could be characterised as communicating in ‘two word’ sentences.

When you ask: “How do you get on with your mother?”, the reply would be “OK”. In order to force them to express a whole sentence, it would be better to ask an open-ended question such as: “Tell me what is your mother like?”, where it would be difficult to answer in ‘two-word’ sentences. Such handicap in communication skills could result in sexually unacceptable behaviour.

I also found that these clients could learn to express themselves more fully by participating in our “Communication and Counselling” course, as explained in this web site. Such person would be asked to “parrot” an interviewee’s responses to a set of general questions about a person’s life.
“Parroting” means repeating word by word a response given by a another member of the group being interviewed. Once skilled in ‘parroting” this person would soon start to give his own interpretation of what an interviewee was saying. So he learned to empathise as a variation of “parroting”, which is a basic skill in intimate communication.

Another social handicap of psychological origin would be a physical disability or stuttering. In the case of stuttering a client should be referred to a speech therapist, because most signs of stuttering are not treatable by mere psychological therapy. A physical handicap or deformity may become part of one’s negative self-image, which can be dealt with in similar fashion as explained in the “wooden leg argument” discussed in the psychotherapy section.

These are some of the psychological examples we need to look for and treat, if we want to help a client overcome his recidivist sexual inclinations that are in conflict with societal norms.

Metabolic Aspects
Sexual offences are rarely committed in isolation from other comorbid personality disorders. In one study of 42 sex offenders it was found that 67% suffered from a life long mood swings, 64% had histories of anxiety attacks, 60% used psychoactive drugs, 53% were diagnosed paraphilic (abnormal sexual interest) and 24% were diagnosed with sexual dysfunction. 15 Many of these symptoms are present in the Hypoglycemic Disease and other disorders involving metabolism.

Tina Zawacki whose research found that perpetrators of sexual assaults that involved alcohol were in most ways similar to perpetrators of sexual assaults that did not involve alcohol, although they differed on impulsivity and several alcohol measures. 16. Many sexual offenders reported to me that they acted on the spur of the moment or acted out of character. Impulsive behaviour is one of the symptoms of hypoglycemia.

Nevertheless, the connection between alcohol abuse and sexual offences cannot be denied 17, 18 ,19 .

By analysing two groups of sexual delinquents in one study, those which have committed rape, attempted rape or committed rape with murder (the first group) and the committers of indecent acts (the second group), it was established that the two groups are substantially different in relation to some of the studied parameters. In the first group of delinquents, there is considerably less of those who are married (35.48%), in relation to the second group (73.68%). Indecent acts are most often committed in the apartment of the sexual offender (63.16%), while this is the case in 22.58% of the offences from the first group. The victims of indecent acts were only minors. In both groups the most frequent psychiatric diagnosis was psychopathy. Alcoholic state at the time of committing the offence was considerably greater in the first group (87.10%), than in relation to the other (47.37%). 20

It was also found that many sexual abusers have experienced sexual abuse as a child.21 The meaning of this is obscure, but it is possible that dysfunctional families not only fosters dysfunctional children and adults environmentally, but also may pass on certain genes that are associated with biochemical disorders.

Intelligence and social status do not necessarily protect perpetrators and victims against sexual offences. In one study of sexually offending physicians it was found that they were highly educated and older, forming a statistically significant subgroup of sex offenders. The majority of physician sex offenders suffered from a sexual disorder (68.4%). Physicians showed more neuropsychological impairment and endocrine abnormalities and less antisocial behaviour than did the general sample of sex offenders but did not differ from the matched control group. Physician offenders who sexually assaulted their patients did not differ from those who had non patient victims. 22 These findings would probably apply to the class of clergy men and other professionals, who have been found to have sexually abused children placed in their custody.

Masturbation
This brings us to the question of the relationship between the practice of masturbation and sexual abuse. Studies have shown that 95% of men have masturbated at least once in their life time. This appears to be a world-wide phenomenon. In a study conducted among Korean soldiers it was found that the percentage of men who reported ever having masturbated was 98.1% (1189/1212) and the average age of initiation of masturbation was 14.26 +/- 1.66 years.23

One could ask, whether this practice, if morally allowed among the clergy, would have reduced the incidence of sexual abuse within the church. One study comparing masturbatory activities among groups of men of abusers and non-abusers suggested that “sexual sobriety from masturbation does not aid in the control of pedophilic fantasies. This may be because the technique is ineffective, or because so few participants are willing to engage in it.”24

Some sex therapists have proscribed masturbation as a socially acceptable alternative outlet of unrequited sex urge and this has been criticised by some authors in claiming that “they may be guilty of colluding with clients in protecting them from intimacy.”25

In another study thirteen rapists and 9 pedophiles filled out the Fantasy Report every 2 days for a period of 60 days. In rapists, negative mood and the presence of conflicts coincided with both overwhelming deviant sexual fantasies and increased masturbatory activities while having such fantasies. Furthermore, the emotions most frequently reported by rapists following conflicts were loneliness, humiliation, anger and feelings of inadequacy and rejection.26

This should emphasise the need of psychotherapy for sexual offenders, regardless of their masturbatory practices. This is clearly demonstrated in the case when non-abusers - usually young teenagers - complain of addiction to masturbation. Most men when socially deprived of contact with the opposite sex - as is the case with long term prisoners - will masturbate as a means of releasing their hormonally driven sex drive, with the aid of external stimuli (sexual material) or internal imagination.
Young people addicted to masturbation are in a situation not unlike that of prisoners, but their prison walls consist of internally driven handicaps to social intercourse.
I have found that such persons become socially liberated, when they complete the self-help PSYCHOTHERAPY course (that I taught in a group setting), which is based on a change of their self-image from the negative to the positive, together with a systematic course that will improve their non-aggressive assertiveness, sensitivity to the feelings of others and desire for the pursuit of higher values and lifestyle. The course should equip the client with the ability to establish emotional contact with members of his ‘cultural’ community and thus enlarge and widen social opportunities.

Conclusion
Sexual offenders are likely to have little insight into their recidivist behaviour. Hence they need to be stopped by whatever means. The usual practice of incarcerating sexual abusers will do little for rehabilitating these offenders. On the contrary the unnatural social environment of jails can only be expected to entrench and reinforce the socially condemned sexual behaviour before he is released into the community again.

I have also found that the treatment of sexual offenders does not have to take place in a special group of “sexual offenders”. My groups that contained a mixture of offenders - not so much by design, but rather by necessity - all benefited from the metabolic/psychological therapeutic approach regardless of the type of offences. There was great emphasis on self-therapy and clients taking responsibility for their own therapy with the tools (lectures and interview exercises, discussions) provided in the group.

The treatment of sexual abuse must include considerations of metabolic and biochemical factors - such as hypoglycemia - that contribute to otherwise recidivist behaviour. To assist in a proper analysis of his biochemical personality he may be asked to have himself tested such as a special GTT for hypoglycemia explained at this web site. These factors need to be treated first, preferably by nutritional means. AND the person needs to undergo a course in PSYCHOTHERAPY to provide him with means of leading a more acceptable and satisfactory social life.

He needs to be offered opportunities for resocialization both metabolically and psychologically.

Further studies in Psychology and crime: Psychology of the rapist, by CR Hollin page 85

1) Simon LM. An examination of the assumptions of specialization, mental disorder, and dangerousness in sex offenders. Behav Sci Law. 2000;18(2-3): 275-308. PMID: 10874290

2) Hanson RK, Gordon A, Harris AJ, Marques JK, Murphy W, Quinsey VL, Seto MC, First report of the collaborative outcome data project on the effectiveness of psychological treatment for sex offenders. Sex Abuse. 2002 Apr;14(2):169-94; discussion 195-7. PMID: 11961890

3) Henn FA, Herjanic M, Vanderpearl RH. Forensic psychiatry: profiles of two types of sex offenders. Am J Psychiatry. 1976 Jun;133(6): 694-6. PMID: 1275101

4) Abbey A, Zawacki T, Buck PO, Clinton AM, McAuslan P. Alcohol and sexual assault. Alcohol Res Health. 2001;25(1): 43-51. PMID: 11496965

5) Some Methodological Problems in Estimating Incidence and Prevalence in Child Sexual Abuse Research. Author/s: Juliette D. G. Goldman Issue: Nov, 2000
http://www.findarticles.com

6) Macleod, John(Ed) (1984), Davidson’s Principles and Practice of Medicine, Churchill Livingston, Melbourne Page 819

7) In one survey of 100 prostitutes revealed that married men constituted 70-80% of their clients. Chamber’s Encyclopaedia, 1959 Vol 11, p 258

8) Christina A. Clark, http://www.findarticles.com/cf_dls/m2372/2_37/64698516/print.jhtml

9) Christina A. Clark, Ibid.

10) Marshall WL, Hamilton K, Fernandez Y. Empathy deficits and cognitive distortions in child molesters. Sex Abuse. 2001 Apr;13(2): 123-30. PMID: 11294123

11) Kenny DT, Keogh T, Seidler K. Predictors of recidivism in Australian juvenile sex offenders: implications for treatment. Sex Abuse. 2001 Apr;13(2): 131-48. PMID: 11294124

12) Bogaert AF, Bezeau S, Kuban M, Blanchard R. Pedophilia, sexual orientation, and birth order. J Abnorm Psychol. 1997 May;106(2): 331-5. PMID: 9131853

13) Cote K, Earls CM, Lalumiere ML. Birth order, birth interval, and deviant sexual preferences among sex offenders. Sex Abuse. 2002 Jan;14(1): 67-81. PMID: 11803596

14) I prefer to use the term ‘genetic behaviour’ - a neutral term - to mammalian animal behaviour, because the latter may be seen as a negative emotive term.

15) Raymond NC, Coleman E, Ohlerking F, Christenson GA, Miner M. Psychiatric comorbidity in pedophilic sex offenders. Am J Psychiatry. 1999 May;156(5): 786-8. PMID: 10327918

16) Abbey A, Zawacki T, Buck PO, Testa M, Parks K, Norris J, Martin SE, Livingston JA, McAuslan P, Clinton AM, Kennedy CL, George WH, Davis KC, Martell J. How does alcohol contribute to sexual assault? Explanations from laboratory and survey data. Alcohol Clin Exp Res. 2002 Apr;26(4): 575-81.

17) Miranda R Jr, Meyerson LA, Long PJ, Marx BP, Simpson SM. Sexual assault and alcohol use: exploring the self-medication hypothesis. Violence Vict. 2002 Apr;17(2): 205-17. PMID: 12033555

18) Abbey A. Alcohol-related sexual assault: a common problem among college students. J Stud Alcohol Suppl. 2002 Mar;(14): 118-28. PMID: 12022717

19) Ullman SE, Brecklin LR. Alcohol and adult sexual assault in a national sample of women. J Subst Abuse. 2000;11(4): 405-20. PMID: 11147236

20) Savic B, Misic-Pavkov G, Novovic Z.[Characteristics of sexual offenders in our data] Med Pregl. 1990;43(9-10): 383-6. Serbo-Croatian (Roman). PMID: 2077374

21) Craissati J, McClurg G, Browne K. Characteristics of perpetrators of child sexual abuse who have been sexually victimised as children. Sex Abuse. 2002 Jul;14(3): 225-39. PMID: 12087684

22) Langevin R, Glancy GD, Curnoe S, Bain J. Physicians who commit sexual offences: are they different from other sex offenders? Can J Psychiatry. 1999 Oct;44(8): 775-80. PMID: 10566107

23) Choi YJ, Lee WH, Rha KH, Xin ZC, Choi YD, Choi HK. Masturbation and its relationship to sexual activities of young males in Korean military service. Yonsei Med J. 2000 PMID: 10817020

24) Brown CM, Traverso G, Fedoroff JP. Masturbation prohibition in sex offenders: a crossover study. Arch Sex Behav. 1996 Aug;25(4): 397-408. PMID: 8836472

25) Christensen C. Prescribed masturbation in sex therapy: a critique. J Sex Marital Ther. 1995 Summer;21(2): 87-99. Review. PMID: 7643426

26) McKibben A, Proulx J, Lusignan R. Relationships between conflict, affect and deviant sexual behaviors in rapists and pedophiles. Behav Res Ther. 1994 Jun;32(5): 571-5. PMID: 8042970

Last updated 17 December, 2006.5