Comparison of Clinical Characteristics, Gender Perceptions, and Rape-Related Beliefs of People Assessed for Criminal Liability for Rape Against Children and Adults. / Çocuga ve Eriskine Yönelik Tecavüz Suçu Nedeniyle Ceza Sorumlulugu Degerlendirilen Kisilerin Klinik Özelliklerinin, Toplumsal Cinsiyet Algilarinin ve Tecavüze Iliskin Inançlarinin Karsilastirilmasi.

OBJECTIVE: This study aimed to compare the criminal, sociodemographic and clinical characteristics, paraphilic behaviors, sexual attitudes, gender perceptions, and rape-related beliefs of people assessed for criminal liability for rape against adults and children. METHOD: The study compared 40 people investigated for criminal liability for rape against an adult (RAA) with 40 individuals investigated for criminal liability for crime of rape against a child (RAC), and 43 age, sex and education matched individuals without any sexual crime history using the Structured Clinical Interview form for DSM-5 disorders, Hendrick Brief Sexual Attitude Scale, Gender Perception Scale, Illinois Rape Myth Acceptance Scale, and Barratt Impulsiveness Scale-11. RESULTS: All participants were male. There was no difference between the groups in terms of lifelong or existing psychiatric diseases. All participants had full criminal responsibility during the crime. No participant in any group was diagnosed with a paraphilic disorder. It was determined that people in both RAC and RAA groups tended to use sexuality as a tool, paid less attention to birth control methods, had a far less egalitarian perception of gender, and their myths about rape were significantly higher compared to the control group. The control group was much more impulsive than the sex offenders. CONCLUSION: Our results show that the act of sexual assault should not be explained only by impulsivity or psychiatric disorders, and that gender perception and sexual myths may also be influential. The fact that all individuals had full criminal responsibility emphasizes the need for more research on the social and cultural origins of sexual violence.

Criminological and Psychiatric Profiles of Immigrant and Refugee Offenders: A Retrospective Analysis of Cases in a Forensic Setting.

This study aimed to scrutinize the characteristics of immigrant and refugee offenders within our institution, focusing on factors such as immigrant status, country of birth, duration of residence in Turkey, as well as psychiatric, socio-demographic, and criminal profiles. The data were obtained through a retrospective examination of case records referred to the Observation Department of the Council of Forensic Medicine for the assessment of criminal responsibility between 2017 and 2022. The study categorized the cases into two groups: refugees and immigrants, comprising 35 and 22 offenders, respectively. Significant differences in educational levels were identified between immigrants and refugees within our study group (p < .001). Notably, drug use disorders were more prevalent among refugees, whereas alcohol use disorders were more common among immigrants, with statistical significance (p < .005). During forensic psychiatric assessments, 57.1% of refugees and 54.5% of immigrants required interpretation services. The most prevalent offense in the refugee group was homicide (37.1%), followed by child sexual abuse (28.6%). In contrast, homicide (31.8%) and theft and extortion (22.7%) were the most common offenses for the immigrant group. Six cases (10.5%) were judged to have reduced or no criminal liability. Among the cases, 52.6% had a history of prior outpatient psychiatric referrals, with the most frequent diagnosis being atypical psychosis at 10.5%. The findings underscore the necessity for additional research and targeted interventions to address the mental health and criminological complexities confronted by this vulnerable population.

Forensic psychiatric and criminal dimensions of juvenile homicide/attempted homicide cases in Turkey.

OBJECTIVE: This study aimed to analyze a sample (n = 65) of juvenile homicide/attempted homicide cases in terms of psychiatric, demographic, criminal characteristics, IQ scores, and Rorschach test (where available) characteristics and decisions on criminal responsibility. METHOD: Data were collected through a retrospective chart review of cases between the ages of 12 and 18 at the time of the offense, who were referred to the Observation Department of the Council of Forensic Medicine (Adli Tip Kurumu Baskanligi, Gözlem Ihtisas Dairesi) for determination of criminal responsibility between 2014 and 2019 and who were assessed under inpatient status by law. RESULTS: There were 65 juvenile homicide/attempted homicide offenders (7 female, 58 male). Reduced or no criminal liability was found in seven cases (10.7 %). Recent and past trauma was found in 21.5 % and 16.9 % of our cases respectively. The percentage of alcohol or illicit drug use disorder was 35.4 %. Non-suicidal self-injury was found in 38.5 % of our cases, and 6.4 % of these had a concurrent suicide attempt. Most of our cases (55.4 %) were neither in employment nor in education at the time of the offense. CONCLUSION: The juvenile homicide/attempted homicide offenders were a heterogeneous group. Rates of serious mental illness were low. School and working functionality were low. Antisocial personality traits, alcohol/substance use disorders, past and recent trauma, emotional regulation problems, and poor school and work functioning appear to be important in the development of this serious offending.

Sociodemographic, psychiatric and criminal characteristics of elderly offenders under evaluation for criminal responsibility in Turkey.

OBJECTIVE: The aim of this study was to examine a sample (n = 150) of elderly offenders to analyse the psychiatric, medical, demographic, criminal and if available neuropsychological test characteristics and criminal responsibility. METHOD: Data were gathered through a retrospective chart review of applicants aged 65 and over who were referred for determination of criminal responsibility from 2014 to 2019 at the Observation Department of Council of Forensic Medicine (Adli Tip Kurumu Baskanligi, Gözlem Ihtisas Dairesi) who were evaluated under inpatient status by law. RESULTS: There were 150 forensic cases aged 65 and over. The majority of the crimes were homicide (25.3%), homicide attempt (10%), and sexual offence (26%). The majority of sexual offence victims were children (34 of 39 cases). The percentages of decisions on criminal liability were as follows: 76% (n = 114) had full criminal liability, 21.3% of them (n = 32) had no criminal liability, 2.7% of them (n = 4) had reduced criminal liability. For the reduced/no criminal liability group, diagnoses were as follows: 37.1% dementia syndromes, 31.4% schizophrenia, 11.5% delusional disorder and 2.8% bipolar disorder manic episode. CONCLUSION: When the findings in our study and current literature data are examined, it is seen that certain crime groups such as murder and attempted murder, and sexual crimes against children are high in elderly forensic psychiatric evaluations.

Mother-daughter incest: A brief review of literature and case report.

Parent-child incest is a traumatic event that causes long-term psychological consequences for victims. Although paternal incest is the most common form, it is known that mothers can also sexually abuse their children. Mother-daughter incest is a type of abuse that is thought to be rare. This article discusses a case of a mother who abused one of her 4-year-old twin daughters for masturbation and used them in a sexual fantasy with her partner. She was sent to the forensic psychiatric observation unit by the court to determine her criminal responsibility. In the literature on mother-daughter incest, the abuser's childhood traumas, early marriage, low self-esteem, and sense of worthlessness are frequently seen. Our case, who did not have a history of psychiatric illness, was referred to us with suspicion of mental illness simply because she abused her daughters. Researchers have found out that in most cases, contrary to common expectations, mothers did not have a severe mental illness. A gender-based approach to incest cases may contribute to the cycle of the abuse continue, and it makes it difficult for victims to speak up and seek help. More studies focused on perpetrators will expand our perception of mother-daughter incest.

[Inflammation and Neurodegeneration in Patients with Early-Stageand Chronic Bipolar Disorder]. / Erken Evre ve Kronik Bipolar Bozukluk Hastalarinda Inflamasyon ve Nörodejenerasyon Bulgulari.

OBJECTIVE: The increase in the circulatory cytokine levels observed in patients with bipolar disorder (BD) may imply involvement of inflammation in the pathogenesis of mood disorders. However, the association between the inflammatory process and the stage and severity of illness is not well understood. In this study, our aim was to investigate the association between neuroinflammation and disease progression in the clinical course of BD. METHOD: IL-6, TNF-α, IL-1 receptor antagonist (IL-1RA), neuronspecific enolase (NSE) and S100B were measured by ELISA in plasma samples of patients at early-stage BD (n=30), chronic BD (n=77) and healthy controls (n=30). RESULTS: Chronic BD patients showed significantly increased levels of all measured inflammatory markers as compared to early-stage BD patients and the healthy controls. IL-6 and IL-1RA levels correlated with NSE and/or S100B levels and TNF-α levels correlated with Montgomery- Asberg Depression Rating Scale scores and Clinical Global Impression Scale scores. CONCLUSION: Our results indicate that inflammation appears to be particularly associated with IL-1RA and IL-6 activity, progressing at later stages of BD and possibly associated with gliosis and neuronal loss.

Prognostic comparison of proliferation markers and World Health Organization 1973/2004 grades in urothelial carcinomas of the urinary bladder.

European treatment guidelines of non-muscle-invasive urothelial carcinoma of the urinary bladder are strongly dependent on grade, but grading reproducibility is wanting. Protocolized proliferation features such as Mitotic Activity Index (MAI), Ki-67, and phosphohistone H3 are prognostic and reproducible. The objective of this population-based study was to compare proliferation biomarkers with each other and with World Health Organization (WHO) 1973/2004 grades with regard to prediction of stage progression. A total of 193 primary non-muscle-invasive urothelial carcinomas were analyzed using WHO73/04 grades and measurement of the proliferation markers mentioned above. Sensitivities, specificities, and positive and negative predictive values with confidence intervals (CIs) were estimated with regard to progression prediction. Kaplan-Meier survival curves were made, and the hazard ratio and Harrell's C-index with 95% CIs, P values, and adjusted C-index for stage progression or not of WHO73, WHO04, and the proliferation markers were calculated. The median follow-up time was 75 months (range, 1-127). A total of 111 patients (52%) experienced recurrence within 5 years, and 14 patients (7%) progressed. High values of MAI predicted stage progression with a positive predictive value of 0.22 (95% CI, 0.12-0.37). The positive predictive value of Ki-67 and phosphohistone H3 were 0.15 (both 95% CIs, 0.07-0.29) and comparable to that of the WHO04. The prognostic value of MAI was strongest, exceeding that of the other proliferation markers and the WHO grading systems. In conclusion, in non-muscle-invasive urinary bladder urothelial carcinomas, proliferation biomarkers have prognostic value, possibly exceeding that of the WHO classifications.

Reproducibility and prognostic value of WHO1973 and WHO2004 grading systems in TaT1 urothelial carcinoma of the urinary bladder.

BACKGROUND: European treatment guidelines of TaT1 urinary bladder urothelial carcinomas depend highly on stage and WHO1973-grade but grading reproducibility is wanting. The newer WHO2004 grading system is still debated and both systems are currently used. AIMS: To compare reproducibility and prognostic value (of stage progression) of the WHO1973 and WHO2004. METHODS: One hundred and ninety-three primary urothelial carcinomas were reviewed. Follow-up data were retrieved from the patient records. Kappa statistics and Harrell's C-index were used. RESULTS: Median follow-up was 75 months (range 1-127). 17 patients (9%) progressed, 82% of these within and 18% after 60 months. The distribution of WHO73-grades 1, 2 and 3 was 23%, 51% and 26%, interobserver agreement for each individual grade was 66% (kappa = 0.68), while for grades 1&2 versus 3 89% (kappa = 0.68). Intraobserver reproducibility was 68-63% for WHO73 and 88-89% for WHO73 as 1&2 vs.3. Progression free survival rates at 5 years were 95% (grade 1), 98% (grade 2) and 82% (grade 3) and 96% and 82% for grades 1&2 versus 3 (Hazard Ratio, HR, 5.4, p = 0.003). Using WHO2004, 62% were low grade and 38% high grade, inter-observer agreement 87% (kappa = 0.70), intraobserver reproducibility 93%, and progression free 5-year survival rates 97% and 85% (HR 6.6, p = 0.004). Positive and negative predictive values for stage progression within 5 years for the WHO73 (1&2 vs. 3) were 18% and 96%, and 15% and 97% for the WHO04. Using Harrell's C-index, none of the grading systems was prognostically superior. CONCLUSION: None of the grading systems is prognostically stronger than the others. Most importantly, inter-observer reproducibility and sensitivities for stage progression of both systems are low and need improvement for optimal treatment.

5-Year outcome of a randomized prospective study comparing bacillus Calmette-Guérin with epirubicin and interferon-α2b in patients with T1 bladder cancer.

PURPOSE: In a multicenter, prospectively randomized study we evaluated the 5-year outcomes of bacillus Calmette-Guérin alone compared to a combination of epirubicin and interferon-α2b in the treatment of patients with T1 bladder cancer. MATERIALS AND METHODS: Transurethral resection was followed by a second resection and bladder mapping. Stratification was for grade and carcinoma in situ. Followup entailed regular cystoscopy and cytology during the first 5 years. The end points assessed in this analysis were recurrence-free survival, time to treatment failure and progression, cancer specific survival and prognostic factors. RESULTS: The study recruited 250 eligible patients. The 5-year recurrence-free survival rate was 38% in the combination arm and 59% in the bacillus Calmette-Guérin arm (p = 0.001). The corresponding rates for the other end points were not significantly different, as free of progression 78% and 77%, treatment failure 75% and 75%, and cancer specific survival 90% and 92%, respectively. The type of treatment, tumor size and tumor status at second resection were independent variables associated with recurrence. Concomitant carcinoma in situ was not predictive of failure of bacillus Calmette-Guérin therapy. An independent factor for treatment failure was remaining T1 stage at second resection. CONCLUSIONS: Bacillus Calmette-Guérin was more effective than the tested combination therapy. The currently recommended management with second resection and 3-week maintenance bacillus Calmette-Guérin entails a low risk of cancer specific death. More aggressive treatment in patients with infiltrative tumors at second resection might improve these results. In particular, concomitant carcinoma in situ was not a predictive factor for poor outcome after bacillus Calmette-Guérin therapy.

Side-effects of post-treatment biopsies in prostate cancer patients treated with endocrine therapy alone or combined with radical radiotherapy in the Scandinavian Prostate Cancer Group-7 randomized trial.

OBJECTIVE: Post-treatment prostate biopsy side-effects were evaluated in patients with locally advanced prostate cancer on endocrine therapy alone or combined with radiotherapy in the Scandinavian Prostate Cancer Group-7 randomized trial. MATERIAL AND METHODS: One-hundred and twenty patients underwent transrectalultrasound-guided biopsy, and were requested to complete a questionnaire on side-effects occurring within 7 days' follow-up. RESULTS: The questionnaire was returned by 109 patients (91%) (endocrine therapy only 52%, combined endocrine therapy and radiotherapy 48%). Previous therapy had no significant influence on pain, urinary flow, haematuria or haematospermia. Pain at biopsy was reported in 63% (mild, 57%; moderate, 5.6%; severe, one patient) and pain at follow-up in 31% (mild, 27%; moderate, four patients). Haematuria (mean duration 2.2 days) was reported in 41%, and reduced urinary flow in 20% (mild, 18%; severe: four patients; no patient had urinary retention). Haematospermia was scarce. No patient reported urinary tract infection. Rectal bleeding occurred in 18% in the endocrine and 35% in the combined therapy group (p = 0.047), with a mean duration of 1.6 and 2.2 days, respectively (p = 0.031). In logistic regression analysis, a trend towards increased rectal bleeding was found in patients on combined endocrine therapy and radiotherapy (odds ratio 2.4, p = 0.050). CONCLUSION: Patient-reported post-treatment prostate biopsy side-effects were mild and self-limiting.

Residual prostate cancer in patients treated with endocrine therapy with or without radical radiotherapy: a side study of the SPCG-7 randomized trial.

PURPOSE: The Scandinavian Prostate Cancer Group-7 randomized trial demonstrated a survival benefit of combined endocrine therapy and external-beam radiotherapy over endocrine therapy alone in patients with high-risk prostate cancer. In a subset of the study population, the incidence and clinical implications of residual prostate cancer in posttreatment prostate biopsy specimens was evaluated. METHODS AND MATERIALS: Biopsy specimens were obtained from 120 of 875 men in the Scandinavian Prostate Cancer Group-7 study. RESULTS: Biopsies were performed at median of 45 months follow-up. In 63 patients receiving endocrine treatment only and 57 patients receiving combined treatment, residual cancer was found in 66% (n = 41) and 22% (n = 12), respectively (p < 0.0001). The vast majority of residual tumors were poorly differentiated (Gleason score ≥ 8). Endocrine therapy alone was predictive of residual prostate cancer: odds ratio 7.49 (3.18-17.7), p < 0.0001. In patients with positive vs. negative biopsy the incidences of clinical events were as follows: biochemical recurrence 74% vs. 27% (p < 0.0001), local progression 26% vs. 4.7% (p = 0.002), distant recurrence 17% vs. 9.4% (p = 0.27), clinical recurrence 36% vs. 13% (p = 0.006), cancer-specific death 19% vs. 9.7% (p = 0.025). In multivariable analysis, biochemical recurrence was significantly associated with residual cancer: hazard ratio 2.69 (1.45-4.99), p = 0.002, and endocrine therapy alone hazard ratio 3.45 (1.80-6.62), p < 0.0001. CONCLUSIONS: Radiotherapy combined with hormones improved local tumor control in comparison with endocrine therapy alone. Residual prostate cancer was significantly associated with serum prostate-specific antigen recurrence, local tumor progression, clinical recurrence, and cancer-specific death in univariable analysis. Residual cancer was predictive of prostate-specific antigen recurrence in multivariable analysis.

Endocrine treatment, with or without radiotherapy, in locally advanced prostate cancer (SPCG-7/SFUO-3): an open randomised phase III trial.

BACKGROUND: Several studies have shown the efficacy of endocrine therapy in combination with radiotherapy in high-risk prostate cancer. To assess the effect of radiotherapy, we did an open phase III study comparing endocrine therapy with and without local radiotherapy, followed by castration on progression. METHODS: This randomised trial included men from 47 centres in Norway, Sweden, and Denmark. Between February, 1996, and December, 2002, 875 patients with locally advanced prostate cancer (T3; 78%; PSA<70; N0; M0) were centrally randomly assigned by computer to endocrine treatment alone (3 months of total androgen blockade followed by continuous endocrine treatment using flutamide; 439 patients), or to the same endocrine treatment combined with radiotherapy (436 patients). The primary endpoint was prostate-cancer-specific survival, and analysis was by intention to treat. This study is registered as an international standard randomised controlled trial, number ISRCTN01534787. FINDINGS: After a median follow-up of 7.6 years, 79 men in the endocrine alone group and 37 men in the endocrine plus radiotherapy group had died of prostate cancer. The cumulative incidence at 10 years for prostate-cancer-specific mortality was 23.9% in the endocrine alone group and 11.9% in the endocrine plus radiotherapy group (difference 12.0%, 95% CI 4.9-19.1%), for a relative risk of 0.44 (0.30-0.66). At 10 years, the cumulative incidence for overall mortality was 39.4% in the endocrine alone group and 29.6% in the endocrine plus radiotherapy group (difference 9.8%, 0.8-18.8%), for a relative risk of 0.68 (0.52-0.89). Cumulative incidence at 10 years for PSA recurrence was substantially higher in men in the endocrine-alone group (74.7%vs 25.9%, p<0.0001; HR 0.16; 0.12-0.20). After 5 years, urinary, rectal, and sexual problems were slightly more frequent in the endocrine plus radiotherapy group. INTERPRETATION: In patients with locally advanced or high-risk local prostate cancer, addition of local radiotherapy to endocrine treatment halved the 10-year prostate-cancer-specific mortality, and substantially decreased overall mortality with fully acceptable risk of side-effects compared with endocrine treatment alone. In the light of these data, endocrine treatment plus radiotherapy should be the new standard.

Bicalutamide 150 mg in addition to standard care for patients with early non-metastatic prostate cancer: updated results from the Scandinavian Prostate Cancer Period Group-6 Study after a median follow-up period of 7.1 years.

OBJECTIVE: The Early Prostate Cancer (EPC) programme is evaluating the efficacy and tolerability of bicalutamide following standard care (radiotherapy, radical prostatectomy or watchful waiting) in patients with localized (T1-2, N0/Nx) or locally advanced (T3-4, any N; or any T, N + ) non-metastatic prostate cancer. Herein we report the latest findings after a median follow-up period of 7.1 years from the Scandinavian Prostate Cancer Group (SPCG)-6 study, one of three trials in the EPC programme. MATERIAL AND METHODS: A total of 1218 patients were randomized on a 1:1 basis to either bicalutamide 150 mg/day (n=607) or placebo (n=611) following standard care; 81.4% were followed conservatively (watchful waiting). The primary endpoints were objective progression-free survival (PFS) and overall survival (OS). RESULTS: In patients with localized disease there was no significant difference in PFS [hazard ratio (HR) 0.85; 95% CI 0.69-1.06; p=0.15] and a trend towards decreased OS with bicalutamide plus standard care compared with standard care alone (HR 1.23; 95% CI 0.96-1.58; p=0.11). In patients with locally advanced disease, bicalutamide significantly improved PFS, reducing the risk of progression by 53% compared with standard care alone (HR 0.47; 95% CI 0.37-0.59; p<0.001). The median time to progression was 8.8 years for bicalutamide plus standard care and 7.1 years for standard care alone. There was a significant improvement in OS with bicalutamide plus standard care, with a reduction in the risk of death of 35% versus standard care alone (HR 0.65; 95% CI 0.50-0.85; p=0.001). CONCLUSION: This analysis of the SPCG-6 study showed that bicalutamide plus standard care offers significant PFS and OS benefits for patients with locally advanced disease, but not for those with localized disease.

Bicalutamide (150 mg) versus placebo as immediate therapy alone or as adjuvant to therapy with curative intent for early nonmetastatic prostate cancer: 5.3-year median followup from the Scandinavian Prostate Cancer Group Study Number 6.

PURPOSE: We evaluated the benefits of adding 150 mg bicalutamide to standard care, that is radical prostatectomy, radiotherapy or watchful waiting (WW), in patients with localized or locally advanced prostate cancer. MATERIALS AND METHODS: A total of 1,218 men with T1-4, M0, any N prostate cancer were recruited from 62 Scandinavian centers and randomized 1:1 to 150 mg bicalutamide or placebo plus standard care. Primary end points were progression-free survival (PFS) and overall survival. RESULTS: At a median 5.3-year followup patients with locally advanced disease had improved survival with bicalutamide (HR 0.68, 95% CI 0.50 to 0.92), while those with localized disease had decreased survival with bicalutamide (HR 1.47, 95% CI 1.06 to 2.03). Bicalutamide significantly improved PFS, decreasing the risk of disease progression by 43% compared with placebo (HR 0.57, 95% CI 0.48 to 0.68, p<0.0001). The rate of events was 35.4% for bicalutamide and 46.2% for placebo. Patients with locally advanced disease gained the greatest PFS benefits with bicalutamide (HR 0.40, 95% CI 0.31 to 0.52). Since 81% of the trial population were untreated before entry and would otherwise have undergone WW, the findings essentially reflect the results of immediate hormone therapy vs WW. CONCLUSIONS: Bicalutamide (150 mg) provides significant benefit in patients with locally advanced disease. In previously untreated patients there may be a tumor burden below which endocrine therapy provides no benefit or may even decrease survival.

[Experiences with ritual circumcision in Norway]. / Erfaringer med rituell omskjaering i Norge.

BACKGROUND: We wanted to provide a survey of the extent and practice of locally performed ritual circumcision of boys born to Muslim parents in Norway. MATERIAL AND METHODS: Newborn boys with Muslim parents in two counties in Norway (Rogaland and Troms) were registered. 56 ritual circumcisions were performed in outpatient departments in the local hospitals during the period under investigation, 11 on newborns, 33 on boys between one and ten, and 12 on boys above ten. RESULTS: The number of circumcised boys in 1999 was 24% of the total number of boys born to Muslim parents that year; in 2000, 48%. Circumcision of boys between one and ten is ten times more time-consuming than circumcision of newborns or boys above ten. INTERPRETATION: An estimated 672 boys are born to Muslim parents in Norway each year. Less than 50% of newborns with Muslim parents are circumcised in local outpatient departments. We recommend that ritual circumcision is restricted to newborns or to boys above ten, and that informed written consent is obtained from boys above ten.