Approach and Avoidance Biases Toward Sexual Stimuli and Their Association with the Dual Control Model of Sexual Response in Heterosexual Men.

Many models of human behavior work in an interaction of a dual system. While one system usually represents controlled and reflective behavioral responses, the other system reflects automatic and impulsive actions. In the impulsive system, positive stimuli initiate approach reactions and negative cues avoidance reactions. Besides stimulus valence, the behavioral response triggered by the impulsive system is influenced by personality (e.g., the propensity to react with approach or avoidance biases in a specific situation). The present study applied a computerized Approach-Avoidance Task (AAT; Rinck & Becker, 2007) to assess automatic behavioral approach and avoidance biases toward sexual and neutral stimuli in heterosexual men (N = 40). Individual AAT-performance was furthermore related to sexual excitation (SES) and the two sexual inhibition factors (SIS1 and SIS2) as proposed by the Dual Control Model of sexual response (Bancroft & Janssen, 2000). Against our hypotheses, participants did not show a stronger approach bias toward sexually preferred (i.e., images of women) than sexually not preferred stimuli (i.e., images of men or children). However, stronger approach biases toward images of women were positively associated with sexual excitation and negatively correlated with sexual inhibition due to a threat of performance failure (SIS1) even after controlling for potential confounds (i.e., general behavioral activation and inhibition). The results support the importance of the influence of dispositional traits measured with the Dual Control Model of sexual response on approach and avoidance biases toward sexually preferred stimuli in heterosexual men.

Virtual reality applications for diagnosis, risk assessment and therapy of child abusers.

Despite the successful application of virtual reality (VR) in a wide variety of mental disorders and the obvious potentials that VR provides, the use of VR in the context of criminology and forensic psychology is sparse. For forensic mental health professionals, VR provides some advantages that outrun general advantages of VR, e.g., ecological validity and controllability of social situations. Most important seems to be the unique possibility to expose offenders and to train coping skills in virtual situations, which are able to elicit disorder-relevant behavior-without endangering others. VR has already been used for the assessment of deviant sexual interests, for testing the ability to transfer learned coping skills communicated during treatment to behavior, and for risk assessment of child abusers. This article reviews and discusses these innovative research projects with regard to their impact on current clinical practice regarding risk assessment and treatment as well as other implementations of VR applications in forensic mental health. Finally, ethical guidelines for VR research in forensic mental health are provided.

Neural correlates of subliminally presented visual sexual stimuli.

In the context of forensic psychiatry, it is crucial that diagnoses of deviant sexual interests are resistant to manipulation. In a first attempt to promote the development of such tools, the current fMRI study focusses on the examination of hemodynamic responses to preferred, in contrast to non-preferred, sexual stimuli with and without explicit sexual features in 24 healthy heterosexual subjects. The subliminal stimulus presentation of sexual stimuli could be a new approach to reduce vulnerability to manipulation. Meaningful images and scrambled images were applied as masks. Recognition performance was low, but interestingly, sexual preference and explicitness modulated stimulus visibility, suggesting interactions between networks of sexual arousal and consciousness. With scrambled masks, higher activations for sexually preferred images and for explicit images were found in areas associated with sexual arousal (Stoleru, Fonteille, Cornelis, Joyal, & Moulier, 2012). We conclude that masked sexual stimuli can evoke activations in areas associated with supraliminal induced sexual arousal.

Changed processing of visual sexual stimuli under GnRH-therapy--a single case study in pedophilia using eye tracking and fMRI.

BACKGROUND: Antiandrogen therapy (ADT) has been used for 30 years to treat pedophilic patients. The aim of the treatment is a reduction in sexual drive and, in consequence, a reduced risk of recidivism. Yet the therapeutic success of antiandrogens is uncertain especially regarding recidivism. Meta-analyses and reviews report only moderate and often mutually inconsistent effects. CASE PRESENTATION: Based on the case of a 47 year old exclusively pedophilic forensic inpatient, we examined the effectiveness of a new eye tracking method and a new functional magnetic resonance imaging (fMRI)-design in regard to the evaluation of ADT in pedophiles. We analyzed the potential of these methods in exploring the impact of ADT on automatic and controlled attentional processes in pedophiles. Eye tracking and fMRI measures were conducted before the initial ADT as well as four months after the onset of ADT. The patient simultaneously viewed an image of a child and an image of an adult while eye movements were measured. During the fMRI-measure the same stimuli were presented subliminally. Eye movements demonstrated that controlled attentional processes change under ADT, whereas automatic processes remained mostly unchanged. We assume that these results reflect either the increased ability of the patient to control his eye movements while viewing prepubertal stimuli or his better ability to manipulate his answer in a socially desirable manner. Unchanged automatic attentional processes could reflect the stable pedophilic preference of the patient. Using fMRI, the subliminal presentation of sexually relevant stimuli led to changed activation patterns under the influence of ADT in occipital and parietal brain regions, the hippocampus, and also in the orbitofrontal cortex. We suggest that even at an unconscious level ADT can lead to changed processing of sexually relevant stimuli, reflecting changes of cognitive and perceptive automatic processes. CONCLUSION: We are convinced that our experimental designs using eye tracking and fMRI could prospectively add additional and valuable information in the evaluation of ADT in paraphilic patients and sex offenders. But with respect to the limited significance of this single case study, these first results are preliminary and further studies have to be conducted with healthy subjects and patients.

Acceptance of a Web-Based Intervention in Individuals Who Committed Sexual Offenses Against Children: Cross-Sectional Study.

BACKGROUND: Individuals who have committed sexual offenses against children often have difficulties finding treatment, despite its potential effectiveness. Although the development of web-based interventions could enhance therapeutic supply, up to now the acceptance thereof among this target group is unknown. OBJECTIVE: For the first time, this study assesses the acceptance of a web-based intervention among individuals who committed sexual offenses against children and analyzes variables that predict acceptance. Following the Unified Theory of Acceptance and Use of Technology (UTAUT), it is assumed that acceptance of web-based interventions in individuals who have committed sexual offenses against children follows the same mechanisms as for individuals in general psychiatry. METHODS: This cross-sectional study is based on the data from an ongoing clinical trial (@myTabu) evaluating the effectiveness of a web-based intervention in individuals who committed sexual offenses against children (N=113). Acceptance level was measured using a questionnaire based on the UTAUT and modified for the target group. Furthermore, predictors of acceptance from the UTAUT (performance expectancy, effort expectancy, and social influence [SI]), attitudes toward web-based interventions, and internet anxiety were assessed at baseline. RESULTS: Most participants (61.1%, 69/113), reported high acceptance, while 36.3% (41/113) of them indicated moderate acceptance, and 2.7% (3/113) of them expressed low acceptance. In a linear regression model, the predictors explained 41.2% of the variance (F11,101=9.055; P=.01). Attitudes toward web-based interventions (B=0.398, 95% CI 0.16-0.64; P=.001) and SI (B=0.183, 95% CI 0.03-0.38; P=.04) significantly predicted acceptance. Post hoc explorative analysis showed that the participants' belief that people close to them would recommend the use of a web-based intervention is a predictor of acceptance. In contrast, the belief that their community supervisor would recommend the use thereof was not predictive in this respect. CONCLUSIONS: For the participants of this study, we identified high acceptance of web-based interventions for the majority of participants. SI and the participants' attitudes toward web-based interventions were important in predicting acceptance. TRIAL REGISTRATION: German Clinical Trial Registration (DRKS, Deutsches Register Klinischer Studien) DRKS 00021256; https://drks.de/search/de/trial/DRKS00021256.

How to prepare for conversations with children about suspicions of sexual abuse? Evaluation of an interactive virtual reality training for student teachers.

BACKGROUND: Training for child interviewing in case of suspected (sexual) abuse must include ongoing practice, expert feedback and performance evaluation. Computer-based interview simulations including these components have shown efficacy in promoting open-ended questioning skills. OBJECTIVE: We evaluated ViContact, a training program for childcare professionals on conversations with children in case of suspected abuse. PARTICIPANTS AND SETTING: 110 student teachers were divided into four groups and took part either in a two-hour virtual reality training through verbal interaction with virtual children, followed by automated, personalized feedback (VR), two days of online seminar training on conversation skills, related knowledge and action strategies (ST), a combination of both (ST + VR), or no training (control group, CG). METHODS: We conducted a pre-registered, randomized-controlled evaluation study. Pre-post changes on three behavioral outcomes in the VR conversations and two questionnaire scores (self-efficacy and - undesirable - naïve confidence in one's own judgment of an abuse suspicion) were analyzed via mixed ANOVA interaction effects. RESULTS: Combined training vs. CG led to improvements in the proportion of recommended questions (ηp2 = 0.75), supportive utterances (ηp2 = 0.36), and self-efficacy (ηp2 = 0.77; all ps < .001). Both interventions alone improved the proportion of recommended questions (VR: ηp2 = 0.67, ST: ηp2 = 0.68, ps < .001) and self-efficacy (VR: ηp2 = 0.24, ST: ηp2 = 0.65, ps < .001), but not supportive utterances (VR: ηp2 = 0.10, ST: ηp2 = 0.13, both n. s.). CONCLUSIONS: The combination of VR and ST proved most beneficial. Thus, VR exercises should not replace, but rather complement classical training approaches.

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

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

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 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.

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.

Sexual attraction modulates interpersonal distance and approach-avoidance movements towards virtual agents in males.

How does sexual attraction alter social interaction behavior? We examined the influence of sexual orientation on locomotor approach-avoidance behavior and interpersonal distance. We immersed androphilic and gynophilic male subjects into a virtual environment and presented various male and female virtual persons. In the first experiment, subjects took a step forward (approach) or backward (avoidance) in response to the sex of the virtual person. We measured reaction time, peak velocity, and step size, and obtained ratings of sexual attractiveness in every trial. In the second experiment, subjects had to approach the virtual person as if they were to engage in a social interaction. Here, we analyzed interpersonal distance and peak velocity of the approaches. Our results suggest that sexual attraction facilitates the approach response and reduces the preferred interpersonal distance. We discuss our findings in terms of proxemics, current findings in sex research, and the applicability of our novel task in other fields of psychological research.

Prevention of Sexual Child Abuse: Preliminary Results From an Outpatient Therapy Program.

In Germany, access to outpatient treatment services devoted to the prevention of (further) sexual offenses against minors and child sexual exploitation material (CSEM) offenses is often limited. The therapy project "Prevention of Sexual Abuse" tries to fill this gap by providing treatment to patients with a self-reported sexual interest in children and adolescents, irrespective of whether or not they are pedophilic or prosecuted by the legal justice system. Within the project, a treatment manual was developed which specifically addresses dynamic risk-factors in child sexual abusers and CSEM offenders. The treatment manual was conceived to reduce recidivism risk and to contribute to the enhancement of the patients' personal well-being. In this paper, results of the accompanying scientific research are presented: offense-supportive attitudes (N = 23), self-reported CSEM use (N = 10), emotional distress (N = 24), and participants' subjective risk perception of committing (further) sexual offenses (N = 25) reduced during the course of treatment. A reduction of offense-supportive attitudes was further observed from pre-intervention to 1-year follow-up (N = 8). Changes with regard to self-efficacy, quality of life, participants' self-perceived ability to control sexual impulses toward children and adolescents permanently, and several measures assessing different kinds of sexual recidivism did not, however, reach any level of significance. During an average observation period of 2.4 years, six patients confessed to have conducted new sexual exploitation material offenses, while no further sexual abuse cases were reported (N = 19). Due to the used research design and small sample sizes, treatment effects cannot be inferred and external validity is limited. This notwithstanding, results provide first evidence for a relationship between treatment participation and self-reported recidivism and psychological well-being.

@myTabu-A Placebo Controlled Randomized Trial of a Guided Web-Based Intervention for Individuals Who Sexually Abused Children and Individuals Who Consumed Child Sexual Exploitation Material: A Clinical Study Protocol.

Background: There is a high demand for evidence-based and cost-effective treatment concepts for convicted individuals who sexually abused children (ISAC) and individuals who consumed child sexual exploitation material (ICCSEM) under community supervision (CS). The @myTabu-consortium developed a guided web-based intervention for convicted ISAC and ICCSEM under CS consisting of six online modules targeting psychological meaningful risk factors. The study aims to evaluate the effectiveness of this guided web-based intervention in reducing dynamic risk factors and the risk to re-offend compared to a placebo condition. Furthermore, these dynamic risk factors are measured before and after every module to evaluate their individual effectiveness to reduce the respective risk factor as well as risk to re-offend. This clinical trial protocol describes the planned methods as well as the intervention concept. Methods: The methodological design is a placebo controlled randomized add-on trial (N = 582) with follow-ups at 8 points in time. The placebo condition controls for attention and expectation effects and comprises the same amount of modules with a comparable temporal effort as the experimental intervention. The trial is conducted as an add-on to community supervision as usually done. Primary outcomes are dynamic risk factors assessed by self-report risk assessment tools and officially recorded re-offenses. Discussion: To the best of our knowledge, the study is the first to compare the (cost-) effectiveness of a guided web-based intervention for convicted ISAC and ICCSEM under community supervision against a placebo condition. Methodological limitations (e.g., potential ceiling- or volunteers-effects) are discussed. Clinical Trial Registration: German Clinical Trial Register (DRKS 00021256). Prospectively registered: 24.04.2020.

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

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

Behavioral Monitoring of Sexual Offenders Against Children in Virtual Risk Situations: A Feasibility Study.

The decision about unsupervised privileges for sexual offenders against children (SOC) is one of the most difficult decisions for practitioners in forensic high-security hospitals. Facing the possible consequences of the decision for the society, a valid and reliable risk management of SOCs is essential. Some risk management approaches provide frameworks for the construction of relevant future risk situations. Due to ethical reasons, it is not possible to evaluate the validity of constructed risk situations in reality. The aim of the study was to test if behavioral monitoring of SOCs in high-immersive virtual risk situations provides additional information for risk management. Six SOCs and seven non-offender controls (NOC) walked through three virtual risk situations, confronting the participant with a virtual child character. The participant had to choose between predefined answers representing approach or avoidance behavior. Frequency of chosen answers were analyzed in regards to knowledge of the participants about coping skills and coping skills focused during therapy. SOCs and NOCs behavior differed only in one risk scenario. Furthermore, SOCs showed in 89% of all cases a behavior not corresponding to their own belief about adequate behavior in comparable risk situations. In 62% of all cases, SOCs behaved not corresponding to coping skills they stated that therapists focused on during therapy. In 50% of all cases, SOCs behaved in correspondence to coping skills therapists stated that they focused on during therapy. Therapists predicted the behavior of SOCs in virtual risk situations incorrect in 25% of all cases. Thus, virtual risk scenarios provide the possibility for practitioners to monitor the behavior of SOCs and to test their decisions on unsupervised privileges without endangering the community. This may provide additional information for therapy progress. Further studies are necessary to evaluate the predictive and ecological validity of behavioral monitoring in virtual risk situations for real life situations.

Web-Based Health Services in Forensic Psychiatry: A Review of the Use of the Internet in the Treatment of Child Sexual Abusers and Child Sexual Exploitation Material Offenders.

In recent years, web-based health services for a variety of mental disorders have been developed and evaluated. Evidence suggests that guided internet-based therapy can be as effective as conventional face-to-face therapy. In forensic psychiatric practice, few web-based treatments have been implemented up to now. However, to our knowledge, there do not yet exist guided internet-based treatments for child sexual abusers and child sexual exploitation material offenders. This review aims at examining under what conditions patients are most likely to benefit from internet-based treatments. In addition, some computer-based health services in forensic psychiatry will be summarized and their potentials and weaknesses will be discussed. Subsequently, the review focuses on the implications for the development of online treatments for child sexual abusers as well as on a variety of ethical and legal issues that practitioners may encounter during the development, evaluation and delivery of online health services. The review will conclude with proposed quality standards for the development and implementation of web-based interventions for child sexual abusers and child sexual exploitation material offenders. By virtue of the low number of psychotherapists offering therapy to this clientele as well as individual barriers to seeking treatment such as fear of stigmatization, feelings of shame, long access routes, or limited mobility due to physical handicaps, the development of mental eHealth services in this sector could close an important healthcare gap. By increasing the density of supply, more child sexual abusers and child sexual exploitation material offenders would have the chance to engage in treatment and, ultimately, more incidents of sexual assault against minors could be prevented.

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.

Sex attracts - neural correlates of sexual preference under cognitive demand.

Neurofunctional correlates of sexual arousal are of interest in basic research as well as in clinical science. In forensic psychiatry, it is important to use designs which are potentially robust against susceptibility to manipulation or deception. We tested a new design to measure neurofunctional correlates of sexual preference. Twenty-two healthy heterosexual men had to solve a mental rotation task while sexually preferred or non-preferred distractors were presented simultaneously. With this challenging active task, subjects' possibility to manipulate their response to the sexual stimuli should be lower than in easier tasks and in passive designs. Participants needed more time to solve the mental rotation task when distractors of women and girls were presented compared to distractors of men and boys. FMRI-results showed a network of three brain regions which specifically responded to sexually preferred distractors. Female and adult distractors evoked stronger responses than male and child distractors in regions comprising parahippocampal/fusiform gyrus and amygdala/basal ganglia/thalamus, respectively. Women distractors elicited stronger responses in the inferior parietal lobe compared to all other distractors. Specifically, sexually preferred distractors elicited a weaker downregulation than other distractors. We suppose a different emotion regulation with respect to the sexual relevance of the distractors. To our knowledge, this study is the first to show neurofunctional correlates of sexual preference under cognitive demand. Further studies should examine whether this design is more robust against susceptibility to manipulation than others, in order to be applied as a measurement of sexual preference in forensic patients.

Impaired Attentional Control in Pedophiles in a Sexual Distractor Task.

Pedophilic disorder, a subtype of paraphilia, is defined as a recurrent sexual interest in prepubescent children, which is characterized by persistent thoughts, fantasies, urges, sexual arousal, or behavior. Besides a deviant sexual preference, sexual preoccupation was found to be a dynamic risk factor for reoffending. Thus, it is conceivable that sex offenders and especially sex offenders against children have difficulties to control their responses to sexual stimuli. In the current study pedophiles, forensic and non-forensic control subjects had to solve a cognitive task, while sexual distractors were presented simultaneously. This kind of task also requires control functions. Therefore, data were analyzed with respect to attentional control while comparing eye movements toward sexual distractors and toward the cognitive task. We were mainly interested in how early (fixation latency) and late (relative fixation time) attentional processes were allocated to both, the cognitive target stimuli and the sexual distractors. Pedophiles demonstrated significantly lower attentional control in the sexual distractor task than both control groups (non-pedophiles). They showed a shorter fixation latency and longer fixation time for sexual distractors than non-pedophiles. Furthermore, pedophiles demonstrated a longer fixation latency and shorter fixation time for cognitive target stimuli. For classification analyses, an attentional control index (ACI) was built, i.e., the difference between eye movements on cognitive target stimuli and sexual distractors. For the ACI of early attentional processes, i.e., fixation latency, a good classification between pedophiles and non-pedophiles was found. We assumed that the measured attentional control represents inhibitory executive functions, specifically interference control. Further studies should examine if low attentional control in pedophiles is due to low motivation to solve the task or rather to a lack of ability to control attention with respect to sexual and/or neutral distractors. Prospectively, this design could be useful to generate hypotheses about clinical important aspects of controllability, the capacity of self-control, and the severity of a paraphilic disorder.