Sunday, October 29, 2017

Sex Scandals - Human Sexual Consciousness and Prevention






Over the past three weeks the country has been rocked by another entertainment business sex scandal.  An endless series of actresses describing very similar inappropriate behaviors and in some cases sexual assault.  The allegations alone at this point have led to major disruptions in family life, businesses, and professional recognition and honors.  Women have been encouraged to come forward and report these incidents and there is a movement to spark a sea change in the culture that lead to the problem of the sexual exploitation of women in the entertainment industry.   In some cases men have come forward. There are also claims that the specifics of child sexual exploitation in Hollywood will soon become public.   This seems to be a familiar scenario that unfolds from time to time, but never before at this scale.  What are the implications?

Looking at the epidemiology of sexual harassment leads to a wide range of statistics.  The first reliable medical reference that I could find was in the American Journal of Psychiatry from 1994. That article was a review of existing literature showing that sexual harassment was commonplace with estimates varying from 42-73% of women and 15-22% of men in occupational and medical educational settings and that a small percentage of the people affected (1-7%) file formal complaints.  The Equal Employment Opportunity Commission (EEOC) is the federal agency that monitors and enforces civil rights in the work place and one of those rights is not to be sexually harassed.  The agency has very little useful information on their web site in terms of epidemiology, primarily looking at enforcement data. Since this represents a minority of incidents and there is overlap from year to year depending on when the claim is settled it has limited utility in determining the scope of the problem.  As far as I can tell there are no definitive studies done with similar definitions across a representative population, but all of the subgroup studies indicate it is an ongoing significant problem despite legislation and the EEOC.

Inappropriate sexual behavior has been a significant focus of every educational and employment situation that I have been in over the course of my career.  The approaches have varied widely from stating rules and implying what was unacceptable right up to prohibitions of behaviors and the fact that violations could lead to reprimands or immediate termination.  The unacceptable behaviors included a wide range of unwanted approaches or statements, suggestive humor, inappropriate touching, and included dating subordinate employees.  There were comprehensive approaches that explained the rationale for all of these rules.  In other cases there were not.  In psychiatry, the boundaries have become even more clear in terms of dating former patients and supervisees.  It is no longer considered appropriate for a psychiatrist to ever date or have a sexual relationship with a former patient. In some places where I have worked with other disciplines - I noticed that there is a time frame where such behavior is allowed for non-psychiatrists.  As far as I can tell - there are no uniform approaches that seem to apply to all employees and all disciplines.

Apart from employment expectations when working in health care environment, sexual trauma is overrepresented in people  being treated in psychiatric settings.  There are high rates of depression, post traumatic stress disorder, suicide attempts, and suicide.  The World Health Organization has several resources on the available statistics for violence toward children and adults and sexual maltreatment and violence.  They classify sexual harassment as a form of sexual violence against women.  Their definition of sexual violence is:

 "any sexual act, attempt to obtain a sexual act, unwanted sexual comments or advances, or acts to traffic, or otherwise directed, against a person’s sexuality using coercion, by any person regardless of their relationship to the victim, in any setting, including but not limited to home and work." 

The available estimates are high.  In the US, 14.8% of women  over the age of 17 report that they have been raped and an additional 2.8% have been subjected to attempted rape. The WHO report documents other forms of sexual assault but had no clear data on sexual harassment.

The WHO report is interesting because it has some suggested strategies for prevention.  They begin by discussing secondary prevention for both the victims and perpetrators of sexual violence.  An educational and developmental model was discussed that includes discussion of a sexual aggression and setting boundaries for appropriate sexual relationships.  Improved health care interventions for victims of sexual violence is another WHO priority ranging from forensic evaluations to the prevention of sexually transmitted diseases.  Legal reform is also suggested as necessary particularly in the areas of legal definitions of sex crimes and the court processes that are used for these cases.  Child marriage is a variation of sexual abuse that continues to exist world wide. In the US, like elsewhere the practice is culturally based (2) and even though there are generally minimum ages for marriage in some states the courts can grant exceptions.  These exceptions allowed children between the ages of 10 and 15 to get married in the US.  The WHO report has a few paragraphs on primary prevention of stopping sexual violence before it occurs.  Most of that is directed at educational programs that target changing cultural and individual attitudes about sexual behavior.

I found a recent paper on a specific subculture (anthropological fieldwork) (3) that was studied by anthropologists. This paper looked at the issue of sexual harassment in the context the expectations of that subculture.  The authors found that when there were clear rules in the workplace and an expectation that they would be enforced - the field experience was more productive and there were far fewer reports of harassing behaviors.  The authors included discriminatory behavior along with harassment and assault.     

I included some of the additional information on sexual violence to show that is only slightly more studied than sexual harassment.  From the descriptions of recent victims, there is a clear association between sexual harassment and sexual violence.   It is apparent to me that the scientific study of problematic human sexual behavior at the levels of epidemiology and causation is primitive to non-existent.   Society seems to depend on a legal model including civil and criminal penalties as potential corrective factors - but there is no evidence that has had much impact.  Society might also be a bit too self congratulatory on attitudes about human sexual behavior. Tolerance for nudity and pornography has not translated into less victimization.  Neither has widespread exposure to detailed information on the mechanics of sexual behavior.

The brain has been left out of the discussion, specifically human sexual consciousness and why there are people who can routinely negotiate this most sensitive aspect of interpersonal relationships, while others leave a number of traumatized victims in their wake.  Retrospective analysis and armchair psychoanalysis is always easy after the fact.  I have seen many of these men referred to as sociopaths, psychopaths, or narcissists.  The perpetrators themselves often claim "sex addiction" as a problem and go to a rehabilitation facility to treat them problem.  Social etiologies are also part of these analyses, especially the idea that most perpetrators are likely victims of sexual abuse.  All of these diagnoses seem to be a function of the crisis situation rather than any useful diagnosis that results in treatment and life change.  The diagnoses also seem to be based on a very simplified model of how the mind/brain work.  The models typically included cognitive, behavioral, moral and social elements that do not produce a viable theory to produce much treatment or prevention.  The models also do not explain individual variation, but generally look at class variation (men versus women).  More biological based models of sexual differences (4) look at imaging studies, limited cognitive tests, and functional imaging and differences are typically minimal.

A consciousness based approach may be more useful to look at real differences between men and women.  The focus of these studies would be to look at the conscious states associated with sexual behavior and what actually happens in the optimal and sub-optimal or abusive states.  Any  study of these conscious states typically begins with phenomenology and in addition to epidemiology - it is lacking in this area.  The largest literature continues to be psychodynamic and psychoanalytical that has produced non-falsifiable theories based case reports and experience with individual cases.  That same literature is also limited by the theories and interpretations of the authors.  A phenomenology of sexual consciousness needs to take a look at the current theories of consciousness and how they might apply to very specific situations.  In a previous post I quoted Tononi and Koch speculating about the complex that occurs when they see a particular actress in a movie.  They focus a lot on the neural correlates associated with the visual representation but also the neurons that are associated with higher order concepts.  What are the specific complexes generated when people meet?  We currently do not know what they are.  There seems to be a broad idea that every person has an internalized moral code or set of rules that comes into play, but is that a realistic way to view the process or any associated problems.  Consciousness researchers seem more focused on ideas about machine intelligence and possible machine consciousness these days than the issue of sexual consciousness.

For now, there does appear to be a societal approach to minimize sexual harassment and abuse, but it is limited by self report.  It depends on transparency and enforcement that is spotty at best. The strong wave of advocacy that we have seen originating in the entertainment industry is a potential positive force - but we have seen these waves in the past lose momentum.  Like many readers of this post, I hope that does not happen.  In the meantime, a focus on sexual consciousness may lead to important ideas about how to address inappropriate sexual behavior and it will lead to a more complete science of human sexual biology.     

 George Dawson, MD, DFAPA


References:

1: Charney DA, Russell RC. An overview of sexual harassment. Am J Psychiatry. 1994 Jan;151(1):10-7. Review. PubMed PMID: 8267106.

2:  Diane Cole.  Children Get Married In The US, Too: 15 Girls   http://www.npr.org/sections/goatsandsoda/2015/10/28/452540839/children-get-married-in-the-u-s-too-15girls

3:  Nelson, R. G., Rutherford, J. N., Hinde, K. and Clancy, K. B. H. (2017), Signaling Safety: Characterizing Fieldwork Experiences and Their Implications for Career Trajectories. American Anthropologist. doi:10.1111/aman.12929

4: Mueller SC, De Cuypere G, T'Sjoen G. Transgender Research in the 21st Century:A Selective Critical Review From a Neurocognitive Perspective. Am J Psychiatry. 2017 Oct 20:appiajp201717060626. doi: 10.1176/appi.ajp.2017.17060626. [Epub ahead of print] PubMed PMID: 29050504.

5: Centers for Disease Control and Prevention.  A Guide to Taking A Sexual History. Link

I included this document to illustrate where the focus is on sexual behaviors - in this case detecting sexually transmitted diseases.


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