Long-Term Follow-Up of Adults with Gender Identity Disorder.

The aim of this study was to re-examine individuals with gender identity disorder after as long a period of time as possible. To meet the inclusion criterion, the legal recognition of participants' gender change via a legal name change had to date back at least 10 years. The sample comprised 71 participants (35 MtF and 36 FtM). The follow-up period was 10-24 years with a mean of 13.8 years (SD = 2.78). Instruments included a combination of qualitative and quantitative methods: Clinical interviews were conducted with the participants, and they completed a follow-up questionnaire as well as several standardized questionnaires they had already filled in when they first made contact with the clinic. Positive and desired changes were determined by all of the instruments: Participants reported high degrees of well-being and a good social integration. Very few participants were unemployed, most of them had a steady relationship, and they were also satisfied with their relationships with family and friends. Their overall evaluation of the treatment process for sex reassignment and its effectiveness in reducing gender dysphoria was positive. Regarding the results of the standardized questionnaires, participants showed significantly fewer psychological problems and interpersonal difficulties as well as a strongly increased life satisfaction at follow-up than at the time of the initial consultation. Despite these positive results, the treatment of transsexualism is far from being perfect.

Assessing reliability, validity, and clinical utility of the BEST-Index in measuring living skills among forensic inpatients.

The assessment of behavioral change as a result of inpatient treatment in forensic psychiatry is an important precondition for violence risk prediction in forensic psychiatry. In relation to a multitude of diagnostically based risk assessment instruments, there is a shortage of appropriate instruments with which to carry out valid and reliable therapeutic assessments that are behaviorally based and therefore appropriate for use within varied psychiatric contexts. There is also a need for instruments which will offer assessors the opportunity to examine possible relationships between criteria of social risk and criteria of more general aspects of social functioning. Tapping the issues pointed out above, the authors present an overview of a normatively based social profiling instrument (the BEST-Index), and discuss evidence for its validity, reliability, and aspects of clinical utility.

The DSM diagnostic criteria for gender identity disorder in adolescents and adults.

Apart from some general issues related to the Gender Identity Disorder (GID) diagnosis, such as whether it should stay in the DSM-V or not, a number of problems specifically relate to the current criteria of the GID diagnosis for adolescents and adults. These problems concern the confusion caused by similarities and differences of the terms transsexualism and GID, the inability of the current criteria to capture the whole spectrum of gender variance phenomena, the potential risk of unnecessary physically invasive examinations to rule out intersex conditions (disorders of sex development), the necessity of the D criterion (distress and impairment), and the fact that the diagnosis still applies to those who already had hormonal and surgical treatment. If the diagnosis should not be deleted from the DSM, most of the criticism could be addressed in the DSM-V if the diagnosis would be renamed, the criteria would be adjusted in wording, and made more stringent. However, this would imply that the diagnosis would still be dichotomous and similar to earlier DSM versions. Another option is to follow a more dimensional approach, allowing for different degrees of gender dysphoria depending on the number of indicators. Considering the strong resistance against sexuality related specifiers, and the relative difficulty assessing sexual orientation in individuals pursuing hormonal and surgical interventions to change physical sex characteristics, it should be investigated whether other potentially relevant specifiers (e.g., onset age) are more appropriate.

Assessing living skills in forensic mental health care with the behavioural status index: a European network study.

Assessment of living skills and violence risk in forensic psychiatric patients is a priority for clinicians. Suitably fine-grained instruments are rare. The goal of this study was to compare a norm-based psychometric assessment battery (the Behavioural Status [BEST] Index) with known valid instruments. Parallel cohort studies were undertaken in four European countries. Inpatients from 24 forensic psychiatric clinics were assessed three times using five instruments measuring living skills, psychological symptoms, aggression, and violence risk. Positive clinical changes were noted in insight, empathy, and some behaviors related to communication and living skills, with little change in violence risk, which was low to medium for most patients. Clinical congruence was observed between logically cognate items of the BEST Index and comparison instruments. Evidence for the scientific and clinical utility of the BEST Index as an effective tool for forensic psychiatric practice is discussed.

Good enough to eat.

In mythology, religion, and literature, there are many examples of cannibalism that have been passed down over the centuries and which do not strike us as shocking as long as they remain fixed in a symbolic context. Things only become problematic when cannibalistic impulses are taken literally and put into practice. Apart from situations of extreme emergency in which this rare phenomenon might enjoy a certain sympathy, it also occurs within the context of serious sexual offences. Recently, in Germany, there was the case of a man who used the internet to find a person who wanted to have himself eaten. The victim's consent unsettled not only the public at large, but also the judiciary, which at first did not know how the case was legally to be appropriately assessed. In a first trial in January 2004, the man was sentenced to a comparatively short prison term of only a few years, a sentence that was lifted by the Federal Supreme Court. In a fresh trial in May 2006, he was sentenced to life imprisonment for murder. In this essay, I discuss to what extent mythological, religious, and artistic models of cannibalism express something fundamentally anthropological and how concrete examples should be assessed against this background.

[The evaluation of living skills in forensic-psychiatric patients]. / Die Beurteilung von lebenspraktischen Fertigkeiten forensisch-psychiatrischer Patienten mit dem BEST-Index.

The role of daily living skills in forensic psychiatric patients in relation to psychotherapeutic progress and the potential reduction of dangerous behaviour has been neglected in the scientific discussion about clinical instruments for the evaluation of dangerousness and recidivism. This is mainly due to the lack of adequate observationally based instruments allowing for valid and reliable therapeutic assessments. Therefore, a new means of assessment focusing on daily living skills and social risk (the BEST-Index [Behavioural Status Index] was applied to n = 86 German forensic psychiatric patients. Two widely known actuarial instruments tapping violence risk were administered for cross validation (Psychopathy Checklist Revised [PCL-R], HCR-20). Within intervals of nine months, all instruments were applied three times. Sufficient inter rater reliability and good convergent validity of the sub-scales in relation to the actuarial instruments (HCR-20, PCL-R) could be demonstrated; supported by empirical data, clinicians working with the BEST-Index may use it to monitor behavioural change over long treatment periods. It is suggested that treatment planning and evaluation of mentally ill offenders might profit from its use.

[Assessment and treatment of sexual offenders]. / Begutachtung und Behandlung von Sexualstraftätern.

Sexual offences are a heterogeneous group of offences that entail very different diagnostic categories relevant for key issues of expert assessment. Sexual offender trials usually deal with issues related to (diminished) responsibility and the necessity of a referral to a forensic psychiatric hospital ( section sign 63 StGB, German penal code). Furthermore, risk assessment is seen as a necessary precondition for relapse prevention and consequently, it forms part of any expert assessment in sex offender trials. In terms of treatment, manualized treatment programs prevail. Usually they lend themselves to psycho-educative, cognitive-behavioral and psychodynamic concepts. Notwithstanding the focus of any individual program, core elements of all programs pertain to offence related (e.g., victim empathy, attitudes and individual values, minimizations, etc.) and more general psychotherapy modules (anger management, substance abuse, social skills training, etc.). Advantages and disadvantages of these programs are named and discussed.

[COMSKILLS: assessing community living skills in offender groups]. / COMSKILLS -- Ein Forschungsprogramm zur Erfassung lebenspraktischer Fertigkeiten psychisch kranker Straftäter.

OBJECTIVE: An international network study involving parallel, complementary interventions in three EU countries and an associate country (Germany, United Kingdom, The Netherlands and Norway) is reported. The aim is to develop a unified approach to the assessment of social risk and related behaviours in offender groups. METHOD: The Behavioural Status Index (BEST-Index) and a set of cross-validating instruments (PCL-R, HCR-20; SCL-90-R; BDHI-D) were applied to a sample of n = 231 mentally ill offenders. RESULTS: Selected results using a sub-sample of n = 89 German offenders are reported and discussed. CONCLUSIONS: The BEST-Index shows convergent validity with respect to a social risk criterion and it helps to determine an objective data base for the improvement of carer assessments, related care planning, and delivery.

What happens in therapy with sexual offenders? A model of process research.

This paper presents two studies (one single case and one comparative study) examining change processes within individual therapy sessions as well as during the course of treatment. The Therapeutic Cycle Model (TCM), developed for general psychotherapy to objectify change events in the course of psychotherapies, is applied to transcribed tape recordings of therapy sessions with sexual offenders. The TCM focuses on emotional experience and cognitive mastery and uses computer assisted text analysis. In addition to the TCM approach clinical ratings are used as independent criteria. The predicted relationship between the phases of the TCM and scores on the respective scales of the clinical ratings were supported.

[Change events during the psychotherapy process of a patient detained by court order due to sexual offences in a high security forensic clinic]. / Veränderungsprozesse im Verlauf der Psychotherapie eines wegen Sexualdelikten im Massregelvollzug untergebrachten Patienten.

BACKGROUND: Psychotherapy of sex offenders is effective and reduces relapse rates when compared with untreated controls. As compared to the effectiveness of psychotherapy at large, however, effect sizes are much lower. OBJECTIVE: To provide evidence for change processes in a therapy with a sex offender. METHOD: This is an exploratory single case study in which the Therapeutic Cycles Model (TCM)--developed for general psychotherapy and based on emotional experience and cognitive mastery--is being applied. In addition to the computer assisted approach of the TCM clinical ratings are used as independent criteria. RESULTS: The predicted relationship between the phases of the TCM, the rating for Quality of Sessions and the Therapeutic Alliance was observed.