Evaluation of the use of pharmacological treatment with prisoners experiencing high levels of hypersexual disorder

This paper presents an evaluation of the impact of pharmacological treatment in reducing hypersexual disorder in adult males who have been incarcerated following conviction for a sexual offence. The evaluation compares two types of pharmacological treatment, one of which is part of the current NICE guidance for treatment of hypersexuality (Antiandrogens), whilst the other type (SSRIs) is off-label use in the UK for hypersexuality. The participant pool comprised 127 adult male prisoners serving sentences for sexual offences in a UK prison. Participants had been voluntarily referred for pharmacological treatment to manage hypersexual disorder. The results demonstrated a significant reduction of hypersexual disorder pre- and post-medication and contribute to the evidence base for the use of pharmacological treatment with individuals for whom hypersexual disorder may be a salient factor in their offending. Limitations of the current research are discussed.     

Hippocampal Agenesis in an Individual who Engaged in Violent Criminal Behaviors After Discontinuing Carbamazepine and Paroxetine Treatment

Antidepressant discontinuation syndrome (ADS) occurs after abrupt discontinuation of an antidepressant medication. A 23‐year‐old man with right hippocampal agenesis demonstrated sexual crime (hypersexuality) since the age of eight and had been successfully treated with carbamazepine since the age of 13. He had required increased doses of paroxetine and carbamazepine owing to the development of an unstable affect after quitting his job. He abruptly stopped taking his medication for 3 days and his criminal behaviors re‐emerged. We examined changes in brain structure and activity before and after medication cessation, using MRI and functional MRI (fMRI). The image of a girl in a swimsuit increased activity in the thalamus only after medication discontinuation. The alteration in thalamic activity might induce hypersexuality. We conclude that a primary hypersexuality had been suppressed with carbamazepine and paroxetine treatment, and the discontinuation of the medication caused the hypersexuality.     

Online solicitation offenders are different from child pornography offenders and lower risk contact sexual offenders

The current study compared 38 lower risk (based on actuarial risk assessments) men convicted of contact sexual offenses against children, 38 child pornography offenders, and 70 solicitation offenders (also known as luring or traveler offenders). Solicitation and child pornography offenders were better educated than contact offenders but did not differ on other sociodemographic variables. In comparison to child pornography offenders, solicitation offenders had lower capacity for relationship stability and lower levels of sex drive/preoccupation and deviant sexual preference. Solicitation offenders were also more problematic than lower risk contact offenders on sex drive/preoccupation and capacity for relationship stability and had greater self-reported use of child pornography. Differences between groups on two actuarial risk measures, the Static-99 and the VASOR, were inconsistent. This study suggests that solicitation offenders differ in meaningful ways from lower risk contact offenders and child pornography offenders and, consequently, in risk, treatment, and supervision needs. (PsycINFO Database Record (c) 2012 APA, all rights reserved).     

Understanding service users’ and therapists’ experiences of pharmacological treatment for sexual preoccupation and/or hypersexuality in incarcerated sex offenders

This research comprises two qualitative studies understanding the experiences of (1) convicted sex offenders voluntarily receiving pharmacological treatment to reduce sexual preoccupation and (2) therapists working with these offenders. The studies form part of a research programme evaluating the use of pharmacological treatment with sexual offenders. In study one, semi-structured interviews were conducted with 13 sexual offenders receiving selective serotonin reuptake inhibitors. In study two, interviews were conducted with eight intervention staff with varying levels of experience of working with offenders taking anti-libidinals. Thematic analysis was used and in study one, two main themes emerged: (i) the impact of the pharmacological treatment on prisoners’ daily functioning; (ii) barriers to compliance/engagement. In study two, three main themes emerged: (i) offenders’ reluctance to engage with pharmacological treatment; (ii) challenges for therapists; (iii) pharmacology: ‘just another piece of the puzzle’. Findings are discussed in relation to practice and future research.     

The paraphilia-related disorders: an investigation of the relevance of the concept in sexual murderers

Paraphilic disorders (PAs) and sexual preoccupation are known risk factors for recidivism in sexual offenders. Nonparaphilic sexual excessive behaviors-so-called paraphilia-related disorders (PRDs), like paraphilias, are also characterized by sexual preoccupation and volitional impairment and can be diagnosed in paraphilic men. The prevalence and clinical significance of PRDs in sexual homicide perpetrators, however, is unknown. We investigated the relationship between PAs and PRDs retrospectively in a sample of 161 sexual murderers. Four groups were compared: men without a PA or a PRD diagnosis, men with at least one PRD but no PA, men with at least one PA but no PRD, and finally, those with a combination of both (PA+PRD). The PA+PRD group had the most lifetime cumulative sexual impulsivity disorders, more developmental problems, the highest persistent frequency of sexual activity, the highest number of previous sexual offences, more sexual sadism, and compulsive masturbation. Men of the PRD subsample had suffered more from childhood sexual abuse, showed more promiscuity, psychopathy, and alcohol problems. The use of the PRD concept in this special offender group should be further investigated with prospectively designed studies.     

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.     

The effect of sexual priming cues on emotional recognition in nonviolent child sexual abusers: a preliminary study

This article describes a study that used a computer-based task to investigate the emotional recognition skills of child sexual abusers. The experiment consisted of two phases (prime and probe) and measured both response time and error rates to facial expressions. The priming phase of the experiment consisted of the presentation of short phrases via computer of either sexual or neutral content. The probe phase of the experiment consisted of the presentation of adult facial expressions depicting either the emotion fear or surprise. Results showed child sexual abusers to be slightly less accurate overall. Furthermore, contrary to prediction, the effect of sexual priming appeared to make child sexual abusers actually better at recognizing fearful faces (p = .055). This result is discussed in relation to current victim empathy theory and treatment implications for sexual offenders.     

In-prison treatment for sexual offenders in Taiwan

The present study was designed to investigate the current status of mandated treatment in prison for sexual offenders in Taiwan. The information-gathering methods were composed of two parts: questionnaires and interviews. The results showed the difficulties of mandated treatment in prison, including poor client adherence, the lack of consistent disciplines for the therapists, a standardized algorithm, and explicit laws and rules, the safety concerns of the therapists, and a shortage of staff. The development of mandated treatment in prison of sexual offenders in Taiwan is still in its early stage, and the treatment models have not yet been integrated. A cooperative and collaborative center for the mandated treatment in prison of sexual offenders and an integrated rule and treatment model should be set up in the future.     

Psychiatric aspects of sexual abuse

Sexual abuse of children and adolescents has become an increasingly publicized phenomenon. Psychiatrists and other mental health professionals are often called upon to evaluate and treat children and adolescents who may have been sexually abused, to provide counseling or treatment to the families of such children, and to provide reports and testimony for proceedings about such cases in the child protection system, the criminal justice system, and in custody disputes. Clarity regarding the medical, psychiatric, and legal aspects of sexual abuse is essential in carrying out such professional activities and in evaluating and formulating research on sexual abuse. In this paper current knowledge regarding these aspects of sexual abuse is summarized, and the role of psychiatrists in clinical and forensic work involving allegations of sexual abuse is discussed.     

Revictimization and self-harm in females who experienced childhood sexual abuse: results from a prospective study

Lifetime trauma histories were ascertained for females with confirmed histories of childhood sexual abuse and comparison females participating in a longitudinal, prospective study. Abused participants reported twice as many subsequent rapes or sexual assaults (p = .07), 1.6 times as many physical affronts including domestic violence (p = .01), almost four times as many incidences of self-inflicted harm (p = .002), and more than 20% more subsequent, significant lifetime traumas (p = .04) than did comparison participants. Sexual revictimization was positively correlated with posttraumatic stress disorder symptoms (PTSD), peritraumatic dissociation, and sexual preoccupation. Physical revictimization was positively correlated with PTSD symptoms, pathological dissociation, and sexually permissive attitudes. Self-harm was positively correlated with both peritraumatic and pathological dissociation. Competing theoretical explanations for revictimization and self-harm are discussed and evaluated.     

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.     

The effectiveness of treatment for sexual offenders: A comprehensive meta-analysis

The article reports a meta-analysis on controlled outcome evaluations of sexual offender treatment. From 2,039 documents published in five languages, 69 studies containing 80 independent comparisons between treated and untreated offenders fulfilled stepwise eligibility criteria (total N = 22,181). Despite a wide range of positive and negative effect sizes, the majority confirmed the benefits of treatment. Treated offenders showed 6 percentage points or 37% less sexual recidivism than controls. Effects for violent and general recidivism were in a similar range. Organic treatments (surgical castration and hormonal medication) showed larger effects than psychosocial interventions. However, this difference was partially confounded with methodological and offender variables. Among psychological programs, cognitive–behavioral approaches revealed the most robust effect. Nonbehavioral treatments did not demonstrate a significant impact. There was no outcome difference between randomized and other designs, however, group equivalence was associated with slightly larger effects. Various other moderators had a stronger impact on effect size (e.g., small sample size, quality of outcome reporting, program completion vs. dropout, age homogeneity, outpatient treatment, and authors’ affiliation with the program). More differentiated, high-quality evaluations are needed to clarify: What works for whom under which circumstances?     

When benefitting a patient increases the risk for harm for third persons — The case of treating pedophilic Parkinsonian patients with deep brain stimulation

This paper investigates the question whether it is ethically justified to treat Parkinsonian patients with known or suspected pedophilia with deep brain stimulation — given increasing evidence that this treatment might cause impulse control disorders, disinhibition, and hypersexuality. This specific question is not as exotic as it looks at a first glance. First, the same issue is raised for all other types of sexual orientation or behavior which imply a high risk for harming other persons, e.g. sexual sadism. Second, there are also several (psychotropic) drugs as well as legal and illegal leisure drugs which bear severe risks for other persons. We show that Beauchamp and Childress' biomedical ethics fails to derive a veto against medical interventions which produce risks for third persons by making the patients dangerous to others. Therefore, our case discussion reveals a blind spot of the ethics of principles. Although the first intuition might be to forbid the application of deep brain stimulation to pedophilic patients, we argue against such a simple way out, since in some patients the reduction of dopaminergic drugs allowed by deep brain stimulation of the nucleus subthalamicus improves impulsive control disorders, including hypersexuality. Therefore, we propose a strategy consisting of three steps: (1) risk assessment, (2) shared decision-making, and (3) risk management and safeguards.     

Hope in the treatment of sexual offenders: the potential application of hope theory

Abstract

The present paper attempts to demonstrate how hope theory is conceptually consistent with current positive approaches to sexual offender treatment. Hope theory and its components of goals, pathways thinking, and agentic thinking is reviewed as defined by Snyder and his colleagues. A theoretical relationship exists between the role of hope and many aspects of sexual offending and treatment. Developmental course, attachment style, and the formation and maintenance of coping styles are reviewed as they relate to hope and sexual offending. A framework by which to apply hope theory to pre-treatment, treatment, and more specifically, self-management or relapse prevention for sexual offenders is proposed. Emphasis is placed on the use of techniques that target hope components, particularly in pre-treatment programs.     

Social problem-solving correlates of sexual deviancy and aggression among adult child molesters

Cognitive-behavioral treatment programs for adult sex offenders often include training geared to improve a perpetrator's social problem-solving skills. However, little empirical evidence exists to date that documents the relationship between problem-solving and deviant sexual interest or behavior among child molesters. As such, this study investigated the association between problem-solving and two aspects of sexual offending—self-reported sexual deviancy and clinician-rated sexual aggression among a recruited sample of incarcerated child molesters. To minimize the potential for biased self-reports, criterion scores on a lie scale were employed to exclude individuals who might be prone to misrepresent their responses. Results indicated this sample to be characterized by significant deficits on all measures of social problem-solving as compared to the general population. In addition, a series of correlational analyses indicated that an avoidant problem-solving style was significantly associated with past sexual aggression, whereas a negative problem orientation and an impulsive/careless problem-solving style were significantly related to a measure of current sexual deviancy. Of particular interest is the finding that a rational problem-solving style (i.e., the constructive style that involves the systematic application of specific problem-solving skills geared toward identifying an effective solution) was not significantly related to either sexual offending measure. The implications of these collective results are discussed.     

The development and psychometric assessment of the adolescent sexual coercion risk scale

The objective of this study was to develop a psychometric measure of risk for sexual victimization from adolescent peers. Items were generated on the basis of the literature and on consultations with a multidisciplinary group of key informants. The items were administered to a sample of 327 female Grade-9 students and examined using exploratory factor analysis. The Adolescent Sexual Coercion Risk Scale items formed two lower-order factors composed of items regarding signaling sexual boundaries and displaying risk behaviors, respectively. Subsequent confirmatory factor analysis supported the two factors, and preliminary psychometric analyses demonstrated that the factors have satisfactory internal consistency. In addition, low scores on the ability to signal sexual boundaries and high scores on risk behaviors were associated with self-reported peer sexual victimization, supporting the validity of the factors as measures of risk. Future validation and potential usage of the measure are discussed.     

Psychosexual characteristics of sexual offenders and the relationship to sexual reconviction

Abstract

The purpose of this study was to determine if the Multiphasic Sex Inventory (MSI) could be used to predict sexual reconviction. The MSI was administered to 119 convicted male sex offenders. Reconviction data were analysed using the receiver operating characteristic (ROC) over 2-, 5- and 10-year follow-up periods. The MSI scales Sexual Obsession and Paraphilia (Atypical Sexual Outlet) obtained good accuracy in predicting sexual reconviction over 2- and 5-year follow-up periods. A confirmatory factor analysis of the MSI scales yielded a four-factor solution: Sexual Deviance, Sexual Desirability, Dysfunctional/Justification, and Normal. The Sexual Deviance factor demonstrated good accuracy in predicting sexual reconviction at 2-year follow-up while the Normal factor was a poor predictor of sexual reconviction. Compared against an actuarial risk assessment measure for sexual offenders, the Sexual Obsession, Sexual/Social Desirability, and Sexual Dysfunction scales, and Sexual Deviance factor made a statistically significant contribution independent of the risk scale in predicting sexual reconviction. It is argued that rather than using the MSI solely as an assessment measure of psychosexual characteristics of sexual offenders in treatment programmes, it can be used to provide additional information as part of an assessment of risk of sexual reconviction.     

Substance abuse among sexual offenders: review of research and clinical implications*

Substance abuse, and in particular alcohol abuse, has been linked to the aetiology and maintenance of violent offending generally and sexual offending specifically. The current paper reviews the literature pertaining to substance abuse among sexual offenders and highlights theoretical developments in the area. An emphasis on issues associated with the therapeutic alliance is stressed when working with high-risk clients who present with multiple needs, including alcohol abuse. The discussion concludes with some practical suggestions regarding assessment and treatment of groups of moderate- to high-risk offenders.     

Effectiveness of sex offender treatment for psychopathic sexual offenders

Meta-analyses have suggested that sexual offender treatment (SOT) completion is associated with lowered sexual recidivism rates for convicted sexual offenders. The paucity of properly designed studies allows for the alternative explanation of less recidivism among treated samples as reflecting that lower risk offenders disproportionately self-select into treatment. A test of the "self-selection explanation" can occur by investigating treatment effect on known high-risk offenders. Psychopathy correlates with increased sexual recidivism risk, such that an exploration of the SOT effect on psychopathic offenders could clarify the accuracy of the self-selection hypothesis. Additionally, the debated degree to which psychopaths are treatable might obtain clarification by a research review. This article examines empirical findings concerning the effectiveness of SOT for psychopathic sexual offenders. Ten studies were found to meet the minimal quality standards used, stemming from only four data sources. Shortcomings of existing research precluded clear conclusions, though trends in the data are delineated.