The Development, Content Validation, and Pilot Testing of the Paraphilic Interests and Disorders Scale

The prevalence rates of paraphilic interests and disorders in the general population have been understudied, in large part due to the lack of a standardized assessment measure. As a result, the Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 provides little information regarding the prevalence of paraphilic disorders. The present study involved the development of a self-report measure, Paraphilic Interests and Disorders Scale (PIDS), that can be used to assess for the eight paraphilic interests/disorders in the DSM-5 for use with general population samples. Study 1 established the content validity of the PIDS using feedback from 22 experts in the field, and recommendations from these experts were utilized to modify the measure. In Study 2, the PIDS was piloted on 100 individuals in the general population, which supported the feasibility of implementation and its limited-efficacy. While the PIDS requires further psychometric support, the current research suggests the PIDS is a promising tool to gather self-report, population-based data on DSM-5 paraphilic interests and disorders.

Risky Sexual Behavior, Paraphilic Interest, and Sexual Offending: The Study of a Community Sample of Young Adults in Hong Kong

Limited information is available on the prevalence and nature of sexual offending in Hong Kong. This cross-sectional study seeks to explore the role of risky sexual behavior (RSB) and paraphilic interests in self-reported sexual offending behavior (i.e., nonpenetrative-only, penetrative-only, and nonpenetrative-plus-penetrative sexual assault) in a community sample of young adults in Hong Kong. Using a large sample (N = 1885) of university students, the lifetime prevalence of self-reported sexual offending was 18% (n = 342; 23% males (n = 166), 15% females (n = 176)). Based on the study subsample of 342 participants who self-reported sexual offending (aged 18-35), the findings indicated that males reported significantly higher levels of general, penetrative-only, nonpenetrative-plus-penetrative sexual assault; and paraphilic interest in voyeurism, frotteurism, biastophilia, scatophilia, and hebephilia than females; while females reported a significantly higher level of transvestic fetishism than males. No significant difference was found in RSB between males and females. Logistic regressions found that the participants who possessed a higher level of RSB, particularly penetrative behaviors, and paraphilic interest in voyeurism and zoophilia were less likely to engage in a nonpenetrative-only sexual offense. Conversely, the participants who possessed higher levels of RSB, especially penetrative behaviors, and paraphilic interest in exhibitionism and zoophilia, were more likely to engage in nonpenetrative-plus-penetrative sexual assault. The implications for practice in areas such as public education and offender rehabilitation are discussed.

ADHD prevalence in patients with hypersexuality and paraphilic disorders: a systematic review and meta-analysis

Hypersexuality and paraphilic disorders have been associated with increased ADHD in several studies. To determine the prevalence of ADHD in hypersexuality and paraphilic disorders. Three databases (Medline, Web of Science and Google Scholar) were explored. Using random effects models, we calculated the pooled estimate of ADHD prevalence. The leave-1-out method and subgroup analyses were carried out to identify sources of heterogeneity. Seven studies from three countries (N = 730 patients with hypersexuality) were included (including five US studies). The overall estimate of the prevalence of ADHD in patients with hypersexuality or paraphilic disorders was 22.6% (95% interval: 17-29.4) with high heterogeneity (I² = 63%). No publication bias was observed according to Egger's test. We found no significant difference in ADHD prevalence between the following subgroups: hypersexuality vs. paraphilic disorders, studies exploring the history of childhood ADHD vs. adult ADHD, US studies vs. others. The French study was a source of heterogeneity with a much lower rate than others (4.5%) but did not significantly change the prevalence estimate. Removing this study increases the prevalence to 25%. We found no association between the year of publication and ADHD prevalence. ADHD is much more frequent in populations with hypersexuality or paraphilic disorders compared to the general population. It should be systematically screened. The subgroup analyses were not sufficient to identify all sources of heterogeneity, other sources should be explored in further studies.

Concordance and Discordance between Paraphilic Interests and Behaviors: A Follow-Up Study

Although paraphilic interests represent significant risk factors for recidivism among sexual offenders, little is known about the magnitude of concordance between paraphilic interests and behaviors in the general population. The goal of this follow-up study was to conduct secondary analyses based on a sample of 1040 adults (475 men; 565 women) recruited in the general population. Levels of associations and active concordance (having both interest and experience), passive concordance (having neither interest nor experience), active discordance (having experience without interest) and passive discordance (having interest without experience) between paraphilic interest and corresponding behavior were assessed. Concordance and discordance indexes were also computed, as well as regressions and moderation analyses. As expected, paraphilic interests predicted corresponding behaviors, although the mean active concordance rate was only approximately 50%. Concordance rates varied with gender and the criminal nature (legal vs. illegal) of paraphilia. Paraphilic interests in adults from the general population may not have the same predictive value as that observed in medico-legal contexts. The possible role of other moderators in the concordance between paraphilic interest and behavior in non-clinical populations should be assessed. These findings have implications for sexual abuse prevention programs aiming at individuals in the community.

Are Female Paraphilias Hiding in Plain Sight? Risqué Male-Male Erotica for Women in Sinophone and Anglophone Regions

Female-oriented male-male erotica is a genre of popular culture often know as Boys' Love (BL), yaoi, and danmei. It is one of the largest by-and-for women sexual subcultures and a global phenomenon. With the largest data sets in the field, we ask: Which risqué sexual content do Sinophone (Chinese-speaking) and Anglophone (English-speaking) participants particularly enjoy in BL and does this differ between cultures?, and Are there sub-demographics in Sinophone and in Anglophone culture who enjoy particular forms of risqué sexual content in BL and do these forms relate also to enjoyment of particular storylines and concern with legal issues? The material studied meets the DSM-5 definition of the paraphilic, and little is known about paraphilias in women or in the general population. Using Categorical Principal Component Analysis we explored one 15-response question from our Sinophone (N = 1922) and Anglophone (N = 1715) BL fandom surveys: Which risqué sexual content do you particularly enjoy in BL? We also tested for associations with seven demographic and other BL content-related questions. Notably, the component structure was nearly replicated between the two independent samples, in order of strength: BDSM Specialist, Mechanoid/Animal Sex Specialist, Underage Sex Specialist, and Minority Paraphilia Specialist. In both samples, it was the avid BL fans and/or those who liked explicitly sexual stories, a largely overlapping demographic, who most engage the risqué content, while, for the Sinophone, this included also more non-heterosexual and/or other-gendered people. We conclude that women's paraphilias have been largely overlooked because they might be expressed more commonly through fantasy than action, that their mass expression has awaited both the means and the market force, and that current conceptualization of, and assumptions about, paraphilias is overly modeled on that of men.

Sex Drive as a Possible Mediator of the Gender Difference in the Prevalence of Paraphilic Interests in a Nonclinical Sample

There is a general gender difference in paraphilic interests, such that men report more interest (and greater engagement) in a variety of paraphilic behaviors. Using a nonclinical sample, Dawson et al. (Sexual Abuse, 28(1):20-45, 2016, https://doi.org/10.1177/1079063214525645 ) found that the gender difference in paraphilic interests was eliminated when scores on measures of sex drive were used as mediators. However, their measures of sex drive were about more than just sex drive and included a measure of hypersexuality (i.e., distress, perceived lack of control, and problematic consequences of one's sexuality). This study had two aims: to replicate Dawson et al.'s mediation results (using the same measures and scoring methods), and to discern the effect of sex drive itself (by replacing their measure of hypersexuality with a measure of sex drive). A nonclinical sample of 517 men and 615 women completed an online questionnaire. As expected, men reported less repulsion than women for most paraphilic themes. The gender difference in paraphilic interests was reduced (but not eliminated) both when reproducing Dawson et al.'s analysis and when examining a mediation model focused on sex drive specifically. The same results were obtained when examining the paraphilic interest with the largest gender difference (i.e., voyeurism). A full mediation effect was obtained in an unplanned supplementary analysis using a factor score (derived from eight measures) putatively assessing sex drive. While the main findings are consistent with Dawson et al.'s conclusions that sex drive is a possible mediator, they also suggest that other factors need to be considered to help explain the gender difference in the prevalence of paraphilic interests.

The Prevalence of Paraphilic Interests in the Czech Population: Preference, Arousal, the Use of Pornography, Fantasy, and Behavior

The number of population-based studies focused on the prevalence of paraphilic sexual interests in men is very low and for women, the subject remains largely unexplored. The two main aims of this study are to investigate the prevalence of paraphilias and to explore sex differences in an online representative sample of Czech men and women using various dimensions of sexual experience. We collected data about sexual motivations and behavior from a representative online sample of 10,044 Czechs (5,023 men and 5,021 women). In a standardized online interview, participants answered questions about selected dimensions of sexual experience within specific paraphilic patterns: sexual preferences, sexual arousal, sexual fantasies in the past 6 months, pornography use in the past 6 months, and experience with paraphilic behaviors. Our results show that 31.3% of men (n = 1,571) and 13.6% of women (n = 683) admitted to at least one paraphilic preference. Moreover, 15.5% of men and 5% of women reported more than one paraphilic preference. Except for beating/torture and humiliation/submission, in terms of real experience with such behaviors almost all paraphilias were more common among men than among women. Our results indicate that the high prevalence of some paraphilic patterns might render their pathologization problematic.

Bestiality Among Sexually Violent Predators

Bestiality, or sexual contact between humans and nonhuman animals, is a poorly understood aspect of sexual behavior. There is a dearth of scientific research on the prevalence of bestiality, the motivations for individuals to engage in the behavior, and the risk that such individuals pose for interpersonal sexual and nonsexual violence. This study is a descriptive analysis of bestiality in all individuals found to be sexually violent predators (SVPs) in the state of Virginia between the years 2003 and 2017. Of 1,248 SVPs, 33 (2.6%) had a history of engaging in bestiality. SVPs with a history of bestiality were significantly more likely to be victims of childhood sexual abuse (P < .005), to engage in nonsexual animal abuse (P < .0001), and to have committed child sexual abuse (P < .005). They were most likely to report sexual contact with dogs and demonstrated a breadth of other atypical sexual behavior. The lifetime prevalence of 2.6 percent is low compared with other published findings, suggesting that offenders may have intentionally minimized their history of atypical sexual behavior. The relationship between childhood sexual victimization and bestiality has not previously been reported in the literature and represents an important nidus for future investigation. Further research is necessary to characterize human-animal sexual interactions in SVPs and other populations.

Estimated prevalence and impact of the experience of becoming a victim of exhibitionism and frotteurism in Korea: A general population based study

Exhibitionism and frotteurism are often considered just nuisance crimes but may cause serious distress to the victims. Previous studies of victim experience have focused on specific groups, such as healthcare professionals or university students. To estimate the prevalence of victimisation by exhibitionism and frotteurism among young general population adults in Korea and to describe the impact of such experiences, trained researchers randomly recruited young adults for face to face interviews at transport hubs and on university campuses. In addition, we posted the questionnaire as a Google survey to a limited number of local websites. Data were analysed descriptively. Of 900 people directly approached, 747 (83%) agreed participation, as did 423 online. These two samples were similar demographically, so combined for analyses. Two hundred and thirty-five (20%) reported experiencing exhibitionism and 130 (11%) frotteurism. Exposure victims were older (means 23.2:21.1 years) and more likely to be women than frotteur victims. All but two exposure and nine frotteur perpetrators were said to be men. Reporting to police was rare (17 exposure, 2 frotteur); most exposure victims (73%) but under half of frotteur victims told family or friends. All but 15% of each group had bad feelings about the experience, varying by experience type. Ten percent of exposure and 20% of frotteur victims described distress lasting months; more reported enduring behaviour changes, like avoiding subways. Although our sample is unlikely to be wholly representative of the general population, our research examines a broader range of people than previous studies. Most victims of these "nuisance crimes" were distressed by them, and, hitherto less well recognised, at least a fifth of such victims may have long-term distress. Further research could establish the extent to which support outside the family or friends' group or treatment would be indicated.

The Relationship Among Online Sexually Explicit Material Exposure to, Desire for, and Participation in Rough Sex

The broad accessibility of online sexually explicit material (SEM) exposes viewers to a wide scope of sexual behaviors. Social concern tends to be heightened over SEM that incorporates highly graphic, "rough" sex. This study assessed the associations among exposure to rough sex in SEM, desire for rough sex, and participation in rough sex while accounting for gender, sexual orientation, and perceived realism of SEM. Young adults (N = 327; ages 19-30; 50.8% men) were recruited through a crowdsourcing website. They completed an anonymous online survey that assessed viewing frequency for a range of sexual behaviors in SEM, the perceived realism of SEM, desire to participate in the behaviors viewed, and if they had ever participated in those behaviors. Hair pulling, spanking, scratching, biting, bondage, fisting, and double penetration were used to create the variable of rough sex. Rough sex desire and participation were common among individuals who have been exposed to rough sex in SEM, with 91.4% desiring to engage in 1 + behaviors at least to a small degree and 81.7% having engaged in 1 + behaviors. Exposure to rough sex in SEM was positively associated with desire for and participation in rough sex, emphasizing the need to ensure that individuals can distinguish between consensual rough sex and sexual violence. This study did not parse out causal effects or directionality, but did provide some insights into the interrelatedness of viewing, desiring, and participating in rough sex.

Deviant Cyber-Sexual Activities in Young Adults: Exploring Prevalence and Predictions Using In-Person Sexual Activities and Social Learning Theory

Technology has shifted some human interactions to the virtual world. For many young adults, sexual encounters now occur through virtual means, as social media, picture exchanges, sexually explicit Web sites, and video chatting have become popular alternative outlets for these activities to occur. This study used the self-report responses of 812 undergraduate students (282 men and 530 women), collected from an online survey. In addition to using 10 personal demographic control variables, this study used five sexual activity/relationship characteristics (number of sexual partners, relationship status, age to first use pornography, frequency of sexual activity/intercourse, and frequency of masturbation), and the four constructs of Akers' social learning theory (identified as differential association, differential reinforcement, imitation/modeling, and definitions favorable) to predict a seven-item count of deviant cyber-sexual activities, and two measures of "sexting" behaviors. Gender, self-esteem, sexual orientation, race, and religion were strongly significant predictors in the models, but Akers' four elements of social learning performed the strongest in predicting the two measures of sexting and the overall deviant cyber-sexual activities scale. This finding indicates that peer associations and peer reinforcements have a strong influence on individuals' willingness to engage in deviant cyber-sexual activities. This study explored different avenues for young adults' engagement in sexual deviancy and the results suggest that sexual behaviors performed in-person may not be the strongest predictors of online sexual behavior.

Contemporary understanding of zoophilia - A multinational survey study

INTRODUCTION

People with paraphilias have sexual interests that are unusual, including inanimate objects, places, or individuals (children, corpses). This study explores zoophiles (=PSA, people who have sex with animals) recruited from the Internet.

METHOD

We administered a survey of own design via the Internet on popular discussion forums targeting the communities of PSA. All responses were quantified as the percentage of agreeing with one of the possible answer choices, plus the interpretation of qualitative data that may have been supplied in additional space.

RESULTS

Survey questions were thematically categorized into four groups - worldview, personal space, sex life, and online space. PSA are remarkably self-aware of their sexuality and recognize that their behavior is illegal (even though they perceive it as an expression of love); they often relate their struggles with finding social acceptance to homosexuality, believing that one way of de-stigmatizing them would be to remove zoophilia from the list of disorders listed in the DSM. Concerning sex life, PSA believe that the quality of sex with animals is much higher than with humans, and physical features, such as the presence of a fur, can be sexually arousing to PSA, especially when seeing animals in public. PSA utilize the Internet to network and connect with other PSA; these Internet-based friendships usually do not extend beyond online conversations, given that PSA tend to be mistrustful of other zoophiles particularly in the area of personal safety.

CONCLUSIONS

One of the most essential basis of zoophilia is relationship seeking behavior as well as interest in forming a long-term relationship with an animal partner.

[Review of cases of zoophilia in patients with Parkinson's disease]

INTRODUCTION

Parkinson's disease (PD) is characterized by motor symptoms such as bradykinesia, rigidity, alteration of postural reflexes and tremor at rest and other non-motor symptoms such as changes in sleep patterns and sexual behavior. However, little is known about paraphilic sexual behaviors.

AIM

To summarize the number of cases of zoophilic behaviors in patients with PD between January 2000 and December 2017.

DEVELOPMENT

A review was carried out in PubMed, Scopus and Virtual Health Library. Eleven articles were identified by title; six were excluded because they did not present cases related to zoophilic behavior. We found five cases of men, usually with PD of several years of course, taking dopamine agonists and who presented the zoophilic behaviors followed increasing of the dose. The zoophilic behaviors decreased with reducing doses of dopamine agonists and taking atypical antipsychotic such as clozapine or quetiapine.

CONCLUSIONS

It is limited the case reports of zoophilic behaviors in patients with PD. The patients reported are men in whom the dose of dopamine agonists was increased. It is important that the clinical follow-up of patients with PD disease includes a careful review of sexual behaviors including those of the paraphilic spectrum.

Relations Between Self-Reported Adverse Events in Childhood and Hypersexuality in Adult Male Sexual Offenders

Hypersexuality, or extreme normophilic sexual urges and behaviors, is a controversial construct that was recently considered as a candidate disorder for the DSM-5 and was rejected. It was also rejected for inclusion in Section III (Conditions for Further Study). Nonetheless, it has been found to be an important predictor of recidivism among sex offenders, and it continues to be discussed widely in the literature. In the present study, we investigated the developmental roots of this construct in a sample of 529 adult male sexual offenders, who were administered the Multidimensional Assessment of Sex and Aggression. Physical, psychological, and sexual abuse experiences were estimated using several scales of early development. Psychological abuse in childhood and adolescence, especially by a father, was found to be the most prominent predictor of subsequent hypersexual thoughts and behaviors. The accumulation of abuse types, however, was also associated with a monotonic increase in the latent trait of hypersexuality. The consequences of these results for conceptualizations of the construct are discussed.

An Online Assessment of Personality, Psychological, and Sexuality Trait Variables Associated with Self-Reported Hypersexual Behavior

"Hypersexual" behavior represents a perceived inability to control one's sexual behavior. To investigate hypersexual behavior, an international sample of 510 self-identified heterosexual, bisexual, and homosexual men and women completed an anonymous online self-report questionnaire battery. In addition to age and sex (male), hypersexual behavior was related to higher scores on measures of sexual excitation, sexual inhibition due to the threat of performance failure, trait impulsivity, and both depressed mood and anxiety. In contrast, hypersexual behavior was related to lower scores on sexual inhibition due to the threat of performance consequences. Higher neuroticism and extraversion, as well as lower agreeableness and conscientiousness, also predicted hypersexual behavior. Interestingly, interactions among the variables assessed did not significantly predict hypersexual behavior, suggesting the possible existence of multiple and predominantly independent taxa for various persons reporting hypersexual behavior. Core personality features may also be present in persons with hypersexual behavior. Clinical implications and future research directions are discussed.

The Prevalence of Paraphilic Interests and Behaviors in the General Population: A Provincial Survey

Paraphilic sexual interests are defined as unusual or anomalous, but their actual occurrence in nonclinical samples is still unknown. This study looked at desire for and experience of paraphilic behaviors in a sample of adult men and women in the general population. A secondary goal was to compare the results of two survey modes-traditional landline telephone versus online. A total of 1,040 persons classified according to age, gender, education, ethnic background, religious beliefs, area of residency, and corresponding to the norm for the province of Quebec were interviewed. Nearly half of this sample expressed interest in at least one paraphilic category, and approximately one-third had had experience with such a practice at least once. Voyeurism, fetishism, frotteurism, and masochism interested both male and female respondents at levels above what is usually considered to be statistically unusual (15.9%). Interestingly, levels of interest in fetishism and masochism were not significantly different for men and women. Masochism was significantly linked with higher satisfaction with one's own sexual life. As expected, the online mode generated more acknowledgment of paraphilic interest than the telephone mode. These results call into question the current definition of normal (normophilic) versus anomalous (paraphilic) sexual behaviors.

Characteristics of paraphilics in Turkey: A retrospective study-20years

OBJECTIVE

This study is carried out to research the frequency of occurrence and the characteristics of paraphilic cases in Turkey and forensic aspects of them and to explain forensic psychiatric studies of people show paraphilic actions and assess them from legal aspects.

METHOD

This research is done by studying a total of 101,208 cases who were sent to Istanbul Forensic Medicine Institute (FMI) by the judicial organs of 4th Specialization Board between 1984 and 2004 to decide whether they show paraphilic actions or not. When choosing the cases of pedophilic actions, incest incidents were excluded and 307 incidents were taken into assessment.

RESULTS

The male subjects are 97.4%, 39.7% of them are 19-29years old, 10% of them are over age 60, 59% of the subjects are single, 36.5% of them are unemployed, 71.7% of the incidents have no physical disorder. The subjects who were imprisoned before were 20.2% and 22.1% of them had undergone psychiatric treatment before the incident. Twenty separate diagnosis are determined by the FMI for the subjects. There were mental retardation, schizophrenia and various personality disorders on the top the diagnosis list. The paraphilia type of the incidents are pedophilia (60.3%), exhibitionism (8.1%), pedophilia and exhibitionism (7.5%) and fetishism (5.9%). It was determined that there were more than one paraphilia type in 40 incidents (13%). FMI decided that 54.7% of them have criminal responsibility, 25.1% of them have no criminal responsibility, and 20.2% of them have reduced criminal responsibility.

CONCLUSION

There were 20 separate type of diagnosis for the incidents. It is understood that paraphilic incidents do not seek for help although they have the symptoms of disorder and they are exposed to psychiatric assessment only when they face a criminal inquiry. This suggests that there are more paraphilic incidents in the society than what we encounter.

Paraphilic Sexual Interests and Sexually Coercive Behavior: A Population-Based Twin Study

Prior research with selected clinical and forensic samples suggests associations between paraphilic sexual interests (e.g., exhibitionism and sexual sadism) and sexually coercive behavior. However, no study to date used a large, representative and genetically informative population sample to address the potential causal nature of this association. We used self-report data on paraphilic and sexually coercive behavior from 5990 18- to 32-year-old male and female twins from a contemporary Finnish population cohort. Logistic regression and co-twin control models were employed to examine if paraphilic behaviors were causally related to coercive behavior or if suggested links were confounded by familial (genetic or common family environment) risk factors. Results indicated that associations between four out of five tested paraphilic behaviors (exhibitionism, masochism, sadism, and voyeurism, respectively) and sexually coercive behavior were moderate to strong. Transvestic fetishism was not independently associated with sexual coercion. Comparisons of twins reporting paraphilic behavior with their paraphilic behavior-discordant twin further suggested that associations were largely independent of shared genetic and environmental confounds, consistent with a causal association. In conclusion, similar to previously reported predictive effects of paraphilias on sexual crime recidivism, paraphilic behavior among young adults in the general population increases sexual offending risk. Further, early identification of paraphilic interest and preventive interventions with at-risk individuals might also reduce perpetration of first-time sexual violence.

Clinical Characteristics of Men Interested in Seeking Treatment for Use of Pornography

Background and aims This study examined the prevalence of, and factors associated with, men's interest in seeking treatment for use of pornography. Methods Using an Internet-based data-collection procedure, we recruited 1,298 male pornography users to complete questionnaires assessing demographic and sexual behaviors, hypersexuality, pornography-use characteristics, and current interest in seeking treatment for use of pornography. Results Approximately 14% of men reported an interest in seeking treatment for use of pornography, whereas only 6.4% of men had previously sought treatment for use of pornography. Treatment-interested men were 9.5 times more likely to report clinically significant levels of hypersexuality compared with treatment-disinterested men (OR = 9.52, 95% CI = 6.72-13.49). Bivariate analyses indicated that interest-in-seeking-treatment status was associated with being single/unmarried, viewing more pornography per week, engaging in more solitary masturbation in the past month, having had less dyadic oral sex in the past month, reporting a history of seeking treatment for use of pornography, and having had more past attempts to either "cut back" or quit using pornography completely. Results from a binary logistic regression analysis indicated that more frequent cut back/quit attempts with pornography and scores on the Hypersexual Behavior Inventory - Control subscale were significant predictors of interest-in-seeking-treatment status. Discussion and conclusions Study findings could be used to inform current screening practices aimed at identifying specific aspects of sexual self-control, impulsivity, and/or compulsivity associated with problematic use of pornography among treatment-seeking individuals.

Syndemic production and sexual compulsivity/hypersexuality in highly sexually active gay and bisexual men: further evidence for a three group conceptualization

Among gay and bisexual men (GBM), a syndemic describes a situation in which negative conditions (e.g., childhood sexual abuse, intimate partner violence, depression, polysubstance use) co-occur such to amplify HIV risk. Research has suggested that sexual compulsivity (SC) may also be a syndemic condition. Between 2011 and 2013, 368 highly sexually active (9+ male partners in 90 days) GBM completed a survey of syndemic factors as well as measures of sexual compulsivity (Sexual Compulsivity Scale [SCS]) and hypersexuality (hypersexual disorder screening inventory [HDSI]). Based on scores on the SCS and HDSI, participants were organized into three groups-negative on both ("Neither SC nor HD"); positive on the SCS only ("SC Only"), and positive on both the SCS and the HDSI ("Both SC and HD"). We found support for the utility of a three-group classification of sexual compulsivity/hypersexuality as one of the syndemic factors that contribute to HIV risk. The average number of syndemic factors experienced was lowest among those who experienced Neither SC nor HD and highest among the group that experienced Both SC and HD, with those experiencing SC Only falling between the two other groups. This study provided further evidence that sexual compulsivity/hypersexuality is a contributing factor to the syndemics model of HIV risk for GBM and that considering three levels of severity (i.e., SC along with HD) led to stronger model predictions than considering SC alone. SC/HD severity provides another modifiable target for HIV prevention intervention development.

Gender identities and gender dysphoria in the Netherlands

Several studies estimate the prevalence of gender dysphoria among adults by examining the number of individuals turning to health services. Since individuals might be hesitant to seek medical care related to gender dysphoria, these studies could underestimate the prevalence. The studies also lack information regarding the variance among different aspects of gender dysphoric conditions. Therefore, the current study estimated the prevalence by examining self-reported gender identity and dysphoria in a Dutch population sample (N = 8,064, aged 15-70 years old). Three measures assessed aspects of gender dysphoria: gender identity, dislike of the natal female/male body, and wish to obtain hormones/sex reassignment surgery. Results showed that 4.6 % of the natal men and 3.2 % of the natal women reported an ambivalent gender identity (equal identification with other sex as with sex assigned at birth) and 1.1 % of the natal men and 0.8 % of the natal women reported an incongruent gender identity (stronger identification with other sex as with sex assigned at birth). Lower percentages reported a dislike of their natal body and/or a wish for hormones/surgery. Combining these figures estimated the percentage of men reporting an ambivalent or incongruent gender identity combined with a dislike of their male body and a wish to obtain hormones/surgery at 0.6 %. For women, this was 0.2 %. These novel findings show that studies based on the number of individuals seeking medical care might underestimate the prevalence of gender dysphoria. Furthermore, the findings argue against a dichotomous approach to gender dysphoria.

Traits of autism spectrum disorders in adults with gender dysphoria

The literature examining the co-occurrence of gender dysphoria (GD) and autistic traits has so far been limited to a series of small case studies and two systematic studies, one looking at autistic traits in gender dysphoric children and the other set within the context of the extreme male brain hypothesis and looking at adults. The current study examined this co-occurrence of GD and autistic traits in an adult population, to see whether this heightened prevalence persisted from childhood as well as to provide further comparison of MtF versus FtM transsexuals and homosexual versus nonhomosexual individuals. Using the Autistic Spectrum Quotient (AQ), 91 GD adults (63 male-to-female [MtF] and 28 female-to-male [FtM]) undertaking treatment at a gender clinic completed the AQ. The prevalence of autistic traits consistent with a clinical diagnosis for an autism spectrum disorder (ASD) was 5.5 % (n = 3 MtF and n = 2 FtM) compared to reports of clinical diagnoses of 0.5-2.0 % in the general population. In contrast to the single previous report in adults, there was no significant difference between MtF and FtM on AQ scores; however, all of those who scored above the clinical cut-off were classified as nonhomosexual with respect to natal sex. Results were considered in the context of emerging theories for the observed co-occurrence of GD and autistic traits.

Prevalence and treatment of frotteurism in the community: a systematic review

This article describes a systematic review of prevalence studies on frotteurism. We searched the following databases for previously published, peer-reviewed studies that used suitable diagnostic methods in adult nonclinical samples: Ovid MEDLINE, PsycINFO, Pubmed, AccessMedicine, Cochrane Library, Books@Ovid, DynaMed, Micromedex, Science Direct, and SciVerse Scopus. We conducted multiple searches using the following terms: frotteu*, frottage, frotteurism, paraphilia, paraphilic, courtship disorder, prevalence, treatment, diagnosis, and chikan, and we evaluated the articles by using a six-point epidemiologic quality tool. We identified four prevalence studies, all of which were of limited methodological quality. Limitations included small sample sizes, the use of local rather than national samples, the failure to apply DSM or ICD-9 diagnostic criteria, and the lack of assessment regarding the reliability of diagnostic tools. One small study, a statistical outlier, reported a prevalence of 35 percent. In the three other studies, the prevalence of frotteurism was 7.9 percent, 9.1 percent, and 9.7 percent. We found no studies addressing treatment that met our inclusion criteria. Our findings reveal a need to develop more rigorous research on this topic.

[Impulsivity in sexual offenders--new ideas or back to basics?]

Despite the fact that the group of sexual offenders remains a population which is still difficult to study, the results of current research are considered novel and interesting. Surprisingly, the very old descriptions applying to paraphilia, which is considered to be one of the reasons of sexual offences, appear to be accurate, especially in the context of similarities between impulsivity and pathologic sexual behaviors. Notably, the nomenclature concerning impulsivity enables a specific and reasonable description of behaviors associated with sexual offences. Moreover, the results of research studies show that it is the lack of inhibition, not pathologic arousal, which is the most important factor in the pathogenesis of forbidden sexual behaviors. In addition, it has been shown that behavioral manifestations of impulsivity (substance abuse, suicide attempts) appear commonly in sexual offenders. Mutual relationships between alcohol drinking, suicide attempts, history of child sexual abuse and sexual offences, both in symptomatologic and etiologic aspect, raise a suggestion that all these phenomena may share a common background of poor inhibitory control.

High-risk sexual offenders: an examination of sexual fantasy, sexual paraphilia, psychopathy, and offence characteristics

High-risk sexual offenders are a complex and heterogeneous group of offenders about whom researchers, clinicians, and law enforcement agencies still know relatively little. In response to the paucity of information that is specifically applicable to high-risk offenders, the present study investigated the potential influence of sexual fantasy, sexual paraphilia, and psychopathy on the offending behaviour of 139 of the highest risk sexual offenders in one province of Canada. The sample included 41 child molesters, 42 rapists, 18 rapist/molesters, 30 mixed offenders, and 6 "other" sexual offenders. Two offenders could not be categorized by type due to insufficient file information. Data analyses revealed significant differences between offender types for a number of criminal history variables including past sexual and nonsexual convictions, number of victims, weapon use, and age of offending onset. Further, there were significant differences between offender types for sexual fantasy themes, paraphilia diagnoses, and levels of psychopathy. For example, results revealed that offenders' sexual fantasies were significantly more likely to correspond with the specific type of index sexual offence that they had committed. Further, offenders scoring high in psychopathy were significantly more likely to have a sadistic paraphilia than offenders with either low or moderate psychopathy scores. Results from the current study provide a refined and informed understanding of sexual offending behaviour with important implications for future research, assessment, and treatment, as well as law enforcement practices when working with high-risk sexual offenders.

Report of findings in a DSM-5 field trial for hypersexual disorder

INTRODUCTION

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria for hypersexual disorder (HD) have been proposed to capture symptoms reported by patients seeking help for out-of-control sexual behavior. The proposed criteria created by the DSM-5 Work Group on Sexual and Gender Identity Disorders require evaluation in a formal field trial.

AIM

This DSM-5 Field Trial was designed to assess the reliability and validity of the criteria for HD in a sample of patients seeking treatment for hypersexual behavior, a general psychiatric condition, or a substance-related disorder.

METHOD

Patients (N = 207) were assessed for psychopathology and HD by blinded raters to determine inter-rater reliability of the HD criteria and following a 2-week interval by a third rater to evaluate the stability of the HD criteria over time. Patients also completed a number of self-report measures to assess the validity of the HD criteria.

MAIN OUTCOME MEASURES

HD and psychopathology were measured by structured diagnostic interviews, the Hypersexual Behavior Inventory, Sexual Compulsivity Scale, and Hypersexual Behavior Consequences Scale. Emotional dysregulation and stress proneness were measured by facets on the NEO Personality Inventory-Revised.

RESULTS

Inter-rater reliability was high and the HD criteria showed good stability over time. Sensitivity and specificity indices showed that the criteria for HD accurately reflected the presenting problem among patients. The diagnostic criteria for HD showed good validity with theoretically related measures of hypersexuality, impulsivity, emotional dysregulation, and stress proneness, as well as good internal consistency. Patients assessed for HD also reported a vast array of consequences for hypersexual behavior that were significantly greater than those diagnosed with a general psychiatric condition or substance-related disorder.

CONCLUSIONS

The HD criteria proposed by the DSM-5 Work Group on Sexual and Gender Identity Disorders appear to demonstrate high reliability and validity when applied to patients in a clinical setting among a group of raters with modest training on assessing HD.

Axis I psychiatric disorders, paraphilic sexual offending and implications for pharmacological treatment

BACKGROUND

Axis I non-sexual psychopathology, especially if associated with other manifestations of impulsivity, could be important to consider during the assessment and pharmacological treatment of paraphilic sexual offenders.

METHOD

The author performed a Medline literature search using combinations of the following terms "sexual offender," "paraphilia," "Axis I," and "comorbid." In addition, individual paraphilic disorders including "exhibitionism," "voyeurism," "frotteurism," "sexual sadism" and "pedophilia" were searched with the terms "Axis I" and "comorbid." From the literature retrieved, 18 relevant specific articles and additional references were reviewed that utilized either a comprehensive prospective methodology to ascertain Axis I psychopathology or a specific diagnosis not typically included in structured diagnostic instruments was ascertained with validated rating instruments.

RESULTS

Unipolar and bipolar mood disorders, social anxiety disorder, attention deficit hyperactivity disorder and other neurodevelopmental conditions (mental retardation, fetal alcohol spectrum disorder, Asperger's disorder) are Axis I psychopathologies reported as co-associated with paraphilic sexual offending. The aforementioned Axis I psychiatric disorders typically manifest during childhood or adolescence, the same age of onset as paraphilic disorders. Alcohol abuse is prevalent among paraphilic offenders as well and its presence serves as an additional disinhibitor. Research supporting the concurrent pharmacological treatment of Axis I comorbidities is modest but offers support that such treatment could mitigate paraphilic behavior.

LIMITATIONS

This review was organized to emphasize positive findings. Studies reviewed varied in both sample types and settings as well as ascertainment and diagnostic methodologies. The literature reviewed is modest in size and additionally limited by small samples.

CONCLUSIONS

A subset of males with Axis I diagnoses of mood disorders, social anxiety disorder, substance use disorders, and ADHD or other childhood neurodevelopmental disabilities may be co-associated with sexual disinhibition and aggression manifested as paraphilias. Pharmacological treatments addressing Axis I comorbidites and paraphilias have been reported to mitigate both sets of disorders but the treatment data should be regarded as preliminary.

Current concepts in the pharmacotherapy of paraphilias

Concerns about paraphilia and its treatment have grown in the past few years. Although the aetiology of paraphilia disorder is still not completely understood, pharmacological treatments have been proposed for this disorder. Paraphilias are a major burden for patients and society; nevertheless, only a few individuals with paraphilias voluntarily seek treatment. Antidepressants have been used in the treatment of certain types of mild (e.g. exhibitionism) and juvenile paraphilias. Antilibidinal hormonal treatments, such as steroidal antiandrogens and gonadotrophin-releasing hormone (GnRH) analogues, have also been studied and they seem to be effective in paraphilic disorders, although caution should be taken in the prescription of these treatments in order to avoid or minimize adverse effects and the risk of victimization. The combination of psychotherapy and pharmacological therapy is associated with better efficacy compared with either treatment as monotherapy. Paraphilia is a chronic disorder and a minimal duration of treatment of 3-5 years is highly recommended for severe paraphilia with a high risk of sexual violence. In conclusion, this review of the literature provides suggestive evidence that paraphilias are well characterized disorders marked by pathological dimensions. Although further research is necessary to confirm treatment efficacy and to improve our knowledge of long-term tolerance, available data on the use of selective serotonin reuptake inhibitors, steroidal antiandrogens and GnRH analogues strongly suggest the efficacy of these treatments for paraphilic disorders.

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.

Paraphilias across cultures: contexts and controversies

Cultures define and describe what is normal and what is deviant. These definitions of normality vary across cultures and are influenced by a number of factors, such as religion. Cultures have been described in various ways, including sex-positive where the sexual act itself is seen as important for pleasure, or sex-negative where the sexual act is seen only as for procreative purposes. The role and development of paraphilias across cultures is also variable, with cultures defining what is legal or illegal. Such differences make collection of epidemiological data and comparison across paraphilias problematic. This discussion suggests that characteristics of cultures may influence the rate of reporting paraphilias, as well as the rate of paraphilias themselves. Furthermore, with increased industrialization and urbanization, families will become more nuclear, with attitudes toward sex and paraphilias changing as well. This review also explores whether paraphilias can be seen as culture-bound syndromes, and recommends consideration of a number of conceptual issues regarding the diagnosis and prevalence of paraphilias as future cross-cultural studies on this topic are developed.

[Urinary disorders, sexual dysfunction and hypersexuality in Parkinson's disease]

INTRODUCTION

As Parkinson's disease progresses, its non-motor manifestations become increasingly more apparent to the point where, in advances phases of the disease, they are the most important clinical symptoms. A very wide range of non-motor symptoms can appear in Parkinson's disease. Impairment of the urinary function and the sexual function (understood as the capacity to carry out sexual activity) can be seen as belonging to the dysautonomic disorders. Hypersexuality would be included within the group of impulse control disorders.

DEVELOPMENT

This study reviews the epidemiology, phenomenology and treatment of urinary disorders, sexual dysfunction and hypersexuality as non-motor symptoms of Parkinson's disease.

CONCLUSIONS

Urinary disorders are the most frequent non-motor symptom in Parkinson's disease. They usually present as nocturia, urgency and increased mictional frequency (pollakiuria). Preferred treatment is with anticholinergic agents. Sexual dysfunction is a frequent complaint in patients with Parkinson. It has a multifactorial aetiology and is more frequent in males than in females. In males it manifests mainly as incapacity to achieve an erection, premature ejaculation or loss of the capacity to ejaculate, whereas in females the predominant signs are decreased libido, lowered arousal and difficulty in reaching an orgasm. Hypersexuality affects young males above all and has been related to the use of dopamine agonists.

Ritual and signature in serial sexual homicide

Ritual and signature are fantasy-driven, repetitive crime scene behaviors that have been found to occur in serial sexual homicide. Notwithstanding numerous anecdotal case reports, ritual and signature have rarely been studied empirically. In a national sample of 38 offenders and their 162 victims, we examined behavioral and thematic consistency, as well as the evolution and uniqueness of these crime scene actions. The notion that serial sexual murderers engage in the same rituals and leave unique signatures at every scene was not supported by our data. In fact, the results suggest that the crime scene conduct of this group of offenders is fairly complex and varied. Implications of these findings for forensic assessments and criminal investigations are discussed.

Mental disorder, predisposition, prediction, and ability to control: evaluating sex offenders for civil commitment

Nearly 20 years after the first sexually violent person (SVP) statutes were introduced in the United States, the civil commitment of sex offenders remains controversial. SVP laws require that a sex offender has a mental condition that predisposes them to commit sex offenses and poses a high risk to reoffend because of serious difficulty controlling behavior. The controversy over the commitment of sex offenders is fueled by different interpretations of those key constructs. This article reviews those constructs; evaluates them from clinical, epidemiologic, and legal perspectives; and proposes interpretations that address both the major criticisms of civil commitment and the challenges in SVP assessment.

Behind closed doors: an exploration of kinky sexual behaviors in urban lesbian and bisexual women

This study of 347 urban, self-identified lesbian (n = 289) and bisexual (n = 58) women examined women's engaging in 4 kinky sexual behaviors: bondage/domination, sadomasochism, photo/video exhibitionism, and asphyxiation/breath play. A cross-sectional, brief-intercept survey was administered at 2 New York City gay, lesbian, and bisexual community events. Over 40% reported engaging in at least 1 of these behaviors, and 25% reported engaging in multiple behaviors. Bisexual women were more likely to have engaged in any kinky sexual behavior and photo/video exhibitionism. White women were more likely than women of color to have engaged in bondage/domination. Compared to older women, younger women were more likely to have engaged in photo/video exhibitionism and asphyxiation/breath play. Participants who were younger when they came out to others, and younger at their same-sex sexual debut, were more likely to have engaged in any and each of the behaviors compared to women who were older at those developmental events.

Paraphilia from a dissociative perspective

A dissociative structural model of the psyche can account for a wide range of symptoms across many DSM-IV categories, including sexual compulsions and addictions. The model leads to a distinct overall plan of treatment and a set of operationalized interventions aimed at integration of the self, rather than suppression of impulses. The model could be tested first in epidemiological studies and later in treatment outcome studies.

Are the mentally retarded and learning disordered overrepresented among sex offenders and paraphilics?

A sample of 2,286 male sex offenders and paraphilics and 241 nonsex offenders was evaluated for the prevalence of mental retardation and learning disorders, using the full Wechsler IQ scales. The sex offenders were generally of average intelligence, and the mentally retarded were not overrepresented among them, but the learning disordered were. There were no differences among sex offenders and controls in overall IQ or in the percentage of mentally retarded or learning-disordered cases, suggesting that the learning difficulties are not peculiar to sex offenders. There was a bias in referral source, with more mentally retarded, borderline-retarded, and/or learning-disordered cases being referred by the Children's Aid Society, prisons, and the Crown, suggesting that referral source may play a significant role in evaluating intelligence and mental retardation among sex offenders; but the overrepresentation of learning disorders among criminals appears to be a significant phenomenon, regardless of referral source.

Personality disorders in a sample of paraphilic and nonparaphilic child molesters: a comparative study

This article renders the results of research that investigated personality disorders in a sample of paraphilic and nonparaphilic child molesters. The sample contained 36 paraphilic child molesters and a matched comparison group of 34 nonparaphilic child molesters. The analyses of the research results show that four personality disorders discriminate between both groups. Only the obsessive-compulsive personality disorder contributes significantly to the explanation of paraphilic child molestation. This result also contributes to the development and differentiation of the treatment of paraphilia-related disorders. For several child molesters, psychological approaches to the treatment of sexual offending (e.g., cognitive-behavioral treatment, psychotherapy in general) are limited and cannot be expected to immediately reduce risk. Interest has been expressed in medical approaches to reduce recidivism, in combination with psychotherapy.

Criminal recidivism in sexual homicide perpetrators

Forensic psychiatric reports on 166 sexual homicide perpetrators in Germany were retrospectively analyzed for criminal risk factors. Follow-up information about release and reconvictions from federal criminal records was available for 139 offenders; 90 (64.7%) had been released. The estimated recidivism rate (Kaplan-Meier analyses) for 20 years at risk was 23.1% for sexual and 18.3% for nonsexual violent reoffences. Three men (3.3%) were reconvicted for attempted or completed homicide. Only young age at the time of sexual homicide resulted in higher sexual recidivism, whereas increased nonsexual violent recidivism was related to previous sexual and nonsexual delinquency, psychopathic symptoms, and higher scores in risk assessment instruments. Increased recidivism with any violent reoffence was associated with age-related factors: young age at first sexual offence, at homicide, and at release and duration of detention. The impacts of the results for risk assessment, relapse prevention, and supervision are discussed.

Psychiatric morbidity among convicted male sex offenders at Kamiti Prison, Kenya

OBJECTIVES

To determine the prevalence and distribution of psychiatric morbidity among convicted male sex offenders and to establish factors associated with sexual offending.

DESIGN

A Cross-sectional descriptive survey.

SETTING

Kamiti Maximum Security Prison, Nairobi, Kenya.

SUBJECTS

Seventy six male convicts.

RESULTS

Forty seven (61.8%) had defilement-related convictions, 23 (30.3%) had rape-related, while six (7.9%) had other convictions. Twenty seven (35.5%) out of 76 had a DSM-IV Axis I disorder, majority of whom (71.1%) were dependent on or abused substances, and 26 (34.2%) had an Axis II disorder, most of whom had antisocial and impulsive personality disorders (46.2%). Of these 12 (15.8%) had an Axis I diagnosis alone, 11 (14.5%) had an Axis II diagnosis alone while 15 (19.7%) had both Axis I and II diagnoses, that is, co-morbidity. Exposure to erotica was statistically associated with both Axis I and II (p = 0.02 and p = 0.0003 respectively) and pre-occupation with thoughts about sex was associated with Axis II disorders (p = 0.01).

CONCLUSIONS

Most of those with psychiatric morbidity targeted children and had antisocial or impulsive personality disorder. Awareness campaigns to enlighten the public of the fact that children are the most common victims and research to determine ways of treating and rehabilitating sexual offenders could reduce the vice.

Family size, birth order, and parental age among male paraphilics and sex offenders

A sample of 1823 male paraphilics, sex offenders, and non-sex offender controls were compared on family size, birth order, and parents' ages at the time of the probands' births. Sample data were also compared to population data from Statistics Canada. The men in all groups were from larger than average Canadian families and they tended to be later born. Paraphilics and sex offenders had even larger families than offender controls. Their parents tended to be older at their birth with 34.2% of mothers and 51.3% of fathers over 30 years of age, but there were no statistically significant subgroup differences. There were also significantly more multiparous teenage mothers than expected and more paraphilics' fathers who were younger than the mothers, both factors associated in the literature with increased risk of perinatal complications and abnormalities. The confounding influences of parental age, birth order, and family size were examined and indicated the need for large samples and multivariate analysis in evaluating the role of family variables associated with paraphilics and sex offenders.

Supplementary analyses regarding Langevin, Langevin, and Curnoe's (2007) findings on fraternal birth order in homosexual men

A recent article by Langevin, Langevin, and Curnoe (2007) reported mixed results regarding the fraternal birth order effect, that is, the repeatedly observed finding that older brothers correlate with homosexuality in later-born males. Using a fraternal birth order index computed as older brothers minus younger brothers, Langevin et al. found that the "homoerotic" probands were born later among their brothers than were the "heteroerotic" probands in their full sample (N = 1194) and in their subsample over age 19 (N = 1122), but not in their subsample over age 31 (N = 698) or in their subsample with mothers over age 46 at the proband's birth (N = 727). The present writer concluded that the results obtained with the larger samples are more reliable, based on analyses demonstrating that (1) the larger samples are unlikely to be seriously affected by incomplete sibships, and (2) the smaller samples have poor statistical power. A separate analysis, based on an approximate reconstruction of Langevin et al.'s raw data, indicated that their heteroerotic probands reported a ratio of 104 older brothers per 100 older sisters, which is close to the normative population value of 106, whereas their homoerotic probands reported a ratio of 137, indicating a statistically significant excess of older brothers. These results suggest that Langevin et al.'s data showed significant evidence of a fraternal birth order effect and that their data were consistent with previous studies of this phenomenon.

[Sexual medicine in primary care--development in the years 1980-1990-2004]

Sexual disorders are common in community samples. Even so these problems are not often addressed by primary care physicians. In 1980, 1990, and 2004 three cohorts of primary care physicians in the German speaking part of Switzerland were asked to answer a questionnaire on the prevalence of sexual problems and disorders in their patients and their knowledge in sexual medicine. The prevalence of sexual disorders in primary care is underestimated by primary care physicians. Female doctors and female patients address sexual problems more often than male doctors and patients. Lack of sexual interest and erectile dysfunction are the most frequent sexual disorders in primary care. In 2004 the participating doctors assess their knowledge in sexual medicine at a higher level compared to 1980. The training of primary care physicians in primary care should further be improved.

Sexual behavior in high-functioning male adolescents and young adults with autism spectrum disorder

Group home caregivers of 24 institutionalized, male, high-functioning adolescents and young adults with Autism Spectrum Disorder, were interviewed with the Interview Sexuality Autism. Most subjects were reported to express sexual interest and to display some kind of sexual behavior. Knowledge of socio-sexual skills existed, but practical use was moderate. Masturbation was common. Many subjects were seeking physical contact with others. Half of the sample had experienced a relationship, while three were reported to have had sexual intercourse. The number of bisexual orientations appeared high. Ritual-sexual use of objects and sensory fascination with a sexual connotation were sometimes present. A paraphilia was present in two subjects. About one third of the group needed intervention regarding sexual development or behavior.

[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.

[Review of symptoms and therapy of paraphylias]

The authors review the historical main milestones in the legislative aspects of sexual deviances, from ancient times through age of enlightenment to present times, including the factors affecting the Hungarian public attitudes towards it. The evolution of nomenclature of sexual orientation disorders is also evaluated thoroughly, detailing the DSM-IV-TR classification and the attempts and difficulties to further develop the present classification system. The authors also review the difficulties of epidemiological studies and sum up the pioneer work of Alfred Kinsey. The etiology of paraphylias is summed up based on biological, psychodynamic and learning theory approaches. Finally, the pharmacological and psychotherapeutic interventions are evaluated considering also comorbidity, outer control and forensic psychiatric aspects.

Elevated Prolactin Levels among Adult Male Sex Offenders

A sample of 528 successive admissions to the Phoenix Program, a voluntary inpatient treatment program for sex offenders, was studied in regards to serum prolactin levels. Serum prolactins were obtained as part of a battery of endocrine tests. A substantial number of patients had prolactin levels above the normal range, i.e., 21.0 μg/L. In this sample, fully 10.0% of the men showed elevated prolactin levels (the maximum being 41.0 μg/L), compared with an expected 2.5% according to laboratory norms. None of these individuals had clinical manifestations of prolactinoma. The significance of this increased rate of hyperprolactinemia in this sample of sexual offenders is unclear. There was a negative correlation with age and no correlation with other endocrine tests.

Sexual offenses and traumatic brain injury

A sample of 476 male sexual offenders, seen at a university psychiatric hospital for forensic assessment, was examined for the incidence of traumatic head injuries. A total of 49.3% had sustained head injuries that led to unconsciousness and of these 22.5% sustained significant neurological insults. A major causative factor was motor vehicle accidents, but lifestyle variables including alcohol and drug abuse and history of violence also contributed. The brain-injured group was convicted for a wide range of sexual offenses and was comparable to the non-injured group in this respect, but tended more often to offend against adults than against children and to show somewhat more exhibiting and polymorphous sexual behavior. In spite of the serious legal implications for these men and the additional distress to their families, psychologists, psychiatrists, and the professional literature have been relatively silent on the subject which calls for more attention to sexual behavior as part of assessments and treatment planning.

High rates of sexual behavior in the general population: correlates and predictors

We studied 2450, 18-60-year-old men and women from a 1996 national survey of sexuality and health in Sweden to identify risk factors and correlates of elevated rates of sexual behavior (hypersexuality) in a representative, non-clinical population. Interviews and questionnaires measured various sexual behaviors, developmental risk factors, behavioral problems, and health indicators. The results suggested that correlates of high rates of intercourse were mostly positive, whereas the correlates of high rates of masturbation and impersonal sex were typically undesirable. For both men and women, high rates of impersonal sex were related to separation from parents during childhood, relationship instability, sexually transmitted disease, tobacco smoking, substance abuse, and dissatisfaction with life in general. The association between hypersexuality and paraphilic sexual interests (exhibitionism, voyeurism, masochism/sadism) was particularly and equally strong for both genders (odds ratios of 4.6-25.6). The results held, with a few exceptions, when controlling for age, being in a stable relationship, living in a major city, and same-sex sexual orientation. We conclude that elevated rates of impersonal sex are associated with a range of negative health indicators in the general population.