Referrals For Gender-Affirming Hormone Treatment in Croatia's National Network for Transgender Healthcare.

A network of healthcare professionals specializing in transgender care was established in Croatia in 2011, and legal advancements were subsequently made in 2014. Both achievements made gender transition more transparent and thus more attainable in Croatia. This observational study was conducted to assess the number of transgender individuals initiating gender-affirming hormone treatment (GAHT) in Croatia and describes trends in age and sex assigned at birth. Between 2011 and 2022, a total of 111 transgender individuals initiated GAHT. Within the cohort, 52 were assigned male at birth (AMAB) and 59 were assigned female at birth (AFAB). The overall annual incidence rate of transgender individuals initiating GAHT was 0.52 per 100,000 age-adjusted individuals. There was a statistically significant increase (p < 0.01) in transgender individuals commencing GAHT before the COVID-19 pandemic. Furthermore, a rising trend toward masculinizing rather than feminizing treatment was identified (p < 0.05), particularly among younger transgender individuals. The COVID-19 pandemic disrupted these trends in 2020, except for the trend of initiating therapy at a younger age (p < 0.01). The annual incidence and age distribution trends of transgender individuals initiating GAHT in Croatia closely mirrored those in other European countries, with a higher prevalence of individuals assigned female at birth. The study underscores a significant rise in the number of individuals initiating gender-affirming hormone treatment, emphasizing the need for proper legal regulation and healthcare system response.

What Makes Forensic Psychiatric Experts Change Their Opinion in Supplemental Evaluations?

There are cases in forensic psychiatric evaluations with inconclusive information or with important information missing. In such situations, when new information becomes available the judge may ask an expert to supplement his/her report in the light of new information. For the purpose of this study, we collected 42 supplemental evaluations written in the University Psychiatric Hospital Vrapce to determine possible factors which were associated with changes in supplemental evaluations. The following data were gathered: demographic data, types of criminal offenses, reasons for the supplement evaluation, court questions, and diagnoses. Changes in supplemental evaluations occured more often when the defendants were diagnosed with a personality disorder (PD) only, compared to those who had a PD with a comorbidity, especially substance use disorders. Defendants with the diagnosis of a substance use disorder were 63.7% less likely to have changed experts' evaluations. The evaluations remained the same when the reason for supplemental evaluations were new witnesses' testimonies. Considering the principle of economy of actions in a judiciary system, a more critical approach should be taken when the judge requests a supplemental report.

Psychiatric and Forensic Characteristics of Sex Offenders With Child and With Adult Victims.

This study presents psychiatric and forensic characteristics of people accused of a sexual crime and sent for evaluation. Data were drawn from the only institutional psychiatric forensic assessment center in Croatia, during a 9-year period, from January 1, 2010 to December 31, 2018. There were 72 cases of sex offenses: 37 with child victims and 35 with adult victims. People accused of sex offenses with child victims were more often sexually abused during childhood and treated psychiatrically as inpatients. They used alcohol less often. Sex offenders with child victims were diagnosed with narcissistic and antisocial personality disorder, dementia, and pedophilic disorder. Those with adult victims were diagnosed with antisocial personality disorder, alcohol related disorders and dementia. Due to these differences, the management of these two groups of offenders in both mental health and penal systems should be different.

Forensic psychiatric evaluations of people charged with rape in Croatia.

Introduction: Sexual violence is a substantial public health problem that is associated with a major impact on victims, and in Croatia, more than half of reported cases of sexual violence involve rape. To help understand their general profiles and consider any implications arising, the aim of this research was to describe the forensic psychiatric characteristics of people charged with rape. Methods: All evaluations of people charged with rape and sent for evaluation at the largest assessment centre in Croatia during the period 2010-2018 were analysed (n = 56). Results: Alleged offences most often took place in a perpetrator or victim's home (71%), while the next most frequent location was the street (15%). Over 80% of alleged victims were known to the accused. Alcohol use and abuse were present in 73% of the accused, and 29% were drinking at the time of the alleged offence. Alcohol-related disorders were presented in 38% of the accused, while 38% had a personal history of drug use, and antisocial and narcissistic personality disorders were present in 48% and 29%, respectively. Psychotic disorders were rare (1.8%). Most of the accused were found to be criminally responsible; however, forensic psychiatric assessment procedures were inadequate when considering psychosexual assessments. Conclusions: Interventions based around public health and education should be considered in this field, and forensic psychiatric assessments should be prioritized for improvement.

The Assessment of Psychopathic Traits in Perpertrators with Schizophrenia and Psychopathy as Comorbidity.

This paper discusses the assessment of psychopatic traits in perpetrators with schizofrenia in the light of common assumption that perpetrators with schizofrenia are not homogenic group but rather heterogenic group whose future risk does not rest exclusively on the psychopathology of the underlying disease. Our sample consists of 150 perperators with schizofrenia who commited a criminal act and were subjects of forensic evaluation in the University Hospital of Psychiatry Vrapce, Center for Forensic Psychiatry throughout a period of 11 years. All data were extracted from written evaluations. In our research, the assessment of psychopatic trait was performed by PCL-R (Psychopathy Checklist- Revised) - the assessment tool rarely used in Croatia. Data were analysed by methods of descriptive statistics and multivariant discriminatory analysis. Our results show that some of psychopatic traits exist in all of our evaluees, but with markedly different intensity. The average PCL-R score was 19.92 (SD=8.30), and by defining the cut off at 26, our subjects were divided into two groups: subjects with a higher level of psychopathy trait (High-P) and those with a lower level of psychopathy trait (Low-P). These two groups showed significant differences in all of the items. The confirmation of our hypothesis opens new areas for discussion and future research: problem of comorbidites in patients with schizofrenia in a forensic setting and a rationale for the routine usage of PCL-R in forensic evaluations.

BARONESS CHARLOTTA CASTELLI GLEMBAY - WAS SHE HYPERSEXUAL?

Hypersexuality disorder (or sexual addiction or excessive sexual drive or compulsive sexual behaviour disorder) is a controversial condition that is present in the International Classification of Disease but not in the Diagnostic and Statistical Manual for Mental Disorders. It is defined as a clinical syndrome characterised by a persistent pattern of failure to control intense, repetitive sexual impulses or urges resulting in repetitive sexual behaviour. The condition is more prevalent in men than in women. Some medical conditions were described in fictional literature before their formal recognition in medicine, like Huntington disease, Pickwick syndrome, and Munchausen syndrome. The aim of this article is to analyse the fictional character of Charlotta Castelli Glembay from Miroslav Krleza's play Messrs Glembays from 1928. Krleza presented a woman with a sexual drive that could be described as uncontrollable, organic (physical) in origin, and different from love and affection (that she also experienced, but only with one particular man). The author gave a special name for her condition ­ erotic intelligence. This sexual behaviour has distressing and devastating consequences. This paper will argue that the play depicts hypersexuality disorder in a woman, with a designation of its aetiology. In concordance with the prevailing attitudes of the time (the early 20th century), hypersexuality in women had negative attributions.

Psychiatric and Forensic Differences Between Men Charged with Sex Offences and Men Charged with Other Offences.

Studies on differences between individuals convicted of sexual offences and nonsexual offences are sparse and there is an on-going debate as to whether sexual offenders differ from other offenders. The primary aim of this study was to determine demographic characteristics, prevalence of mental disorders, alcohol and drug use at the time of the crime and the criminal responsibility of individuals charged with sexual offences, compared to nonsexual crimes, with the aim of bringing awareness to the similarities and differences between men charged with sex offences and those charged with other crimes. This is a single-institution retrospective study of subjects charged with sexual offences and sent for institutional psychiatric evaluation to a Forensic Psychiatric Centre in an urban, academic, tertiary-care center. The control group consisted of individuals charged with nonsexual offences referred to the same center. Results showed significant differences between individuals charged with sexual offences and nonsexual offences. Men charged with sex offences more frequently committed their crimes alone and victimized children equally as often as adults. They also less frequently pleaded guilty in court. They were more likely to be abused in childhood and more often had antisocial personality disorder and paraphilias and less often substance-related disorders. The majority were considered criminally responsible. Our results show that sex offenders are different from nonsex offenders in many characteristics of their personal history, offence characteristics and forensic evaluations and these particular differences warrant different approaches to the prevention of future re-offending, compared to nonsex offenders.

The attitudes of medical doctors, nurses and lay people towards schizophrenia, depression and PTSD.

BACKGROUND: The stigma attached to mental illness has negative effects on individuals who experience the condition, and, while it is present in the attitudes of both lay people and mental health professionals, it is reduced in people who have had previous contact with those with mental illness. The present study focused on the influence of medical professionals' contact with individuals with three mental disorders, namely, schizophrenia, depression and posttraumatic stress disorder (PTSD), in order to determine whether it is contact in general or specific contact with a certain disorder that reduces stigma. SUBJECTS AND METHODS: A total of 270 nurses, 30 medical doctors and 87 lay people (>75% women) assessed 15 items for each of the mental disorders on a Likert-type scale. RESULTS: The stigma attached to PTSD was of a lower level than the stigma attached to schizophrenia, but higher than that attached to depression. Medical doctors attached the lowest level of stigma to mental illness, and lay people attached the highest. No correlation was found between stigma and age or gender. Those who knew a person with a particular mental illness attached less of a stigma to that condition, but not to the other two disorders. CONCLUSION: Contact with people with mental illness reduces the stigma associated with people with that same illness, but not that which is attached to other mental disorders.

Sex Offenders in Croatia: Fifteen Years Later.

BACKGROUND: The aim of the study was to compare the characteristics of sex offenders today, and those who committed a sex crime fifteen years ago, in regard to their psychiatric-forensic aspects. SUBJECTS AND METHODS: Data from the University psychiatric hospital Vrapce, Center for forensic psychiatry on court people sent for psychiatric and forensic evaluation, who were accused of sex offense in two time frames (1998-2001 and 2010-2016) were analysed. In total there were 50 and 57 male subjects sent for an evaluation. RESULTS: In both groups rape was the most prevalent offence, and both groups had the same prevalence of abuse, earlier psychiatric treatment and the majority of offenders were diagnosed with dissocial personality disorder and other personality disorders. Paedophilia was diagnosed in only a minority (14% and 7% respectively) of cases. The latter group (2010-2016) committed more sex offences against children, more often were with no mental disorder and less often had alcohol dependence and mental retardation. Up to one third of the later group were not giving their defence, compared to 4% of the former group. CONCLUSIONS: Changes in court case law and psychiatrists' usage of diagnostic criteria have influenced the prevalent diagnoses in sex offenders. Paraphilias are not often diagnosed in sex offenders because they do not confirm the act, and in recent years more often use not to give their defence (which makes reaching the diagnosis more challenging).

An Unusual Case of Infertility: Urethral Coitus Due to Cribriform Hymen.

Urethral coitus is a rare type of sexual practice, usually due to vaginal agenesis or hymeneal anomalies. We report a case of urethral coitus in a healthy couple who were evaluated for infertility. The female partner had cribriform hymen and dilated urethral orifice but did not report any problems except infertility and her genital anatomy was normal. The male partner reported concerns over his penile size but was otherwise healthy. After incision of hymen, they were able to have vaginal coitus and successfully conceived. While urethral coitus is rare, it should be suspected in women presenting with infertility and a dilated urethral orifice.

Impact of a Nursing in Psychiatry Course on Students' Attitudes Toward Mental Health Disorders.

Negative attitudes toward patients with mental illnesses are not uncommon among health professionals, and lead to poorer quality and outcomes of care. Because attitudes are formed early in life, the current study aimed to investigate if teaching psychiatry in secondary school nursing students (i.e., adolescents) changes attitudes toward three prevalent psychiatric disorders: schizophrenia, posttraumatic stress disorder (PTSD), and depression. A pilot quasi-experimental study was conducted with 51 fourth-year students in secondary nursing school who completed a questionnaire regarding attitudes toward these disorders on the first and last day of their Nursing in Psychiatry course. Results show that the stigma attached to all three disorders was significantly reduced after students completed the course. Students attached greater stigma to schizophrenia than PTSD, and to PTSD than depression, before and after the course. The study indicates that education in psychiatry helps reduce negative attitudes toward PTSD, schizophrenia, and depression. [Journal of Psychosocial Nursing and Mental Health Services, 56(3), 45-51.].

[THE FIRST CROATIAN GUIDELINES FOR DIAGNOSIS, TREATMENT AND FOLLOW-UP OF PERSONS WITH PREMATURE EJACULATION].

Premature ejaculation (PE) is a sexual disorder with high prevalence, defined by three characteristics: short intravaginal ejaculation latency time, poor control over delaying ejaculation and personal and/or partner distress. The diagnosis is reached by a thorough and comprehensive history taking, which should include presence/absence of other ­co-morbid conditions (e.g. erectile dysfunction, anxiety), and assessing the type of PE (primary, secondary, variable, subjective). It is important to counsel the patient (and, if possible, the partner) about this condition and treatment options. The first line of treatment is selective serotonin reuptake inhibitors (dapoxetine, which is the only drug with an official label for this indication, paroxetine, sertraline, fluoxetine, citalopram, escitalopram). The first line of treatment also includes psychological/sexological treatment methods, such as behavioural methods (stop-start and squeeze techniques), and new functional sexological treatment. The choice of the method depends on the type of PE and on the patient preference. The second line of treatment are clomipramine and local anaesthetics, and the third line is tramadol.

The sociocultural aspects, professional characteristics, and motivational factors of the first fellows of the European committee of sexual medicine.

INTRODUCTION: After a century of development in the field of sexology and decades of attempts to establish the field of sexual medicine, the first examination that led to the qualification as Fellows of the European Committee of Sexual Medicine (FECSM) was held in December 2012. AIM: This study aims to describe the first European specialists in sexual medicine, their clinical practice, motivation, and professional self-identification. METHODS: A web-based survey of the first FECSM on demographic data, data on the practices of their work (gender of clients, setting, and time frame), and reasons for entering the sexual medicine (five-point Likert rating of motives and open question on other reasons) was conducted. MAIN OUTCOME MEASURE: Gender, religion, specialty, region, and their association with professional practices of the first FECSM. RESULTS: The first FECSM have a wide range of experience in the field of sexual medicine (0-30 years) and were mainly men (79%) and urologists (56%). Only 15.5% had other qualifications related to sexual medicine and 60% self-identified as sexual medicine specialists. Only a small proportion of the professional time was dedicated to the practice of sexual medicine. The primary speciality influenced the gender of their patients seen, setting of work (couple vs. individuals), and time spent with patients. Only a minority managed sexual problems in women; hypoactive sexual desire is treated by 41% of FECSM and dyspareunia by 17%. The participants were motivated by the pleasure of knowing new things and desire to understand and to help patients, whereas prestige, finances, and own sex lives are less important. CONCLUSIONS: The first FECSM are very diverse in terms of age, culture, religion, and primary specialty. Their practice is strongly influenced by their primary specialty, and this needs to be taken into account in future development of the speciality.

A case of painful erections after pelvic surgery.

There are no data in the literature on the incidence or treatment of posttraumatic painful erections not related to surgery of the genital system. A case of a 27-year-old man with painful erections after fracturing his sacral, pubic, and ischial bones in a motorbike accident is presented. His painful erections occurred in coitus, masturbation, and morning tumescence. No penile or neural pathology was found to account for the pain. He was treated with diazepam 2 mg before masturbation for 2 weeks, when the symptoms disappeared. The possible causes of the problem and its resolution are discussed.

Patients with combat-related and war-related posttraumatic stress disorder 10 years after diagnosis.

AIM: To establish how many patients diagnosed with posttraumatic stress disorder (PTSD) in 1996 used psychiatric facilities and had psychiatric symptoms 10 years later, and assess their sociodemographic characteristics, comorbid disorders, and type of treatment. METHODS: Medical records of patients diagnosed with PTSD in 1996 were reviewed in the period 2007-2009 and the patients who contacted a psychiatrist in that period (n=85) and those who did not (n=158) were compared. RESULTS: There were 36.7% of men and 20% of women diagnosed with PTSD in 1996 who contacted a psychiatrist in the period 2007-2009. Patients who contacted a psychiatrist and those who did not did not differ in sex, age, the number of visits and hospitalizations in 1996, and employment status. The majority of patients still had PTSD and/or were enduring personality change in the period 2007-2009, and 54.8% had some comorbidity (mostly depression, alcohol-related disorders, and personality disorders). Patients were most often treated with anxiolytics and antidepressants. CONCLUSION: Ten years after the traumatic experience, one third of patients with PTSD received psychiatric help, regardless of their sex, age, and employment status. Half of them had comorbid disorders and the majority of them were treated with anxiolytics and antidepressants.

Does post-traumatic stress disorder carry a higher risk of sexual dysfunctions?

INTRODUCTION: Previous studies have shown that patients with post-traumatic stress disorder (PTSD) have a higher incidence of sexual dysfunction. However, such studies have not examined the influence of traumatic experience on sexual dysfunction. AIM: This study was conducted to compare various components of sexual functioning among five groups of males: (i) untreated patients with PTSD; (ii) patients with PTSD treated with selective serotonin reuptake inhibitors (SSRIs); (iii) untreated patients with subthreshold PTSD symptoms; (iv) patients with subthreshold PTSD symptoms treated with SSRIs; and (v) subjects who had suffered a traumatic experience but presented no mental disorder. METHODS: All participants were evaluated using the Clinician-Administered PTSD Scale, the Minnesota Multiphasic Personality Inventory, the Structured Clinical Interview, and the International Index of Erectile Function. MAIN OUTCOME MEASURES: Results on individual subscales of the International Index of Erectile Function in men with PTSD symptoms and subthreshold PTSD symptoms, treated and untreated. RESULTS: Patients with PTSD did not differ from patients with subthreshold PTSD symptoms in any of the domains of sexual functioning. Differences were found between this group and subjects with no mental disorder only in the domain of sexual desire. Patients with subthreshold PTSD symptoms treated with SSRIs showed better results in all domains of sexual functioning in comparison with those treated with PTSD. CONCLUSIONS: The results show that patients who suffered a traumatic experience have the same level of sexual functioning (or the same incidence of sexual dysfunction) regardless of the severity of PTSD. Treatment with SSRIs helps reduce sexual problems in patients with subthreshold PTSD symptoms.

Adverse effects of benzodiazepines in psychiatric outpatients.

BACKGROUND: Benzodiazepines are among the most frequently prescribed drugs. Of all their side effects, hip fractures and possibility of developing dependence are usually studied. OBJECTIVE: The aim of this study was to determine how often do psychiatric outpatients suffer from adverse effects of benzodiazepines, and which adverse effects do they notice. SUBJECTS AND METHOD: 109 patients on two consecutive days were asked to fill in the questionnaire. Among them were 29 women and 80 men. Ten women (1/3) and 20 men (1/4) refused to participate in the study. RESULTS: 68% of women and 93% of men used benzodiazepines at least once in a lifetime; 40% of women used benzodiazepines in the last seven days, and 93% of men (32% of women and 44% of men used benzodiazepines every day for the last seven days). Unfortunately, 8% of men used more then one benzodiazepine daily. All of the women who used benzodiazepines had at least one adverse effect; and 91% of men had adverse effects. One third of women and one quarter of men stopped taking benzodiazepines due to adverse effects. The mean number of adverse effects was 4.8 both in men and women. Those who stopped taking benzodiazepines didn't have more adverse effects in comparison to those who continued to use them. More than half of the participants suffered from sleepiness, slowness and fatigue. One third of the participants said they noticed the change in sexual drive. More then 30% of women noticed dizziness and only 6% of men. None of the participants said to have jaundice after using benzodiazepines. The same adverse effects were present in those who stopped taking the drugs and in those who continued to use them. CONCLUSION: The prevalence of benzodiazepine use is very high in psychiatric patients. Many of them notice adverse effects, but mainly continue to use the drug.