Timing of peripubertal steroid exposure predicts visuospatial cognition in men: Evidence from three samples.

Experiments in male rodents demonstrate that sensitivity to the organizational effects of steroid hormones decreases across the pubertal window, with earlier androgen exposure leading to greater masculinization of the brain and behavior. Similarly, some research suggests the timing of peripubertal exposure to sex steroids influences aspects of human psychology, including visuospatial cognition. However, prior studies have been limited by small samples and/or imprecise measures of pubertal timing. We conducted 4 studies to clarify whether the timing of peripubertal hormone exposure predicts performance on male-typed tests of spatial cognition in adulthood. In Studies 1 (n = 1095) and 2 (n = 173), we investigated associations between recalled pubertal age and spatial cognition in typically developing men, controlling for current testosterone levels in Study 2. In Study 3 (n = 51), we examined the relationship between spatial performance and the age at which peripubertal hormone replacement therapy was initiated in a sample of men with Isolated GnRH Deficiency. Across Studies 1-3, effect size estimates for the relationship between spatial performance and pubertal timing ranged from. -0.04 and -0.27, and spatial performance was unrelated to salivary testosterone in Study 2. In Study 4, we conducted two meta-analyses of Studies 1-3 and four previously published studies. The first meta-analysis was conducted on correlations between spatial performance and measures of the absolute age of pubertal timing, and the second replaced those correlations with correlations between spatial performance and measures of relative pubertal timing where available. Point estimates for correlations between pubertal timing and spatial cognition were -0.15 and -0.12 (both p < 0.001) in the first and second meta-analyses, respectively. These associations were robust to the exclusion of any individual study. Our results suggest that, for some aspects of neural development, sensitivity to gonadal hormones declines across puberty, with earlier pubertal hormone exposure predicting greater sex-typicality in psychological phenotypes in adulthood. These results shed light on the processes of behavioral and brain organization and have implications for the treatment of IGD and other conditions wherein pubertal timing is pharmacologically manipulated.

Transgender and Gender Diverse Children and Adolescents: Fact-Checking of AAP Policy.

The American Academy of Pediatrics (AAP) recently published a policy statement: Ensuring comprehensive care and support for transgender and gender-diverse children and adolescents. Although almost all clinics and professional associations in the world use what's called the watchful waiting approach to helping gender diverse (GD) children, the AAP statement instead rejected that consensus, endorsing gender affirmation as the only acceptable approach. Remarkably, not only did the AAP statement fail to include any of the actual outcomes literature on such cases, but it also misrepresented the contents of its citations, which repeatedly said the very opposite of what AAP attributed to them.

The Revised Screening Scale for Pedophilic Interests (SSPI-2) May Be a Measure of Pedohebephilia.

INTRODUCTION: The Revised Screening Scale for Pedophilic Interests (SSPI-2) was developed as a screening measure for pedophilia (sexual interest in prepubescent children), but the SSPI-2 items reflect offending against both prepubescent and pubescent children, roughly corresponding to victims under age 15. AIM: We examined whether the SSPI-2 is better interpreted as a measure of pedohebephilia (sexual interest in both prepubescent and pubescent children) by reanalyzing the original SSPI-2 data and reporting its new psychometric properties. METHODS: The sample was comprised of 1,900 men whose clinical assessment data were entered into an archival database. All men in the sample had at least 1 child victim. Phallometric indices based on sexual responses to children relative to adults were used to classify individuals as having pedophilia only, hebephilia only (sexual interest in pubescent children), or pedohebephilia. MAIN OUTCOME MEASURE: The 5 SSPI-2 items were scored based on official file information sent by the referral source and self-disclosures about offending history made during the assessment. RESULTS: The phallometric indices revealed that pedohebephilia was most frequently observed (24%), followed by hebephilia only (16%) and pedophilia only (1%). Classification accuracy analyses suggest that the SSPI-2 may be more appropriately interpreted as a measure of pedohebephilia than hebephilia only; there were too few cases of pedophilia only for classification analysis. Sensitivity, specificity, and positive and negative predictive values are presented to assist users in selecting appropriate SSPI-2 cut-offs. CLINICAL IMPLICATIONS: The SSPI-2 should be interpreted as a measure of pedohebephilia when used in clinical practice or research, and test users should select the most appropriate cut-off score based on their assessment context. Classification accuracy results are modest, and the scale may be most appropriately used in research or as a screening measure. STRENGTHS & LIMITATIONS: The study used a comprehensive clinical database with well-validated measures. A limitation is that the dataset did not contain other assessment measures of sexual interest in children, and we were unable to examine if the SSPI-2 could detect pedophilia only due to its low base rate. CONCLUSION: The SSPI-2 may be best conceptualized as a measure of pedohebephilia. Further, there was significant overlap between pedophilia and hebephilia; pedophilia only was rarely observed. Stephens S, Seto MC, Cantor JM, et al. The Revised Screening Scale for Pedophilic Interests (SSPI-2) May Be a Measure of Pedohebephilia. J Sex Med 2019;16:1655-1663.

Age Diversity Among Victims of Hebephilic Sexual Offenders.

Hebephilia refers to sexual interest in pubescent children who are beginning to show early signs of sexual development but are sexually immature. The present study examined the relationship between hebephilia and victim age choice in a sample of 2,238 adult male sexual offenders. On average, offenders were 39 years old at the time of their assessments, and approximately half (48%) were referred by probation or parole offices. Assessment data included self-report, sexual arousal measured by volumetric phallometry, and victims' ages. Results suggested that, similar to pedophilia, hebephilia had a medium sized association with a greater number of victims under age 11 and a small sized association with a greater number of victims ages 11 to 14. Unlike pedophilia, a small positive association was consistently found between hebephilia and a greater number of victims ages 15 or 16. Furthermore, a small positive association was observed between victim age polymorphism and hebephilia and pedophilia. The present results suggested that hebephilia was associated with a greater number of victims age 14 or younger and had similar victim age correlates to pedophiles.

The Relationships Between Victim Age, Gender, and Relationship Polymorphism and Sexual Recidivism.

Victim choice polymorphism refers to victim inconsistency in a series of offenses by the same perpetrator, such as in the domains of victim age, victim gender, and victim-offender relationship. Past studies have found that victim age polymorphic offenders have higher rates of sexual recidivism than offenders against adults only and offenders against children only. Few studies, however, have examined gender and relationship polymorphism, or accounted for the impact of the number of past victims. The present study analyzed the relationship between polymorphism and sexual recidivism, while controlling for the number of victims. The sample consisted of 751 male adult sexual offenders followed for an average of 10 years, 311 of whom were polymorphic (41% of the total sample). The main finding suggested that there was an association between sexual recidivism and age and relationship polymorphism; however, these associations were no longer significant after controlling for the number of victims.

Hypersexuality: A Critical Review and Introduction to the "Sexhavior Cycle".

An empirical review of hypersexuality is timely as "compulsive sexual behavior" is being considered as an impulse control disorder for inclusion in the forthcoming International Classification of Diseases, 11th ed. Specifically, hypersexuality has been conceptualized in the literature as the inability to regulate one's sexual behavior that is a source of significant personal distress. Various theoretical models have been posited in an attempt to understand the occurrence of hypersexuality, although disagreement about these divergent conceptualizations of the condition has made assessment and treatment of hypersexual clients more challenging. Theories of sexual compulsivity, sexual impulsivity, dual control (sexual inhibition/excitation), and sex addiction are critically examined, as are the diagnostic criteria for clinically assessing hypersexuality as a sexual disorder. Our discussion of hypersexuality covers a diversity of research and clinical perspectives. We also address various challenges associated with reliably defining, psychometrically measuring, and diagnosing hypersexuality. Furthermore, literature is reviewed that expresses concerns regarding whether hypersexuality (conceptualized as a disorder) exists, whether it is simply normophilic behavior at the extreme end of sexual functioning, or alternatively is a presenting problem that requires treatment rather than a clinical diagnosis. Following our literature review, we developed the "sexhavior cycle of hypersexuality" to potentially explain the neuropsychology and maintenance cycle of hypersexuality. The sexhavior cycle suggests that, for some hypersexual persons, high sexual arousal may temporarily and adversely impact cognitive processing (cognitive abeyance) and explain a repeated pattern of psychological distress when interpreting one's sexual behavior (sexual incongruence). We also suggest that further research is required to validate whether hypersexuality is a behavioral disorder (such as gambling), although some presentations of the condition appear to be symptomatic of a heterogeneous psychological problem that requires treatment.

An Online Assessment of Personality, Psychological, and Sexuality Trait Variables Associated with Self-Reported Hypersexual Behavior.

"Hypersexual" behavior represents a perceived inability to control one's sexual behavior. To investigate hypersexual behavior, an international sample of 510 self-identified heterosexual, bisexual, and homosexual men and women completed an anonymous online self-report questionnaire battery. In addition to age and sex (male), hypersexual behavior was related to higher scores on measures of sexual excitation, sexual inhibition due to the threat of performance failure, trait impulsivity, and both depressed mood and anxiety. In contrast, hypersexual behavior was related to lower scores on sexual inhibition due to the threat of performance consequences. Higher neuroticism and extraversion, as well as lower agreeableness and conscientiousness, also predicted hypersexual behavior. Interestingly, interactions among the variables assessed did not significantly predict hypersexual behavior, suggesting the possible existence of multiple and predominantly independent taxa for various persons reporting hypersexual behavior. Core personality features may also be present in persons with hypersexual behavior. Clinical implications and future research directions are discussed.

Evidence of Construct Validity in the Assessment of Hebephilia.

Hebephilia refers to a persistent intense sexual interest in pubescent children. Although not as widely studied as pedophilia, studies of hebephilia have indicated convergence in self-report and sexual arousal. The present study expanded on previous work by examining convergent and divergent validity across indicators of hebephilia that included self-report, sexual behavior, and sexual arousal in a sample of 2238 men who had sexually offended. We included men who denied such interest and specifically examined the overlap between hebephilia and pedophilia and examined pedohebephilia (i.e., sexual interests in both prepubescent and pubescent children). Results indicated that there was considerable convergence across indicators of hebephilia. The results suggested poor divergent validity between hebephilia and pedophilia, as there was substantial overlap between the two constructs across analyses. Finally, a distinct pattern of sexual arousal was found in offenders with pedohebephilia. The results of the present study were discussed with a focus on implications for the assessment of sexual interest in children and the conceptualization of pedohebephilia.

The Revised Screening Scale for Pedophilic Interests (SSPI-2): Development and Criterion-Related Validation.

The Screening Scale for Pedophilic Interests (SSPI) is a structured rating scale of four child victim characteristics: number, age, gender, and relationship of victims. Sexual offenders against children who score higher on the SSPI are more likely to be identified as having pedophilic sexual arousal and are more likely to sexually reoffend. Recent research suggests that child pornography offending is a valid and perhaps independent indicator of pedophilia. In this study, we examined whether child pornography offending would add to the criterion-related validity of the SSPI. In the construction sample of 950 offenders with child victims, the SSPI with a fifth item of child pornography (Screening Scale for Pedophilic Interests-2 [SSPI-2]) was significantly associated with phallometrically assessed sexual arousal to children. In a validation sample of 950 offenders with child victims, the SSPI-2 was again related to phallometrically assessed sexual arousal to children, outperforming the original SSPI. We recommend clinicians and researchers use the SSPI-2 as a structured method of assessing pedophilic sexual interests based on offending behavior.

Leg Length Versus Torso Length in Pedophilia: Further Evidence of Atypical Physical Development Early in Life.

Adult men's height results from an interaction among positive and negative influences, including genetic predisposition, conditions in utero, and influences during early development such as nutritional quality, pathogen exposure, and socioeconomic status. Decreased height, reflected specifically as a decreased leg length, is strongly associated with increased risk of poorer health outcomes. Although prior research has repeatedly shown that pedophiles are shorter than nonpedophiles, the largest study to date relied on self-reported height. In the present study, pedophiles demonstrated reduced measured height and reduced leg length as compared with teleiophiles. Given the prenatal and early childhood origins of height, these findings contribute additional evidence to a biological, developmental origin of pedophilia. In addition, the magnitude of this height difference was substantially larger than that found in children exposed to a variety of early environmental stressors, but similar to that seen in other biologically based neurodevelopmental disorders.

Sensitivity and Specificity of the Phallometric Test for Hebephilia.

INTRODUCTION: The phallometric test has been examined most widely in the literature with regard to its ability to detect pedophilia; however, it has become of increasing interest to clinicians and researchers to ascertain to what extent the test accurately detects hebephilia: Whereas pedophilia refers to an adult's sexual interest in prepubescent children (age 10 or younger, on average), hebephilia refers to an adult's sexual interest in pubescent children (ages 11-14, on average). AIM: The aim of this study was to estimate the accuracy of volumetric phallometry in distinguishing pedophilic men and hebephilic men from men who are teleiophilic (primarily sexually interested in adults, age 17 or older). METHODS: A retrospective chart review was conducted on the cumulate database of a large phallometric laboratory and clinic to identify a group of 239 men who committed sexual offenses against extrafamilial adults age 17 or older and a group of 996 men who committed sexual offenses against extrafamilial children age 14 or younger, all of whom professed a greater sexual interest in adults over children. MAIN OUTCOME MEASURES: The sensitivity and specificity of the phallometric test is calculated for its accuracy in distinguishing sexual preferences for children spanning various age ranges. RESULTS: Receiver operator characteristic curves were highly significant for each classification decision: Using its previously established cut-point of +0.25 standard deviation (SD) units, the phallometric test detected hebephilia with a sensitivity and specificity of 70.0% and 90.7%, detected pedophilia with 46.9% and 100%, and detected pedohebephilia with 75.3% and 90.7%. At a new cut-point of +0.0 SD units, the sensitivity and specificity of the test for pedophilia was 71.9% and 95.3%. CONCLUSIONS: Volumetric phallometry significantly distinguishes teleiophilic sex offenders from each of pedophilic, hebephilic, and pedohebephilic sex offenders and can serve as a reliable diagnostic test of sexual age preference among men who deny sexual interest in children.

Patient Characteristics by Type of Hypersexuality Referral: A Quantitative Chart Review of 115 Consecutive Male Cases.

Hypersexuality remains an increasingly common but poorly understood patient complaint. Despite diversity in clinical presentations of patients referred for hypersexuality, the literature has maintained treatment approaches that are assumed to apply to the entire phenomenon. This approach has proven ineffective, despite its application over several decades. The present study used quantitative methods to examine demographic, mental health, and sexological correlates of common clinical subtypes of hypersexuality referrals. Findings support the existence of subtypes, each with distinct clusters of features. Paraphilic hypersexuals reported greater numbers of sexual partners, more substance abuse, initiation to sexual activity at an earlier age, and novelty as a driving force behind their sexual behavior. Avoidant masturbators reported greater levels of anxiety, delayed ejaculation, and use of sex as an avoidance strategy. Chronic adulterers reported premature ejaculation and later onset of puberty. Designated patients were less likely to report substance abuse, employment, or finance problems. Although quantitative, this article nonetheless presents a descriptive study in which the underlying typology emerged from features most salient in routine sexological assessment. Future studies might apply purely empirical statistical techniques, such as cluster analyses, to ascertain to what extent similar typologies emerge when examined prospectively.

Diffusion Tensor Imaging of Pedophilia.

Pedophilia is a principal motivator of child molestation, incurring great emotional and financial burdens on victims and society. Even among pedophiles who never commit any offense,the condition requires lifelong suppression and control. Previous comparison using voxel-based morphometry (VBM)of MR images from a large sample of pedophiles and controls revealed group differences in white matter. The present study therefore sought to verify and characterize white matter involvement using diffusion tensor imaging (DTI), which better captures the microstructure of white matter than does VBM. Pedophilics ex offenders (n=24) were compared with healthy, age-matched controls with no criminal record and no indication of pedophilia (n=32). White matter microstructure was analyzed with Tract-Based Spatial Statistics, and the trajectories of implicated fiber bundles were identified by probabilistic tractography. Groups showed significant, highly focused differences in DTI parameters which related to participants' genital responses to sexual depictions of children, but not to measures of psychopathy or to childhood histories of physical abuse, sexual abuse, or neglect. Some previously reported gray matter differences were suggested under highly liberal statistical conditions (p(uncorrected)<.005), but did not survive ordinary statistical correction (whole brain per voxel false discovery rate of 5%). These results confirm that pedophilia is characterized by neuroanatomical differences in white matter microstructure, over and above any neural characteristics attributable to psychopathy and childhood adversity, which show neuroanatomic footprints of their own. Although some gray matter structures were implicated previously, only few have emerged reliably.

Minor Physical Anomalies as a Window into the Prenatal Origins of Pedophilia.

Evidence is steadily accumulating to support a neurodevelopmental basis for pedophilia. This includes increased incidence of non-right-handedness, which is a result primarily of prenatal neural development and solidified very early in life. Minor physical anomalies (MPAs; superficial deviations from typical morphological development, such as un-detached earlobes) also develop only prenatally, suggesting them as another potential marker of atypical physiological development during the prenatal period among pedophiles. This study administered the Waldrop Physical Anomaly Scale to assess the prevalence of MPAs in a clinical sample of men referred for assessment following a sexual assault, or another illegal or clinically significant sexual behavior. Significant associations emerged between MPA indices and indicators of pedophilia, including penile responses to depictions of children, number of child victims, and possession of child pornography. Moreover, greater sexual attraction to children was associated with an elevated craniofacial-to-peripheral anomalies ratio. The overall sample demonstrated a greater number of MPAs relative to prior samples of individuals with schizophrenia as well as to healthy controls.

Vorarephilia: a case study in masochism and erotic consumption.

Vorarephilia ("vore") is an infrequently presenting paraphilia, characterized by the erotic desire to consume or be consumed by another person or creature. Few data exist on vore though several cases have been reported which appear to be consistent with basic vorarephilic interests. Because this sexual interest cannot be enacted in real life due to physical and/or legal restraints, vorarephilic fantasies are often composed in text or illustrations and shared with other members of this subculture via the Internet. Similarities with aspects of bondage/dominance sadomasochism interests, more specifically dominance and submission, are noted. The current case report describes a man with masochistic sexual interests which intersected with submissive vorarephilic fantasy.

Specificity of sexual arousal for sexual activities in men and women with conventional and masochistic sexual interests.

Prior studies consistently report that men's genital responses correspond to their sexual activity interests (consenting vs. coercive sex) whereas women's responses do not. For women, however, these results may be confounded by the sexual activities studied and lack of suitable controls. We examined the subjective and genital arousal responses of men and women with conventional (22 men and 15 women) or masochistic sexual interests (16 men and 17 women) to narratives describing conventional sex or masochistic sex. The aims of the studies were twofold: (1) to examine whether gender differences in the specificity of sexual arousal previously observed for gender also exist for sexual activity interests; and (2) to examine whether men and women with masochistic sexual interests demonstrate specificity of sexual response for their preferred sexual activities. Surprisingly, the pattern of results was very similar for men and women. Both men and women with conventional sexual interests (WCI) reported more sexual arousal, and responded more genitally, to conventional than to masochistic sex, demonstrating specificity of sexual arousal for their preferred sexual activities. Despite showing specificity for conventional sexual activities, the genital responses of WCI were still gender nonspecific. In contrast, women and men with masochistic sexual interests demonstrated nonspecific subjective and genital responses to conventional and masochistic sex. Indices of genital and subjective sexual arousal to masochistic versus conventional stimuli were positively and significantly correlated with self-reported thoughts, fantasies, interests, and behaviors involving masochism. The results suggest that gender similarities in the specificity of sexual arousal for sexual activity exist despite consistent gender differences in the specificity of sexual arousal for gender.

Elevated rates of atypical handedness in paedophilia: theory and implications.

Multiple factors determine handedness including genetics, prenatal stress and post-natal environmental conditions. Atypical handedness, whether manifest as increased sinistrality or decreased strength of lateral preference, has been noted in a wide variety of populations with neuropathology. Those with atypical sexual preferences, specifically paedophilia, also manifest reduced rates of right-handedness. This paper uses the largest sample of phallometrically assessed men to date to establish the pattern of atypical handedness in paedophilia. Specifically, whereas prior research has largely characterized participants dichotomously as right-handed or non-right-handed and/or used self-report of writing hand, this paper expands upon such reports by using the Edinburgh Handedness Inventory's laterality quotient. Participants' handedness and phallometrically assessed sexual preference were analyzed both as continuous and categorical variables, and the responses of those scoring in the range of ambiguous-handedness were evaluated to ascertain whether they were ambiguously handed or more accurately described as mixed-handed. Results indicated those producing scores in the range of ambiguous-handedness demonstrated response patterns consistent with ambiguous-handedness, rather than mixed-handedness. Paedophiles demonstrated high rates of non-right-handedness primarily manifested as sinistrality, whereas those who had a sexual preference for pubescent children evidenced increased ambiguous-handedness. Results support a view of ambiguous-handedness as less pathological than previously hypothesized, and of a neurodevelopmental origin of paraphilic sexual preferences.

A treatment-oriented typology of self-identified hypersexuality referrals.

Men and women have been seeking professional assistance to help control hypersexual urges and behaviors since the nineteenth century. Despite that the literature emphasizes that cases of hypersexuality are highly diverse with regard to clinical presentation and comorbid features, the major models for understanding and treating hypersexuality employ a "one size fits all" approach. That is, rather than identify which problematic behaviors might respond best to which interventions, existing approaches presume or assert without evidence that all cases of hypersexuality (however termed or defined) represent the same underlying problem and merit the same approach to intervention. The present article instead provides a typology of hypersexuality referrals that links individual clinical profiles or symptom clusters to individual treatment suggestions. Case vignettes are provided to illustrate the most common profiles of hypersexuality referral that presented to a large, hospital-based sexual behaviors clinic, including: (1) Paraphilic Hypersexuality, (2) Avoidant Masturbation, (3) Chronic Adultery, (4) Sexual Guilt, (5) the Designated Patient, and (6) better accounted for as a symptom of another condition.

Is homosexuality a paraphilia? The evidence for and against.

Whether homosexuality should be described as one among many paraphilic sexual interests or an altogether different dimension of sexual interest has long been discussed in terms of its political and social implications. The present article examined the question instead by comparing the major correlates and other features of homosexuality and of the paraphilias, including prevalence, sex ratio, onset and course, fraternal birth order, physical height, handedness, IQ and cognitive neuropsychological profile, and neuroanatomy. Although those literatures remain underdeveloped, the existing findings thus far suggest that homosexuality has a pattern of correlates largely, but not entirely, distinct from that identified among the paraphilias. At least, if homosexuality were deemed a paraphilia, it would be relatively unique among them, taxonometrically speaking.