Osteoporosis associated with the treatment of paraphilias: a clinical review of seven case reports

Osteoporosis and long-term androgen suppression in the treatment of paraphilias has been documented with surgical castration and the use of gonadotropin-releasing hormone agonists. The literature has suggested that the use of cyproterone acetate (CPA) may be protective against osteoporosis, although there are case reports of osteoporosis in men treated with CPA. This pilot study represents a case series of seven patients diagnosed with severe paraphilias and treated with CPA, leuprolide, or surgical castration. Two of the four patients treated with CPA developed significant osteoporosis, while the other two had normal bone density studies. The remaining three patients, one treated with leuprolide and two with surgical castration, had osteopenia. Based upon the current literature, the finding of significant osteoporosis in two of four patients treated with CPA, but not those treated with leuprolide or castration, is surprising. Monitoring of all patients treated with long-term androgen suppression for osteoporosis is suggested.     

Criminal diversity and paraphilic interests among adult males convicted of sexual offenses against children

Official demographic and offense history data (n = 362) and confidential self-report data on paraphilic interests and behavior (n = 221) obtained on adult males convicted of sexual offenses against children were analyzed. Considerable criminal diversity was observed, with all standard categories of offenses represented in offenders' criminal histories. Most (86%) of the offenders' previous convictions were for nonsexual offenses, and most (92%) of the recidivist offenders had previously been convicted of at least one nonsexual offense. The prevalence of diagnosable paraphilias was low, with only 5% meeting formal diagnostic criteria for multiple (two or more) paraphilias other than pedophilia. Sexual offenders' paraphilic interests were unrelated to the extent of their sexual offense convictions but were significantly related to the extent of their nonsexual offense convictions. The results are better explained by a general theory of crime than by traditional clinical conceptions linking sexual offenses specifically with sexual psychopathology.     

The association between childhood sexual abuse and sexual coercion in men: a test of possible mediators

ABSTRACT

We examined the associations between childhood sexual abuse (CSA), childhood physical abuse (CPA), sexual domain variables, antisocial tendencies, and sexually coercive behaviour in a non-forensic sample of 173 heterosexual men. CSA was associated with paraphilic interests and experiences, a more extensive sexual life history, and early antisocial tendencies. CPA was associated with paraphilic interests and experiences, more self-reported delinquency, higher sensation seeking, and early antisocial tendencies. Sexual domain variables (e.g. number of sexual partners, sexual interest in sadomasochism) mediated the link between CSA and sexually coercive behaviour, but antisocial domain variables (e.g. delinquency, sensation seeking) did not. Of the two sexual domains examined, extensive sexual life history rather than paraphilias mediated the association between CSA and sexually coercive behaviour. These results suggest CSA and CPA are associated with both sexual and antisocial outcomes, and that, for some victims of CSA, having an extensive sexual life history may account for the association between CSA and sexually coercive behaviour later in life.     

The influence of brain abnormalities on psychosocial development, criminal history and paraphilias in sexual murderers

The aim of this study was to investigate the number and type of brain abnormalities and their influence on psychosocial development, criminal history and paraphilias in sexual murderers. We analyzed psychiatric court reports of 166 sexual murderers and compared a group with notable signs of brain abnormalities (N = 50) with those without any signs (N = 116). Sexual murderers with brain abnormalities suffered more from early behavior problems. They were less likely to cohabitate with the victim at the time of the homicide and had more victims at the age of six years or younger. Psychiatric diagnoses revealed a higher total number of paraphilias: Transvestic fetishism and paraphilias not otherwise specified were more frequent in offenders with brain abnormalities. A binary logistic regression identified five predictors that accounted for 46.8% of the variance explaining the presence of brain abnormalities. Our results suggest the importance of a comprehensive neurological and psychological examination of this special offender group.     

Self-reported versus diagnosed paraphilias in outpatient sexual offenders

Literature has repeatedly reaffirmed sexual deviance as a risk factor for sexual recidivism, making it an important subject to examine. Yet, not all studies confirm the relevance of sexual deviance and there is a lack of consensus regarding the assessment of it. In the current study, 499 Dutch adult male subjects, admitted for sexual misconduct (possession of child abuse material, child molestation and other types of inappropriate sexual behaviour) to an outpatient forensic treatment facility, were compared regarding sexual paraphilias using self-reports from clients and official DSM-IV-TR diagnoses assessed by professionals. Analyses revealed a relatively low similarity between self-reports and diagnoses, self-reports generating considerably more information. Furthermore, correlating the paraphilias revealed paedophilia associated minimally with the other paraphilias. Lastly, the different types of offenders varied significantly in number of self-reported and diagnosed paraphilias, with the miscellaneous group presenting the most. Considering these outcomes may help assessment and target treatment goals in forensic psychiatry.     

Parent Perceptions of Participating in a Program for Adolescents Who Are Violent at Home

Child-to-parent abuse (CPA) is an under-addressed form of family violence and relatively few resources are available for families experiencing CPA. The Step-Up program is a CPA-specific, family-level, group format intervention program in King County, Washington. Qualitative and long-term research on CPA intervention programs is lacking, and it is unknown how parents perceive the effects of participating in Step-Up after program completion. Fifteen parents who completed Step-Up with their adolescent child participated in individual semi-structured telephone or in-person interviews. Participants were asked about their perceptions of the effects of Step-Up participation, how they and their child have used skills taught in the program, and which program features were most and least effective. Participants expressed largely positive effects of participating in Step-Up, including decreased violent behavior by their adolescents and improved parent-child relationships. Recommendations for improving Step-Up included the inclusion of follow-up sessions to further reinforce behavior change and increased program accessibility.     

Sex offending and sexual appetite: the clinical and theoretical relevance of hypersexual desire

Disinhibited sexual desire, clinically manifested as hypersexual desire disorders, can be operationally defined by considering three behavioral domains associated with sexual motivation or appetitive behavior: (a) sexual preoccupation (time/day consumed by fantasies, urges, and activities), (b) the repetitive frequency of enacted sexual behavior (total sexual outlet/week), and (c) adverse consequences associated with repetitive sexual behavior: Data are presented suggesting that clinical samples of males with paraphilias, paraphilia-related disorders, and sexual coercion may be associated with disinhibited sexual appetite. These conditions need to be addressed by an integrated combination of psychotherapeutic and psychopharmacologic interventions that specifically target disinhibited sexual appetitive behaviors, their antecedents, and consequences. Although combination therapies (empirically based specific psychotherapies in conjunction with psychopharmacological treatments) have demonstrated superior efficacy in many Axis I psychiatric disorders, such combination therapies to reduce paraphilias, paraphilia-related disorders, and adult sexual coercion are currently underutilized in both North and South America and Europe.     

Disorders of sexual preference and medicolegal issues thereof

Disorders of sexual preference or paraphilias are bizarre patterns of sexual behavior that have diverse manifestations and are of complicated sexual orientations. Some of these are harmless, while others are not, robbing sufferers and possibly their partners of loving sexual relationship. At least 40 paraphilias have been named, but the full extent of the field, perhaps, is still undiscovered. Recent studies have reported many paraphilias as long-term effects of sexual abuse in childhood, and the more frequent and persistent the abuse is, the worse the long-term psychologic, behavioral, and relationship problems. Psychopathology within this group of disorders may lead to criminal behavior, ranging from infringement of decency to some of the most heinous crimes known.     

Concentrations of zolpidem and zopiclone in venous blood samples from impaired drivers compared with femoral blood from forensic autopsies

The concentrations of zolpidem and zopiclone were determined in peripheral blood samples in two forensic materials collected over a 10-year period (2001-2010). The z-hypnotics were determined in venous blood from living subjects (impaired drivers) and in femoral blood from deceased persons (forensic autopsies), with the latter classified as intoxication or other causes of death. The z-hypnotics were determined in blood by capillary column gas chromatography (GC) with a nitrogen-phosphorous (N-P) detector after solvent extraction with n-butyl acetate. The analytical limit of quantitation (LOQ) was 0.02mg/L for zopiclone and 0.05mg/L for zolpidem and these have remained unchanged throughout the study. When death was attributed to drug intoxication (N=918), the median concentration of zopiclone in blood was 0.20mg/L compared with 0.06mg/L for other causes of death (N=1215) and 0.07mg/L in traffic offenders (N=691) (p<0.001). Likewise, a higher median concentration (0.30mg/L) was found in intoxication deaths involving zolpidem (N=357) compared with 0.13mg/L for other causes of death (N=397) or 0.19mg/L in impaired drivers (N=837) (p<0.001). Median concentration in blood of both z-hypnotics were appreciably higher in intoxication deaths when no other substances were identified; 0 70mg/L (N=12) for zopiclone and 1.35mg/L (N=12) for zolpidem. The median concentrations of z-hypnotics in blood decreased as the number of co-ingested substances increased for intoxication deaths but not other causes of death. The most prevalent co-ingested substances were ethanol in autopsy cases and diazepam in the motorists. This large compilation of forensic cases should prove useful when toxicologists are required to interpret concentrations of z-hypnotics in blood samples in relation to cause of death.     

Scheduling of new psychoactive substance the Swiss way: A review and critical analysis

Since the introduction of the European Early Warning System in 2005, >700 new psychoactive substances (NPS) have been listed. This review article presents for the first time the Swiss narcotic law in perspective of scheduling of NPS, and compares it to the regulations of the German speaking neighbours Austria and Germany.The Swiss way is a fast and effective way for scheduling NPS, with the purpose to restrict drug trafficking and for controlling the NPS drug market: the legal basis for scheduling substances of abuse is the “Law about narcotics and psychotropic substances” (BetmG, SR 812.121), which includes the “narcotic law directory (BetmVV-EDI, SR 812.121.11) suitable for listing all controlled substances. The BetmVV-EDI, SR 812.121.11 contains seven indices, with index e specifically designed for the fast scheduling of NPS. Newly appearing NPS can either be controlled under a structure analogues definition or by listing single substances. The list of single substances is updated at least once per year, and structure analogues definitions can be implemented, in order to keep track with new developments on the NPS market. The latest version from November 30th 2018 contains ten different structure analogue definitions and 207 single substances. Requirements to list NPS are their appearance on the NPS market, suspected psychotropic effects and their suggestions by Forensic professionals. As soon as substances are newly placed, on Schedule I of the 1961 Convention or Schedule II of the 1971 Convention by the Commission on Narcotic Drugs of the World Health Organization they can easily be transferred from index e to index a-d of the BetmVV-EDI, SR 812.121.11. The Austrian law uses a structure analogue and single substances approach (introduced in 2012, one update in 2016), whereas the German NPS law (established in 2016, no update yet) only lists two structure-analogue-definitions. All three legislations have defined which core structures, kinds and sites of substitutions are regulated.     

Effectiveness of citizen police academies in changing the attitudes, beliefs, and behavior of citizen participants

The purpose of this study was to determine whether the citzen police academies (CPA) in two cities were effective in changing participants’ attitudes, beliefs, and behavior toward police. Pre-and post-test questionnaires were used to obtain participants’ ratings of their attitudes and beliefs concerning police officers and their willingness to cooperate with police. Participants were also asked to indicate what cooperative behaviors they had actually engaged in before and/or during the CPA. At the end of the CPA, participants in both cities rated themselves as having more positive attitudes toward police, and more willingness to engage in behaviors that would help police. There was also an increase in actual performance of some cooperative behaviors during the CPA. These changes did not seem to be overly dependent on the jurisdiction (large versus small city), the demographics of the CPA participants, or the specific characteristics of the CPA curriculum.     

The relationship between serial sexual murder and autoerotic asphyxiation

This case series documents and examines the association between autoerotic asphyxiation, sadomasochism, and serial sexual murderers. Autoerotic asphyxiation, along with other paraphilias found in this population, is reviewed. Five cases of serial sexual killers who engaged in autoerotic asphyxiation were identified worldwide: four from the United States and one from Russia. Case reports for each are provided. All (100%) were found to have sexual sadism in addition to autoerotic asphyxiation. Furthermore, two (40%) had bondage fetishism, and two (40%) had transvestic fetishism, consistent with these paraphilias co-occurring in those with autoerotic asphyxiation. Overall the group averaged 4.0 lifetime paraphilias. Some possible relationships were observed between the offenders' paraphilic orientation and their modus operandi, e.g., all of these serial killers strangled victims-suggesting an association between their sadistic and asphyxiative paraphilic interests. The overlap of seemingly polar opposite paraphilias in this sample--sexual sadism and autoerotic asphyxiation--is explored from a historical and clinical perspective. Multiple commonalities shared between these five offenders and serial sexual murderers in general are addressed. A primary limitation of this study is its small sample size and empirical basis; the results may not be generalizable beyond the sample. The findings from this study support the supposition that crime scene behaviors often reflect paraphilic disturbances in those who commit serial sexual homicides.     

HIV-1- prevalence among drug deaths in major cities of central and northern Europe.

Since 1985, a number of Institutes of Forensic Medicine in Germany have cooperated in a multicenter study, to provide a constant monitoring of HIV-1-prevalence among drug related deaths. In 1990/91, the Institutes in Copenhagen, Stockholm, Vienna and Zürich also participated in this study. HIV-1-prevalence is decreasing in the German cities, whereas the epidemiological development is not uniform in the other major cities. Regional differences are obvious. In 1991, the prevalence rates were as follows: Berlin 15% (n = 220), Hamburg 4% (n = 179), Frankfurt 17% (n = 167), Munich 9% (n = 136), Stockholm 10% (n = 79), Copenhagen 14% (n = 130), Vienna 20% (n = 56), and Zürich 23% (n = 84).     

Fatal aviation accidents in Lower Saxony from 1979 to 1996

So far no national or regional studies have been published in Germany regarding the number of fatal aviation accidents and results of autopsy findings. Therefore, we evaluated all fatal aviation accidents occurring in Lower Saxony from 1979 to 1996. A total of 96 aviation accidents occurred in this period involving 73 aeroplanes. The crashes resulted in the death of 154 people ranging in age from 19 to 68 years. The greatest number of victims in a single crash of an aircraft was (n=7). Other types of fatal accidents were crashes of aircraft and helicopter while on the ground (n=5), hot-air balloons (n=2), parachutes (n=10), hang glider accidents (n=5) and the striking of a bystander by a model airplane. Autopsies were performed on 68 of the 154 victims (44.2%), including 39 of the 73 pilots (53.4%). Some of the autopsies yielded findings relevant to the cause of the accident: gunshot wounds, the presence of alcohol or drugs in blood and preexisting diseases. Our findings emphasize the need for autopsy on all aviation accident victims, especially pilots, as this is the only reliable method to uncover all factors contributing to an accident.     

Practical GC/MS analysis of oxidation dye components in hair fiber as a forensic investigative procedure

The purpose of this study was to improve the reliability of discrimination (or identification) of dyed hair by analyzing chemical substances present in the hair, as an addition to the conventional macroscopical and microscopical examinations and ABO blood group examination. Oxidation hair-dye components such as p-phenylenediamine (PPDA), toluylene-2,5-diamine (T-2,5-DA), o-aminophenol (OAP), m-aminophenol (MAP), p-aminophenol (PAP) and p-amino-o-cresol (PAOC) were selected as the object of study. After alkaline-digestion, hair samples were adjusted to a pH of 12.6 to 12.8, and applied onto an Extrelut column. After 15 min, the components were simultaneously extracted and derivatized with n-hexane including 1% heptafluoro-n-butyryl (HFB) chloride. Their HFB derivatives within a condensed sample were diluted in ethyl acetate, and analyzed by gas chromatography-mass spectrometry (GC-MS) with full mass scanning or selected ion monitoring. For estimating their levels, 2,4,6-trimethylaniline was used as the internal standard. Standard curves obtained by preparing a 5 cm segment of control hair spiked with authentic substances were linear, ranging from 0.1 to 4.0 micrograms for PPDA and T-2,5-DA, and from 0.01 to 0.4 microgram for OAP, MAP, PAP and PAOC. The coefficient of variation of inter-day precisions (each n = 4) was below 16% for PPDA, below 20% for OAP and PAP and below 24% for T-2,5-DA, MAP and PAOC. These components were detectable even at 6 ng for PPDA, T-2,5-DA, MAP and PAP, 8 ng for OAP, and 4 ng for PAOC. Recovery percents using this procedure ranged from 54 to 86%. By using actual dyed hair samples this method was shown to provide high sensitivity for accurate detection.     

The general toxicology unknown. II. A case report: doxylamine and pyrilamine intoxication

A general toxicology unknown case is presented to demonstrate our systematic approach. A 20-year-old male was found dead with multiple suicide notes. Overdose was suspected but substances were not known. Blood alcohol was negative. Urine was analyzed by enzyme-multiplied immunoassay technique and was negative for all drugs assayed. Urine was then extracted with ethyl acetate:hexane (1:1) at pH 10 and back-extracted into 1.0N sulfuric acid. The acidic layer was adjusted to pH 10, and re-extracted with ethyl acetate:hexane (1:1). The residue was analyzed by gas chromatography (GC) on a 3% OV-101 column. It was found to be negative for all commonly screened substances. However, several unknown peaks were observed. Electron impact mass spectra of these unknown peaks were obtained and searched for in our computer library of more than 25000 mass spectra. These unknown peaks were identified as doxylamine and pyrilamine by gas chromatography/mass spectrometry. The base peak and molecular ion for pyrilamine were at m/z 121 and 285, respectively. The base peak for doxylamine was at m/z 58. No molecular ion was observed for doxylamine. Both doxylamine and pyrilamine are antihistamines, but are promoted and used in the management of insomnia. Quantitation was performed on a GC using dexbrompheniramine as an internal standard. Blood concentrations for doxylamine and pyrilamine were 0.7 and 7.0 mg/L, respectively. Concentrations in other tissues were determined. Death was caused by combined doxylamine and pyrilamine intoxication; the manner of death was suicide.     

Treatment of paraphilia in young adults with leuprolide acetate: a preliminary case report series

Some juveniles who engage in sexual offenses may have a paraphilia, a psychiatric disorder characterized by a pervasive pattern of deviant and impairing sexual fantasies, thoughts, and/or behaviors. Though there is no known cure for these conditions, paraphilias can be effectively managed using a multimodal treatment approach. This may include the use of psychotherapeutic and pharmacological treatment interventions, including antiandrogen medications. One such agent, leuprolide acetate (leuprolide), a luteinizing hormone-releasing-hormone agonist, has been shown to be effective in reducing paraphilic symptoms in adult patients. To date, however, there is no published data on its use and effectiveness in adolescent and young adult paraphilic patients. This study consists of a case report series of six young adult patients treated with leuprolide. All subjects had been diagnosed with at least one paraphilia (i.e., Pedophilia, Sexual Sadism, Frotteurism, and Paraphilia Not Otherwise Specified). All subjects had been refractory to treatment in a residential program for adolescent sex offenders prior to initiation of leuprolide. All six subjects reported a reduction in sexually deviant symptoms following treatment with leuprolide. Clinicians rated four as much improved and two as moderately improved. The treatment was well tolerated in all six subjects. This preliminary case series supports the conclusion that leuprolide deserves further examination as a potentially safe and effective component in the treatment of young adult patients with paraphilia.     

液液萃取-超高效液相色谱-串联质谱法测定常见食用植物油中5种鸦片生物碱

目的建立酸化甲醇(pH=3)液液萃取-超高效液相色谱-串联三重四极杆质谱(UPLC-MS/MS)测定常见食用植物油中5种鸦片生物碱吗啡、可待因、蒂巴因、罂粟碱、那可汀的检验方法。方法样品加入正己烷摇匀后用酸化甲醇(pH=3)提取,BEH C18色谱柱分离,乙腈(0.01%甲酸)-水(0.01%甲酸+0.05%氨水,体积比)梯度洗脱,电喷雾离子源正离子(ESI+)及多反应监测模式检测。结果结果显示5种待测成分在0.5~300ng/g范围内线性关系良好;方法检出限(S/N=3)在0.1~2ng/g间、定量限(S/N=10)在0.5~3ng/g间;回收率(20ng/g,200ng/g)在82.0%~101.4%间,相对标准偏差(RSD,n=6)为1.4%~4.2%,基质效应(20ng/g,200ng/g)在-5.3%~5.8%间,日间精密度为2.8%~6.7%。结论本方法前处理简单、耗时短,溶剂使用量少,灵敏度高,适合大批量常见食用植物油中5种鸦片生物碱的同时检测。     

A Rare Case of Poisoning with a Volatile Substance: Quantitative Determination of n‐Butane in Postmortem Tissue

Poisoning with volatile substances remains exceptional. Authors report the case of a married couple who were found in a car with a butane gas bottle: the woman was dead and her husband alleged it was an unsuccessful suicide pact. A specific research of volatile substances on postmortem samples with headspace gas chromatography–mass spectrometry following a quantitative determination was performed. The n‐butane concentrations detected were composed of 610 μg/L (cardiac blood), 50 μg/kg (brain), 134 μg/kg (lungs), 285 μg/kg (liver), and 4090 μg/kg (heart) and were compatible with the rare lethal concentrations evoked in the literature. The cause of death was determined to be asphyxiation through n‐butane criminal poisoning. Authors recommendation therefore is to take samples immediately and place them in properly sealed containers and hence analyzing the samples as soon as possible after collecting them or storing them under ?30°C (?22°F) if analyses cannot be performed immediately.