The Role of Testosterone in Sexuality and Paraphilia—A Neurobiological Approach. Part II: Testosterone and Paraphilia

Is Stopping of Testosterone-Lowering Medication in Men Convicted of Sexual Offenses Associated With an Increase in Recidivism Risk?

There is some evidence that testosterone-lowering medications (TLM) may be an effective treatment for men convicted of sexual offenses by attenuating paraphilic sexual fantasies and behaviors and reducing the recidivism risk. To date, however, only little is known about the effects of TLM stopping on risk-relevant aspects. Therefore, the current study aimed at examining the recidivism risk as measured by Stable-2007 as well as official records of reoffenses in 29 men having stopped TLM treatment as compared to 37 men with ongoing TLM treatment. The Stable-2007 was rated retrospectively at 4 time points: committal to forensic treatment (T1), starting (T2) and stopping of TLM treatment (T3), and at reporting date (T4). There was a significant decrease in Stable-2007 scores over time, but there were no significant group differences. Within the stopped-TLM group, there were no significant differences between T3 and T4, implying that the recidivism risk remained stable over an average observation period of 4.5 years after TLM stopping. In addition, there was no significant difference in actual reoffending rates between the groups. For sexual reoffending, the percentages were 17.2% for the stopped-TLM group and 10.8% for the ongoing-TLM group. However, although the current results suggest that there is at least no increase in risk assessment (i.e., Stable-2007) after having stopped TLM, the actual reoffending rates of both groups were higher than expected. This once again demonstrates that TLM stopping decisions remain very difficult to make. Further studies are urgently needed to draw clearer conclusions.

Paraphilia in Geriatric Patients: A Case Series From a General Hospital Setting

Stroke can lead to various late-presenting complications that manifest weeks to months after acute stroke. While sexual dysfunction is common among stroke patients, hypersexuality and paraphilia are rare manifestations. This case series presents five cases of paraphilia showing the onset of abnormal sexual behaviors following an incident of stroke. The paraphilias in these five cases include sexual sadism, exhibitionism, transvestic fetishism, sexual masochism, fetishism, and zoophilia. Each case presents a unique manifestation of atypical sexual tendencies along with neuroimaging data and treatment approach. This case series contributes to the knowledge about the relationship between the incidence of stroke and the onset of paraphilia.

Sexual offenses and the brain

Sexual offenses are a great concern worldwide due to the devastating physical and psychological consequences the victims of such crimes often experience. It is an important task to investigate potential mechanisms that may underlie sexual offending and predispose an individual for such antisocial behavior. Advanced techniques in neuroscience are increasingly used to uncover biomarkers in psychiatric disorders and organic brain disease. As this type of research is flourishing, preliminary studies with the aim to explore the neural basis of sex offenders have started to appear. To this purpose, researchers began to study the brain's structural and functional changes and the neurocognitive profiles of sex offenders, in comparison to nonoffenders and nonsex offenders, or among different subtypes of sex offenders. Most of the research to date has focused on pedophilia, with some inconsistent findings, which hampers the translation of the results into the forensic and clinical context. Any attempt to increase convergent evidence may profit from the harmonization of data analysis and avoidance of methodological inconsistencies, which can account for the different results across studies. Today, uncovering the neural basis of sex offences has to become a priority, not only for clinical interventions, but might also be important knowledge for crime prevention.

Patterns of risk-Using machine learning and structural neuroimaging to identify pedophilic offenders

Background

Child sexual abuse (CSA) has become a focal point for lawmakers, law enforcement, and mental health professionals. With high prevalence rates around the world and far-reaching, often chronic, individual, and societal implications, CSA and its leading risk factor, pedophilia, have been well investigated. This has led to a wide range of clinical tools and actuarial instruments for diagnosis and risk assessment regarding CSA. However, the neurobiological underpinnings of pedosexual behavior, specifically regarding hands-on pedophilic offenders (PO), remain elusive. Such biomarkers for PO individuals could potentially improve the early detection of high-risk PO individuals and enhance efforts to prevent future CSA.

Aim

To use machine learning and MRI data to identify PO individuals.

Methods

From a single-center male cohort of 14 PO individuals and 15 matched healthy control (HC) individuals, we acquired diffusion tensor imaging data (anisotropy, diffusivity, and fiber tracking) in literature-based regions of interest (prefrontal cortex, anterior cingulate cortex, amygdala, and corpus callosum). We trained a linear support vector machine to discriminate between PO and HC individuals using these WM microstructure data. Post hoc, we investigated the PO model decision scores with respect to sociodemographic (age, education, and IQ) and forensic characteristics (psychopathy, sexual deviance, and future risk of sexual violence) in the PO subpopulation. We assessed model specificity in an external cohort of 53 HC individuals.

Results

The classifier discriminated PO from HC individuals with a balanced accuracy of 75.5% (sensitivity = 64.3%, specificity = 86.7%, P ₅₀₀₀ = 0.018) and an out-of-sample specificity to correctly identify HC individuals of 94.3%. The predictive brain pattern contained bilateral fractional anisotropy in the anterior cingulate cortex, diffusivity in the left amygdala, and structural prefrontal cortex-amygdala connectivity in both hemispheres. This brain pattern was associated with the number of previous child victims, the current stance on sexuality, and the professionally assessed risk of future sexual violent reoffending.

Conclusion

Aberrant white matter microstructure in the prefronto-temporo-limbic circuit could be a potential neurobiological correlate for PO individuals at high-risk of reoffending with CSA. Although preliminary and exploratory at this point, our findings highlight the general potential of MRI-based biomarkers and particularly WM microstructure patterns for future CSA risk assessment and preventive efforts.

Androgens, brain and androgen deprivation therapy in paraphilic disorders: A narrative review

Sexual delinquency is a global problem where those with paraphilic disorders, such as paedophiles, are more likely to commit and reoffend. Androgen deprivation therapy (ADT) has been suggested as a solution. The objective of this narrative review is to present current information on its risks, benefits and limitations as a treatment for paraphilias. The importance of testosterone in sexual function, the effect of its deficiency by age or by pharmacological treatment (anti-androgens, GnRH agonists and GnRH antagonists) and the effect of testosterone replacement therapy will be reviewed. The relationship between androgens, brain, sexual behaviour and pathophysiology of paraphilic disorders will also be explored. ADT reduces sexual urges, but has adverse effects and, because its reversible nature, it does not ensure less recidivism. Likewise, the research quality of ADT drugs is limited and not enough to support their use. Child sex offenders, and not paraphilic subjects who have not committed assaults, show signs of elevated prenatal exposure to androgens and a higher methylation state of the androgen receptor gene. Sexual behaviour is regulated by subcortical (hypothalamus, brainstem and spinal cord) and cortical structures of the brain, in addition to brain circuits (dopaminergic, serotonergic). Those with paraphilic disorders show abnormalities at these levels that could relate to the risk of sexual offences. In conclusion, androgens represent a significant part of the pathophysiology of paraphilias and therefore, ADT seems promising. Nonetheless, more studies are needed to make definite conclusions about the efficacy of long-term ADT in paraphilic patients.

Neurochemical and Hormonal Contributors to Compulsive Sexual Behavior Disorder

Purpose of Review

Compulsive sexual behavior disorder has been recently included in the 11th revision of the International Classification of Diseases (ICD-11), and the possible contribution of neurochemical and hormonal factors have been reported. However, relatively little is known concerning the neurobiology underlying this disorder. The aim of this article is to review and discuss published findings in the area.

Recent Findings

Evidence suggests that the neuroendocrine systems are involved in the pathophysiology of compulsive sexual behavior. The hypothalamus-pituitary adrenal axis, the hypothalamus-pituitary–gonadal axis, and the oxytocinergic system have been implicated.

Summary

Further studies are needed to elucidate the exact involvement of neuroendocrine and hormonal systems in compulsive sexual behavior disorder. Prospective longitudinal studies are particularly needed, especially those considering co-occurring psychiatric disorders and obtaining hormonal assessments in experimental circumstances with appropriate control groups.

Elevated free testosterone levels and reduced very low-density lipoprotein levels in men with lifelong premature ejaculation: a preliminary study

Objective

To investigate sex hormone and blood lipid levels in patients with lifelong premature ejaculation (LPE) in China.

Methods

Sex hormone and blood lipid levels were measured in 156 patients with LPE and 76 healthy controls. The Premature Ejaculation Diagnostic Tool (PEDT) and Chinese Index of Sexual Function for Premature Ejaculation-5 Questionnaires (CIPE-5) were applied to diagnose and grade LPE.

Results

PEDT and CIPE-5 scores were significantly altered in the LPE group compared with the control group. Free testosterone levels were significantly higher in the LPE group than in the control group. Free testosterone levels were also significantly higher in the mild, moderate, and severe LPE subgroups than in the control group. Total testosterone and prolactin levels tended to be lower in the control group than in the LPE group. Very low-density lipoprotein levels were significantly lower in the LPE group and LPE subgroups than in the control group. Triglyceride levels were highest in controls and decreased with progression of LPE.

Conclusions

Patients with LPE have higher free testosterone levels and lower very low-density lipoprotein levels than controls. These findings indicate that these factors might be indices for LPE. However, the reasons for these phenomena need to be further investigated.

Risk Factors for Sexual Offending in Self-Referred Men With Pedophilic Disorder: A Swedish Case-Control Study

Background

The risk of child sexual abuse among non-forensic, non-correctional patients with Pedophilic Disorder (PD) is largely unknown.

Methods

We recruited a consecutive sample of 55 help-seeking, non-correctional adult men diagnosed with DSM-5 PD at a university-affiliated sexual medicine outpatient unit in Sweden. PD participants were compared with 57 age-matched, non-clinical control men on four literature-based dynamic risk domains and self-rated child sexual abuse risk.

Results

PD participants scored higher than controls on all tested domains (0-3 points); expectedly so for pedophilic attraction (2.5 vs. 0.0, Cohen's d = 2.40, 95% confidence interval (CI): [1.91-2.89]), but also for sexual preoccupation (1.6 vs. 1.0, d = 1.11, 95% CI: [0.71-1.51]), impaired self-regulation (1.4 vs. 1.0, d = 0.44, 95% CI: [0.06 to 0.81]), impaired cognitive empathy and antisocial traits (0.9 vs. 0.1, d = 1.18, 95% CI: [0.78-1.59]), and self-rated child sexual abuse risk (1.0 vs. 0.0, d = 1.56, 95% CI: [1.13-1.98]). When summarizing all five domains into a pre-specified composite score (0-15 points), PD subjects scored substantially higher than matched control men (7.5 vs. 2.1, d = 2.12, 95% CI: [1.65-2.59]). Five (9%) PD participants self-reported any previous conviction for a contact child sexual offense and eight (15%) for possession of child sexual abuse material or non-contact sexual offending (adult or child victim). Eighteen subjects (34%) acknowledged past week, child-related sexual behaviors.

Conclusion

Self-referred, help-seeking men with PD scored higher (small to very large effect sizes) than non-clinical control men on psychiatric measures of dynamic risk of child sexual abuse suggested in prior research with correctional samples diagnosed with PD. Our findings, including the composite risk measure, might inform clinical practice, but needs validation against actual sexual offending behavior.

Effect of Gonadotropin-Releasing Hormone Antagonist on Risk of Committing Child Sexual Abuse in Men With Pedophilic Disorder: A Randomized Clinical Trial

IMPORTANCE

Evidence-based treatments from randomized clinical trials for pedophilic disorder are lacking.

OBJECTIVE

To determine whether a gonadotropin-releasing hormone antagonist reduces dynamic risk factors for committing child sexual abuse.

DESIGN, SETTING, AND PARTICIPANTS

This academically initiated, double-blind, placebo-controlled, parallel-group, phase 2 randomized clinical trial was conducted at the ANOVA center in Stockholm, Sweden, from March 1, 2016, to April 30, 2019. Individuals who contacted PrevenTell, the national telephone helpline for unwanted sexuality, were recruited. Eligible participants were men seeking help aged 18 to 66 years with a pedophilic disorder diagnosis and no contraindications to the intervention. The primary end point was assessed by intent-to-treat analysis.

INTERVENTIONS

Randomization to receive either 2 subcutaneous injections of 120 mg of degarelix acetate or equal volume of placebo.

MAIN OUTCOMES AND MEASURES

The primary end point was the mean change between baseline and 2 weeks in the composite risk score of 5 domains of child sexual abuse ranging from 0 to 15 points; each domain could be rated from 0 to 3 points. Secondary end points included efficacy at 2 and 10 weeks as measured by the composite score, each risk domain, quality of life, self-reported effects, and adverse events.

RESULTS

A total of 52 male participants (mean [SD] age, 36 [12] years) were randomized to receive either degarelix (n = 25; with 1 withdrawal) or placebo (n = 26). At 2 weeks, the composite risk score decreased from 7.4 to 4.4 for participants in the degarelix group and from 7.8 to 6.6 for the placebo group, a mean between-group difference of -1.8 (95% CI, -3.2 to -0.5; P = .01). A decrease was seen in the composite score at 10 weeks (-2.2 [95% CI, -3.6 to -0.7]) as well as in the domains of pedophilic disorder (2 weeks: -0.7 [95% CI, -1.4 to 0.0]; 10 weeks: -1.1 [95% CI, -1.8 to -0.4]) and sexual preoccupation (2 weeks: -0.7 [95% CI, -1.2 to -0.3]; 10 weeks: -0.8 [95% CI, -1.3 to -0.3]) in the degarelix group compared with the placebo group. No difference was seen for the domains of self-rated risk (2 weeks: -0.4 [95% CI, -0.9 to 0.1]; 10 weeks: -0.5 [95% CI, -1 to 0.0]), low empathy (2 weeks: 0.2 [95% CI, -0.3 to 0.6]; 10 weeks: 0.2 [95% CI, -0.2 to 0.6]), and impaired self-regulation (2 weeks: -0.0 [95% CI, -0.7 to 0.6]; 10 weeks: 0.1 [95% CI, -0.5 to 0.8]), or quality of life (EuroQol 5 Dimensions questionnaire index score, 2 weeks: 0.06 [95% CI, -0.00 to 0.12], and 10 weeks: 0.04; 95% CI, -0.02 to 0.10; EuroQol visual analog scale, 2 weeks: 0.6 [95% CI, -9.7 to 10.9], and 10 weeks: 4.2 [95% CI, -6.0 to 14.4]). Two hospitalizations occurred from increased suicidal ideation, and more injection site reactions (degarelix: 22 of 25 [88%]; placebo: 1 of 26 [4%]) and hepatobiliary enzyme level elevations were reported by participants who received degarelix (degarelix: 11 of 25 [44%]; placebo: 2 of 26 [8%]). Among the 26 participants randomized to receive degarelix, 20 (77%) experienced positive effects (eg, improved attitude or behavior) on sexuality and 23 (89%) reported adverse effects on the body.

CONCLUSION AND RELEVANCE

This trial found that degarelix reduced the risk score for committing child sexual abuse in men with pedophilic disorder 2 weeks after initial injection, suggesting use of the drug as a rapid-onset treatment option. Further studies are warranted into the effects and long-term adverse effects of hormone deficiency.

TRIAL REGISTRATION

EU Clinical Trials Register Identifier: 2014-000647-32.

Normal Testosterone but Higher Luteinizing Hormone Plasma Levels in Men With Hypersexual Disorder

INTRODUCTION

Hypersexual disorder as suggested to be included in the Diagnostic and Statistical Manual of Mental Disorders-5 integrates aspects of sexual desire deregulation, impulsivity, and compulsivity. However, it is unknown how it affects gonadal activity and the function of the hypothalamus-pituitary-gonadal (HPG) axis.

AIM

The aim of this study was to investigate testosterone and luteinizing hormone (LH) levels in hypersexual men compared with healthy controls. Furthermore, we investigated associations between epigenetic markers and hormone levels.

METHODS

Basal morning plasma levels of testosterone, LH, and sex hormone-binding globulin (SHBG) were assessed in 67 hypersexual men (mean age: 39.2 years) compared with 39 age-matched healthy controls (mean age: 37.5 years). The Sexual Compulsivity Scale and the Hypersexual Disorder: Current Assessment Scale were used for assessing hypersexual behavior, the Montgomery-Åsberg Depression Scale-self rating was used for depression severity, and the Childhood Trauma Questionnaire (CTQ) was used for assessing history of childhood adversity. The genome-wide methylation pattern of more than 850 K CpG sites was measured in whole blood using the Illumina Infinium Methylation EPIC BeadChip. CpG sites located within 2,000 bp of the transcriptional start site of hypothalamus pituitary adrenal (HPA) and HPG axis-coupled genes were included.

MAIN OUTCOME MEASURES

Testosterone and LH plasma levels in association with clinical rating and a secondary outcome was the epigenetic profile of HPA and HPG axis-coupled CpG sites with testosterone and LH levels.

RESULTS

LH plasma levels were significantly higher in patients with hypersexual disorder than in healthy volunteers. No significant differences in plasma testosterone, follicle stimulating hormone, prolactin, and SHBG levels were found between the groups. There were no significant associations between DNA methylation of HPA and HPG axis-coupled genes and plasma testosterone or LH levels after multiple testing corrections.

CONCLUSIONS

Subtle dysregulation of the HPG axis, with increased LH plasma levels but no difference in testosterone levels may be present in hypersexual men. Chatzittofis A, Boström AE, Öberg KG, et al. Normal Testosterone but Higher Luteinizing Hormone Plasma Levels in Men With Hypersexual Disorder. Sex Med 2020;8:243-250.

Child sexual offenders show prenatal and epigenetic alterations of the androgen system

Child sexual offending (CSO) places a serious burden on society and medicine and pedophilia (P) is considered a major risk factor for CSO. The androgen system is closely linked to sexual development and behavior. This study assessed markers of prenatal brain androgenization, genetic parameters of androgen receptor function, epigenetic regulation, and peripheral hormones in a 2 × 2 factorial design comprising the factors Offense (yes/no) and Pedophilia (yes/no) in analyzing blood samples from 194 subjects (57 P+CSO, 45 P-CSO, 20 CSO-P, and 72 controls) matched for age and intelligence. Subjects also received a comprehensive clinical screening. Independent of their sexual preference, child sexual offenders showed signs of elevated prenatal androgen exposure compared with non-offending pedophiles and controls. The methylation status of the androgen receptor gene was also higher in child sexual offenders, indicating lower functionality of the testosterone system, accompanied by lower peripheral testosterone levels. In addition, there was an interaction effect on methylation levels between offense status and androgen receptor functionality. Notably, markers of prenatal androgenization and the methylation status of the androgen receptor gene were correlated with the total number of sexual offenses committed. This study demonstrates alterations of the androgen system on a prenatal, epigenetic, and endocrine level. None of the major findings was specific for pedophilia, but they were for CSO. The findings support theories of testosterone-linked abnormalities in early brain development in delinquent behavior and suggest possible interactions of testosterone receptor gene methylation and plasma testosterone with environmental factors.

Are There Any Biomarkers for Pedophilia and Sexual Child Abuse? A Review

The use of biomarkers in medicine is a common and valuable approach in several clinical fields. Understanding the relationship between measurable biological processes and clinical outcomes not only is indispensable in the face of understanding physiological processes in healthy as well as in diseased organisms but also for understanding and evaluating treatment effects. Therefore, also in the context of forensic psychiatry, biomarkers and their potentially beneficial effects are of growing interest. The objective of this review is to examine if there are biomarkers that may serve as a tool to support diagnostic process, treatment evaluation, and risk assessment of pedophilic individuals and child sexual offenders. In the first part, we present an overview of the current neurobiological, as well as physiological and psychophysiological approaches to characterize pedophilia and child sexual offending. Secondly, we discuss and evaluate the impact of these approaches on the development of biomarkers for diagnosis, therapy, and risk assessment in pedophilic subjects and child sexual offenders. We conclude that a lot of research has already enhanced our neurobiological knowledge about pedophilia and child sexual offending. Although there surely exist promising parameters and approaches, in our view currently none of these is ready yet to serve as a clinically applicable diagnostic, response, or predictive biomarker for pedophilia and child sexual offending. Therefore, further work remains to be done. The development of a composite diagnostic biomarker to assess deviant sexual interest, combining several measures like functional magnetic resonance imaging, electroencephalogram, eye tracking, and behavioral approaches seems to be most promising. A valid and reliable measurement of deviant sexual interest, insensitive to manipulations could significantly support clinical diagnostic process. Similarly, regarding therapy evaluation and risk assessment, a composite biomarker to assess inhibitory control functions seems to be promising. Furthermore, the application of the Research Domain Criteria-approach, a new approach for investigating and classifying mental disorders, offers the possibility to take research to a new level.

Validation of the Change or Stop Testosterone-Lowering Medication (COSTLow) Scale Using the Delphi Method Among Clinical Experts

Guidelines for pharmacological treatment of patients with paraphilic disorders have been developed by a working group of the World Federation of Societies of Biological Psychiatry (Thibaut et al., 2010 ). With an increasing duration of experience and number of treated patients as well as aging patients, change of or withdrawal from testosterone-lowering medications (TLM) has become an important issue. The current study aimed to assess the quality of a structured professional judgment procedure that helps switching or discontinuing TLM in patients with paraphilic disorders. We used the Delphi method to estimate the quality of 10 factors originally proposed by the authors. A total of 30 experts participated in the first stage; 18 experts participated in the second stage. The experts' assessment resulted in an instrument of 15 factors that can be used to structure the process of changing or discontinuing TLM. These factors can be grouped into five broader categories: age and duration of treatment; therapeutic alliance; psychopathology and risk factors; motivation; and compliance and level of control. The developed COSTLow-R Scale provides an instrument that can be used to structure the process of changing or discontinuing TLM in patients with severe paraphilic disorders.

Do Sex Offenders Have Higher Levels of Testosterone? Results From a Meta-Analysis

The purpose of the current study is to review the available scientific evidence on the relationship between testosterone and sexual aggression. A systematic search for all primary studies comparing basal testosterone levels in sex offenders and non-sex offenders was undertaken across 20 electronic databases using an explicit search strategy and inclusion/exclusion criteria. A total of seven studies were identified and 11 effect sizes were computed; effects were pooled using both fixed and random effects meta-analysis models. Although individual study findings present a mix of results wherein sex offenders have higher or lower baseline levels of testosterone than non-sex offenders, pooled results indicate no overall difference between groups. Moderators of the analyses suggest possibly lower rates of testosterone in child molesters than controls; however, results are dependent on study weighting. Limitations, policy implications with respect to chemical castration laws, and future directions for research are discussed.

Pedophilic sex offenders are characterised by reduced GABA concentration in dorsal anterior cingulate cortex

A pedophilic disorder is characterised by abnormal sexual urges towards prepubescent children. Child abusive behavior is frequently a result of lack of behavioral inhibition and current treatment options entail, next to suppressing unchangeable sexual orientation, measures to increase cognitive and attentional control. We tested, if in brain regions subserving attentional control of behavior and perception of salient stimuli, such inhibition deficit can be observed also on the level of inhibitory neurotransmitters. We measured GABA concentration in the dorsal anterior cingulate cortex (dACC) and in a control region, the pregenual anterior cingulate cortex (pgACC) in pedophilic sex offenders (N = 13) and matched controls (N = 13) using a 7 Tesla STEAM magnetic resonance spectroscopy (MRS). In dACC but not in the control region pedophilic sex offenders showed reduced GABA/Cr concentrations compared to healthy controls. The reduction was robust after controlling for potential influence of age and gray matter proportion within the MRS voxel (p < 0.04). Importantly, reduced GABA/Cr in patients was correlated with lower self-control measured with the Barratt Impulsiveness Scale (p = 0.028, r = -0.689). In a region related to cognitive control and salience mapping, pedophilic sex offenders showed reduction of the inhibitory neurotransmitter GABA which may be seen as a neuronal correlate of inhibition and behavioral control.

Gonadotrophin-releasing hormone agonist treatment for sexual offenders: A systematic review

BACKGROUND

Sexual offending is a significant international issue causing long-term consequences for victims, perpetrators and society.

AIMS

The purpose of this study was to review the existing research data assessing the efficacy of gonadotrophin-releasing hormone agonists for treating adult, male, sexual offenders.

METHOD

The method of this review involved the examination of studies involving participants prescribed at least one month of a gonadotrophin-releasing hormone agonist for the purposes of reducing sexual drive related to offending. The primary outcome measures were recidivism rates and sexual functioning. Secondary outcome measures included assessment of side effects and effects on interpersonal/psychiatric functioning. Studies in the English language that were dated 1969-2015 were included.

RESULTS

Twelve eligible studies (323 participants) were identified. A reduction in a variety of measures of sexual functioning and/or risk was found in all studies. Robust recidivism data was limited. Medication was rarely described as ineffectual. All studies reported side effects. Reduction in bone density and potential long-term reduction in fertility in some subjects were issues of concern.

CONCLUSION

Whilst identified studies showed promising results with respect to sexual functioning, challenges in performing randomised control trials in this subject group meant that included studies were methodologically limited. This review recommends that future research must be performed before the effectiveness and tolerability of gonadotrophin-releasing hormone agonists in this population can be confirmed.

The Neurobiology and Psychology of Pedophilia: Recent Advances and Challenges

A pedophilic disorder is recognized for its impairment to the individual and for the harm it may cause to others. Pedophilia is often considered a side issue and research into the nature of pedophilia is delayed in comparison to research into other psychiatric disorders. However, with the increasing use of neuroimaging techniques, such as functional and structural magnetic resonance imaging (sMRI, fMRI), together with neuropsychological studies, we are increasing our knowledge of predisposing and accompanying factors contributing to pedophilia development. At the same time, we are faced with methodological challenges, such as group differences between studies, including age, intelligence, and comorbidities, together with a lack of careful assessment and control of child sexual abuse. Having this in mind, this review highlights the most important studies investigating pedophilia, with a strong emphasis on (neuro-) biological studies, combined with a brief explanation of research into normal human sexuality. We focus on some of the recent theories on the etiology of pedophilia such as the concept of a general neurodevelopmental disorder and/or alterations of structure and function in frontal, temporal, and limbic brain areas. With this approach, we aim to not only provide an update and overview but also a framework for future research and to address one of the most significant questions of how pedophilia may be explained by neurobiological and developmental alterations.

Sex Offenders Seeking Treatment for Sexual Dysfunction--Ethics, Medicine, and the Law

INTRODUCTION

The treatment of sexual dysfunction in patients with prior sexual offenses poses ethical and legal dilemmas. Sex offenders are not obligated by law to disclose this history to medical professionals. Over 20% of sex offenders experience sexual dysfunction; however, the number of sex offenders seeking evaluation for sexual dysfunction is unknown.

AIMS

The aims of this study were to determine the incidence and characteristics of sex offenders seeking treatment in our clinic; and to review data regarding sex offender recidivism and ethics pertaining to the issue as it relates to treating physicians.

METHODS

Sex offenders were identified via three methods: new patient screening in a dedicated sexual medicine clinic, chart review of those on intracavernosal injection (ICI) therapy for erectile dysfunction (ED), and review of patient's status-post placement of penile prosthesis. Charts were cross-referenced with the U.S. Department of Justice National Sex Offender Public Website. Patient characteristics and details of offenses were collected.

MAIN OUTCOME MEASURES

The main outcome measures used were a self-reported sexual offense and national registry data.

RESULTS

Eighteen male sex offenders were identified: 13 via new patient screening; 3 by review of ICI patients; 1 by review of penile prosthesis data; and 1 prior to penile prosthesis placement. All were primarily referred for ED. Of those with known offenses, 64% were level 3 offenders (most likely to re-offend). The same number had committed crimes against children. All those with complete data had multiple counts of misconduct (average 3.6). Ninety-four percent (17/18) had publicly funded health care. Twelve (67%) were previously treated for sexual dysfunction.

CONCLUSIONS

Registered sex offenders are seeking and receiving treatment for sexual dysfunction. It is unknown whether treatment of sexual dysfunction increases the risk of recidivism of sexual offenses. Physicians currently face a difficult choice in deciding whether to treat sexual dysfunction in sex offenders.

Neurobiological correlates in forensic assessment: a systematic review

BACKGROUND

With the increased knowledge of biological risk factors, interest in including this information in forensic assessments is growing. Currently, forensic assessments are predominantly focused on psychosocial factors. A better understanding of the neurobiology of violent criminal behaviour and biological risk factors could improve forensic assessments.

OBJECTIVE

To provide an overview of the current evidence about biological risk factors that predispose people to antisocial and violent behaviour, and determine its usefulness in forensic assessment.

METHODS

A systematic literature search was conducted using articles from PsycINFO, Embase and Pubmed published between 2000 and 2013.

RESULTS

This review shows that much research on the relationship between genetic predisposition and neurobiological alterations with aggression is performed on psychiatric patients or normal populations. However, the number of studies comparing offenders is limited. There is still a great need to understand how genetic and neurobiological alterations and/or deficits are related to violent behaviour, specifically criminality. Most studies focus on only one of the genetic or neurobiological fields related to antisocial and/or violent behaviour. To reliably correlate the findings of these fields, a standardization of methodology is urgently needed.

CONCLUSION

Findings from the current review suggest that violent aggression, like all forms of human behaviour, both develops under specific genetic and environmental conditions, and requires interplay between these conditions. Violence should be considered as the end product of a chain of life events, during which risks accumulate and potentially reinforce each other, displaying or triggering a specific situation. This systematic review did not find evidence of predispositions or neurobiological alterations that solely explain antisocial or violent behaviour. With better designed studies, more correlation between diverse fields, and more standardisation, it might be possible to elucidate underlying mechanisms. Thus, we advocate maintaining the current case-by-case differentiated approach to evidence-based forensic assessment.

Which factors influence the appropriateness of testosterone-lowering medications for sex offenders? A survey among clinicians from German forensic-psychiatric institutions

OBJECTIVES

Although testosterone-lowering medications (TLM) are a frequently used addition to psychotherapy in sex offender treatment, discord still seems to exist amongst clinicians as to in which cases administering TLM is justified. The depo-Provera scale (DPS), which was published by Maletzky and Field (Aggress Violent Behav 2003;8:391), assesses the appropriateness of TLM administration in sex offender treatment.

METHODS

The DPS was sent to all forensic psychiatric institutions in Germany. The clinical directors of these institutions were asked to rate the importance of each item of the DPS on a six-point Likert scale.

RESULTS

Twenty-nine clinicians participated. The most important reason selected for the prescription of TLM for sex offender treatment was a "history of sexual offender treatment failure". The least important item was "deviant sexual interest, by plethysmograph or Abel Screen" (neither plethysmograph nor Abel Screen is used in Germany).

CONCLUSIONS

Clinicians' attitudes towards the DPS correspond to the suggestions made in the current WSFBF-guidelines for the pharmacological treatment of sex offenders (Thibaut et al. 2010 ; World J Biol Psychiatry 11:604-655). Use of the DPS could therefore contribute to a more structured approach towards helping clinicians come to a decision about whether or not to treat a sex offender with TLM.

Changed processing of visual sexual stimuli under GnRH-therapy--a single case study in pedophilia using eye tracking and fMRI

BACKGROUND

Antiandrogen therapy (ADT) has been used for 30 years to treat pedophilic patients. The aim of the treatment is a reduction in sexual drive and, in consequence, a reduced risk of recidivism. Yet the therapeutic success of antiandrogens is uncertain especially regarding recidivism. Meta-analyses and reviews report only moderate and often mutually inconsistent effects.

CASE PRESENTATION

Based on the case of a 47 year old exclusively pedophilic forensic inpatient, we examined the effectiveness of a new eye tracking method and a new functional magnetic resonance imaging (fMRI)-design in regard to the evaluation of ADT in pedophiles. We analyzed the potential of these methods in exploring the impact of ADT on automatic and controlled attentional processes in pedophiles. Eye tracking and fMRI measures were conducted before the initial ADT as well as four months after the onset of ADT. The patient simultaneously viewed an image of a child and an image of an adult while eye movements were measured. During the fMRI-measure the same stimuli were presented subliminally. Eye movements demonstrated that controlled attentional processes change under ADT, whereas automatic processes remained mostly unchanged. We assume that these results reflect either the increased ability of the patient to control his eye movements while viewing prepubertal stimuli or his better ability to manipulate his answer in a socially desirable manner. Unchanged automatic attentional processes could reflect the stable pedophilic preference of the patient. Using fMRI, the subliminal presentation of sexually relevant stimuli led to changed activation patterns under the influence of ADT in occipital and parietal brain regions, the hippocampus, and also in the orbitofrontal cortex. We suggest that even at an unconscious level ADT can lead to changed processing of sexually relevant stimuli, reflecting changes of cognitive and perceptive automatic processes.

CONCLUSION

We are convinced that our experimental designs using eye tracking and fMRI could prospectively add additional and valuable information in the evaluation of ADT in paraphilic patients and sex offenders. But with respect to the limited significance of this single case study, these first results are preliminary and further studies have to be conducted with healthy subjects and patients.

[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.

[Deviant sexual behaviors, paraphilias, perversions]

OBJECTIVE

To know the new concept of paraphilias, their clinical presentation and their link with a personality disorder as perversion, the French legislation concerning them and the different therapeutic options.

MATERIAL AND METHODS

Review of guidelines published on this subject in the Medline database and a reflexion from our own clinical experience, especially in the judicial expertise.

RESULTS

Deviant sexual behavior is, in current classifications, known as paraphilia. This clinical entity corresponds to any sexual behavior considered "abnormal" compared with sexual acts in the society where the person lives. It means precisely, firstly, suffering caused by this disorder or deterioration of social, professional, or family life. Paraphilia such as pedophilia have strict age limits. The victim must be aged below 16 years, with an age difference of at least 5 years with the author of the act. Sexual acts which are illegal are crimes or offences according to the degree, and are sanctioned by the law. In ordinary terms, they are known as perverts, committing perversions. This concept is different from that of paraphilia, a pervert can have, or not have, paraphiliac behavior. In order to diagnose a personality disorder such as perversion, all the criteria must be included: narcissism, use of a person as an object for pleasure, with, primarily, mechanisms of denial and a split personality which removes any feeling of guilt from the perpetrator.

CONCLUSION

Medical treatment of paraphilia alone is not satisfactory for the denial mechanism is such that only the sex drive is affected with a high risk of recurrence. Only psychotherapy can modify the pathological element of a perverted personality.

Sexual disorders and crime

PURPOSE OF REVIEW

Highlighting the relationship between sexual disorders and crime, reviewing and summarizing the articles published throughout 2011 which add to the current knowledge on this subject.

RECENT FINDINGS

Studies on specific populations confirm the association between sexual disorders and crime, particularly between paraphilias and sexual crimes regarding male offenders. Female offenders are less likely to be diagnosed with a sexual disorder. Some case reports focus on unusual paraphilias and lead us to question the vast possibilities of paraphilic contents and sexual arousal patterns. The variations of paraphilic-associated sexual arousal patterns, unconventional sex behaviors or paraphilic disorders are constantly changing. In this sense, the American Psychiatric Association's DSM-5 current proposals for a sexual dysfunction diagnostic category are under intense discussion because of their important clinical and forensic consequences.

SUMMARY

Sexual violence is a theme not well understood yet. Because of its nature, researching it can raise many ethical problems. There is no possibility of clinical trials and of case-control studies. Even cohort studies may be problematic in themselves. So, most of the research involves biased samples or case reports, or is merely theoretical. Further research is needed to improve our understanding of the subject, so that preventive and rehabilitative measures can be taken.

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.