[Interrater reliability of the criteria-based assessment of criminal responsibility in paraphilic disorders]. / Interrater-Reliabilität der kriteriengeleiteten Beurteilung der Schuldfähigkeit bei paraphilen Störungen.

BACKGROUND: For the assessment of criminal responsibility in the context of sexual delinquency, the evaluation of the severity of a paraphilic disorder and the ability to be controlled are of particular importance. Established assessment criteria are insufficiently operationalized. AIM AND METHODS: The existing criteria were tested by experts of various professional groups with respect to the reliability. For this purpose, 14 experts assessed the criteria of 2 different sets of criteria based on 2 case vignettes (see electronic supplementary material). RESULTS AND CONCLUSION: The interrater reliability (IRR) with reference to the criteria of Briken and Müller was higher than the previously established criteria of Boetticher et al. The evaluation of the subjective importance of the criteria of both assessment scales showed that all criteria were rated as at least of average importance. It could thus be useful to initially include both sets of criteria for a greater transparency in the assessment process and to investigate this procedure in further studies.

[Standards for treatment in forensic committment according to § 63 and § 64 of the German criminal code : Interdisciplinary task force of the DGPPN]. / Standards für die Behandlung im Maßregelvollzug nach §§ 63 und 64 StGB : Interdisziplinäre Task-Force der DGPPN.

People who have been convicted of a crime due to a severe mental disorder and continue to be dangerous as a result of this disorder may be placed in a forensic psychiatric facility for improvement and safeguarding according to § 63 and § 64 of the German Criminal Code (StGB). In Germany, approximately 9000 patients are treated in clinics for forensic psychiatry and psychotherapy on the basis of § 63 of the StGB and in withdrawal centers on the basis of § 64 StGB. The laws for treatment of patients in forensic commitment are passed by the individual States, with the result that even the basic conditions differ in the individual States. While minimum requirements have already been published for the preparation of expert opinions on liability and legal prognosis, consensus standards for the treatment in forensic psychiatry have not yet been published. Against this background, in 2014 the German Society for Psychiatry and Psychotherapy, Psychosomatics and Neurology (DGPPN) commissioned an interdisciplinary task force to develop professional standards for treatment in forensic psychiatry. Legal, ethical, structural, therapeutic and prognostic standards for forensic psychiatric treatment should be described according to the current state of science. After 3 years of work the results of the interdisciplinary working group were presented in early 2017 and approved by the board of the DGPPN. The standards for the treatment in the forensic psychiatric commitment aim to initiate a discussion in order to standardize the treatment conditions and to establish evidence-based recommendations.

[Trans healthcare : Between depsychopathologization and a needs-based treatment of accompanying mental disorders]. / Trans*-Gesundheitsversorgung : Zwischen Entpsychopathologisierung und bedarfsgerechter Behandlung begleitender psychischer Störungen.

BACKGROUND: Historically, the function of psychiatry and psychotherapy in the healthcare treatment of transsexualism has been impaired by the basic assumption that non-conforming gender experiences and behavior are automatically considered as expressions of psychopathology. OBJECTIVE: In line with revision of the diagnostic criteria and changing standards of care and treatment recommendations, the therapeutic relationship between mental healthcare professionals and transgender individuals is critically discussed aiming at providing a needs-based psychiatric and psychotherapeutic treatment and a patient-centered approach for trans persons. MATERIAL AND METHODS: Literature search focusing on the prevalence of trans persons and the presence of accompanying mental disorders. Discussion of professional experiences with mental healthcare of trans persons. RESULTS: Trans persons without clinically relevant mental distress do not need any kind of psychiatric or psychotherapeutic treatment; however, trans people with clinically relevant mental impairment need safe access to mental healthcare without linking the trans identity a priori to a mental disorder. CONCLUSION: In order to ensure individual trans healthcare in the long term, the therapeutic relationship should take into account both the body knowledge and self-determination of trans persons as well as the clinical expertise of mental healthcare professionals.

Are medical students interested in sexual health education? A nationwide survey.

The majority of medical students and medical healthcare providers do not feel comfortable when addressing sexual problems. It was suggested that more courses in sexual health are needed at medical schools to overcome this shortcoming. To assess medical students' interest in and attitude about sexual health education at medical schools in Germany, a 13-item online questionnaire was developed. The link to the questionnaire was distributed at all medical schools in Germany. In total, 3264 medical students (69.9% female) from all 37 medical schools in Germany participated. Students from all universities indicated that contents related to sexual health are taught at their university. The majority (n=1809; 62.1%) answered that courses in sexual health should be mandatory. The types of educational experiences that were viewed as most appropriate were lectures (n=2281, 78.3%) and seminars without patient contact (n=1414, 48.5%). Students were most interested in child sexual abuse and sexually transmitted infections. It should be ensured that all medical students have acquired basic knowledge in diagnosing and treating frequent sexual problems at the end of their medical studies. Suggestions are made about how to improve current efforts of sexual health education at medical schools.

What Keeps Them Together? Insights into Sex Offender Couples Using Qualitative Content Analyses.

Research on sex offenders' relationships is scarce. The aim of this qualitative study was to investigate sex offenders' relationships as well as their female partners' adjustment strategies by means of interview analysis. Both partners profit from the relationship in terms of mutual support and acceptance. The sexual offense is a taboo subject, and the female partners were found to demonstrate cognitive distortions. The imbalance of power found in the sex offenders' relationships is discussed, as is the finding that those sexual offenders interviewed live out their need for dominance and sometimes their aggression. The women interviewed were found to cling to their partners as a result of their insecure attachment style. We discuss couples counseling and therapy as possibilities for addressing the imbalance of power and casting light upon the sexual aspect of the relationship.

[Assessment of criminal responsibility in paraphilic disorder. Can the severity of the disorder be assessed with items of standardized prognostic instruments?]. / Beurteilung der Schuldfähigkeit bei paraphiler Störung. Kann der Schweregrad der Störung mithilfe von Kriterien aus Prognoseinstrumenten erfasst werden?

BACKGROUND: Assessment of the severity of paraphilic disorders is an important aspect of psychiatric court reports for assessing criminal responsibility and placement in a forensic psychiatric hospital according to the German penal code (§§ 20, 21, 63 StGB). The minimum requirements for appraisal of criminal responsibility published by an interdisciplinary working group under the guidance of the German Federal Court of Justice define the standards for this procedure. OBJECTIVES AND METHODS: This paper presents a research concept that aims to assess the severity of paraphilic disorders by using items of standardized prognostic instruments. RESULTS AND CONCLUSIONS: In addition to a formal diagnosis according to the international classification of diseases (ICD) and the diagnostic and statistical manual of mental diseases (DSM) criteria, the items "deviant sexual interests" and "sexual preoccupations" from the prognosis instrument Stable 2007 are used to assess the severity of paraphilic disorders. Other criteria, such as "relationship deficits" are used to support the appraisal of the severity of the disorder. The items "sexual preoccupation", "emotional collapse" and "collapse of social support" from the prognosis instrument Acute 2007 are used to assess the capacity for self-control. In a next step the validity and reliability of this concept will be tested.

[Sexual addiction? When sexual behavior gets out of control]. / Sexuelle Sucht? Wenn sexuelles Verhalten ausser Kontrolle gerät.

The authors differentiates deviant (paraphilic) and non-deviant forms of a sexual addictive symptomatology. For the non-deviant forms, the diagnostic term paraphilia-related disorder is used. According to etiological factors, the authors discuss an interaction of a biological vulnerability, attachment and relationship problems, disorders of affect regulation as well as disinhibition of sexual excitation. Some individuals react to negative emotions, like depression or anxiety, with an increased sexual arousal. They may try to cope with negative emotions by being sexually active. However, the importance of the sexual stimulus itself should not be ignored. The authors describe specific psychotherapy, the attendance of self-help groups, and pharmacological treatment, especially with selective serotonin reuptake inhibitors.

[Criminal responsibility in sexual homicide perpetrators]. / Schuldfähigkeit bei sexuellen Tötungsdelikten.

OBJECTIVE: Evaluation of criteria for criminal responsibility, esp. in paraphilias and personality disorders. METHODS: We compared sexual murderers with diminished responsibility or not-guilty for reasons of insanity (n = 73) and those held fully responsible (n = 61) regarding psychiatric disorders, signs of severe paraphilias, level of personality structure (using Operationalized Psychodynamic Diagnostics) and offence related criteria. RESULTS: Sexual murderers found as diminished responsible or not-guilty, especially those detained in forensic psychiatric hospitals, showed more signs of a progressive sadistic development and lower levels of personality structure. Offence related criteria that are regarded as not supporting a diminished capacity plea (purposeful actions, long duration, complex, stepwise course of the offence) were found more frequent in those offenders that were detained in forensic hospitals. CONCLUSIONS: Signs for severity of paraphilias and personality disorders are useful in decisions about criminal responsibility. Criteria regarding purposeful course of action appear not to be adequate for the assessment of paraphilic sexual offenders.

[Comparison of sexual murderers in forensic psychiatric hospitals and in prison]. / Sexuelle Tötungsdelikte. Vergleich von Tätern im Straf- und im Massregelvollzug.

Empirical data are lacking that answer the question of how sexual murderers detained in forensic mental hospitals can be differentiated from those sentenced to prison. Psychiatric court reports and national criminal records on sexual murderers detained in a forensic mental hospital (n=45) were compared with those of prisoners (n=89) regarding diagnostic, criminologic, and prognostic characteristics and criminal recidivism rates after detention. Sexual murderers detained in forensic mental hospitals were characterized by higher psychiatric morbidity and slightly higher risk of future sexual and nonsexual violence. They were released from incarceration less often than the prison inmates but did not show higher sexual or nonsexual violence recidivism rates than those from the prison group.

[Selective serotonine reuptake inhibitors (SSRI) in the treatment of paraphilia]. / Selektive Serotoninwiederaufnahmehemmer (SSRI) in der Behandlung von Paraphilien.

For about 15 years selective serotonine reuptake inhibitors (SSRI) have been used in the treatment of paraphilias. In an open, uncontrolled, retrospective study, which was the first in the German speaking countries we investigated 16 male outpatients, who have been treated for different paraphilias with SSRI and psychotherapy. There was a marked reduction in paraphilic symptoms. Despite high rates of sexual side effects most patients reported a high overall treatment satisfaction. SSRI are an important addition in pharmacological treatment of paraphilic patients, especially with a risk of so called "hands-off" delinquency.

[Pornography and sexual abuse in the Internet]. / Pornographie und sexuelle Gewalt im Internet.

Internet pornography has been regarded as either stimulating sexual aggression and abuse or as serving as a safety valve. This controversy is an important issue in health, media and legal politics. According to empirical studies on pornography in general, soft-core pornography and nonviolent pornography can be regarded as harmless, whereas non-violent hard-core pornography and violent pornography may increase aggression. Individuals with a high risk for sexual aggression show more interest in violent pornography and are stimulated more strongly through such material. Two case histories illustrate the characteristics of internet pornography and "cybersex": easy access, anonymity, affordability, wide range and deviation of the material, unlimited market, blurring the borders between consumer and producer, interactive communication, space for experimenting between fantasy and in real-life behavior, virtual identities, easy contact between offender and victim or among offenders, and low risk of apprehension. The phenomenon of "sexual addiction" (or paraphilia- related disorder) is particularly relevant for the problematic use of internet pornography. Preventive measures to protect possible victims are presented as well as treatment strategies for offenders. Beside limiting access to the internet, these include therapy of comorbid psychiatric disorders and psychological problems (social isolation, bereavement, stress- and anger-management, guilt and shame, childhood traumata, cognitive distortion, victim empathy), psychopharmacotherapy and the enhancement of a more integrative and relationship-oriented sexuality.

[Paraphilia, sexual preference disorders. Diagnosis, etiology, epidemiology, treatment and prevention]. / Störung der Sexualpräferenz (Paraphilie): Diagnostik, Atiologie, Epidemiologie, Behandlung und präventive Aspekte.

Hostility towards relationships is one prominent characteristic symptom for disorders of sexual preference (ICD-10) and paraphilias (DSM-IV). Paraphilic symptoms sometimes progress to obsessive or addictive- like forms leading to a loss of self-control but can occur also as single incidents or as episodic events. Besides constitutional aspects, problems in the development of close relationships to primary caregivers (attachment) play an important role in the development of these disorders. Actual relationship- and self-confidence problems often trigger the severity of disturbance, especially in the episodic forms of paraphilia. For patients who are in conflict with the law, cognitive-behavioral therapeutic approaches with the aim to minimize self-deception regarding the effects of the paraphilic behavior have become more and more relevant. Regarding the medical treatment, anti-hormonal therapy plays an important role, but also treatment with serotonergic agents and naltrexone are used. Only little can be advised in terms of prevention; general psycho-hygiene (regarding the parent-child relationship) is recommended. Beside these general measures, institutions which offer special treatment for people in danger to become delinquents may be able to prevent serious harm for possible victims of abuse.

Antihormonal treatment of paraphilic patients in German forensic psychiatric clinics.

The aim of this study was to investigate which antihormonal treatment strategies are used in German forensic psychiatric institutions. Forensic clinics were asked about the number of treated patients. Four hundred seventy-four patients were committed for sex offences; 12% received either CPA (n = 29) or LHRH- agonists (n = 29). Differences in efficacy were small. Several side effects confirm the importance of a protocol for minimizing medical complications.

[Atypical neuroleptics in the treatment of aggression and hostility in schizophrenic patients]. / Atypische Neuroleptika in der Behandlung von Aggressivität und Feindseligkeit bei schizophrenen Patienten.

The treatment of aggressive symptoms in schizophrenic patients is a relevant clinical problem. We systematically review the efficacy of the different atypical neuroleptics on acute or persistent aggressive symptoms also regarding methodological problems. Currently typical neuroleptics are still first choice in treating acute aggressive symptoms, while risperidone and olanzapine could be alternatives. In persistent aggression clozapin shows the best specific results. Typical depot neuroleptics should be considered in cases when medication compliance is a problem.

Treatment of paraphilia with luteinizing hormone-releasing hormone agonists.

Up to now there have been no published results of therapy of paraphilia (for example, pedophilia or sadism) and sexual aggressive impulsiveness with luteinizing hormone-releasing hormone (LHRH) agonists in the German-speaking countries. After a short introduction about physiologic features and the present state of investigations in treatment of paraphilia with LHRH agonists we describe 11 patients who were treated with the LHRH agonist Leuprolide Acetate over a period of 12 months. The patients showed no tendency toward sexually aggressive behavior and reported an evident reduction of penile erection, ejaculation, masturbation, sexually deviant impulsiveness, and fantasies. One patient died from suicide. In combination with other treatments, LHRH Agonists seem to be a very promising alternative to cyproterone acetate and its possible carcinogene effects.

[Current German laws for foreigners as a contributory factor in the treatment of a first-time acute schizophrenic episode]. / Das geltende Ausländerrecht als krankheitsaufrechterhaltender Faktor in der Behandlung eines schizophrenen Ersterkrankten.

In a case report we describe an 18 year old Croat refugee with a first episode schizophrenia to discuss the current German laws for foreigners as a possible factor for the maintenance of the disease. Short residence permits, the release of the professional discretion to the authorities, deficient information about the laws and the unclear situation in the native country of the patients can lead to a worst course and prognosis of the disease.

[Treatment of paraphilia and sexually aggressive impulsive behavior with the LHRH-agonist leuprolide acetate]. / Therapie mit dem LHRH-Agonisten Leuprorelinacetat bei Paraphilien und sexuell aggressiven Impulshandlungen.

Up to now there are no published results of therapy of paraphilia (Pedophilia, Sadism) and sexual aggressive impulsiveness with LHRH-(luteinizing hormone-releasing hormone) Agonists in the Germanspeaking countries. In this report we describe 11 patients which were treated with the LHRH-Agonist Leuprolide Acetate in a period of 12 months. The patients showed no tendency of sexual aggressive behaviour and reported an evident reduction of penile erection, ejaculation, masturbation, sexual deviant impulsiveness and fantasies. One patient died from suicide. In combination with other treatments LHRH-Agonists seem to be a very promising alternative to cyproterone acetate and its possible carcinogene effects.

[Sexual homicide--a data collection from psychiatric records]. / Sexualdelikte mit Todesfolge. Eine Erhebung aus Gutachten.

After an analysis of the concerning literature we conceptualized a questionnaire with 124 items, which describes the most common characteristics of sexual murderers. The relevance of these characteristics was examined on the basis of psychiatric records. The hypothesis was, that persons who murdered more than once show these characteristics more evidently than single murderers. We compared 20 psychiatric records about single sexual murderers with those about 10 repetitive sexual murderers. Planned offenses, chronic isolation, narcism and tendency to perversity were found more often in persons that murdered more than once. Especially the psychosocial factors were found less often than in the angloamerican literature. More pronounced were the differences between a group of sadistic murderers compared with nonsadistic murderers, using criteria for sadism extracted from Kafft-Ebings first description (1892), Schorsch and Becker (1977), MacCulloch et al. (1983) and Ressler et al. (1988). A case example illustrates the importance of an elaborated concept of sadism and its relation to personality disorder.