Psychological treatment of problematic sexual interests: cross-country comparison.

This paper reviews the use of psychotherapeutic approaches to treat individuals who have committed sex crimes and/or have problematic sexual interests (PSI); including types of psychotherapy used, descriptions of preventive and reintegration programmes, and highlighting specific theoretical controversies. In the second part, experts from Canada, the Czech Republic, Russia, the United Kingdom, and the United States, who participated in an International Consensus Meeting held in Prague (2017), summarize treatment programmes in their countries. The comparison revealed some general findings: each country has variability between its own programmes; most countries have different programmes for people who are in custody and who are in the community; the state-directed treatment programmes are primarily focused on criminal individuals, while non-criminal individuals are treated in preventive programmes and/or in special clinics or are untreated; the presence of PSI in patients is acknowledged in most programmes, although specific programmes exclusively for individuals with PSI rarely exist. Studies on effectiveness are difficult to compare due to methodologic, political, and cultural differences. Further communication between more countries to share knowledge about successful treatments and preventive approaches is needed, especially enhanced international collaboration between researchers and clinicians to verify the effectiveness of current clinical and experimental program, rs.

[Failure of a study in forensic psychiatric hospitals : Clinical trial to investigate the additive effect of triptorelin on the efficacy of psychotherapy]. / Vom Scheitern einer Studie in Maßregelvollzugskrankenhäusern : Klinische Prüfung zum additiven Effekt von Triptorelin auf die Wirksamkeit von Psychotherapie.

BACKGROUND: A testosterone-lowering medication is relatively commonly used as a form of treatment for sexual offenders with severe paraphilic disorders in German forensic psychiatric hospitals; however, a double-blind, controlled and randomized study, which investigates the efficacy of this medication, is still lacking. AIM: This article describes the process from the planning to the rejection of a clinical trial over the period from 2009 to 2015. METHODS AND RESULTS: Despite the careful planning with an interdisciplinary team and giving special consideration to the complex legal situation, the Federal Institute for Drugs and Medical Devices (BfArM) rejected the proposed trial in a brief formal letter with reference to the German Drug Law (§ 40 para. 1 p. 3 nr. 4 AMG). The ethics committee of the Hamburg Medical Association considered that clinical research is basically not possible with patients detained in a forensic psychiatric hospital. DISCUSSION: In the opinion of the authors, the described facts illustrate how legal regulations that should protect vulnerable groups in medical research, in a specific case can lead to the fact that a therapy form relevant to the corresponding patient group cannot be scientifically investigated.

Vampirism, vampire cults and the teenager of today.

The aim of this paper is to summarize the limited literature on clinical vampirism, vampire cults and the involvement of adolescents in vampire-like behavior. The various definitions of clinical vampirism are outlined and the emergence of vampire cults from Gothic culture is examined. Further, the clinical features of cult behavior, the attraction to cults, the risk factors for cult involvement, and the clinical management of cult members are discussed. Additionally, vampire popular media is briefly introduced and a case study presented.

Paraphilias in adult psychiatric inpatients.

BACKGROUND: The goal of the present study was to examine the prevalence of paraphilias in an adult inpatient psychiatric population. METHODS: One hundred twelve consecutive, voluntarily admitted, adult male psychiatric inpatients were administered the Structured Clinical Interview for DSM-IV, Sexual Disorders Module, Male Version, to assess the rates of DSM-IV paraphilias. RESULTS: Fifteen patients (13.4%) reported symptoms consistent with at least one lifetime DSM-IV paraphilia. The most common paraphilias were voyeurism (n = 9 [8.0%]), exhibitionism (n = 6 [5.4%]), and sexual masochism (n = 3 [2.7%]). Patients who screened positive for a paraphilia had significantly more psychiatric hospitalizations (P = .006) and, on a trend level, were more likely to have attempted suicide. In addition, patients with paraphilias were significantly more likely to report having been sexually abused than patients without a paraphilia (P = <.001). Only 2 of the 15 paraphilic patients (13.3%) carried an admission diagnosis of a paraphilia. CONCLUSIONS: Paraphilias appear to be more common in adult male psychiatric inpatients than previously estimated. The study also demonstrated that these disorders were not screened for by the treating physician and thus may go untreated. Further, larger-scale studies are necessary in order to further examine the rates of these disorders in the general population.

Mental disorder, predisposition, prediction, and ability to control: evaluating sex offenders for civil commitment.

Nearly 20 years after the first sexually violent person (SVP) statutes were introduced in the United States, the civil commitment of sex offenders remains controversial. SVP laws require that a sex offender has a mental condition that predisposes them to commit sex offenses and poses a high risk to reoffend because of serious difficulty controlling behavior. The controversy over the commitment of sex offenders is fueled by different interpretations of those key constructs. This article reviews those constructs; evaluates them from clinical, epidemiologic, and legal perspectives; and proposes interpretations that address both the major criticisms of civil commitment and the challenges in SVP assessment.

Resistance, reluctance, and readiness in perpetrators of abuse against women and children.

Perpetrators of abuse and violence against women and children are often reluctant participants in intervention programs. They frequently fail to attend scheduled appointments, are sometimes openly hostile to intervention staff, and often judge program materials as irrelevant to their situation. Recognizing this problem, researchers and practitioners have begun to develop models and tools to more appropriately assess and intervene with reluctant clients. Unfortunately, the resulting proliferation and inconsistent application of terms and theories have led to considerable confusion in characterizing reluctant clients and have significantly hampered research on strategies that may be helpful to better meet the needs of this client group. The purpose of this review is to help standardize the definition and measurement of treatment reluctance as it applies to violence perpetration and to review evidence for the importance of these aspects of client reluctance to intervention. Recommendations for assessing reluctance in research and clinical practice are also provided.

[Pornography and sexual abuse in the Internet]. / Pornographie und sexuelle Gewalt im Internet.

Internet pornography has been regarded as either stimulating sexual aggression and abuse or as serving as a safety valve. This controversy is an important issue in health, media and legal politics. According to empirical studies on pornography in general, soft-core pornography and nonviolent pornography can be regarded as harmless, whereas non-violent hard-core pornography and violent pornography may increase aggression. Individuals with a high risk for sexual aggression show more interest in violent pornography and are stimulated more strongly through such material. Two case histories illustrate the characteristics of internet pornography and "cybersex": easy access, anonymity, affordability, wide range and deviation of the material, unlimited market, blurring the borders between consumer and producer, interactive communication, space for experimenting between fantasy and in real-life behavior, virtual identities, easy contact between offender and victim or among offenders, and low risk of apprehension. The phenomenon of "sexual addiction" (or paraphilia- related disorder) is particularly relevant for the problematic use of internet pornography. Preventive measures to protect possible victims are presented as well as treatment strategies for offenders. Beside limiting access to the internet, these include therapy of comorbid psychiatric disorders and psychological problems (social isolation, bereavement, stress- and anger-management, guilt and shame, childhood traumata, cognitive distortion, victim empathy), psychopharmacotherapy and the enhancement of a more integrative and relationship-oriented sexuality.

[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.

The Oregon depo-Provera program: a five-year follow-up.

In 1999, the Oregon State Legislature, concerned about the risk certain sexual offenders might pose to their communities upon release from prison, enacted House Bill 2500. This bill required selected offenders to be evaluated prior to their release to determine whether medical treatment with medroxyprogesterone acetate (MPA), also known by its trade name of depo-Provera, was indicated to reduce their risk. The present study reviewed the first 275 men to be evaluated under this program from the years 2000 through 2004. Data were collected on diagnoses and outcome on three groups: men judged to need MPA who eventually went on to actually receive it; men recommended to receive MPA who, for a variety of reasons, did not receive the medication; and men deemed not to need MPA. Outcome measures included recidivism data, including reoffenses, parole violations, and reincarcerations, and whether these were sexual in nature. Data were also collected on employment and whether supervising officers believed the men in each group were doing well. Significant differences emerged among these three groups, with men actually receiving depo-Provera committing no new sexual offenses and also committing fewer overall offenses and violations compared to the other two groups. In addition, almost one third of men judged to need medication but who did not receive it committed a new offense and almost 60% of these were sexual in nature. While generalizations from these types of retrospective and partially subjective findings are inherently limited, the present study lends credence to the belief that, in selected offenders, anti-androgenic medication can be a valuable, if time-limited, addition to a cognitive and behavioral treatment program. Suggestions for more practical and far-reaching implementation of this adjunctive approach are offered.

Circumferential change scores in phallometric assessment: normative data.

Phallometric testing is a procedure that has enjoyed considerable popularity as an objective component in the assessment of sexual offenders. The value of this procedure may be most notably compromised in the realm of interpretation, and problems in interpretation are particularly acute for those participants where full arousal is not obtained during testing. The calculation of Percent Full Erection (PFE) scores has of necessity involved a speculative component in such cases. Eliminating this speculation through empirical investigation was the purpose of the current research. Circumferential change scores (from flaccidity to full erection) were obtained for 724 respondents at nine North American correctional facilities, allowing for the calculation of descriptive statistics and a determination of the distribution characteristics of these scores. The results provide an empirical basis for calculating PFE scores and interpreting phallometric data in those cases where full arousal is not obtained, and specific confidence levels associated with interpretation are offered. It is suggested that only through a more rigorous application of the principles of science will the procedure of phallometric assessment fulfill its true potential.

Olfactory aversion: notes on procedure, with speculations on its mechanism of effect.

The use of a self-administered noxious agent to suppress deviant sexual arousal is the focus of this paper. A recommended procedure for the use of olfactory aversion is described. Data from two publications by the author, wherein different noxious agents had been used, are presented and discussed. Several explanations for the mechanism of effect in olfactory aversion have been offered. Two of these, one using a nausea-producing agent and one using a pain-producing agent are described. The procedure using the pain-producing agent is the simplest to implement, the least ambiguous, and offers the least cumbersome explanation for the behavioral effect observed in olfactory aversion. However, a conditioning explanation is probably too simple. Several examples of cognitive mediation in conditioning procedures are presented and discussed.

Outcome of an institutional sexual offender treatment program: a comparison between treated and matched untreated offenders.

Data from a sexual offender treatment program operated by the Correctional Service of Canada at the Regional Psychiatric Center (Saskatoon) supported the conclusion that cognitive behavioral treatment can reduce sexual offense recidivism. The study compared 296 treated and 283 untreated offenders followed for a mean of 6 years after their release. An untreated comparison subject was located for each treated offender on three dimensions: (a) age at index offense, (b) date of index offense, and (c) prior criminal history. Data were analyzed using tests of proportion, survival analysis, and analysis of offender Criminal Career Profiles. Over a mean follow-up period of almost 6 years, convictions for new sexual offenses among treated offenders were 14.5% versus 33.2% for untreated offenders. During the follow-up period, 48% of treated offenders remained out of prison compared to 28.3% of untreated offenders. Time series comparisons of treated and comparison samples also showed that treated men reoffended at significantly lower rates after 10 years. A Criminal Career Profile (CCP) was constructed by taking the Age at First Conviction and plotting the offender's successive lengths of time free against time incarcerated. Pre- and posttreatment slopes of the CCP were lower for both groups posttreatment; however, the degree of change was significantly greater for the treated group, indicating a greater reduction in criminal activity among these offenders. Taken together, the results of all three analytic techniques supported the efficacy of appropriate correctional treatment for effective reduction of recidivism.

Judges' knowledge about sexual offenders, difficulties presiding over sexual offense cases, and opinions on sentencing, treatment, and legislation.

Forty-two Midwestern trial judges responded to a survey designed to assess knowledge about sexual offenders; attitudes toward adjudication, sentencing, treatment, and release; and opinions regarding sexual offender-related legislation. Results indicated that the judges held a variety of beliefs regarding the etiology and dynamics involved in sexual offending which differ from those of most professionals in the field of sexual offender management. However, the judges accurately identified important issues related to victims and some myths about offenders. The importance of retribution and rehabilitation for sexual offenders was emphasized, and considerable support was revealed for controversial legislative issues such as community notification, mandatory registration, and civil commitment of sexual predators. Of particular interest is the finding that, compared to other cases, sexual offense cases were rated by judges as more difficult over which to preside from a legal and technical standpoint, a personal and emotional viewpoint, and a public scrutiny and public pressure perspective. These issues, as well as judges' comments on current systemic and decision-making difficulties, are discussed in terms of the importance of judicial education programs and future research.

Unresolved issues in scientific sexology.

A number of unresolved issues in sexology research and practice are reviewed. Penile volume assessment of sexual arousal has consistently proved more sensitive than penile circumference assessment and requires much shorter exposure to the erotic stimuli eliciting the arousal, reducing the subjects' ability to modify their responses. Failure to acknowledge this has allowed acceptance of evidence based on penile circumference assessment that behavioral treatments such as directed masturbation can increase the ability of sex offenders to be heterosexually aroused and aversive therapy can reduce their deviant urges whereas penile volume assessment indicates these procedures are ineffective. A randomized controlled trial of relapse prevention versus no treatment for sex offenders found more treated than untreated subjects reoffended after a mean follow-up period of 4 years. Researchers and therapists accepted that a post hoc statistical manipulation of the results provided evidence of a treatment effect. Subsequently it has been recommended that randomized controlled evaluations of treatments of sex offenders be abandoned. Meta-analysis of outcome studies has been used uncritically. The majority of men and women who report homosexual feelings and/or behavior report predominant heterosexual feelings and behavior and do not identify as homosexual. These consistent findings remain ignored. Studies of the etiology and development of homosexuality and heterosexuality treat them as distributed categorically rather than dimensionally and investigate only self-identified homosexuals and heterosexuals. With this methodology the predominantly heterosexual majority are excluded or misclassified. The belief that the European concept of the homosexual is a late 19th-century invention is based on an inadequate reading of literature. Limitations of the DSM classification of sexual and gender identity disorders are pointed out. The validity of self-report of sexual behavior has been questioned on the basis that men report a markedly higher average number of sexual partners than women. Possible sex differences in reporting the number of partners who are of the same sex, casual, or perpetrators or victims of sexual coercion and child abuse have not been taken into account. Failure of sexology to progress due to lack of resolution of conflicting issues may contribute to the low impact factor of its journals.

Sexual behaviors in autism: problems of definition and management.

Surveys of sexual behavior in autism suggest a variety of behavioral expression. However, the course of sexual development in autism is unplotted, leaving questions about the normalcy of specific behaviors. Even less is known about deviations of sexual development and the incidence of paraphilias in this population. We explore the problems of definition of sexual behaviors and describe a case report that highlights the difficulties of management. An application of a testosterone-suppressing medication and its effect on sexual behavior are reported. After failure of behavioral and educational programs, leuprolide, an injectable antiandrogen, resulted in suppression of behaviors and retention of the participants' community placement. Follow-up for almost 3 years shows no abnormal physical effects. Dosage has been tapered over that period to a low but effective dose. Directions for research are discussed.