Sexual offending runs in families: A 37-year nationwide study

Immigrant Background and Rape Conviction: A 21-Year Follow-Up Study in Sweden

While extensive research exists on the severe consequences among rape victims, little is known about specific predictors in relation to rape convictions among immigrants to Europe. This study from Sweden (having one of Europe's highest per capita rates of rape) investigates individuals convicted of rape, aggravated rape, attempted rape, or attempted aggravated rape, collectively termed as rape+, against women 18 years or older, from 2000 to 2020. In this case-control study, we analyzed data from Swedish population-based registers. The analysis includes 4,032 individuals convicted of rape+ and 20,160 matched controls. We used logistic regression models to examine the relationship between immigrant background and rape+ convictions, while adjusting for several potential confounders. We found that 36.9% of the convicted individuals and 69.5% of the controls were Swedish-born with two Swedish-born parents. The odds of being convicted of rape were higher for individuals with an immigrant background across all models. After adjusting for potential confounders (socioeconomic status, substance use disorders, psychiatric disorders, and criminal behavior), these odds decreased but remained significant, especially for those born outside Sweden and arriving at age 15 or older. Our findings reveal a strong link between immigrant background and rape convictions that remains after statistical adjustment. The mechanisms behind the overrepresentation of individuals with an immigrant background among those convicted of rape+ need further exploration.

Offending Trajectories in Violent Offenders: Criminal History and Early Life Risk Factors

The understanding of offending, and thus its possible prevention, is expanded through longitudinal studies on criminal trajectories depicting early life risk factors. This longitudinal study aimed to explore criminal trajectories, criminal histories, and early life risk factors in a cohort of violent offenders. A Swedish nationally representative cohort of male violent offenders (n = 266), clinically assessed while imprisoned aged 18 to 25, was followed through national registers from age 15 to 25-34. Substantial differences in criminal histories between violent offenders and a matched comparison group (n = 10,000) were demonstrated. Five trajectory groups were identified: four persisting and one desisting. Although differences were observed between persisting trajectory groups, a higher prevalence of early life risk factors was generally displayed compared to the desisting, especially in conduct problems and experiences of out-of-home placements. Neurocognitive ability and prevalence of ADHD and autism were similar across trajectories. Severe early life risks highlight the population's need for early interventions.

Prediction of reoffending risk in men convicted of sexual offences: development and validation of novel and scalable risk assessment tools (OxRIS)

BACKGROUND

Current risk assessment tools have a limited evidence base with few validations, poor reporting of outcomes, and rarely include modifiable factors.

METHODS

We examined a national cohort of men convicted of sexual crimes in Sweden. We developed prediction models for three outcomes: violent (including sexual), any, and sexual reoffending. We used Cox proportional hazard regression to develop multivariable prediction models and validated these in an external sample. We reported discrimination and calibration statistics at prespecified cut-offs.

FINDINGS

We identified 16,231 men convicted of sexual offences, of whom 14.8% violently reoffended during a mean follow up of 38 months, 31.4% for any crime (34 months), and 3.6% for sexual crimes (42 months). Models for violent and any reoffending showed good discrimination and calibration. At 1, 3, and 5 years, the area under the curve (AUC) was 0.75-0.76 for violent reoffending and 0.74-0.75 for any reoffending. The prediction model for sexual reoffending showed modest discrimination (AUC = 0.67) and good calibration. We have generated three simple and web-based risk calculators, which are freely available.

INTERPRETATION

Scalable evidence-based risk assessment tools for sexual offenders in the criminal justice system and forensic mental health could assist decision-making and treatment allocation by identifying those at higher risk, and screening out low risk persons.

Adverse Childhood Experiences, Aggression, Empathy, and Psychopathology in Adult Males Accused of Rape

BACKGROUND

Investigating the underlying psychosocial factors is a cornerstone of planning need-based intervention for adult males accused of rape. Unresolved debates on its etiology, mediation, or interaction among causal psychosocial variables fuel curiosity to scrutinize it further. Hence, we studied potential influence of and relation between adverse childhood experiences, aggression, empathy, and psychopathology in adult males accused of rape in India and investigated the risk factors for the same.

METHODS

With a correlational research design, 40 literate and consenting adult males medically confirmed for rape were recruited using convenient sampling. The assessment was done on Adverse Childhood Experiences, Aggression Questionnaire, Symptom Checklist-90, and Interpersonal Reactivity Index. Descriptive statistics, Pearson's product-moment correlation, and stepwise linear regression analysis were calculated.

RESULTS

Approximately 75% of the participants experienced at least one category of Adverse Childhood Experiences. Scores above cut-off points were obtained on anger, hostility, fantasy, and personal distress. Significant correlations were obtained between adverse childhood experiences and psychopathology; between hostility and psychopathology, perspective taking, and personal distress; and in case of indirect aggression, with perspective taking and empathetic concerns. Regression analysis revealed that an increase in Symptom Checklist-90 global scores increases hostility and that lower personal distress predicts higher scores on hostility on Aggression Questionnaire.

CONCLUSIONS

Adverse childhood experiences, aggression, and psychopathology play a critical role and, therefore, should be included as core components of the prevention of rape or relapse prevention programs at the community level.

What determines violent behavior in men? Predicting physical, psychological, and sexual violent offending based on classification and regression tree analysis

Despite compelling evidence that victimization and offending co-occur, it remains unclear what types of victimization are linked to specific forms of perpetration. Here we examined the relationship between physical, psychological, and sexual violence with respect to influencing variables including mental health, risk-taking behaviors, and coping strategies. Data from 5385 men were collected as part of an epidemiological study on violence experience. A classification and regression tree analysis identified the main predictors of violence perpetration and classified violent offending into high- and low-risk groups. Results indicate that violence is best predicted by previous exposure to violence and polyvictimization. Physical violence is best predicted by prior exposure to physical violence and this is further influenced by the frequency of and the age at which violence was experienced. Drug use was a strong predictor of physical and psychological violence. The latter is best predicted by a history of polyvictimization, the severity and the originator of violence. Sexual violence is strongly predicted by one's sexual violence experience. Other factors such as demographic characteristics are less predictive. Our results may contribute to the development of early prevention and intervention approaches that account for different risk factors. The significance of violence exposure suggest that intervention measures must focus on victims of early and prolonged experience of violence. On the strength of the link between drug use and violence, exposure to violence should be considered in drug prevention and intervention and vice versa.

Does Treatment for Sexual Offending Work?

PURPOSE OF REVIEW

We review and synthesize the literature on the effectiveness of offense-focused treatment for sexual offending. Specifically, we consider whether the extant literature suggests treatment is effective in reducing sexual reoffending and features of effective interventions. We also consider how the design of program evaluations may influence treatment outcomes.

RECENT FINDINGS

Recent research suggests that offense-focused psychological treatment for sexual offending shows some level of effectiveness in reducing both sexual and general reoffending. Further, there appear to be key program, individual, and study design features associated with treatment effectiveness. Although recent findings paint an optimistic outlook for offense-focused psychological treatment for sexual offending, further high-quality differential studies are needed to fully understand the range of content, delivery, and individual factors associated with successful treatment outcomes so as to establish what works best for whom.

Portrait of an Exhibitionist

Exhibitionism has been viewed through many lenses, from the perspectives of sexual deviance, forensic psychiatry, psychopathology, psychological dynamics, feminism, behaviorism, and psychopharmacology. Starting from the description of one psychotherapy patient, the aim of this paper is to synthesize this disparate literature. The findings of the synthesis include an estimate of the lifetime male prevalence of exhibitionism, 2-4%, peaking in late adolescence. Insecure attachment, sexual abuse in childhood, substance abuse, and sexual dysfunction are acknowledged risk factors. Motives behind the act of genital exposure remain obscure, constructed of both sexual and non-sexual impulses. The usual response of women victims is alarm and disgust. Successful treatment relies on a strong therapeutic alliance with specific psychological and psychopharmacological interventions - comparative effectiveness not yet determined. In conclusion, precedents for exhibitionism vary. The frequency of the behavior usually wanes with age and, while exhibitionists may pose a risk to others, they usually do not. There is, as yet, no gold standard treatment; the recommendation for therapists is to respond to individual facets of the patient's circumstances and history.

Severe mental illness diagnoses and their association with reoffending in a sample of men adjudicated for sexual offences

The current study examined the relationship between mental illness and recidivism in a sample of 409 men adjudicated for sexual offences who scored higher than average on an established risk assessment tool (Static-99R). Participants were from all provincial correctional systems (except Prince Edward Island) and all regions of the Correctional Service of Canada. Severe mental illness diagnoses, with the exception of some personality disorders, were not associated with recidivism (after an average follow-up of 11 years). While some personality diagnoses were initially related to recidivism, this relationship often disappeared or was attenuated after controlling for substance misuse and risk score on the Static-99R. There were two exceptions: Histrionic and narcissistic personality disorders continued to predict sexual recidivism after controlling for Static-99R and substance misuse history. In sum, the current study suggests that severe mental illness diagnoses are not associated with higher rates of recidivism after accounting for risk score and substance misuse in men with sexual offences, with the exception of histrionic and narcissistic personality disorder diagnoses. For this reason, risk judgements that weigh both known risk factors and severe mental illness may overestimate an individual’s risk to reoffend.

Characteristics of convicted male-on-female rapists in the South of Sweden between 2013 and 2018: a pilot study

The objective of this study was to evaluate the main characteristics of adult male offenders convicted of rape or aggravated rape against adult females. We reviewed all convictions (n = 21) based on court documents from the District Court, the Court of Appeal and information from the Swedish Tax Agency in Malmö, Sweden, between 2013 and 2018. The findings indicated that the most common offender characteristics were a single status, mean age of 33 years and foreign background. The rapes primarily occurred within a private setting while the victims (who were often younger and knew the offender) were unconscious. Although assumptions based on these results should be made with caution, our findings provide a clear image of the typical circumstances under which these rapes occurred. This study should be viewed as a first attempt to create a database of characteristics of convicted rapists. As more data are added, more sophisticated analyses can be performed and stronger generalizations may be made. Information of this kind may also be important for further research, classification of rapists in offender profiling, and case linking.

Child Maltreatment and Adult Sexual Assault Victimization: Genetic and Environmental Associations

Despite the pervasiveness of adult sexual assault (ASA), evidence-based knowledge on the risk factors for sexual victimization is insufficient. Here, we investigated the etiology of ASA in a population-based Finnish twin sample. Specifically, we estimated the extent of the genetic and environmental influences on the risk of ASA, and we examined its phenotypic and genetic associations with five types of child maltreatment (CM). We found large unique environmental, but also small genetic influences on the risk of ASA, motivating further research on situational and behavioral conditions potentially exploited by sexually motivated perpetrators. The prevalence of ASA was highest among victims of severe child sexual abuse. However, when accounting for the co-occurrence of multiple types of CM, emotional abuse was the strongest predictor of ASA. We further examined, and could not entirely rule out, the possibility of common genetic and environmental pathways underlying CM and ASA. Lastly, we focused on sex differences. Emotional and physical abuse were the strongest predictors of ASA in women and men, respectively, and genetic influences on the risk of ASA were larger in women than men. However, such higher heritability did not reflect sex-limited genetic effects, but, rather, women's systematic exposure to environmental risk of ASA.

Childhood maltreatment experiences and problematic sexual outcomes in adult males who have sexually offended: Further evidence of the potency of male caregiver psychological abuse

BACKGROUND

Although research on the developmental antecedents of sexual offending has tended to focus on sexual abuse, recent research in juveniles and adults who have sexually offended suggests that psychological abuse perpetrated by a male caregiver may be a particularly important factor in the development of problematic sexual interests and behaviors.

OBJECTIVE

This study aimed to extend previous findings by investigating the association between psychological abuse by a male caregiver and problematic sexual outcomes in a sample of adult males who had sexually offended.

PARTICIPANTS

Participants were 529 adult males incarcerated for sexual offenses, 21% of whom were civilly committed.

METHODS

Childhood maltreatment and problematic sexual outcomes were assessed using the Multidimensional Assessment of Sex and Aggression, a contingency-based inventory that assesses domains related to sexual aggression. Hierarchical regressions were calculated examining the association between childhood abuse types and sexual outcomes.

RESULTS

Childhood sexual abuse was associated with child sexual (β = .247, p < .001) and other paraphilic interests (β = .189, p < .001). Male caregiver psychological abuse also emerged as marginally associated with child sexual interest (β = .100, p = .059), even after controlling for other abuse types.

CONCLUSIONS

These results partially replicate recent findings in a juvenile sample and challenge conventional developmental theories of sexual offending, by suggesting that male caregiver psychological abuse may play a role in the etiology of child sexual interest among males who have sexually offended. This study also suggests a possible gender symmetry effect moderating the developmental consequences of abuse.

Genetic Vulnerability to Experiencing Child Maltreatment

Although biological factors may influence the risk of experiencing negative life events, the role of genes in the vulnerability to child victimization remains poorly understood. In a large population-based Finnish sample (N = 13,024), we retrospectively measured multiple experiences of child victimization and, in a subsample of twins (n = 9,562), we estimated the extent to which genetic and environmental factors influenced these experiences. In particular, we investigated whether genetic and environmental influences varied depending on the type of child victimization, the genetic relatedness with the perpetrator, and the sex of the victim. Our quantitative genetic analyses supported the presence of both genetic and environmental influences on the occurrence and co-occurrence of child abuse and neglect. We also identified one common etiological pathway underlying multiple child victimizations, and after accounting for this common etiology, we singled out risk factors specific to sexual abuse. Environmental factors shared and nonshared between twins raised together influenced the risk of victimization by genetically related and unrelated perpetrators, respectively. Furthermore, we estimated sex differences in the etiology of emotional and sexual victimization, including larger unshared environmental influences for men and sex-limited genetic effects for women. These findings can inform child protection as they contribute to explaining why certain individuals are at increased risk of experiencing one or more types of child maltreatment.

Does specialized psychological treatment for offending reduce recidivism? A meta-analysis examining staff and program variables as predictors of treatment effectiveness

A meta-analysis was conducted to examine whether specialized psychological offense treatments were associated with reductions in offense specific and non-offense specific recidivism. Staff and treatment program moderators were also explored. The review examined 70 studies and 55,604 individuals who had offended. Three specialized treatments were examined: sexual offense, domestic violence, and general violence programs. Across all programs, offense specific recidivism was 13.4% for treated individuals and 19.4% for untreated comparisons over an average follow up of 66.1 months. Relative reductions in offense specific recidivism were 32.6% for sexual offense programs, 36.0% for domestic violence programs, and 24.3% for general violence programs. All programs were also associated with significant reductions in non-offense specific recidivism. Overall, treatment effectiveness appeared improved when programs received consistent hands-on input from a qualified registered psychologist and facilitating staff were provided with clinical supervision. Numerous program variables appeared important for optimizing the effectiveness of specialized psychological offense programs (e.g., arousal reconditioning for sexual offense programs, treatment approach for domestic violence programs). The findings show that such treatments are associated with robust reductions in offense specific and non-offense specific recidivism. We urge treatment providers to pay particular attention to staffing and program implementation variables for optimal recidivism reductions.

Are There Early Risk Markers for Pedophilia? A Nationwide Case-Control Study of Child Sexual Exploitation Material Offenders

Although prior research suggests associations between parental characteristics and later sexual offending in offspring, possible links between early pregnancy-related factors and sexual offending remain unclear. Early risk markers unique to sexual offending, however, may be more prominent among sexual offenders with atypical sexual interests, such as individuals involved with child sexual exploitation material (CSEM; also referred to as child pornography). We examined the prospective association between parental and pregnancy-related risk markers and a behavioral indicator of pedophilic interest, CSEM offending. All 655 men born in Sweden and convicted of CSEM offending between 1988 to 2009 were matched 1:5 on sex, birth year, and county of birth in Sweden to 3,928 controls without sexual or nonsexual violent convictions. Paternal age (adjusted odds ratio [AOR] = 1.3, 95% confidence interval [CI] [1.1, 1.7]), parental education (AOR = 0.8, 95% CI [0.6, 0.9]), parental violent criminality (AOR = 2.9, 95% CI [2.2, 3.8]), number of older brothers (AOR = 0.8, 95% CI [0.6, 0.9] per brother), and congenital malformations (AOR = 1.7, 95% CI [1.2, 2.4]) all independently predicted CSEM convictions. This large-scale, nationwide study suggests parental risk markers for CSEM offending. We did not, however, find convincing evidence for pregnancy-related risk markers, with the exception of congenital malformations and having fewer older brothers.

Blaming rape on sleep: A psychoanalytic intervention

The governance of sleep sex (or sexsomnia) in the criminal law is a nightmare. Press reports of sleeping, often drunk, men acquitted as automatons of raping adults and children suggest cases are rising. The use of automatism, rather than insanity, in these cases is strong evidence of the immemorial struggle faced by legal psychiatry in appropriately construing unconscious defendants. This paper responds by drawing on well-established psychoanalytic conceptions of unconsciousness to present sexsomnia as dispositional to the defendant. Taking the Freudian concepts of eros and death instinct, it asserts that sexsomniacs are acting on repressed sadistic desires. Accordingly, those on notice of their sexsomnia, who fail to mitigate the risk of further attacks, should be guilty of rape. Reliance on (a reformed) insanity defence - being a denial of responsibility at the time of the offence - undermines the scope of the criminal law to self-responsibilise sexsomniacs against perpetrating unwanted sex.

Thought leader perspectives on benefits and harms in precision medicine research

Precision medicine research is underway to identify targeted approaches to improving health and preventing disease. However, such endeavors raise significant privacy and confidentiality concerns. The objective of this study was to elucidate the potential benefits and harms associated with precision medicine research through in-depth interviews with a diverse group of thought leaders, including primarily U.S.-based experts and scholars in the areas of ethics, genome research, health law, historically-disadvantaged populations, informatics, and participant-centric perspectives, as well as government officials and human subjects protections leaders. The results suggest the prospect of an array of individual and societal benefits, as well as physical, dignitary, group, economic, psychological, and legal harms. Relative to the way risks and harms are commonly described in consent forms for precision medicine research, the thought leaders we interviewed arguably emphasized a somewhat different set of issues. The return of individual research results, harm to socially-identifiable groups, the value-dependent nature of many benefits and harms, and the risks to the research enterprise itself emerged as important cross-cutting themes. Our findings highlight specific challenges that warrant concentrated care during the design, conduct, dissemination, and translation of precision medicine research and in the development of consent materials and processes.

Executive Functioning in Pedophilia and Child Sexual Offending

OBJECTIVES

Pedophilia (P) is a psychiatric disease associated with sexual attraction toward children and often accompanied by child sexual offending (CSO). Consequently, it is important to address the understanding of executive dysfunctions that may increase the probability of CSO. Moreover, this research field has been lacking to disentangle executive deficits associated with pedophilia (as a deviant sexual preference) from those associated with CSO (as a deviant sexual behavior).

METHODS

The German multi-sided research network NeMUP offers the opportunity to overcome these limitations. By applying the Cambridge Automated Neuropsychological Test Battery in four carefully matched groups of men: (1) pedophiles with (N=45) and (2) without (N=45) a history of sexual offending against children; (3) child molesters without pedophilia (N=19), and (4) non-offending controls (N=49), we were able to analyze executive functioning in pedophilia and CSO independently.

RESULTS

Both CSO groups as compared to both non-CSO groups exhibited worsened response inhibition ability. However, only non-pedophilic offenders showed additionally disabled strategy use ability. Regarding set-shifting abilities, the P+CSO group showed the best performance. We also found that performances were affected by age: only in pedophiles, response inhibition worsened with age, while age-related deficits in set-shifting abilities were restricted to non-pedophilic participants. The latter also differentiated between both sexual preference groups.

CONCLUSIONS

Our results are the first to demonstrate that executive dysfunctions are related to offense status rather than pedophilic preference. Furthermore, there was evidence for differentiating age and performance correlations between pedophiles and non-pedophiles, which warrants further investigation. (JINS, 2017, 23, 460-470).

The Exploitive Mating Strategy of the Dark Triad Traits: Tests of Rape-Enabling Attitudes

The Dark Triad traits have been repeatedly labeled as facilitating an exploitive mating strategy. However, various researchers have repeatedly conflated short-term mating or casual sex with an exploitive mating strategy. In this study using Mechanical Turk participants (N = 252; 142 men, 110 women), we provided a better test of just how sexually exploitive those high on the Dark Triad traits might be by examining how the traits related to rape-enabling attitudes. We examined how each trait may facilitate rape, whether these associations were robust to partialing the variance associated with the Big Five traits and similar in men and women, and showed that one reason why men may be more likely to rape than women is they are characterized by the Dark Triad traits more than women are. In so doing, we test the confluence model of rape that asserts that personality traits similar to the Dark Triad traits act as one pathway to rape.

Parental and perinatal risk factors for sexual offending in men: a nationwide case-control study

BACKGROUND

Prior studies suggest parental and perinatal risk factors are associated with later offending. It remains uncertain, however, if such risk factors are similarly related to sexual offending.

METHOD

We linked socio-demographic, family relations, and perinatal (obtained at birth) data from the nationwide Swedish registers from 1973 to 2009 with information on criminal convictions of cases and control subjects. Male sex offenders (n = 13 773) were matched 1:5 on birth year and county of birth in Sweden to male controls without sexual or non-sexual violent convictions. To examine risk-factor specificity for sexual offending, we also compared male violent, non-sexual offenders (n = 135 953) to controls without sexual or non-sexual violent convictions. Predictors included parental (young maternal or paternal age at son's birth, educational attainment, violent crime, psychiatric disorder, substance misuse, suicide attempt) and perinatal (number of older brothers, low Apgar score, low birth weight, being small for gestational age, congenital malformations, small head size) variables.

RESULTS

Conditional logistic regression models found consistent patterns of statistically significant, small to moderate independent associations of parental risk factors with sons' sexual offending and non-sexual violent offending. For perinatal risk factors, patterns varied more; small for gestational age and small head size exhibited similar risk effects for both offence types whereas a higher number of older biological brothers and any congenital malformation were small, independent risk factors only for non-sexual violence.

CONCLUSIONS

This nationwide study suggests substantial commonalities in parental and perinatal risk factors for the onset of sexual and non-sexual violent offending.

Paraphilic Sexual Offenders Do Not Differ From Control Subjects With Respect to Dopamine- and Serotonin-Related Genetic Polymorphisms

INTRODUCTION

Rape and pedophilic child molestation are the most commonly convicted sexual offenses in Poland. Recent studies have suggested a possible genetic contribution toward pathologic sexual interests and behaviors.

AIM

To analyze and compare functional polymorphisms of genes associated with the activity of the serotonin and dopamine systems in a group of paraphilic sexual offenders and control subjects.

METHODS

The study sample (n = 97) consisted of two groups: paraphilic sexual offenders (65 pedophilic child molesters and 32 rapists) and controls (n = 76). Genetic polymorphisms previously associated with behavioral control, addictive behaviors, and sexual functions were chosen for analyses. Specifically, functional polymorphisms in dopamine receptors genes (DRD1, DRD2, DRD4), catechol-O-methyltransferase gene (COMT), dopamine transporter gene (DAT), serotonin transporter gene (SLC6A4), serotonin type 2A receptor gene (5HTR2A), tryptophan hydroxylase 2 gene (TPH2), monoamine oxidase A gene (MAOA), and brain-derived neurotrophic factor gene (BDNF) were analyzed.

MAIN OUTCOME MEASURES

An association between a history of sexual offense and the distribution of genotypes and alleles in the analyzed polymorphisms.

RESULTS

Our results found no association between a history of sexual offense and the distribution of genotypes or alleles in the analyzed polymorphisms.

CONCLUSION

Although these results are limited by the small sample and are exploratory, they highlight a novel approach to sample selection in a population that is difficult to access and study. Future research should include larger samples and other relevant polymorphisms to advance this field of study.

Genetic and environmental determinants of violence risk in psychotic disorders: a multivariate quantitative genetic study of 1.8 million Swedish twins and siblings

Patients diagnosed with psychotic disorders (for example, schizophrenia and bipolar disorder) have elevated risks of committing violent acts, particularly if they are comorbid with substance misuse. Despite recent insights from quantitative and molecular genetic studies demonstrating considerable pleiotropy in the genetic architecture of these phenotypes, there is currently a lack of large-scale studies that have specifically examined the aetiological links between psychotic disorders and violence. Using a sample of all Swedish individuals born between 1958 and 1989 (n=3 332 101), we identified a total of 923 259 twin-sibling pairs. Patients were identified using the National Patient Register using validated algorithms based on International Classification of Diseases (ICD) 8-10. Univariate quantitative genetic models revealed that all phenotypes (schizophrenia, bipolar disorder, substance misuse, and violent crime) were highly heritable (h(2)=53-71%). Multivariate models further revealed that schizophrenia was a stronger predictor of violence (r=0.32; 95% confidence interval: 0.30-0.33) than bipolar disorder (r=0.23; 0.21-0.25), and large proportions (51-67%) of these phenotypic correlations were explained by genetic factors shared between each disorder, substance misuse, and violence. Importantly, we found that genetic influences that were unrelated to substance misuse explained approximately a fifth (21%; 20-22%) of the correlation with violent criminality in bipolar disorder but none of the same correlation in schizophrenia (Pbipolar disorder<0.001; Pschizophrenia=0.55). These findings highlight the problems of not disentangling common and unique sources of covariance across genetically similar phenotypes as the latter sources may include aetiologically important clues. Clinically, these findings underline the importance of assessing risk of different phenotypes together and integrating interventions for psychiatric disorders, substance misuse, and violence.

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.

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

The primary aim of these guidelines was to evaluate the role of pharmacological agents in the treatment of adolescents with paraphilic disorders who are also sexual offenders or at-risk of sexual offending. Psychotherapeutic and psychosocial treatments were also reviewed. Adolescents with paraphilic disorders specifically present a different therapeutic challenge as compared to adults. In part, the challenge relates to adolescents being in various stages of puberty and development, which may limit the use of certain pharmacological agents due to their potential side effects. In addition, most of the published treatment programmes have used cognitive behavioural interventions, family therapies and psychoeducational interventions. Psychological treatment is predicated in adolescents on the notion that sexually deviant behaviour can be controlled by the offender, and that more adaptive behaviours can be learned. The main purposes of these guidelines are to improve the quality of care and to aid physicians in their clinical decisions. These guidelines brought together different expert views and involved an extensive literature research. Each treatment recommendation was evaluated and discussed with respect to the strength of evidence for efficacy, safety, tolerability and feasibility. An algorithm is proposed for the treatment of paraphilic disorders in adolescent sexual offenders or those who are at risk.