The World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the treatment of adolescent sexual offenders with paraphilic disorders

The Hamburg Youth Prevention Project (HYPP) for adolescents with sexual interest in children

Paedophilic sexual interest is often linked to an emergence during adolescence, but concrete empirical knowledge on its development and early viable treatments remains scarce. The aim of this article is to provide an overview about the current state of research on juveniles with sexual interest in children as well as to introduce the Hamburg Youth Prevention Project (HYPP). The HYPP aims to better comprehend the development of sexual interests in adolescents and seeks to find a basis for improved treatment strategies during this critical developmental period. In this perspective, we outline the framework, goals, and treatment approach for this project. It addresses adolescents who are sexually attracted to younger children or engage in sexual acts with children and who have not yet been in contact with the justice system. The project offers a diagnostic process, anonymous counselling, and treatment. It is grounded in a biopsychosocial perspective on psychosexual development and an integrative family-centred approach. The project is based on the core assumption that in adolescent participants, there is still great flexibility for development, including their sexual interests.

Scoping Review of the Definitions Used to Describe and Understand Harmful Sexual Behaviors in Children and Young People

There is a growing body of evidence that adolescents, and other children, are responsible for a significant proportion of sexual abuse against children. However, there are substantial differences in how this phenomenon is defined and conceptualized between and within sectors. This scoping review explored the current definitions of harmful sexual behaviors (HSB), and other similar terms, used across a range of stakeholder groups. In all, 141 papers were reviewed from both empirical and gray literature sources, including key policy and practice documents. Included papers needed to list a clear definition for the behavior of interest. There was disagreement and inconsistency across the included papers in their conceptualization of harmful, abusive, or problematic sexual behavior (PSB) in children and adolescents. Although the term HSB has been adopted as an umbrella term or continuum in many policy, practice, and research settings, there is a large variance in behaviors, treatment needs, etiology, and harms present across different types of sexual behavior. Relying solely on one term to describe a wide range of sexual behaviors in children and young people may limit the understanding of this issue and imply similarities between groups that are not present. We suggest that clearly defined subsets of HSB, such as sexual abuse, technology-assisted HSB, and PSB, may give more context to the behavior of concern and may be helpful in informing further research, prevention, and best practice approaches.

Three Quarks for Hypersexuality Research

In some areas of sex research, we note room for methodological improvement of research practices. In particular, in the field of hypersexuality research, where societal norms have been influential, methodological improvement might advance goals of objectivity in research. We propose that hypersexuality research should: firstly, take into account relevant subpopulations; secondly, use Item Response Theory (IRT) to construct item banks for measurement instruments; and, thirdly, measure sexual desire and related important constructs where and how they play out—in daily life, changing from moment to moment. We show that comparing relevant subpopulations can lead to depathologizing normative, but highly frequent, sexual behavior. Using IRT can lead to more precise measurement instruments by assessment of characteristics of individual items. Measuring sexual desire as an inherently fluctuating process in everyday life, and as part of emotion regulation processes, can direct research towards relevant associations other research methods might miss. Bringing into practice our three proposals for improvement can procure a number of advantages. We illustrate these advantages mainly for the field of hypersexuality research, but our suggestions might also be beneficial for sex research in general.

Sex offending among adolescents and young men with history of psychiatric inpatient care in adolescence

BACKGROUND

Some mental disorders have been associated with increased likelihood of sexual offending in adolescents (and adults), but relevant studies tend to be of established sex offenders.

AIMS

To examine relationships between adolescent mental disorders and subsequent involvement in sex offending and to explore any predictive value of primary diagnoses for subsequent interpersonal offending, whether sexual or violent.

METHODS

We analyse national register-based longitudinal data on males in Finland admitted for their first psychiatric inpatient treatment between the ages of 13-17 in the period 1980-2010 (N = 6749). Cox regression was used for the analysis of multivariate associations.

RESULTS

A subsequent criminal record for sex crime in the 10-year follow up was rare among former child and adolescent psychiatric (CAP) inpatient males (1.5%). Having a subsequent criminal record for non-sex-related violent crime was more common (25%). Time to either sex crimes or non-sex-related violent crimes after a first CAP inpatient treatment was 3-4 years. Whilst the risk of committing non-sex-related violent crimes was elevated in all diagnostic groups compared to those with schizophrenia spectrum disorders, the risk of committing subsequent sex crimes was elevated only in the group with substance use, conduct or personality disorders. Among those with pre-existing criminal history of sex crime, the risk of a subsequent criminal record for sex crime after CAP treatment was increased 11-fold, but the risk for later non-sex-related violent crimes was not increased compared to the rest of the male adolescent CAP population.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

In this first longitudinal study of criminal convictions for sex offending after a period of inpatient psychiatric treatment as an adolescent such convictions were rare, but the difference in post discharge risk of further convictions for sexual offending and non-sexual violent offending raises questions about whether more attention and specific treatment for aberrant sexual behaviours is needed for male adolescents with severe mental disorders.

Efficacy of outpatient treatment of sex offenders

The efficacy of sex offender treatment (SOT) is a matter of ongoing discussion and research in forensic psychotherapy. This study evaluates the efficacy of outpatient SOT after discharge from prison. Recidivism rates of participants treated in outpatient departments for sex offenders in Bavaria between 2008 and 2016 (treatment group, TG; n = 353) were compared with those of a matched group of released offenders without treatment (control group, CG; n = 353). The mean follow-up period was 4.5 years. The primary outcome of interest was whether the rates of reoffending differed significantly between the two groups. We compared general and specific rates of reoffending, time to reoffending, and type of reoffending. The groups differed significantly regarding the rates and time of violent reoffending and reoffending overall, but not regarding sexual reoffending respectively the type of sexual reoffending. The results indicate that outpatient SOT is effective in reducing the general but not the specific risk of reoffending.

Sex Differences in Voyeuristic and Exhibitionistic Interests: Exploring the Mediating Roles of Sociosexuality and Sexual Compulsivity from an Evolutionary Perspective

Sociosexuality and sexual compulsivity predict sex differences in voyeuristic interest in the population. In this study, we used a sample of 1113 participants from the UK (46% men) to consider whether sociosexuality and sexual compulsivity interacted to explain these sex differences and whether this relationship extended to the related domain of exhibitionism. In doing so, we tested novel predictions derived from an evolutionary perspective which views voyeuristic and exhibitionistic interest as manifestations of a short-term mating strategy. Participants reported their levels of repulsion toward voyeurism and exhibitionism and their interest in performing such acts under different levels of risk. There were clear sex differences in voyeuristic and exhibitionistic repulsion that were partially mediated by the serial combination of sociosexuality and sexual compulsivity. Examining the sexes separately revealed qualitatively different relationships between sociosexuality and sexual compulsivity when predicting exhibitionistic, but not voyeuristic, repulsion. Combined, sociosexuality and sexual compulsivity also mediated the sex difference in willingness to commit acts of voyeurism, but not exhibitionism, which was equally low for both sexes. The results highlight the role sociosexuality plays in voyeuristic and exhibitionistic interest, which coupled with an evolutionary perspective, may have implications for how we view courtship disorders.

Are Juveniles Who Have Committed Sexual Offenses the Same Everywhere? Psychometric Properties of the Juvenile Sex Offender Assessment Protocol-II in a Portuguese Youth Sample

Over the last decade, we have witnessed consistent advances in risk assessment procedures, namely the validation of those used with juveniles who have committed sexual offenses. The adaptation of these instruments into other languages requires research examining the conceptual and metric equivalence of the instruments, not just translation equivalence. Informed by data from 141 boys, aged 13 to 18, the psychometric properties of the Portuguese version of the Juvenile Sex Offender Assessment Protocol-II (J-SOAP-II), regarding reliability and construct validation, are presented and discussed. Factor structure, internal consistency, and interrater reliability were examined, and a reliable factorial structure that was consistent with the original validation of the J-SOAP was found. Scales 2 and 3 had good internal consistency, and Scale 1 had acceptable internal consistency. Results regarding concurrent validity revealed mostly statistically significant correlations. The implications of this research for juvenile sex offender risk assessments are discussed.

“From an old life to a new life”: Group therapy for cognitive disorders and affective deficits in adolescents who have committed sexual offenses

The purpose of the current article is to shed light on the unique population of adolescents who have committed sexual offenses, suffering from cognitive disorders, by presenting the disorders and challenges that characterize these youngsters and discussing the issues that are relevant to the therapeutic process of sexual offenses. In our article we show the correlations and adaptations that we made to provide these boys with the most effective treatment possible, both to enable them to undergo an optimal process and to lower their risk level for recidivism.

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.

Pharmacotherapy of Sexual Addiction

PURPOSE OF REVIEW

We reviewed recent data on sexual addiction and its treatment. We examined the different definitions of this disorder, related to the pathophysiological mechanisms. We addressed the pharmacological treatment of sexual addiction.

RECENT FINDINGS

Hypersexual behavior can be considered an addictive disorder. Sexual addiction is accompanied by significant psychiatric and addictive comorbidities and is responsible for life impairment. A comprehensive and efficient treatment must be proposed. Selective serotonin reuptake inhibitors seem the first-line pharmacological treatment for sexual addiction. Naltrexone could be another therapeutic option. Psychotherapy and preferentially cognitive-behavioral therapy should be used in association with pharmacotherapy and treatments of comorbidities.

Pharmacological treatment of patients with paraphilic disorders and risk of sexual offending: An international perspective

Objectives: The present study aims to evaluate existing policy and practice relating to the use of pharmacological treatments with patients suffering from paraphilic disorders who are at risk of committing further sexual offences.Methods: A systematic literature search was conducted to document current legal policies across 26 different countries. In addition, a questionnaire assessing the practice of pharmacological treatment was sent to practitioners involved in the treatment of patients with paraphilic disorders.Results: Legal policies concerning the preconditions of using pharmacological treatments differ considerably between countries, and for most jurisdictions do not exist. Drawing on the responses of 178 practitioners, pharmacological agents are a useful addition to psychotherapeutic interventions, especially with those patients classified as medium or high risk for sexually violent behaviours. It would appear that most patients are medically examined, are informed of the risks and possible side effects before treatment commences and are also obliged to sign a consent form.Conclusions: Although pharmacological agents can be seen as an intrusion into a patients' sexual self determination, results indicate that ethical and clinical standards are being met in the majority of cases. However, further promotion of current WFSBP treatment guidelines would help to standardise practice across North American and European countries.

Treatment of Paraphilic Disorders in Sexual Offenders or Men With a Risk of Sexual Offending With Luteinizing Hormone-Releasing Hormone Agonists: An Updated Systematic Review

BACKGROUND

Different pharmacologic agents are used in the treatment of paraphilic disorders in sexual offenders or men with a risk of sexual offending, with luteinizing hormone-releasing hormone (LHRH) agonists being the agents introduced more recently to treatment regimens.

AIM

To summarize the relevant literature concerning LHRH agonist treatment of paraphilic disorders in sexual offenders and update the previously published systematic review by Briken et al (J Clin Psychiatry 2003;64:890-897).

METHODS

The PubMed and Google Scholar databases were searched for literature published from January 2003 through October 2017 using the following key words: LHRH agonists, GnRH agonists, antiandrogens AND paraphilia, pedophilia, sex offenders.

OUTCOMES

Evaluation of the effectiveness and side effects of LHRH agonist treatment of paraphilic disorders in sexual offenders.

RESULTS

After screening for duplicates and applying specific selection criteria, the search yielded 24 eligible studies reporting on a sample of 256 patients. There is increasing evidence that LHRH agonists are more effective than steroidal antiandrogens in lowering paraphilic sexual thoughts and behaviors. Current research also is based on methods that might be less susceptible to faking (eg, eye-tracking, brain imaging, and viewing-time measures). Side effects occurring most frequently are fatigue, hot flashes, depressive mood, weight gain, high blood pressure, diabetes, gynecomastia, loss of erectile function, and loss of bone mineral density.

CLINICAL IMPLICATIONS

Although LHRH agonists seem to be the most effective drugs in the treatment of paraphilic fantasies and behaviors, they should be reserved for patients with a paraphilic disorder and the highest risk of sexual offending because of their extensive side effects.

STRENGTHS AND LIMITATIONS

This systematic review considers all types of research on LHRH agonist treatment in patients with paraphilic disorders, thereby providing a complete overview of the current state of research. However, most studies are case reports or observational studies and randomized controlled clinical trials have not been conducted or published.

CONCLUSIONS

LHRH agonists are a useful treatment when combined with psychotherapy in patients with a paraphilic disorder and the highest risk of sexual offending. However, throughout treatment, close monitoring of side effects is needed and ethical concerns must always be kept in mind. Turner D, Briken P. Treatment of Paraphilic Disorders in Sexual Offenders or Men With a Risk of Sexual Offending With Luteinizing Hormone-Releasing Hormone Agonists: An Updated Systematic Review. J Sex Med 2018;15:77-93.

State of the Art Treatment Options for Actual and Potential Sexual Offenders and New Prevention Strategies

Sexual violence is a significant and devastating issue for men and women throughout the world. Its consequences are not only disastrous for victims of sexual violence but are also extremely costly (estimated cost of $41,000 per rape) for society. Successful treatment of sexual offenders is therefore an important goal for society as well as for victims and offenders themselves. Over the years, multiple treatment approaches for sex offenders have been developed. Treatment programs range from the risk-need-responsivity (RNR) model, which focuses on providing tailored treatment for high-risk and low-risk offenders, to psychodynamic models. This article presents an overview for clinicians of state-of-the-art offender treatment, describing the most common treatment approaches, in particular the RNR model, cognitive-behavioral programs (relapse prevention programs, sexual offender treatment programs), psychodynamic approaches (transference-focused psychotherapy, mentalization-based therapy), the Good Lives Model, as well as pharmacological options. In addition, it provides an evaluation of the various treatment programs. However, given the fact that most acts of sexual violence will never be reported to the police, the question arises if treating convicted perpetrators is enough. Do we need rather-in terms of preventive work-a program for potential sexual offenders and men with delinquent sexual fantasies? Given the prevalence of sexual violence and its impact on victims, society, and the medical community, it would be remiss not to try to reach potential/unconvicted perpetrators. This article offers novel ideas and a project the goal of which is to prevent sexual offenses against women by introducing the "I CAN CHANGE" program from Hannover Medical School.

Psychological treatment of problematic sexual interests: cross-country comparison

This paper reviews the use of psychotherapeutic approaches to treat individuals who have committed sex crimes and/or have problematic sexual interests (PSI); including types of psychotherapy used, descriptions of preventive and reintegration programmes, and highlighting specific theoretical controversies. In the second part, experts from Canada, the Czech Republic, Russia, the United Kingdom, and the United States, who participated in an International Consensus Meeting held in Prague (2017), summarize treatment programmes in their countries. The comparison revealed some general findings: each country has variability between its own programmes; most countries have different programmes for people who are in custody and who are in the community; the state-directed treatment programmes are primarily focused on criminal individuals, while non-criminal individuals are treated in preventive programmes and/or in special clinics or are untreated; the presence of PSI in patients is acknowledged in most programmes, although specific programmes exclusively for individuals with PSI rarely exist. Studies on effectiveness are difficult to compare due to methodologic, political, and cultural differences. Further communication between more countries to share knowledge about successful treatments and preventive approaches is needed, especially enhanced international collaboration between researchers and clinicians to verify the effectiveness of current clinical and experimental program, rs.

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.

Pharmacological treatment of sexual offenders in German outpatient treatment centers

In Germany, depending on a sexual offender's culpability and the severity of the offence, he/she can be placed either in the forensic-psychiatric or the correctional system. Numbers related to the pharmacological treatment of sexual offenders for the correctional system are missing so far. In sexual offenders, the pharmacological treatment of paraphilic disorders is of special importance. The present study aimed at assessing the prevalence of pharmacological sexual offender treatment in German outpatient treatment centers supervising mainly clients from the correctional sector. An online questionnaire was sent to 112 outpatient treatment centers and 21 provided data relevant for the present study. The included institutions reported about a total of 813 sexual offenders, of whom 200 (24.6%) were treated with pharmacological agents, most frequently antipsychotics (14.8%) and selective-serotonin-reuptake-inhibitors (7.1%). Of the total sample, 26.7% of sexual offenders were diagnosed with a paraphilic - mainly with a pedophilic - disorder. Only 2% were treated with androgen-deprivation therapy. Compared with forensic-psychiatric institutions, only a minority of sexual offenders are treated with medication specifically addressing paraphilic symptomatology. However, the prevalence of paraphilic disorders found in the present study suggests that pharmacological treatment of paraphilic fantasies and behaviors could be of great importance in the correctional sector as well.

European Psychiatric Association (EPA) guidance on forensic psychiatry: Evidence based assessment and treatment of mentally disordered offenders

Forensic psychiatry in Europe is a specialty primarily concerned with individuals who have either offended or present a risk of doing so, and who also suffer from a psychiatric condition. These mentally disordered offenders (MDOs) are often cared for in secure psychiatric environments or prisons. In this guidance paper we first present an overview of the field of forensic psychiatry from a European perspective. We then present a review of the literature summarising the evidence on the assessment and treatment of MDOs under the following headings: The forensic psychiatrist as expert witness, risk, treatment settings for mentally disordered offenders, and what works for MDOs. We undertook a rapid review of the literature with search terms related to: forensic psychiatry, review articles, randomised controlled trials and best practice. We searched the Medline, Embase, PsycINFO, and Cochrane library databases from 2000 onwards for adult groups only. We scrutinised publications for additional relevant literature, and searched the websites of relevant professional organisations for policies, statements or guidance of interest. We present the findings of the scientific literature as well as recommendations for best practice drawing additionally from the guidance documents identified. We found that the evidence base for forensic-psychiatric practice is weak though there is some evidence to suggest that psychiatric care produces better outcomes than criminal justice detention only. Practitioners need to follow general psychiatric guidance as well as that for offenders, adapted for the complex needs of this patient group, paying particular attention to long-term detention and ethical issues.

Zoophilia in an adolescent with high-functioning autism from Sri Lanka

OBJECTIVE

Zoophilia is a rare paraphilic disorder with intense sexual urges involving animals. Autism is characterised by impairments in social communication and repetitive, restricted behaviours (RRB). Reported cases of zoophilia are limited worldwide, and zoophilia in autism is rarer.

METHOD

This is a case report describing this unique and relatively unrecognised association in a male adolescent from Sri Lanka.

RESULTS

A 17-year-old boy diagnosed with autism has average intelligence and academic capabilities. He had spent increasing time at his grandparents' cattle house. First, he was found masturbating near the cows and later having penetrative intercourse with a heifer. The shocked parents first sought traditional healing in the form of 'thovil', a demonic ritual of exorcist nature. Later, clinical evaluation found intense sexual urges towards cattle, which had led to marked distress and academic impairment. Sex hormone profile was normal. The adolescent was treated with a combination of cognitive-behaviour therapy and a selective serotonin reuptake inhibitor.

CONCLUSION

We postulate that his persistent social difficulties contributed to the development of a paraphilic disorder. Unlike with his RRBs, he was markedly distressed about this sexual behaviour. Further research is required to explore this rarely reported, potential association.

Treatment for youth paraphilic disorders: opportunities to reduce harm

OBJECTIVE

To outline current understanding and recommended treatments for paraphilic or sexual deviant disorders in adolescents and youth.

METHOD

An overview of the diagnosis, development and scope of paraphilic disorders. Evidence and an algorithm for pharmacological treatments in youth are outlined.

RESULTS

Paraphilic disorders are relatively common in adolescents and youth, with fantasies and urges preceding the onset of deviant behaviour by a handful of years. Research in youth is sparse, but the available evidence supports that paraphilic disorders respond favourably to psychological and pharmacological treatments.

CONCLUSIONS

The detection of paraphilic disorders in adolescents and youth presents a window of opportunity, where treatment may be provided before deviant behaviour occurs, potentially reducing the future incidence of sexual abuse.

Juvenile Sex Offenders

Sexual offending by juveniles accounts for a sizable percentage of sexual offenses, especially against young children. In this article, recent research on female juvenile sex offenders (JSOs), risk factors for offending in juveniles, treatment, and the ways in which these youth may differ from general delinquents will be reviewed. Most JSOs do not go on to develop paraphilic disorders or to commit sex offenses during adulthood, and as a group, they are more similar to nonsexual offending juvenile delinquents than to adult sex offenders. Recent research has elucidated some differences between youth who commit sex offenses and general delinquents in the areas of atypical sexual interests, the use of pornography, and early sexual victimization during childhood.

The efficacy, safety and ethics of the use of testosterone-suppressing agents in the management of sex offending

PURPOSE OF REVIEW

The use of endocrine medications to reduce sexual offending recidivism is established and may involve clinicians from diverse specialities. The present review aims to outline relevant background information and note a Medical Ethics framework upon which to facilitate decision-making.

RECENT FINDINGS

There have been several systematic reviews in recent years. A number of problems with research in the area of the medical treatment of sex offenders have been highlighted. There remains scope for improvement in the research to answer a number of relevant clinical issues. Nonetheless, some very useful indicators of relevance to clinical practice have emerged.

SUMMARY

The use of medication to manage the risk of sex offending in males is appropriate under the right circumstances. These include, for example, hypersexuality with sexual deviance and psychological-treatment interfering sexual preoccupation.

Pharmacological treatment of sex offenders

Most people recognize that incarceration alone will not solve sexual violence. Indeed, treating the offenders is critical in an approach to preventing sexual violence and reducing victimization. In most cases, a diagnosis of paraphilia is associated with sexual violence. This review is intended to present and summarize the first recently published international guidelines about pharmacological treatment of paraphilias. Pharmacological interventions should be part of a more comprehensive treatment plan including psychotherapy and, in most cases, behavior therapy. Antiandrogens, and mostly GnRH analogues, significantly reduce the intensity and frequency of deviant sexual arousal and behavior. GnRH analogue treatment constitutes the most promising treatment for sex offenders at high risk of sexual violence, such as pedophiles or serial rapists, however informed consent is necessary. SSRIs remain an interesting option in adolescents, in patients with depressive or OCD disorders, or in mild paraphilias such as exhibitionism.

Disclosure of interest

The author has not supplied his declaration of competing interest.