Richard B. Krueger

Diagnosis, Assessment, and Treatment of Hypersexuality

This article reviews the current evidence base for the diagnosis, assessment, and treatment of hypersexual conditions. Controversy concerning this diagnosis is discussed. Terminology and diagnostic criteria, as well as psychological, psychopharmacological, and other treatment approaches, are presented.

The DSM Diagnostic Criteria for Sexual Sadism

I reviewed the empirical literature for 1900–2008 on the paraphilia of Sexual Sadism for the Sexual and Gender Identity Disorders Workgroup for the forthcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). The results of this review were tabulated into a general summary of the criticisms relevant to the DSM diagnosis of Sexual Sadism, the assessment of Sexual Sadism utilizing the DSM in samples drawn from forensic populations, and the assessment of Sexual Sadism using the DSM in non-forensic populations. I conclude that the diagnosis of Sexual Sadism should be retained, that minimal modifications of the wording of this diagnosis are warranted, and that there is a need for the development of dimensional and structured diagnostic instruments.

Depot-leuprolide acetate for treatment of paraphilias: a report of twelve cases.

A new class of antiandrogen medications, gonadotropin-releasing hormone agonists, offers promise in the treatment of the paraphilias, with substantially less side effects than medroxyprogesterone acetate or cyproterone acetate. This paper reports the results of treatment using a depot suspension of leuprolide acetate on 12 patients with paraphilic disorders or with sexual disorders not otherwise specified to suppress or help these individuals control their deviant sexual behavior or impulses. The method involved uncontrolled observations of individuals treated with depot-leuprolide acetate for various lengths of time, from 6 months to 5 years, with the follow-up intervals ranging from 6 months to 6 years. Leuprolide acetate resulted in a significant suppression of deviant sexual interests and behavior as measured by self-report and was well tolerated. However, the three patients who were on long-term therapy developed bone demineralization, suggesting that this is a significant side effect of prolonged therapy. Leuprolide acetate shows promise as a treatment for the paraphilias.

The Paraphilic and Hypersexual Disorders: An Overview

In this article, the first of a two-part series, the authors present reasons for considering the paraphilic and hypersexual disorders together and provide an overview of these disorders. The DSM-IV diagnostic criteria for paraphilias are reviewed, and proposed criteria for hypersexual disorders are presented. The question of whether the paraphilic and hypersexual disorders should be considered within the spectrum of obsessive-compulsive disorders is considered. The authors then review the epidemiology of these disorders, and discuss some implications of recent sexual predator legislation. The authors discuss the etiology of the paraphilias and hypersexual disorders, and consider the role of endocrinological function, findings from brain imaging and neuropsychological testing, findings from primate research, the monoamine hypothesis, the imprinting hypothesis, social learning theory, the concept of courtship disorder, the role of obsessive-compulsive elements, psychodynamic theories, and genetic factors. The phenomenology of the paraphilias and hypersexual disorders is discussed, including the tendency for multiple paraphilias to co-occur, the lack of a specific offender profile, the predominance of males among those with paraphilias, the incidence of a history of victimization in individuals with paraphilias and compulsive sexual disorders, the onset and course of both types of disorders, and the lack of internal motivation for change in individuals with paraphilias and hypersexual disorders. The authors then discuss disorders that commonly co-occur with paraphilias and compulsive sexual disorders, including mood disorders, substance abuse and dependence disorders, attention-deficit/hyperactivity disorder, anxiety and impulse control disorders, and personality disorders. The second article in the series will discuss the clinical assessment and the behavioral and psychopharmacological treatment of these disorders. A guide for clinicians and patients on where and how to find specialized clinicians and treatment resources in the United States will also be provided.

Disorders related to sexuality and gender identity in the ICD-11: revising the ICD-10 classification based on current scientific evidence, best clinical practices, and human rights considerations.

In the World Health Organizations forthcoming eleventh revision of the International Classification of Diseases and Related Health Problems (ICD‐11), substantial changes have been proposed to the ICD‐10 classification of mental and behavioural disorders related to sexuality and gender identity. These concern the following ICD‐10 disorder groupings: F52 Sexual dysfunctions, not caused by organic disorder or disease; F64 Gender identity disorders; F65 Disorders of sexual preference; and F66 Psychological and behavioural disorders associated with sexual development and orientation. Changes have been proposed based on advances in research and clinical practice, and major shifts in social attitudes and in relevant policies, laws, and human rights standards. This paper describes the main recommended changes, the rationale and evidence considered, and important differences from the DSM‐5. An integrated classification of sexual dysfunctions has been proposed for a new chapter on Conditions Related to Sexual Health, overcoming the mind/body separation that is inherent in ICD‐10. Gender identity disorders in ICD‐10 have been reconceptualized as Gender incongruence, and also proposed to be moved to the new chapter on sexual health. The proposed classification of Paraphilic disorders distinguishes between conditions that are relevant to public health and clinical psychopathology and those that merely reflect private behaviour. ICD‐10 categories related to sexual orientation have been recommended for deletion from the ICD‐11.

The DSM Diagnostic Criteria for Sexual Masochism

I reviewed the empirical literature for 1900–2008 on the paraphilia of Sexual Masochism for the Sexual and Gender Identity Disorders Work Group for the forthcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. The results of this review were tabulated into a general summary of the criticisms relevant to the DSM diagnosis of Sexual Masochism, the assessment of Sexual Masochism utilizing the DSM in samples drawn from forensic populations, and the assessment of Sexual Masochism using the DSM in non-forensic populations. I concluded that the diagnosis of Sexual Masochism should be retained, that minimal modifications of the wording of this diagnosis were warranted, and that there was a need for the development of dimensional and structured diagnostic instruments. It should be noted that this summary reflects my original literature review. Subsequently, interactions with other members of the workgroup and advisors have resulted in modification of these initial suggestions.

Behavioral and Psychopharmacological Treatment of the Paraphilic and Hypersexual Disorders

In this article, the second of a two-part series, the authors present information on the clinical assessment of individuals with paraphilias and hypersexual disorders. They review ethical considerations in the assessment and treatment of individuals with paraphilias. The role of interview and subjective and objective instruments in the assessment of individuals with paraphilias and hypersexual disorders is discussed. The authors discuss the use of penile plethysmography or phallometry, polygraphy, and viewing time assessments. Risk assessment of sexual offenders is reviewed. The authors then discuss behavioral, environmental, and psychopharmacological treatments for paraphilias and hypersexual disorders. Cognitive-behavioral therapy appears to be the most effective nonpharmacological strategy. The authors describe cognitive-behavioral techniques for decreasing and/or controlling sexual urges (e.g., satiation, covert sensitization, fading, cognitive restructuring, victim empathy therapy) as well as methods for enhancing appropriate sexual interest and arousal (e.g., social skills training, assertiveness skills training, sex education, couples therapy). The authors also discuss the role of relapse prevention therapy and 12-step programs, as well as other nonbiological therapies such as surveillance networks. The importance of providing appropriate treatment for comorbid conditions (e.g., depression, substance abuse or dependence) is stressed. The authors then review psychopharmacological treatments, including serotonin reuptake inhibitors (SRIs) and antiandrogens, in particular, the use of gonadotropin-releasing hormone (GNRH) agonists. SRIs have been studied in these disorders in an uncontrolled way and appear promising. Earlier antiandrogens (e.g., estrogen, progesterone, and cyproterone acetate) have demonstrated efficacy in the treatment of paraphilias. The newer GNRH agonists have the advantage over the earlier treatments of being available in long-acting depot formulations and having fewer side effects. Preliminary studies and case reports with these agents appear promising. Further study of both the SRIs and GNRH agonists in these disorders is needed. The article concludes with a treatment algorithm, in which the authors suggest beginning with less restrictive treatments (e.g., behavioral or verbal therapies), if possible, and moving to more restrictive alternatives (e.g., biological therapies, institutionalization) as needed. A guide for clinicians and patients about where and how to find appropriate clinicians and treatment resources in the United States is provided.

Does ECT permanently alter seizure threshold

Recent research has raised the possibility that electroconvulsive therapy (ECT) results in a persistent elevation of seizure threshold among males. In this study, seizure threshold, quantified by the method of limits procedure, was assessed at the first and last treatments of 148 consecutive depressed patients. Patients with and without a prior history of ECT did not differ in seizure threshold at the first treatment, seizure duration at the first treatment or averaged across all treatments, or in the magnitude of the seizure threshold increase over the ECT course. No evidence was obtained that history of ECT was associated with alterations of seizure threshold or seizure duration.

Sexual and Other Axis I Diagnoses of 60 Males Arrested for Crimes Against Children Involving the Internet

OBJECTIVE This study was conducted to describe Axis I sexual diagnoses of 60 males arrested for possession of child pornography obtained via the Internet and/or attempting to meet children via the Internet. METHODS Data was obtained from a chart review of evaluations conducted on 60 males referred for a psychosexual evaluation following an arrest for possession of child pornography and/or attempting to meet children. All crimes involved use of the Internet. Information obtained from the chart review was entered into SAS. All diagnoses were made according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Simple descriptive statistics were computed and cross tabulations were tested for significance using chi2 or Fishers Exact test. RESULTS Of the total sample, 40% had at least one paraphilia. Thirty-one percent had a diagnosis of pedophilia and 18% of a paraphilia not otherwise specified (NOS). Thirty-three percent had a sexual disorder NOS, characterized by hypersexuality. Seventy percent of the total sample had an Axis I disorder that antedated and was judged to be contributory to the behavior leading to their arrest. CONCLUSIONS This sample of men arrested for committing crimes against children and adolescents via the Internet has a high incidence of lifetime sexual and other psychopathology.

Compulsive sexual behaviour disorder in the ICD‐11

deciding what is immediately implementable, versus that which requires a supportive framework which has yet to be created. All digital health research and claims are informative. Some offer immediate solutions to health care that should be implemented today and others highlight the potential of what may be possible. However, blurring the line between actual and aspirational can be counterproductive. Claiming that aspirational digital health research is ready for immediate use can lead to immediate negative results and broad disappointment. It may even inadvertently contribute to digital health “hype” and foster undue skepticism for the field. However, ignoring digital health technologies with good evidence for real-world implementation is a missed opportunity for improving patient outcomes. Appreciating how aspirational research can guide, inform, and inspire current efforts is also important. Likewise, appreciating the real world success of actualized efforts can help guide aspirational research to be more translatable into health care systems. There is no superior designation, as both ends of the actual and aspirational spectrum have critical roles that cannot be separated. However, the value of both depends upon correct identification of where any given project lies on this spectrum – and further consideration of populations sampled and incentives used are critical to determining this.