John M. W. Bradford

The neurobiology, neuropharmacology, and pharmacological treatment of the paraphilias and compulsive sexual behaviour.

There has been in creas ing in ter est in the treat ment of sex ual dis or ders in re cent years. Sex ual dis or ders are clas si fied in DSM-IV as sex ual dysfunctions, paraphilias, and gen der iden tity dis or ders. The sex ual dysfunctions are nondeviant or nonparaphillic. The sex ual dys func tion dis or ders should in clude “hy per ac tive sex ual de sire dis or der” un der sex ual de sire dis or ders . Fur ther, there should be a speci fier for paraphilias of “with hypersexuality” or “with out hypersexuality. ” There is still in com plete un der stand ing of the neurobiology of sex ual dis or ders al though func tional neuroanatomy and neoropharmcological re search has ex posed the neurotransmitters, re cep tors, and hor mones that are in volved in sex ual de sire. Var i ous phar ma co log i cal agents in clud ing se ro to nin reuptake in hib i tors, antiandrogens, LHRH agonists, and oth ers have been doc u mented as re duc ing sex ual de sire. An al go rithm for the use of these drugs in the treat ment of the paraphilias as well nonparaphilic hypersexuality is out lined. The modes of ac tion, dos ages, aims of treat ment, and usual meth ods of pre scrib ing these agent s is re viewed in this ar ti cle. Some fu ture di rec tions of re search in phar ma co log i cal treat ment is also dis cussed.

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

Abstract 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.

Double-blind placebo crossover study of cyproterone acetate in the treatment of the paraphilias

Cyproterone acetate is a powerful antiandrogen used in the treatment of the paraphilias for at least a decade. Studies have reported it effective in reducing the recidivism rates of sexual crimes perpetrated by men. It acts through competitive inhibition of the androgen receptors blocking the effects of testosterone and dihydrotestosterone. Systematic clinical study of its effectiveness and its clinical effects on sexual behavior is lacking, however. In the current study 19 paraphilic men who had also recidivated in a variety of sexual crimes were treated with cyproterone acetate and placebo in a double-blind crossover design. The use of active drug was associated with a significant reduction of some aspects of sexual behavior, particularly sexual fantasies. There were also significant effects on levels of circulating sex hormones and some effects on physiological measurements and self-reports of sexual arousal.

Offender and Offense Characteristics of Sexual Sadists: A Comparative Study

This paper compares the offender and offense characteristics of 30 sexually sadistic criminals studied by Dietz et al. with those of 29 sexually sadistic criminals and 28 nonsadistic sexual offenders from the Royal Ottawa Hospital. We examined whether the characteristics noted by Dietz et al. would be found among a less violent group of sadistic offenders and also to what extent these characteristics were specific to sexual sadism. Results suggest some offender and offense characteristic are specific to sexual sadism and that others appear to be common to sexually aggressive offenders more generally. In addition, there were a number of characteristics found exclusively among the most violent offenders described by Dietz et al. An explanation of these results in terms of a biopsychosocial understanding of sexual sadistic offenders is provided.

Prediction of Recidivism in Incest Offenders

Approximately 6.5 years after their conviction, the percentage of incest offenders who had committed a sexual, violent, or criminal offense of any kind was 6.4, 12.4, and 26.7, respectively. The sexual recidivists scored higher on the Michigan Alcohol Screening Test (MAST), and the Psychopathy Checklist-Revised (PCL-R). The violent recidivists had higher MAST and PCL-R scores as well as more violence in their police records. Regarding any criminal recidivism, recidivists were older and reported higher rates of being physically abused, and being removed from their homes prior to 16 years of age. They demonstrated more hostility on the Buss-Durkee Hostility Inventory, and higher MAST and PCL-R scores. They also had more previous charges or convictions for sexual, violent, and criminal acts. A combination of total criminal offenses, PCL-R, age, and the number of previous sexual offenses correctly classified 97.6% of the nonrecidivists and 35.4% of the recidivists for any reoffense.

A Comparison of Modified Versions of the Static-99 and the Sex Offender Risk Appraisal Guide

The predictive validity of 2 risk assessment instruments for sex offenders, modified versions of the Static-99 and the Sex Offender Risk Appraisal Guide, was examined and compared in a sample of 258 adult male sex offenders. In addition, the independent contributions to the prediction of recidivism made by each instrument and by various phallometric indices were explored. Both instruments demonstrated moderate levels of predictive accuracy for sexual and violent (including sexual) recidivism. They were not significantly different in terms of their predictive accuracy for sexual or violent recidivism, nor did they contribute independently to the prediction of sexual or violent recidivism. Of the phallometric indices examined, only the pedophile index added significantly to the prediction of sexual recidivism, but not violent recidivism, above the Static-99 alone.

Pornography use and sexual aggression: the impact of frequency and type of pornography use on recidivism among sexual offenders

In this study, we examined the unique contribution of pornography consumption to the longitudinal prediction of criminal recidivism in a sample of 341 child molesters. We specifically tested the hypothesis, based on predictions informed by the confluence model of sexual aggression that pornography will be a risk factor for recidivism only for those individuals classified as relatively high risk for re-offending. Pornography use (frequency and type) was assessed through self-report and recidivism was measured using data from a national database from the Royal Canadian Mounted Police. Indices of recidivism, which were assessed up to 15 years after release, included an overall criminal recidivism index, as well as subcategories focusing on violent (including sexual) recidivism and sexual recidivism alone. Results for both frequency and type of pornography use were generally consistent with our predictions. Most importantly, after controlling for general and specific risk factors for sexual aggression, pornography added significantly to the prediction of recidivism. Statistical interactions indicated that frequency of pornography use was primarily a risk factor for higher-risk offenders, when compared with lower-risk offenders, and that content of pornography (i.e., pornography containing deviant content) was a risk factor for all groups. The importance of conceptualizing particular risk factors (e.g., pornography), within the context of other individual characteristics is discussed.

The paraphilias : a multiplicity of deviant behaviours

The DSM-II and DSM-III both allow for multiple diagnoses. The DSM-III acknowledges that a patient may have multiple paraphilias but the true nature and extent of the multiplicity has only been documented recently. In order to study the degree of crossover between the various paraphiliac acts, a study of men who admitted to at least one paraphilia was conducted. A proportional index of multiple deviation was obtained. In addition, the mean number of admitted sexually deviant incidents per paraphilic category was computed as an estimate of the extent of deviant acts committed by this population. The results indicated that paraphiliacs tend to have multiple types of sexual aberrations as well as a high frequency of deviant acts per individual.

Arson: a clinical study.

Psychiatric, psychosocial and medicolegal issues related to 34 arsonists and 50 controls are described. Arson was most frequently committed by males who suffered from personality disorder, mental retardation or depressive neurosis. Poor school and work records also characterized their background when compared to the control forensic psychiatric patients. The offence more frequently occurred within a one mile radius of their own home in residential property. Revenge or a “cry for help” was the most frequent motivation for the firesetting activity.

Homicidal and Nonhomicidal Child Molesters: Psychological, Phallometric, and Criminal Features

Seventeen extrafamilial homicidal child molesters (HCM) were compared to 35 convicted extrafamilial child molesters (CM) who had not murdered, or attempted to murder, their victims. The two groups did not differ on age, IQ, education, history of marriage, or family history, although marriage rates of both groups were well below the national average. Similarly, both groups had high rates of features representing family instability. HCM more frequently victimized strangers. The results on the self-report psychological inventories, the Derogatis Sexual Functioning Inventory (DSFI) and the Buss-Durkee Hostility Inventory (BDHI), did not distinguish between the groups, although the DSFI revealed sexual inadequacy in both groups. The BDHI did not describe the groups as pathological. The Psychopathy Checklist—Revised Total Score, Factor 1, and Factor 2 described both groups as demonstrating high levels of psychopathy, with the HCM scoring significantly higher. Factor 1 and Factor 2 scores placed the HCM group in the 93rd and 82nd percentiles, respectively, compared to published norms for forensic patients. A greater proportion of HCM suffered from antisocial personality disorders and paraphilias, especially sexual sadism. Over 53% of the HCM, and none of the CM, were comorbid for pedophilia and sexual sadism. Significantly more HCM received three or more DSM III-R diagnoses. The phallometric assessments generally supported DSM diagnoses. The HCM demonstrated significantly higher levels of deviant arousal to pedophilic and adult assault stimuli. Police files revealed that, prior to the index offense, a significantly greater proportion of HCM had been charged with, or convicted of, violent nonsexual, and sexual offenses. The HCM had been charged with, or convicted of, more than 2.5 times as many criminal charges than the CM. A discriminant function analysis revealed that two variables, Factor 1 of the PCL-R and the number of violent entries in the police records, correctly predicted 78.6% of the HCM and 97.1% of the CM. Implications for understanding homicidal child molesters and for future research are discussed.