International guidelines for the prevention of sexual violence: A systematic review and perspective of WHO, UN Women, UNESCO, and UNICEF's publications.

BACKGROUND: Sexual violence is a major public health issue worldwide, with a high prevalence and extensive human and financial costs. Implementing prevention programs is complex, requiring not only evidence-based practices and high ethical standards, but also close collaboration with local governments and non-governmental organizations. In order to guide and support all stakeholders necessary to achieve large-scale prevention (e.g., politicians, decision-makers, in-field professionals), it is essential to establish international benchmarks for the prevention of sexual violence. OBJECTIVE: The main goal of this collaborative study was to conduct a systematic review of the frameworks adopted by WHO, UN Women, UNESCO, and UNICEF to help prevent sexual violence worldwide, according to the PRISMA methodology. A secondary objective was to highlight the levels of prevention and determinants of health targeted by these organizations. RESULTS: Overall, 1008 references were identified, of which 50 met the inclusion criteria. All international guidelines were limited to primary or tertiary prevention, and they were not specifically dedicated to sexual violence. In addition, each organization had developed idiosyncratic prevention strategies. Common primary prevention determinants of health were still found across organizations, including education, socio-economic inequalities, and life skills training. Tertiary prevention was poorly developed and polarized between victims and perpetrators. Secondary prevention was never addressed, however, despite the effectiveness of approaches such as helplines for people sexually attracted to children. DISCUSSION: Given these results, an international French-speaking consortium of professional teams, all involved in the secondary prevention of sexual violence, was recently formed with a ratified charter presented here.

Risk Factors for Sexual Offenses Committed by Men With or Without a Low IQ: An Exploratory Study.

Although risk factors associated with offending and recidivism are relatively well-established for mainstream sexual offenses, much less is known about men with a low IQ who have sexually offended (MIQSO), let alone those with forensic involvement. In this exploratory study, 137 convicted for the commission of at least one sexual offense and found not criminally responsible because a mental disorder were recruited in a maximum-security hospital. They were all assessed with the SORAG (static risk factors) and the RSVP (dynamic risk factors). Compared with MIQSO (N = 76), men with an average or higher IQ who have sexually offended (MSO, N = 61) obtained significantly higher scores on static factors related with general delinquency (histories of alcohol abuse, non-violent criminality, violent criminality, and sexual offense) and dynamic factors related with sexual delinquency, paraphilia, and recidivism (chronicity, psychological coercion, escalation, sexual deviance, and substance abuse). In contrast, MIQSO obtained significantly higher scores on major mental illness, problems with planning and problems with self-awareness. Logistic regressions revealed that both the SORAG and RSVP were useful to predict group membership. It is concluded that risk factors related with general and sexual delinquency better describe offenses committed by MSO, whereas risk factors related with mental disorder, lack of insight and contextual impulsivity better describe offenses committed by MIQSO.

Predicting forensic inpatient violence with odor identification and neuropsychological measures of impulsivity: A preliminary study.

Although most persons with a schizophrenia-spectrum disorder are not aggressive, a minority is at higher risks to commit violent acts, especially in forensic settings. The first goal of this study was to assess inpatients in a maximum-security hospital with a self-report questionnaire, neuropsychological tests of behavioral impulsivity/attentional capacities and olfactory functions to determine the strength of association between these measures. A secondary objective was to assess the predictive value of these measures for the commission of violent acts within the institution. Sixty-two male inpatients were evaluated with the neuropsychological battery. As expected, self-report assessment of trait impulsivity (questionnaire) did not significantly correlate with behavioral measures of state impulsivity. In addition, neuropsychological measures of impulsivity and attention were significantly associated with odor identification capacities. Finally, attentional deficits (but not impulsivity) and odor identification were both significant and independent predictors of institutional violence. Neuropsychological assessments and odor functions might help predicting (and explaining) institutional violence committed in forensic settings.

Sexual Violence Against Persons With Disabilities: A Meta-Analysis.

A growing number of large-scale studies suggest that people with disabilities are at greater risk of sexual victimization than nondisabled individuals. However, certain results are inconsistent and whether potential moderators explain this variability in previous findings remain to be considered. This meta-analysis aimed to determine the magnitude of the difference in risk of being sexually victimized based on the presence of a disability. An additional objective was to evaluate the relative influence of gender, age, type of disability, type of sexual violence, and relationship with the perpetrator on the association between the presence of a disability and sexual victimization. Studies were searched using pertinent databases and retained if they included a group with a disability, provided data that quantify the occurrence of abuse, indicated the type of sexual violence, and was published between 1970 and 2018 in French or English. A total of 68 studies, allowing 84 independent samples and 12,427 participants, were included. Individuals with disabilities were at significantly higher risk of sexual victimization than persons without disabilities (odds ratio = 2.27). The risk of sexual victimization among individuals with a disability was significantly higher in adult participants compared with the risk in minor participants. Sensory impairment was the type of disability associated with the highest risk of sexual victimization. Odds of sexual victimization among individuals with a disability were significantly higher in African countries compared with all others, and odds in Western Europe were significantly lower than in the United States. No significant differences emerged across eras.

Concordance and Discordance between Paraphilic Interests and Behaviors: A Follow-Up Study.

Although paraphilic interests represent significant risk factors for recidivism among sexual offenders, little is known about the magnitude of concordance between paraphilic interests and behaviors in the general population. The goal of this follow-up study was to conduct secondary analyses based on a sample of 1040 adults (475 men; 565 women) recruited in the general population. Levels of associations and active concordance (having both interest and experience), passive concordance (having neither interest nor experience), active discordance (having experience without interest) and passive discordance (having interest without experience) between paraphilic interest and corresponding behavior were assessed. Concordance and discordance indexes were also computed, as well as regressions and moderation analyses. As expected, paraphilic interests predicted corresponding behaviors, although the mean active concordance rate was only approximately 50%. Concordance rates varied with gender and the criminal nature (legal vs. illegal) of paraphilia. Paraphilic interests in adults from the general population may not have the same predictive value as that observed in medico-legal contexts. The possible role of other moderators in the concordance between paraphilic interest and behavior in non-clinical populations should be assessed. These findings have implications for sexual abuse prevention programs aiming at individuals in the community.

Sexual Knowledge, Desires, and Experience of Adolescents and Young Adults With an Autism Spectrum Disorder: An Exploratory Study.

Although most persons with an Autism Spectrum Disorder (ASD) wish to have romantic and/or sexual relationships, little is known about self-report sexuality of adolescents/young adults with ASD. In this exploratory study, 172 male and female adolescents/young adults (68 with ASD and 104 without ASD) completed an online version of the Sexual Behavior Scale-Third edition. Although many more similarities than differences were observed between the groups for views and desires about romantic relationships (e.g., wishing to have a girlfriend/boyfriend), fewer participants with ASD (mostly boys) had experience with a variety of sexual/dyadic behaviors, and approximately half of girls with ASD reported negative sexual experiences. Significantly higher rates of participants with ASD felt their knowledge about sexuality was limited and found it difficult to understand sexual education compared with typically developing (TD) participants. Significantly lower rates of participants with ASD reported that they identify to their assigned gender compared with TD participants. Multiple regressions revealed that being older at first diagnosis and possessing better knowledge about sexuality were significant predictors of both positive and negative sexual experience. This study explores strengths and challenges related with the sexual health of adolescents/young adults with ASD and implications for clinical and educational practice are discussed.

What Is So Appealing About Being Spanked, Flogged, Dominated, or Restrained? Answers from Practitioners of Sexual Masochism/Submission.

A growing number of studies have demonstrated that BDSM (Bondage/Discipline-Domination/Submission-Sadism/Masochism) practices are not signs of mental illness. However, the reasons for engaging in such behaviors are not well understood, especially for sexual masochism or submission (m/s). A thorough review of the literature was conducted, as well as a search in Internet forums and an online survey to obtain testimonies that provide information on the origins of interest in m/s and the reasons for engaging in it. A qualitative content analysis was performed on narratives from 227 m/s practitioners. Sixteen themes emerged from this analysis, eight related to the origins of interest in m/s and eight to the reasons for engaging in m/s. The origins described were seen as either intrinsic or extrinsic. Reasons to engage in m/s were related to one of three main types of activities: use of interpersonal power; experiencing physical pain; and altering one's state of mind. These results concord with accounts found in non-academic books and small-scale studies suggesting that m/s interests are often present early in life and usually practiced to reach an altered state of mind associated with sexual arousal. Possible reasons for choosing m/s over more common means of mind alteration are discussed.

Executive Functions and Social Cognition in Juveniles Who Have Sexually Offended.

Although neuropsychological assessments provide valuable information for those working in forensic mental health, few neuropsychological studies concern persons who sexually offend, particularly juveniles who have sexually offended (JSO). It has been suggested that, contrary to current theories, executive function in JSO, as a group, is no more impaired than it is in juvenile delinquents in general. However, JSO with child victims seem to be more impulsive than JSO whose victims are peers or adults. To verify this potentially important (and unexpected) finding, a sample of adolescent males (N = 134; 15.6 ± 1.5 years old) that included JSO, general delinquents, and underprivileged nondelinquents was assessed using a battery of behavioral and psychological tests that focus on impulsivity. No difference was found between groups regarding higher order executive functions as measured with the Wisconsin Card Sorting Task but JSO with child victims were found to be the most impulsive subgroup as evidenced with the Iowa Gambling Task, the Stop-Signal Reaction Task, and the Impulsive scale of the Social Problem Solving Inventory. They also had the highest number of prescriptions for attention deficit hyperactivity disorder (ADHD) medication. These results, which contradict hypotheses derived from assessment of adult sex offenders, illustrate an important difference between the cognitive profiles of adult and juvenile males who sexually offended. They also confirm that JSO whose victims are children appear to be more impulsive.

Suppression of Sensorimotor Alpha Power Associated With Pain Expressed by an Avatar: A Preliminary EEG Study.

Several studies using functional magnetic resonance imaging (fMRI) showed that empathic capabilities are associated with the activation (and deactivation) of relatively specific neural circuits. A growing number of electroencephalography studies also suggest that it might be useful to assess empathy. The main goal of this study was to use quantitative electroencephalography (qEEG) to test whether observation of pain expressed by an avatar (virtual reality) induces a suppression of alpha waves over sensorimotor cortical areas, as it is observed with human stimuli. Not only was it the case, but also the magnitude of alpha suppression was correlated with perspective-taking capacity of participants. Both empathy levels and magnitude of sensorimotor alpha suppression (SAS) were significantly higher in women than men. Interestingly, a significant interaction emerged between levels of individual empathy and specificity of experimental instructions, where SAS in participants with good perspective-taking was higher during passive observation of the distressed avatar, while the opposite was true during an active (trying to understand) condition. These results suggest that: (1) synthetic characters are able to elicit SAS; (2) SAS is indeed associated with perspective-taking capacities; (3) Persons with poorer perspective-taking capacities can show significant SAS when proper instructions are provided. Therefore, qEEG represents a low-cost objective approach to measure perspective-taking abilities.

The Prevalence of Paraphilic Interests and Behaviors in the General Population: A Provincial Survey.

Paraphilic sexual interests are defined as unusual or anomalous, but their actual occurrence in nonclinical samples is still unknown. This study looked at desire for and experience of paraphilic behaviors in a sample of adult men and women in the general population. A secondary goal was to compare the results of two survey modes-traditional landline telephone versus online. A total of 1,040 persons classified according to age, gender, education, ethnic background, religious beliefs, area of residency, and corresponding to the norm for the province of Quebec were interviewed. Nearly half of this sample expressed interest in at least one paraphilic category, and approximately one-third had had experience with such a practice at least once. Voyeurism, fetishism, frotteurism, and masochism interested both male and female respondents at levels above what is usually considered to be statistically unusual (15.9%). Interestingly, levels of interest in fetishism and masochism were not significantly different for men and women. Masochism was significantly linked with higher satisfaction with one's own sexual life. As expected, the online mode generated more acknowledgment of paraphilic interest than the telephone mode. These results call into question the current definition of normal (normophilic) versus anomalous (paraphilic) sexual behaviors.

Exploring Emotion Regulation in Juveniles Who Have Sexually Offended: An fMRI Study.

This exploratory study compared juveniles who sexually offend to nonoffending juveniles in their capacities to behaviorally and neurologically regulate, or reappraise, negative emotions. Participants were 39 juvenile males, including 10 healthy, nonoffending control subjects and 29 juveniles who sexually offend, comprising 12 juveniles who sexually offend with history of child sexual abuse. Participants completed a clinical assessment and a reappraisal task during functional magnetic resonance imaging. Difficulties in Emotional Regulation Scale results showed significantly less difficulties in emotion regulation among controls compared to juveniles who sexually offend, but when self-rating reappraisal abilities during the functional magnetic resonance imaging, all groups obtained comparable results. The imaging results showed no significant differences in fronto-temporal regions between controls and juveniles who sexually offend. Differences were found in other regions indicated in cognitive control, working memory, and emotional processing between controls and juveniles who sexually offend as well as between juveniles who sexually offend and those without history of child sexual abuse. Findings suggest that juveniles who sexually offend are capable of emotion regulation.

Anterior cingulate hyperactivations during negative emotion processing among men with schizophrenia and a history of violent behavior.

BACKGROUND: Evidence suggests a 2.1-4.6 times increase in the risk of violent behavior in schizophrenia compared to the general population. Current theories propose that the processing of negative emotions is defective in violent individuals and that dysfunctions within the neural circuits involved in emotion processing are implicated in violence. Although schizophrenia patients show enhanced sensitivity to negative stimuli, there are only few functional neuroimaging studies that have examined emotion processing among men with schizophrenia and a history of violence. OBJECTIVE: The present study aimed to identify the brain regions with greater neurofunctional alterations, as detected by functional magnetic resonance imaging during an emotion processing task, of men with schizophrenia who had engaged in violent behavior compared with those who had not. METHODS: Sixty men were studied; 20 with schizophrenia and a history of violence, 19 with schizophrenia and no violence, and 21 healthy men were scanned while viewing positive, negative, and neutral images. RESULTS: Negative images elicited hyperactivations in the anterior cingulate cortex (ACC), left and right lingual gyrus, and the left precentral gyrus in violent men with schizophrenia, compared to nonviolent men with schizophrenia and healthy men. Neutral images elicited hyperactivations in the right and left middle occipital gyrus, left lingual gyrus, and the left fusiform gyrus in violent men with schizophrenia, compared to the other two groups. DISCUSSION: Violent men with schizophrenia displayed specific increases in ACC in response to negative images. Given the role of the ACC in information integration, these results indicate a specific dysfunction in the processing of negative emotions that may trigger violent behavior in men with schizophrenia.

Discriminant factors for adolescent sexual offending: On the usefulness of considering both victim age and sibling incest.

Understanding the pathways and circumstances of juvenile sexual offending is of utmost importance. However, juvenile sexual offenders (JSO) represent an especially diverse group of individuals, and several categorizations have been proposed to obtain more homogeneous subgroups. Victim age-based and family relation-based categorizations are particularly promising because they seem theoretically and clinically relevant. Empirical results however are still inconsistent, and most studies have not considered these two dimensions jointly. The first goal of this study was to further examine the value of subgrouping JSO according to the age of their victim. A second goal was to determine the supplementary value, if any, of considering sibling incest. Based on a sample of 351 male JSO, it was first confirmed that sexual abuse of children was more strongly related to asociality (social skill deficits) than sexual abuse of peers, the latter being more closely associated with antisociality (general delinquency). The relevance of considering mixed-type JSO (with both child and peer victims) separately was also confirmed. More importantly, multivariate statistical analyses demonstrated that adding sibling incest to the equation was useful. JSO of intra-familial child were significantly more likely to have been victimized during their own childhood compared to JSO with extra-familial victims. Nevertheless, adolescents who had committed sibling incest obtained middle ground results on most variables (except for crime severity), suggesting that they constitute a distinct but not extreme, subgroup. This study confirmed the utility of using both the age and the family relation with the victim in characterizing juvenile sexual offending.

The Neuropsychology of Adolescent Sexual Offending: Testing an Executive Dysfunction Hypothesis.

Although executive dysfunctions are commonly hypothesized to contribute to sexual deviance or aggression, evidence of this relationship is scarce and its specificity is unproven, especially among adolescents. The objective of this study was to compare the executive functioning (EF) of adolescents with sexual offense convictions (ASOC) to that of non-sex-delinquents (NSD). A secondary goal was to assess the relationship among specific sexual offense characteristics (i.e., victim age), history of childhood sexual abuse (CSA), and EF. It was hypothesized that as a group, ASOC would present similar EF profiles as NSD. It was further hypothesized that ASOC with child victims would present significantly higher rates of CSA and more severe impairment of EF than ASOC with peer-aged or older victims and NSD. A total of 183 male adolescents (127 ASOC and 56 NSD) were interviewed to collect demographic information, sexual development history, history of CSA, an assessment of living conditions, and history of delinquency and sexual offending. Participants were administered the Delis-Kaplan Executive Functioning System and the Hare Psychopathy Checklist-Youth Version. In accord with the first hypothesis, ASOC and NSD presented similar EF scores, well below normative values. Thus, EF deficits may not characterize the profiles of adolescents with sexual behavior problems. Contrarily to our second hypothesis, however, offending against children and or experiencing CSA were not associated with poorer EF performance. On the contrary, ASOC with child victims obtained significantly higher scores on measures of higher order EF than both ASOC with peer-aged or older victims and NSD. Implications of these results and future directions are discussed.

Defining "Normophilic" and "Paraphilic" Sexual Fantasies in a Population-Based Sample: On the Importance of Considering Subgroups.

INTRODUCTION: According to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), a sexual fantasy (SF) is paraphilic if it concerns activities outside the realm of "genital stimulation or preparatory fondling with phenotypically normal, physically mature, consenting human partners" (normophilic). Intensity of the paraphilic SF is also "greater than or equal to normophilic interests." Surprisingly, however, very few data are available to corroborate that definition of a paraphilic SF. Although the relatively high prevalence of paraphilic SF in the general population is well known, the magnitude of difference between intensity of "normophilic" and "paraphilic" SF remains to be assessed. AIM: The main goal of this study was to analyze the SF of adults recruited in the general population to obtain person profiles based on the nature and intensity of their SF. METHODS: Multiple correspondence analysis (MCA) were used with data collected from 1,501 adults recruited in the general population to generate subgroups of participants based on the nature and intensity of their SF. MAIN OUTCOME MEASURES: The main outcome measures used was a revised version of the Wilson Sex Fantasy Questionnaire. RESULTS: When all participants are considered as a unique group, the mean intensity of the most intense "normophilic" SF (oral sex) is significantly higher than the mean intensity of the most intense "paraphilic" SF (being sexually dominated for women and watching two women having sex for men), as expected from the DSM-5. When clusters of participants are considered separately, however, conclusions are nuanced. Four significant clusters of participants (two predominantly female and two predominantly male) reported at least one paraphilic SF with intensity as high as that of their most intense "normophilic" SF. In fact, 57% of this sample met the criteria of paraphilia. CONCLUSION: These results suggest that the current criteria for paraphilia are too inclusive. Suggestions are given to improve the definition of pathological sexual interests, and the crucial difference between SF and sexual interest is underlined. Joyal CC. Defining "normophilic" and "paraphilic" sexual fantasies in a population-based sample: On the importance of considering subgroups. Sex Med 2015;3:321-330.

What exactly is an unusual sexual fantasy?

INTRODUCTION: Although several theories and treatment plans use unusual sexual fantasies (SF) as a way to identify deviancy, they seldom describe how the fantasies referred to were determined to be unusual. AIM: The main goal of this study was to determine which SF are rare, unusual, common, or typical from a statistical point of view among a relatively large sample of adults recruited from the general population. A secondary goal was to provide a statistical comparison of the nature and intensity of sexual fantasies for men and women. This study also aims at demonstrating with both quantitative and qualitative analyses that certain fantasies often considered to be unusual are common. METHODS: An Internet survey was conducted with 1,516 adults (799 ♀; 717 ♂) who ranked 55 different SF and wrote their own favorite SF. Each SF was rated as statistically rare (2.3% or less), unusual (15.9% or less), common (more than 50%), or typical (more than 84.1% of the sample). MAIN OUTCOME MEASURES: An extended version of the Wilson's Sex Fantasy Questionnaire with an open question. RESULTS: Only two sexual fantasies were found to be rare for women or men, while nine others were unusual. Thirty sexual fantasies were common for one or both genders, and only five were typical. These results were confirmed with qualitative analyses. Submission and domination themes were not only common for both men and women, but they were also significantly related to each other. Moreover, the presence of a single submissive fantasy was a significant predictor of overall scores for all SF in both genders. CONCLUSION: Care should be taken before labeling an SF as unusual, let alone deviant. It suggested that the focus should be on the effect of a sexual fantasy rather than its content.

Virtual faces expressing emotions: an initial concomitant and construct validity study.

BACKGROUND: Facial expressions of emotions represent classic stimuli for the study of social cognition. Developing virtual dynamic facial expressions of emotions, however, would open-up possibilities, both for fundamental and clinical research. For instance, virtual faces allow real-time Human-Computer retroactions between physiological measures and the virtual agent. OBJECTIVES: The goal of this study was to initially assess concomitants and construct validity of a newly developed set of virtual faces expressing six fundamental emotions (happiness, surprise, anger, sadness, fear, and disgust). Recognition rates, facial electromyography (zygomatic major and corrugator supercilii muscles), and regional gaze fixation latencies (eyes and mouth regions) were compared in 41 adult volunteers (20 ♂, 21 ♀) during the presentation of video clips depicting real vs. virtual adults expressing emotions. RESULTS: Emotions expressed by each set of stimuli were similarly recognized, both by men and women. Accordingly, both sets of stimuli elicited similar activation of facial muscles and similar ocular fixation times in eye regions from man and woman participants. CONCLUSION: Further validation studies can be performed with these virtual faces among clinical populations known to present social cognition difficulties. Brain-Computer Interface studies with feedback-feedforward interactions based on facial emotion expressions can also be conducted with these stimuli.