Sexual interest and sexual self-control in men with self-reported sexual interest in children - A first eye tracking study.

Sexual child abuse is one of the most destructive events for child development. One possible approach to avert it is the preventive treatment of individuals with a sexual interest in children. The aim of the current eye tracking study was to compare people with a self-reported sexual interest in children who participate in the outpatient preventive treatment project "PsM", pedophilic forensic inpatients, and a non-pedophilic control group. Groups were compared with respect to sexual interest and attentional control in the presence of sexual stimuli, both assessed independently of self-report. Two approaches were applied, namely the initial orientation approach for measuring sexual interest, and a sexual distractor task for measuring attentional control. Our data showed for the first time that outpatients with a self-reported sexual interest in children differed from pedophilic forensic inpatients with respect to attentional control but not with regard to sexual interest. Outpatients showed similar sexual interest in children as pedophilic forensic inpatients. They demonstrated significantly better attentional control than pedophilic forensic inpatients in the face of adult sexual stimuli, but the difference regarding child sexual stimuli did not reach significance. This might reflect a higher capacity for self-control and self-regulation in these patients. Nevertheless, child stimuli remain to be important distractors for them. Our results provide valuable additional information for the diagnosis and therapy of outpatients with a self-reported sexual interest in children. Obviously, these data are preliminary and further studies with larger groups should examine if they are replicable.

[Treatment structures for men with pedosexual problems]. / Versorgungsstrukturen für Männer mit pädosexueller Problematik.

Pedophilia is defined as a persistent or dominating sexual preference for prepubescent children characterized by persistent thoughts, fantasies, urges, sexual arousal and behavior. Less than 50% of all child abusers fulfill the diagnostic criteria and an even smaller part exclusively has a preference for children. Following psychiatric classification systems, pedophilia must be distinguished from child sexual abuse. Outpatient treatment and treatment in forensic psychiatry clinics, sociotherapeutic facilities and in correction facilities are different aspects of prevention. So-called grey area projects (Dunkelfeldprojekte) are special facilities of primary and secondary prevention. The aim is to prevent sexual abuse by reducing and controlling of risk factors.

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.

[Is disulfiram (Antabus) indicated in the treatment of offenders with alcohol use disorders?]. / Ist Disulfiram (Antabus) zur Behandlung von Patienten mit Alkoholproblemen im Massregelvollzug indiziert?

BACKGROUND: Research studies and clinical experience provided us with valuable information about the efficacy of disulfiram. Although supervised disulfiram treatment has been shown to improve outcome in court-referred patients too it is obviously rarely used in German forensic hospitals. METHOD: Two cases illustrated the application of disulfiram to constitute an adjunct to treatment of forensic inpatients. RESULTS: Disulfiram can be used as an adjunct for maintenance of abstinence when the relapse risk is due to insufficient impulse control. DISCUSSION: The decision to use disulfiram to assure sobriety for high risk groups, e.g. criminal offenders is discussed.