[Interrater reliability of the criteria-based assessment of criminal responsibility in paraphilic disorders]

BACKGROUND

For the assessment of criminal responsibility in the context of sexual delinquency, the evaluation of the severity of a paraphilic disorder and the ability to be controlled are of particular importance. Established assessment criteria are insufficiently operationalized.

AIM AND METHODS

The existing criteria were tested by experts of various professional groups with respect to the reliability. For this purpose, 14 experts assessed the criteria of 2 different sets of criteria based on 2 case vignettes (see electronic supplementary material).

RESULTS AND CONCLUSION

The interrater reliability (IRR) with reference to the criteria of Briken and Müller was higher than the previously established criteria of Boetticher et al. The evaluation of the subjective importance of the criteria of both assessment scales showed that all criteria were rated as at least of average importance. It could thus be useful to initially include both sets of criteria for a greater transparency in the assessment process and to investigate this procedure in further studies.

Operationalisierte, kriteriengeleitete Beurteilung der Schuldfähigkeit bei paraphilen Störungen – Stand und Ausblick

Die vorliegende Arbeit beschäftigt sich mit der operationalisierten, kriteriengeleiteten Beurteilung für die Begutachtung der Schuldfähigkeit bei paraphilen Störungen. Zunächst werden frühere Überlegungen und Ansätze dargestellt und um neue empirische, vorläufige Ergebnisse, welche erste Annahmen zu Reliabilität und Validität des Vorgehens ermöglichen, erweitert. Anschließend werden kurz die Ergebnisse einer Expertendiskussion zum Thema ergänzt, um vorläufige Schlussfolgerungen und einen Ausblick darzustellen. Insgesamt wird mit der operationalisierten, kriteriengeleiteten Beurteilung für die Begutachtung der Schuldfähigkeit bei paraphilen Störungen ein Verfahren vorgeschlagen, das als vielversprechend angesehen werden kann und zu einer Erweiterung des Vorgehens, den weiteren interdisziplinären Dialog und die weitere empirische Prüfung animiert.

What Keeps Them Together? Insights into Sex Offender Couples Using Qualitative Content Analyses

Research on sex offenders' relationships is scarce. The aim of this qualitative study was to investigate sex offenders' relationships as well as their female partners' adjustment strategies by means of interview analysis. Both partners profit from the relationship in terms of mutual support and acceptance. The sexual offense is a taboo subject, and the female partners were found to demonstrate cognitive distortions. The imbalance of power found in the sex offenders' relationships is discussed, as is the finding that those sexual offenders interviewed live out their need for dominance and sometimes their aggression. The women interviewed were found to cling to their partners as a result of their insecure attachment style. We discuss couples counseling and therapy as possibilities for addressing the imbalance of power and casting light upon the sexual aspect of the relationship.

Selektive Serotoninwiederaufnahmehemmer (SSRI) in der Behandlung von Paraphilien

For about 15 years selective serotonine reuptake inhibitors (SSRI) have been used in the treatment of paraphilias. In an open, uncontrolled, retrospective study, which was the first in the German speaking countries we investigated 16 male outpatients, who have been treated for different paraphilias with SSRI and psychotherapy. There was a marked reduction in paraphilic symptoms. Despite high rates of sexual side effects most patients reported a high overall treatment satisfaction. SSRI are an important addition in pharmacological treatment of paraphilic patients, especially with a risk of so called "hands-off" delinquency.

[Pornography and sexual abuse in the Internet]

Internet pornography has been regarded as either stimulating sexual aggression and abuse or as serving as a safety valve. This controversy is an important issue in health, media and legal politics. According to empirical studies on pornography in general, soft-core pornography and nonviolent pornography can be regarded as harmless, whereas non-violent hard-core pornography and violent pornography may increase aggression. Individuals with a high risk for sexual aggression show more interest in violent pornography and are stimulated more strongly through such material. Two case histories illustrate the characteristics of internet pornography and "cybersex": easy access, anonymity, affordability, wide range and deviation of the material, unlimited market, blurring the borders between consumer and producer, interactive communication, space for experimenting between fantasy and in real-life behavior, virtual identities, easy contact between offender and victim or among offenders, and low risk of apprehension. The phenomenon of "sexual addiction" (or paraphilia- related disorder) is particularly relevant for the problematic use of internet pornography. Preventive measures to protect possible victims are presented as well as treatment strategies for offenders. Beside limiting access to the internet, these include therapy of comorbid psychiatric disorders and psychological problems (social isolation, bereavement, stress- and anger-management, guilt and shame, childhood traumata, cognitive distortion, victim empathy), psychopharmacotherapy and the enhancement of a more integrative and relationship-oriented sexuality.

[Paraphilia, sexual preference disorders. Diagnosis, etiology, epidemiology, treatment and prevention]

Hostility towards relationships is one prominent characteristic symptom for disorders of sexual preference (ICD-10) and paraphilias (DSM-IV). Paraphilic symptoms sometimes progress to obsessive or addictive- like forms leading to a loss of self-control but can occur also as single incidents or as episodic events. Besides constitutional aspects, problems in the development of close relationships to primary caregivers (attachment) play an important role in the development of these disorders. Actual relationship- and self-confidence problems often trigger the severity of disturbance, especially in the episodic forms of paraphilia. For patients who are in conflict with the law, cognitive-behavioral therapeutic approaches with the aim to minimize self-deception regarding the effects of the paraphilic behavior have become more and more relevant. Regarding the medical treatment, anti-hormonal therapy plays an important role, but also treatment with serotonergic agents and naltrexone are used. Only little can be advised in terms of prevention; general psycho-hygiene (regarding the parent-child relationship) is recommended. Beside these general measures, institutions which offer special treatment for people in danger to become delinquents may be able to prevent serious harm for possible victims of abuse.

Antihormonal treatment of paraphilic patients in German forensic psychiatric clinics

The aim of this study was to investigate which antihormonal treatment strategies are used in German forensic psychiatric institutions. Forensic clinics were asked about the number of treated patients. Four hundred seventy-four patients were committed for sex offences; 12% received either CPA (n = 29) or LHRH- agonists (n = 29). Differences in efficacy were small. Several side effects confirm the importance of a protocol for minimizing medical complications.

[Atypical neuroleptics in the treatment of aggression and hostility in schizophrenic patients]

The treatment of aggressive symptoms in schizophrenic patients is a relevant clinical problem. We systematically review the efficacy of the different atypical neuroleptics on acute or persistent aggressive symptoms also regarding methodological problems. Currently typical neuroleptics are still first choice in treating acute aggressive symptoms, while risperidone and olanzapine could be alternatives. In persistent aggression clozapin shows the best specific results. Typical depot neuroleptics should be considered in cases when medication compliance is a problem.

Treatment of paraphilia with luteinizing hormone-releasing hormone agonists

Up to now there have been no published results of therapy of paraphilia (for example, pedophilia or sadism) and sexual aggressive impulsiveness with luteinizing hormone-releasing hormone (LHRH) agonists in the German-speaking countries. After a short introduction about physiologic features and the present state of investigations in treatment of paraphilia with LHRH agonists we describe 11 patients who were treated with the LHRH agonist Leuprolide Acetate over a period of 12 months. The patients showed no tendency toward sexually aggressive behavior and reported an evident reduction of penile erection, ejaculation, masturbation, sexually deviant impulsiveness, and fantasies. One patient died from suicide. In combination with other treatments, LHRH Agonists seem to be a very promising alternative to cyproterone acetate and its possible carcinogene effects.

[Current German laws for foreigners as a contributory factor in the treatment of a first-time acute schizophrenic episode]

In a case report we describe an 18 year old Croat refugee with a first episode schizophrenia to discuss the current German laws for foreigners as a possible factor for the maintenance of the disease. Short residence permits, the release of the professional discretion to the authorities, deficient information about the laws and the unclear situation in the native country of the patients can lead to a worst course and prognosis of the disease.

[Treatment of paraphilia and sexually aggressive impulsive behavior with the LHRH-agonist leuprolide acetate]

Up to now there are no published results of therapy of paraphilia (Pedophilia, Sadism) and sexual aggressive impulsiveness with LHRH-(luteinizing hormone-releasing hormone) Agonists in the Germanspeaking countries. In this report we describe 11 patients which were treated with the LHRH-Agonist Leuprolide Acetate in a period of 12 months. The patients showed no tendency of sexual aggressive behaviour and reported an evident reduction of penile erection, ejaculation, masturbation, sexual deviant impulsiveness and fantasies. One patient died from suicide. In combination with other treatments LHRH-Agonists seem to be a very promising alternative to cyproterone acetate and its possible carcinogene effects.

[Sexual homicide--a data collection from psychiatric records]

After an analysis of the concerning literature we conceptualized a questionnaire with 124 items, which describes the most common characteristics of sexual murderers. The relevance of these characteristics was examined on the basis of psychiatric records. The hypothesis was, that persons who murdered more than once show these characteristics more evidently than single murderers. We compared 20 psychiatric records about single sexual murderers with those about 10 repetitive sexual murderers. Planned offenses, chronic isolation, narcism and tendency to perversity were found more often in persons that murdered more than once. Especially the psychosocial factors were found less often than in the angloamerican literature. More pronounced were the differences between a group of sadistic murderers compared with nonsadistic murderers, using criteria for sadism extracted from Kafft-Ebings first description (1892), Schorsch and Becker (1977), MacCulloch et al. (1983) and Ressler et al. (1988). A case example illustrates the importance of an elaborated concept of sadism and its relation to personality disorder.