Rare, but potentially risky, high individual increase of self-reported sexual arousal in men, who have committed sexual offenses against children, while being confronted with experimental sexual stimuli - a retrospective data analysis.

This data analysis was initiated to further understand the infrequent yet intense instances of sexual arousal and signs of decompensation that emerge after exposing men who have committed sexual offenses against children to experimental sexual stimuli. We analyzed retrospectively and exploratory data of a self-developed sexual arousal questionnaire ("Current-State-of-Emotions-Questionnaire", CSEQ) with the following objectives: (i) examine subjective sexual arousal changes elicited during confrontation with experimental sexual stimuli, (ii) analyze these sexual arousal changes at an individual level to detect large responses, and (iii) ask for associations between large responses in sexual arousal and individual characteristics of participants, e.g., demographic, clinical, and criminological parameters. The sample consisted of 241 adult, male Germans, comprising four groups: Ten individuals who have committed sexual offenses against children and have been placed in forensic psychiatric facilities (ISOCFP), 31 non-hospitalized individuals with sexual interest in children (ISIC), eight individuals who have committed other offenses and have been placed in forensic psychiatric facilities (IOFP), and 192 individuals without sexual interest in children and offense histories (IWO). We found a significant increase in subjective sexual arousal after confrontation with sexual stimuli (three experiments: initial orientation: Z = -4.819, p < .001, sexual distractor task: Z = -2.954, p = .003, stimulus rating: Z = -6.899, p < .001). Up to 14.3% of participants indicated high sexual arousal values before, but mainly after the experiments, with 20.0% of ISOCFP, 12.9% of ISIC, 12.5% of IOFP, and 14.6% of IWO. ISOCFP and ISIC with high sexual arousal were more likely to be diagnosed with paraphilia (pedophilia) and/or affective disorders, and to receive anti-depressive treatment. We assume a higher emotional lability or/and reduced emotion regulation abilities in those individuals. A careful weighing up of anticipated scientific knowledge gain and a potentially, though rare, increased risk of recidivism or decompensation seems indispensable.

Predictive Validity of Operationalized Criteria for the Assessment of Criminal Responsibility of Sexual Offenders With Paraphilic Disorders-A Randomized Control Trial With Mental Health and Legal Professionals.

The prevention of sexual violence is a major goal of sexual health. In cases of accused sexual offenders, the assessment of diminished criminal responsibility of the accused is one of the most important procedures undertaken by experts in the German legal system. This assessment follows a two-stage method assessing first the severity of a paraphilic disorder and then second criteria for or against diminished capacity. The present study examines the predictive validity of two different sets of criteria for the assessment of criminal responsibility in the context of paraphilic disorders combined with sexual offending. Two exemplary case vignettes of two suspected sexual offenders were developed to assess the criteria. For each participant, one of the two exemplary case vignettes was randomly presented. The presentation of the two different sets of criteria was also randomized, so that each participant was assigned only one of the two criteria sets to rate one of the presented cases. N = 349 participants from different professional backgrounds (mental health and legal professionals) completed their assessments and were included in the data analysis. The data were evaluated using logistic regression. Results show that the more recently published criteria set (Briken and Müller, 2014) predicts both the severity of the disorder as well as the diminished capacity twice as good as the older criteria set of Boetticher et al. (2005) currently used regularly for forensic court reports. In preliminary conclusion, the new criteria of Briken and Müller (2014) form an empirically based assessment of criminal responsibility. However, the proposed criteria cannot replace an extensive exploration of the accused person and a careful file analysis. Validity and reliability of the results are also limited due to the methodical choice of a vignette study.

Are There Any Biomarkers for Pedophilia and Sexual Child Abuse? A Review.

The use of biomarkers in medicine is a common and valuable approach in several clinical fields. Understanding the relationship between measurable biological processes and clinical outcomes not only is indispensable in the face of understanding physiological processes in healthy as well as in diseased organisms but also for understanding and evaluating treatment effects. Therefore, also in the context of forensic psychiatry, biomarkers and their potentially beneficial effects are of growing interest. The objective of this review is to examine if there are biomarkers that may serve as a tool to support diagnostic process, treatment evaluation, and risk assessment of pedophilic individuals and child sexual offenders. In the first part, we present an overview of the current neurobiological, as well as physiological and psychophysiological approaches to characterize pedophilia and child sexual offending. Secondly, we discuss and evaluate the impact of these approaches on the development of biomarkers for diagnosis, therapy, and risk assessment in pedophilic subjects and child sexual offenders. We conclude that a lot of research has already enhanced our neurobiological knowledge about pedophilia and child sexual offending. Although there surely exist promising parameters and approaches, in our view currently none of these is ready yet to serve as a clinically applicable diagnostic, response, or predictive biomarker for pedophilia and child sexual offending. Therefore, further work remains to be done. The development of a composite diagnostic biomarker to assess deviant sexual interest, combining several measures like functional magnetic resonance imaging, electroencephalogram, eye tracking, and behavioral approaches seems to be most promising. A valid and reliable measurement of deviant sexual interest, insensitive to manipulations could significantly support clinical diagnostic process. Similarly, regarding therapy evaluation and risk assessment, a composite biomarker to assess inhibitory control functions seems to be promising. Furthermore, the application of the Research Domain Criteria-approach, a new approach for investigating and classifying mental disorders, offers the possibility to take research to a new level.

Eye movements in pedophiles: automatic and controlled attentional processes while viewing prepubescent stimuli.

Recent theories in sexuality highlight the importance of automatic and controlled attentional processes in viewing sexually relevant stimuli. The model of Spiering and Everaerd (2007) assumes that sexually relevant features of a stimulus are preattentively selected and automatically induce focal attention to these sexually relevant aspects. Whether this assumption proves true for pedophiles is unknown. It is aim of this study to test this assumption empirically for people suffering from pedophilic interests. Twenty-two pedophiles, 8 nonpedophilic forensic controls, and 52 healthy controls simultaneously viewed the picture of a child and the picture of an adult while eye movements were measured. Entry time was assessed as a measure of automatic attentional processes and relative fixation time in order to assess controlled attentional processes. Pedophiles demonstrated significantly shorter entry time to child stimuli than to adult stimuli. The opposite was the case for nonpedophiles, as they showed longer relative fixation time for adult stimuli, and, against all expectations, pedophiles also demonstrated longer relative fixation time for adult stimuli. The results confirmed the hypothesis that pedophiles automatically selected sexually relevant stimuli (children). Contrary to all expectations, this automatic selection did not trigger the focal attention to these sexually relevant pictures. Furthermore, pedophiles were first and longest attracted by faces and pubic regions of children; nonpedophiles were first and longest attracted by faces and breasts of adults. The results demonstrated, for the first time, that the face and pubic region are the most attracting regions in children for pedophiles.

Diagnostic accuracy of eye movements in assessing pedophilia.

INTRODUCTION: Given that recurrent sexual interest in prepubescent children is one of the strongest single predictors for pedosexual offense recidivism, valid and reliable diagnosis of pedophilia is of particular importance. Nevertheless, current assessment methods still fail to fulfill psychometric quality criteria. AIMS: The aim of the study was to evaluate the diagnostic accuracy of eye-movement parameters in regard to pedophilic sexual preferences. METHOD: Eye movements were measured while 22 pedophiles (according to ICD-10 F65.4 diagnosis), 8 non-pedophilic forensic controls, and 52 healthy controls simultaneously viewed the picture of a child and the picture of an adult. Fixation latency was assessed as a parameter for automatic attentional processes and relative fixation time to account for controlled attentional processes. MAIN OUTCOME MEASURES: Receiver operating characteristic (ROC) analyses, which are based on calculated age-preference indices, were carried out to determine the classifier performance. Cross-validation using the leave-one-out method was used to test the validity of classifiers. RESULTS: Pedophiles showed significantly shorter fixation latencies and significantly longer relative fixation times for child stimuli than either of the control groups. Classifier performance analysis revealed an area under the curve (AUC) = 0.902 for fixation latency and an AUC = 0.828 for relative fixation time. The eye-tracking method based on fixation latency discriminated between pedophiles and non-pedophiles with a sensitivity of 86.4% and a specificity of 90.0%. Cross-validation demonstrated good validity of eye-movement parameters. CONCLUSIONS: Despite some methodological limitations, measuring eye movements seems to be a promising approach to assess deviant pedophilic interests. Eye movements, which represent automatic attentional processes, demonstrated high diagnostic accuracy.

Initial orienting towards sexually relevant stimuli: preliminary evidence from eye movement measures.

It has been proposed that sexual stimuli will be processed in a comparable manner to other evolutionarily meaningful stimuli (such as spiders or snakes) and therefore elicit an attentional bias and more attentional engagement (Spiering and Everaerd, In E. Janssen (Ed.), The psychophysiology of sex (pp. 166-183). Bloomington: Indiana University Press, 2007). To investigate early and late attentional processes while looking at sexual stimuli, heterosexual men (n = 12) viewed pairs of sexually preferred (images of women) and sexually non-preferred images (images of girls, boys or men), while eye movements were measured. Early attentional processing (initial orienting) was assessed by the number of first fixations and late attentional processing (maintenance of attention) was assessed by relative fixation time. Results showed that relative fixation time was significantly longer for sexually preferred stimuli than for sexually non-preferred stimuli. Furthermore, the first fixation was more often directed towards the preferred sexual stimulus, when simultaneously presented with a non-sexually preferred stimulus. Thus, the current study showed for the first time an attentional bias to sexually relevant stimuli when presented simultaneously with sexually irrelevant pictures. This finding, along with the discovery that heterosexual men maintained their attention to sexually relevant stimuli, highlights the importance of investigating early and late attentional processes while viewing sexual stimuli. Furthermore, the current study showed that sexually relevant stimuli are favored by the human attentional system.

The role of testosterone in sexuality and paraphilia--a neurobiological approach. Part I: testosterone and sexuality.

INTRODUCTION: Antiandrogen therapy has been used for 30 years to treat paraphilic patients and sexual offenders. Yet the therapeutic success of antiandrogens is uncertain. Furthermore, there is still a lack of comprehensive knowledge about the effects of androgen-lowering therapy in paraphilic patients. AIM: This article reviews current neurobiological and clinical knowledge about testosterone and its impact on sexuality, acquired from animal and human basic research. This knowledge may not only enhance our understanding of the great variability of the therapeutic outcome, but could also offer new opportunities to evaluate the effect of androgen-lowering therapy in paraphilia. METHODS: A comprehensive review of the human and animal literature is presented, considering the classical and non-classical mechanisms of androgens and the androgen brain receptors. Furthermore, the clinical evidence about the impact of testosterone on human sexual behavior is discussed. These are integrated into two current neurobiological theories of sexual behavior, the four-component model and the dual-control model. RESULTS: The wide distribution of androgen receptors throughout the whole brain and their numerous mechanisms demonstrate that androgens can modulate almost every aspect of sexual behavior-i.e., not only autonomic functions, but also emotional, motivational, and cognitive aspects. Furthermore, testosterone participates in excitatory and inhibitory processes of sexual functions by modulating the activity of mainly dopaminergic neurotransmitter systems. CONCLUSIONS: Using the data presented, we combine the two models and present a new integrated approach to understand the role of testosterone in the excitation and inhibition of sexual function, at the neurochemical, neuroanatomical, and behavioral levels. This knowledge will help us to gain a better understanding of the few and inconsistent data that are currently available concerning (i) the association between testosterone and paraphilic behavior; and (ii) the highly variable effects of antiandrogen therapy, discussed in Part II of this review.

The role of testosterone in sexuality and paraphilia--a neurobiological approach. Part II: testosterone and paraphilia.

INTRODUCTION: Antiandrogen therapy has been used for 30 years to treat paraphilic patients and sexual offenders. Yet the therapeutic success of antiandrogens is uncertain. Furthermore, there is still a lack of comprehensive knowledge about the effects of androgen-lowering therapy in paraphilic patients. AIM: We discuss endocrinological, neurobiological, and therapeutic aspects of paraphilia with the aim of integrating these on the basis of the current neurobiological and clinical knowledge on testosterone that was set out in Part I of this review. METHODS: Our review of the human literature comprises the current knowledge about the neurobiology of paraphilia and the known endocrinological, pathophysiological, and genetic aspects of this disorder. The role of testosterone is discussed. A survey of antiandrogen therapy and its outcome in paraphilic patients and sex offenders is provided. RESULTS: Although not all data are consistent, current imaging research suggests that structural and functional changes in pedophilia appear for the most part in brain regions also involved in sexual functions. Not exclusively testosterone but also some other endocrinological and neurochemical parameters could be disturbed in pedophilic patients and child molesters; these include changes in hypothalamic-pituitary function, prolactin levels, and dopaminergic or serotonergic functions. There appears to be a sex-steroid-related genetic influence on antisocial traits, externalizing behavior, and sexual behavior. Most of the studies in which antiandrogen therapy in paraphilic patients and sex offenders have been examined were case reports, or observational or open-label studies, and many did not include adequate control groups. Only a few placebo-controlled double-blind studies have been published with inconsistent results concerning treatment effects. Outcome measures differ between the studies and do not seem ideally suited to their purpose. CONCLUSIONS: On the basis of the current knowledge about testosterone and its effects on brain and behavior as described in Part I, and of available results on the relationship between testosterone and paraphilia as well as antiandrogen therapy, we present from a neurobiological perspective an extended scientific proposal for design features to investigate the effects of antiandrogen treatment in large clinical trials.

Motor-induced brain activation in cortical, subcortical and cerebellar regions in schizophrenic inpatients. A whole brain fMRI fingertapping study.

Motor symptoms including neurological soft signs have been found to be more prevalent in schizophrenic patients. In addition, catatonic symptoms and neuroleptic treatment as well may influence cortical and subcortical motor organization in schizophrenia. The results of previous neuroimaging studies exploring motor function in patients with schizophrenia are inhomogenous reporting on a decreased activity in cortical motor regions in some studies and normal activity in others. Using fMRI, we studied 40 subjects performing a unilateral self-paced fingertapping task. Analyzing a general linear model of four groups, we compared patients with schizophrenia according to DSM-IV treated with olanzapine (OL; 10) or haloperidol (HA; 10) to healthy controls (HC; 10) and untreated patients (UN; 10). Brainvoyager software was used for data analyzing. In all groups, the contralateral motor cortex was significantly activated. Significant activation of the ipsilateral cerebellum was found in the UN group, the control group and the OL group. The contralateral basal ganglia were activated in UN and in controls. Motor-induced cortical and subcortical brain activation in HC was significantly higher than in patients with schizophrenia. UN with schizophrenia showed a significant overactivation than the other groups. In conclusion, we revealed a diminished activation in the patient group treated with neuroleptic drugs. This study outlines the importance of further fMRI studies to investigate interindividual activation differences under different conditions especially focusing on basal ganglia.