Evaluating and Reducing Risk in Online Child Pornography Cases.

In their article on the subject of risk assessment of online child sexual exploitation offenders, Hirschtritt and colleagues highlight an important finding derived from an analysis of group data which concludes that the vast majority of individuals convicted for accessing child pornography online (and who have had no prior conviction for a contact sexual offense) are at low risk of becoming a contact, hands-on, sexual offender. This commentary is intended to complement their observations by emphasizing the importance of performing a comprehensive psychiatric-forensic evaluation when assessing risk. It argues that greater emphasis should be placed upon reducing any risk that may be identified rather than simply asserting its presence. While not arguing against legal sanctions, this commentary questions their severity in some instances based upon the above noted finding. This commentary suggests that effectively addressing the mental health needs of child pornography accessors and exploring methods of primary prevention should be considered aspects of risk reduction.

A Conceptual Overview and Commentary on Gender Dysphoria.

Gender Dysphoria is a distressed state of mind that is of interest to psychiatrists, including forensic psychiatrists. Forensic matters can be best addressed only after one has a good appreciation of relevant psychiatric knowledge and concepts. In this commentary I review the nature of Gender Dysphoria, its relationship to cross-dressing and erotic arousal, and the question of whether it should be thought of as a psychiatric disorder. I also review the complexity of sex and gender; alternative conceptualizations of Gender Dysphoria, its etiology, its multicultural history, and its typical course over time in a given individual. Finally, I summarize treatment options, treatment outcomes, and difficulties of treating Gender Dysphoria within an inmate population.

Androgen deprivation treatment of sexual behavior.

Gonadotropin-releasing hormone agonists are underutilized in patients seeking diminution of problematic sexual drives. This chapter reviews the literature on surgical castration of sex offenders, anti-androgen use and the rationale for providing androgen deprivation therapy, rather than selective serotonin reuptake inhibitors or more conservative interventions, for patients with paraphilias and excessive sexual drive. Discussions of informed consent, side effects, contraindications and case examples are provided.

Commentary on pedophilia diagnostic criteria in DSM-5.

Human beings differ in sexual makeup. Most adults are not sexually attracted to prepubescent children, but some are. Societal values can be of relevance in determining whether such a difference is considered to be a psychiatric condition. Were a society to believe that adult-child sexual interactions should not be prohibited, such a difference might not be viewed as a disorder. According to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR), a difference in sexual makeup can be considered a disorder when it causes interpersonal difficulty or marked distress. In contemporary society, pedophilia can do both. According to DSM-IV-TR, for a diagnosis of pedophilia, there must be both a qualitative difference in sexual makeup (i.e., sexualized urges directed toward children) and a quantitative difference (i.e., the sexualized urges must be intense). However, just as a heterosexual man with low (i.e., nonintense) sexual urges is still heterosexual, DSM-5 should similarly allow that individuals with low sexual urges in response to children qualify for a diagnosis of pedophilia.

Risk/benefit ratio of androgen deprivation treatment for sex offenders.

Androgen deprivation treatment (ADT) significantly lowers testosterone. That, in turn, can decrease sexual drive, facilitating better self-control and lower recidivism rates among sexually disordered offenders. Potential side effects can include: decreases in bone density; development of a metabolic syndrome involving weight gain, accompanied by changes in glucose and lipid metabolism; and rarely, depression. In the presence of a proper treatment protocol designed either to prevent or to minimize side effects, particularly the development of osteoporosis, the risks associated with ADT are generally within the same range as those associated with many other commonly prescribed psychotropic interventions.

Basic science and neurobiological research: potential relevance to sexual compulsivity.

A unique challenge posed by advancing scientific knowledge about the biology of human behavior is how to integrate that understanding with the desire to hold ourselves--and one another--morally accountable. As human beings, we are something more than just passive agents whose behavior is the sum product of biologic determinism. Because of the existence of the mind, we are also active agents with the capacity to influence, at least to some extent, our own destinies. Behavior may be determined, but it is not predetermined. We are one of its determinants. Misconduct by a person of sound mind should not be attributed improperly to brain pathology. On the other hand, suffering, legitimate mental disorder, and associated impairments should not be trivialized. Historically, persons who once were labeled "lazy" are often more appropriately understood by modern standards as clinically depressed. Frequently they are more in need of pharmacologic treatments that alter brain chemistry than "a kick in the behind." Gluttony, one of the original cardinal sins, is often more properly understood as morbid obesity, a condition that deserves appropriate medical care. Persons who have alcoholism, once judged morally as "bums in the gutter," are more frequently referred to treatment facilities, such as The Betty Ford Clinic. One should not approach the issue of human sexual behavior without at least some appreciation of moral values and scientific research. Although clearly some persons choose to act in a sexually selfish and self-indulgent fashion with wanton disregard, others seem to be more genuinely burdened and struggle to integrate their sexual desires into an otherwise healthy and fully responsible lifestyle. When a person, whether male or female, seems to be so driven that it becomes difficult to master erotic desires and he or she experiences difficulty serving his or her own best longterm interests, the concept of sexual compulsivity seems to be relevant. Ultimately, a better understanding of any associated neuropathologies may help to facilitate future treatments and public acceptance. The possibility exists, at least in some instances, that a sexually compulsive individual is less an example of a bad person deserving of punishment than a "broken mind" in need of repair. In time, increased knowledge about the precise workings of the brain in reciprocally initiating and sustaining the sexual interests of the mind may facilitate a much clearer appreciation of the issues at hand.

The use of actuarials at civil commitment hearings to predict the likelihood of future sexual violence.

Some have argued that acturarial methods such as the RRASOR, the MNSOSTR, and the Static-99, can outperform clinical judgments when utilized at a civil commitment hearing to make a prediction. Although actuarial data can be used to identify a group of persons to be considered for possible civil commitment, at present it cannot be used to accurately predict the likelihood of future acts of sexual violence with respect to any specific individual within such a group. For that reason, it might be best to restrict the use of acturial data to the initial screening process, rather than introducing it at the commitment hearing itself.

Sexual deviancy: diagnostic and neurobiological considerations.

Individuals who engage in sexual offenses may be afflicted with a paraphilic disorder or sexual deviation syndrome. Paraphilias are psychiatric disorders characterized by deviant and culturally non-sanctioned sexual fantasies, thoughts, and/or behaviors. A proportion of these individuals may also suffer from symptoms of mental illness that can go unrecognized. Although the etiology and pathophysiology of paraphilic disorders continue to be under investigation, data from empirical, biomedical, and psychopharmacological studies suggest abnormalities at a biological level. This article will discuss and review clinical and neurobiological characteristics of the paraphilias. To this end, we will begin with a general exploration and overview of basic principles that are germane to the subject matter and will conclude with an examination of the most recent relevant research findings.

Sex hormones, neurotransmitters, and psychopharmacological treatments in men with paraphilic disorders.

Paraphilic disorders are psychiatric syndromes primarily characterized by deviant sexual thoughts, cravings, urges, and/or behaviors. Paraphilic men may engage in inappropriate sexual behaviors when cravings for socially unacceptable sexual acts become overpowering. These often chronic disorders may not only cause emotional distress and social embarrassment to the afflicted patient but also to the targets of their paraphilic focus. The primary objective of this article is to examine and review data on the efficacy and tolerability of the testosterone-lowering agents medroxprogesterone acetate, cyproterone acetate, and leuprolide acetate. The secondary goal is to review data on less conventional and more innovative pharmacological treatments, particularly the serotonin-specific reuptake inhibitors.

Sex offender treatment and legislation.

The current issue of the Journal contains three articles related to sex offenders. The first, by Scott and Holmberg, discusses legislation that mandates either "chemical or surgical castration." The second, by Saleh and Guidry, reviews diagnostic and treatment considerations. The third, by Scott and Gerbasi, discusses sex offender registration and community notification. Much of the relevant sex offender legislation, including that pertaining to testosterone-lowering treatments, has been enacted in response to intense public passion. When it comes to the issue of sex offenders, there is a pressing need to develop a coherent body of evidence-based forensic concepts and knowledge that can rationally inform both clinical practice and future public policy. That may require a closer collaboration between both the criminal justice and legislative sectors, and the scientific-medical communities. The three papers published in this issue provide useful information that may assist toward such a goal.

Pedophilia.

This article addresses the risk factors associated with the psychiatric disorder pedophilia, its treatment, and treatment outcomes. It addresses physician responsibilities associated with case identification of victims and possible roles in the medical management of pedophilia. The essential feature of pedophilia is that an individual is sexually attracted exclusively or in part to prepubescent children. While pedophilia may be limited to fantasies and impulses, pedophilic behaviors are the primary concern of both the mental health and criminal justice systems. Remote risk factors for development of pedophilia often include the individual having been sexually abused as a child. Proximate risk factors for its behavioral expression are prevalence of comorbid psychiatric disorders and substance abuse disorders. Current treatment goals focus on stopping the behavior and achieving long-term behavioral control in the community. Common treatment methods are cognitive-behavioral, group therapy, and, when appropriate, medications such as androgen-lowering agents that can act as sexual appetite suppressants. Meta-analyses have established that treatment is more effective than nontreatment in preventing recidivism of sexual offenders in general, a finding that has a high probability of application to individuals with pedophilia. Pedophilia is a chronic psychiatric disorder, but it is treatable in terms of developing strategies for preventing behavioral expression. Ultimately, reducing the prevalence of pedophilic behavior requires further collaboration between the criminal justice system and the health care communities.