Granting Leave to Patients in Bavarian Forensic-Psychiatric Hospitals: A Survey to Describe the Current Process and Develop Guidelines.

Forensic-psychiatric patients reoffending or absconding during the leave granted to them (hereafter referred to as "granted leave") have gained increased attention by researchers and the general public. The patients' right to freedom on the one hand and the need for protection of the general public from serious harm on the other hand represent broadly discussed ethical issues. Thus, demands on quality regarding decisions on patients' granted leaves might be high. Despite such requirements, research on decision-making processes regarding granting leave in forensic psychiatry is very limited and focuses primarily on particular aspects. The present study aims at providing a first overview of the decision-making processes regarding granted leave in forensic psychiatry as a whole. Furthermore, the link between the particular steps of the process and absconding should be explored. In this way, the study results should contribute to provide a theoretical framework for the development of guidelines concerning granted leave in forensic psychiatry. A combination of qualitative and quantitative approaches will be used to collect data: information about risk assessment, decisions on granted leave, and documentation systems in forensic psychiatry will be collected via semi-structured interviews and quantified for further analyses using a checklist developed for this study; data on the implementation of risk assessment tools and documented patient information will be obtained via two self-constructed questionnaires; information about the absolute number of abscondences per hospital will be obtained from the Bavarian Authority for Forensic Commitment. The sample will include staff from all 13 forensic-psychiatric hospitals in Bavaria (Germany) comprising six professional groups: hospital directors, security officers, complementary therapists, psychiatrists, psychologists, social workers, and nursing staff. In each hospital, at least one member of each professional group should participate in the study. In total, 151 interviews will be held. As the study goals are descriptive, there are no pre-formulated hypotheses. Developing guidelines would be the first step towards further standardization of the granted leave decisional process in forensic psychiatry and to make it more transparent for patients, staff members, hospital directors, and the government.

Sexual Interest in Children Among Women in Two Nonclinical and Nonrepresentative Online Samples.

INTRODUCTION: Regarding women, little research is available about the prevalence of sexual interest in children (SIC), especially in nonclinical samples. AIM: The present study aimed to investigate the extent to which adult women from 2 nonclinical and nonrepresentative samples indicate sexual interest in prepubescent and/or pubescent children. METHODS: Participants took part in an online survey either via general websites or via websites directed toward individuals with a SIC. MAIN OUTCOME MEASURES: The self-report survey included questions about the use of online abuse material including children and teenagers as well as about sexual fantasies involving prepubescent and pubescent children. Both measures were included as main outcome measures. RESULTS: Results showed that few women reported having used online abuse material including children (total sample: n = 7 [0.8%], general websites: n = 3 [0.4%], SIC websites: n = 4 [9.5%]) or teenagers (total sample: n = 44 [5.0%], general websites: n = 37 [4.4%], SIC websites: n = 7 [16.7%]). Results further revealed that some women reported sexual fantasies involving prepubescent (total sample: n = 98 [7.0%], general websites: n = 92 [6.8%], SIC websites: n = 6 [11.1%]) or pubescent children (total sample: n = 136 [9.6%], general websites: n = 129 [9.5%], SIC websites: n = 7 [13.0%]). CONCLUSIONS: The samples included are nonrepresentative and therefore not generalizable to the female population. Nevertheless, they strongly suggest that SIC is a phenomenon also found in women. We therefore recommend professionals in the field of sexual medicine to increase their attention and engagement for women with SIC. Based on the present results, the development of preventive treatment services specifically tailored to women with a SIC has to be strongly encouraged in the near future. Tozdan S, Dekker A, Neutze J, et al. Sexual Interest in Children Among Women in Two Nonclinical and Nonrepresentative Online Samples. Sex Med 2020;8:251-264.

Online sexual solicitation by adults and peers - Results from a population based German sample.

Prevalence of Internet use among adolescents is high, but little is known about the online sexual activities of German adolescents. This study aimed to describe the 12-month prevalence of German adolescents' online sexual experiences with a focus on Online Sexual Solicitation (OSS, subjectively negative online sexual experiences with a peer or any sexual online experience, positive or negative, with an adult). A sample of male and female adolescents aged 14-17 (N=2238) was recruited using online survey panel. The sample was representative for gender and education. Subjects completed an online survey reporting their online sexual activities (i.e., sexual conversation, exchanging pictures, and cybersex) with peers (14-17y.) and/or adults (≥18y.). Findings illustrated that 51.3% (n=1148) of adolescents had experienced online sexual activity, which mostly involved peers (n=969; 84.4%). In contrast, 23.2% (n=519) of the adolescents experienced OSS with 2.6% (n=57) reporting subjectively negative online sexual interactions with peers and 22.2% (n=490) reporting online sexual interactions with adults, of which 10.4% (n=51) were perceived as negative. The findings suggest that adolescents frequently engage in sexual interactions on the Internet with only a relatively small number perceiving such contacts as exploitative. In addition, females and adolescents with incomplete family situation, foreign nationality, higher education, homo- or bisexual orientation, and those without perceived social support reported OSS significantly more often.

Child sex tourism - prevalence of and risk factors for its use in a German community sample.

BACKGROUND: To investigate the prevalence of child sex tourism (CST) in a large German community sample, and to compare those who made use of CST with other child sexual abusers regarding established characteristics and risk factors for child sexual abuse. METHODS: Adult German men were recruited through a German market research panel and questioned by means of an anonymous online survey. Group assignment was accomplished based on information on previous sexual contacts with children and previous use of CST. Characteristics and risk factors were compared between the groups using t- and Chi-square tests. Binary logistic regression analysis was performed to predict CST. Data collection was conducted in 2013, data analysis in January 2015. RESULTS: Out of 8718 men, 36 (0.4%) reported CST use. The CST group differed from the nonCST group (n = 96; 1.1%) with regard to pedophilic sexual and antisocial behaviors as well as own experiences of sexual abuse. Social difficulties, pedophilic sexual interests, and hypersexuality were not distinct features in the CST group. Own experiences of sexual abuse, child prostitution use, and previous conviction for a violent offense predicted CST in a logistic regression model. CONCLUSIONS: This study is a first step to gain insight into the prevalence and characteristics of men using CST. Findings could help to augment prevention strategies against commercial forms of sexual abuse in developed as well as in developing countries by fostering the knowledge about the characteristics of perpetrators.

How Common is Men's Self-Reported Sexual Interest in Prepubescent Children?

Consistent evidence exists for sexual interest in children in nonclinical/nonforensic male populations. However, prevalences for community men's self-reported sexual interest in children have been based on indiscriminate definitions including postpubescent individuals, age-restricted samples, and/or small convenience samples. The present research assessed men's self-reported sexual interest in children (including child prostitution and child sex tourism) on the community level and examined the link between strictly defined sexual fantasies and behaviors involving prepubescent children. In an online survey of 8,718 German men, 4.1% reported sexual fantasies involving prepubescent children, 3.2% reported sexual offending against prepubescent children, and 0.1% reported a pedophilic sexual preference. Sexual fantasies involving prepubescent children were positively related to sexual offending against prepubescent children. Sexual interest in children was associated with subjectively perceived need for therapeutic help. In contrast to findings from forensic samples, men who reported child pornography use exclusively were identified as a subgroup differing from contact sexual offenders against prepubescent children and men who reported both child pornography use and contact sexual offenses against prepubescent children. The empirical link between child-related sexual fantasies and sexual victimization of prepubescent children and high levels of subjective distress from this inclination underscore the importance of evidence-based child sexual abuse prevention approaches in the community. Findings are discussed in terms of their relation to pedophilic disorder.

Undetected and detected child sexual abuse and child pornography offenders.

Current knowledge about risk factors for child sexual abuse and child pornography offenses is based on samples of convicted offenders, i.e., detected offenders. Only few studies focus on offenders not detected by the criminal justice system. In this study, a sample of 345 self-referred pedophiles and hebephiles was recruited from the community. All participants met DSM-IV-TR criteria for pedophilia or hebephilia (paraphilia not otherwise specified), were assured of confidentiality, and self-reported lifetime sexual offending against prepubescent and/or pubescent children. Two sets of group comparisons were conducted on self-report data of risk factors for sexual reoffending. Measures of risk factors address the following dimensions identified in samples of convicted offenders: sexual preferences (i.e. co-occurring paraphilias), sexual self-regulation problems, offense-supportive cognitions, diverse socio-affective deficits, and indicators of social functioning (e.g., education, employment). Men who admitted current or previous investigation or conviction by legal authorities (detected offenders) were compared with those who denied any detection for their sexual offenses against children (undetected offenders). Group comparisons (detected vs. undetected) were further conducted for each offense type separately (child pornography only offenders, child sexual abuse only offenders, mixed offenders). Although there were more similarities between undetected and detected offenders, selected measures of sexual-self regulation problems, socio-affective deficits, and social functioning data demonstrated group differences.

Assessment of pedophilia using hemodynamic brain response to sexual stimuli.

CONTEXT: Accurately assessing sexual preference is important in the treatment of child sex offenders. Phallometry is the standard method to identify sexual preference; however, this measure has been criticized for its intrusiveness and limited reliability. OBJECTIVE: To evaluate whether spatial response pattern to sexual stimuli as revealed by a change in the blood oxygen level-dependent signal facilitates the identification of pedophiles. DESIGN: During functional magnetic resonance imaging, pedophilic and nonpedophilic participants were briefly exposed to same- and opposite-sex images of nude children and adults. We calculated differences in blood oxygen level-dependent signals to child and adult sexual stimuli for each participant. The corresponding contrast images were entered into a group analysis to calculate whole-brain difference maps between groups. We calculated an expression value that corresponded to the group result for each participant. These expression values were submitted to 2 different classification algorithms: Fisher linear discriminant analysis and κ -nearest neighbor analysis. This classification procedure was cross-validated using the leave-one-out method. SETTING: Section of Sexual Medicine, Medical School, Christian Albrechts University of Kiel, Kiel, Germany. PARTICIPANTS: We recruited 24 participants with pedophilia who were sexually attracted to either prepubescent girls (n = 11) or prepubescent boys (n = 13) and 32 healthy male controls who were sexually attracted to either adult women (n = 18) or adult men (n = 14). MAIN OUTCOME MEASURES: Sensitivity and specificity scores of the 2 classification algorithms. RESULTS: The highest classification accuracy was achieved by Fisher linear discriminant analysis, which showed a mean accuracy of 95% (100% specificity, 88% sensitivity). CONCLUSIONS: Functional brain response patterns to sexual stimuli contain sufficient information to identify pedophiles with high accuracy. The automatic classification of these patterns is a promising objective tool to clinically diagnose pedophilia.

Predictors of child pornography offenses and child sexual abuse in a community sample of pedophiles and hebephiles.

Little is known about factors that distinguish men who act upon their self-identified sexual interest in prepubescent or pubescent children from those who do not. Even less is known about pedophiles or hebephiles who are not involved with the criminal justice system. In this study, a sample of 155 self-referred pedophiles and hebephiles was recruited from the community. All participants met DSM-IV-TR criteria for pedophilia (or paraphilia not otherwise specified for those who were sexually attracted to pubescent children). Two sets of group comparisons were conducted on sociodemographic variables and measures of dynamic risk factors. The first set was based on recent activity and compared men who had committed child pornography only or child sexual abuse offenses in the past six months with men who remained offense-free during the same period. The second set was based on lifetime offense history (excluding the most recent six months) and compared child pornography offenders with child sexual abuse offenders and men who had committed both kinds of offenses. Overall, there were more similarities than differences between groups.

Potential and Dunkelfeld offenders: two neglected target groups for prevention of child sexual abuse.

Little is known about men who have not yet committed child sexual abuse but may be at risk of doing so (potential offenders) and the factors that distinguish these men from undetected child sexual abuse offenders with a sexual interest in children (Dunkelfeld offenders). The present study describes and compares potential and Dunkelfeld offenders, which can be viewed as ideal target groups for (primary) prevention efforts with respect to child sexual abuse. Also, this study seeks to demonstrate the feasibility of using a telephone screening procedure to conduct research with these groups. Using a computer assisted telephone interview (CATI), data on demographics, mental health, sexuality, criminal history, and victim characteristics were collected from respondents in a nation-wide media campaign, which informed potential (re-)offenders of child sexual abuse of a research and treatment project. Many participants reported recurrent sexual fantasies involving minors, as well as related distress, suggesting a high prevalence of pedophilia and hebephilia. More than half feared they would sexually abuse a minor, and Dunkelfeld offenders reported 3.2 victims on average. Group comparisons revealed that Dunkelfeld offenders were, for example, more likely to perceive themselves being at risk of offending, compared to potential offenders. The results suggest that targeting potential and Dunkelfeld offenders could prove a worthwhile approach in the prevention of child sexual abuse.