Karolinska Psychodynamic Profile for Sexual Disorders: KAPP-SD. A proposal for a psychodynamic rating scale for sexual disorders.

Abstract Objective: Our first objective in this paper was to review the literature on psychodynamic rating scales of sexual disorders. Our second objective, based on the findings from our review, was to develop a psychodynamic rating scale for people with sexual disorders: the KAPP-SD. Method: We developed the KAPP-SD by modifying an existing psychodynamic rating scale, which assesses stable modes of mental functioning and character traits, the Karolinska Psychodynamic Profile (KAPP). We removed items 13 and 14 of the KAPP and replaced them with three other items—sexual fantasies, conceptions and role of gender identity, and conceptions and role of sexual orientation. These items are part of the assessment of an individual's sexuality and are used to evaluate a person with a sexual disorder psychodynamically. Results: The KAPP-SD, a modified version of the KAPP, can be found in the Appendix. Conclusion: We developed the KAPP-SD in order to help sex therapists make a rigorous psychodynamic evaluation of persons with sexual disorders, which would give information on the prognosis and on the type of treatment to offer.

S exology is the scientifi c study of human sexuality. It is very infl uenced by medical thought, particularly the bio-psycho-social model. It is characterized by the practice of the diagnostic and curative medical model. Psychotherapeutic techniques are the main means for sexologists ' interventions (1, 2).
Traditionally, the psychotherapy of sexual disorders has been psychoanalytically oriented and individual. The 1970s saw the birth of different kinds of psychotherapeutic approaches, such as behavioral psychotherapy, Masters and Johnson ' s couple therapy, body work, hypnosis and group therapy (1, 3). The enormous popularity of these different sex therapies has led many clinicians to consider that psychoanalytic approaches are less important. In the late 1970s, Kaplan offered a therapeutic approach that combined behavioral techniques with a psychoanalytic perspective (1, 4).
Evidence-based medicine shows that the effectiveness of sex therapy is limited and integrative approaches are to be preferred (1,5).
Several psychoanalysts and sexologists have sought to use psychoanalytical theory to fi t the context of sex therapy (1, 3, 4, 6 -11).
However, no one has yet proposed a psychodynamic rating scale for sexual disorders. Several authors have developed psychodynamic personality scales (12 -18) but the scales have no items directly related to sexuality.
In this paper, we have developed a psychodynamic rating scale for people with sexual disorders, by modifying an existing psychodynamic rating scale of modes of mental functioning and character traits, the Karolinska Psychodynamic Profi le (KAPP) (19 -21), in order to help sex therapists make a rigorous psychodynamic evaluation of persons with sexual disorders, which would give Item 14 assesses sexual satisfaction. However, it is composed of several factors including the activity or passivity in sexuality, sexual desire, capacity to achieve orgasms and sexual fantasies. While some factors may be related to the dynamic unconscious (sexual fantasies, activity -passivity) mixing them with factors not related to the unconscious representation makes it unusable. For example, the ability or not to have an orgasm or the vicissitudes of coital sexual desire are not only related to unconscious representations, but may have organic origins (29).
Moreover, Scharff (11) has created a theoretical model to explain sexual desire. This model is based on the theory of object relations and it assesses the relationship to a desired object as well as identifi cation with a desiring object. We also do not feel that sexual desire itself is the right assessment item for the clinical manifestations of the unconscious representations. We believe that these unconscious representations consciously manifest themselves in items concerning the assessment of object relations in the KAPP, in sexual fantasies and in attitudes toward one ' s own gender identity and sexual orientation.
We have therefore removed the items 13 and 14, replacing them with three other items: sexual fantasies, conceptions of gender identity and the role of gender identity, and conceptions of sexual orientation. These items are part of the assessment of an individual ' s sexuality (30) and are used to psychodynamically evaluate a person with a sexual disorder.

Sexual fantasies
Sexual fantasies can be used by people with a neurotic organization to increase sexual desire and strengthen gender identity or people with a psychotic organization to defend themselves against dissolution the self (31 -33). They are mental representations created with conscious intentions, but fueled by unconscious fantasies. They express narcissistic or defensive satisfaction against unconscious fantasies (9,31,34,35), can be psychic containers of split-off parts of the self and metaphorical reprints of traumatic mental experience, which could otherwise not be represented (31,35,36).
We designed the item " sexual fantasies " in order to evaluate, from a psychodynamic standpoint, the ability to get in contact with sexual fantasies, which allows contact with the conscious perceptions of unconscious representations. This requires indulgence towards the non-rational parts of our personality, an " ego strength " insurance policy in order to allow contact with repressed parts of self.
The ability to get in touch with sexual fantasies can be voluntary, characterized by the ability to calmly and temporarily waive the reality principle, all the while keeping the ability to stop the regression, if so desired. On the other hand, patients can get in touch with their sexual fantasies in an uncontrollable, compulsive manner. information on the prognosis and on the type of treatment to offer.

Methods
In this study, we fi rst performed a review of the literature searching for psychodynamic rating scales of sexual dysfunction, and in a second step we developed a psychodynamic rating scale for people with sexual disorders: the KAPP-SD.

Review of the scientifi c literature
A review of the literature was conducted on Medline PsychINFO, PEP-Web. The key words used were: assessment, profi le, scale, sexual disorders, sexual * , psychodynamic, psychoanalytic, diagnos * . The references of articles were also examined for additional studies.
We did not fi nd any psychodynamic rating scales designed to assess the psychodynamic component of sexual disorder.

Development of KAPP-SD
Starting from an existing scale, the KAPP (19 -21), we have developed a scale that includes specifi c items on sexuality.
As previously mentioned, we chose the KAPP as it is a validated scale, based on psychoanalytic theory, which allows the psychodynamic assessment of relatively stable modes of mental functioning and character traits, as refl ected in the patient ' s self-image and in his or her relationships with others (19 -22). Above all, the KAPP is the only psychodynamic rating scale containing items concerning sex. In sub-scales 13 and 14, it provides an assessment of sexuality, specifi cally function and satisfaction. In addition, the KAPP assesses dimensions of clinical practice that are very important in sexology, such as quality of interpersonal relationships, experience, the expression of affect, as well as the conception of appearance and body functionality (23 -26). Finally, the KAPP is designed to closely match clinically observable phenomena, which satisfi es our desire to provide a useful tool for clinical practice.
However, we decided to modify the KAPP as its items on sexuality give a phenomenological assessment and not a psychodynamic one. For the assessment to be psychodynamic, an item should describe a clinical feature directly related to unconscious mental functioning, ego defense mechanisms, identifi cations, object relations, the ego ideal, the superego and unconscious fantasies.
Item 13 evaluates function and sexual disorder, which are not directly linked to the unconscious dynamics. In 1969, Osevey makes a clear distinction between psychodynamic thinking and etiological speculation (27, 28). As sexual disorder is often related to organic causes, item 13 does not distinguish between psychological or organic origins. tions of gender identity and the role of gender identity are usually stereotyped and characterized by the illusion of perfection. Through experiences, in interaction with others, these conceptions gradually become modifi ed, and, normally the individual is able to accept fl aws of gender identity and of the role of gender identity and tolerate the discrepancy between the ideal and reality. The infantile, perfectionist ideal usually persists as conscious and unconscious fantasy without giving rise to any disturbance in self-esteem. Congruence between gender identity, the role of gender identity, the primary and secondary sexual characteristics, and socially or culturally allocated gender roles, usually has an impact on self-esteem (37 -54). However, fl exibility in accepting gender traits and gender roles of the other sex also has an impact on self-esteem. Normally, individuals can accept their fl aws and keep their perfectionist ideals in their fantasies, living their gender and its sexual role within their own abilities.
If, however, there are problems in psychosexual development, gender identity and role of gender identity may become ego-dystonic, and self-esteem becomes crucially dependent upon the evaluation of the role of gender identity, individuals may attempt to reach out defensively to their ideal gender roles using narcissistic behavior, may avoid all situations involving gender roles and gender identities (i.e. sexuality), or may obsessively think about changing their primary or secondary sexual characteristics.

Conceptions of sexual orientation
Sexual orientation is a psychological confi guration that includes the sex of the object that is the source of sexual arousal. Some authors believe that there are biological predispositions that infl uence the development of sexual orientation at the time of the Oedipal phase (55). Family background and unconscious confl icts infl uence the choice of object. Sexual orientation refl ects aspects of the unconscious representations of object relations (45, 56 -61), aspects of the identifi cation with the desiring object (11) and rearrangements of the ego ideal that are resolved during adolescent confl ict resolution (62).
It is important to avoid any etiological speculation when working with sexual orientation (27). Our interest in sexual orientation focuses on the individual ' s conception of it, specifi cally the more or less harmonious or confl ictual personal experience that the person has from this psychological confi guration.
We designed the item " conceptions of sexual orientation " to psychodynamically evaluate the patient ' s conscious conceptions of his/her sexual orientation, which allows contact with unconscious balance of different gender-related object relations, negotiated in pre-Oedipal and Oedipal confl icts. One can observe the needs that the object must meet in order to be rewarding, how one should treat it and be treated by it.
It is important to highlight the differences in these two contrasting ways of getting in touch with sexual fantasies in that they point to different underlying unconscious dynamics.

Conceptions of gender identity and the role of gender identity
Gender identity refers to a psychological confi guration that includes a male and/or female sense of self. Factors contributing to its formation are biological factors, cultural infl uences, parental beliefs and infl uences, psychological factors such as cognitive ability and psychodynamic factors such as ego function, developmental identifi cation and disidentifi cation to same sex and opposite sex objects, object relations, the ego ideal, the superego as well as body image (37 -45).
The role of gender identity refers to a psychological confi guration that includes all personality traits, attitudes and behaviors, considered specifi c to men or to women in a given culture, which a person uses to express his masculinity or her femininity. Factors contributing to its formation are biological factors, cultural infl uences, parental beliefs and infl uences, psychological factors such as cognitive ability and psychodynamic factors such as ego function, developmental identifi cation and disidentification to same sex and opposite sex objects, the ego ideal, the superego, intrapsychic representation of the self and the type of object relationship one has with others according to their masculinity or femininity. These representations are grouped with elements of gender identity in the child ' s representation of the self (39, 40, 45 -54).
Our interest in gender identity and the role of gender identity focuses on the individual ' s conception of them, specifi cally the more or less harmonious or confl ictual personal experience that the person has from these psychological confi gurations. We designed the item " conceptions of gender identity and the role of gender identity " for the psychodynamic evaluation of the patient ' s conscious perception of gender identity and of its role, which makes contact with the unconscious balance of identifi cations with different gendered objects. An individual ' s earliest experiences of him/herself as a person and of his/her surroundings are intimately connected to gender identity and the role of gender identity. An integral component of the individual ' s self-image is an evaluation of his/her own gender identity and the role of gender identity.
According to psychoanalytic theory, the individual ' s conception of his/her own gender identity and the role of gender identity, and the extent to which his/her selfesteem is based upon it, is decided in early childhood (37 -54). By their attitudes and manner, parents and other signifi cant persons contribute to the evolution of the child ' s conceptions of his/her own gender identity and the role of gender identity and its value. Infantile concep-NORD J PSYCHIATRY·VOL 69 NO 1·2015 description of psychic reality in sub-scales is inevitably artifi cial, arbitrary and limited. The mental modes of operation described in the subscales are not " functions " with an independent existence. The KAPP-SD is a tool that aims to conceptualize complex realities. Each subscale describes different levels of mental functioning, with intervals ranging progressively from the relatively normal to increasing degrees of mental disorder. Instructions for using this scale are the same as the KAPP, which you can fi nd on pages 8 and 9 of Weinryb and Rossel ' s 1991 article on the KAPP (19).

Discussion
Psychodynamic diagnosis is important for the planning of treatment: it provides information about prognosis helps with the communication of empathy and reduces dropouts (71).
Freud built his theoretical corpus on the basis of psychosexuality. Psychosexuality is what organizes the individual ' s personality. To be interested in psychosexuality is to be interested in the individual and his/her unconscious psychodynamic functioning (1, 6, 72 -74).
As sexologists and psychodynamically trained therapists, we wanted to focus in this article on how to assess the " psychosexuality of sexuality " , that is to say how to be interested in the psychodynamic components of adult sexuality. To do this we must look to conscious sexual fantasies, to gender identity and the role of gender identity and sexual orientation, which have links with the unconscious psychosexual experience. Furthermore, they also have close ties with parental identifi cations, the superego, the ego ideal and the type of object relationship.
The three items we have chosen touch questions that are often present in and easily accessible to the consciousness of patients with a sexual disorder. Together with the other items of the KAPP, they are a gateway to the psychodynamic assessment of patients with sexual disorders. They are a gateway to the " psychosexuality of sexuality. " While this scale was designed on the basis of our clinical experience with patients with sexual disorder, this scale can be used to psychodynamically evaluate all types of patients, regardless of the type problems that have led them to consult.
In addition, our contribution to the psychodynamic assessment of sexuality may be helpful to all psychotherapists, who for different reasons are not able to discuss sexuality with their patients in their psychodynamic psychotherapy or in their psychoanalysis. Some analytical treatments only show a positive change when the therapist, overcoming shame and the diffi culty of fi nding the right distance, dares to confront the issue of sexuality directly (35).
An individual ' s earliest experiences of himself as a person and of his/her surroundings are intimately connected to sexual orientation. The evaluation of his/her own sexual orientation is an integral component of his/ her self-image. The individual ' s conception of his/her own sexual orientation, and the extent to which his/her selfesteem is based upon it, is decided in early childhood (45, 56 -61). By their attitudes and manner, parents and other signifi cant persons contribute to the evolution of the child ' s conceptions of his/her own sexual orientation. The infantile conception of the love object, the relationship with it and its ability to meet all needs is characterized by illusions of perfection, which will be frustrated by actual experience and bring about change to this idealized conception. Normally, individuals will negotiate a balance between the frustrations of reality and the perfectionist ideals of fantasy life, and will seek to build a more or less harmonious and satisfactory sexual relationship with another. The infantile, perfectionist ideal usually persists as conscious and unconscious fantasy without giving rise to any disturbance in self-esteem. Ego-syntonic sexual orientation contributes to good self-esteem, strengthening and enrichment of gender identity, and the role of gender identity and relationships with others (45, 55 -62). If, however, there are problems in psychosexual development, sexual orientation may become ego-dystonic and self-esteem becomes crucially dependent upon evaluation of sexual orientation, individuals may avoid all situations involving sexual orientation (i.e. sexuality).
Several authors (9, 63, 64) have reported a higher incidence of homosexual fantasies in women and a greater ability to integrate them into their erotic fantasies in a more fl uid, plastic way and less threatening way. These authors and others (64 -70) have expanded on Stoller ' s theory of primary femininity and have suggested that masculine gender identity is more fragile in relation to female gender identity. For them, as male gender identity is constructed partly as a defensive structure against femininity, men would experience homosexual fantasies more often than women, as a threat of a loss of their gender identity.

Results
The KAPP-SD, a modifi ed version of the KAPP, can be found in the Appendix.
The KAPP-SD, as the original KAPP, is a scale based on psychoanalytic theory, which allows the assessment of psychodynamic modes of relatively stable mental functioning and character traits, as refl ected in the patient ' s self-image and relationships with others. It is composed of 19 items, including three for the psychodynamic evaluation of sexuality.
The KAPP-SD is designed to correspond closely with clinically observable phenomena. Delimitation and

Signifi cant outcomes
The KAPP-SD brings a psychodynamic diagnosis to • sexual disorders and provides information about prognosis, helps with the communication of empathy and reduces drop-outs. The KAPP-SD highlights the importance of sexual fan-• tasy, gender identity and the role of gender identity, sexual orientation and the role of sexual orientation in sex therapy. The KAPP-SD may be helpful to all psychotherapists, • who for different reasons are not able to discuss sexuality with their patients in their psychodynamic psychotherapy.

Limitations
This modifi ed scale emerges from clinical experience • and theoretical constructs and therefore needs to be validated scientifi cally. In sex therapy, the multimodal approach should be • favored: to work in an exclusively psychodynamic way would be reductive regarding sexuality.

Declaration of interest:
The authors report no confl icts of interest. The authors alone are responsible for the content and writing of the paper.