Childhood Sexual Abuse by Women of Boys Who Go On to Sexually Offend: Review and Critical Analysis.

PURPOSE OF REVIEW: Sexual offending perpetrated by women has historically been overlooked and understudied, and the potentially unique impact of that abuse is even more so. RECENT FINDINGS: Women who have sexually offended against children typically do so against older boys, use little or no forms of force or coercion during the abuse, and are unlikely to be prosecuted or sentenced following the abuse. Boys whom women have sexually abused are unlikely to report or disclose the abuse that they have experienced, perhaps because social structures surrounding sexual abuse of boys by women are designed to minimize, excuse, or even encourage such sexual contact. The intersection of these unique features may help understand the role of childhood sexual abuse perpetrated by women in subsequent sexual offending among adult men. Men who have sexually offended experience high rates of childhood sexual abuse perpetrated by women. The relationship between experienced sexual abuse and subsequent perpetration of sexual abuse is neither linear nor causal; however, the characteristics associated with this form of abuse, such as non-disclosure and lack of sentencing, may contribute to adulthood sexual maladjustment and vulnerability to offending among men.

The Relation Between the Paraphilias and Anxiety in Men: A Case-Control Study.

Despite a multitude of theoretical views, it is still unclear how individuals develop and sustain paraphilic interests (e.g., sexual attraction to children, interest in non-consensual violence). It is also not clear from these views why many paraphilic interests, and especially many paraphilias and paraphilic disorders, are much more common in men than in women. One possible factor affecting male's higher rate of paraphilias is anxiety, because anxiety can potentiate sexual arousal in men. We speculated that paraphilic interests could develop when feelings of anxiety are recurrently generated by atypical sexual stimuli, and when that anxiety repeatedly potentiates sexual arousal, reinforcing sexual response to atypical stimuli. It follows that men with paraphilic interests are susceptible to anxiety disorders, because an anxiety disorder would facilitate the hypothesized developmental process. We conducted a retrospective file review of 1048 consecutive patients (944 male patients retained for analysis) referred to an outpatient sexual behavior clinic at a psychiatric hospital to investigate the link between paraphilias and anxiety. Male patients with a paraphilia had 1.64 greater odds than male patients without a paraphilia of having been diagnosed with an anxiety disorder, but they also had elevated rates of many other types of disorders. Therefore, there does not seem to be a specific link between paraphilias and anxiety in this sample. The discovery of a general link between the paraphilias and psychological disorders in men opens new avenues for studying the developmental origins and consequences of male paraphilic interests.

Substance Use Disorders and Antisocial Personality Disorder among a Sample of Incarcerated Individuals with Inadequate Health Care: Implications for Correctional Mental-Behavioural Health and Addiction Services.

Epidemiological estimates of substance use disorders (SUD) are critical for the planning of evidence-informed intervention and services. In this study, 250 incarcerated individuals in Nigeria were interviewed with the Mini International Neuropsychiatric Inventory (MINI) to diagnose SUD and antisocial personality disorder (ASPD). Most of the participants were males (97.6%), and the mean age was 35.4 (SD=13.5) years. Substance use disorder and ASPD were prevalent in 57.6% and 11.2% of the participants, respectively. Of those diagnosed with SUD, 35.2% and 22.4% had poly-SUD and mono-SUD respectively. Psychotic and dependence syndromes involving cannabis misuse were the most prevalent poly-SUD, and mono-SUD was characterized by alcohol, nicotine, and opioid dependence syndromes. Substance use disorder was more likely in participants charged with robbery and convicted, while ASPD was associated with prior and long-term imprisonment. There is a need for effective integration of treatment for ASPD/SUD into correctional mental health services in settings with inadequate health care using an appropriate model and a viable strategy.

Concordance of Paraphilic Interests and Behaviors.

We examined the concordance of paraphilic interests and behaviors across 13 themes in an online sample of 1,036 men and women. Paraphilic interests were significantly and positively correlated with behaviors across all 13 themes. Associations were strongest for masochism and sadism, and weakest for pedohebephilia and frotteurism. Paraphilic interest and behavior were significantly and positively correlated after accounting for gender and sexual orientation. Moderated moderation analysis was significant for five themes. Gender was a moderator for eroticized gender, but only among heterosexual participants, where concordance was higher for heterosexual men than for heterosexual women. For both exhibitionism and frotteurism, gender was a significant moderator, but only for nonheterosexual participants, where concordance was stronger for nonheterosexual men than for nonheterosexual women. For pedohebephilia, interest was significantly associated with behavior for heterosexual men, heterosexual women, and nonheterosexual men, but not for nonheterosexual women. For zoophilia, there was a significant association between interest and behavior for heterosexual men, nonheterosexual men, and nonheterosexual women, but not heterosexual women. Additional analyses found sex drive moderated the positive associations of 7 of 13 paraphilic themes, with 5 of these 7 showing the expected effect of higher concordance of interests and behaviors at higher levels of sex drive.

Vicarious Trauma and PTSD in Forensic Mental Health Professionals.

In their article about countertransference and vicarious trauma in work with sexual offenders, Barros and colleagues highlight the importance of awareness of risk for vicarious trauma in forensic psychiatrists and psychologists. This commentary supports the need for more research related to the risk of vicarious trauma and posttraumatic stress disorder (PTSD) in forensic experts. Also, forensic mental health professionals need to be aware of the level of risk to which they are exposed in their work evaluating and treating sexual offenders. As more knowledge has developed about PTSD and the diagnostic criteria have evolved between the fourth and fifth editions of the Diagnostic and Statistical Manual of Mental Disorders, there is also more awareness of the effects of traumatic exposure on different professional groups and laypeople. For example, judicial authorities in Canada have recently become aware of the traumatic impacts of evidentiary material on jurors, including testimony, print, and video material. Workplace exposure to trauma in inpatient psychiatric centers has received limited research focus. Actual or threatened death or sexual violation in these settings can result in compassion fatigue and burnout. Exposure to video material in the workplace, particularly in forensic settings, can result in PTSD.

The World Federation of Societies of Biological Psychiatry (WFSBP) 2020 guidelines for the pharmacological treatment of paraphilic disorders.

Objectives: The primary aim of these guidelines is to evaluate the role of pharmacological agents in the treatment and management of patients with paraphilic disorders, with a focus on the treatment of adult males. Because such treatments are not delivered in isolation, the role of specific psychotherapeutic interventions is also briefly covered. These guidelines are intended for use in clinical practice by clinicians who diagnose and treat patients, including sexual offenders, with paraphilic disorders. The aim of these guidelines is to bring together different views on the appropriate treatment of paraphilic disorders from experts representing different countries in order to aid physicians in clinical decisions and to improve the quality of care.Methods: An extensive literature search was conducted using the English-language-literature indexed on MEDLINE/PubMed (1990-2018 for SSRIs) (1969-2018 for hormonal treatments), supplemented by other sources, including published reviews.Results: Each treatment recommendation was evaluated and discussed with respect to the strength of evidence for its efficacy, safety, tolerability, and feasibility. The type of medication used depends on the severity of the paraphilic disorder and the respective risk of behaviour endangering others. GnRH analogue treatment constitutes the most relevant treatment for patients with severe paraphilic disorders.Conclusions: An algorithm is proposed with different levels of treatment for different categories of paraphilic disorders accompanied by different risk levels.

Pornography use and sexual aggression: the impact of frequency and type of pornography use on recidivism among sexual offenders.

In this study, we examined the unique contribution of pornography consumption to the longitudinal prediction of criminal recidivism in a sample of 341 child molesters. We specifically tested the hypothesis, based on predictions informed by the confluence model of sexual aggression that pornography will be a risk factor for recidivism only for those individuals classified as relatively high risk for re-offending. Pornography use (frequency and type) was assessed through self-report and recidivism was measured using data from a national database from the Royal Canadian Mounted Police. Indices of recidivism, which were assessed up to 15 years after release, included an overall criminal recidivism index, as well as subcategories focusing on violent (including sexual) recidivism and sexual recidivism alone. Results for both frequency and type of pornography use were generally consistent with our predictions. Most importantly, after controlling for general and specific risk factors for sexual aggression, pornography added significantly to the prediction of recidivism. Statistical interactions indicated that frequency of pornography use was primarily a risk factor for higher-risk offenders, when compared with lower-risk offenders, and that content of pornography (i.e., pornography containing deviant content) was a risk factor for all groups. The importance of conceptualizing particular risk factors (e.g., pornography), within the context of other individual characteristics is discussed.

The admissibility of expert evidence in Canada.

Recent decisions in Canadian Law suggest that it is evolving in a manner heavily influenced by American law. A recent Supreme Court decision uses the framework of prevailing law and superimposes the more stringent criteria enunciated in Daubert v. Merrell Dow Pharmaceuticals, Inc. We trace this development, reviewing the intervening cases that have contributed, and conclude with a summary of the law as it stands today.

On sexual violence.

PURPOSE OF REVIEW: Sexual violence is a multidimensional concept that is not completely understood even within forensic psychiatry. Violent sexual behaviour such as sexually sadistic homicides would be included within the definition, but it is commonly defined more broadly as any deviant sexual behaviour. In this review, the broadest definition of sexual violence is used in order to facilitate the most comprehensive review of scientific articles in the field. RECENT FINDINGS: This review covers sexual violence from the extreme of sexually motivated homicides to sexual violence in Internet crimes. The review can be divided into four subject areas. The first relates to extreme sexual violence such as sexually motivated homicide, the second area refers to Internet sexual offending, the third relates to studies on the characteristics of the perpetrators of sexual offending behaviour and the fourth relates to risk evaluation and the prevalence of sexual violence. SUMMARY: Significant advances have been made in relation to sexual sadism. Deviant sexual behaviour using the Internet is being studied. Significant research advances continue in understanding clinical characteristics of various types of sexual offenders. Other important areas of research relate to meta-analytical studies of sexual offenders.

Long-term follow-up of exhibitionists: psychological, phallometric, and offense characteristics.

Exhibitionism has historically been viewed as more of a nuisance than a serious criminal justice matter. Research has demonstrated that the number of exhibitionists who are detected re-offending is a significant under-representation of the number who actually re-offend. The objective of this study was to extend a previous study conducted on exhibitionists, while attempting to solve the limitations described in that study. Two hundred eight exhibitionists were assessed at a university teaching hospital between 1983 and 1996. Archival data were derived from police and medical files. Results indicated that, over a mean follow-up period of 13.24 years, 23.6, 31.3, and 38.9 percent of exhibitionists were charged with or convicted of sexual, violent, or criminal offenses, respectively. Undoubtedly, this is an under-representation of the true rate, as we have no way of knowing how many exhibitionists re-offended and did not get caught. Nevertheless, in the present investigation, sexual recidivists compared with non-recidivists were less educated, scored higher on the Michigan Alcohol Screening Test (MAST), the Psychopathy Checklist, Revised (PCL-R), and the Pedophile Index. Violent recidivists were also less educated and scored higher on the MAST, PCL-R, and the Pedophile Index, and had accumulated a greater number of prior violent or criminal charges and/or convictions. Criminal recidivists were less educated; scored higher on the MAST, Buss-Durkee Hostility Inventory (BDHI), PCL-R, and Pedophile Index; and had accumulated a greater number of prior sexual, violent, and criminal offenses. Finally, the hands-on sexual recidivists accumulated a greater number of prior violent and criminal charges and or convictions than did the hands-off sexual recidivists.

The World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the treatment of adolescent sexual offenders with paraphilic disorders.

The primary aim of these guidelines was to evaluate the role of pharmacological agents in the treatment of adolescents with paraphilic disorders who are also sexual offenders or at-risk of sexual offending. Psychotherapeutic and psychosocial treatments were also reviewed. Adolescents with paraphilic disorders specifically present a different therapeutic challenge as compared to adults. In part, the challenge relates to adolescents being in various stages of puberty and development, which may limit the use of certain pharmacological agents due to their potential side effects. In addition, most of the published treatment programmes have used cognitive behavioural interventions, family therapies and psychoeducational interventions. Psychological treatment is predicated in adolescents on the notion that sexually deviant behaviour can be controlled by the offender, and that more adaptive behaviours can be learned. The main purposes of these guidelines are to improve the quality of care and to aid physicians in their clinical decisions. These guidelines brought together different expert views and involved an extensive literature research. Each treatment recommendation was evaluated and discussed with respect to the strength of evidence for efficacy, safety, tolerability and feasibility. An algorithm is proposed for the treatment of paraphilic disorders in adolescent sexual offenders or those who are at risk.

Reliability and validity of the DSM-IV-TR and proposed DSM-5 criteria for pedophilia: Implications for the ICD-11 and the next DSM.

We tested the inter-rater reliability and criterion-related validity of the DSM-IV-TR pedophilia diagnosis and proposed DSM-5 pedohebephilia diagnosis in a sample of 79 men who had committed child pornography offenses, contact sexual offenses against children, or who were referred because of concerns about whether they had a sexual interest in children. Participants were evaluated by two independent psychiatrists with an interview and questionnaire regarding demographic characteristics, sexual history, and self-reported sexual interests; they also completed phallometric and visual reaction time testing. Kappa was .59 for ever meeting DSM-IV-TR criteria for pedophilia and .52 for ever meeting the proposed DSM-5 criteria for pedohebephilia. Ever meeting DSM-IV-TR diagnosis was significantly related to self-reported index of sexual interest in children (highest AUC=.81, 95% CI=.70-.91, p<.001) and to indices of sexual interest in children from phallometric testing (AUC=.70; 95% CI=.52-.89; p<.05) or a computerized assessment based on visual reaction time and self-report (AUC=.75; 95% CI=.62-.88; p<.005). Ever meeting the proposed DSM-5 "diagnosis" was similarly related to self-report (AUC=.84, 95% CI=.74-.94, p<.001) and to the two objective indices, with AUCs of .69 (95% CI=.53-.85; p<.05) and .77 (95% CI=.64-.89; p<.001), respectively. Because the pDSM-5 criteria did not produce significantly better reliability or validity results and users are more familiar with the current DSM-5 criteria, we believe these results suggest the revision of DSM-5 and development of ICD-11 could benefit from drawing on the current DSM-5 criteria, which are essentially the same as DSM-IV-TR except for a distinction between having a paraphilia (the interest) and a paraphilic disorder (the paraphilia plus clinically significant distress or impairment).

A comparison of incest offenders based on victim age.

The purpose of the present study was to compare incest offenders (IOs) whose victims include infants or toddlers to IOs with adolescent victims on several variables commonly examined in the sexual offender literature. Participants were 48 men whose youngest victim was less than 6 years of age (younger-victim incest offenders; YVs); and 71 men whose youngest victim was 12 to 16 years of age (older-victim incest offenders (OVs). In general, YVs showed more emotional disturbance and pathology than OVs. Compared with OVs, YVs had a greater history of substance abuse and more current problems with alcohol. In addition, YVs reported significantly poorer sexual functioning and were significantly more psychiatrically disturbed. YVs were also more likely to have a male victim, to have victimized a nephew/niece or grandson/granddaughter, and to have denied their offense(s). It was evident that both the YVs and OVs demonstrated clinically significant difficulty with normal sexual functioning and exhibited deviant sexual arousal.

Osteoporosis associated with the treatment of paraphilias: a clinical review of seven case reports.

Osteoporosis and long-term androgen suppression in the treatment of paraphilias has been documented with surgical castration and the use of gonadotropin-releasing hormone agonists. The literature has suggested that the use of cyproterone acetate (CPA) may be protective against osteoporosis, although there are case reports of osteoporosis in men treated with CPA. This pilot study represents a case series of seven patients diagnosed with severe paraphilias and treated with CPA, leuprolide, or surgical castration. Two of the four patients treated with CPA developed significant osteoporosis, while the other two had normal bone density studies. The remaining three patients, one treated with leuprolide and two with surgical castration, had osteopenia. Based upon the current literature, the finding of significant osteoporosis in two of four patients treated with CPA, but not those treated with leuprolide or castration, is surprising. Monitoring of all patients treated with long-term androgen suppression for osteoporosis is suggested.

Pharmacologic treatment of paraphilias.

The treatment of paraphilias remains a challenge in the mental health field. Combined pharmacologic and psychotherapeutic treatment is associated with better efficacy. The gold standard treatment of severe paraphilias in adult males is antiandrogen treatment with cognitive behavioral therapy. Selective serotonin reuptake inhibitors have been used in mild types of paraphilia and in cases of sexual compulsions and juvenile paraphilias. Antiandrogen treatments seem to be effective in severe paraphilic subjects committing sexual offenses. In particular, gonadotropin-releasing hormone analogs have shown high efficacy working in a similar way to physical castration but being reversible at any time. Treatment recommendations, side effects, and contraindications are discussed.

Can sexual offenders be treated?

There are many misconceptions about sexual offender treatment. This is not only a problem in the lay press and media but is also a problem amongst mental health professionals. In part, this relates to the inadequate teaching about sexual deviation in medical schools and psychiatric residency programs and even in forensic psychiatric fellowships. Other disciplines, such as psychology, have educated mental health professionals in a more balanced way related to the assessment and treatment of sexual offenders but still the understanding, knowledge and acceptance that sexual offender treatment is available, is evidence-based, and is successful as shown in treatment outcome studies is still misunderstood. This review covers the evidence-based studies that support the efficacy of sexual offender treatment.

Developing a clinical typology of dysfunctional anger.

BACKGROUND: This study attempted to validate a clinical typology of dysfunctional anger proposed by DiGiuseppe and Tafrate (2007) using assessment data obtained from 197 participants assessed at an outpatient clinic for anger problems. METHODS: Several self-report scales assessing anger, hostility, impulsivity and aggression, as well as a structured interview regarding anger experience and expression, were administered; Axis I and II comorbidity were assessed using clinical assessment and the SCID-II PQ. RESULTS: We found support for four of the proposed eight types described by DiGiuseppe and Tafrate - Pervasive Dysfunctional Anger, Impulsive Type; Pervasive Dysfunctional Anger, Mixed Type; Impulsive Aggressive Dysfunctional Anger; and Suppressed Dysfunctional Anger - with significant, predicted group differences on self-report measures of anger, aggression, and impulsivity, as well as differences in Axis I and II diagnoses. LIMITATIONS: Patients were rarely assigned to the other four dysfunctional anger types and thus we could not examine the validity of these types. We relied heavily on self-report data. CONCLUSIONS: Anger is a common symptom in outpatient psychiatry clinics. It is associated with both mood and anxiety disorder diagnoses, and often co-occurs with substance use problems. Different types of angry patients will likely require different assessment and treatment approaches.

Familial paraphilia: a pilot study with the construction of genograms.

Biological factors are likely predisposing and modulating elements in sexually deviant behavior. The observation that paraphilic behavior tends to cluster in some families is intriguing and potentially raises questions as to whether shared genetic factors may play a role in the transmission of paraphilia. This pilot study introduces five families in which we found presence of paraphilia over generations. We constructed genograms on the basis of a standardized family history. Results document the aggregation of sexual deviations within the sample of families and support a clinical/phenomenological heterogeneity of sexual deviation. The concept of paraphilia in relation to phenotypic expressions and the likelihood of a spectrum of related disorders must be clarified before conclusions can be reached as to family aggregation of paraphilia based on biological factors.

The role of central and peripheral hormones in sexual and violent recidivism in sex offenders.

Hormonal factors are important in multifactorial theories of sexual offending. The relationship between hormones and aggression in nonhumans is well established, but the putative effect in humans is more complex, and the direction of the effect is usually unclear. In this study, a large sample (N = 771) of adult male sex offenders was assessed between 1982 and 1996. Gonadotrophic (follicle-stimulating hormone and luteinizing hormone) and androgen hormone (total and free testosterone; T) levels were assessed at Time 1, along with indicators of sex drive and hostility. Individuals were observed up to 20 years in the community, with an average time at risk of 10.9 years (SD 4.6). Gonadotrophic hormones correlated positively with self-reported hostility and were better predictors of recidivism than was T (area under the curve (AUC), 0.58-0.63). Self-reported hostility emerged as a partial mediator of this relationship between gonadotrophic hormones and recidivism. These results point to a potentially new area of investigation for hormones and sexual aggression.