A brief unstructured literature review on the history of paraphilias.

This unstructured review is based on a comprehensive literature search leading to a variety of selected studies that summarize the historical development of paraphilias. Firstly, paraphilias in ancient times are discussed. Secondly, the development of paraphilia diagnoses, including current critical aspects, is outlined. Finally, a short description of the development of treatment approaches for individuals with paraphilic disorders and those who commit sexual offenses, including medical and psychotherapeutic approaches as well as online intervention programs, is presented. The destigmatization of people with deviant sexual interest is deemed necessary. However, it is also recommended to always strive for a balance between protecting paraphilic individuals' rights and protecting vulnerable groups to whom paraphilic people can pose a danger.

Factors Associated With Contact Sexual Offending Among a Non-Forensic Sample of Women With Sexual Interest in Children - Results From an Anonymous Online Survey.

This study aimed at assessing the extent to which factors associated with male child sexual offending may also be applicable to women with a self-identified sexual interest in children. Participants (n = 42) took part in an anonymous online survey covering questions about general characteristics, general sexuality, sexual interest in children, and previously-perpetrated contact child sexual abuse. Group comparisons between women who reported committing contact child sexual abuse compared to those who had not were conducted in terms of sample characteristics. Furthermore, the two groups were compared regarding the factors of high sexual activity, use of child abuse material, indication of ICD-11 pedophilic disorder diagnosis, exclusivity of sexual interest in children, emotional congruence with children, and childhood maltreatment. Our results revealed that high sexual activity, indication of ICD-11 pedophilic disorder diagnosis, exclusivity of sexual interest in children, and emotional congruence with children were associated with previous contact child sexual abuse perpetration. We recommend further research on potential risk factors relating to child sexual abuse on the part of women.

Compulsive sexual behavior and paraphilic interests in adults with chronic tic disorders and Tourette syndrome: a survey-based study.

Early research suggested that compulsive sexual behavior (CSB) and paraphilic interests (PI) are more prevalent in adults with primary tic disorders compared to the general population. However, recent data on this topic remain scarce. We conducted an anonymous online survey capturing data on CSB and PI in adult patients with primary tic disorders. We also explored the role of antipsychotic tic medication and the impact of neuropsychiatric comorbidities like attention-deficit hyperactivity disorder and depression. In total, 62 participants (26 females/36 males) completed the survey. The prevalence of CSB and PI were 12.9% and 19.4%, respectively. There was no association with antipsychotic medication nor with symptoms of depression. However, the presence of attention-deficit hyperactivity disorder was associated with a higher prevalence of both CSB and PI. The current results contrast with earlier reports and show that in adults with primary tic disorders, the prevalence of CSB and PI is not overly prominent.

Comparing female- to male-perpetrated child sexual abuse as presumed by survivors - A qualitative content analysis.

BACKGROUND: Female-perpetrated child sexual abuse (CSA) is taboo topic in society and an under-recognized issue in research and mental health care. OBJECTIVE: The aim of the present study was to examine perspectives of individuals surviving female-perpetrated CSA (in parts in addition with male-perpetrated CSA) on the question whether female-perpetrated CSA and its sequelae were considered different compared to male-perpetrated CSA. PARTICIPANTS AND SETTING: The perspectives of 212 survivors of female-perpetrated CSA were captured in a cross-sectional online study. METHODS: Answers to the questions "How does female-perpetrated CSA differ from male-perpetrated CSA?" and "How do consequences of female-perpetrated CSA differ from those of male-perpetrated CSA?" were analyzed using qualitative content analysis. RESULTS: The analyses reveal ten categories of differences, such as a more subtle approach, different levels of violence, and more psychological manipulation. Further, the analyses suggest ten categories of different personal consequences, such as less belief and support, more psychological sequelae, and disturbed relationships with women. CONCLUSIONS: Approaches to raise awareness about gender stereotypes in the context of CSA are needed and special needs of survivors of female-perpetrated CSA in psychotherapeutic treatment can be derived from the results of this study.

What do women with sexual interest in children tell us about the assumed cause of their sexual interest in children, (non-)disclosure, and professional help?-Results of a qualitative content analysis.

Research on women with sexual interest in children is still rare, especially regarding women's own theories about the cause of their sexual interest in children, their experiences with (non-)disclosure, and professional help. In the context of a broader online study, we provided 50 women with a sexual interest in children under the age of 14 years (mean age: 33.6, SD = 11.1) with open questions regarding their own theories about what causes their sexual interest in children, experiences with disclosure and non-disclosure, and experiences with and opinions about professional help. Analyses were conducted using an inductive qualitative content analysis method that aimed at ordering and structuring manifest and latent content by categorizing qualitative data. Results revealed that participants mainly think that past experiences caused their sexual interest in children (Σ = 16), e.g., abusive or non-abusive sexual experiences during childhood. Some participants think that their sexual interest in children is a disposition they were born with (Σ = 8). Disclose of sexual interest in children to another person was reported by 56.0% of the present sample and led to rather positive consequences (Σ = 24, e.g., acceptance or support). Those who did not disclose (44.0%) mainly did so due to fear of rejection and/or stigmatization (Σ = 24). A total of 30.0% already sought help due to their sexual interest in children and frequently reported negative experiences (Σ = 15). A frequent statement participants made on how to reach women with sexual interest in children in order to offer professional help was the destigmatization of sexual interest in children (Σ = 14). We recommend that women with sexual interest in children should be taken more seriously among research and in prevention measures.

Changing or stopping testosterone-lowering medication in men convicted of sexual offenses: clinical evaluation of the COSTLow-R Scale.

BACKGROUND: Individuals convicted of a sexual offense (ICSO) can be treated with testosterone-lowering medication (TLM) in order to support the control of paraphilic sexual fantasies and to decrease the risk of sexual recidivism. However, due to partly severe side effects, TLM should not be a lifelong treatment. AIM: The aim of the current study was to further evaluate the Change or Stop Testosterone-Lowering Medication (COSTLow)-R Scale in forensic outpatient aftercare practice. The scale was developed to assist forensic professionals in deciding on whether to change or stop TLM treatment in ICSO. METHODS: The COSTLow-R Scale was applied retrospectively in a forensic-psychiatric outpatient institution in Hesse, Germany, on 60 ICSO. TLM was terminated in 24 patients (40%). Moreover, 10 forensic professionals of the institution as well as an experienced working group within the institution focusing on the treatment of ICSO, qualitatively evaluated the COSTLow-R Scale by participating in an open designed survey. OUTCOMES: The COSTLow-R Scale ratings as assessed by forensic professionals were collected. In addition, a survey was performed among these professionals about the usefulness of the scale and their practical experiences with it. RESULTS: A binary logistic regression analysis was conducted to ascertain the predictive power of the scale regarding the stopping of TLM. Three items of the COSTLow-R Scale significantly predicted stopping decisions: the possibility of psychotherapy before TLM treatment, psychopathic traits, and a substantial decrease of paraphilic severity. Thus, a decision towards stopping TLM was more likely for patients who showed greater treatment readiness before starting TLM, lower psychopathy scores, and a higher decrease of paraphilic severity. The forensic professionals described the scale as a good and structured tool that displays which aspects are important to consider during TLM treatment decisions. CLINICAL IMPLICATIONS: The COSTLow-R Scale provides structure to the decision of whether to change or stop TLM and should thus be implemented in the forensic treatment process of patients with TLM more frequently. STRENGTHS AND LIMITATIONS: Although the small sample size limits generalizability of the findings, the present study was conducted directly in a forensic outpatient practice and, therefore, has high external validity and a strong impact on the life and health of patients treated with TLM. CONCLUSION: The results indicate that the COSTLow-R Scale can be a useful instrument facilitating the TLM decision-making process by providing a structured compendium of criteria. Further research is still needed to evaluate the scale and to provide additional evidence for the results of the current study.

Women with Sexual Interest in Children - Results from an Online Survey Among a Non-Forensic Female Sample.

Little research has examined adult women's sexual interest in children, particularly in non-forensic samples. We aimed to describe characteristics of women with sexual interest in children by recruiting 52 women (mean age: 33.2 years) who have a self-identified sexual interest in children under the age of 14 years into an anonymous online self-report study. Measures of interest referred to general characteristics (e.g., age, education level), general sexuality (e.g., sexual orientation, masturbation), and sexual interest in children (e.g., exclusivity, motivation to change). Results showed that women with sexual interest in children are similar to non-forensic samples of men with sexual interest in children in previous studies and rather differ from women from the general population regarding the investigated characteristics in this study. Our results clearly indicate that women with sexual interest in children need to be taken into account in future research and clinical practice. Treatment programs preventing sexual offenses against children or the consumption of abuse material need to explicitly address females as well.

Acceptance of Sexual Interest in Minors in Self-Referred Individuals Under Treatment - An Exploratory Pilot Study.

Some therapists/scientists argue that "acceptance" of sexual interest in minors (SIM), i.e., the integration of the sexual preference into the individual self-concept, is a prerequisite for dealing with SIM in a responsible way. However, if one assumes that - even in some persons - SIM might change over time, "acceptance" could also run counter to therapeutic targets because the motivation to change as well as the specific self-efficacy for modifying SIM might be reduced. This exploratory pilot study analyzes the relationship between acceptance of SIM and (1) dynamic risk for contact sexual reoffending, (2) SIM and frequency of the use of child/adolescent (sexual abuse) imagery, (3) frequency of sexual desire/behavior toward children/adolescents, and (4) the change of the level of acceptance of SIM during the course of treatment. The majority of the participants (N = 79) was not exclusively interested in children (85%) and used child pornography but did not commit child sexual abuse (54%). Acceptance of SIM, frequency of the use of child/adolescent (sexual abuse) imagery and frequency of sexual desire/behavior toward children/adolescents are assessed via self-report questionnaires, dynamic risk for contact sexual reoffending is measured by STABLE-2007. Pretreatment data are analyzed via Spearman's correlation (N = 79). Intragroup analysis compares acceptance of SIM from pre- and posttreatment (n = 35). There was no correlation between acceptance of SIM and dynamic risk for contact sexual reoffending. However, there was a medium, positive correlation between acceptance of SIM and the frequency of the use of legal imagery of children, a positive correlation between the item "My inclination is an integral part of my personality" and the frequency of the use of legal imagery of children, and a positive correlation between acceptance of SIM and the frequency of sexual activities with minors. Acceptance of SIM did not change during the course of treatment. The results suggest that "acceptance" of SIM has to be discussed in a differentiated way, i.e., as possibly being associated with positive and negative outcomes as well.

[Lifetime prevalences of nonconsensual sexual intercourse and touch and associations with health-related factors : Results from the German Health and Sexuality Survey (GeSiD)]. / Lebenszeitprävalenz des Erlebens von Sex und sexueller Berührung gegen den eigenen Willen sowie Zusammenhänge mit gesundheitsbezogenen Faktoren : Ergebnisse aus der Studie Gesundheit und Sexualität in Deutschland (GeSiD).

BACKGROUND: In the last decade, the negative effects of sexual violence on health have again become a focus of health policies worldwide. So far, representative population data on lifetime prevalence for different age groups and specific links to health-related factors for Germany are lacking. OBJECTIVES: The study aimed to assess 1) the lifetime prevalence of self-reported nonconsensual sexual intercourse and sexual touch in childhood and across the lifespan and 2) associations with health-related factors. MATERIALS AND METHODS: Using a two-step stratified, randomized sample of residents' registration offices, 4955 persons aged 18 to 75 years were interviewed within the scope of the nationwide scientific survey on health and sexuality in Germany (GeSiD). The associations between experiences of sexual violence and socio-demographic and health-related factors were age-adjusted and stratified for gender using logistic regression. RESULTS: For women, the lifetime prevalence of (attempted/completed) nonconsensual intercourse was 14.9% and in the form of (attempted/completed) nonconsensual sexual touching was 40.8%; for men the prevalences were 3.1% and 13.2%, respectively. Regarding forced experiences in childhood, the prevalence of sex was 2.1% and of sexual touching was 7.5%. For both genders, the prevalence of nonconsensual intercourse was significantly higher in the case of low quality of life, poor health condition, a chronic illness or disability, or treatment for depression or for another mental disorder. CONCLUSIONS: The results illustrate the strong links between sexual violence and mental and somatic health. This points to the urgency to routinely explore experiences of sexual aggression.

The role of stigmatization in developing post-traumatic symptoms after experiencing child sexual abuse by a female perpetrator.

Background: The context in which individuals are exposed to child sexual abuse (CSA) and reactions to the disclosure of such abuse experiences play a major role in post-traumatic mental health. Female-perpetrated CSA is an under-recognized issue in society and mental health care, and is therefore supposed to be a breeding ground for stigmatization. Objective: The aim of the current study was to examine the mediating role of internalized and anticipated stigma on the effects of so-called victim-blaming experiences and the perception of abuse in the childhood of survivors of female-perpetrated CSA on their post-traumatic symptom severity. Method: A total of 212 individuals who reported experiences of female-perpetrated CSA were assessed in an anonymous online survey. The International Trauma Questionnaire (ITQ) served as the primary outcome parameter for detecting differences in post-traumatic symptom severity within mediation analyses, where victim-blaming and abuse awareness served as predictors and anticipated as well as internalized stigma served as mediator variables. Results: Internalized stigma fully mediated the deteriorating effect of victim-blaming on post-traumatic symptom severity, while abuse awareness and anticipated stigma showed no statistically significant effects as predictor and mediator variables. Yet, victim-blaming had a significant increasing effect on anticipated stigma. Conclusions: Efforts to enhance awareness of female-perpetrated CSA in society are needed and mental health care professionals should pay attention to the adverse effects of victim-blaming and internalized stigma on post-traumatic symptoms in individuals affected by female-perpetrated CSA.

Antecedentes: El contexto en el cual los individuos están expuestos al abuso sexual infantil (ASI) y a las reacciones luego de revelar tales experiencias de abuso desempeñan un papel importante para la salud mental postraumática. El problema del ASI perpetrado por una mujer es poco reconocido por la sociedad y dentro de los cuidados de salud mental y, por lo tanto, se asume que es un terreno fértil para la estigmatización. Objetivo: El objetivo de este estudio fue el evaluar el papel mediador del estigma internalizado y anticipado sobre los efectos de las denominadas experiencias de culpabilización a la víctima; además, evaluar la percepción de los sobrevivientes al ASI perpetrado por una mujer sobre la severidad de sus síntomas postraumáticos. Método: Se evaluó a 212 individuos que experimentaron ASI perpetrado por una mujer mediante una encuesta anónima en línea. El Cuestionario Internacional de Trauma (ITQ por sus siglas en inglés) sirvió como el parámetro de resultado principal para detectar diferencias en la severidad de los síntomas postraumáticos dentro de los análisis de mediación, donde la culpabilización a la víctima y la conciencia del abuso sirvieron como predictores y el estigma anticipado e internalizado sirvieron como variables mediadoras.Resultados: El estigma internalizado medió completamente el efecto de deterioro que la culpabilización a la víctima ejerce sobre la severidad de los síntomas postraumáticos, mientras que la conciencia del abuso y el estigma anticipado no mostraron efectos estadísticamente significativos como variables predictoras ni mediadoras. Sin embargo, la culpabilización a las víctimas generaba un incremento cada vez mayor del estigma anticipado.Conclusiones: Se necesitan esfuerzos para aumentar la conciencia sobre el ASI perpetrado por una mujer en la sociedad; los profesionales de la salud mental deben prestar atención a los efectos adversos que la culpabilización a la víctima y el estigma internalizado ejercen sobre los síntomas postraumáticos en las personas afectadas por el ASI perpetrado por una mujer.

Hypersexuality and Impulsivity in Self-Referred Men With Sexual Interest in Minors: Are They Related? Do They Change During Treatment? An Exploratory Pilot Study.

INTRODUCTION: Studies on characteristics of self-referred men with sexual interest in minors (SIM) and treatment approaches in this group of patients are still relatively rare. AIM: The aim of this exploratory pilot study was to investigate hypersexuality and impulsivity as 2 dynamic risk factors that could possibly change during treatment in self-referred men with SIM. METHODS: Data were collected at the "Kein Täter Werden (means: not become an offender)" network site in Hamburg. Using self-report questionnaires, the extent of hypersexuality and impulsivity was analyzed with the samples' pretreatment data via descriptive statistics and compared with nonclinical samples of other studies. The relation between hypersexuality and impulsivity was analyzed via Spearman's correlation coefficient with pretreatment data (N = 77). Intragroup analysis compared hypersexuality and impulsivity from pre- and posttreatment (n = 29). MAIN OUTCOME MEASURES: Hypersexual Behavior Inventory and Barratt Impulsiveness Scale Version 11. RESULTS: The degree of generalized impulsivity in the SIM group was comparable to that in nonclinical samples while the degree of hypersexuality was considerably higher than in nonclinical samples. Sixty-four percent of the participants were in the range of clinically relevant hypersexuality. Impulsivity and hypersexuality were weakly positively correlated with each other. During treatment hypersexuality significantly decreased while impulsivity did not differ significantly between before beginning treatment and after (partial) completion. CONCLUSION: Hypersexuality, but not impulsivity, was pronounced in the group of self-referred men with SIM and should be targeted in treatment. In order to improve treatment outcome regarding risk reduction in self-referred men with SIM, a focus on treatment approaches that were developed to treat hypersexuality can be expected to be effective while focusing on generalized impulsivity may be less relevant. Lampalzer U, Tozdan S, von Franqué F, et al. Hypersexuality and Impulsivity in Self-Referred Men With Sexual Interest in Minors: Are They Related? Do They Change During Treatment? An Exploratory Pilot Study. Sex Med 2021;9:100429.

Sexual aggression against males: Differences between acts by males and females - Results from the German Health and Sexuality Survey (GeSiD).

BACKGROUND: Current research examining sexual aggression against males is rare and representative studies often do not sufficiently differentiate between male and female affected persons, male and female offending person, as well as between different types of sexual aggression. OBJECTIVE: We investigated the prevalence of sexual aggression against males perpetrated by males and females distinguished by the type of sexual aggression and examined differences between sexual aggression against males committed by males and females in characteristics of the sexual aggression. PARTICIPANTS AND SETTING: We examined representative self-report data collected in the German Health and Sexuality Survey (GeSiD; n = 4,955). A total of 305 male participants (12.3 % of all male participants) experienced at least one incident of sexual aggression. METHOD: We investigated differences between characteristics of male- and female-perpetrated sexual aggression against males in cases of (1) sexual aggression against minors by adults, (2) sexual aggression among minors/peers, and (3) sexual aggression among adults. Characteristics of sexual aggression included were frequency, relation of accused person, disclosure, participant's age at first incident, and accused person's age at first incident. RESULTS: Our results revealed that the proportion of sexual aggression by females against males is rather low in cases of sexual aggression against minors by adults (9 %) compared with sexual aggression among minors/peers (56 %) and among adults (52 %). Although the majority of characteristics of sexual aggression were similar, some differences between male- and female-perpetrated sexual aggression were found. CONCLUSIONS: Sexual aggression against males appears to be an under-researched phenomenon, especially when it is perpetrated by a female person. More research on sexual aggression against males as well as on the differences between male- and female-perpetrated sexual aggression is therefore considered necessary.

Referral for group or individual treatment? Factors for consideration in the case of self-referred individuals with a sexual interest in minors.

In Germany, several treatment programs offer psychotherapy for individuals with a sexual interest in minors (SIM) who are currently not in contact with the criminal justice system. The patients present anonymously in relation to the health insurance and judicial system. Group therapy plays an important role in these programs. However, to date there is poor empirical evidence on indication criteria for group vs. individual treatment for this specific group of individuals. This study examined individuals with SIM who voluntarily participated in a treatment program in Hamburg. We investigated via post-hoc analysis whether there were significant differences regarding readiness to participate in group therapy, dynamic risk factors, psychopathic characteristics, impulsivity and empathy between individuals indicated for group therapy (n = 26) and individuals referred for individual therapy (n = 47). Results show that individuals referred for individual therapy were significantly more impulsive than individuals referred for group therapy, but comparable in respect to readiness to participate in group therapy, dynamic risk, psychopathy, and empathy. These findings suggest that assignment to group vs. individual therapy is mainly based on other criteria than these characteristics. Implications for clinical practice and future research are discussed.

Sexual Interest in Children Among Women in Two Nonclinical and Nonrepresentative Online Samples.

INTRODUCTION: Regarding women, little research is available about the prevalence of sexual interest in children (SIC), especially in nonclinical samples. AIM: The present study aimed to investigate the extent to which adult women from 2 nonclinical and nonrepresentative samples indicate sexual interest in prepubescent and/or pubescent children. METHODS: Participants took part in an online survey either via general websites or via websites directed toward individuals with a SIC. MAIN OUTCOME MEASURES: The self-report survey included questions about the use of online abuse material including children and teenagers as well as about sexual fantasies involving prepubescent and pubescent children. Both measures were included as main outcome measures. RESULTS: Results showed that few women reported having used online abuse material including children (total sample: n = 7 [0.8%], general websites: n = 3 [0.4%], SIC websites: n = 4 [9.5%]) or teenagers (total sample: n = 44 [5.0%], general websites: n = 37 [4.4%], SIC websites: n = 7 [16.7%]). Results further revealed that some women reported sexual fantasies involving prepubescent (total sample: n = 98 [7.0%], general websites: n = 92 [6.8%], SIC websites: n = 6 [11.1%]) or pubescent children (total sample: n = 136 [9.6%], general websites: n = 129 [9.5%], SIC websites: n = 7 [13.0%]). CONCLUSIONS: The samples included are nonrepresentative and therefore not generalizable to the female population. Nevertheless, they strongly suggest that SIC is a phenomenon also found in women. We therefore recommend professionals in the field of sexual medicine to increase their attention and engagement for women with SIC. Based on the present results, the development of preventive treatment services specifically tailored to women with a SIC has to be strongly encouraged in the near future. Tozdan S, Dekker A, Neutze J, et al. Sexual Interest in Children Among Women in Two Nonclinical and Nonrepresentative Online Samples. Sex Med 2020;8:251-264.

@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.

Uncovering Female Child Sexual Offenders-Needs and Challenges for Practice and Research.

This article provides a short literature overview on female child sexual offenders (FCSO) focusing on the discrepancy between prevalence rates from different sources, characteristics of FCSO and their victims, as well as the societal "culture of denial" surrounding these women. FCSO are a powerful social taboo. Even professionals in the healthcare or justice system were shown to respond inappropriately in cases of child sexual abuse committed by women. As a result, offences of FCSO may be underreported and therefore difficult to research. The lack of scientific data on FSCO lowers the quality of child protection and treatment services. We therefore deem it particularly necessary for professionals in health care to break the social taboo that is FCSO and to further stimulate research on the topic of FCSO. We provide some general implications for professionals in health care systems as well as specific recommendations for researchers. We end with an overall conclusion.

Validation of the Change or Stop Testosterone-Lowering Medication (COSTLow) Scale Using the Delphi Method Among Clinical Experts.

Guidelines for pharmacological treatment of patients with paraphilic disorders have been developed by a working group of the World Federation of Societies of Biological Psychiatry (Thibaut et al., 2010 ). With an increasing duration of experience and number of treated patients as well as aging patients, change of or withdrawal from testosterone-lowering medications (TLM) has become an important issue. The current study aimed to assess the quality of a structured professional judgment procedure that helps switching or discontinuing TLM in patients with paraphilic disorders. We used the Delphi method to estimate the quality of 10 factors originally proposed by the authors. A total of 30 experts participated in the first stage; 18 experts participated in the second stage. The experts' assessment resulted in an instrument of 15 factors that can be used to structure the process of changing or discontinuing TLM. These factors can be grouped into five broader categories: age and duration of treatment; therapeutic alliance; psychopathology and risk factors; motivation; and compliance and level of control. The developed COSTLow-R Scale provides an instrument that can be used to structure the process of changing or discontinuing TLM in patients with severe paraphilic disorders.