Phallometric testing with sexual offenders: limits to its value

The World Federation of Societies of Biological Psychiatry (WFSBP) 2020 guidelines for the pharmacological treatment of paraphilic disorders

Objectives: The primary aim of these guidelines is to evaluate the role of pharmacological agents in the treatment and management of patients with paraphilic disorders, with a focus on the treatment of adult males. Because such treatments are not delivered in isolation, the role of specific psychotherapeutic interventions is also briefly covered. These guidelines are intended for use in clinical practice by clinicians who diagnose and treat patients, including sexual offenders, with paraphilic disorders. The aim of these guidelines is to bring together different views on the appropriate treatment of paraphilic disorders from experts representing different countries in order to aid physicians in clinical decisions and to improve the quality of care.Methods: An extensive literature search was conducted using the English-language-literature indexed on MEDLINE/PubMed (1990-2018 for SSRIs) (1969-2018 for hormonal treatments), supplemented by other sources, including published reviews.Results: Each treatment recommendation was evaluated and discussed with respect to the strength of evidence for its efficacy, safety, tolerability, and feasibility. The type of medication used depends on the severity of the paraphilic disorder and the respective risk of behaviour endangering others. GnRH analogue treatment constitutes the most relevant treatment for patients with severe paraphilic disorders.Conclusions: An algorithm is proposed with different levels of treatment for different categories of paraphilic disorders accompanied by different risk levels.

Stimuli used in the measurement of problematic sexual interests

Penile plethysmography (PPG) is the primary physiologic assessment method used to gauge sexual responses in adult men. Depending on the country or jurisdiction of assessment, stimuli used to elicit arousal can include videos, still images, and audio materials. It can depict a variety consenting and non-consenting sexual scenarios as well as neutral, non-sexual scenarios. Models in visual stimuli can be clothed, semi-clothed, or nude. Variation in stimuli modality and the type of sexual interest being tested can have a large impact on PPG outcomes. This paper reviews research on types of PPG stimuli, the different sexual interests being assessed, reliability and validity, and the impact of anonymizing models depicted in assessment materials. Innovations in stimuli development in three labs located in Canada, the United States, and the Czech Republic are also discussed. The work done in these three labs and the broader range of research on assessment stimuli are presented to highlight the need for a unified, multi-site, standardized approach to assess problematic sexual interests and their change in response to treatment.

Diagnostic Issues in the Paraphilias

PURPOSE OF REVIEW

To examine the empirical bases underlying the diagnoses of the paraphilias. We address issues concerning the reliability of these diagnoses and their implications for etiology, treatment, and prognosis.

RECENT FINDINGS

Research on these issues with the paraphilias is quite limited except for those paraphilics whose interests lead them to sexually offend. Even among these clients, research has, for the most part, failed to distinguish those who meet criteria for a paraphilia from those who do not, thereby limiting the possibility of drawing firm conclusions regarding the value of a paraphilic diagnosis. Speculations regarding the etiology of the paraphilias are for the most part limited to those who sexually offend and these theories do not distinguish those who do, or do not, meet paraphilic criteria. Treatment of sex offenders, when effective, appears to have the same impact regardless of whether or not clients meet criteria for a paraphilia. In terms of prognosis, it was only among untreated child molesters that a paraphilic diagnosis (in this case "pedophilia") predicted long-term outcome. In the face of these problems, we suggest a dimensional approach to diagnoses may represent an improvement over the current categorical model.

Convergent Validity of Three Measures of Sexual Sadism: Value of a Dimensional Measure

Sexual sadism can be described as the sexual pleasure produced by acts of cruelty and bodily punishment. The most common method for evaluating sexual sadism is clinical evaluation, that is, evaluation based on the diagnostic criteria of nosological instruments such as the Diagnostic and Statistical Manual of Mental Disorders ( DSM) or the International Classification of Diseases (ICD). It is also possible to evaluate sadistic sexual preferences by phallometry, which provides a physiological measure of sexual excitation by deviant and nondeviant scenarios. The most recently developed evaluation method is the Severe Sexual Sadism Scale (SESAS), a dimensional instrument that has been empirically validated. Despite the availability of all these measurement techniques, very little research has been conducted on their degree of convergence. Consequently, the aim of the current study was to assess the relationship between these three measures of sexual sadism. Our analyses were conducted on a sample of rapists ( N = 72), assessed in a maximum-security penitentiary. There was no significant relation between phallometric scores and other measures of sexual sadism. There was, however, an important correlation between SESAS scores and Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV) sexual sadism diagnosis. Our results are consistent with other phallometric studies, which reported no difference in the penile responses of individuals diagnosed as sadists and those not diagnosed as sadists. Results and implications for future research are discussed.

Increasing Valid Profiles in Phallometric Assessment of Sex Offenders with Child Victims: Combining the Strengths of Audio Stimuli and Synthetic Characters

Penile plethysmography (PPG) is a measure of sexual interests that relies heavily on the stimuli it uses to generate valid results. Ethical considerations surrounding the use of real images in PPG have further limited the content admissible for these stimuli. To palliate this limitation, the current study aimed to combine audio and visual stimuli by incorporating computer-generated characters to create new stimuli capable of accurately classifying sex offenders with child victims, while also increasing the number of valid profiles. Three modalities (audio, visual, and audiovisual) were compared using two groups (15 sex offenders with child victims and 15 non-offenders). Both the new visual and audiovisual stimuli resulted in a 13% increase in the number of valid profiles at 2.5 mm, when compared to the standard audio stimuli. Furthermore, the new audiovisual stimuli generated a 34% increase in penile responses. All three modalities were able to discriminate between the two groups by their responses to the adult and child stimuli. Lastly, sexual interest indices for all three modalities could accurately classify participants in their appropriate groups, as demonstrated by ROC curve analysis (i.e., audio AUC = .81, 95% CI [.60, 1.00]; visual AUC = .84, 95% CI [.66, 1.00], and audiovisual AUC = .83, 95% CI [.63, 1.00]). Results suggest that computer-generated characters allow accurate discrimination of sex offenders with child victims and can be added to already validated stimuli to increase the number of valid profiles. The implications of audiovisual stimuli using computer-generated characters and their possible use in PPG evaluations are also discussed.

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.

Sex Offender Risk Assessment and Management

Sexual violence is common and can have profound effects on victims compared with other forms of violence. This violence includes unwelcome and forced sexual contact on adults or children. Assessment of individuals who perpetrate sexual violence starts with a comprehensive biopsychosocial evaluation after a finding of guilt. Clinicians should then evaluate risk. Based on this assessment, a risk management plan should be developed, directed at the specific risk of the offender. Management options include external control (eg, incarceration, probation), psychotherapeutic interventions, pharmacologic interventions, and treatment of comorbidity. This organized approach aids in reducing the risk of future sexual violence.

Covert Association

This article describes the application of a procedure derived from Cautela's covert sensitization, which expands the behavioral chain leading to the terminal behavior and dispenses with the need for the consequences to be repeatedly experienced as aversive. Covert association was applied to a child molester who abused boys. Results indicate that treatment produced a significant reduction in urges and fantasies relating to boys and reduced sexual responding to boys. Other features of the intervention produced an increased comfort by the client concerning his adult homosexual orientation and more effective social functioning. The covert association procedure is recommended for wider use.

Olfactory Aversion and Directed Masturbation in the Modification of Deviant Preferences

A description is provided of the use of olfactory aversion and directed masturbation with a chronic child molester. Evidence of changes assessed by phallometry demonstrated the effectiveness of these procedures in reducing deviant sexual interests and in enhancing the sexual attractiveness of consensual sex with an adult partner. Attitude change procedures were also employed to facilitate the client's ability to act on these changed sexual preferences. Follow-up data revealed the enduring nature of the changed preferences and there was no evidence of further sexual misconduct.

Overcoming Deception in Sexual Preference Testing

This report describes a strategy that was developed to detect and correct attempts by a child molester to fake normal at phallometric testing. The strategy was successful and led to a full admission of deviant sexual preferences that could then be addressed in treatment.

Ammonia Aversion With an Exhibitionist

This case study illustrates the effectiveness of a simple aversion procedure. Having an exhibitionist use smelling salts as an aversive agent effectively reduced the frequency and intensity of urges to expose and as a result, eliminated acts of exposing. Furthermore, these reductions in exhibitionistic behaviors markedly improved the client's mood and strengthened his self-confidence, thereby allowing him to expand his social life, begin a relationship, and plan educational upgrading to obtain a secure job. Suggestions aremade for the clinical use of the procedure.

Standardization of Penile Plethysmography Testing in Assessment of Problematic Sexual Interests

Penile plethysmography (PPG) is an objective measure of sexual arousal for men, commonly used to assess sexual arousal to both abnormal (i.e., paraphilic) and normal stimuli. While PPG has become a standard measure in the assessment and treatment of male sex offenders and men with paraphilic interests in both Canada and the United States, there is a lack of standardization of stimulus sets and interpretation of results between sites. The current article critically reviews the current state of the art while highlighting clinical and research efforts that may be undertaken in an attempt to reduce issues arising from lack of standardization across sites. Types and themes of stimulus sets, assessment apparatuses, laboratory preparation, and testing procedures are discussed. The continued development of standardized testing protocol and procedures across multiple international sites continues to be encouraged to promote unified PPG administration and interpretation, thus further enhancing the practical utility of the measurements and decreasing inter-rater discrepancies and error.

Assessment of problematic sexual interests with the penile plethysmograph: an overview of assessment laboratories

Phallometric testing, or penile plethysmography (PPG), is an objective measure of sexual arousal for males. While extensive research on the reliability and validity of PPG has promoted its reputation as the "gold standard" of objective measurement of sexual arousal, there is a lack of standardization of stimulus sets and interpretation of results between sites. This article describes the laboratory protocol employed for PPG at the Royal Ottawa Mental Health Centre's Sexual Behaviours Clinic (SBC) in Ottawa, Ontario, as well as those used by the Sexual Behaviors Clinic and Lab (SBCL) in the Community and Public Safety Psychiatry Division (CPSPD) of the Department of Psychiatry and Behavioral Sciences at Medical University of South Carolina (MUSC) in Charleston, South Carolina. The need for standardization in both testing protocol and stimuli use across sites are highlighted.

A pilot development of virtual stimuli depicting affective dispositions for penile plethysmography assessment of sex offenders

There are concerns regarding the reliability, realism, and validity of stimulus materials used in the assessment of sexual interests among sex offenders. This article explores new stimulus materials for use with penile plethysmography (PPG) assessments. First, this paper presents a pilot study where undergraduate students rated virtual characters (male and female) on perceived age. In addition, the materials developed are unique in that they depict the characters exhibiting varying affective dispositions, including neutral, fearful, sad, joyful, and seductive. Participants in the first study were also asked to identify the affective disposition of the virtual characters, and results suggest that affective disposition was largely perceived as intended, especially in terms of identifying the general emotional valence of the affective dispositions (i.e., positive versus negative). In a second pilot study, we used the computer-generated images to measure sexual arousal responses in a group of non-deviant males recruited in the community. Responses measured through penile plethysmography suggest participants responded to the stimuli as expected, as the greatest amount of sexual arousal was recorded when participants were shown the adult female character. In addition, participants responded with significant arousal only when the adult female character was depicted as sexually open (joyful or seductive), rather than sexually closed or neutral. Results suggest these materials may discriminate sexual interests if applied within clinical forensic assessment of sex offenders.

[Pedophilia: etiology, diagnostics and therapy]

Child sexual abuse is one of the most destructive events for healthy child development. Following psychiatric classification systems, pedophilia must be distinguished from child sexual abuse. Approximately only one half of all child abusers fulfill the diagnostic criteria for pedophilia which is defined as a persistent or dominating sexual preference for prepubescent children characterized by persistent thoughts, fantasies, urges, sexual arousal or behavior. This article describes the diagnostic criteria and potential differential diagnoses as well as epidemiological and etiological findings. From an etiological point of view multifactorial mechanisms are currently considered to be responsible especially genetic factors, learning theoretical and neurobiological factors. Psychotherapeutic and pharmaceutical treatment options will be discussed. According to the current state of knowledge cognitive-behavioral psychotherapy is the method of choice in the treatment of pedophilia and has demonstrated positive treatment effects in meta-analyses regarding relapse prevention. Medicinal treatment of pedophilia is only indicated for severe forms of pedophilia. Important aspects of risk management in the treatment of pedophilia and aspects which must be considered in the forensic psychiatric assessment are presented.

Direct and indirect measures of sexual maturity preferences differentiate subtypes of child sexual abusers

To aid risk assessment, management, and treatment planning it is essential to assess child sexual abusers' deviant sexual interests (DSI) and preferences (DSP) for sex with children. However, measurement of DSI/DSP is fraught with psychometric problems. In consequence, research interest has shifted to latency-based indirect measures as a measurement approach to complement self-report and physiological assessment. Utilizing the Explicit and Implicit Sexual Interest Profile (EISIP)-a multimethod approach consisting of self-report, viewing time, and Implicit Association Test (IAT) DSI/DSP measures-we replicated phallometric DSI/DSP differences between child sexual abuser subgroups in a sample of intrafamilial, extrafamilial, and child pornography offenders. DSI/DSP was associated with recidivism risk, offense-behavioral measures of pedophilic interest, and sexual fantasizing. It also negatively correlated with antisociality. Distinguishing between child sexual abuser subtypes and being related to recidivism risk, the EISIP is a useful tool for sexual offender assessments.

LGBTQs and the DSM-5: a critical queer response

This article outlines a community-based collaboration in Toronto, Canada that led to an official response to the APA's call for comments and suggestions regarding diagnostic criteria revisions for the DSM-5 with a focus on disorders that have or may have an impact on the lives of LGBTQ people. We identified two diagnostic categories: gender dysphoria and paraphilias. The diagnostic categories and their respective disorders are deconstructed utilizing a critical queer analysis with recommendations for change. In addition, we explore the limitations of the APA review process itself and politics within the APA and the LGBTQ communities.

Phallometric assessments of sexual interests: an update

This paper reviews recent evidence on the value of phallometric (i.e., erectile) measures of sex offenders plus earlier crucial papers. Distinctions are made between types of measuring devices with the volumetric instrument appearing to be the most sensitive. Considering the meaning of responses it is concluded that arousal below 10 % of full erection is not reliably interpretable and that only deviant profiles (those displaying equal or greater arousal to deviant sex) can be confidently interpreted. The specificity and sensitivity of phallometry is satisfactory with child molesters but not with other types of sex offenders, although there remains a need to satisfactorily distinguish among subtypes of child molesters. There are enduring disagreements concerning the meaning of rapists' responses and no test has yet reliably identified deviance among exhibitionists. It is concluded that despite its long history, problems remain with phallometric assessments and clinicians should be cautious in interpreting the meaning of these responses.

Using eye tracking to identify faking attempts during penile plethysmography assessment

Penile plethysmography (PPG) is considered the most rigorous method for sexual interest assessment. Nevertheless, it is subject to faking attempts by participants, which compromises the internal validity of the instrument. To date, various attempts have been made to limit voluntary control of sexual response during PPG assessments, without satisfactory results. This exploratory research examined eye-tracking technologies' ability to identify the presence of cognitive strategies responsible for erectile inhibition during PPG assessment. Eye movements and penile responses for 20 subjects were recorded while exploring animated human-like computer-generated stimuli in a virtual environment under three distinct viewing conditions: (a) the free visual exploration of a preferred sexual stimulus without erectile inhibition; (b) the viewing of a preferred sexual stimulus with erectile inhibition; and (c) the free visual exploration of a non-preferred sexual stimulus. Results suggest that attempts to control erectile responses generate specific eye-movement variations, characterized by a general deceleration of the exploration process and limited exploration of the erogenous zone. Findings indicate that recording eye movements can provide significant information on the presence of competing covert processes responsible for erectile inhibition. The use of eye-tracking technologies during PPG could therefore lead to improved internal validity of the plethysmographic procedure.

Assessment of implicit sexual associations in non-incarcerated pedophiles

Offences committed by pedophiles are crimes that evoke serious public concern and outrage. Although recent research using implicit measures has shown promise in detecting deviant sexual associations, the discriminatory and predictive quality of implicit tasks has not yet surpassed traditional assessment methods such as questionnaires and phallometry. The current research extended previous findings by examining whether a combination of two implicit tasks, the Implicit Association Task (IAT) and the Picture Association Task (PAT), was capable of differentiating pedophiles from non-pedophiles, and whether the PAT, which allows separate analysis for male, female, boy and girl stimulus categories, was more sensitive to specific sexual associations in pedophiles than the IAT. A total of 20 male self-reported pedophiles (10 offender and 10 non-offenders) and 20 male self-reported heterosexual controls completed the two implicit measures. Results indicated that the combination of both tasks produced the strongest results to date in detecting implicit pedophilic preferences (AUC = .97). Additionally, the PAT showed promise in decomposing the sexual associations in pedophiles. Interestingly, as there was an equal distribution of offenders and non-offenders in the pedophile group, it was possible to test for implicit association differences between these groups. This comparison showed no clear link between having these implicit sexual associations and actual offending.

The Validity of Implicit Association Test (IAT) measures of sexual attraction to children: a meta-analysis

The current study presents a quantitative review of the discriminative and convergent validity of Implicit Association Test (IAT) measures adapted to assess sexual interest in children. IAT measures were able to distinguish sex offenders against children (SOC) from non-SOC (M weighted d from random-effects = 0.63, 95 % CI [0.42-0.83], N = 707, k = 12). The largest group differences were found between SOC and non-offenders, followed by non-sex offenders and rapists. IAT measures using sex versus not sex (and similar attribute categories, such as sex vs. neutral) provided superior discrimination compared to IAT measures using sexy versus not sexy (and similar attribute categories, such as erotic vs. non-erotic). The IAT measures had a moderate relationship to self-report (r = .27, 95 % CI [.13-.40], N = 182), sexual offense history variables (r = .27, 95 % CI [.08-.43], N = 145), and viewing time (r = .30, 95 % CI [.16-.43], N = 180) measures of sexual interest in children. Although these IAT measures can discriminate between groups and show convergence with other measures of sexual interest, a better understanding of the construct validity of these tools is required before their use in the assessment, treatment, and supervision of sex offenders.

Sexual sadism in the context of rape and sexual homicide: an examination of crime scene indicators

This study investigates the convergent and predictive validity of behavioral crime scene indicators of sexual sadism in the context of rape and sexual homicide. The study is based on a sample of 268 adult males sentenced to a federal penitentiary in Canada. Information regarding crime scene behaviors was gathered from police records, a clinical interview with a psychologist, and a semistructured interview with the offender. A series of logistic regressions were performed to determine whether behavioral crime scene indicators of sexual sadism were associated with an official diagnosis of sexual sadism and were able to distinguish between sexual aggressors against women and sexual murderers. Findings suggest that several crime scene behaviors overlap with an official diagnosis of sexual sadism as well as being able to distinguish between sexual aggressors of women and sexual murderers. Importantly, the majority of crime scene behaviors associated with a clinical diagnosis of sexual sadism are not the same as those associated with sexual homicide.

Diagnostic accuracy of eye movements in assessing pedophilia

INTRODUCTION

Given that recurrent sexual interest in prepubescent children is one of the strongest single predictors for pedosexual offense recidivism, valid and reliable diagnosis of pedophilia is of particular importance. Nevertheless, current assessment methods still fail to fulfill psychometric quality criteria.

AIMS

The aim of the study was to evaluate the diagnostic accuracy of eye-movement parameters in regard to pedophilic sexual preferences.

METHOD

Eye movements were measured while 22 pedophiles (according to ICD-10 F65.4 diagnosis), 8 non-pedophilic forensic controls, and 52 healthy controls simultaneously viewed the picture of a child and the picture of an adult. Fixation latency was assessed as a parameter for automatic attentional processes and relative fixation time to account for controlled attentional processes.

MAIN OUTCOME MEASURES

Receiver operating characteristic (ROC) analyses, which are based on calculated age-preference indices, were carried out to determine the classifier performance. Cross-validation using the leave-one-out method was used to test the validity of classifiers.

RESULTS

Pedophiles showed significantly shorter fixation latencies and significantly longer relative fixation times for child stimuli than either of the control groups. Classifier performance analysis revealed an area under the curve (AUC) = 0.902 for fixation latency and an AUC = 0.828 for relative fixation time. The eye-tracking method based on fixation latency discriminated between pedophiles and non-pedophiles with a sensitivity of 86.4% and a specificity of 90.0%. Cross-validation demonstrated good validity of eye-movement parameters.

CONCLUSIONS

Despite some methodological limitations, measuring eye movements seems to be a promising approach to assess deviant pedophilic interests. Eye movements, which represent automatic attentional processes, demonstrated high diagnostic accuracy.

Behavioral discriminators of sexual sadism and paraphilia nonconsent in a sample of civilly committed sexual offenders

Sexual sadism continues to be a diagnosis fraught with controversy concerning its reliability and validity. The current study examined the offense behavior of 39 civilly committed sexual offenders diagnosed with sexual sadism compared to a group of similarly committed individual diagnoses with Paraphilia Not Otherwise Specified (NOS)- Nonconsent. In addition, offense elements common across studies of sadism were identified. Specifically, offense behaviors including victim abduction and confinement, beating the victim during a sexual assault, and using restraints were indicative of sexual sadism across studies. In addition, this study found the use of noncontingent threats as well as gestures of mutuality to be more common among sadists. Results overall suggest that sadistic acts may be more characterized by humiliation of the victim through the exercise of power and control than by the use of violence. Differential diagnosis between Sexual Sadism and Paraphilia NOS-Nonconsent, may be aided by close inspection of offense behavior.

The World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the biological treatment of paraphilias

OBJECTIVES

The primary aim of these guidelines was to evaluate the role of pharmacological agents in the treatment and management of paraphilia, with a focus on the treatment of adults males. Because such treatments are not delivered in isolation, the role of specific psychosocial and psychotherapeutic interventions was also briefly covered. These guidelines are intended for use in clinical practice by clinicians who diagnose and treat patients with paraphilia. The aim of these guidelines is to improve the quality of care and to aid physicians in clinical decisions.

METHODS

The aim of these guidelines was to bring together different views on the appropriate treatment of paraphilias from experts representing different continents. To achieve this aim, an extensive literature search was conducted using the English language literature indexed on MEDLINE/PubMed (1990-2009 for SSRIs) (1969-2009 for antiandrogen treatments), supplemented by other sources, including published reviews.

RESULTS

Each treatment recommendation was evaluated and discussed with respect to the strength of evidence for its efficacy, safety, tolerability and feasibility.

CONCLUSIONS

An algorithm was proposed with six levels of treatment for different categories of paraphilias.

Blanchard's Autogynephilia Theory: a critique

Over the last 20 years, Ray Blanchard, Ph.D., with a variety of coauthors and collaborators, has proposed a theory that links the sexual orientation of male-to-female transsexuals with the presence or absence of autogynephilia (erotic arousal by the thought or image of "himself" as a woman). Blanchard's Autogynephilia Theory suggests that the association between sexual orientation and autogynephilia among male-to-female transsexuals is clinically important and the association is always (or almost always) present. Although the theory has been criticized by clinicians, researchers, and transsexuals themselves, it has not been critiqued in a peer-reviewed article previously. This article will attempt to fill that gap. Key studies on which the theory is based will be analyzed and alternative interpretations of the data presented. I conclude that although autogynephilia exists, the theory is flawed.

Does victim age differentiate between perpetrators of sexual child abuse? A study of mental health, psychosocial circumstances, and crimes

To test the theory that sexual offenders who abuse very young children (0-5 years) have more severe mental health and psychosocial problems than those who victimize older children, authors compared psychiatric diagnoses, social circumstances, and crime-related data in all sexual offenders against minors referred to forensic psychiatric investigation in Sweden during a 5-year period. Thirty-one men had committed index crimes involving victims between the ages of 0 and 5 years (Group 1), 90 had 6-to 11-year-old victims (Group 2), and 41 had 12- to 15-year-old victims (Group 3). All three offender groups were characterized by severe mental health problems, in many cases fulfilling American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (4th ed.) criteria for both Axis I and Axis II diagnoses, but these problems did not differ between groups. Neither did social situation or sexual orientation. Offenders with 0- to 5-year-old victims significantly more often abused both boys and girls. Frequencies of retrospectively diagnosed childhood-onset behavior disorders were high in all three offender groups. The authors' data did not support previous findings of increasingly severe mental health problems with decreasing victim age.

Discriminative and predictive validity of the penile plethysmograph in adolescent sex offenders

The current study addresses the discriminative and predictive validity of the penile plethysmograph (PPG) in a sample of 132 male adolescent sex offenders who were admitted to a sex offender treatment program. The subjects were assessed pretreatment and posttreatment, under two different instructions sets: an Arouse condition, where subjects allowed themselves to become aroused; and a Suppress condition, where subjects attempted to suppress or control their arousal. Under the pretreatment Arouse condition, the group with male child victims demonstrated significantly greater arousal to child stimuli than the group with female nonchild victims. However, the group with female child victims could not be differentiated from the group with female nonchild victims. Under the Suppress condition, there was no evidence of discriminative validity for any of the PPG indices. As for predictive validity, posttreatment arousal to male and female children was significantly related to sexual offense recidivism. Posttreatment inability to suppress deviant arousal to male and female children was also significantly related to sexual offense recidivism over the 6-year follow-up period. In light of these findings, the implications for adolescent sex offender research and treatment are discussed.

The importance of individual differences in pornography use: theoretical perspectives and implications for treating sexual offenders

This article reviews the extant literature regarding pornography's influence on antisocial attitudes, sexual arousal, and sexually aggressive behavior in both noncriminal and criminal samples. The article concludes that when examined in the context of multiple, interacting factors, the findings are highly consistent across experimental and nonexperimental studies and across differing populations in showing that pornography use can be a risk factor for sexually aggressive outcomes, principally for men who are high on other risk factors and who use pornography frequently. Finally, this article presents theoretical implications based on these findings, as well as some clinical implications relevant to the assessment and treatment of sexual offenders.

Neurobiologische Forschung bei Pädophilie – Ergebnisse und deren Konsequenzen für die Diagnostik pädosexueller Straftäter

Die Schwierigkeit bei der Diagnostik pädophiler Sexualstraftäter liegt in der validen Einschätzung eines pädosexuellen Interesses. Die aktuell angewendeten Verfahren und Methoden können die psychometrischen Gütekriterien nur zum Teil erfüllen. Angesichts einer zunehmenden Fülle bildgebender Befunde zu den neuronalen Korrelaten pädophilen Erlebens scheinen sich neue Möglichkeiten für die Diagnostik pädosexueller Straftäter zu ergeben. Die Zusammenfassung aller bisherigen neurobiologischen Untersuchungen zeigt allerdings sehr heterogene Ergebnisse. Diagnostisch relevante Befunde, die auf die Einzelperson valide übertragen werden können, existieren noch nicht. Auch eine Überprüfung der psychometrischen Gütekriterien für die angewendeten neurobiologischen Paradigmen steht noch aus. Ihr Potential in Hinblick auf die Diagnostik pädosexueller Straftäter muss die neurobiologische forensisch-psychiatrische Forschung erst noch unter Beweis stellen.

Treatment of sexual offenders with psychopathic traits: recent research developments and clinical implications

This article provides a review of recent literature related to the treatment of psychopathy in forensic settings, with particular focus on studies with sexual offenders. The lack of empirical support for the position that psychopaths are untreatable is noted, and data suggesting optimism is discussed. Research demonstrating an interaction between psychopathy and substance abuse and between psychopathy and sexual deviance is also presented. Both substance abuse disorders and inappropriate arousal are frequently encountered in high-risk groups of sexual offenders. These topics are of relevance, in that the question of whether treatment is beneficial with high-risk sexual offenders, including those who are psychopathic, cannot be answered unless groups presenting with typical concurrent disorders (paraphilias, substance abuse, dependence) are discussed. It is argued that, although the evidence is still preliminary, there is reason for optimism with reference to whether psychopathic sexual offenders are responsive to treatment, including offenders presenting with concurrent disorders.

Sex offender care for adolescents in secure care: critical factors and counseling strategies

Sexual offenses perpetrated by adolescents have reportedly reached epidemic proportions. Adolescent sex offenders have been transferred to secure care facilities for their primary care. The elevated awareness and recognition of the problematic growth of adolescent sexual offenses has stimulated discussion among psychologists concerning the etiology, characteristics, classification, assessment, treatment interventions, and risk of recidivism. This article explores the critical factors and counseling strategies of those adolescents who have been adjudicated of sexual offenses.

The utility of the diagnosis of pedophilia: a comparison of various classification procedures

This study examined the utility of the diagnosis of pedophilia in a sample of extra-familial child molesters assessed at a university teaching hospital between 1982 and 1992. Pedophilia was defined in one of four ways: (1) DSM diagnosis made by a psychiatrist; (2) deviant phallometric profile; (3) DSM diagnosis and a deviant phallometric profile; and, (4) high scores based on the Screening Scale for Pedophilic Interest (Seto & Lalumière, 2001). Demographic data, psychological tests, and offence history were obtained and group differences were analyzed along with the ability of certain variables to contribute uniquely to the classification of pedophilia. Results indicated that few significant differences existed on psychological measures between pedophilic and nonpedophilic extra-familial child molesters regardless of the classification system employed. Finally, results indicated that the procedures used to define pedophilia were not significantly related to one another. Results are discussed in terms of the utility of the diagnosis of pedophilia.

Assessing sexual arousal with adolescent males who have offended sexually: self-report and unobtrusively measured viewing time

Sexual arousal was assessed using three approaches: the Affinity (Version. 1.0) computerized assessment of unobtrusively measured viewing time (VT), Affinity self-report ratings of sexual attractiveness, and a self-report sexual arousal graphing procedure. Data were collected from 78 males, aged 12-18 (M=15.09; SD=1.62), who acknowledged their sexual assaults. The pattern of responses to all three assessment techniques was remarkably similar, with maximal sexual interest demonstrated and reported for adolescent and adult females. Both self-report procedures could significantly distinguish those adolescents who assaulted a child from those who assaulted peers or adults. The self-report procedures could also significantly discriminate those adolescents with male child victims. The Affinity VT approach significantly differentiated those adolescents who assaulted male children from those who assaulted other individuals. No assessment technique could accurately identify those adolescents with exclusively female child victims. Overall, the results suggest that structured, self-report data regarding sexual interests can be useful in the assessment of adolescents who have offended sexually.

Assessing sexual arousal with adolescent males who have offended sexually: self-report and unobtrusively measured viewing time

Sexual arousal was assessed using three approaches: the Affinity (Version. 1.0) computerized assessment of unobtrusively measured viewing time (VT), Affinity self-report ratings of sexual attractiveness, and a self-report sexual arousal graphing procedure. Data were collected from 78 males, aged 12-18 (M=15.09; SD=1.62), who acknowledged their sexual assaults. The pattern of responses to all three assessment techniques was remarkably similar, with maximal sexual interest demonstrated and reported for adolescent and adult females. Both self-report procedures could significantly distinguish those adolescents who assaulted a child from those who assaulted peers or adults. The self-report procedures could also significantly discriminate those adolescents with male child victims. The Affinity VT approach significantly differentiated those adolescents who assaulted male children from those who assaulted other individuals. No assessment technique could accurately identify those adolescents with exclusively female child victims. Overall, the results suggest that structured, self-report data regarding sexual interests can be useful in the assessment of adolescents who have offended sexually.

Sexual fantasies of adolescent male sex offenders in residential treatment: a descriptive study

An attenuating sample of 87 male adolescent sexual offenders logged sexual fantasies during their entire time in therapy. These patients were attending residential treatment and kept a log recording all normal and deviant sexual fantasies which they experienced. Patients recorded which fantasies were interrupted and which fantasies were accompanied by masturbation. Typically, at the beginning of treatment, the reported rate of normal fantasies was maximal, the occurrence of deviant fantasies was minimal, and there was little effort to interrupt the deviant fantasies. The reported frequency of deviant fantasies increased substantially (about 380%) during the first 5 months of treatment and then steadily declined (approximately 47%) over the remaining months in therapy. Following an initial decline in the early months of treatment, an increase in the rates of normal fantasies was reported. Additionally, over the course of treatment, the frequency of deviant fantasies decreased relative to all fantasies. While deviant fantasies remained predominant to normal sexual fantasies and were more frequently paired with masturbation, patients reported substantial changes in the proportion of deviant fantasies that were interrupted (from about 20% to 70%). Implications of the results for juvenile sex offender treatment are discussed.

Sexually violent predator evaluations: empirical evidence, strategies for professionals, and research directions

Several states have passed civil commitment laws that allow the precautionary detention of sex offenders who have completed their criminal sentences. Over 2,500 sex offenders have been committed across states with such statutes and several thousand more sex offenders have been evaluated. Most statutes call for an evaluation of risk by a mental health professional and, although each state statute is worded differently, three main elements common to sexually violent predator evaluations are used to guide evaluators: mental abnormality, volitional capacity, and likelihood of future sexual violence. The current article presents empirical evidence for the main tenants of these forensic evaluations, provides recommendations for evaluators in light of current limitations of evidence, and offers suggestions for future research in this area of forensic assessment.

A model for the assessment of static and dynamic factors in sexual offenders

A sample of 519 sexual offenders who were consecutive admissions to the Ontario Region of Correctional Service of Canada (CSC) were assessed with reference to a large series of variables thought to be related to sexual offending. We grouped these variables into five domains: criminality, social competence, sexual deviance, substance abuse and treatment readiness. We standardized scores on each of these domains to facilitate the calculation of total scores for each domain. We then performed a variety of analyses to determine whether these domains might constitute a reasonable model for the comprehensive evaluation of sexual offenders. Analyses indicated that overall the model received a moderate level of support.

Toward a multidimensional model for sexual recidivism risk

The paradigm underlying current sexual offender recidivism risk assessment procedures conceptualizes such risk in a linear fashion, ranging on a single continuum from 0% to 100%. Each risk and protective characteristic thought of relevance in an evaluation is used as an indicator of increased or decreased risk, respectively, along that same continuum. This conceptualization of risk was useful as a starting place for the application of empirically supported risk and protective factors. On the other hand, this perspective is likely simplistic and therefore potentially results in some errors that a more sophisticated assessment model would avoid. Recent research findings indicate support for a multidimensional model for sexual recidivism risk. This article explores what we already know about the existence of multiple risk dimensions, what those dimensions may be, and which risk factors assess which dimension. Implications for risk assessment procedures are discussed including how risk evaluations using this model might be conducted.

An exploration of developmental factors related to deviant sexual preferences among adult rapists

The aim of this study was to investigate developmental factors related to deviant sexual preferences in a sample of 118 sexual aggressors against women. For each subject, developmental factors were collected through a semistructured interview, whereas sexual preferences were assessed phallometrically using French translations of audiotaped stimuli developed by G. G. Abel, E. B. Blanchard, J. V. Becker, and A. Djenderedjian (1978). Using multiple regression analyses, our results showed that a sexually inappropriate family environment, use of pornography during childhood and adolescence, and deviant sexual fantasies during childhood and adolescence are related to the development of deviant sexual preferences. These results are in agreement with Knight and Sims-Knight's model of sexual aggression (R. A. Knight & J. E. Sims-Knight, in press).

Are rapists differentially aroused by coercive sex in phallometric assessments?

In this chapter we examine whether rapists are sexually aroused by coercive, nonconsensual sex. This question is theoretically important because it speaks to a potential sexual motivation underlying rape. It is also clinically important in that it may reveal an important assessment and treatment target. We first revisit and update quantitative reviews of studies that examined the phallometric responses of rapists and other men. We then present new data on the discriminative and diagnostic validity of a phallometric test for rapists. Finally, we discuss methodological and conceptual issues in phallometric assessment and the nature of rapists' sexual interests.

A brief history of behavioral and cognitive behavioral approaches to sexual offenders: Part 1. Early developments

This is the first of two papers which briefly outline the development of behavioral and cognitive behavioral treatment of sexual offenders from the mid-1800s to 1969. We first consider the historic role of Sigmund Freud and note that a broad scientific interest in deviant sexual behaviour was well established by 1900. In the early to mid-20th century, two psychologies were prominent in the development of behaviorial approaches, those of John B. Watson and Alfred Kinsey. Behavior therapy for a variety of problems emerged in the 1950s and soon found application to deviant sexuality. The development of penile plethysmography helped to focus interest on deviant sexual preference and behavior. While nonbehavioral approaches to sexual offenders paralleled these developments, a combination of behavioral and cognitive behavioral treatments began to emerge in the late 1960s which ultimately developed into the approaches more commonly seen today.

A brief history of behavioral and cognitive behavioral approaches to sexual offender treatment: Part 2. The modern era

This paper is the second in our attempt to highlight the major influences, trends, and emerging issues in cognitive behavioral approaches to treating sexual offenders. In this paper the developments from 1970 until the present are covered.

Sexual deviancy: diagnostic and neurobiological considerations

Individuals who engage in sexual offenses may be afflicted with a paraphilic disorder or sexual deviation syndrome. Paraphilias are psychiatric disorders characterized by deviant and culturally non-sanctioned sexual fantasies, thoughts, and/or behaviors. A proportion of these individuals may also suffer from symptoms of mental illness that can go unrecognized. Although the etiology and pathophysiology of paraphilic disorders continue to be under investigation, data from empirical, biomedical, and psychopharmacological studies suggest abnormalities at a biological level. This article will discuss and review clinical and neurobiological characteristics of the paraphilias. To this end, we will begin with a general exploration and overview of basic principles that are germane to the subject matter and will conclude with an examination of the most recent relevant research findings.

Treatment of adult sexual offenders: a therapeutic cognitive-behavioural model of intervention

Recent research indicates that, of the various forms of treatment available to sexual offenders, cognitive-behavioural methods are likely to have the greatest impact in reducing rates of sexual re-offending. Cognitive-behavioural treatment typically targets attitudes that support sexual offending, anger management, victim empathy, deviant sexual arousal, and relapse prevention. More recently, treatment has targeted cognitive processes more generally, management of other emotional states in addition to anger, intimacy deficits, and risk self-management (Marshall, Anderson, & Fernandez, 1999; Yates, Goguen, Nicholaichuk, Williams, & Long, 2000). This article describes the components of cognitive-behavioural treatment with sexual offenders, including recent developments, assessment, treatment methods, and the importance of therapist characteristics on the therapeutic process and on treatment outcome.