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

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

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

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

Validity in Phallometric Testing for Sexual Interests in Children: A Meta-Analytic Review.

Valid assessment of pedohebephilic interests (i.e., sexual interest in children) is fundamental to forensic clinical practice. Phallometric testing-which measures changes in penile circumference or volume, while stimuli depicting different ages and sexual activities are presented-is widely used in clinical and research settings to detect such interests. This meta-analysis summarizes studies comparing sexual offenders against children and various types of controls on phallometric tests for pedohebephilic interests (37 samples; N = 6,785) and studies examining the relationship between phallometric test scores and sexual reoffending (16 samples; N = 2,709). The findings suggest that several phallometric testing procedures are valid indicators of pedohebephilic interest. Certain methodological features of phallometric tests were associated with greater validity, such as, slide or audio-plus-slide stimuli and z-score-based indices. In addition, phallometric tests for pedohebephilic, pedophilic, and hebephilic interests predicted sexual reoffending which provides further evidence that phallometric test scores are valid indicators of sexual interest in children. In general, the interpretation of phallometric test scores as indicators of pedohebephilic interests is supported.

Age Diversity Among Victims of Hebephilic Sexual Offenders.

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

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

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

Taxometric analyses of pedophilia utilizing self-report, behavioral, and sexual arousal indicators.

Pedophilia refers to the recurrent, intense sexual interest in prepubescent children who, by definition, have not developed any secondary sex characteristics. Researchers have begun to investigate whether persons with pedophilia are qualitatively different from those without pedophilia (pedophilia is a taxon) or if people vary in their level of sexual interest toward children (pedophilia is dimensional). Two relatively small studies have previously attempted to address this question, but produced conflicting results. The present study built on these studies with a substantially larger sample of 2,227 men who committed sexual offenses and were assessed at a sexual behavior clinic. The present study also examined a broader range of measures more closely approximating the diagnostic criteria for pedophilic disorder, including phallometric assessment of sexual arousal patterns. The results of 3 taxometric analyses did not find support for the assertion that pedophilia is a taxon. (PsycINFO Database Record

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

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

Multiple indicators of sexual interest in prepubescent or pubescent children as predictors of sexual recidivism.

OBJECTIVE: Sexual interest in children is a well-known risk factor for sexual reoffending (recidivism). The present study examined the relationship between sexual interest in prepubescent children (pedophilia) or pubescent children (hebephilia) and sexual recidivism. It extended previous work by using multiple indicators of sexual interest, using a more sensitive phallometric procedure that measures change in penile blood volume, and examining both hebephilia alongside pedophilia, as well as noncontact sexual recidivism. METHOD: Six hundred fifty-six men who had committed a sexual offense underwent a comprehensive sexological assessment that included multiple sexual interest measures: volumetric phallometry, self-report, and sexual behavior. Criminal record data were acquired to examine recidivism. Offenders were followed for an average of 10 years of opportunity. RESULTS: Indicators of hebephilia and pedophilia were significantly associated with noncontact sexual recidivism, but inconsistently associated with contact recidivism. The relationship with phallometrically assessed pedophilia and contact sexual recidivism was significant after controlling for offender age statistically. Phallometrically assessed sexual arousal to children did not add to risk appraised by an actuarial measure. CONCLUSION: Both hebephilia and pedophilia were predictive of noncontact sexual recidivism. The results for contact sexual recidivism are discussed, including a potential confound in previous work on the assessment of sexual interest in children. (PsycINFO Database Record

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

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

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

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

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

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

Evidence of Construct Validity in the Assessment of Hebephilia.

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

The effects of common medications on volumetric phallometry.

Phallometry is a physiological measure of sexual response widely used for the assessment of paedophilia among sexual offenders. Although many medications decrease penile response sufficiently to interfere with sexual intercourse, it is unknown to what extent such medications might interfere with phallometric testing. In the current study, we utilized a naturalistic convenience sample of 1078 men who attended a clinic for assessment of sexual preferences, mostly related to sexual offence convictions. In the present analyses, we quantified the differences in penile response during phallometric assessment associated with taking a range of common medications. Participants on medication typically showed less penile output than participants not taking medications; however, differences were largely accounted for by age rather than by medication status. Though most medications were associated with decreases in penile responsivity during volumetric phallometric testing, such changes were small in absolute terms and appeared to be associated with ageing rather than with the medications themselves.

Diffusion Tensor Imaging of Pedophilia.

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

Sensitivity and Specificity of the Phallometric Test for Hebephilia.

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

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

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

Factor structure of the Edinburgh Handedness Inventory versus the Fazio Laterality Inventory in a population with established atypical handedness.

The Edinburgh Handedness Inventory (EHI) has consistently remained the most used handedness inventory despite its limitations. The psychometric properties of handedness inventories, however, are increasingly important due to their use in matching groups for neuroimaging research. This study compared the performance of the EHI and the Fazio Laterality Inventory (FLI) in a population with atypical handedness. Whereas the EHI demonstrated a single-factor loading in this population, the FLI's previously demonstrated single factor dissociated into two factors: fine motor/ballistic movements and expressive/instrumental movements. This dissociation is similar to that seen when tests of cognitive constructs--which tend to load on a single factor in intact populations--dissociate when administered to populations with difficulties in the assessed domain. This pattern of performance lends further support for the use of the FLI to more accurately assess handedness. Future research in other populations with atypical laterality may illuminate additional factors of the FLI.