Current Legal Situation for Patients with Paraphilic disorders and Implications of the ICD-11 for Paraphilic Disorders for Germany

Assessment and treatment of compulsive sexual behavior disorder: a sexual medicine perspective

INTRODUCTION

The addition of compulsive sexual behavior disorder (CSBD) into the ICD-11 chapter on mental, behavioral, or neurodevelopmental disorders has greatly stimulated research and controversy around compulsive sexual behavior, or what has been termed "hypersexual disorder," "sexual addiction," "porn addiction," "sexual compulsivity," and "out-of-control sexual behavior."

OBJECTIVES

To identify where concerns exist from the perspective of sexual medicine and what can be done to resolve them.

METHODS

A scientific review committee convened by the International Society for Sexual Medicine reviewed pertinent literature and discussed clinical research and experience related to CSBD diagnoses and misdiagnoses, pathologizing nonheteronormative sexual behavior, basic research on potential underlying causes of CSBD, its relationship to paraphilic disorder, and its potential sexual health consequences. The panel used a modified Delphi method to reach consensus on these issues.

RESULTS

CSBD was differentiated from other sexual activity on the basis of the ICD-11 diagnostic criteria, and issues regarding sexual medicine and sexual health were identified. Concerns were raised about self-labeling processes, attitudes hostile to sexual pleasure, pathologizing of nonheteronormative sexual behavior and high sexual desire, mixing of normative attitudes with clinical distress, and the belief that masturbation and pornography use represent "unhealthy" sexual behavior. A guide to CSBD case formulation and care/treatment recommendations was proposed.

CONCLUSIONS

Clinical sexologic and sexual medicine expertise for the diagnosis and treatment of CSBD in the psychiatric-psychotherapeutic context is imperative to differentiate and understand the determinants and impact of CSBD and related "out-of-control sexual behaviors" on mental and sexual well-being, to detect forensically relevant and nonrelevant forms, and to refine best practices in care and treatment. Evidence-based, sexual medicine-informed therapies should be offered to achieve a positive and respectful approach to sexuality and the possibility of having pleasurable and safe sexual experiences.

The impact of testosterone-lowering medication on recidivism in individuals convicted of sexual offenses

INTRODUCTION

Treatment of individuals who have committed sexual offences with Testosterone-Lowering Medication (TLM) is a comparatively intrusive kind of intervention, which regularly takes place in coercive contexts. Thus, the question of efficacy, but also the question of who should be treated, when and for how long, are of great importance.

METHODS

Recidivism rates of TLM-treated high-risk individuals (+TLM; n = 54) were compared with high-risk individuals treated with psychotherapy only in the same forensic outpatient clinic (-TLM; n = 79).

RESULTS

Group differences suggested a higher initial risk of + TLM (e.g. higher ris-assessment, previous convictions). Despite the increased risk, after an average time at risk of six years, +TLM recidivated significantly less often and significantly later than - TLM (27.8% vs. 51.9%). Such an effect was also found for violent (1.9% vs. 15.2%), but not for sexual (5.6% vs. 10.1%) and serious recidivism (5.6% vs. 10.1%), which could be explained partly by the small number of cases. In the course of treatment, TLM proved to be a significant variable for a positive process, whereas a high risk-assessment score indicated a rather negative course. In total, n = 19 individuals had stopped their TLM treatment, of these 31.6% recidivated.

CONCLUSION

The results support the efficacy of TLM, particularly in the group of high-risk offenders.

Changes in the Risk of Sexual Reoffending: The Role and Relevance of Perceived Self-Efficacy and Adult Attachment Styles in Correctional Treatment

According to the Risk-Need-Responsivity (RNR) model, treatment effectiveness increases when treatment addresses all three associated core principles. While researchers have focused on the risk and need principles, responsivity remains under-investigated. The theoretical foundation of the RNR model and former research indicates low perceived self-efficacy and inadequate adult attachment styles as potential responsivity factors that can impede treatment of the underlying risk factors. This study assesses firstly whether these factors predict treatment attrition, and secondly changes in the assessed risk of sexual reoffending. Participants were N = 146 men sentenced for sexual offenses in a German social-therapeutic correctional facility. Younger age, higher number of previous convictions, and higher scores on the interpersonal facet of the Psychopathy Checklist-Revised are associated with a higher risk of treatment attrition. Unemployment prior to incarceration was found to be an aggravating factor, whereas substance abuse emerged as a mitigating factor, according reducing the risk of reoffending. Neither pre-treatment self-efficacy nor attachment styles revealed as responsivity factors in this study. Future studies should examine if the consideration of these factors during treatment might impact treatment outcomes.

Survey on the Prescription Patterns of Pharmacological Agents in Individuals Who Have Committed Sexual Offenses During Forensic Outpatient Treatment in Germany: How Many Discontinue Testosterone Lowering Medication Under Parole?

BACKGROUND

The number of individuals who sexually offended, and who are continued to be treated with pharmacological agents to reduce sex drive after their release from prison or forensic psychiatry, are not known. Furthermore, figures on the number of those who stop their sexdrive supressing antiandrogen treatment in the outpatient setting are unknown as well. This is of central importance though as it might be associated with an increased risk of recidivism.

AIM

To assess prescription patterns as well as adherence to pharmacological treatment in outpatient clinics in Germany for individuals who have sexually offended and were released from prison or forensic psychiatric hospital.

METHODS

A self-constructed online survey assessing the pharmacological treatment modalities was sent by e-mail to n = 103 forensic outpatient clinics in Germany. Thirty-three (32.0%) completed the questionnaire and reported about 834 patients.

OUTCOMES

Prevalence of the use of different pharmacological agents in the treatment of individuals convicted for sexual offenses as well as the number of patients who have discontinued testosterone-lowering medication (TLM).

RESULTS

Among all institutions, 22.4% (n = 187) of individuals received pharmacological treatment, with 40.1% receiving gonadotropin-releasing-hormone-agonists, 26.2% antipsychotics, 24.6% selective serotonin reuptake inhibitors, 6.4% cyproterone acetate, and 2.7% a combination of gonadotropin-releasing-hormone-agonists and cyproterone acetate. A significant positive correlation was found between the number of patients released from a forensic-psychiatric hospital and the number of patients treated with TLM. Within 1 year 8.6% (n = 16) stopped their TLM during or at the end of the supervision period, most of them against treatment providers advice.

CLINICAL IMPLICATIONS

Substantial regional differences indicate uncertainties regarding the prescription of pharmacological agents for outpatients who have committed sexual offences in Germany. The discontinuiation of TLM within the first year of treatment against treatment providers advise in a substantial proportion of patients could be associated with a serious risk for reoffending.

STRENGTHS & LIMITATIONS

The present survey captures prevalences of the pharmacotherapy in forensic aftercare facilities for individuals who have offended sexually, and is the first to record the number of discontinuations. This is a cross-sectional survey covering only 1 country, but includes a large number of individuals.

CONCLUSION

Even though the number of treated individuals has increased in prisons, the majority of pharmacological treatment is still provided by forensic hospitals, which then translates into the outpatient setting. The number of those who stop taking such medication is a highly relevant topic for both forensic treatment providers and legal decision makers Sauter J, Rettenberger M, Briken P, et al. Survey on the Prescription Patterns of Pharmacological Agents in Individuals Who Have Committed Sexual Offenses During Forensic Outpatient Treatment in Germany: How Many Discontinue Testosterone Lowering Medication Under Parole?. J Sex Med 2022;19:1147-1155.

Testosterone-Lowering Medication and Its Association With Recidivism Risk in Individuals Convicted of Sexual Offenses

For a particular subgroup of individuals with severe paraphilic disorders and a high risk of sexual recidivism, the combination of sex drive-reducing medications and psychotherapy is a promising treatment approach. The present quasi-experimental study aims at comparing differences in clinical characteristics and dynamic risk factors between persons receiving (+TLM, n = 38) versus not receiving (-TLM, n = 22) testosterone-lowering medications (TLMs). Individuals receiving TLM were more frequently diagnosed with paraphilic disorders. Neither the criminal history nor average risk scores differed between the two groups. In the +TLM, Stable-2007 scores showed a stronger decrease after TLM treatment was started. This accounted especially for the general and sexual self-regulation subscales. Individual variations in risk, however, were not predicted by TLM but were significantly related to treatment duration and Psychopathy Checklist-Revised (PCL-R) Factor I. Paraphilic patients with problems in self-regulatory abilities seem to profit most from pharmacological sex drive-reducing treatment. Furthermore, therapists seem to underestimate deviant sexual fantasies in medicated patients.

Mandated or Voluntary Treatment of Men Who Committed Child Sexual Abuse: Is There a Difference?

Child sexual abuse is associated with multiple and often severe consequences for people who are affected by it. From the perspective of indicative prevention, the treatment of people who have sexually abused children represents one important strategy, with the assumption that there is often a risk for sexual recidivism. However, there is still very limited knowledge about how men who have not been convicted of child sexual abuse but participate in voluntary treatment (here called non-forensic clients) differ from those who have been convicted and undergo mandated treatment (here called forensic clients). This study compared 22 forensic and 22 non-forensic clients regarding pedophilic interests, static and dynamic risk factors, responsivity features, and treatment progress during an individualized treatment based on the principles of risk, need, and responsivity. We found neither differences in the rates in the DSM-5 diagnosis of pedophilic disorder, nor in risk and responsivity associated scores at the beginning of treatment. In both groups, a low to moderate risk for sexual re-offending was estimated. Both groups improved their functioning on dynamic risk and responsivity factors under treatment, while age at the beginning of therapy also had a positive effect on all outcomes. Non-forensic clients had a higher amount of responsivity associated resources than forensic clients during treatment. The limitations of these results and their implications for further research and prevention approaches are discussed.

Predictive Validity of Operationalized Criteria for the Assessment of Criminal Responsibility of Sexual Offenders With Paraphilic Disorders-A Randomized Control Trial With Mental Health and Legal Professionals

The prevention of sexual violence is a major goal of sexual health. In cases of accused sexual offenders, the assessment of diminished criminal responsibility of the accused is one of the most important procedures undertaken by experts in the German legal system. This assessment follows a two-stage method assessing first the severity of a paraphilic disorder and then second criteria for or against diminished capacity. The present study examines the predictive validity of two different sets of criteria for the assessment of criminal responsibility in the context of paraphilic disorders combined with sexual offending. Two exemplary case vignettes of two suspected sexual offenders were developed to assess the criteria. For each participant, one of the two exemplary case vignettes was randomly presented. The presentation of the two different sets of criteria was also randomized, so that each participant was assigned only one of the two criteria sets to rate one of the presented cases. N = 349 participants from different professional backgrounds (mental health and legal professionals) completed their assessments and were included in the data analysis. The data were evaluated using logistic regression. Results show that the more recently published criteria set (Briken and Müller, 2014) predicts both the severity of the disorder as well as the diminished capacity twice as good as the older criteria set of Boetticher et al. (2005) currently used regularly for forensic court reports. In preliminary conclusion, the new criteria of Briken and Müller (2014) form an empirically based assessment of criminal responsibility. However, the proposed criteria cannot replace an extensive exploration of the accused person and a careful file analysis. Validity and reliability of the results are also limited due to the methodical choice of a vignette study.

The Predictive Properties of Psychiatric Diagnoses, Dynamic Risk and Dynamic Risk Change Assessed by the VRS-SO in Forensically Admitted and Released Sexual Offenders

Psychiatric diagnoses, static risk factors, and criminogenic needs at time of admission and release were examined in a mentally ill sample of psychiatrically detained sexual offenders. Although clinically found to be at low or even very low risk at discharge, 12% reoffended sexually over an average follow-up of 7 years. Psychotic disorders were present in only 5% of offenders, whereas 93% had a personality disorder diagnosis and 76% a paraphilic disorder diagnosis. Only exhibitionism and alcohol misuse were associated with relapse. Static risk factors captured by the Static-99 also did not significantly predict recidivism; however, the VRS-SO-a structured risk assessment tool that assesses criminogenic needs and changes in risk from treatment or other change agents, rated retrospectively on the present sample-predicted sexual recidivism as well as any new imprisonment or psychiatric placement. In particular, the sexual deviance factor of the VRS-SO had large in magnitude predictive associations with sexual reoffending, while treatment related changes assessed on this factor were significantly related to non-reoffending. Findings corroborate the advantages of structured risk assessment and structured change monitoring, particularly for complex clientele such as mentally ill sexual offenders.