J. Paul Fedoroff

Sexsomnia—A New Parasomnia?

Objective: To describe a distinct parasomnia involving sexual behaviour, which we have named sexsomnia. Method: We have used a case series as a basis for the description of sexsomina. Results: Eleven patients with distinct behaviours of the sexual nature during sleep are described. The features in common with other nonrapid eye movement arousal parasomnias, such as sleepwalking are documented. Some patients had simply been referred to a tertiary sleep clinic for investigation of unrelated sleep problems. A small number had been involved in medicolegal issues. Sexsomnia has some distinct features that separate it from sleepwalking. The automatic arousal is more prominent, motor activities are relatively restricted and specific, and some form of dream mentation is often present. Conclusions: A significant number of patients with this unusual parasomnic behaviour were identified only after specific questions were asked, suggesting that the behaviour is more common than previously thought.

Sadism, Sadomasochism, Sex, and Violence

The true prevalence of sexual sadism (and its variants) is unknown. However, all clinicians will knowingly or unknowingly encounter patients with this disorder. Regretfully, few programs offer adequate education in normal sexuality and even less provide training in the assessment and treatment of pathologic sexual interests. This review synthesizes current theories about possible etiologies of criminal sexual sadism and the resulting implications for diagnosis and treatment of this sexual disorder. Included is a review of theories of criminally sadistic sexual motivations, response patterns, and physiology, including possible neurophysiologic factors and more complex interactions. This review focuses primarily on published English-language scientific studies of sexual sadism. It should be noted that my use of the term sadism refers to nonconsensual sexual aggression.

Problems with Paraphilias in the DSM-5

This paper critiques changes in the diagnositic criteria for the paraphilias as set out in the DSM-5. In addition to general areas of concern, five specific problem areas are identified. This includes: definitions by exclusion; culturally based criteria; ignoring etiology; minimizing consent issues; and lack of field trials. A suggestion to improve the diagnostic criteria is offered.

Sleep Apnea as a Possible Factor Contributing to Aggression in Sex Offenders

ABSTRACT: Sleep disorders, such as obstructive sleep apnea (OSA), are often unrecognized and undertreated. A disruption in normal sleep may be associated with increased irritability and aggression. To elucidate further the impact of OSA on hostility of forensic patients, we performed a retrospective chart review of 10 consecutive outpatient sex offenders who were diagnosed with OSA and treated with continuous positive airway pressure (CPAP). The Buss–Perry Aggression Questionnaire was compared pre‐ and posttreatment. Following treatment, the total Buss–Perry score was significantly lower, with lower scores on the anger, physical aggression, hostility, and verbal aggression subscales. These results suggest that in sex offenders suffering from OSA, aggression and hostility may be significantly reduced through CPAP treatment. Further investigation is required to investigate if reducing aggression and hostility in this manner impacts recidivism and overall functioning.

Evidence That Arousal to Pedophilic Stimuli Can Change: Response to Bailey, Cantor, and Lalumière

We thank Drs. Bailey, Cantor, and Lalumiere for their careful reviews of Muller et al. (2014), hereafter referred to as ‘‘our study’’or‘‘our article.’’Our study reported on the results of a retrospective analysis of a group of men assessed at the Sexual Behaviours Clinic at the Royal Ottawa Mental Health Centre between 1983 and 2011, who fulfilled the following inclusion criteria: DSM-III, IV or IV-TR (American Psychiatric Association, 1980, 1994, 2000) diagnosis of pedophilia, an initial penileplethysmographytest (PPT) indicativeofsexual interest in children, and a second PPT test at least 6 months later. Because we were interested in testing the hypothesis that arousal topedophilic stimulicanchange,weselectedmenwhose PPT at Time 1 showed a greater increase in penile circumference in response to children compared to adults. Of this group, about halfshowedagreaterincreaseinpenilecircumferenceinresponse to adults (as compared to children) at Time 2. In the article, we noted that the men who changed PPT response profiles demonstrated both a decrease of penile circumference change in responsetoaudiotapesdescribingsexual interactionwithchildren and an increase in penile circumference change in response to audiotapes describing sexual interactions between adults. In our article, we suggested that the demonstration of a statistically significant decrease in sexual response toward children (p\.001), combined with a statistically significant increase in sexual response to adults (p\.001), presents a challenge to the claim that pedophilic sexual interest is unchangeable. We note that there was an error that has been formally communicated to the Editor of the Journal of Sexual Medicine, due to the misclassification of three of the men in the study. The removal of these cases and complete re-analysis of the data did not change the results or our conclusions. Bailey, Cantor, and Lalumiere each claimed that the notion of the immutability of pedophilic interest is not challenged by the findings of our study and attempted to offer some non-evidencebased support for their opinions. We are grateful for the opportunity to respond and do so below by reviewing each commentary in alphabetized author order. Bailey began his commentary by equating sexual orientation with sexual arousal,‘‘Because a man’s sexual orientation/ erotic interest is identical to his characteristic sexual response pattern...’’We disagree because sexual orientation is different from sexual arousal. Men who have sex with men are not necessarily gay, and a gay man is still gay even if he loses his sex drive or is unable to get an erection. In our article, we speculated that the reluctance of researchers to accept there is evidence that pedophilic sexual interest can change is due to confusion between sexual orientation and sexual interest. It should be noted that our study was never designed to investigate change insexualorientationandweexplicitlystated in thearticle thatour study does not support any recommendations aimed at changing sexual orientation. Equating orientation with interest confuses interpretation of the issue and may be clinically harmful. Bailey wrote that‘‘...sometimes men do not get sufficient erection during a PPT to be accurately classified.’’ We agree. This is why we selected men who initially produced more changein penile circumference in response tochild stimuli than to adults, as well as only those who demonstrated a change in J. P. Fedoroff (&) S. Curry R. Ranger J. Bradford Forensic Research Unit, University of Ottawa Institute of Mental Health Research, Royal Ottawa Health Care Group, 1145 Carling Ave., Ottawa, ON K1Z 7K4, Canada e-mail: paul.fedoroff@theroyal.ca

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.

Assessment and Treatment of Sexual People with Complaints of Hypersexuality

This article presents a literature review of contemporary research on the definition, diagnosis, assessment, and treatment methods of so-called “sexual compulsivity,” “sexual hyperactivity,” and “hypersexuality,” We review published literature on proposed diagnostic criteria, symptomatology, and treatments. The Sexual Compulsivity Scale (SCS), Compulsive Sexual Behaviour Inventory (CSBI), Sexual Addiction Screening Test (SAST), and Hypersexual Behaviour Inventory (HBI) were found to be the most frequently used assessment tools. Although all of these scales have demonstrated high internal consistency, each scale is based on a unique perspective and understanding of “hypersexuality.” This article discusses the validity and reliability, as well as applicable populations for assessment, foe each of the scales. These of multiple assessment strategies is encouraged in order to glean greater insight into the nature of hypersexuality sexual compulsivity. We briefly discuss the importance of multimodal intervention strategies, while providing in-depth evaluation of cognitive-behavioural psychotherapy and 12-step programs. The article also highlights and provides a discussion of the Sexual Behaviours Clinic (SBC) intervention strategies for individuals labelled as “sex addicts.” Finally, we suggest directions for future emphasis in research in diagnosis, assessment, and treatment in order to reduce conceptual ambiguity and enhance empirical efficacy.

Sexsomnia: Sleep Sex Research and Its Legal Implications

Abstract“Sleep sex,” also known as sexsomnia, is a sleep disorder characterized by sexual behaviors committed while asleep. There has recently been increased interest in sexsomnia due to controversies arising in legal trials that have been widely publicized in the social and public media. This article attempts to marshal the current information about sexsomnia from the forensic literature and provides an overview of sexsomnia including common features, precipitating factors, prevalence rates, diagnostic procedures, and treatment. As sexsomnia represents a condition in which sexual acts are committed without awareness or intention, this paper also reviews the development of sexsomnia as a legal defense and summarizes Canadian case law on the topic. It provides an overview of the hurdles presented to defense attorneys attempting to utilize the defense and examines popular public notions surrounding the legitimacy of sexsomnia and the possibility of malingering. We conclude that sexsomnia is a legitimate sleep disorder for which case law now exists to support its use in legal defenses based on automatism. The question of whether it is an example of “sane” or “insane” automatism remains to be determined by the courts. Regardless of whether or not sexsomnia is determined to be a mental disorder by the courts, it is now a recognized and well-described sleep disorder that can be safely treated and managed by knowledgeable clinicians.

A Time Series Modeling Approach in Risk Appraisal of Violent and Sexual Recidivism

For over half a century, various clinical and actuarial methods have been employed to assess the likelihood of violent recidivism. Yet there is a need for new methods that can improve the accuracy of recidivism predictions. This study proposes a new time series modeling approach that generates high levels of predictive accuracy over short and long periods of time. The proposed approach outperformed two widely used actuarial instruments (i.e., the Violence Risk Appraisal Guide and the Sex Offender Risk Appraisal Guide). Furthermore, analysis of temporal risk variations based on specific time series models can add valuable information into risk assessment and management of violent offenders.

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.