Pharmacological Interventions in Paraphilic Disorders: Systematic Review and Insights.

(1) Background: Paraphilic disorders, marked by intense sexual fantasies and behaviors, present formidable challenges. This review addresses concerns fueled by scandals and child abuse. Emphasizing paraphilias' complexity, it systematically reviews the pharmacotherapy literature, aiming to enhance understanding and guide future research. (2) Methods: A comprehensive search from 1990 to 2023 across major databases identified 28 relevant English-language studies. Inclusion criteria focused on adult pharmacotherapy for paraphilias, and results were evaluated using the Newcastle-Ottawa Scale. (3) Results: Synthesizing data from selected studies, diverse treatments such as SSRIs and antiandrogens were analyzed, revealing variable effectiveness and side effect profiles. Poor quality of the current literature has been reported. (4) Conclusions: Highlighting the pivotal role of the serotonergic system, this review underscores the efficacy of SSRIs and androgen deprivation therapy. GnRH analog-associated side effects and the importance of a combined assessment approach are discussed. Critical insights contribute to understanding and ethical considerations in paraphilic disorders.

Forensic Implications of the Parasomnias.

Although many sleep-related behaviors are benign, others can result in physical or sexual aggression toward bed partners or others. Individuals who engage in sleep-related violence (SRV) and sexual behavior in sleep (SBS) may face legal sanctions for their behavior. Attorneys or legal decision-makers may call on an expert to evaluate a defendant and opine about the veracity of an alleged parasomnia diagnosis, the criminal responsibility of the defendant, and his risk of violence to others. This article reviews the phenomena of SRV and SBS and guides evaluators in the forensic considerations relevant to parasomnias.

Development of a risk assessment tool for Japanese sex offenders: The Japanese Static-99.

In Japan, sexual offending, especially paraphilic sexual offending, has become a major problem, and approximately 3000 people are arrested for frotteuristic and voyeuristic behavior each year. Considering the repetitive nature of such behaviors, determining the recidivism risk is imperative. Globally, Static-99 is one of the most widely used actuarial risk assessment tools to predict recidivism among sex offenders. However, sexual offending is largely influenced by social and cultural backgrounds, and whether risk factors identified in the West are applicable to other countries is unknown. Therefore, we developed a Japanese version of the Static-99 and examined its reliability and validity with 167 Japanese paraphilic sex offenders. The results showed good internal consistency (Cronbach's alpha coefficient = 0.88) and predictive accuracy (area under the curve = 0.76). The results indicate that the Japanese Static-99 can be used with Japanese sex offenders. Moreover, risk factors identified in the Western context are applicable to Japanese sex offenders despite the different nature and manifestations of their offending.

The Development, Content Validation, and Pilot Testing of the Paraphilic Interests and Disorders Scale.

The prevalence rates of paraphilic interests and disorders in the general population have been understudied, in large part due to the lack of a standardized assessment measure. As a result, the Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 provides little information regarding the prevalence of paraphilic disorders. The present study involved the development of a self-report measure, Paraphilic Interests and Disorders Scale (PIDS), that can be used to assess for the eight paraphilic interests/disorders in the DSM-5 for use with general population samples. Study 1 established the content validity of the PIDS using feedback from 22 experts in the field, and recommendations from these experts were utilized to modify the measure. In Study 2, the PIDS was piloted on 100 individuals in the general population, which supported the feasibility of implementation and its limited-efficacy. While the PIDS requires further psychometric support, the current research suggests the PIDS is a promising tool to gather self-report, population-based data on DSM-5 paraphilic interests and disorders.

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

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

Androgens, brain and androgen deprivation therapy in paraphilic disorders: A narrative review.

Sexual delinquency is a global problem where those with paraphilic disorders, such as paedophiles, are more likely to commit and reoffend. Androgen deprivation therapy (ADT) has been suggested as a solution. The objective of this narrative review is to present current information on its risks, benefits and limitations as a treatment for paraphilias. The importance of testosterone in sexual function, the effect of its deficiency by age or by pharmacological treatment (anti-androgens, GnRH agonists and GnRH antagonists) and the effect of testosterone replacement therapy will be reviewed. The relationship between androgens, brain, sexual behaviour and pathophysiology of paraphilic disorders will also be explored. ADT reduces sexual urges, but has adverse effects and, because its reversible nature, it does not ensure less recidivism. Likewise, the research quality of ADT drugs is limited and not enough to support their use. Child sex offenders, and not paraphilic subjects who have not committed assaults, show signs of elevated prenatal exposure to androgens and a higher methylation state of the androgen receptor gene. Sexual behaviour is regulated by subcortical (hypothalamus, brainstem and spinal cord) and cortical structures of the brain, in addition to brain circuits (dopaminergic, serotonergic). Those with paraphilic disorders show abnormalities at these levels that could relate to the risk of sexual offences. In conclusion, androgens represent a significant part of the pathophysiology of paraphilias and therefore, ADT seems promising. Nonetheless, more studies are needed to make definite conclusions about the efficacy of long-term ADT in paraphilic patients.

The Influence of Clinician Gender and Attitudes on Judgments Related to Forensic Considerations in ICD-11 Paraphilic Disorders: An Internet-based Field Study

Aim: This study aimed to identify whether clinicians’ gender, clinical experience, and personal attitudes influenced their perception of criminality of specific sexual behaviours, their judgments about criminal liability if mentally disordered, and the need for treatment as part of criminal settings for those having ICD-11 paraphilic disorders. Method: In a secondary analysis of data only vignettes with the least (do not meet paraphilic disorder diagnostic requirements) and most extreme (met paraphilic disorder diagnostic requirements) descriptions of ICD-11 frotteuristic, coercive sexual sadism, and exhibitionistic arousal patterns and related behavior were randomly presented to participants. A total of 1,101 clinicians rated one to three vignettes (a total of 1,884) answering questions regarding diagnosis, criminal features, and their own attitudes. Results: The ICD-11 diagnostic guidelines were adequately used to distinguish paraphilic disorders from non-pathological arousal patterns.Vignette severity was the most important predictor for clinicians’ determination that a crime was committed. Results showed an interaction of the classification of paraphilic disorders, clinicians’ gender, and personal attitudes with judgments about concepts associated with criminality, criminal liability if a diagnosis was indicated, and the need for treatment in forensic settings. Conclusions: Increased formal education, clinical training about these disorders, and evidence-based treatment guidelines are required to avoid biases that may come from preconceived ideas and personal attitudes. Laws and policies that unnecessarily restrict the treatment of these patients in non-forensic settings—for example, when the individual is distress about the arousal pattern but no crime has been committed—should be examined. (AU)

Objetivo: Se diseñó un estudio con el objetivo de identificar si el género, la experiencia clínica y las actitudes personales de los clínicos influyen en su percepción de la criminalidad de conductas sexuales concretas, sus juicios sobre la responsabilidad criminal en evaluaciones forenses en presencia de un trastorno mental y con la necesidad de tratamiento para aquellos que tienen un trastorno parafílico de la CIE-11. Método: En un análisis secundario de los datos, se presentaron al azar viñetas con una descripción mínima (no cumple con los requisitos diagnósticos para un trastorno parafílico) y una descripción completa (cumple con los requisitos diagnósticos para un trastorno parafílico) de los patrones de excitación froteurismo, sadismo sexual coercitivo, exhibicionismo y conductas relacionadas de la CIE-11. Un total de 1,101 clínicos calificaron de una a tres viñetas (un total de 1,884) respondiendo a preguntas sobre el diagnóstico, las características criminales y sus propias actitudes. Resultados: Las guías diagnósticas de la CIE-11 fueron adecuadamente utilizadas por los clínicos para distinguir los trastornos parafílicos de los patrones de excitación no patológicos. La gravedad de la viñeta fue el predictor más importante para la determinación de los clínicos de que se había cometido un delito. Los resultados mostraron una interacción de la clasificación de los trastornos parafílicos, el género de los clínicos y las actitudes personales con los juicios sobre conceptos asociados con la criminalidad, la responsabilidad criminal en presencia de un trastorno mental y la necesidad de tratamiento en contextos de evaluación forenses. Conclusiones: Se requiere mayor educación formal, entrenamiento clínico sobre estos trastornos y guías de tratamiento basadas en evidencia para evitar sesgos que puedan provenir de ideas preconcebidas y actitudes personales. (AU)

ADHD prevalence in patients with hypersexuality and paraphilic disorders: a systematic review and meta-analysis.

Hypersexuality and paraphilic disorders have been associated with increased ADHD in several studies. To determine the prevalence of ADHD in hypersexuality and paraphilic disorders. Three databases (Medline, Web of Science and Google Scholar) were explored. Using random effects models, we calculated the pooled estimate of ADHD prevalence. The leave-1-out method and subgroup analyses were carried out to identify sources of heterogeneity. Seven studies from three countries (N = 730 patients with hypersexuality) were included (including five US studies). The overall estimate of the prevalence of ADHD in patients with hypersexuality or paraphilic disorders was 22.6% (95% interval: 17-29.4) with high heterogeneity (I2 = 63%). No publication bias was observed according to Egger's test. We found no significant difference in ADHD prevalence between the following subgroups: hypersexuality vs. paraphilic disorders, studies exploring the history of childhood ADHD vs. adult ADHD, US studies vs. others. The French study was a source of heterogeneity with a much lower rate than others (4.5%) but did not significantly change the prevalence estimate. Removing this study increases the prevalence to 25%. We found no association between the year of publication and ADHD prevalence. ADHD is much more frequent in populations with hypersexuality or paraphilic disorders compared to the general population. It should be systematically screened. The subgroup analyses were not sufficient to identify all sources of heterogeneity, other sources should be explored in further studies.

Off-label Uses of Selective Serotonin Reuptake Inhibitors (SSRIs).

Psychiatric drugs have primacy for off-label prescribing. Among those, selective serotonin reuptake inhibitors (SSRIs) are highly versatile and, therefore, widely prescribed. Moreover, they are commonly considered as having a better safety profile compared to other antidepressants. Thus, when it comes to off-label prescribing, SSRIs rank among the top positions. In this review, we present the state of the art of off-label applications of selective serotonin reuptake inhibitors, ranging from migraine prophylaxis to SARS-CoV-2 antiviral properties. Research on SSRIs provided significant evidence in the treatment of premature ejaculation, both with the on-label dapoxetine 30 mg and the off-label paroxetine 20 mg. However, other than a serotoninergic syndrome, serious conditions like increased bleeding rates, hyponatremia, hepatoxicity, and post-SSRIs sexual dysfunctions, are consistently more prominent when using such compounds. These insidious side effects might be frequently underestimated during common clinical practice, especially by nonpsychiatrists. Thus, some points must be addressed when using SSRIs. Among these, a psychiatric evaluation before every administration that falls outside the regulatory agencies-approved guidelines has to be considered mandatory. For these reasons, we aim with the present article to identify the risks of inappropriate uses and to advocate the need to actively boost research encouraging future clinical trials on this topic.

Trastornos parafílicos: caracterización clínica y tratamiento

Introducción: Los trastornos parafílicos son comportamientos sexuales no tradicionales como la actividad sexual con niñas/os, exhibir los genitales a una persona desprevenida u otros. Objetivo: Sistematizar los referentes teóricos que sustentan la caracterización clínica y el tratamiento de los trastornos parafílicos en el mundo y en Cuba. Métodos: La búsqueda bibliográfica se efectuó en las bases de datos PubMed/Medline y ClinicalKey, además, se utilizaron investigaciones cubanas. Resultados: Parafilias es cualquier interés sexual intenso y persistente que no sea el interés en la estimulación genital o caricias preparatorias con parejas humanas fenotípicamente normales, físicamente maduras, con consentimiento; son trastornos parafílicos cuando las parafilias causan distress o deterioro en lo social, laboral u otros. Características clínicas relevantes: predominan en el sexo masculino, existen distorsiones cognitivas, comorbilidad con trastornos por uso de sustancias, trastornos de personalidad y otras. El tratamiento farmacológico abarca inhibidores selectivos de la recaptación de serotonina, en Cuba se usa la sertralina (100-200 mg/día); análogos de la hormona liberadora de hormona gonadotrópica y antiandrógenos, en el país existe el Androcur (50-100 mg/día). Técnicas de psicoterapia cognitivo-conductual útiles: sensibilización cubierta, desarrollo de empatía hacia las víctimas y reestructuración cognitiva. Conclusiones: Clínicamente es imprescindible diferenciar parafilias de trastornos parafílicos, considerados enfermedades mentales, que tienen un curso por lo general crónico, distorsiones cognitivas, cada paciente habitualmente tiene varios tipos de trastornos parafílicos y otras comorbilidades psiquiátricas. En Cuba, para su tratamiento se usa sertralina o androcur y técnicas de la psicoterapia cognitivo-conductual.

Introduction: Paraphilic disorder are non tradicional sexual behaviors like the sexual activity with the boys/girls, to exhibit the genital to an unaware person or others. Objective: To systematize the theoretical bases that sustain the clinical characterization and the treatment of the paraphilic disorder in the world and in Cuba. Methods: The bibliographical search was made in the electronic databases ClinicalKey and PubMed, Cuban investigations were used. Results: Paraphilia is any intense and persistent sexual interest that is not the interest in the genital stimulation or preparatory caresses with a human normal, mature physically, with consenting persons; they are paraphilics disorders when the paraphilia causes distress or deterioration in the social, labor or others. Excellent clinical characteristics: they prevail in the masculine sex, cognitive distortions exist, comorbidities among different types of paraphilics disorders, dysfunctions for use of substances and disorders personality. The pharmacological treatment embraces the selective serotonin reuptake inhibitors, in Cuba the Sertraline is used (100-200 mg/day); analogues of the hormone Gonadotropin-Releasing Hormone Agonists and antiandrogens used in the country Androcur (50-100 mg/day). Technical of cognitive and behavioral psychotherapy: covered sensitization, empathy development toward the victims and cognitive restructuring. Conclusions: Clinically it is indispensable to differentiate the paraphilia of the paraphilics disorders, considered mental illnesses, with generally chronic course and generally comorbid psychiatric. In Cuba, for their treatment it is used the Sertraline or Androcur and technical of cognitive and behavioral psychotherapy.

Impulsive conditions in Parkinson's disease: A pharmacosurveillance-supported list.

BACKGROUND: "Impulse Control Disorders" are behavioral conditions (e.g., gambling, hypersexuality), which are increasingly reported as reactions to dopamine agonists in Parkinson's disease. The Questionnaire for Impulsive-Compulsive Disorders in Parkinson's disease focuses only on 6 behaviors. Nonetheless, impulsivity could affect the entire range of human practices. Because of their heterogeneity and undefined boundaries, it is not clear what conditions should be considered as Impulse Control Disorders. This results in poorly standardized scientific literature and underdiagnosis. OBJECTIVE: We aimed to create a comprehensive list of possible manifestations of drug-induced Impulse Control Disorders in Parkinson's disease and test it on pharmacosurveillance data. METHODS: PubMed was used to identify reviews in English about Impulse Control Disorders in Parkinson's disease. Mentioned conditions were charted and translated to the lexicon of MedDRA, ICD-11, and DSM-5. The relevant MedDRA terms were used to test potential association with dopamine agonists on the FDA Adverse Event Reporting System. RESULTS: 50 reviews published between 2001 and 2020 were identified. 66 conditions were collected as possible Impulse Control Disorders. Pathological gambling, shopping, eating and sexuality, dopamine dysregulation syndrome, hobbyism and punding were the most frequently mentioned, together with leisure activities, body-focused compulsivity, disruptive, impulse control and conduct disorders, and substance abuse. All these conditions were disproportionately reported with dopamine agonists, except for substance abuse. CONCLUSIONS: We defined a potential extended list of ICDs, which, along with its conversion to international taxonomies, can support the identification of drug-induced conditions in pharmacovigilance archives, as well as monitoring processes in clinical practice.

Review of cases, case series and prevalence studies of zoophilia in the general population. / Revisión de casos, series de casos y estudios de prevalencia de zoofilia en la población general.

BACKGROUND: Information about the frequency of zoophilic behaviour in the general population is scarce. OBJECTIVE: To review cases, case series and prevalence studies of zoophilia in adults in the general population. METHODS: A review of publications was carried out in MEDLINE via PubMed, Scopus and the Biblioteca Virtual en Salud [Virtual Health Library] ranging from January 2000 to December 2017. RESULTS: Thirteen papers were reviewed (ten case reports, two case series and one cross-sectional study). Twelve patients were described, the case series totalled 1,556 people and the cross-sectional study included 1,015 participants and reported a prevalence of zoophilic behaviour of 2%. CONCLUSIONS: Information on the prevalence of zoophilic behaviour in the general population is limited. The Internet will probably be a valuable tool for further investigating these behaviours in coming years.

Revisión de casos, series de casos y estudios de prevalencia de zoofilia en la población general / Review of cases, case series and prevalence studies of zoophilia in the general population

RESUMEN Introducción: El conocimiento de la frecuencia de comportamientos zoofílicos en la población general es escaso. Objetivo: Revisar casos, series de casos y estudios de prevalencia de zoofilia en adultos de la población general. Métodos: Se realizó una revisión en las bases de datos de MEDLINE, a través de PubMed, Scopus y la Biblioteca Virtual en Salud de publicaciones desde enero de 2000 hasta diciembre de 2017. Resultados: Se revisaron 13 trabajos (10 informes de casos, 2 series de casos y 1 estudio transversal). Entre los casos se describió a 12 pacientes; las series de casos sumaron a 1.556 personas y el estudio transversal incluyó a 1.015 participantes e informó de una prevalencia de comportamientos zoofílicos del 2%. Conclusiones: Es escasa la información sobre la prevalencia de comportamientos zoofílicos en la población general. Es probable que internet permita investigar mejor estos comportamientos en los próximos años.

ABSTRACT Background: Information about the frequency of zoophilic behaviour in the general population is scarce. Objective: To review cases, case series and prevalence studies of zoophilia in adults in the general population. Methods: A review of publications was carried out in MEDLINE via PubMed, Scopus and the Biblioteca Virtual en Salud [Virtual Health Library] ranging from January 2000 to December 2017. Results: Thirteen papers were reviewed (ten case reports, two case series and one cross-sectional study). Twelve patients were described, the case series totalled 1,556 people and the cross-sectional study included 1,015 participants and reported a prevalence of zoophilic behaviour of 2%. Conclusions: Information on the prevalence of zoophilic behaviour in the general population is limited. The Internet will probably be a valuable tool for further investigating these behaviours in coming years.

ICD-11 Paraphilic Disorders: A South African Analysis of Its Utility in the Medico-Legal Context.

BACKGROUND: In an effort to improve the clinical utility of the ICD-10, the WHO Working Group on the Classification of Sexual Disorders and Sexual Health recommended a new classification of Paraphilic Disorders in the ICD-11 to replace the ICD-10 section on Disorders of Sexual Preference. The proposed classification may have different implications for different countries. AIM: To examine South African national laws and policies, within which Paraphilic Disorders are encountered, and to assess the implications of the new classification. METHOD: A South African working group - representing experts within the disciplines of criminal law, psychiatry, psychology, public health, and criminology - reviewed: (i) national laws affected by reclassification, (ii) current practices in the psycho-legal assessment of sexual offenders, (iii) the implications of the reclassification for assessment and decision-making in forensic practice and other health settings, (iv) specific implications of the reclassification for diagnosis, and (v) implications of the reclassification as it relates to the demographic and sociocultural context of South Africa. OUTCOMES: As a rule, South African courts do not accept the existence of a Paraphilic Disorder on its own to be sufficient grounds to absolve any defendant from criminal responsibility though defence. Nevertheless, a diagnosis such as coercive sexual sadism disorder runs the risk of medicalization of criminal behavior with inappropriate use to mitigate sentences. CLINICAL IMPLICATIONS: The ICD-11 approach is clinically useful in emphasizing that a broad range of sexual behavior fall under the rubric of healthy sexual behavior, but also that compulsive sexual behavior can be pathological. STRENGTHS AND LIMITATIONS: This analysis was conducted by an interdisciplinary expert group, aligning international forensic mental health and national legal constructs in a low-middle income country (LMIC). The analysis is limited by its reliance on expert opinion rather than empirical data. CONCLUSIONS: It is recommended that the ICD-11 includes a cautionary statement for forensic use, highlighting the fact that the mere inclusion of a diagnosis in the ICD-11 does not necessarily have forensic relevance. Artz L, Swanepoel M, Nagdee M, et al. ICD-11 Paraphilic Disorders: A South African Analysis of Its Utility in the Medico-Legal Context. J Sex Med 2021;18:526-538.

Association of ADHD and hypersexuality and paraphilias.

Subjects with ADHD suffer from inattention, hyperactivity, and impulsivity. Clinicians often assume that specific symptoms of ADHD are bound to affect sexual desire by increasing the frequency of hypersexuality. There is a lack of knowledge about the comorbidity between ADHD, hypersexuality, and paraphilias. The aim of this article was to provide a review of the literature on the association of ADHD and hypersexuality and paraphilias and to discuss the screening and the management of these syndromes when associated with ADHD. A systematic review of the literature was performed in PubMed, PsychInfo, and Embase databases. The studies reviewed show that some individuals who suffer from ADHD report hypersexuality and paraphilias, but no clear data emerged supporting the idea that hypersexuality and paraphilias are more frequent in an ADHD population. On the other hand, some studies showed a high prevalence of ADHD in hypersexual and paraphilic subjects. This is the first systematic review of hypersexuality and paraphilias in individuals with ADHD. However, the results are limited by differences in the methodology and measurement instruments for hypersexuality and paraphilias as well as by the small number of studies and the small sample sizes of many studies.

Hypersexuality In A Rape Victim Child

@#Hypersexuality is rare in children. Our case describes a 14-year-old girl who presented with a history suggestive of hypersexuality. She was repeatedly raped and exposed to video pornography at a very young age. Consequently, she became addicted to pleasure during sexual intercourse and actively involved in multiple unprotected sexual intercourses. Management, in this case, was challenging, where early intervention with contraceptive methods and cognitive behavioural therapy were unsuccessful. Subsequently, alternative treatment with Islamic psycho-spiritual therapy combined with conventional therapy resulted in an improvement in her sexual pre-occupation. This case highlights the importance of recognition of hypersexuality, especially among children with a history of sexual abuse as management proofs to be challenging, and requires a multimodal approach to prevent a potentially devastating outcome.

Legal and Policy Considerations in Lebanon Related to Proposals for Paraphilic Disorders in World Health Organization's International Classification of Diseases Manual, 11th Version.

INTRODUCTION: The World Health Organization's general assembly, in its last meeting of May 2019, has approved the suggested changes to the International Classification of Diseases manual, 11th version (ICD-11). Some of the proposed recommendations include the revision of "Disorders of Sexual Preference", now called Paraphilic Disorders, currently listed under the International Classification of Diseases-10 Mental and Behavioural Disorders. AIM: This article presents findings on the analysis of the existing laws and policies that are relevant to paraphilic disorders in Lebanon. METHODS: A literature review of all official and unofficial documents, reports, and articles published on laws and health policies relevant to paraphilic disorders in Lebanon was conducted, including a thorough review on Lebanese laws on that matter. Moreover, interviews with government representatives, including the Ministry of Public Health, the Ministry of Justice, the Ministry of Social Affairs, representatives of Non-Governmental Organizations working in child protection, and mental health professionals from the private and public sector, were conducted. MAIN OUTCOME MEASURE: Covered are (i) the health system in Lebanon including policies and laws related to mental health care provision and relevance to paraphilic disorders, (ii) the legal framework and the mental health evaluation and treatment in the Lebanese criminal justice system: the case of paraphilic disorders, (iii) adjudication of sex offenders in Lebanon, (iv) criminal responsibility relevant to paraphilic disorders, and (v) the relationship between legal and clinical issues for non-forensic health professionals. RESULTS: The treatment of paraphilic disorders would follow the treatment of all mental health conditions in Lebanon as no specific services for paraphilic disorders are available within these health-care systems. Legally, sexual crimes in Lebanon are not judged according to the individual's urges, fantasies, or state of mind, rather are assessed according to the acts committed by the individual. Therefore, an individual diagnosed with a paraphilic disorder is not culpable of any crime should he not act on this disorder by committing acts that fall under the scope of the penal code. An analysis of sexual acts that qualify as crimes reveals that the element of consent is rarely taken into consideration as most sexual crimes are defined as such with reference to violation of social norms, primarily "morals and public morality." Therefore, a change in the diagnostic classification of mental and behavioral disorders (ICD or Diagnostic and Statistical Manual of Mental Disorders) should not be a factor in their definition. Furthermore, in the course of enforcing criminal sanctions on individuals diagnosed with a mental disorder, the determining factor will be the individual's state of awareness at the time of the act. Psychiatric expertise initiated in that context lacks standardized criteria for diagnosis and is not bound by law to rely on international classifications; it is usually based on nonstructured interviews. Should it be assessed that the individual was fully aware of the consequences of his or her act, the paraphilic disorder diagnosis should not play any role in the sentencing. CLINICAL IMPLICATIONS: Clinicians in Lebanon can now be aware of the legal sanctions that patients with paraphilic disorders may fall under, should criminal acts be committed. Clinicians can also be familiar with the role of mental health disorders in the legal system, specifically with relevance to "awareness" at the time of the criminal act. Moreover, clinicians can freely use the updated diagnoses of paraphilic disorders in the ICD-11, as they form no legal detriments in Lebanon. STRENGTH & LIMITATIONS: The interviewing technique used in this study ensured that participants spoke about issues pertinent to their experience and expertise and helped achieve data saturation. Nonetheless, although this is a review, a quality and bias screening tool was not used because of the search mostly pertaining to legal laws and cases instead of research articles. furthermore, no software was used to analyze the qualitative data from the interviews. In addition, some of the documents reviewed were in Arabic, and therefore, some nuances, while translating the essential findings to English, might have been lost in translation. CONCLUSION: Compared with the ICD-10, the categories and definitions in ICD-11 should not create any additional obstacles nor offer any direct positive consideration, as the diagnostic classifications of mental disorders (ICD or Diagnostic and Statistical Manual of Mental Disorders) are not relevant to the definition of criminal sexual acts in Lebanon. Makhlouf Y, Kerbage H, Khauli N, et al. Legal and Policy Considerations in Lebanon Related to Proposals for Paraphilic Disorders in World Health Organization's International Classification of Diseases Manual, 11th Version. J Sex Med 2020;17:491-504.

Predictive Validity of Operationalized Criteria for the Assessment of Criminal Responsibility of Sexual Offenders With Paraphilic Disorders-A Randomized Control Trial With Mental Health and Legal Professionals.

The prevention of sexual violence is a major goal of sexual health. In cases of accused sexual offenders, the assessment of diminished criminal responsibility of the accused is one of the most important procedures undertaken by experts in the German legal system. This assessment follows a two-stage method assessing first the severity of a paraphilic disorder and then second criteria for or against diminished capacity. The present study examines the predictive validity of two different sets of criteria for the assessment of criminal responsibility in the context of paraphilic disorders combined with sexual offending. Two exemplary case vignettes of two suspected sexual offenders were developed to assess the criteria. For each participant, one of the two exemplary case vignettes was randomly presented. The presentation of the two different sets of criteria was also randomized, so that each participant was assigned only one of the two criteria sets to rate one of the presented cases. N = 349 participants from different professional backgrounds (mental health and legal professionals) completed their assessments and were included in the data analysis. The data were evaluated using logistic regression. Results show that the more recently published criteria set (Briken and Müller, 2014) predicts both the severity of the disorder as well as the diminished capacity twice as good as the older criteria set of Boetticher et al. (2005) currently used regularly for forensic court reports. In preliminary conclusion, the new criteria of Briken and Müller (2014) form an empirically based assessment of criminal responsibility. However, the proposed criteria cannot replace an extensive exploration of the accused person and a careful file analysis. Validity and reliability of the results are also limited due to the methodical choice of a vignette study.

[Neurotransmitter mechanisms of paraphilic disorders]. / Neirotransmitternye mekhanizmy razvitiia parafil'nykh rasstroistv.

AIM: To investigate serotonin and catecholamine levels in people with paraphilic disorders and identify correlations between transmitter dysfunction and clinical signs of paraphilic disorders. MATERIAL AND METHODS: Fifteen men with paraphilic disorders were studied using clinical-psychopathological, sexological, biochemical and statistical methods. RESULTS: There were an increase in the levels of serotonin and norepinephrine and a decrease in the concentration of DOPAC (3,4-dihydroxyphenylacetic acid) in the urine of patients with paraphilic disorders. The concentrations of serotonin and norepinephrine are correlated with obsessive disturbances. The level of DOPAC was associated with affective and dissociative disorders. CONCLUSION: The relationships between biochemical and psychopathological signs suggest a role of biological mechanisms in the organization of abnormal sexual behavior. Correlations between psychopathological phenomena and DOPAC indicate a key role of central dopamine in the pathogenesis of paraphilic disorders and disturbances of conscious regulation of behavior.

Forensic Implications of the New Classification of ICD-11 Paraphilic Disorders in Brazil.

INTRODUCTION: The World Health Organization (WHO) Department of Mental Health and Substance Abuse appointed a Working Group on Sexual Disorders and Sexual Health in order to revise and propose changes to ICD-10 categories. AIM: Analyze ethical and legal implications in Brazil of the proposed ICD-11 diagnostic criteria for paraphilic disorders. METHODS: A forensic working group of Brazilian experts in collaboration with representatives of WHO reviewed the proposed modifications to the classification of Disorders of Sexual Preference in ICD-10 (F65), which is recommended to be replaced by Paraphilic Disorders in ICD-11. Proposals were reviewed through a medicolegal lens, using a legal and policy analysis guide put forth by WHO. The premise of this review was to understand that, although the ICD classification is intended to provide a basis for clinical and statistical health interventions, medical diagnostics may also be entangled in the complex legal, normative, and political environment of various countries. MAIN OUTCOME MEASURE: The most important proposed change to this section is to limit the concept of paraphilic disorders primarily to patterns of sexual arousal involving a focus on others who are unwilling or unable to consent, but this change has not affected the ethical and legal aspects of psychiatric functioning in the Brazil. RESULTS: Because Brazilian criminal law is directed toward criminal behavior and not to specific psychiatric diagnoses, the changes proposed for ICD-11 are not expected to create obstacles to health services or to modify criminal sentencing. CLINICAL IMPLICATIONS: Although ICD-11 has a number of changes in its content, there are no significant clinical implications in the Brazilian context, but a better clarity of conceptual definitions and diagnostic criteria. STRENGTHS & LIMITATIONS: The study is conducted with people from different Brazilian states, which is important for a comprehensive view. On the other hand, considering that it is a very heterogeneous country, there is the limitation that an even wider scope of the study is not possible. CONCLUSION: In the Brazilian context, the new guidelines for paraphilic disorders contribute to clinical utility and are not expected to create difficulties related to the legal, social, and economic consequences of sexual offenses in the country. Abdalla-Filho E, de Jesus Mari J, Diehl A, et al. Forensic Implications of the New Classification of ICD-11 Paraphilic Disorders in Brazil. J Sex Med 2019; 16:1814-1819.