Effects of internet-delivered cognitive behavioral therapy on use of child sexual abuse material: A randomized placebo-controlled trial on the Darknet

INTRODUCTION

The use of child sexual abuse material (CSAM) is an international public health and child protection challenge.

OBJECTIVE

To investigate whether Prevent It, a therapist-supported, internet-delivered, eight-week, cognitive behavioral therapy, reduces CSAM viewing among users.

METHODS

We conducted a global online single-blind (participants), parallel-group, superiority, randomized, psychological placebo-controlled trial with a one-month follow-up, 2019-2021 (ISRCTN76841676). We recruited anonymous participants, mainly from Darknet forums. Inclusion criteria: age 18+ years, past week CSAM use, and sufficient English language skills; exclusion criteria: severe psychiatric illness or non-serious intent to participate. The main outcome was change in self-reported, weekly viewing time from pre- to post-treatment, according to the Sexual Child Molestation Risk Assessment+.

RESULTS

A total of 160 participants (157 male, 2 non-binary, and 1 not reporting gender) from all world regions (age intervals [%]: 18-29 [49]; 30-39 [30]; 40-49 [15]; 50-59 [6]) were randomized (1:1) to Prevent It (N = 80) or Placebo (N = 80). Between-group, intention-to-treat analyses suggested a significantly larger decrease in viewing time in Prevent It participants vs. controls pre- to post-treatment (Prevent It: N = 76, Placebo: N = 78, estimate -0.25, 95 % CI, -0.46 to -0.04, p = .017, Cohen's d 0.18). Negative side effects from treatment were fewer in Prevent It compared to control participants and neither group reported severe adverse events.

CONCLUSION

We provide initial support for the feasibility, efficacy, and safety of Prevent It to reduce CSAM viewing among motivated users. Further research is needed to validate these findings.

A randomised controlled trial of fluoxetine versus naltrexone in compulsive sexual behaviour disorder: presentation of the study protocol

BACKGROUND

Compulsive sexual behaviour disorder is a new disorder in the International Classification of Diseases (ICD-11), and is associated with negative consequences in different areas of life. Evidence for pharmacological treatment of compulsive sexual behaviour disorder is weak and treatment options are limited. This proposed study will be the largest and the first randomised controlled trial comparing the efficacy and tolerability of two active drugs in compulsive sexual behaviour disorder.

METHODS AND ANALYSIS

Eighty adult participants with compulsive sexual behaviour disorder according to ICD-11 will be randomised to receive either naltrexone 25-50 mg or fluoxetine 20-40 mg for 8 weeks, followed by 6 weeks without treatment. The study will be conducted in a subspecialised outpatient sexual medicine unit at Karolinska University Hospital, Stockholm, Sweden. The study is financed by grants and entirely independent of the manufacturers.Exclusion criteria include severe psychiatric or psychical illness, changes to concurrent medication and non-compatible factors contraindicating the use of either drug. The primary outcome measure is the Hypersexual Disorder: Current Assessment Scale (HD: CAS), and tolerability will be assessed by the Udvalg for Kliniske Undersogelser side effect rating scale (UKU), drug accountability, adherence to treatment and drop-out rate. Participants will complete questionnaires at regular intervals, with the main endpoint for efficacy after 8 weeks (end of treatment) and after 14 weeks (follow-up). Blood chemistry will be repeatedly collected as a safety precaution and for research purposes. The results will be analysed using an appropriate analysis of variance model or a mixed model, depending on the distribution of HD: CAS and the extent of missing data.

ETHICS AND DISSEMINATION

The Swedish Ethical Review Authority and the Swedish Medical Products Agency have approved the study on 27 May 2020 and 4 June 2020, respectively (ref. no. 2020-02069 and ref. no. 5.1-2020-48282). Findings will be published in peer-reviewed journals and presented at relevant conferences.

TRIAL REGISTRATION NUMBER

2019-004255-36.

High Plasma Oxytocin Levels in Men With Hypersexual Disorder

CONTEXT

Hypersexual disorder (HD) involves excessive, persistent sexual behaviors related to various mood states and the diagnosis compulsive sexual behavior disorder is included as an impulse control disorder in the 11th revision of the International Classification of Diseases. Although the neurobiology behind the disorder is not clear, some studies suggest dysregulated hypothalamic-pituitary-adrenal axis. Oxytocin acts as counterregulatory neuroendocrine hormone to cortisol and is also involved in sexual behavior.

OBJECTIVE

We hypothesized that oxytocin may play a role in the pathophysiology of HD with compensatory actions to cortisol.

DESIGN

Longitudinal.

SETTING

ANOVA clinic (Karolinska University Hospital).

PATIENTS OR OTHER PARTICIPANTS

64 males with HD and 38 age-matched healthy volunteers.

MAIN OUTCOME MEASURES

Plasma oxytocin levels, measured with radioimmunoassay; Hypersexual Disorder Screening Inventory; and Hypersexual Disorder: Current Assessment Scale for assessing hypersexual symptoms.

INTERVENTIONS

A patient subgroup (n = 30) completed the manual-based group-administered cognitive-behavioral therapy (CBT) program for HD, and posttreatment oxytocin levels were measured.

RESULTS

Hypersexual men (n = 64) exhibited significantly higher oxytocin plasma levels (mean ± SD: 31.0 ± 9.9 pM) compared with healthy volunteers (16.9 ± 3.9 pM; P < 0.001). There were significant positive correlations between oxytocin levels and the rating scales measuring hypersexual behavior. Patients who completed CBT treatment (n = 30) had a significant reduction of oxytocin plasma levels from pretreatment (30.5 ± 10.1 pM) to posttreatment (20.2 ± 8.0 pM; P < 0.001).

CONCLUSIONS

The results suggest that the hyperactive oxytocinergic system in hypersexual men may be a compensatory mechanism to attenuate hyperactive stress.

HPA axis dysregulation is associated with differential methylation of CpG-sites in related genes

DNA methylation shifts in Hypothalamic-pituitary-adrenal (HPA) axis related genes is reported in psychiatric disorders including hypersexual disorder. This study, comprising 20 dexamethasone suppression test (DST) non-suppressors and 73 controls, examined the association between the HPA axis dysregulation, shifts in DNA methylation of HPA axis related genes and importantly, gene expression. Individuals with cortisol level ≥ 138 nmol/l, after the low dose (0.5 mg) dexamethasone suppression test (DST) were classified as non-suppressors. Genome-wide methylation pattern, measured in whole blood using the EPIC BeadChip, investigated CpG sites located within 2000 bp of the transcriptional start site of key HPA axis genes, i.e.: CRH, CRHBP, CRHR-1, CRHR-2, FKBP5 and NR3C1. Regression models including DNA methylation M-values and the binary outcome (DST non-suppression status) were performed. Gene transcripts with an abundance of differentially methylated CpG sites were identified with binomial tests. Pearson correlations and robust linear regressions were performed between CpG methylation and gene expression in two independent cohorts. Six of 76 CpG sites were significantly hypermethylated in DST non-suppressors (nominal P < 0.05), associated with genes CRH, CRHR1, CRHR2, FKBP5 and NR3C1. NR3C1 transcript AJ877169 showed statistically significant abundance of probes differentially methylated by DST non-suppression status and correlated with DST cortisol levels. Further, methylation levels of cg07733851 and cg27122725 were positively correlated with gene expression levels of the NR3C1 gene. Methylation levels of cg08636224 (FKBP5) correlated with baseline cortisol and gene expression. Our findings revealed that DNA methylation shifts are involved in the altered mechanism of the HPA axis suggesting that new epigenetic targets should be considered behind psychiatric disorders.

Frequency of Pornography Use and Sexual Health Outcomes in Sweden: Analysis of a National Probability Survey

BACKGROUND

Little is known about pornography use and its relationship with sexual health outcomes in the general population.

AIM

To assess frequency of pornography use and the association of sexual health outcomes with frequent pornography use in Sweden.

METHODS

Cross-sectional analysis of 14,135 participants (6,169 men and 7,966 women) aged 16-84 years in a Swedish nationally representative survey from 2017. We used logistic regression to assess the association of sexual health outcomes with use of pornography ≥3 times/wk.

OUTCOMES

Frequency of pornography use (never; less than once/mo to 3 times/mo; 1-2 times/wk; 3-5 times/wk; and daily or almost daily) and sexual health outcomes (eg, sexual satisfaction and sexual health problems).

RESULTS

In total, 68.7% of men and 27.0% of women used pornography. Among men aged 16-24 years, 17.2% used pornography daily or almost daily, 24.7% used pornography 3-5 d/wk and 23.7% used pornography 1-2 d/wk. Among women aged 16-24 years, the proportions were 1.2% for daily or almost daily, 3.1% for 3-5 times/wk, and 8.6% for 1-2 times/wk. Frequency of pornography use decreased with age among both men and women. While 22.6% of all men and 15.4% of all women reported that their or a sex partner's pornography use predominantly had positive effects on their sex life, 4.7% of men and 4.0% of women reported that the effects were predominantly negative. Variables indicating sexual dissatisfaction and sexual health problems were associated with use of pornography ≥3 times/wk: for example, dissatisfaction with sex life (age-adjusted odds ratio [aOR]: men 2.90 [95% CI 2.40-3.51]; women 1.85 [95% CI 1.09-3.16]), not having sex in the preferred way (aOR: men 2.48 [95% CI 1.92-3.20]; women 3.59 [95% CI 2.00-6.42]) and erection problems (aOR: men 2.18 [95% CI 1.73-2.76]).

CLINICAL IMPLICATIONS

While frequent pornography use is common, potential effects on sexual health outcomes are likely to differ between individuals.

STRENGTH & LIMITATIONS

We used a large and recent nationally representative survey with detailed information regarding frequency of pornography use. The temporality of associations of sexual health variables with frequency of pornography use could not be assessed.

CONCLUSION

In this analysis of a nationally representative survey in Sweden, we found that frequent pornography use was common among young men; that reporting predominantly positive effects of pornography use on the sex life was more common than reporting predominantly negative effects; and that sexual dissatisfaction and sexual health problems were associated with using pornography ≥3 times/wk. Malki K, Rahm C, Öberg KG, et al. Frequency of Pornography Use and Sexual Health Outcomes in Sweden: Analysis of a National Probability Survey. J Sex Med 2021;18:1735-1751.

Impulsivity in Compulsive Sexual Behavior Disorder and Pedophilic Disorder

BACKGROUND AND AIMS

Impulsivity is regarded as a risk factor for sexual crime reoffending, and a suggested core feature in Compulsive Sexual Behavior Disorder. The aim of this study was to explore clinical (e.g. neurodevelopmental disorders), behavioral and neurocognitive dimensions of impulsivity in disorders of problematic sexuality, and the possible correlation between sexual compulsivity and impulsivity.

METHODS

Men with Compulsive Sexual Behavior Disorder (n = 20), and Pedophilic Disorder (n = 55), enrolled in two separate drug trials in a specialized Swedish sexual medicine outpatient clinic, as well as healthy male controls (n = 57) were assessed with the Hypersexual Behavior Inventory (HBI) for sexual compulsivity, and with the Barratt Impulsiveness Scale (BIS) and Connors' Continuous Performance Test-II (CPT-II) for impulsivity. Psychiatric comorbidity information was extracted from interviews and patient case files.

RESULTS

Approximately a quarter of the clinical groups had Attention-Deficit/Hyperactivity Disorder (ADHD) or Autism Spectrum Disorder. Both clinical groups reported more compulsive sexuality (r = 0.73-0.75) and attentional impulsivity (r = 0.36-0.38) than controls (P < 0.05). Based on results on univariate correlation analysis, BIS attentional score, ADHD, and Commissions T-score from CPT-II were entered in a multiple linear regression model, which accounted for 15% of the variance in HBI score (P < 0.0001). BIS attentional score was the only independent positive predictor of HBI (P = 0.001).

DISCUSSION

Self-rated attentional impulsivity is an important associated factor of compulsive sexuality, even after controlling for ADHD. Psychiatric comorbidity and compulsive sexuality are common in Pedophilic Disorder.

CONCLUSION

Neurodevelopmental disorders and attentional impulsivity - including suitable interventions - should be further investigated in both disorders.

Normal Testosterone but Higher Luteinizing Hormone Plasma Levels in Men With Hypersexual Disorder

INTRODUCTION

Hypersexual disorder as suggested to be included in the Diagnostic and Statistical Manual of Mental Disorders-5 integrates aspects of sexual desire deregulation, impulsivity, and compulsivity. However, it is unknown how it affects gonadal activity and the function of the hypothalamus-pituitary-gonadal (HPG) axis.

AIM

The aim of this study was to investigate testosterone and luteinizing hormone (LH) levels in hypersexual men compared with healthy controls. Furthermore, we investigated associations between epigenetic markers and hormone levels.

METHODS

Basal morning plasma levels of testosterone, LH, and sex hormone-binding globulin (SHBG) were assessed in 67 hypersexual men (mean age: 39.2 years) compared with 39 age-matched healthy controls (mean age: 37.5 years). The Sexual Compulsivity Scale and the Hypersexual Disorder: Current Assessment Scale were used for assessing hypersexual behavior, the Montgomery-Åsberg Depression Scale-self rating was used for depression severity, and the Childhood Trauma Questionnaire (CTQ) was used for assessing history of childhood adversity. The genome-wide methylation pattern of more than 850 K CpG sites was measured in whole blood using the Illumina Infinium Methylation EPIC BeadChip. CpG sites located within 2,000 bp of the transcriptional start site of hypothalamus pituitary adrenal (HPA) and HPG axis-coupled genes were included.

MAIN OUTCOME MEASURES

Testosterone and LH plasma levels in association with clinical rating and a secondary outcome was the epigenetic profile of HPA and HPG axis-coupled CpG sites with testosterone and LH levels.

RESULTS

LH plasma levels were significantly higher in patients with hypersexual disorder than in healthy volunteers. No significant differences in plasma testosterone, follicle stimulating hormone, prolactin, and SHBG levels were found between the groups. There were no significant associations between DNA methylation of HPA and HPG axis-coupled genes and plasma testosterone or LH levels after multiple testing corrections.

CONCLUSIONS

Subtle dysregulation of the HPG axis, with increased LH plasma levels but no difference in testosterone levels may be present in hypersexual men. Chatzittofis A, Boström AE, Öberg KG, et al. Normal Testosterone but Higher Luteinizing Hormone Plasma Levels in Men With Hypersexual Disorder. Sex Med 2020;8:243-250.

Hypermethylation-associated downregulation of microRNA-4456 in hypersexual disorder with putative influence on oxytocin signalling: A DNA methylation analysis of miRNA genes

Hypersexual disorder (HD) was proposed as a diagnosis in the DSM-5 and the classification ‘Compulsive Sexual Behavior Disorder’ is now presented as an impulse-control disorder in ICD-11. HD incorporates several pathophysiological mechanisms; including impulsivity, compulsivity, sexual desire dysregulation and sexual addiction. No previous study investigated HD in a methylation analysis limited to microRNA (miRNA) associated CpG-sites. The genome wide methylation pattern was measured in whole blood from 60 subjects with HD and 33 healthy volunteers using the Illumina EPIC BeadChip. 8,852 miRNA associated CpG-sites were investigated in multiple linear regression analyses of methylation M-values to a binary independent variable of disease state (HD or healthy volunteer), adjusting for optimally determined covariates. Expression levels of candidate miRNAs were investigated in the same individuals for differential expression analysis. Candidate methylation loci were further studied for an association with alcohol dependence in an independent cohort of 107 subjects. Two CpG-sites were borderline significant in HD – cg18222192 (MIR708)(p < 10E-05,p_FDR = 5.81E-02) and cg01299774 (MIR4456)(p < 10E-06, p_FDR = 5.81E-02). MIR4456 was significantly lower expressed in HD in both univariate (p < 0.0001) and multivariate (p < 0.05) analyses. Cg01299774 methylation levels were inversely correlated with expression levels of MIR4456 (p < 0.01) and were also differentially methylated in alcohol dependence (p = 0.026). Gene target prediction and pathway analysis revealed that MIR4456 putatively targets genes preferentially expressed in brain and that are involved in major neuronal molecular mechanisms thought to be relevant for HD, e.g., the oxytocin signalling pathway. In summary, our study implicates a potential contribution of MIR4456 in the pathophysiology of HD by putatively influencing oxytocin signalling.

Interpersonal violence, early life adversity, and suicidal behavior in hypersexual men

Background and aims There are significant gaps in knowledge regarding the role of childhood adversity, interpersonal violence, and suicidal behavior in hypersexual disorder (HD). The aim of this study was to investigate interpersonal violence in hypersexual men compared with healthy volunteers and the experience of violence in relation to suicidal behavior. Methods This case-control study includes 67 male patients with HD and 40 healthy male volunteers. The Childhood Trauma Questionnaire - Short Form (CTQ-SF) and the Karolinska Interpersonal Violence Scale (KIVS) were used for assessing early life adversity and interpersonal violence in childhood and in adult life. Suicidal behavior (attempts and ideation) was assessed with the Mini-International Neuropsychiatric Interview (version 6.0) and the Montgomery-Åsberg Depression Rating Scale - Self-rating. Results Hypersexual men reported more exposure to violence in childhood and more violent behavior as adults compared with healthy volunteers. Suicide attempters (n = 8, 12%) reported higher KIVS total score, more used violence as a child, more exposure to violence as an adult as well as higher score on CTQ-SF subscale measuring sexual abuse (SA) compared with hypersexual men without suicide attempt. Discussion Hypersexuality was associated with interpersonal violence with higher total scores in patients with a history of suicide attempt. The KIVS subscale exposure to interpersonal violence as a child was validated using the CTQ-SF but can be complemented with questions focusing on SA for full assessment of early life adversity. Conclusion Childhood adversity is an important factor in HD and interpersonal violence might be related to suicidal behavior in hypersexual men.

Methylation of HPA axis related genes in men with hypersexual disorder

Hypersexual Disorder (HD) defined as non-paraphilic sexual desire disorder with components of compulsivity, impulsivity and behavioral addiction, and proposed as a diagnosis in the DSM 5, shares some overlapping features with substance use disorder including common neurotransmitter systems and dysregulated hypothalamic-pituitary-adrenal (HPA) axis function. In this study, comprising 67 HD male patients and 39 male healthy volunteers, we aimed to identify HPA-axis coupled CpG-sites, in which modifications of the epigenetic profile are associated with hypersexuality. The genome-wide methylation pattern was measured in whole blood using the Illumina Infinium Methylation EPIC BeadChip, measuring the methylation state of over 850K CpG sites. Prior to analysis, the global DNA methylation pattern was pre-processed according to standard protocols and adjusted for white blood cell type heterogeneity. We included CpG sites located within 2000bp of the transcriptional start site of the following HPA-axis coupled genes: Corticotropin releasing hormone (CRH), corticotropin releasing hormone binding protein (CRHBP), corticotropin releasing hormone receptor 1 (CRHR1), corticotropin releasing hormone receptor 2 (CRHR2), FKBP5 and the glucocorticoid receptor (NR3C1). We performed multiple linear regression models of methylation M-values to a categorical variable of hypersexuality, adjusting for depression, dexamethasone non-suppression status, Childhood Trauma Questionnaire total score and plasma levels of TNF-alpha and IL-6. Of 76 tested individual CpG sites, four were nominally significant (p<0.05), associated with the genes CRH, CRHR2 and NR3C1. Cg23409074-located 48bp upstream of the transcription start site of the CRH gene - was significantly hypomethylated in hypersexual patients after corrections for multiple testing using the FDR-method. Methylation levels of cg23409074 were positively correlated with gene expression of the CRH gene in an independent cohort of 11 healthy male subjects. The methylation levels at the identified CRH site, cg23409074, were significantly correlated between blood and four different brain regions. CRH is an important integrator of neuroendocrine stress responses in the brain, with a key role in the addiction processes. Our results show epigenetic changes in the CRH gene related to hypersexual disorder in men.