israel journal of psychiatry and related sciences

israel journal of

psychiatry

Vol. 49 - Number 4 2012

ISSN: 0333-7308

246

Editorial: Paraphilia

Volume 49, Number 4, 2012 Israel Journal of Psychiatry and Related Sciences

Paraphilias: Diagnosis and treatment

Eliezer Witztum and Ariel Rรถsler

248

Paraphilic Diagnoses in DSM-5

Richard B. Krueger and Meg S. Kaplan

255

Axis I Psychiatric Disorders, Paraphilic Sexual Offending and Implications for Pharmacological Treatment Martin Kafka

262

History of Abuse and Organic Difficulties in a Convenience Sample of 46 Ultra-orthodox Males with Pedophilia Eliezer Witztum, Netzer Daie, Ayala Daie-Gabai and Ariel Rosler

270

Victim and Victimizer: The Role of Traumatic Experiences as Risk Factors for Sexually Abusive Behavior Lucinda A. Rasmussen

280

Identifying Psychological Traits Potentially Subserving Aberrant Motivation or Inhibitory Failure in Pedophilic Behavior Lisa J. Cohen and Igor Galynker

291

Cognitive-Behavioral Treatment of the Paraphilias

Meg S. Kaplan and Richard B. Krueger

297

Pharmacological Treatment of Paraphilias Florence Thibaut

306

Double-blind, Controlled, Clinical Trial Planned in Germany to Investigate the Efficacy of Psychotherapy Combined with Triptorelin in Adult Male Patients with Severe Pedophilic Disorders: Presentation of the Study Protocol Peer Briken, Wolfgang Berner and the P278 study group

israel journal of

psychiatry and related sciences

The Official Publication of the Israel Psychiatric Association Vol. 49 - Number 4 2012

Paraphilias: Diagnosis and treatment

291 > Cognitive-Behavioral

David Roe Rael Strous Gil Zalsman

246 > Editorial: Paraphilia

297 > Pharmacological

Book reviews editor

248 > Paraphilic Diagnoses in DSM-5

EDitor

David Greenberg

Treatment of the Paraphilias

Meg S. Kaplan and Richard B. Krueger

DEPUTY EDITORS

Yoram Barak PAst Editor

Eli L. Edelstein Founding Editor

Heinz Z. Winnik Editorial Board

Alean Al-Krenawi Alan Apter Elliot Gershon Talma Hendler Ehud Klein Ilana Kremer ltzhak Levav Yuval Melamed Shlomo Mendlovic Ronnen Segman Eliezer Witztum Zvi Zemishlany International Advisory Board

Yoram Bilu Aaron Bodenheimer Carl Eisdorfer Julian Leff Margarete Mitscherlich-Nielsen Peter Neubauer Phyllis Palgi Leo Rangell Melvin Sabshin Robert Wallerstein Myrna Weissman

Eliezer Witztum and Ariel Rösler

Treatment of Paraphilias

Richard B. Krueger and Meg S. Kaplan

Florence Thibaut

305 > List of reviewers for the Israel Journal of Psychiatry 2013

255 > Axis I Psychiatric

306 > Double-blind, Controlled, Clinical

Disorders, Paraphilic Sexual Offending and Implications for Pharmacological Treatment Martin Kafka

262 > History of Abuse and Organic

Difficulties in a Convenience Sample of 46 Ultra-orthodox Males with Pedophilia

Eliezer Witztum, Netzer Daie, Ayala Daie-Gabai and Ariel Rosler

Trial Planned in Germany to Investigate the Efficacy of Psychotherapy Combined with Triptorelin in Adult Male Patients with Severe Pedophilic Disorders: Presentation of the Study Protocol

Peer Briken, Wolfgang Berner and the P278 study group

314 > Book reviews

Yoram Barak, Assaf Shelef

270 > Victim and Victimizer:

The Role of Traumatic Experiences as Risk Factors for Sexually Abusive Behavior Lucinda A. Rasmussen

Hebrew Section

280 > Identifying Psychological Traits Potentially Subserving Aberrant Motivation or Inhibitory Failure in Pedophilic Behavior Lisa J. Cohen and Igor Galynker

317 > Position paper on the treatment of anorexia in life threatening situations 320 > Abstracts

ASSOCIATE EDITOR

Rena Kurs Assistant Editor

Joan Hooper

Marketing: MediaFarm Group

+972-77-3219970 23 Zamenhoff st.

Tel-Aviv 64373, Israel

amir@mediafarm.co.il www.mediafarm.co.il

The Warrior Yona Ezra-Chai I thank God that I have been blessed with an ability to see hidden features in pieces of wood and turn them into works of art. When a person strives towards a goal, he is a warrior. The power to succeed is dependent on the virtue of the cause. I wish to win this battle and remove the stigma that exists against those with mental illness.

Photograph: Irit Elad

Isr J Psychiatry Relat Sci - Vol. 49 - No 4 (2012)

Editorial: Paraphilia The diagnosis and treatment of disorders of sexual drive, previously referred to as perversions, were long neglected, and for many years were rejected. While disorders of sexual drive appeared in all the editions of the DSM and ICD, some claimed, and continue to express their doubts, as to whether pedophilia, the most significant disorder of this group, is a psychiatric disorder (1).

In recent years research has demonstrated it to be a condition of significance, while the sexual abuse has severe consequences, particularly in child victims, in terms of psychological effects and psychopathology.

Each year in the United States between 100,000 and 500,000 children are sexually molested by men. High rates have also been reported in Canada, Australia, the United Kingdom, the Netherlands, Denmark, Germany, and Belgium.

Most researchers assume that a significant fraction, if not the vast majority, of offenses are not reported and the numbers of affected children are probably higher.

On the basis of epidemiological studies, it is estimated that 10 to 20 percent of children have been sexually molested by the age of 18 years. These findings indicate that deviant sexual behavior (paraphilia) in men is a serious problem (2).

In a retrospective cohort study conducted from 1995 to 1997 among 17,337 adults in San Diego, California, participants completed a survey about abuse or household dysfunction during childhood. Childhood sexual abuse (CSA) was reported by 16% of males and 25% of females. Men reported female perpetration of CSA nearly 40% of the time, and women reported female perpetration of CSA 6% of the time. CSA significantly increased the risk of the outcomes (3).

During the past decades, research on the long-term behavioral, social, and mental health consequences of childhood maltreatment has proliferated. Studies examining the long-term effects of childhood abuse and related stressors have found increased risk for outcomes such as substance use and misuse, psychiatric disorders, suicide, and numerous other health and social problems (3). For all the reasons given above, the development of research of the disorders of sexual drive and their effective treatment are both significant and important.

The international conference that took place in Jerusalem in June 2010 on Contemporary Treatments 246

of Paraphilias was organized by the two guest editors.

The leading researchers in the field participated, and the occasion was an opportunity to summarize the current knowledge and evaluate the development of future interventions. From the papers presented at the conference, eight appear here on a range of issues, from diagnosis, characteristics of the perpetrators in terms of their background and trauma history, descriptions of treatments and suggestions for future research.

The first article by Krueger and Kaplan relates to the forthcoming DSM-5 which has been under revision since 1999 and is scheduled for publication in 2013. Paraphilias have been assigned their own chapter in DSM-5 and a distinction has been made between Paraphilias and Paraphilic Disorders. Victim numbers have been included in diagnosis of paraphilias that involve victims and remission and severity measures have been added to all paraphilias. Overall, the changes of Paraphilic Disorders Section of the DSM-5 represent a significant departure from DSM-IV-TR. In the next paper, based on a literature review, Kafka examines the Axis I psychiatric disorders that have a co-morbidity with paraphilic sexual offending and the implications for pharmacological treatment. He concludes that a subdivision of males with Axis I diagnoses of mood disorders, social anxiety disorder, substance use disorders, and ADHD or other childhood developmental disabilities may be co-associated with sexual disinhibition and aggression manifested as paraphilias.

Pharmacological treatments addressing Axis I co-morbidities and paraphilias have been reported to mitigate both sets of disorders.

The next theme is the history of abuse and characterization of victim and victimizer. Witztum, Daie, Daie-Gabai, and Rosler describe abuse history and organic difficulties among 46 Ultra-orthodox males with Pedophilia. Based on self reports combined with corroborating reports together with indications in psychological tests, they found that 38 were victims of sexual trauma as children and 40 suffer from some kind of organic vulnerability. The authors tried to explain these results in terms of the uniqueness of the sample. The participants were ultra-religious, meaning they live in a very conservative, authoritarian and unisex environment from early childhood until marriage. It is possible

Eliezer Witztum and Ariel Rösler

this environment raises the odds of engaging in samesex relationships as well as of being abused by same-sex older perpetrators. The sample was referred mostly by religious leaders of the community or as self-referrals for assessment and treatment. Another possible explanation is linked to the second finding – that for most participants (40/46) indications were found for some type of organic vulnerability that might have put them at further risk for childhood abuse.

Rasmussen examined the role of traumatic experiences as risk factors for sexually abusive behavior. She used the “The Victim to Victimizer” paradigm to explain the connection between being a victim of sexual abuse and becoming a perpetrator, attributing sexually abusive behavior to a predictable cycle of cognitive distortions and self-destructive and/or abusive behaviors. In same line of research, Cohen and Galynker sought to identify psychological traits of potentially aberrant motivation or failure of inhibition in Pedophilic behavior. They used self-reports from three groups - male subjects with pedophilic behavior, opiate addicted subjects and healthy controls. Groups were compared on personality traits related to social anxiety/inhibition, impulsivity, propensity for cognitive distortions and psychopathy along with the incidence of sexual abuse in their own childhoods. The results supported an increased prevalence of child sexual abuse, psychopathic traits and traits related to a propensity for cognitive distortions in the pedophilic group relative to healthy controls.

The next section is devoted to intervention. Kaplan and Krueger describe the model of cognitive-behavioral treatment of the paraphilias, which has been the mainstay of treatment for sex offenders and the paraphilias for the past three decades. They describe the history of cognitive-behavioral therapy, its techniques, and examine its efficacy. Thibaut reviews the pharmacological treatment of paraphilias. She discusses the recommendations for the treatment of paraphilias of the World Federation of Societies of Biological Psychiatry, concluding that Antiandrogens, mostly GnRH analogues, significantly reduce the intensity and frequency of devi-

ant sexual arousal and behavior. This treatment constitutes the most promising treatment for sex offenders at high risk of sexual violence Briken and Berner attempt to cope with the difficult moral and ethical problems in a double-blind, controlled, clinical trial to investigate the efficacy of psychotherapy combined with triptorelin. Two open, uncontrolled clinical studies using the synthetic LHRH-agonist triptorelin suggested that, combined with psychotherapy, Antiandrogens treatment reduced deviant sexual fantasies, urges, and behaviors in paraphilic patients. They suggest using cognitive-behavioral psychotherapy together with intramuscular (IM) 3-monthly injections of triptorelin in adult men with severe pedophilia in a special setting of convicted male sexual offenders in a forensic psychiatric hospital. They suggest assessment of outcome relates to three target parameters: changes in psychosexual characteristics, changes in the risk of violent sexual behavior and changes in serum testosterone concentration. The question remains to what extent this is a reflection of the real world, but it is the nearest we can get.

We thank all the authors for their willingness to contribute to this special issue, and hope it will provide a basis for increasing knowledge and stimulate interest in researchers and practitioners in this area.

References 1. Green R. Is pedophilia a mental disorder? Arch Sex Behav 2002;31:467–471.

2. Rösler A, Witztum E. Treatment of men with paraphilia with a longacting analogue of gonadotropin-releasing hormone. N Engl J Med 1998;12;338:416-422.

3. Dube SR, Anda RF, Whitfield CL, Brown DW, Felitti VJ, Dong M, Giles WH. Long-term consequences of childhood sexual abuse by gender of victim. Am J Prev Med 2005;28:430-438.

Eliezer Witztum Ben-Gurion University of the Negev elyiit@actcom.co.il

Ariel Rösler Hadassah Medical School, Hebrew University

Guest editors

247

Isr J Psychiatry Relat Sci - Vol. 49 - No 4 (2012)

Paraphilic Diagnoses in DSM-5 Richard B. Krueger, MD, and Meg S. Kaplan, PhD Columbia University, College of Physicians & Surgeons, Department of Psychiatry, and Sexual Behavior Clinic, New York State Psychiatric Institute, New York, New York, U.S.A.

Abstract Background: The DSM-5 has been under revision since 1999 and is scheduled for publication in 2013. This article will review the major proposed modifications of the Paraphilias.

Method: The information reviewed was obtained from PubMed, PsychInfo, the DSM-5.org website and other sources and reviewed.

Results: Pedohebephilia, Hypersexual Disorder and Paraphilic Coercive Disorder are new proposed diagnoses.

Paraphilias have been assigned their own chapter in DSM5 and a distinction has been made between Paraphilias and Paraphilic Disorders. Victim numbers have been included in diagnosis of paraphilias that involve victims and remission and severity measures have been added to all paraphilias. Transvestic Disorder can apply to males or females, Fetishistic Disorder now includes partialism, and Sexual Masochism Disorder has Asphyxiophilia as a specifier.

Limitations: This study is based on a literature review and influenced by the knowledge and biases of the authors.

Conclusions: The Paraphilic Disorders Section of the DSM-5 represents a significant departure from DSMIV-TR.

Background The revision of The Diagnostic and Statistical Manual of Mental Disorders began in 1999 (1) and DSM-5 is

scheduled for publication in May of 2013 (2). Major changes are being proposed for both the specific criteria and for the overall organizational structure of The Diagnostic and Statistical Manual of Mental Disorders (1, 3) . The paraphilias are no exception to these changes (4). Significant controversy has surrounded both the DSM-5 (5) and its proposed revisions for paraphilic diagnoses (6). This article will review the major revisions proposed for the paraphilic disorders as well as some of the significant criticisms.

Method A literature search was conducted on PubMed and PsychoInfo databases from the year 1990 through April of 2011. The search used search terms of “paraphilias,” “exhibitionism,” “voyeurism,” “frotteurism,” “sadism,” “masochism,” “fetishism,” “transvestic fetishism,” “paraphilia-related disorder,” “hypersexual,” “hypersexuality,” “sexual addiction,” “sexual compulsion,” “paraphilic coercive disorder,” “hebephilia,” “pedophilia,” and “paraphilic rape.” Titles and/or abstracts were inspected to ascertain if the article contained criticisms relevant to the current DSM-5. Relevance was ascertained by any mention of any of the Diagnostic Manuals, or by reference to criticism or diagnostic criteria in their title and/or abstracts. In addition, the authors drew upon, in an unsystematic way, secondary references, textbooks, textbook chapters, and newspaper articles that commented on the DSM or DSM-5. Finally, the DSM-5. org website was consulted extensively. Inevitably, the selection of articles was influenced by the experience and biases of the authors, but an attempt was made to present both positive and negative criticism on the major issues in a balanced way.

Address for Correspondence: Richard B. Krueger, MD, Medical Director, Sexual Behavior Clinic, New York State Psychiatric Institute, 1051 Riverside Drive, Unit #45, New York, New York 10032, U.S.A. rbk1@columbia.edu

248

Richard B. Krueger and Meg S. Kaplan

Results Proposed Changes Affecting All or Several of the Paraphilias 1. Proposed Separate Categorization for the Paraphilias

A significant proposed change is that the diagnostic category of Paraphilias has been moved from within the section of Sexual and Gender Identity Disorders in DSM-IV-TR to its own separate section, coequal with other disorders. Two new diagnoses, Paraphilic Coercive Disorder and Hypersexual Disorder, have been proposed for consideration for inclusion in the appendix (4, 7).

2. Paraphilias vs. Paraphilic Disorders

A second change that affects all of the paraphilias is the distinction between paraphilias and paraphilic disorders. A paraphilia (8) corresponds to the A criteria, which define an atypical or deviant sexual interest, and would be “ascertained” according to the A criteria.

However, to qualify for a diagnosis, the B criteria, which specify clinically significant distress or impairment, or, in the case of paraphilias which involve a victim (exhibitionism, frotteurism, pedophilia, sexual sadism and voyeurism) also include a specification that a person has acted on these sexual urges with a nonconsenting individual, must in addition be fulfilled.

Blanchard argued that this distinction would be useful to researchers in that “It would prevent a paraphilia from becoming invisible to clinical science just because it lacks any secondary effect of disturbing the individual or others” (9, p. 307). Thus, researchers could contemplate epidemiological studies of alternative sexual interest patterns using the DSM-5 A criteria without the necessity that these would be disorders.

Further, this new conceptualization addresses some of the concerns raised by groups advocating for those with paraphilic sexual interests, such as the National Coalition for Sexual Freedom, who demand that paraphilias be removed entirely from the DSM because their inclusion is stigmatizing, by listing these non-disordered paraphilias in the “Other Conditions That May Be a Focus of Clinical Attention” chapter of DSM-5 (10).

Indeed Wright (11) described a child custody case in which the proposed revisions for DSM-5 were cited and a mother, involved with sexual sadism, was allowed to keep her children.

First (10) opined that this distinction “has strong conceptual and practical advantages” (p. 250). Wakefield (12) referred to this as a “welcome but more a terminological revision rather than an actual change in the criteria” (p. 203) and noted that this distinction had been implicitly recognized since DSM-III-R. Others have been more critical. Moser, writing about the non-criminal paraphilias (13), suggested that “ascertainment” would not prevent misuse of these paraphilic diagnostic categories, and the impression that one had been “diagnosed” with such a paraphilia.

Fedoroff (14) wrote that if an ascertained paraphilic interest was not causing any dysfunction, then it was not a mental disorder and should not be contained in the DSM at all. Further, he wrote that once a person’s paraphilic interest was ascertained, it would be difficult to imagine that he would not be considered as being diagnosed. O’Donohue (15) questioned the meaning and implications of the term “ascertained” and said that its use doubled the psychometric problems of the DSM because it would now have to ask questions about the reliability and validity not only of diagnosis, but also of ascertainment.

3. Victim Number

The Paraphilias Subworkgroup suggested another broad change; this involved including a specific victim number in the B criteria for those disorders involving nonconsenting persons. Several rationales were given (8). One was that since the majority of patients evaluated were referred after a criminal offense they were not reliable historians. A reliance on a specific victim number, contained in criminal records, would lessen the dependence on self-report of urges and fantasies. A second rationale was that the words “recurrent” and “intense” in the DSM-IV-TR A criteria had been criticized as being too vague to be useful (16) and requiring a minimum number of victims would increase the certitude in diagnosing these disorders in non-cooperative patients.

This reliance on victim count has been vigorously criticized, especially in light of the requirements for data set forth as a precondition for criterion change in the DSM, which require, for a substantial change, that there be a broad consensus of expert clinical opinion, that there be empirical support from a number of validators, and that such change should not be based solely on reports from a single researcher or research team (17).

First (18) reviewed the proposals for including a specific victim count, and found that for all of the disorders, 249

Paraphilic Diagnoses in DSM-5

only a single study (20) was cited as justification for adopting a diagnostic threshold involving victims.

Another line of criticism against victim number has been that a requirement for a minimum number of victims would result in false negatives. In the case of Pedohebophilia, for instance, an individual who had abused only one child for at least 6 months would not necessarily make criteria for this diagnosis under DSM-5 (15). O’Donohue (15) also raised the question of why the unit of analysis was the victim, as opposed to the number of abusive incidents. On the other hand, Wakefield (12) expressed that setting such a threshold was a positive step against making false positive diagnoses.

4. Remission

The term “In Remission” has been added to the diagnostic criteria for each of the paraphilias. In fact, DSMIV-TR allowed for the use of “in partial remission” or “in full remission” for most disorders (20, p. 2), but these were not specifically included as part of the diagnostic criteria for any of the paraphilias. The designation of remission also can only be given if the patient is in an uncontrolled environment; otherwise, a notation is made that the patient is in a controlled environment.

5. Severity Measures

DSM-5 has required dimensional ratings for all of its disorders (21-23) and these have been added for the paraphilias. Both clinician-rated and patient-rated severity measures have been suggested. The clinician rating scales involve a rating over the past two weeks, comparing paraphilic with normophilic interests and behaviors. These ratings range from 1 (mild), where the paraphilic sexual fantasies, urges or behaviors are weaker than normophilic sexual interests and behaviors (8), to 4 (very severe) where the paraphilic urges completely replace normophilic sexual interests and behaviors. In concert with the rest of DSM-5, there are also patient self-rating measures (8).

These severity ratings represent a substantial change from DSM-IV-TR, where there were guidelines for severity that could be applied to all of the diagnoses, but which only consisted of “mild,” “moderate,” and “severe” (20, p. 2). These new dimensional questions are clear and offer reasonable metrics which could help quantify the degree of severity of a paraphilia and which could be psychometrically validated. In fact, there are currently no validated instruments for rating the severity 250

of a paraphilia and these scales offer a significant step towards providing such scales.

Proposed Changes Affecting Specific Paraphilias 1. Pedohebephilic Disorder

Perhaps the most controversial of the proposed paraphilic diagnoses in DSM-5 concerns Pedophilia. The Paraphilias Subworkgroup has recommended renaming Pedophilia to Pedohebephilic Disorder and expanding its definition to include hebephilia, which is a sexual desire for early pubescent children. In DSM-IV-TR, Pedophilia referred to an interest only in a prepubescent child or children, and the proposed revision for DSM-5 would expand this to include pubescent children.

Blanchard set forth the rationale for these changes (9, 24, 25) which were also listed on the DSM-5 website (26). The principal reasons given were: hebephilia and pedophilia are similar, with both involving attraction to immature persons; many men do not differentiate between prepubescent and pubescent children; many individuals who offend against pubescent children are being diagnosed as pedophilic anyway; and this change would harmonize the DSM with the ICD definition of Paedophilia, which is “A sexual preference for children, boys or girls or both, usually of prepubertal or early pubertal age” (ICD-10 F65.4. . .)” (26).

Some critics have asserted that such a definition pathologizes legal behavior, where, in much of the world, legal consent would permit sexual relations with pubescents, and that psychiatry is becoming an agent of social control (27, 28). Frances and First (29) wrote that the merger of pedophilia and hebephilia within the same diagnosis could be justified if there was empirical evidence demonstrating that across high-priority validators, such as familial aggregation, diagnostic stability, course of illness or response to treatment, these two conditions were identical; unfortunately, they could find no such studies. They also pointed to several studies (30-32) demonstrating that sexual arousal to pubescent individuals was common and within the range of normality. Finally, they suggested that because of the blurry dividing line between pubescent and prepubescent children, diagnosis would become more difficult and diagnostic reliability compromised. Others from the United States have argued that the extension of pedophilia to hebephilia is a back-door way of trying

Richard B. Krueger and Meg S. Kaplan

to expand the scope of diagnoses that can be utilized in civil commitment procedures (where individuals with a severe history of sexual offenses can be committed indefinitely to a treatment facility)(12, 33). Wakefield (12) opined of this suggested change, “In sum, the hebephilia proposal is probably the Workgroup’s most flawed and blatantly over-pathologizing paraphilia proposal. Hebephilia as a diagnosis violates the basic constraint that disorder judgments should not be determined by social disapproval. This is a case where crime and disorder are being hopelessly confused (p. 206).”

Blanchard responded to these criticisms, saying that the criteria as they stand in DSM-IV-TR “would exclude from diagnosis a sizable proportion of those men whose strongest sexual feelings are for physically immature persons” and reviewed substantive research which supports this proposed change (34, p. 334).

Another novel aspect of the proposed criteria for Pedohebephilic Disorder is the inclusion of child pornography in the criteria. According to the DSM-5 website, the rationale for the addition of this is that “Some research indicates that child pornography use may be at least as good an indicator of erotic interest in children as ‘hands-on’ offenses” (26). A 2006 study by Seto, Cantor and Blanchard (35) compared phallometric testing on 100 offenders arrested for charges involving child pornography with 178 sex offenders with child victims and demonstrated significantly greater arousal to children on the part of the child pornography offenders than on the part of the offenders against children. It is also makes intuitive sense that a person’s pornography preference may be a more accurate indicator of his underlying sexual interest than other factors because “people opt for pornography that corresponds to their sexual interests” (36). However, First (10) analyzed this criterion and suggested that its inclusion as a B criterion, where use of it could lead to severe negative consequences because of its illegal nature, made it dependent on the particular legal system in which a patient might reside. This jurisdiction might not consider certain sorts of child pornography, such as virtual child pornography, where rendering did not involve any actual children, as illegal, and thus would not allow the person to fulfill the negative function of criterion B. Further, he pointed out this criterion was based on one study from one group, which may not at all be typical (10). Other studies have found that only a minority of individuals arrested for child pornography meet criteria for pedophilia (37, 38).

Finally, it should be noted that there are two ongoing studies, not funded or officially sanctioned by the American Psychiatric Association (39, 40), which should produce data to compare the DSM-IV-TR diagnostic criteria with the proposed DSM-V criteria. These studies, it should be noted, represent a substantial improvement over the studies supporting previous manuals.

These studies represent a significant improvement over prior studies for the paraphilias in the DSM. Blanchard (41) summed the total of all patients studied in conjunction with prior revisions of the DSM involving paraphilias; there were only three.

2. Paraphilic Coercive Disorder

The DSM-5 Subworkgroup has proposed Paraphilic Coercive Disorder for inclusion in the appendix. This disorder (42) would apply to men who obtained sexual arousal from sexual coercion and were not sexual sadists. The suggestion of this disorder for the DSM is not new; in 1985 the DSM-III Workgroup proposed the diagnosis of paraphilic rapism (43), which was extensively criticized at the time.

This proposed disorder has continued to draw criticism, especially in the United States, where it is seen as a diagnosis with little empirical support and one which could enable civil commitment, by expanding the number of diagnoses which could be used as a basis for commitment (44, 45). Indeed, a vote taken following a debate before forensic psychiatrists in Arizona in October of 2010 overwhelmingly decided against inclusion of the new paraphilic coercive disorder (along with pedohebephilia and hypersexual disorder) in the DSM-5 (44). On the other hand, Stern (46) suggested that this diagnosis would replace the misuse of Paraphilia Not Otherwise Specified diagnoses with specific criteria, which would lessen the likelihood of inappropriate diagnoses. Research continues to suggest that there are unique features to sexually coercive men (47) and field trials of this disorder examining both diagnostic reliability and validity are underway (40).

3. Hypersexual Disorder

A third controversial diagnosis suggested by the DSM-5 Paraphilias Subworkgroup is Hypersexual Disorder (48). This disorder, which is now listed in the Sexual Dysfunctions part of the DSM-5 website and which is being considered for the appendix (49), identifies recurrent and intense normophilic sexual fantasies, urges, and behavior as being pathological if they are 251

Paraphilic Diagnoses in DSM-5

excessively time consuming, in response to stress or dysphoric moods, cannot be controlled, disregard the risk of harm to others and cause distress or impairment in functioning.

This disorder has evoked much criticism. Zonana (50) noted that hypersexuality was a symptom, not a disorder, in DSM-IV, and both he and Fedoroff (14) opined that these criteria could easily apply to almost any adult who was sexually active. Halpern (51) asserted that this diagnosis medicalized aberrant sexual activity, was redundant, lacked an empirical base, and would result in false positive diagnoses. Moser (52) criticized this diagnosis as being “based on faulty and inconsistent logic, imprecise criteria, historical inaccuracies, and poorly conceived constructs” (p. 229).

4. Transvestic Disorder

DSM-5 has (53) proposed changes in the criteria for this disorder so as to allow females to be so diagnosed and added specifiers of fetishism (being sexually aroused by fabrics, materials, or garments), autogynephilia (being aroused by the thought or image of oneself as female), and autoandrophilia (being aroused by the thought or image of self as male). Swedish health officials removed transvestism from the official list of diseases and mental disorders (54) and others have called for its removal from the DSM because they do not believe it is a mental illness (55). However, the World Professional Association for Transgender Health (WPATH), after a consensus process, advised retaining the diagnosis, albeit with some change in the criteria (56).

4. Fetishistic Disorder

Fetishistic Disorder has undergone modest changes, expanding the diagnosis to include an interest in nonerogenous body parts in addition to an interest in nonliving objects. Kafka (57) reviewed the literature for fetishism and found that for most of the history of this disorder it had been characterized by persistent arousal to both non-living objects and nonerogenous body parts (referred to as partialism). Accordingly, Fetishism was revised from its previous criteria which specified sexual arousal only towards nonliving objects to include “sexual arousal from either the use of non-living objects or a highly specific focus on non-genital body part(s) . . .” (58). Although this disorder has not received as much criticism as others, some have argued for its removal from the ICD-10 (59) because it stigmatizes those practicing these behaviors.

252

6. Sexual Masochism Disorder

Sexual Masochism, aside from the generic changes described earlier to the paraphilias, has remained largely unchanged, with the exception that the Specifier “With Asphyxiophilia (Sexually Aroused by Asphyxiation)” was added and the phrase “Real, not simulated” was deleted from the criteria, as it did not appear to add any real distinction and no rationale could be found for this in the literature (60). Hypoxyphilia, or the production of sexual excitement by asphyxia, was found in several studies on Sexual Masochism; the Paraphilias Subworkgroup discussed this and asked for an analysis of the literature by Hucker (61, 62). This concluded that individuals engaging in this behavior obtained sexual arousal mainly through restriction of breathing, originally termed “asphyxiophilia” by Money (63) and therefore this specification was added. This change was criticized by Fedoroff (14) as failing to distinguish between those who were aroused by being asphyxiated and those who were aroused by asphyxiating others.

Shindel and Moser (64), citing lack of evidence that sexual masochism was harmful and asserting that continuing the diagnosis in the DSM continued the harmful labeling effect of this disorder, have called for its frank exclusion from the DSM. Limitations The main limitation of this study is the fact that it is a literature review, which is influenced by the knowledge and biases of the authors. Additionally, the paraphilias have not had the funding, research base, or development of scientific studies that other areas of psychiatry have enjoyed. Thus, many of the studies upon which the knowledge base of the paraphilias is based are drawn from samples of convenience, not from epidemiologically sound samples, and subject to bias. Finally, much of the data for this study was retrieved from the DSM-5 website, which has been revised and will continue to be revised as new information and feedback on the proposed criteria is obtained and responded to. Nevertheless, this article represents a comprehensive “snapshot” of the current major proposed changes in the DSM-5 Paraphilic Disorders at a late stage in their development.

Conclusions The Paraphilic Disorders Section of the DSM-5 represents a significant departure from DSM-IV-TR. Many

Richard B. Krueger and Meg S. Kaplan

changes have been proposed, including listing the paraphilias as a separate chapter in the DSM, making a distinction between Paraphilias and Paraphilic Disorders, requiring a specific victim number for those paraphilias that involve nonconsenting persons, including remission specifiers in the paraphilic diagnoses, and specifying severity measures for each of the paraphilias. Two major new diagnoses have been proposed for the appendix, Paraphilic Coercive Disorder, and Hypersexual Disorder, and a major change to an existing diagnosis, Pedohebephilic Disorder, has been suggested. More modest changes have been proposed for Transvestic Disorder, Fetishistic Disorder, and Sexual Masochism Disorder. All of these modifications have evoked considerable criticism and controversy. However, such controversy is not new to this field (65) and hopefully the criteria, which are still in a process of refinement and may still be revised (66), will be the better for it.

References 1. American Psychiatric Association. DSM-5 Overview: The future manual.

2011 [cited May 28th, 2011]; Available from: http://www.dsm5.org/ about/Pages/DSMVOverview.aspx.

2. American Psychiatric Association. DSM-5: The future of psychiatric diagnosis. 2011 [cited May 28th, 2011]; Available from: http://www. dsm5.org/Pages/Default.aspx.

3. American Psychiatric Association. Frequently asked questions. 2011 [cited May 27th, 2011]; Available from: http://www.DSM-5.org.

4. American Psychiatric Association. DSM-5/Home/Proposed Revisions/ Paraphilias. 2011 [cited May 28th, 2011]; Available from: http://www. dsm5.org/ProposedRevision/Pages/Paraphilias.aspx.

5. Spitzer RL. APA and DSM-V: Empty promises. Psychiatric Times 2009; 26:1.

6. Frances A. Whither DSM-V? Br J Psychiatry 2009;195:391-392.

7. American Psychiatric Association. Sexual dysfunctions. 2011 [citedMay 28th, 2011]; Available from: http://www.dsm5.org/proposedrevision/ Pages/Paraphilias.aspx.

8. American Psychiatric Association. U 05 Sexual sadism disorder. [cited May 28th, 2011]; Available from: http://www.dsm5.org/ ProposedRevision/Pages/proposedrevision.aspx?rid=188.

9. Blanchard R. The DSM diagnostic criteria for pedophilia. Arch Sex Behav 2010;39:304-316.

10. First MB. The inclusion of child pornography in the DSM-5 diagnostic criteria for pedophilia: Conceptual and practical problems. J Am Acad.

Psychiatry Law 2011;39:250-254.

11. Wright S. Depathologizing consensual sexual sadism, sexual masochism, transvestic fetishism, and fetishism. Arch Sex Behav 2010;39:1229-1230.

12. Wakefield JC. DSM-5 proposed diagnostic criteria for sexual paraphilias: Tensions between diagnostic validity and forensic utility. Int J Law Psychiatry 2011;34:195-209.

13. Moser C. Problems with ascertainment. Arch Sex Behav 2010;39:12251227.

14. Fedoroff JP. Forensic and diagnostic concerns arising from the proposed DSM-5 criteria for sexual praphiic disorder. J Am Acad Psychiatry Law 2011;39:238-241.

15. O’Donohue W. A critique of the proposed DSM-V diagnosis of pedophilia. Arch Sex Behav 2010: 39:587-590.

16. O’Donohue W, Regev LG, Hagstrom A. Problems with the DSM-IV diagnosis of pedophilia. Sex Abuse 2000;12:95-105.

17. Kendler K, Kupfer D, Narrow W, Phillips K, Fawcett J. Guidelines for making changes to DSM-V Revised 10/21/2009. American Psychiatric Association, 2009 [cited May 28th, 2011]. Available from: DSM-5.org.

18. First MB. DSM-5 proposals for paraphilias: Suggestions for reducing false positives related to use of behavioral manifestations. Arch Sex Behav 2010;39:1239-1244.

19. Blanchard R, Klassen P, Dickey R, Kuban ME, Blak T. Sensitivity and specificity of the phallometric test for pedophilia in nonadmitting sex offenders. Psychol Assess 2001;13:118-126.

20. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. Text Revision. DSM-IV-TR. 4th ed. American Psychiatric Association, Washington, DC, 2000: pp. 1-943.

21. Helzer JE, Wittchen H-U, Krueger RF, Kraemer HC. Dimensional options for DSM-V: The way forward. In: Helzer JE, Kraemer HC, Krueger RF, Wittchen H-U, Sirovatka PJ, Regier DA, editors. Dimensional approaches in diagnostic classification. Refining the Research Agenda for DSM-V. American Psychiatric Association; Arlington, VA, 2008: pp. 115-127.

22. Helzer JE, Kraemer HC, Krueger RF, Wittchen H-U, Sirovatka PJ, Regier DA. Dimensional approaches in diagnostic classification. Refining the research agenda for DSM-V. In: Helzer JE, Kraemer HC, Krueger RF, Wittchen H-U, Sirovatka PJ, Regier DA, editors. Dimensional Approaches in Diagnostic Classification. Refining the Research Agenda for DSM-V. American Psychiatric Association, Arlington, VA, 2008: pp. 1-136.

23. Kraemer HC. DSM categories and dimensions in clinical and research contexts. Int J Methods Psychiatr Res 2007;16:S8-S15.

24. Blanchard R, Lykins AD, Wherrett D, Kuban ME, Cantor JM, Blak T, et al.

Pedophilia, hebephilia, and the DSM-V. Arch Sex Behav 2009;38:335-350.

25. Blanchard R. Reply to letters regarding pedophilia, hebephilia, and the DSM-V. Arch Sex Behav 2009;38:331-334.

26. American Psychiatric Association. U 03 Pedohebephilic Disorder. 2011 [cited 2011 May 28th, 2011]; Available from: http://www.dsm5.org/ ProposedRevision/Pages/proposedrevision.aspx?rid=186.

27. Green R. Sexual preference for 14-year-olds as a mental disorder: You can’t be serious!! Arch Sex Behav 2010; 39:585-586.

28. Green R. Hebephilia is a mental disorder? Sexual Offender Treat 2010;5:1-7.

29. Frances A, First MB. Hebephilia is not a mental disorder in DSM-IVTR and should not become one in DSM-5. J Am Acad Psychiatry Law 2011;39:78-85.

30. Barbaree HEM, W.L. Erectile responses among heterosexual child molesters, father-daughter incest offenders, and matched non-offenders: five distinct age preference profiles. Can J Behav Sci 1989;12:70-82.

31. Freund K, Costell R. The structure of erotic preference in the nondeviant male. Behav Res Ther 1970;8:15-20.

32. Quinsey VL, Steinman CM, Bergersen SG, Holmes TF. Penile circumference, skin conductance, and ranking responses of child molesters and “normals” to sexual and nonsexual visual stimuli. Behav Ther 1975;6:213-219.

33. Franklin K. The public policy implications of “hebephilia”: A response to Blanchard et al. (2008). Arch Sex Behav 2009;38:319-320.

34. Blanchard R. Reply to letters regarding pedophilia, hebephilia, and the DSM-V. Arch Sex Behav 2009; 38; 331-334.

35. Seto MC, Cantor JM, Blanchard R. Child pornography offenses are a valid diagnostic indicator of pedophilia. J Abnorm Child Psychol 2006;115:610-615.

36. Seto MC. Child pornography use and internet solicitation in the diagnosis of pedophilia. Arch Sex Behav 2010; 39:591-593.

37. Krueger RB, Kaplan MS, First MB. Sexual and other Axis 1 diagnoses of 60 males arrested for crimes against children involving the internet.

CNS Spectrums 2009;14:623-631.

38. Krueger RBK, Kaplan MS. Non-contact sexual offenses: Exhibitionism,

253

Paraphilic Diagnoses in DSM-5

voyeurism, possession of child pornography, and interacting with children over the internet. In: Hoberman HP, Phoenix A, editors. Sex Offenders: Diagnosis, Risk Assessment, & Management. New York: Springer, 2012. In press.

39. Fedoroff JP. Personal communication. July 1st, 2011.

40. Thornton D. Personal communication. Study under the guidance of Robin Wilson (Florida), David Thornton (Wisconsin) and David Thornton & Deirdre D'Orazio (California) August 1st, 2011.

41. Blanchard R. A brief history of field trials of the DSM diagnostic criteria for paraphilias. Arch Sex Behav 2011; 40:1-2.

42. American Psychiatric Association. Paraphilic coercive disorder. [cited 2011 May 28th, 2011]; Available from: http://www.dsm5.org/ proposedrevision/Pages/proposedrevision.aspx?rid=416.

43. Fuller AK, Fuller AE, Blashfield RK. Paraphilic coercive disorder. J Sex Educ Ther 1990;16:164-171.

44. Zander TK. Inventing diagnosis for civil commitment of rapists. J Am Acad Psychiatry Law 2008;36:459-469.

45. Franklin K. Letter to the Editor. J Am Acad Psychiatry Law 2011;39:137.

46. Stern P. Paraphilic coercive disorder in the DSM: The right diagnosis for the right reasons. Arch Sex Behav 2010;39:1443-1447.

47. Yoon J, Knight RA. Sexual material perception in sexually coercive men: Disattending deficit and its covariates. Sex Abuse 2011;23:275-291.

48. Kafka MP. Hypersexual disorder: A proposed diagnosis for DSM-V. Arch Sex Behav 2009; 39:377-400 49. American Psychiatric Association. Hypersexual disorder. [cited May 28th, 2011]; Available from: http://www.dsm5.org/proposedrevision/ Pages/proposedrevision.aspx?rid=415.

50. Zonana H. Sexual disorders: New and expanded proposals for the DSM-5: Do we need them? J Am Acad Psychiatry Law 2011;39:245-249.

51. Halpern AL. The proposed diagnosis of hypersexual disorder for inclusion in DSM-5: Unnecessary and harmful. Arch Sex Behav 2011; 40:487-488.

52. Moser C. Hypersexual disorder: Just more muddled thinking. Arch Sex Behav 2011;40:227-229.

254

53. American Psychiatic Association. U 06 Transvestic disorder. [cited 2011 May 28th, 2011]. Available from: http://www.dsm5.org/ ProposedRevision/Pages/proposedrevision.aspx?rid=189 54. The Associated Press. Sweden says transvestism is not a disease. The Associated Press Archive. 2008, November 19, 2008, Sect. 1.

55. Reiersol O, Skeid S. The ICD diagnoses of fetishism and sadomasochism.

J Homosex 2006;50:243-262.

56. Gijs L. Carroll RA. the Should transvestic fetishism be classified in DSM5? Recommendations from WPATH consensus process for revision of the diagnosis of transvestic fetishism. Int J Transgenderism 2010;12:189-197.

57. Kafka MP. The DSM diagnostic criteria for fetishism. Arch Sex Behav 2009; 39:357-362 58. American Psychiatric Association. U 01 Fetishistic disorder. [cited May 28th, 2011]; Available from: http://www.dsm5.org/ProposedRevision/ Pages/proposedrevision.aspx?rid=63.

59. Reiersol O, Skeid S. The ICD diagnoses of fetishism and sadomasochism.

In: Kleinplatz PJ, Moser C, editors. Sadomasochism: Powerful pleasures.

Binghamton, N.y.: Harrington Park Press, 2006: pp. 243-262.

60. American Psychiatric Association. U 04 Sexual masochism disorder. [cited May 28th, 2011]; Available from: http://www.dsm5.org/ ProposedRevision/Pages/proposedrevision.aspx?rid=187.

61. Hucker SJ. Hypoxyphilia. Arch Sex Behav 2011; 40:1323-1326.

62. Krueger RB. The DSM diagnostic criteria for sexual masochism. Arch Sex Behav 2010;39:346-356.

63. Money J. Lovemaps. Clinical concepts of sexual/erotic health and pathology, paraphilia, and gender transposition in childhood, adolescence, and maturity. New York, N.y.: Irvington, 1986: pp. 1-331.

64. Shindel AW, Moser CA. Why are the paraphilias mental disorders? J Sex Med 2011; 8:2955-2956.

65. Zucker KJ. Introduction to the special section on pedophilia: Concepts and controversy. Arch Sex Behav 2002;31:465.

66. American Psychiatric Association. [cited June 15th, 2011]; Available from: http://www.dsm5.org/Pages/Default.aspx.

Isr J Psychiatry Relat Sci - Vol. 49 - No 4 (2012)

Axis I Psychiatric Disorders, Paraphilic Sexual Offending and Implications for Pharmacological Treatment Martin Kafka, MD Clinical Associate Professor of Psychiatry, Harvard University Medical School, Boston, Massachusetts, U.S.A.

that such treatment could mitigate paraphilic behavior.

Abstract 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

Address for Correspondence:

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.

This manuscript is based on a presentation delivered at the symposium Contemporary Treatments of Paraphilias, Jerusalem, Israel. June 16-20, 2010.

Introduction In the Diagnostic and Statistical Manuals of the American Psychiatric Association (DSM-IV and proposed DSM-5), paraphilic disorders are generally structured into “A” and “B” criterion where the former provides an operational description for a specific paraphilic focus of sexual arousal (e.g., recurrent, persistent sexual arousal to pre-pubertal children for pedophilia) and the latter criterion describes the clinical necessity of significant personal distress or social role impairment resulting from criterion A arousal or behavior.

Martin Kafka, MD, 22 Mill St., Suite #306, Arlington, MA 02476, U.S.A.

mpkafka@rcn.com

255

Axis I Psychiatric Disorders

There is, if you will, an unspoken clinical assumption that “A” could lead to “B” but the clinical conditions or circumstance associated with this assumption are not inherently evident. For example, there are men who may have had repetitive, intense and enduring sexual arousal associated with voyeurism, pedophilia, exhibitionism or rape fantasies but never acted against victims. As is being proposed for DSM-5, under these circumstances a paraphilia may be ascertained (Criterion A only) but a paraphilic disorder or formal diagnosis would require the additional clinical significance threshold (Criterion A plus Criterion B) (1). This observation leads to an interesting and important question: what risk factors or characteristics are more likely to intensify or disinhibit someone with a Criterion A paraphilia to progress to a paraphilic disorder?

At present, in addition to the presence of a persistent paraphilia (Criterion A) whose intrinsic intensity may vary over time, there are additional risk factors or characteristics that have been reported associated with repetitively enacted paraphilic sexual offending.

These factors fall into five general domains: 1. Gender (male) 2. Age (inverse relationship) 3. Significant developmental adversity (especially in hands-on offenders) 4. Axis I psychopathology 5. Axis II psychopathology Although the research literature on sexual offenders, especially sexually violent repeat offenders, has focused on Axis II psychopathology (2-4), salient non-sexual Axis I psychopathology has also been noted. There are several reasons to assume that “non-sexual” Axis I psychopathology, especially if known to be associated with other manifestations of behavioral disinhibition (i.e., impulsivity), could be important to consider during the assessment and treatment of paraphilic sexual offenders.

First, most Axis I neuropsychiatric disorders are associated with limbic, cingulate and prefrontal neural pathways in the brain, networks that are also associated with the regulation of sexual motivation and behavioral control (5). Second, the orbital-frontal area in particular, commonly affected by Axis I psychiatric disorders, is one of the major final pathways associated with “executive functions” such as cognitive planning, attention, working memory, anticipation, motivation, reward salience, synthesizing complex sensory information, 256

social judgment and impulse control. In mammalian models of sexual disinhibition, the prefrontal cortex has been specifically associated with sexual disinhibition (6).

Third, if it could be demonstrated that the predominant Axis I psychopathologies associated with sexual deviance and paraphilically motivated sexual offending had their onset during childhood or adolescence, then this would additionally strengthen the importance of a non-random co-association as paraphilic sexual arousal is predominantly reported to have a similar age of onset (7). Last, while there is considerable controversy as to the best multimodal treatment approaches to address and ameliorate recidivistic sexual offending, pharmacological treatments that ameliorate comorbid Axis I disorders associated with sexual impulsivity or appetitive drive dysregulation may help to mitigate such behaviors (8). On these bases, the identification and treatment of Axis I comorbidity is an important clinical consideration for paraphilic sexual offenders.

Methods 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 methodology to ascertain Axis I psychopathology or a specific diagnosis not typically included in such structured diagnostic instruments was ascertained with validated rating instruments.

In samples of adolescents, I tried to search for manuscripts or book chapters that described hands-on sexual offenses. According to DSM-IV-TR, paraphilic diagnoses cannot be applied to adolescents (9) but, rather than eliminate several samples, I have included them with the caveat that such individuals cannot be definitively characterized as “paraphilic.”

In addition, I have included here previously unpublished data from a sample of consecutively evaluated outpatient males (n=180), that included paraphilic sexual offenders (n=73). This data was drawn from my clinical practice and collected from October 2000 – January 2004. Written informed consent was obtained from each subject and approved by the McLean Hospital

Martin Kafka

Institutional Review Board, affiliated with Harvard Medical School (10). The assessment of DSM-IV Axis I psychopathology in that sample was ascertained utilizing the same diagnostic instruments reported in a previous publication by this author (11). A comprehensive diagnostic checklist for DSM-IV was administered and reviewed by clinician and subject, that included the lifetime assessment of dysthymic disorder, major depression, bipolar disorder (Types I and II), psychotic disorders, social anxiety disorder, generalized anxiety disorder, panic disorder, post-traumatic stress disorder,

obsessive compulsive disorder, alcohol abuse, cocaine abuse, marijuana abuse, attention deficit disorders and conduct disorder.

Results In the following tables, I have tried to organize the extant literature that I reviewed on this subject. I have emphasized “positive� or predominant disorder prevalence findings in this report. When specific lifetime prevalence of Axis I disorders in paraphilic sexual offenders

Table 1. Lifetime Prevalence of Mood Disorders in Paraphilic Sexual Offenders Axis I diagnosis

Sample Size

Sample Description

Methodology

Lifetime Prevalence

Raymond (1999) (33)

45

adult pedophiles

SCID-DSM-IV

56%

Leue (2004) (34)

30

adult forensic offenders

Mini-DIPS (DSM-IV)

30%

Grant (2005) (35)

25

adult exhibitionists

SCID-DSM-IV

40%

Galli (1999) (36)

22

adolescent child molesters

SCID-DSM-III-R

52%

Dunseith (2004) (37)

84

adult paraphilic offenders

SCID-DSM-IV

42%

Eher (2003) (38)

75

paraphilic rapists and pedophiles

SCID-DSM-IV

28%

Kafka (1994) (39)

34

adult paraphilic offenders

checklist for DSM-III-R disorders

67%

Kafka (1998) (40)

21

adult paraphilic offenders

checklist for DSM-III-R disorders

70%

Kafka (2002) (11)

60

adult paraphilic offenders

checklist for DSM-IV disorders

69%

Kafka (2010) (10)

73

adult paraphilic offenders

checklist for DSM-IV disorders

60%

Major depression

Bipolar disorder

Dysthymic disorder

Mini-DIPS: Diagnostic Interview for Psychiatric Disorders-short version (in German) (41) SCID for DSM-III-R Psychiatric Disorders (42) SCID for DSM IV Axis I Disorders (43)

Table2. Lifetime Prevalence of Axis I Anxiety Disorders in Paraphilic Sexual Offenders Axis I diagnosis

Sample Size

Sample Description

Methodology

Lifetime Prevalence

22

adolescent child molesters

SCID-DSM-III-R

32%

Dunseith (2004) (37)

84

adult paraphilic offenders

SCID-DSM-IV

13%

Kafka (1994) (39)

34

adult paraphilic offenders

checklist for DSM-III-R disorders

20%

Kafka (1998) (40)

21

adult paraphilic offenders

checklist for DSM-III-R disorders

30%

Kafka (2002) (11)

60

adult paraphilic offenders

checklist for DSM-IV disorders

20%

Kafka (2010) (10)

73

adult paraphilic offenders

checklist for DSM-IV disoders

23%

Leue (2004) (34)

30

adult forensic offenders

Mini-DIPS (DSM-IV)

53%

45

adult pedophiles

SCID-DSM-IV

24%

adult exhibitionists

SCID-DSM-IV

12%

Post-traumatic stress disorder Galli (1999) (36) Social phobia

Panic Disorder Raymond (1999) (33)

Generalized Anxiety Disorder Grant (2005) (35)

25

257

Axis I Psychiatric Disorders

Table 3. Lifetime Prevalence of Axis I Alcohol Abuse in Paraphilic Sexual Offenders Axis I diagnosis

Sample Size

Sample Description

Methodology

Lifetime Prevalence

Dunseith (2004) (37)

84

adult paraphilic offenders

SCID-DSM-IV

10 %

Raymond (1999) (33)

45

adult pedophiles

SCID-DSM-IV

51%

Galli (1999) (36)

22

adolescent child molesters

SCID-DSM-III-R

36%

Harsch (2006) (44)

40

adult forensic sex offenders

SCID-DSM-IV

55%

Kafka (1994) (39)

34

adult paraphilic offenders

checklist for DSM-III-R disorders

41%

Kafka (1998) (40)

21

adult paraphilic offenders

checklist for DSM-III-R disorders

40%

Kafka (2002) (11)

60

adult paraphilic offenders

checklist for DSM-IV disorders

32%

Kafka (2010) (10)

73

adult paraphilic offenders

checklist for DSM-IV disorders

31%

Alcohol abuse

Table 4. Lifetime Prevalence of Axis I Attention Deficit Hyperactivity Disorder and Conduct Disorder in Paraphilic Sexual Offenders Axis I diagnosis

Sample Size

Sample Description

Methodology

Lifetime Prevalence

adult paraphilic offenders

checklist for DSM-III-R disorders

53%

Attention deficit hyperactivity disorder Kafka (1998) (40)

21

Kafka (2002) (11)

60

adult paraphilic offenders

ADHD Rating Scale, WURS

42%

Kafka (2010) (10)

73

adult paraphilic offenders

ADHD Rating Scale

42%

Galli (1999) (36)

22

adolescent child molesters

SCID-DSM-III-R

71%

Fago (1999) (45)

35

adolescent mixed offenders

Connors’ ADHD rating scales

77%

Kavoussi (1988) (46)

58

adolescent mixed offenders

Kiddie SADS-E

7%

Kavoussi (1988) (46)

58

adolescent mixed offenders

Kiddie SADS-E

67%

Galli ( 1999) (36)

22

adolescent child molesters

SCID-DSM-III-R

94%

Kafka (2002) (11)

60

adult paraphilic offenders

checklist for DSM-IV disorders

23%

Kafka (2010) (10)

73

adult paraphilic offenders

checklist for DSM-IV disorders

25%

Conduct disorder

ADHD Rating Scale (47,48) Wender-Utah Retrospective Scale for ADHD (49) Connors’ Parent Rating Scale and Teacher’s Rating Scale (50) Children’s Schedule for Affective Disorders and Schizophrenia (41) SCID for DSM IV Axis I Disorders (43)

Table 5. Lifetime Prevalence of Additional Axis I Neurodevelopmental Disorders in Sexual Offenders Axis I Diagnosis

Sample Size

Prevalence of Sex Offending

Sample Description

Methodology

adolescent mixed offenders

comprehensive diagnostic assessment

49%

adolescents, mostly child molesters

CSBQ

20%

Fetal alcohol spectrum disorders Streissguth (2004) (32)

415

Autism-spectrum disorders, including Asperger’s disorder 't Hart-Kerkhoffs (2009) (51)

114

Mental retardation syndromes Cochrane (2001) (52)

1710

federal defendant offenders forensic clinicians, DSM-IIIR

criteria

11%

Blanchard (1999) (53)

678

pedophiles

IQ testing, phallometric testing

10%

Children’s Social Behavior Questionnaire (54)

258

Martin Kafka

(as opposed to non-paraphilic sexual offenders) were determined in articles or could be approximately calculated from the data presented, they are listed in the Tables as well.

Discussion From this literature review, it is suggested that mood disorders are relatively prevalent Axis I psychopathologies co-associated with paraphilic sexual offending. In addition, social anxiety disorder, ADHD and conduct disorder can be associated with paraphilic sexual disinhibition. Alcohol abuse is prevalent among adult paraphilic offenders but its role is more likely associated with situational disinhibition In adolescent sexual offenders, complex post-traumatic stress disorder, conduct disorder, ADHD and additional neurodevelopmental disorders (fetal alcohol spectrum, Asperger’s Disorder) have been reported with a higher incidence than in adult paraphilic offenders as evidenced in the Tables. The latter neurodevelopmental disorders, however, are not systematically evaluated in adults or in “comprehensive” rating instruments such as the Structured Clinical Interview for DSM-IV (SCID).

It is noteworthy that mood disorder symptoms typically include appetitive drive dysregulation affecting sleep, eating and sexual behavior. Dysthymic disorder can be characterized by an early age of onset (e.g., before 21 years), a waxing and waning clinical course, and a comorbid association with some clinical syndromes associated with externalizing behaviors substance abuse, eating disorders and personality disorders (12-14).

Successful antidepressant treatment of paraphilias with comorbid unipolar mood disorders has been reported in several consecutive case series (15-20) although there have been no definitive double-blind placebo controlled studies.

Bipolar-spectrum disorders (during which hypomanic phase symptoms may manifest for only one to two days or symptom counts are subthreshold) are more difficult to differentiate in patients than repetitive behavioral sexual impulsivity. Although the gold standard for hypomania in bipolar II disorder in DSM-IV and DSM-IV-TR is an episode duration lasting four or more days, recent research has shown that the mean duration of hypomanic episodes in community and outpatient samples is one to two days (21, 22) and that up to 40% of persons who have episodes of major depression have sub-threshold hypomanic symptoms (23).

Increased or disinhibited sexual motivation, excessive involvement in pleasurable activities and risk-taking, including sexual indiscretions, are recognized among the polythetic cardinal manifestations of hypomania.

A wider boundary for hypomania during diagnostic assessment should alert clinicians that sexually impulsive behavior, including paraphilic sexual offending, may be found in both polarities of mood disorders.

There is only a small literature demonstrating efficacy of mood stabilizers for the amelioration of paraphilias in persons with concurrent bipolar disorders (24-27) and a retrospective case series of bipolar paraphiliacs prescribed valproate sodium suggested that valproate was not effective for mitigating paraphilias (28).

Childhood onset and the attenuated persistence as “adult” ADHD has received considerable research and clinical attention during the past decade. In incarcerated populations, however, where childhood-onset ADHD-combined subtype would be expected to have a higher prevalence because of its comorbidity with antisociality and conduct disorder, this diagnosis is frequently not assessed (29). In adult sexual offenders who are incarcerated, ADHD assessment is over-looked in preference to assessing Axis II psychopathology, most commonly antisocial personality disorder (30). While the former diagnosis is readily treatable with medication such as a psychostimulant, the latter diagnosis denotes both a poor prognosis and pharmacological non-responsivity. Psychostimulants, accompanied by SSRI antidepressants for paraphilics, including sexual offenders, have demonstrated some efficacy in a case series (31) but I could not find any other reports in the literature.

Fetal alcohol syndrome (FAS) and the more broadly defined fetal alcohol effects (FAE) are not designated as specific “psychiatric” diagnoses in DSM-IV-TR despite recent evidence that fetal alcohol exposure may be the leading preventable cause of mental retardation in the United States (32). In this clinician’s experience, the sexual impulsivity of patients with FAE or FAS can meet criteria for a paraphilia (e.g., pedophilia, coprophilia) but their sexual behavior can also be less coherently organized or planned, as might be the case for persons with paraphilias. For example, an adolescent or adult with FAE might receive an incorrect diagnosis of frotteurism or exhibitionism but his sexually disinhibited behavior is indiscriminate: he would more likely repetitively target nearby peers or adults, not strangers as those with paraphilias would more deliberately victim259

Axis I Psychiatric Disorders

ize. At present, in contrast to unipolar, bipolar disorder or ADHD, there is no uniform psychotherapeutic or psychopharmacological treatment algorithm for persons with a history of alcohol-related teratogenic effects.

Persons afflicted by prenatal exposure to neurotoxic substances such as alcohol are frequently clustered in structured residential programs, including incarceration settings.

Review Limitations This literature review was organized to emphasize positive findings from the research literature. For example, if mood or anxiety disorders were systematically evaluated, the most prevalent lifetime diagnosis was reported.

The studies included varied in both sample types and settings as well as ascertainment and diagnostic methodologies. As a result, not all studies reported exactly the same broad spectrum of Axis I disorders. For example, only a few studies ascertained attention deficit hyperactivity disorder or conduct disorder retrospectively in paraphilic adults. Some studies did not delineate specific paraphilic diagnoses but rather emphasized paraphilic disorders as a group of diverse behaviors.

Many of the studies reported small samples which further limit any definitive findings or conclusions.

The psychopharmacological treatment of paraphilic disorders based on the premise of treating concurrent Axis I comorbidity is limited as well. The evidence is strongest for the prescription of serotonergic antidepressants in non-biploar paraphilic offenders.

Conclusion A subset of males with Axis I diagnoses of mood disorders, social anxiety disorder, ADHD, substance use disorders, and/or neurodevelopmental disabilities such as mental retardation and fetal alcohol effects may be particularly vulnerable to sexual disinhibition. These psychiatric disorders have a chronic or recurrent course and typically manifest during childhood or adolescence, the developmental period during which sexual arousal patterns and preferences are primarily established.

These neuropsychiatric vulnerabilities, exacerbated by the complex familiar discord that may occur in response to their symptomatic expression, could have a malignant pathoplastic effect on developing sexuality and impulse control in vulnerable males. In some instances, psychoactive substance abuse, most notably 260

alcohol, pours “salt on the wound� vulnerability of adolescents and men with a combination of such afflictions.

Pharmacological treatment reports suggest that ameliorating comorbid Axis I can diminish sexual impulsivity (5,8) but the evidence should still be considered as preliminary: the current literature neither definitively proves or disproves the hypothesis that treating Axis I comorbidity effectively ameliorates paraphilic sexual offending behavior. Heightened clinical awareness and the correct identification of Axis I comorbidities could help to ameliorate the human suffering and victimization associated with paraphilias, but more definitive research and clinical reports of treatment are needed.

References 1. Blanchard R. The DSM diagnostic criteria for transvestic fetishism.

Arch Sex Behav 2010;39:363-372.

2. Becker J, Stinson J, Tromp S, Messer G. Characteristics of individuals petitioned for civil commitment. Int J Offend Ther Compar Crimin 2003;47:185-195.

3. Levenson JS. Sexual predator civil commitment: A comparison of selected and released offenders. Int J Offend Ther Compar Crimin 2004;48:638-648.

4. Jackson RL, Richards HJ. Diagnostic and risk profiles among civilly committed sex offenders in Washington State. Int J Offend Ther Compar Crimin 2007;51:313-323.

5. Kafka MP. Neurobiological processes and comorbidity in sexual deviance.

In: Laws DR, O'Donohue W, editors. Sexual deviance: Theory, assessment and treatment. Second Edition. New York: Guilford, 2008: pp. 571-593.

6. Davis JF, Loos M, Di Sebastiano AR, Brown JL, Lehman MN, Coolen LM. Lesions of the medial prefrontal cortex cause maladaptive sexual behavior in male rats. Biol Psychiatry 2010;67:1199-1204.

7. American Psychiatric Association. Paraphilias. In: Association AP, ed.

Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington D.C.: American Psychiatric Association, 2000: pp. 567-569.

8. Briken P, Kafka MP. Pharmacological treatments for paraphilias and sexual offenders. Curr Opin Psychiatry 2007;20:609-613.

9. Nolen-Hoeksema S. Sex differences in response to depression. Sex differences in depression. Stanford, Cal.: Stanford University Press 1990: pp. 160-177.

10. Kafka MP. Axis I psychiatric diagnoses associated with sexual impulsivity disorders. Unpublished data (see Methods section of this manuscript), 2010.

11. Kafka MP, Hennen J. A DSM IV Axis I comorbidity study of males (n=120) with paraphilias and paraphilia-related disorders. Sex Abuse: J Res Treatment 2002;14:349-366.

12. Klein DN, Schatzberg AF, McCullough JP, Keller MB, Dowling F, Goodman D, et al. Early- versus late-onset dysthymic disorder: Comparison in out-patients with superimposed major depressive episodes. J Affect Dis 1999;52:187-196.

13. Perez M, Joiner TE, Lewinsohn PM. Is major depression or dysthymia more strongly associated with bulimia nervosa? Int J Eat Disord 2004;36:55-61.

14. Lilenfeld LR, Ringham R, Kalarchian MA, Marcus MD. A family history study of binge-eating disorder. Compr Psychiatry 2008;49:247-254.

15. Coleman E, Gratzer T, Nesvacil L, Raymond N. Nefazodone and the treatment of nonparaphilic compulsive sexual behaviors. J Clin Psychiatry 2000;61:282-284.

Martin Kafka

16. Greenberg DM, Bradford JMW, Curry S, O'Rourke A. A comparison of treatment of paraphilias with three serotonin reuptake inhibitors: A retrospective study. Bull Am Acad Psychiatry Law 1996;24:525-532.

17. Kraus C, Strohm K, Hill A, Habermann W, Berner W, Briken P. Selektive serotoninwiederaufnahmehemmer (SSRI) in der behandlung von paraphilien:eine retrospektive studie (Selective serotonine reuptake inhibitors (SSRI) in the treatment of paraphilia: A retrospective study).

Fortschr Neurol Psychiat 2007:351-356.

18. Kafka MP, Prentky R. Fluoxetine treatment of nonparaphilic sexual addictions and paraphilias in men. J Clin Psychiatry 1992;53:351-358.

19. Kafka MP. Sertraline pharmacotherapy for paraphilias and paraphiliarelated disorders; an open trial. Ann Clin Psychiatry 1994;6:189-195.

20. Kruesi MJP, Fine S, Valladares L, Phillips RA, Rapoport JL. Paraphilias: A double-blind crossover comparison of clomipramine versus desipramine.

Arch Sex Behav 1992;21:587-593.

21. Judd LL, Akiskal HS. The prevalence and disability of bipolar spectrum disorders in the US population: A re-analysis of the ECA database taking into account subthreshold cases. J Affect Dis 2003;73:123-131.

22. Judd LL, Akiskal HS, P.J. S, Coryell W, Endicott J, Maser JD, et al.

A prospective investigation of the natural history of the long-term weekly symptomatic status of Bipolar II disorder. Arch Gen Psychiatry 2003;60:261-269.

23. Angst J, Cui L, Swendson J, Rothen S, Cravchik A, Kessler RC, et al.

Major depressive disorder with subthreshold bipolarity in the National Comorbidity Study Replication. Am J Psychiatry 2010;167:1194-2101.

24. Cesnik JA, Coleman E. Use of lithium carbonate in the treatment of autoerotic asphyxia. Am J Psychother 1989;43:277-286.

25. Ward NG. Successful lithium treatment of transvestism associated with manic-depression. J Nerv Ment Dis 1975;161:204-206.

26. Corretti G, Baldi I. Oxcarbamazepine reduces exhibitionistic urges and behaviors in a paraphilic patient. Arch Sex Behav 2010;39:1025-1026.

27. Varela D, Black DW. Pedophilia treated with carbamazepine and clonazepam. Am J Psychiatry 2002;159:145-146.

28. Nelson E, Briusman L, Holcomb J, Soutullo C, Beckman D, Welge JA, et al. Divalproex sodium in sex offenders with bipolar disorders and comorbid paraphilias: An open retrospective study. J Affect Dis 2001;64:249-255.

29. James DJ, Glaze LE. Mental health problems of prison and jail inmates.

2006, retrieved December 14, 2006 : http://www.ojp.usdoj.gov/bjs/pub/ pdf/mhppji.pdf.

30. Zander TK. Civil committment without psychosis: The laws reliance on the weakest link in psychodiagnosis. J Sexual Offender Civil Commitment: Science and the Law 2005;1:17-82.

31. Kafka MP, Hennen J. Psychostimulant augmentation during treatment with selective serotonin reuptake inhibitors in males with paraphilias and paraphilia-related disorders: A case series. J Clin Psychiatry 2000;61:664-670.

32. Streissguth AP, Bookstein FL, Barr HM, Sampson PD, O'Malley K, Young JK. Risk factors for adverse life outcomes in fetal alcohol syndrome and fetal alcohol effects. Dev Behav Pediatrics 2004;25:228-238.

33. Raymond NC, Coleman E, Ohlerking F, Christenson GA, Miner M. Psychiatric comorbidity in pedophilic sex offenders. Am J Psychiatry 1999;156:786-788.

34. Leue A, Borchard B, Hoyer J. Mental disorders in a forensic sample of sexual offenders. Eur Psychiatry 2004;19:123-130.

35. Grant JE. Clinical characteristics and psychiatric comorbidity in males with exhibitionism. J Clin Psychiatry 2005;66:1367-1371.

36. Galli V, McElroy SL, Soutello CA, Kizer D, Raute N, Keck PE, et al.

The psychiatric diagnoses of twenty two adolescents who have sexually molested other children. Compr Psychiatry 1999;40:85-87.

37. Dunsieth NW, Nelson EB, Brusman-Lovins LA, Holcomb JL, Beckman D, Welge JA, et al. Psychiatric and legal features of 113 men convicted of sexual offenses. J Clin Psychiatry 2004;65:293-300.

38. Eher R, Neuwirth W, Fruehwald S, Frottier P. Sexualization and lifetime impulsivity: Clinically valid discriminators in sexual offenders. Int J Offend Ther Compar Crimin 2003;47:452-467.

39. Kafka MP, Prentky RA. Preliminary observations of DSM III-R Axis I comorbidity in men with paraphilias and paraphilia-related disorders.

J Clin Psychiatry 1994;55:481-487.

40. Kafka MP, Prentky RA. Attention Deficit Hyperactivity Disorder in males with paraphilias and paraphilia-related disorders: A comorbidity study. J Clin Psychiatry 1998;59:388-396.

41. Mergraf J. Diagnostisches Kurz-Interview bei psychischen StorungenMiniDIPS. Handbuch und Interviewleitfaden (Mini-DIPS User Manual).

Berlin, Germany: Springer, 1994.

42. Spitzer RL, Williams JB, Gibbon M, First MB. Structured Clinical Interview for DSM-III-R-Patient Edition ( SCID-P, version 1.0).

Washington D.C.: American Psychiatric, 1990.

43. First MB, Spitzer RL, Gibbon M. Structured Clinical Interview for DSM-IV Axis I Disorders-Patient Edition. New York, N.Y.: New York State Psychiatric Institute: Biometric Research, 1996.

44. Harsch S, Bergk JE, Steinert T, Keller F, Jockusch U. Prevalence of mental disorders among sexual offenders in forensic psychiatry and prison. Int J Law Psychiatry, 2006;29:443-449.

45. Fago DP. Comorbidity of attention deficit hyperactivity disorder in sexually aggressive children and adolescents. In: Schwartz B, editor. The sex offender: Theoretical advances, treating special populations and legal developments. Kingston, N.J.: Civic Research Institute 1999: pp. 16.1-.5.

46. Kavoussi RJ, Kaplan M, Becker JV. Psychiatric diagnoses in adolescent sex offenders. J Amer Acad Child Adolesc Psychiatry 1988; 27:241-243.

47. DuPaul GJ. Parent and teacher ratings of ADHD symptoms: Psychometric properties in a community sample. J Clin Child Psychology 1991;20:245253.

48. Findling RL, Schwartz MA, Flannery DJ, Manas MJ. Venlafaxine in adults with attention deficit hyperactivity disorder: An open clinical trial. J Clin Psychiatry 1996;57:184-189.

49. Ward MF, Wender PH, Reimherr FW. The Wender Utah Rating Scale: An aid in the retrospective diagnosis of childhood attention deficit hyperactivity disorder. Am J Psychiatry 1993;150:885-889.

50. Connors CK. Attention deficit hyperactivity disorder: Assessment and treatment for children and adolescents. Toronto, Ontario, Canada: MultiHealth Systems, 1994.

51. 't Hart-Kerkhoffs LA, Jansen LM, Doreleijers TA, Vermeiren R, Minderaa RB, Hartman CA. Autism spectrum disorder symptoms in juvenile suspects of sex offenses. J Clin Psychiatry 2009;70:266-272.

52. Cochrane RE, Grisso T, Frederick RI. The relationship between criminal charges, diagnoses, and psycholegal opinions among federal pretrial defendants. Behav Sci Law 2001;19:565-582.

53. Blanchard R, Watson MS, Choy A, Dickey R, Klassen PE, Kuban M, et al. Pedophiles: Mental retardation, maternal age, and sexual orientation.

Arch Sex Behav 1999;28:335-350.

54. Hartman CA, Luteijin E, Serra M. Refinement of the Children's Social Behavior Questionnaire (CSBQ): An instrument that describes the diverse problems seen in milder forms of PDD. J Autism Dev Dis 2006;36:325-342.

261

Isr J Psychiatry Relat Sci - Vol. 49 - No 4 (2012)

History of Abuse and Organic Difficulties in a Convenience Sample of 46 Ultra-orthodox Males with Pedophilia Eliezer Witztum, MD,1 Netzer Daie, MA,2 Ayala Daie-Gabai, PhD,3 and Ariel Rosler, MD4 1

Mental Health Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel Senior Clinical Psychologist, Private Practice, Mevaseret Zion, Israel 3 The Jerusalem Center for Mental Health, Mental-Health Clinic, Maale Adumim, Israel 4 Hadassah Hebrew University Medical Center, Former Head of the Division of Endocrinology at Mount Scopus Hadassah Hospital, Jerusalem, Israel 2

Abstract Background: Evidence has started to accumulate that relates pedophilia to a history of being a victim of sexual abuse as well as to comorbidity with organic vulnerabilities. During a naturalistic study regarding treatment of pedophilia, the authors had access to clinical and psychodiagnostic evaluations of Israeli Jewish ultraorthodox male pedophiles outside the forensic system.

Using psychiatric examination as well as a battery of psychological tests, presence of history of trauma as well as comorbidity with organic vulnerabilities among this unique sub-group was examined.

Method: This survey was part of a larger scale research on the effectiveness of Decapeptyl injections as treatment for pedophilia. All participants in the original research underwent comprehensive psychological assessment including an extensive clinical interview as well as psychological tests (Bender, Rorschach and TAT). Of the patients participating in the research, this survey focused on the group of 46 ultra-orthodox male pedophiles. Cross-tabs analyses were conducted in order to examine prevalence of history of trauma and organic vulnerabilities in this specific group.

Results: Based on self reports combined with corroborating reports (obtained from parents, educators and medical staff), together with indications in psychological tests, we found that 82.6% of participants

Address for Correspondence:

262

were victims of sexual trauma as children and 87% suffer from some kind of organic vulnerability (learning disabilities, disinhibitions, etc.).

Limitations: Limitations of this small convenience sample that influence ability to generalize are discussed.

Conclusions: The current survey indicates that in this sample, the ultra-orthodox male pedophile was frequently a victim of childhood sexual trauma, and exhibited indications of organic vulnerabilities. This is more pronounced than findings in previous studies, and calls for further research in order to understand the underlying causes.

This survey was part of a study that was approved by an Institutional Ethics Committee of the Ezrat Nashim Hospital in Jerusalem, and written informed consent was obtained from all patients.

Sexual abuse in the ultra-orthodox community is a serious and under-researched phenomenon. This community tends to keep such instances secret and often forensic systems are not even aware of them. In particular, the clinical risk factors that lead individuals in this community to engage in pedophilic behavior are poorly understood. The aim of this paper was to portray clinical characteristics of a convenient sample of ultra-orthodox males who meet criteria for pedophilia.

Professor Eliezer Witztum, 4 Revadim St., Jerusalem 93391, Israel

  email elyiit@actcom.co.il

Eliezer Witztum et al.

The ultra-orthodox Jews (the Haredim) Ultra-orthodox Jews (Haredim) constitute about 250,000 to 350,000 of Israel’s Jews. Ultra-orthodox Jews are characterized by their commitment to the study of the Torah and Talmud in yeshivas (religious academies) and by strict adherence to the Jewish law, the Halachah (“the way”). Haredim are distinguished from other Israeli Jews by their clothes. They wear modest clothing which covers most parts of the body; women wear a head covering; this may range from a kerchief over a shorn head for the most extreme to a wig for those less so. They live in segregated neighborhoods and send their children to their own schools, thus excluding people who do not share their values and lifestyles (1).

The ultra-orthodox Jews and sexuality

The Haredim follow a puritan way of life, maintaining strict separation between the sexes from an early age.

Men are the carriers of the religious traditions while women are responsible for the household and, in many instances, become the breadwinners of the family. Boys are enrolled at the age of three in the heder (kindergarten) where they are taught to read and study religious texts (2). From infanthood the sexes are educated separately, while from age 6 they socialize separately.

Social mixing between the sexes is discouraged, and even after marriage, men will often be careful not to speak to women other than their wives.

The Haredim are also overwhelmingly endogamous, and marriages are arranged by the parents of the bride and groom (3). Introductions for marriage are arranged by parents. In some sections of ultra-orthodox society the couple meet only once before they marry, and rarely more than 4–5 times. They will meet under supervision and will only be allowed to converse with each other.

The decision to marry rests with the young couple (2).

It is important to distinguish the concepts of the sexual act and reproductive act. While in the first, the goal is pleasure and satisfaction; in the latter, the first and primary goal of ejaculation is to achieve pregnancy.

According to the Jewish Halacha (way of life) husband and wife are permitted to commit the reproductive act only, and only during the period of time when the woman is not menstruating. As a result, there are relatively long periods of time in which the religious man is not allowed to touch his wife, let alone achieve sexual intimacy or relief.

Jewish males are supposed to refrain from “destruction of seed” (masturbation) based on interpretations of biblical verses. This transgression has been equated with the taking of human life, as the potential for life has been destroyed. Explication of “destruction of seed” has generated considerable discussion from early Talmudic times through the present, and contemporary rulings have their roots in the earlier, precedent-setting interpretations (4). Masturbation is therefore strictly forbidden and considered a serious sin.

Ultra-orthodox adolescents live in boarding schools with all-male populations, are not given sexual education until marriage, and are under a severe prohibition against any sexual relief. Most youngsters are not familiar at all with inter-gender sexuality and some are exposed to temptation and seduction from other males.

The young males may be aroused sexually without realizing that their experiences may be prohibited.

Clinical reports support the assumption that sexual exposure and presence of an all-male environment in high school and religious seminaries set the stage for young boys’ exposure to sexual abuse by older boys.

These behaviors in turn might be repeated when the younger boys reach the age of the older boys.

Overview

Some psychotherapists who treat sex offenders against children appear to adhere to the theory that pedophilia, or at least an individual’s proneness to sexually offend in adulthood, is caused by the offender’s having himself been sexually abused in childhood (5, 6). The clinical and research literature suggests that having experienced childhood sexual abuse may increase the likelihood that males will later commit sexual offenses (7), or in other words a history of childhood abuse is a predisposing factor in many who abuse others in later life (7). Garland and Dougher (8) coined this “the abused abuser hypothesis.”

Some support for this hypothesis had been found.

Freund, Watson, and Dickey (6), for example, analyzing self-reports of pedophiles, found that the proportion of sexual abuse in childhood was larger than for nonperpetrators. Freund and Kuban (5) also found that self-report of having been sexually abused in childhood is mainly connected with pedophilia (compared to non-pedophilic perpetrators). Lee and colleagues (9) report childhood sexual abuse as a risk factor for paraphilic behaviors, and specifically pedophilia. Lisak and colleagues (10) found that 70% of all perpetrators reported some sort of childhood abuse.

263

History of Abuse and Organic Difficulties in Ultra-orthodox Males with Pedophilia

The main problem of this hypothesis is that it is based on retrospective self-reports, and in particular on such reports of accused or charged sex offenders against children. In this situation, as explained below, self-reports may not be very dependable (7).

In attempts to address this limitation of self-reports, Glasser and colleagues (11) focused on a mostly clinical sample rather than perpetrators standing trial, thus minimizing the patients’ interest in altering their self-reports.

They reported from a retrospective review of 843 subjects attending a specialist forensic psychotherapy center, that males (but not females) who had been a victim of sexual abuse were more likely to become perpetrators.

Another interesting finding is that many of the sexual perpetrators suffer from varying cormorbidities. Kafka and Hennen (12) consecutively evaluated outpatient males with paraphilias and paraphilia-related disorders for developmental variables and DSM-IV-TR (13) disorders. The prominent comorbidities were mood disorders, especially early onset dysthymic disorder and major depression; anxiety disorders, especially social phobia; and substance abuse, especially alcohol abuse. Harsch and colleagues (14) similarly found high prevalence of substance abuse, paraphilias, sexual dysfunction, mood disorders, anxiety disorders, somatoform disorders and adjustment disorders in a sample of sexual offenders in forensic psychiatric departments.

In addition to psychiatric comorbidities, many have also reported increased organic vulnerabilities among sexual perpetrators. Kafka and Hennen (12) found that 35.8% of their sample met criteria for retrospectively diagnosed attention deficit hyperactivity disorder (ADHD) and this was statistically associated with paraphilia-status. According to Craig and Hutchinson (15) due to methodological differences between studies, the prevalence of sexual offending by men with learning disabilities is not clear, but some studies found slightly higher prevalence rates of sexual offending among individuals with learning disabilities (up to two times higher). These offenders also start offending at an early age, had a history of multiple offences and a tendency to re-offend (up to 6.8 times more than non-disabled sexual offenders), and tended to commit sexual and arson offences. Hodgins (16) reported that offenders with learning disabilities were more likely to commit a violence offence, including rape and molestation compared to non-learning disabled offenders. It is important to note that much of the research on prevalence rates has relied on data from prison populations and does 264

not taken into account individuals diverted from the criminal justice system.

There is also considerable evidence to suggest people with learning disabilities are in fact at higher risk of being sexually abused: Prevalence rates vary enormously, but range from 8% to 95%, depending upon definitions used (17). It is possible that children with organic vulnerabilities, such as ADHD or learning disabilities are more at risk to be sexually abused. Ouyang and colleagues (18), for example, found that childhood ADHD symptoms were associated with self-reported child maltreatment.

The current survey

As part of a large scale study on the effectiveness of Decapeptyl injections as treatment for sexual urge dysfunctions, patients underwent comprehensive psychological assessment including psychiatric evaluation, extensive clinical interview and psychological tests.

Focusing on Jewish ultra-orthodox participants, the aim of the current survey was to give a detailed report of the findings in this unique sub-group, and surmise as to their possible meanings and explanations.

Method Participants

Jewish ultra-orthodox male pedophiles (N=46) who were referred for clinical evaluation by ultra-orthodox community leaders with no connection to the forensic system. They underwent comprehensive psychological assessment including psychiatric evaluation, extensive clinical interview and psychological tests in order to assess their physical and mental fitness for treatment with Decapeptyl injections.

Procedure

All participants in this study volunteered and signed an informed consent form, and were assessed in order to examine their fitness to the study. All assessments were conducted before any treatment was initiated. Each participant was assessed within the first month of being referred.

All participants went through psychiatric evaluation conducted by the first author (EW) who is a psychiatrist who specializes in paraphilias. Following this evaluation they underwent clinical interview and psychological tests by the second author (ND) who is a clinical psychologist who specializes in paraphilias. All evaluations were conducted by the same psychologist, alleviating

Eliezer Witztum et al.

the possibility of the data contaminated by interviewer differences. All data were scored immediately after assessment in order to decide whether the participant can be treated with Decapeptyl. As the data were collected as part of a different study, there was no bias of the hypotheses on the collection process.

Measures

All participants completed the Bender Visual Motor Gestalt Test (19), Rorschach test (20), and Thematic Apperception Test (TAT) (21). Of the psychological tests applied, while there is no validation to the TAT test, there are acceptable scales for the Rorschach test (22) and the Bender-Gestalt test (23). In addition, we conducted qualitative analysis of the content of the Rorschach and TAT. It is important to note that expert opinion based on qualitative projective testing is admissible in Israeli criminal courts.

The Bender Visual Motor Gestalt Test (19): A test used to evaluate neuropsychological impairment as well as emotional indicators. The test consists of nine figures, each appears on a card. The subject is shown each figure and asked to copy it onto a piece of blank paper. The subject’s designs are then rated on their relative degree of accuracy and overall integration.

In the current study, we scored the Bender based on Marley’s scoring system (23).

The Rorschach Test (20): A projective test consisting of a set of 10 bilaterally symmetrical inkblots. Subjects are asked to tell the examiner what the inkblots remind them of. The interpretations on Rorschach data can provide information on variables such as motivations, response tendencies, cognitive operations, affectivity, and personal and interpersonal perceptions. In the current study, we scored the Rorschach based on comprehensive scoring systems (22, 24) as well as on dynamic clinical analysis (20, 25).

The Thematic Apperception Test (TAT) (21): A projective technique consisting of a series of 20 ambiguous pictures. The examinee is requested to create a story of what is occurring in each picture; the thoughts and feelings of the characters; the events that led up to the situation; and the outcome of the story. The examiner can interpret the responses either quantitatively (using rating scales to measure intensity, duration, and frequency of needs) or qualitatively (evaluating the story themes using clinical judgment). The interpretations reveal some of the dominant drives, emotions, sentiments, complexes, and conflicts of personality. The results are typically used to

supplement other psychological tests because the TAT produces not only highly rich, varied, and complex types of information, but also personal data (i.e., subject’s inner reality) that is theoretically being projected onto the stimulus. In the current study, we analyzed the TAT qualitatively (see results section for examples).

Definition of Variables Sexual Trauma

Sexual trauma was defined as sexual exposure to an adult as a child, including various types of sexual interpersonal exposure, such as the touching of sexual organs, fondling, kissing each other on the mouth. These acts are considered a violation of sexual modesty among ultra-orthodox Jews, and therefore are experienced as sexual offenses.

Indication of history of sexual trauma was based on the following: 1. The participant reported in the clinical interview an occurrence of sexual abuse by an older male followed by a change in affect, behavior, academic achievements and frequently sexual preference. For example, one participant was abused at the age of 13, and reported in the interview that he was interested in girls until the age of 13, and after he was forced to perform oral sex with an older male, he started to be sexually excited by men.

2. Contents of sexual assault appeared in the TAT. For example: “He raped her and she died” in card 13FM; “The child is asleep and an old man comes to molest him” in card 12M; “They did something bad to this child (what?) they touched his genitals and he is sad and crying” in card 3BM; “This child is dreaming of taking the rifle and killing the one who abused him” in card 8BM. 3. A combination of the following in the Rorschach Test: at least two anatomic responses (An); one or more blood responses (Bl); one or more sex responses (Sx); and content responses such as “two males are doing it, there is a lot of blood and pain” for card II (W response) or “A huge man with a huge genital threatening ‘take this card from me’” for card IV (W response) or “This is an ass and a penis rubbing against it” for Card VI (D1+D2).

Organic vulnerability

Organic vulnerability was defined as the presence of: learning disabilities or ADHD; perseverations and 265

History of Abuse and Organic Difficulties in Ultra-orthodox Males with Pedophilia

disinhibition; or the combination of these. Indications of organic vulnerability were based on combined information from the clinical interview and the Bender Visual Motor Gestalt Test.

Learning disabilities were determined based on one of the following in participant’s history: • Self or parent report of an existing diagnosis (based on neurological, psychological or didactic assessment); • Self-report of learning difficulties in childhood or adolescence following head trauma; or self-report of changing schools due to learning or concentration difficulties.

protocol stage; The presence of at least one contamination in memory stage; The presence of one or more rotations in either stage of the test; or the presence of one or more retrogressions in either stage of the test.

Disinhibition was defined based on The Bender Visual Motor Gestalt Test (Marley’s criteria of retrogression and collision - 23) as well as on the Rorschach contents of fire, blood, explosion and the determinant of pure color (C).

For example, when a participant reported a bicycle accident including head injury at the age of five, and there were indications of impulsivity and perseveration in the Bender-Gestalt Test, indication of organic vulnerability was marked as positive.

Perseveration and disinhibition

Analysis

Learning disabilities

Perseveration and disinhibition were accompanied by history of head trauma in childhood. Participants reported head trauma occurring in childhood (such incidents as falling from bicycles or in the playground and hitting the head on a sharp metal object). Frequently, these reports were accompanied by clear scars or history of hospitalization or both.

In addition to this self-report, the following indications had to appear: For perseveration, the subsequent Bender criteria (based on Marley’s scoring system - 23): Confused sequence, including three or more changes in direction; Presence of collision (when one or more of the figures touch each other) in either stage of the test (protocol stage or memory stage); More than two instances of angulation; The presence of two or more type B perseverations, or one or more type C perseveration, or both; The presence of two or more line extension in

Prevalence of different variables was established by calculating the percentages of participant exhibiting said variable. Analysis of the relationship between age of participant when sexually traumatized and age of victim was done using Pearson correlational analyses.

Results Demographics

Participants’ ages ranged from 15 to 42 (Mean=33.87, SD= 14.0), 50% of participants were single, 39% were married, and 11% were divorced.

Diagnosis and comorbidity

All participants were diagnosed as pedophiles according to DSM-IV-TR; 54% of participants had one additional

Graph 1: Comorbidity Personality Disorder Affective Disorder Other Sexual Disorders PTSD Psychosis Addiction 0

266

1

2

3

4

5

6

7

8

Eliezer Witztum et al.

DSM-IV-TR diagnosis, while 13% had more than one additional diagnosis, as presented at Graph 1.

Of the current sample, 35 individuals, constituting 76%, reported a history of sexual trauma as children.

All participants were assaulted by ultra-orthodox males.

However, when indicators of trauma from psychological tests were added to the picture (see definition of variables under method for details), it seems that this percentage is as high as 82.6% (n=38) as can be seen in Table 1.

learning disabilities: an existing diagnosis of learning disabilities was reported by 34.7% (n = 16) of participants and 19.6% (n = 9) reported learning difficulties in childhood or adolescence following head trauma or changing schools due to learning or concentration difficulties. Indications of perseverations and disinhibition in psychological tests were also examined (according to criteria specified in the Method section), as displayed in Table 2. When adding all reports and indications, it seems that 87% (n = 40) of participants have some organic vulnerability.

Table 1: Previous history of trauma

Table 2: History and indications of organic vulnerability

Previous history of trauma

Indications of trauma in psychological tests

Report of sexual trauma Present

Absent

Total

Present

58.7% (27)

6.5% (3)

65.2% (30)

Absent

17.4% (8)

17.4% (8)

34.8% (16)

Total

76.0% (35)

23.9% (11)

100% (46)

Correlation between ages of assault for perpetrator and victim

Participants’ victims’ ages ranged from 4 to 21. The age of perpetrators’ assault and the age of their victims significantly correlated (r=0.36), as shown in Graph 2.

When participants had more than one victim, we used the age of the youngest victim.

Organic vulnerabilities

Table 2 offers information regarding organic vulnerabilities. As can be seen, 54.3% reported a history of Graph 2: Correlation between ages of assault for perpetrator and victim

Minimum Age of Victims

25 20 15 10 5 0

0

5 10 15 Age of participant at the time sexual trauma accurred

20

Indications of perseveration and disinhibition in the tests

Report of learning disabilities Present

Absent

Total

Present

32.6% (15)

13% (6)

46% (21)

Absent

41.3% (19)

13% (6)

54% (25)

Total

54.3% (34)

26% (12)

100% (46)

Discussion The aim of the current survey was to examine and characterize a group of Jewish ultra-orthodox male pedophiles who were encountered during assessment for treatment. The current data offered two main findings.

First, a very high percentage of childhood abuse was found among ultra-orthodox pedophilic participants.

This finding was in accordance with previous studies (4-6, 9, 11) and the “abused-abuser” theory (8). Second, the findings indicated a significant correlation between the age of participants at time of being sexually assaulted and the age of their victim, which further supported the "abused-abuser" theory. Regarding other comorbidities (both Axis I and Axis II) the current findings were similar to those found in the literature (26).

In this sample of Jewish ultra-orthodox, childhood sexual abuse was found to be quite high among pedophiles relative to other published reports (5-10) and there are several possible explanations. The first possible explanation is that this survey used a broader definition of abuse, encompassing various types of sexual interpersonal exposure, such as the touching of sexual organs, fondling, kissing each other on the mouth. These acts are considered a violation of sexual modesty among ultra-orthodox Jews, and therefore are experienced as sexual offenses.

267

History of Abuse and Organic Difficulties in Ultra-orthodox Males with Pedophilia

A second explanation regards the uniqueness of the sample. The participants were ultra-religious, meaning they live in a very conservative, authoritarian and unisex environment from early childhood up to their marriage (2, 27). It is possible this environment raises the odds of engaging in same-sex relationships as well as of being abused by same-sex older perpetrators. Another unique aspect of this sample is that perpetrators were referred mostly by religious leaders of the community or as self-referrals for assessment and treatment. Usually ultra-orthodox will go to great lengths not to expose sexual issues to the police, welfare or the general public.

The first authors have worked with this community for many years and, as a result, were exposed to a wide spectrum of sexual problems in this population. This is somewhat different from previous literature that focused mostly on forensic cases. It is also possible that this sample may simply have had a higher prevalence of childhood abuse compared to other populations, and this should be examined in further studies.

A third possible explanation is linked to the second finding – that for many participants (87%) indications were found for some type of organic vulnerability (learning disabilities, ADD/ADHD, disinhibition, etc.), that might have put them at further risk for childhood abuse. The percentage of organic vulnerabilities in the current sample was in accordance with other findings in the literature (12, 18). One possible interpretation of the current results would be that they suggest people with organic vulnerabilities may be at a significant risk to develop pedophilia. It is possible that these individuals are by definition compromised in their impulse control, judgment and self-regulation and may have more difficulties inhibiting inappropriate sexual impulses. Likewise, their organic vulnerabilities may impair their interpersonal skills, rendering younger children more attractive to them as either emotional or sexual partners. This assumption should be examined in further researches.

However, another way of interpreting the results is that they indicate a more complex picture. It is possible that children with organic vulnerabilities are more prone to being abused (an assumption that has some support in the literature - see 12, 28) and being a victim of sexual abuse thereby increases the likelihood of becoming a perpetrator as an adult, in accordance with the “abused-abuser hypothesis” (8). It would be helpful to further study the issue of organic vulnerabilities and exposure to childhood abuse.

268

It is important to note the socio-cultural characteristics of the current sample. It consists of ultra-orthodox males who grew up in a learning culture that emphasizes discipline, studying and concentration, with a certain lack of tolerance for those who do not follow the common route (2, 3). The ultra-orthodox educational system does not include an educational consultant or psychologist, and children with difficulties are often sent outside the classroom. From the clinical interviews conducted in this survey, some of the participants indeed reported spending long hours as children outside the classroom or school, thus leaving them more exposed to perpetrators.

Again, this assumption should be further examined.

The current study has several limitations that should be noted. First, the sample used was a convenience sample of perpetrators referred by religious leaders and selfreferrals, and we cannot be certain how representative this sample is of the larger perpetrator population. It is possible that perpetrators who were not referred are different in their history or characteristics, but it is practically impossible to reach this population. Second, the sample was relatively small. However, it is difficult to collect large samples of such a unique population. These limitations decrease ability to generalize from the current study. Therefore, the findings should be interpreted with caution, and the study should be replicated in a larger sample of perpetrators. Third, our data base was a clinical data base, and clinical measures were used that arouse some criticism at times. However, according to Archer and colleagues (29), although there have been some concerns regarding the use of traditional clinical measures in forensic assessment, such tests are widely accepted. Specifically, this statement is valid in the Israeli forensic system. In response to such possible criticisms it should also be noted that the current survey included an integration of information from several clinical tests and combined them with a thorough clinical evaluation of each participant’s history conducted separately by two veteran professionals (a psychiatrist and a clinical psychologist). Such combination and cross validation of information from several sources improves diagnostic abilities (30).

Despite these limitations, the current survey is unique in that it is the first report and characterization of Jewish ultra-orthodox male pedophiles in a non-forensic context. As such, this survey has important educational and therapeutic implications. Specifically, it contributes to the better understanding of specific risk factors for pedophilia and their combination among ultra-ortho-

Eliezer Witztum et al.

dox male perpetrators, thus offering a chance to make a difference in this society. Hopefully mapping these risk factors, and specifically the connection between history of trauma and inflicting such trauma on others, will crack the taboo, secrecy and denial surrounding sexual abuse in the ultra-orthodox society, bring ultraorthodox leaders to pay more attention to victims’ complaints, and be the first step towards breaking this vicious cycle. Early identification of at-risk population will also enable to build appropriate educational systems and offer therapy for children who have been exposed.

References 1. Witztum E, Goodman Y. Narrative construction of distress and therapy: A model based on work with ultra-orthodox Jews. Transcultural Psychiatry 1999; 36:403-436.

2. Greenberg D, Stravynski A, Bilu Y. Social phobia in ultra-orthodox Jewish males: Culture-bound syndrome or virtue? Mentl Health, Religion Culture 2004; 7: 289-305.

3. Heilman S, Witztum E. Value-sensitive therapy: Learning from ultraorthodox patients. Am J Psychother 1997; 51:522-541.

4. Ribner D Ejaculatory restrictions as a factor in the treatment of Haredi (Ultra-orthodox) Jewish couples. Arch Sex Behav 2004; 33:303-308.

5. Freund K, Kuban M. The basis of the abused abuser theory of pedophilia: A further elaboration on an earlier study. Arch Sex Behav 1994; 23:553-563.

6. Freund K, Watson R, Dickey R. Does sexual abuse in childhood cause pedophilia: An explanatory study. Arch Sex Behav 1990;19:557-568.

7. Romano E, De Luca RV. Male sexual abuse: A review of effects, abuse characteristics, and links with later psychological functioning. Aggress Violent Behav 2001;6:55-78.

8. Garland R, Dougher M. The abused/abuser hypothesis of child sexual abuse: A critical review of theory and research. In: Fierman J, editor.

Pedophilia: Biosocial dimensions. New York: Springer-Verlag, 1990: pp. 488-509.

9. Lee JK, Jackson HJ, Pattison P, Ward T. Developmental risk factors for sexual offending. Child Abuse Negl 2002; 26:73-92.

10. Lisak D, Hopper J, Song P. The relationship between child abuse, gender adjustment and perpetration in men. J Trauma Stress 1996; 9:721-743.

11. Glasser M, Kolvin I, Campbell D, Glasser A, Leitch I, Farrelly S. Cycle of child sexual abuse: Links between being a victim and becoming a perpetrator. Br J Psychiatry 2001;179:482-494.

12. Kafka MP, Hennen, JA. DSM-IV axis I comorbidity study of males with paraphilias and paraphilia-related disorders. Sex Abuse 2002;14:349-366.

13. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (4th ed. TR). Washington, DC: American Psychiatric Association, 2000.

14. Harsch S, Bergk JM, Steinert T, Keller F, Jockusch U. Prevalence of mental disorders among sexual offenders in forensic psychiatry and prison. Int J Law Psychiatry 2006; 26:443-449.

15. Craig LA, Hutchinson RB. Sexual offenders with learning disabilities: Risk, recidivism and treatment. J Sexual Aggression 2005; 11:289-304.

16. Hodgins S. Mental disorder, intellectual deficiency, and crime: Evidence from a birth cohort. Arch Gen Psychiatry 1992; 49:476-483.

17. Peckham NG. The vulnerability and sexual abuse of people with learning disabilities. Br J Learn Disabil 2007; 35:131-137.

18. Ouyang L, Fang X, Mercy J, Perou R, Grosse SD. Attention-deficit/ hyperactivity disorder symptoms and child maltreatment: A populationbased study. J Pediatr 2008; 153:851-856.

19. Bender L. A visual motor gestalt test and its clinical uses (Research Monograms No. 3). New York: American Orthopsychiatric Association, 1938.

20. Rorschach H. Psychodiagnostik (Hans Huber Verlag, Trans.). Bern, Switzerland: Bircher, 1941 (Original work published 1921).

21. Murray HA. Thematic Apperception test manual. Cambridge, Mass.: Harvard University, 1943.

22. Exner JE. A Rorschach workbook for the comprehensive system (5th ed). Asheville, N.C.: Rorschach Workshops, 2000.

23. Marley ML. Organic brain pathology and the Bender-Gestalt test: A differential diagnostic scoring system. New York: Grune & Stratton, 1982.

24. Small L. Rorschach location and scoring manual. New York: Grune & Stratton, 1956.

25. Piotrowski ZA. A Rorschach compendium: Revised and enlarged.

Psychiatr Q 1950; 24:543-596.

26. Cohen LJ, Galynker II. Clinical features of pedophilia and implications for treatment. J Psychiatr Pract 2002;8:276-289.

27. Greenberg D, Witztum E. Sanity & sanctity: Mental health work among the Ultra-Orthodox in Jerusalem. London: Yale University, 2001.

28. Green G, Gray NS, Willner P. Factors associated with criminal convictions for sexually inappropriate behaviour in men with learning disabilities.

J Forens Psychiatry 2002;13:578-607.

29. Archer RP, Buffington-Vollum JK, Vauter Stredny R, Handel RW. A survey of psychological test use patterns among forensic psychologists.

J Pers Assess 2006; 87:84-94.

30. Finkelhor D, Browne A. Initial and long-term effects. In: Finkelhor D, editor. A sourcebook on child sexual abuse. Beverly Hills: Sage, 1986.

269

Isr J Psychiatry Relat Sci - Vol. 49 - No 4 (2012)

Victim and Victimizer: The Role of Traumatic Experiences as Risk Factors for Sexually Abusive Behavior Lucinda A. Rasmussen, PhD, LCSW School of Social Work, San Diego State University, San Diego, California, U.S.A.

Abstract The Victim to Victimizer paradigm purports to explain the connection between being a victim of sexual abuse and becoming a perpetrator, attributing sexually abusive behavior to a predictable cycle of cognitive distortions and self-destructive and/or abusive behaviors.

Integration of two ecological models, Trauma Outcome Process Assessment and Family Lovemap provides a more comprehensive explanation of salient contributors to sexually abusive behavior in youth (i.e., trauma). A case example illustrates the parallel Trauma Outcome Process in a victim, and the victim’s perpetrator, identifying protective factors beneficial for trauma recovery.

Two decades ago a paradigm was proposed purporting to explain why juveniles offend sexually: “Victim to Victimizer” (1). Its premise: both offenders and victims have “issues of power and control” that for the victim may be “the outcome of abuse” and for the offender “triggers for offending.” Traumatic situations post victimization trigger “a progression of thoughts and feelings” which for some victims involves “a dysfunctional response cycle” (e.g., drug/alcohol abuse, eating disorders and suicide attempts). Others (those who become offenders) enact a “sexual assault cycle” (i.e., “a predictable pattern of negative feelings, cognitive distortions, and control seeking behaviors” leading to a sexual offense) (1, pp. 328-329). “Victim to Victimizer” became a popular term describing this purported link between prior sexual abuse and youthful sexual offend-

ing. Although “there is widespread belief in a ‘cycle’ of child sexual abuse, there is little empirical evidence for this belief ” (2, p. 482).

A more encompassing paradigm is the Trauma Outcome Process Assessment (TOPA) model (3-7).

In TOPA, outcomes of sexual abuse and other abusive trauma and subsequent behavioral responses (i.e., selfvictimization and/or abuse) are viewed as a multidimensional process, intrinsically influenced by a priori risk and protective factors in key ecological domains (i.e., neuropsychological elements, family history and dynamics, community and cultural context). TOPA goes beyond the Victim to Victimizer paradigm by including a “recovery” response involving salient predisposing variables present prior to trauma (i.e., self-awareness, protective factors mitigating negative outcomes). It is congruent with another ecological model, Family Lovemap (8, 9), and both models are consistent with validation findings on the MEGA risk assessment tool for youth ages 4-19 years (10-12).

Challenging the Victim to Victimizer Paradigm Examining the hypothesized connection between prior sexual abuse and current sexual offending is daunting, given little prospective research has followed samples of sexual abuse victims over time. Studies have found sexually abused children have a significantly higher percentage of sexualized (not abusive) behaviors than normative samples (13, 14). Engaging in sexualized behavior does not necessarily imply increased risk for sexually abusive behaviors, and most victims of sexual abuse do not become offenders. The Victim to Victimizer

Address for Correspondence: Lucinda A. Rasmussen, PhD, LCSW, School of Social Work, San Diego State University, 5500 Campanile Drive, San Diego, CA 92182-4119, U.S.A. lucindarasmussen@cox.net

270

Lucinda A. Rasmussen

Figure 1. Trauma Outcome Process Assessment (TOPA Model) © 2010, L. Rasmussen, Ph.D., LCSW

A Priori Risk & Protective Factors Neurobiological, Family Dynamics, Ecological & Cultural

Recovery & Integration

Safety Trauma Outcomes Self-perceptions Self-regulation Neurobiological

SelfAwareness & Choice

Trigger

Abuse Self Victimize Denial

paradigm may inadvertently support the misconception that all sexual abuse victims are prone to developing sexually abusive behavior (15). This in turn may subject victims to unfounded accusations related to subsequent behaviors, eroding their self-esteem and increasing likelihood of negative outcomes.

Concepts of social learning theory (i.e., modeling [by a perpetrator] and reinforcement [for rule breaking]), along with classical conditioning (related to orgasm), provide a more viable explanation for a youth’s sexually abusive behaviors, both the initial act and a continued pattern (16). Social learning theory takes into account the multiple factors influencing whether a sexual abuse victim will become abusive, including specific behaviors that are modeled for the youth, then learned and reinforced. Those few victims who go on to become sexually abusive may tend to mirror their perpetrators, engaging in behavior that “replicates the offender’s own experience of abuse” (2, p. 482). A study of male adolescent sexual abusers with histories of childhood sexual abuse found they were likely to utilize similar methods when sexually abusing their victims as their perpetrators had used when molesting them (e.g., babysitting, giving favors, making threats, using physical force) (16), thus supporting a social learning paradigm.

Gender must be considered when considering the dynamics involved in a victim becoming a victimizer.

Girls are much more likely to have experienced multiple sexual victimizations at younger ages (17), yet girls account for only 2 to 10% of reported juvenile sex offenses (18). Biological (as opposed to environmental) risk factors may better explain the difference between males and females, whether the individual manifests sexually abusive behavior as a youth or eventually develops a paraphilia as an adult. The late sexologist Dr. John Money asserted: “the biological complexities of becoming male, coupled with other crucial developmental events, may contribute to the organism’s developing a paraphilia later” (as cited in 8, p. 93).

Although laudable in its attempt to explain behavior of sexually abused youth who become sexually abusive, the Victim to Victimizer paradigm frankly falls short in the face of the innumerable victims who, in fact, never perpetrate a sexual crime (9). The key question is: what is different about those victims that go on to sexually abuse others? A large descriptive study (N = 656, 72% of whom were youth) provides informative clinical data. Findings showed sex offenders who were previously victims of sexual abuse experienced significantly more life stressors than those without such histories (i.e., divorce/separation, trouble with the law, trouble with the law because of sex, hospitalization, hospitalization due to psychiatric illness, sex difficulties, change in residence, relationship difficulties, and school difficulties). They were also significantly more likely to have a family member who committed suicide or aggression toward others or to come from families in which a member tried to kill someone (19).

“Victims” who perpetrate sex offenses are different kinds of victims. Some do horrendous, vicious, violent, heinous, cruel things to other humans, even though they themselves may have endured such trauma. The society at large does not want to recognize these individuals as victims. They are rightly called perpetrators, as they absolutely are, but they are also victims….distinctly different from other victims. There is something about this kind of victim that may explain why they become sexual perpetrators. TOPA attempts to answer this question.

Differentiating Responses to Sexual Victimization: The TOPA Model The ecologically based Trauma Outcome Process Assessment (TOPA) model presumes individuals have different behavioral pathways they may take subsequent 271

Victim and Victimizer

to a traumatic experience; two maladaptive (i.e., Selfvictimization and Abuse) and one adaptive (i.e., Recovery and Integration) (see Figure 1). The Victim to Victimizer paradigm considers only the individual’s deficits that potentially lead to dysfunctional and abusive behaviors.

TOPA, on the other hand, affirms resilience in the face of daunting challenges, both acute and ongoing. Many victims cope effectively with their abuse and are neither self-destructive nor sexually abusive. Protective factors (e.g., family support, positive influences in school, work, neighborhood, and community) enable these victims to show “positive adaptation…..despite experiences of significant adversity or trauma” (20, pp. 739-740).

Figure 1 illustrates the Trauma Outcome Process pathway from experiencing a trauma to engaging in maladaptive or adaptive behavior. A priori risk and protective factors within the individual (e.g., inheritable characteristics, neuropsychological elements) and the environment (i.e., family dynamics and community and cultural influences) are represented by the oval shape shown at the top of the Figure. They invariably affect (positively or negatively) outcomes of trauma and the individual’s responses. Trauma outcomes (illustrated by the first circle in the middle of Figure 1) are observed in three areas: self-regulation, expressed self-perceptions, and neurobiological symptoms (e.g., Posttraumatic Stress Disorder [PTSD]). Self-awareness (the second circle) consists of thoughts, feelings, sensations, motivations, and actions (21) and is a key variable in the model.

Impaired self-awareness creates vulnerability to selfdestructive and/or abusive behaviors, both at the time of the traumatic experience, but also to later “trigger events” reminiscent of the trauma.

Trigger events (depicted as a “star” at the bottom of Figure 1) may involve any of the senses (i.e., sight, hearing, smell, taste, touch); as well as actions of others; body states (e.g., hunger); and/or cognitive associations (e.g., the anniversary of a loss). Failing to connect a current trigger event to a past trauma may reflect impaired self-awareness (perhaps associated with a dissociative process), making it more likely the individual will follow a maladaptive pathway. The three behavioral pathways of the Trauma Outcome Process are illustrated by the large circles on the right side of Figure 1. The pathways of Self-victimization and Abuse overlap, indicating that an individual can sometimes be self-destructive and abusive at the same time. A circle of “Safety” surrounds Recovery and Integration, signifying a safe environment is needed for trauma to be integrated. In contrast, 272

Self-victimization and Abuse are immersed in “Denial” which in this context is a cognitive distortion used by the individual to try to squash self-awareness. Diminished self-awareness, in a sense, is an oxymoron. Although self-awareness may be impaired, it is impossible to not have some degree of self-awareness.

A well-known case of brutal sexual abuse that occurred in the United States helps demonstrate differences between victims who become sex offenders and victims who are “victims only,” as well as serves to illustrate the three responses in the TOPA model. The example involves two qualitatively different victims: Elizabeth Smart and Brian David Mitchell. The TOPA model will examine these victims at post-victimization, considering developmental variables that come into play.

Case Example: Overview

At approximately 2 a.m. on June 5, 2002, Elizabeth Smart, age 14, was kidnapped at knifepoint from the bedroom she shared with her 9-year-old sister. According to her testimony at the trial of her abductor (Brian David Mitchell, age 49 at the time of the kidnapping), Mitchell forced her to hike through 4 miles of rough terrain in the hills behind her home until they arrived at his campsite. There (in the consenting presence of his wife) he performed a “marriage ceremony” after which he raped Elizabeth; then shackled her ankle to a heavy metal cable between two trees, where she was tied for 6 weeks (22, 23). Mitchell and his wife Wanda Barzee (age 57 at the time) held Elizabeth captive for 9 months, during which time Mitchell raped her “on a daily basis up to 3 to 4 times” (24, p. 11). Elizabeth reported she was forced to watch Mitchell and Barzee engage in sexual acts, and then repeat them with Mitchell. She claimed Mitchell forced her to drink alcohol, take drugs, and smoke cigarettes, and once allowed her to lie in her own vomit following drinking (22, 23).

Brian David Mitchell, like Elizabeth, also experienced severe trauma as a child. Per the report of his siblings, there was significant parental discord and “all of the children were exposed to physical and verbal abuse” (25, p. 51). In one instance, Brian’s father allegedly beat him with a garden hose (26). His father once left him in an unknown location, several miles from home, telling him that “if he didn’t like where he lived, he could live on his own” (25, p. 51). Brian, about 9 or 10 at the time, borrowed money from a passerby, and found his way home (27). Shadows of this experience were perhaps evident some 37 years later when Brian Mitchell kidnapped

Lucinda A. Rasmussen

Elizabeth Smart and took her to his isolated campsite.

Thus a “victim” became a “victimizer.”

Elizabeth Smart and Brian David Mitchell share many characteristics. Both grew up in Salt Lake City, Utah, in intact two-parent Caucasian families with multiple siblings; and both families were practicing members of the Church of Jesus Christ of Latter Day Saints (Mormons).

As children, both were involved in activities outside of school (i.e., Cub Scouts and Little League for Brian, and playing a musical instrument [harp] for Elizabeth). Both fathers were professionals who dealt with the public, although their professions reflected differences in socioeconomic status. Elizabeth’s father was a successful real estate developer and the Smart family lived in a million dollar home in an affluent area of the city. Brian’s father was a social worker and the Mitchell family frequently changed residences (i.e., living in four or five apartments, with the paternal grandmother, and in a house the father constructed) (27). Despite their similarities, the a priori risk and protective factors of Elizabeth and Brian were distinctively different, perhaps accounting for their divergent outcomes and contrasting behavioral responses post trauma.

Biological and Neuropsychological Risk Factors for Sexually Abusive Behavior

The effects of traumatic experiences on the brain are well documented, affirming the brain is “the organ mediating the adaptive – and maladaptive – responses relating to traumatic stress” (28, p. 1). Negative outcomes of traumatic experiences are integrally linked to neuropsychological risk factors that may include, but are not limited to distorted self-perceptions and impaired selfregulation (29-31). Difficulties in executive functioning often seen in sexual abusers (e.g., attention deficits, poor self-regulation, impulsivity) may have little to do with the “dysfunctional response cycle” (1) of Victim to Victimizer, but rather reflect biological complexities affecting brain functioning, including inheritable characteristics (30, 32). The MEGA risk assessment validation studies found a good percentage of youths in the samples (N = 1184 and N = 1056) had neuropsychological difficulties (e.g., low intellectual functioning, impulsivity, attention problems, learning disabilities), variables found to be associated with risk for coarse sexual improprieties and/or sexually abusive behaviors (10-12). The MEGA research empirically supports the TOPA premise that a priori ecological risk factors are related to the victim to victimizer dynamic. Neuropsychological difficulties

profoundly affect outcomes of traumatic experiences, and as seen in the MEGA data, perhaps relate to an individual’s vulnerability to engage in the Abuse response of the TOPA model.

Many youth develop Posttraumatic Stress Disorder (PTSD) secondary to sexual abuse and other severe traumatic experiences, manifesting clinical symptoms of: (a) reexperiencing (e.g., flashbacks, nightmares, reenacting the trauma); (b) avoidance of cues associated with the trauma; and/or (c) hyperarousal/physiological responses (i.e., increased heart rate, blood pressure, respiration, and muscle tone) (33). Victims who experience symptoms of PTSD typically have difficulties in self-regulating emotions, sometimes alternating between being: (a) emotionally overwhelmed by symptoms of intrusiveness and hyperarousal; or (b) emotionally shut down and detached, as seen in avoidance, numbness, and in some cases dissociation.

Symptoms of PTSD are often part of the TOPA Selfvictimization response and relate to the individual’s awareness of feelings, thoughts, and body sensations associated with a particular trauma (see Figure 1). The Self-victimization response is characterized by problems in self-regulation and distorted self-perceptions including: suppression and avoidance of feelings; possible explosive episodes (directed toward self, not others); deteriorating self-esteem; and self-destructive behaviors (i.e., suicidal gestures or attempts, substance abuse, eating disorders, placing self in dangerous situations) (3, 7).

PTSD is hypothesized to be frequently present for sexually abusive youth who have histories of significant trauma. Rates of prior sexual abuse vary considerably across studies (0 to 80%) but “are almost always found to be higher than the general population” (16, p. 277).

Likewise, up to two thirds have histories of physical abuse and/or histories of domestic violence (34). Hunter asserted, “PTSD in juvenile sex offenders appears to be high and its presence very likely directly or indirectly impacts the behavior and treatment outcomes of afflicted youth” (34, p. 368). However, to date, only one study has provided incidence data of PTSD; of 40 adolescent sex offenders, two thirds met diagnostic criteria for PTSD. For 85% of these youth, triggers for sexual offending were reportedly related to factors associated with their trauma (35).

History of sexual abuse specifically “may play a direct role in the emergence of sexual behavior problems in some youth, and very likely exacerbates the sexual behavior problems of many others.” (34, p. 368). A review of 45 studies comparing sexually abused and non-abused 273

Victim and Victimizer

children found two symptoms consistently differentiated the two groups: sexualized behaviors and PTSD (36). It may be that the two symptoms are interrelated, that is, children who are sexualized may manifest underlying PTSD (intrusive symptoms) which may then manifest as “repetitive reenactment of their victimization experience” (34, p. 368).

Brian David Mitchell. A priori neuropsychological risk factors are evident for Brian Mitchell, whose family history reflects serious mental illness and an obsessive focus on religion. Brian’s paternal grandfather reportedly had a mental disorder and history of psychiatric hospitalization. His father, Shirl Mitchell, reported having unusual spiritual experiences (e.g., hearing a voice when he was a boy saying “You are Christ”) (27). Shirl Mitchell spent over 50 years writing a “1066 page tome” entitled Spokesman of the Infant God or Goddess. He claimed to be the “divine emissary” spoken of in the tome and quit his employment in order to work fulltime on the document (25, p. 51).

Brian Mitchell began to show signs of serious mental illness by age 32, and at age 49, when he kidnapped Elizabeth, Mitchell was a self-proclaimed prophet, unkempt with long beard and dressed in a white robe.

He claimed he was called by God to reform the Mormon Church (referring to himself as Immanuel David Isaiah).

Like his father, he wrote a spiritual manifesto (i.e., the 27-page Book of Immanuel David Isaiah), which contained a purported commandment from God for him to forcibly take “seven times seven” sisters to be his wives.

His obsession with polygamy appears to be the primary motivator for his kidnapping Elizabeth Smart (25, p. 51).

According to the TOPA model, Mitchell’s mental illness put him at risk for distorted self-perceptions (i.e., grandiose religious delusions) and poor self-regulation, and impaired his self-awareness. Evidence of problems in self-regulation is clear in Brian’s history. Shirl Mitchell described his son as physically aggressive to his siblings, frequently truant from school and “isolated…in his own world” (27). As an adolescent, Brian abused drugs and alcohol, which continued throughout his adult life, including during the 9 months when he held Elizabeth Smart captive. At age 16, Brian began to manifest sexually abusive behavior when he was arrested for luring a 4-year-old girl to his home, exposing himself and asking her to touch his penis (25). Brian’s responses to his childhood trauma include behaviors characteristic of the TOPA Self-victimization response (i.e., substance abuse), as well as behaviors that were clearly abusive 274

(i.e., aggression, luring a child, exposing himself, and kidnapping and sexually assaulting Elizabeth Smart).

Elizabeth Smart. There was an absence of psychiatric illness and/or hospitalizations in Elizabeth Smart’s family.

There were no reports that Elizabeth had any problems prior to her kidnapping. She was described as a “kind, smart, shy and obedient child” and “an intelligent and diligent student” (37). Elizabeth was an accomplished harpist, an avocation requiring intense focus, concentration, and the self-discipline of daily practice sessions, thus demonstrating she had a good ability to self-regulate.

She was also skilled in horseback riding and was a long distance runner who was training to compete in crosscountry racing (37), activities that likewise required focus, concentration and self-governance.

At first glance, Elizabeth Smart appears to have escaped having PTSD, self-destructive behaviors or other indicators of the Self-victimization response, despite the terrible nature of her trauma. She did not report any PTSD symptoms (e.g., intrusive thoughts, nightmares, hyperarousal) and, surprisingly, did not avoid cues associated with the horrendous things she endured.

On the night of her rescue from her perpetrators and reunion with her family (after 9 months of captivity), she elected to sleep in the bedroom (and same bed) where she was kidnapped, remarkably telling her family “don’t worry; I’ll be here in the morning” (38). A few weeks after her return home, she hiked with her family to the campsite where Mitchell had taken her and later said, “It felt triumphant!” (38). Elizabeth’s initial comment (“don’t worry; I’ll be here in the morning”) is perplexing.

Does it reflect Elizabeth’s resilience in the face of severe trauma? Does it evidence aspects of family intimacy, that is, Elizabeth’s trust that her parents will protect her?

Or is her comment reflective of denial, that is, lack of self-awareness of the egregiousness of her trauma and its profound emotional effects? Does it represent deficits in Elizabeth’s ability to be self-nurturing, sensitive and attentive to the emotional wounds from her trauma?

Over the years of Elizabeth’s recovery, there were no reports of emotional outbursts, problems with selfesteem, or anger problems or abusive behaviors. On the contrary, in an interview with Oprah Winfrey 6 years after her kidnapping, Elizabeth stated, “I’m doing great. I don’t see myself different than anybody else” (39). Some adult sexual abuse survivors have challenged the validity of Elizabeth’s statements, claiming Elizabeth could not possibly have endured the atrocities she reported (e.g., being raped over 1000 times in a 9 month period) without

Lucinda A. Rasmussen

subsequently showing emotional distress and PTSD symptoms. They speculate Elizabeth has either denied or repressed her feelings (possibilities in the TOPA Selfvictimization response), or is hiding something and lying about what happened to her (40). These survivors assert that Elizabeth’s claim of a relatively quick and purportedly complete recovery (without having therapy) (38) does a disservice to the thousands of rape victims and other sexual abuse survivors who suffer years of emotional pain and PTSD symptoms subsequent to traumas similar to those Elizabeth experienced. The TOPA model would support that it is possible, albeit very rare, for a trauma victim to emerge relatively unscathed from extreme trauma, provided there are protective factors in a priori neuropsychological functioning, family dynamics and community support. However, the TOPA model would also support that it is possible to deny the effects of one’s trauma, to hide or suppress one’s feelings, thereby increasing one’s vulnerability to maladaptive self-destructive and/or abusive responses later on (3, 7).

Family Risk Factors for Sexually Abusive Behaviors

The Victim to Victimizer paradigm explores the internal motivators (i.e., feelings and thoughts) of a sexually abusive youth’s behavior, but fails to consider how environmental influences affect the youth’s motivation.

Severely disturbed sexually abusive children typically come from chaotic family environments characterized by enmeshed or disengaged relationships, role reversal between parent and child, and/or loss of a parent through death, separation, or divorce (41, 42). The great majority of sexually abusive youth have experienced some type of abuse (i.e., sexual, physical, exposure to domestic violence, neglect) (10-12, 32, 43). Many sexually abusive youth have also been subject to other types of trauma (e.g., serious life threats and/or injuries, witnessing injury and/or death of another, involvement in gang violence, and/or family criminal lifestyle) (44).

A meta-analysis of 59 studies compared 3,855 adjudicated male adolescent sex offenders and 13,393 adjudicated male adolescent nonsexual offenders (some of whom may have been sexually abusive) (45). They found the adolescent sex offenders were more likely to have been sexually abused, exposed to sexual violence in their family and/or experienced other types of abuse or neglect (consistent with the research reviewed above). They had more anxiety and problems with low self-esteem.

All of these variables are important when assessing the outcomes of prior trauma for sexually abusive youth.

TOPA and another ecological model, the Family Lovemap (8, 9), emphasize that both internal and environmental factors must be considered when assessing youth who have coarse sexual improprieties and/or are sexually abusive. The Family Lovemap paradigm describes how intimacy is expressed or not expressed in a family. Family Lovemap includes “a family’s hereditary predispositions or manifestations of inheritable characteristics, its history of romantic bonding, erotic bonding, reproductive bonding, and the products of such (i.e., the sexualities)” (9, p. 96). Traumatic abusive experiences occurring within the family impact the youth’s Family Lovemap. This can be seen in two important areas, first the degree of attachment, love and caring between children and their parents (4, 41); and next, the children’s ability to make and sustain relationships (8,10,11) and relate socially with their peers (45, 46).

The TOPA model asserts sexually abusive behavior may emerge, not only subsequent to sexual abuse, but also when violence in the home is coupled by a high degree of sexual awareness engendered by a sexualized environment, although not necessarily sexual abuse (47). Children may be “eroticized,” that is, “prematurely exposed to sexual material through any media form (e.g., TV, Internet, still photos, DVD/video recordings of movies, writings, tapes, songs) beyond their sexual developmental readiness age (Miccio-Fonseca, 1993)” (48, p. 89). This may include “actual sexual behaviors, either observed, or participatory” (48, p. 96). Seto and Lalumière’s meta-analysis (45) is also relevant here: the study not only found that adolescent sex offenders were more likely to be sexually abused than adolescent nonsexual offenders; they were also more likely to be socially isolated, have early exposure to pornography, and show more atypical sexual interests.

Brian David Mitchell. Brian Mitchell’s history is replete with risk factors related to the Family Lovemap.

Abuse and/or neglect often impair erotic and romantic development and contribute to “a ‘vandalized Lovemap’ (Money, 1986a, 1986b)” (8, p. 96). For Brian, this is seen in physical aggression between him and his mother and alleged emotional abuse and neglect from his father (i.e., being left in an unknown area to find his way home).

Although he grew up in a two-parent home, there was conflict in his parents’ marriage and they eventually divorced. His father’s testimony at his trial indicated Brian’s physical aggression toward his mother and sister resulted in him being sent to live with his paternal grandmother. Brian had difficulty engaging in and maintaining 275

Victim and Victimizer

relationships, as evidenced by his father’s statements that Brian’s childhood and adolescence were characterized by “alienation” (27). As an adult, his ability to relate to others was skewed, as evidenced by poor reality testing, religious delusions, and erratic and bizarre behaviors. In aggregate, these behaviors reflect an inability to relate to, or have concern or empathy for others. According to the Family Lovemap model, the degree of sexual violence that Brian perpetrated against Elizabeth (i.e., using a weapon, making lethal threats, raping her on multiple occasions) reflects an individual with profound intimacy deficits, coupled with a history of problems in expressions of intimacy within his family (9).

When interviewed following his son’s arrest for the kidnapping of Elizabeth Smart, Shirl Mitchell reported that Brian “was a latchkey kid” who had access “to books of an erotic nature maybe too much – novels that I’d bring into the house” (49). The author of the Family Lovemap model asserts that sexually abusive individuals “often come from unorthodox, unconventional families, having sexually deviant proclivities or unorthodox lifestyles traceable from prior family generations (Miccio-Fonseca, 1994)” (8, p. 96). There are indications in Mr. Mitchell’s history that he, like his son, had unconventional sexual interests. In Spokesman for the Infant God or Goddess, the senior Mr. Mitchell ruminated on sexual topics (e.g., erotic play by children, sex between teens) and disclosed having “an addictive voyeurism” (i.e., he fondled young girls as a child and peeped in women’s windows as an adult) (50).

Elizabeth Smart. Family Lovemap centers on the capacity for intimacy in a family as it is played out through a family’s previous generations, ultimately influencing a youth’s ability to have and sustain trusting, close and intimate relationships with the world at large (10). Elizabeth Smart’s history appears on the surface to be absent major problems in family relationships. She came from an intact family (no separation from parents) and was not a victim of physical or emotional abuse or sexual abuse or neglect.

Her parents have appeared caring and supportive; her relationships with her four siblings were harmonious; and she has had a network of close friends, both before and after her kidnapping. Support from family and close friends is a protective factor that may mitigate negative outcomes of traumatic experiences, as it apparently did for Elizabeth. However, the long-term effectiveness of support as a protective factor is contingent on whether it is consistently rich and sustaining, or infrequent and sporadic, with extended periods when support is largely 276

absent. In the TOPA model, inconsistent emotional support erodes the sense of “safety” needed to facilitate the adaptive response of Recovery and Integration (see Figure 1).

Community and Cultural Influences

Cultural factors are important to consider when assessing trauma outcomes and responses post trauma. The role of community and cultural factors is not taken into account by the Victim to Victimizer paradigm; rather, all victims of sexual abuse are assumed to be vulnerable to similar cognitive distortions and predictable patterns of dysfunctional behavior. Both TOPA and the Family Lovemap consider these ecological factors to be integral in influencing trauma outcomes and individuals’ responses (particularly when abuse or other trauma occurs within the family). According to TOPA, a specific culture’s view on abuse may adversely impact youths who have experienced sexual abuse and contribute to maladaptive responses, to include self-victimizing or abusive behavior (3, 5).

Likewise, the Family Lovemap paradigm considers the individual’s culture among “the fundamentals of a family’s combined biological, physiological, psychological, sexual, social, and cultural history” (8, p. 96).

A youth’s relationship with the social environment includes immediate connections with neighborhood and community, that is, “those entities with which the individual has direct communication, involvement, and some degree of influence (e.g., school, work, church congregation, clubs, and medical, mental health, and social services)” (51, p. 26). Aspects of the family’s environment (e.g., poverty, unemployment, instability of residence) create ecological risk factors that impact children’s ability to form stable interpersonal relationships, inhibit formation of a positive support system, and place them at greater risk for sexually abusive behavior and maladaptive responses to trauma (3, 5, 41). A supportive environment in a youth’s immediate social connections within a culture is an essential component for promoting adaptive coping with the effects of abuse trauma (52).

Brian David Mitchell. Brian’s family reportedly made several changes of residence during his childhood and adolescence (27). The family was described by neighbors as “Mormon, frugal, and a little weird,” perhaps due to their unusual dietary practices (i.e., eating only wheat products and vegetables) and the fact that all children were born at home (26). Other reports indicate Brian’s parents “were not especially active in the [Mormon] church” (25, p. 51). From these statements, one may infer that the family may have been somewhat lacking

Lucinda A. Rasmussen

in community support, which may have contributed to Brian’s own isolation.

Elizabeth Smart. Community and cultural support are seen in the strong connection of Elizabeth Smart and her family with their faith, the Church of Jesus Christ of Latter Day Saints (Mormon) and its social network.

Over 700 of the Smart’s neighbors in their predominantly Mormon neighborhood showed up to help search for Elizabeth in the days following her kidnapping (53). In an interview 10 years after her kidnapping, Elizabeth attributed her survival and her remarkable recovery to: “my family, and to my friends and community who really supported me, who really loved me and who never treated me any different” (54).

The community support evident in Elizabeth’s experience (i.e., 700 people searching for her) is atypical and unprecedented. Victims of sexual abuse typically do not experience such an outpouring of support from their families and communities. Support and/or community resources may be absent altogether – or intermittent and inconsistent. For many victims, messages received from others are not helpful or encouraging, but rather blaming and discounting. Victims may encounter such statements as: “It’s your fault because of the way you dressed”; “What happened to you is no big deal; other people have had it much worse”; and “Why don’t you just get over it?” Such statements may echo similar statements made by the perpetrator at the time of the abuse (3).

Events that occur once abuse is discovered (i.e., negative reactions from family members, inadequate interventions from law enforcement and child welfare) can be almost as traumatic as the abuse itself. Victims are often isolated and feel alone, making them vulnerable to TOPA’s Self-victimization response. Contrary to the experience of many victims, Elizabeth Smart was enthusiastically welcomed home after her captivity, then sheltered by her parents and nurtured by her family and friends, thus enhancing the possibilities of recovering from and moving beyond the horrific trauma she experienced.

Recovery and Integration

The ecologically-based TOPA model helps explain why some victims like Elizabeth may not evidence PTSD symptoms or other behaviors indicative of the Selfvictimization or Abuse responses. Such victims remain relatively intact and are able to engage in a process of Recovery and Integration of their traumatic experiences. According to TOPA, such recovery is facilitated by protective factors, particularly emotional support from

family and community, consistent with other authors who have stressed the importance of protective factors and influences in mitigating effects of trauma (20, 55). The keys for opening the door of Recovery and Integration are self-awareness and safety (see Figure 1). An emotionally supportive environment creates a safe therapeutic space wherein the traumatized victim can sort through the conflicting thoughts and feelings associated with the trauma, take responsibility for his or her recovery, and grieve the losses engendered by the traumatic experience (3, 7).

After being rescued by police from her kidnappers, Elizabeth Smart successfully reunited with her parents and five siblings, reintegrated socially with a network of positive friends, and resumed her school activities, horseback riding, and harp performances and recitals.

She went on to major at music performance at Brigham Young University, then completed a successful missionary experience in France for the Church of Jesus Christ of Latter Day Saints. She testified articulately at her abductor’s trial and spoke to the United States Congress at the signing of the 2006 Adam Walsh Child Protection and Safety Act (i.e., a U.S. Federal statute that imposed lifetime registration on the most serious sex offenders [56]). An advocate for victim rights, Elizabeth has made numerous appearances at child abuse conferences across the country and discussed her trauma and recovery. She recently married a young man she met on her Mormon mission to France, and was hired by ABC news as an expert on missing persons' cases (57).

All reports indicate Elizabeth has made an extraordinary recovery from the egregious long-term trauma of being kidnapped at knifepoint, held captive for 9 months, and repeatedly sexually assaulted. Remarkably, Elizabeth’s recovery was accomplished without therapy. She declined therapy, although her parents offered it. In an interview 6 years following the kidnapping, she explained, “I don’t feel the need to talk about what happened to me, but if I do, I know my family is there” (38). Elizabeth Smart evidently was able to find a therapeutic space of safety through the emotional support of her family, her music and her religion. Unlike many sexual abuse victims, Elizabeth was able to see her perpetrator arrested, charged, and ultimately brought to justice, which was perhaps vindicating and allowed her to move on. At the time of Mitchell’s sentencing, Elizabeth proclaimed, “I have forgiven him…..I am at peace with what’s happened” (58).

Elizabeth’s story causes pause. Her courage – in facing her perpetrator and testifying for several days against 277

Victim and Victimizer

him – and her resilience – in embracing her life and moving forward – are admirable. Her recovery, however, provokes lingering questions. How does one recover from the terror of being kidnapped at knifepoint and 9 months of captivity and repeated and brutal sexual assault? The answers are perhaps found in the TOPA model.

Summary The overall conclusion of this review is that the Victim to Victimizer paradigm, while it perhaps explains sexually abusive behavior in some youth, is restrictive, attributing sexually abusive behavior solely to distorted patterns of thinking and patterned behaviors. Responses to traumatic experiences (as demonstrated by the Elizabeth Smart case) are inherently more complex, influenced by the neuropsychological workings of the executive functions of the brain and environmental context of family, culture, and community. The Victim to Victimizer paradigm does not consider these complexities.

Two contemporary ecological models provide comprehensive and multidimensional explanations of the relationship of prior sexual abuse and sexually abusive behavior: Trauma Outcome Process Assessment (TOPA) and Family Lovemap. These models are supported by contemporary empirical research on sexually abusive youth (10-12) and thus provide a more evidence-based explanation of sexually abusive behavior than the Victim to Victimizer paradigm.

The above case example of Elizabeth Smart and Brian David Mitchell serves to illustrate how TOPA can differentiate between victims of abuse who cope effectively with their trauma and those who manifest maladaptive behaviors that may be self-destructive and/or sexually abusive. A notable limitation of the case example is that it is part of the public domain and well known throughout the U.S. Information about such cases is often inflated and possibly peppered with inaccuracies. The author took steps to ensure that information about the case was well documented and cross-checked. Official sources (court records, psychiatric evaluations) were utilized whenever possible. Other sources utilized were reputable and respected news organization generally recognized as a reliable news sources. Included in the information reviewed were direct interviews with Elizabeth Smart (including some that were videotaped).The result is a case study that provides an in-depth analysis of the dynamics of victim to victimizer in a sexual abuse case and serves to show the application of the TOPA model.

278

References 1. Ryan G. Victim to victimizer: Rethinking victim treatment. J Interpers Violence 1989; 4: 325-341.

2. Glasser M, Kolvin I, Campbell D, Glasser A, Leitch I, Farrelly S. Cycle of abuse: Links between being a victim and being a perpetrator. Brit J Psychiat 2001; 179: 482-494.

3. Rasmussen L A. The trauma outcome process: An integrated model for guiding clinical practice with children with sexually abusive behavior problems. J Child Sexual Abuse 1999; 8: 3-33.

4. Rasmussen L A. Integrating cognitive-behavioral and expressive therapy interventions: Applying the Trauma Outcome Process in treating children with sexually abusive behavior problems. J Child Sexual Abuse 2001; 10: 1-29.

5. Rasmussen L A. Differentiating youth with sexual behavior problems: Applying a multidimensional framework when assessing and treating subtypes. Special Edition, J Child Sexual Abuse 2004; 13: 57-82.

6. Rasmussen L A. Trauma Outcome Process Assessment (TOPA Model): An ecological paradigm for treating traumatized sexually abusive youth.

J Child Adol Trauma 2012; 5: 63-80.

7. Rasmussen L A, Burton J, Christopherson B J. Precursors to offending and the Trauma Outcome Process in sexually reactive children. J Child Sexual Abuse 1992; 1: 33-48.

8. Miccio-Fonseca LC. Challenging the myths about sex disorders: Understanding the role of bio-physio process, family lovemaps, and paraphilic fugue states. In: Prescott DS, editor. Knowledge & practice: Challenges in the treatment and supervision of sexual abusers (pp. 91107). Oklahoma City, Oklahoma: Wood ‘N’ Barnes, 2007.

9. Miccio-Fonseca LC. Family Lovemap, eroticized children and a constellation of sexually related risk variables. Manuscript submitted for publication.

10. Miccio-Fonseca LC. MEGA: A new paradigm in protocol assessing sexually abusive children and adolescents. J Child Adolesc Trauma 2009; 2: 124-141.

11. Miccio-Fonseca LC. MEGA: An ecological risk assessment tool of risk and protective factors for assessing sexually abusive children and adolescents.

J Aggression Maltreat Trauma 2010; 19: 734-756.

12. Miccio-Fonseca LC. MEGA: A new paradigm in risk assessment tools for sexually abusive youth. Manuscript submitted for publication.

13. Friedrich WN, Grambsch P, Damon L, Hewitt S K, Koverola C, Lang R A, et al. Child Sexual Behavior Inventory: Normative and clinical comparisons. Psychol Assessment 1992; 4: 303-311.

14. Gale J, Thompson R J, Moran T, Sack WH. Sexual abuse in young children: Its clinical presentation and characteristic patterns. Child Abuse Neglect 1988; 12: 163-170.

15. Johnson TC. Understanding your child’s behavior: What’s natural and healthy. Oakland, Cal.: New Harbinger, 1999.

16. Burton DL. Male adolescents: Sexual victimization and subsequent sexual abuse. Child Adolesc Soc Work J 2003; 20: 277-296.

17. Miccio-Fonseca LC. Adult and adolescent female sex offenders: Experiences compared to other females and male sex offenders. Special Edition, J Psychol Hum Sex 2000; 11: 75-88.

18. Finkelhor D, Ormrod R, Chaffin M. Juveniles who commit sex offenses against minors. Office of Juvenile Justice and Delinquency Prevention Juvenile Justice Bulletin 2009, December: 1-11.

19. Miccio-Fonseca LC. Research report: On sex offenders, victims and their families. Special Edition, J Offender Rehabil 1996;23: 71-83.

20. Luthar SS. Resilience in development: A synthesis of research across five decades. In: Cicchetti D, Cohen D, editors. Developmental psychopathology: Risk, disorder, and adaptation, Vol. 3, 2nd ed. New York: John Wiley & Sons, 2006: pp. 739-795.

21. Miller S, Nunnally E W, Wackman DB. Alive and aware: Improving communication in relationships. Minneapolis, Minn.: Interpersonal Communications Programs, Inc., 1975.

22. Salt Lake Tribune Utah News (November 8, 2010). Nov. 8 transcript:

Lucinda A. Rasmussen

Elizabeth Smart. Retrieved May 7, 2012 from: http://breaking.sltrib.com/ mitchell/nov8elizabethsmarttranscript.php 23. Salt Lake Tribune Utah News (November 9, 2010). Nov. 9 transcript: Elizabeth Smart. Retrieved May 7, 2012 from: http://breaking.sltrib.com/ mitchell/nov9elizabethsmarttranscript.php 24. United States District Court for the District of Utah Central Division, Case 208CR125, October 1, 2009, Elizabeth Smart testimony.

25. Welner M. Forensic psychiatric evaluation submitted to Brent Tolman, U.S. Attorney. Salt Lake City, Utah: The Forensic Panel, June 16, 2009.

Retrieved May 4, 2012 from: http://www.forensicpanel.com/data/Unsorted/ BDM_CST_Report.pdf 26. Griggs B. Tribune archive: Mitchell’s journey to “Immanual”: His life changed dramatically from diligent family man to delusional vagabond.

Salt Lake Tribune Utah News, November 1, 2010. Retrieved May 4, 2012 from: http://www.sltrib.com/sltrib/home/50581425-76/story.csp 27. Salt Lake Tribune Utah News, November 17, 2010. Nov. 17 transcript: Shirl Mitchell, defendant’s father. Retrieved May 4, 2012 from: http://breaking. sltrib.com/mitchell/nov17shirlmitchelltranscript.php 28. Perry B. Stress, trauma, and post-traumatic stress disorders in children: An introduction. Child Trauma Academy Interdisciplinary Education Series 1999; 2(5). Retrieved February 21, 2010 from: http://www.childtrauma. org/ctamaterials/ptsd_interdisc.asp 29. Creeden K. Trauma and neurobiology: Considerations for the treatment of sexual behavior problems in children and adolescents. In: Longo RE, Prescott DS, editors. Current perspectives in working with sexually aggressive youth and youth with sexual behavior problems (pp. 395-418).

Holyoke, Mass.: NEARI, 2006.

30. Miccio-Fonseca LC. Somatic and mental symptoms of male sex offenders: A comparison among offenders, victims, and their families. J Psychol Hum Sex 2001; 13: 103-114.

31. Streeck-Fischer AS, van der Kolk BA. Down will come baby, cradle and all: Diagnostic and therapeutic implications of chronic trauma on child development. Aust N Z J Psychiatry 2000; 34: 903-916.

32. Venziano C, Venziano L. Adolescent sex offenders: A review of the literature. Trauma Violence Abuse 2003; 3: 247-260.

33. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders Fourth Edition Text Revision (DSM-IV-TR). Washington, DC: Author, 2000.

34. Hunter J. Prolonged exposure treatment of chronic PTSD in juvenile sex offenders: Promising results from two case studies. Child Youth Care Forum 2010; 39: 367-384.

35. McMackin RA, Leisen MB, Cusack JF, LaFratta J, Litwin P. The relationship of trauma exposure to sex offending behavior among male juvenile offenders. J. Child Sexual Abuse 2002; 11: 25-40.

36. Kendall-Tackett KA, Williams LM, Finkelhor D. Impact of sexual abuse on children: A review and synthesis of recent empirical studies. Psychol Bull 1993; 113:164-180.

37. Bio. True Story. Elizabeth Smart. Biography. 2012. Retrieved May 5, 2012 from: http://www.biography.com/people/elizabeth-smart-17176406 38. Free C, Tresniowski A. Heroes of the year. People 2008; 69. Retrieved May 6, 2012 from: http://www.people.com/people/archive/article/0,,20207194,00. html 39. Oprah. Elizabeth Smart, John Ramsey: The stories that captured the nation. September 10, 2008. Retrieved from: http://www.oprah.com/ showinfo/Elizabeth-Smart-John-Ramsey-Stories-That-Captured-a-Nation 40. Alethea, blog (n.d.). Elizabeth Smart raped up to 1,000 times, forced into repugnant sex acts and tied to a tree; but shows no sign of having suffered

trauma and never needed therapy? Evil sits at the dinner table. Retrieved May 7, 2012 from: http://ordinaryevil.wordpress.com/2010/11/18/ elizabeth-smart-raped-at-least-once-a-day-forced-into-sex-with-awoman-and-tied-to-a-tree-but-shows-no-sign-of-having-suffered-traumaand-never-needed-therapy/ 41. Friedrich WN. Psychological assessment of sexually abused children and their families. Thousand Oaks, Cal.: Sage, 2002.

42. Hall DK, Mathews F, Pearce J. Factors associated with sexual behavior problems in young sexually abused children. Child Abuse Neglect 1998; 22: 1045-1063.

43. Righthand S, Welch C. Characteristics of youth who sexually offend. J Child Sexual Abuse 2004; 13: 15-32.

44. McMackin RA, Leisen MB, Cusack JF, LaFratta J, Litwin P. The relationship of trauma exposure to sex offending behavior among male juvenile offenders. J Child Sexual Abuse 2002; 11: 25-40.

45. Seto M C, Lalumière ML. What is so special about male adolescent sexual offending? A review and test of explanations through meta-analysis.

Psychol Bull 2010; 136: 526-575.

46. Letourneau E, Schoewald SK, Sheidow AJ. Children and adolescents with sexual behavior problems. Child Maltreatment 2004; 9: 49-61.

47. Araji SK. Sexually aggressive children: Coming to understand them.

Thousand Oaks, Cal.: Sage, 1997.

48. Rasmussen LA, Miccio-Fonseca LC. Paradigm shift: Implementing MEGA, a new tool proposed to define and assess sexually abusive dynamics in youth ages 19 and under. J Child Sexual Abuse 2007; 16: 85-106.

49. CNN.com (March 15, 2003). Father describes Brian David Mitchell’s behavior. CNN Access. Retrieved May 5, 2012 from: http://edition.cnn. com/2003/US/West/03/14/cnna.shirl.mitchell/index.html 50. Carrier S. The ongoing mysteries of the Elizabeth Smart case. Mother Jones.

December 14, 2010. Retrieved May 5, 2012 from: http://www.motherjones. com/politics/2010/12/elizabeth-smart-verdict?page=2 51. Miccio-Fonseca LC, Rasmussen LA. Implementing MEGA, a new tool for assessing risk of concern for sexually abusive behavior in youth ages 19 and under: An empirically guided paradigm for risk assessment: Revised Version. 2006. Available from California Coalition on Sexual Offending Web site, http://www.ccoso.org 52. Sinacore-Guinn AL. The diagnostic window: Culture- and gender-sensitive diagnosis and training. Couns Educ Superv 1995; 35: 18-34.

53. ABC News. Neighbors help in hunt for Utah girl. June 6, 2002. Retrieved May 5, 2012 from: http://abcnews.go.com/US/story?id=91586&page=1 54. KOAA.com. Elizabeth Smart shares her story of survival, and hope.

March 13, 2012. Retrieved May 6, 2012 from: http://www.koaa.com/news/ elizabeth-smart-shares-her-story-of-survival-and-hope/ 55. Katz M. On playing a poor hand well: Insights from the lives of those who have overcome childhood risks and adversities. New York: W. W. Norton, 1997.

56. U.S.Legal Adam Walsh Child Protection and Safety Law and legal definition.

2012. Retrieved August 3, 2012 from: http://www.definitions.uslegal. com/a/adam-walsh-child-protection-and-safety-act/ 57. Deseret News. Elizabeth to join ABC for missing person insight. July 7, 2011. Retrieved: May 7, 2012 from: http://www.deseretnews.com/ article/700149961/Elizabeth-Smart-to-join-ABC-for-missing-personsinsight.html 58. Smolowe J. Elizabeth Smart “I forgive him.” People 2011; 75(22).

Retrieved May 5, 2012 from: http://www.people.com/people/archive/ article/0,,20498386,00.html

279

Isr J Psychiatry Relat Sci - Vol. 49 - No 4 (2012)

Identifying Psychological Traits Potentially Subserving Aberrant Motivation or Inhibitory Failure in Pedophilic Behavior Lisa J. Cohen, PhD, and Igor Galynker, MD, PhD Albert Einstein College of Medicine, New York, N.Y., U.S.A.

Submitted to the Proceedings for the Conference on Contemporary Treatments of Paraphilias, Jerusalem, June 16-18, 2010.

Abstract Background: This paper presents data from a research program investigating personality traits or childhood historical factors that may contribute to the motivation for or failure to inhibit pedophilic behavior.

Method: The entire sample included 51 male subjects with pedophilic behavior, 53 opiate addicted subjects (69% males), and 84 healthy controls (77% males). Groups were compared on personality traits related to social anxiety/inhibition, impulsivity, propensity for cognitive distortions and psychopathy along with the incidence of sexual abuse in their own childhoods (CSA).

Results: Results supported an increased prevalence of CSA, psychopathic traits and traits related to a propensity for cognitive distortions in the pedophilic group relative to healthy controls. Compared to opiate addicted subjects, pedophilic subjects had higher rates of childhood sexual abuse, more schizoid traits, and lower impulsivity and behavioral psychopathy scores. While the group with pedophilic behavior scored higher than controls on some measures related to social anxiety, they did not differ from the opiate addicted group.

Limitations: Measures relied on self-report and demographic variables varied across groups.

Conclusion: Subjects with pedophilic behavior may show distinct personality and historical traits related to both inhibitory and motivational factors.

Address for Correspondence:   Lcohen@chpnet.org

280

Introduction Despite a large number of publications on the topic of pedophilia and sophisticated forensic research, surprisingly little is known about the etiology, development, underlying mechanisms, and/or neurobiology of pedophilia, information which is necessary for maximal clinical effectiveness. Hence, a solid understanding of the psychobiology of pedophilia is critical to inform treatment, prevention and public policy. The purpose of this paper is to present data from a research program studying the psychological correlates of pedophilia. We will first consider pedophilia as a single coherent entity.

We will then address the issue of the heterogeneity among pedophilic individuals (1, 2).

The choice of terminology to describe adults who desire, fantasize about or actually engage in sexual activity with children raises a number of complications. The clinical term, pedophilia, is defined in DSM-IV-TR by sexual fantasies, attraction or behavior towards a prepubescent child (generally aged 13 or younger) for at least 6 months (3). While this definition is fairly stringent, it does not distinguish between those who do and do not act on sexual desires towards children and does not pertain to sexual molesters of children who do not meet the 6-month criterion. Thus individuals with pedophilic behavior may not meet DSM-IV TR criteria for pedophilia. In contrast, legal and forensic terms, such as sexual offender or child molester, only pertain to those who have engaged in sexual

Dr. Lisa Cohen, Beth Israel Medical Center, 1st Ave. & 16th St., New York, N.Y. 10003, U.S.A.

Lisa J. Cohen and Igor Galynker

activity with a child and do not reference the core psychological characteristic of sexual attraction to children. As the protection of children from sexual abuse is of utmost social importance, it is necessary for research to cast a net wide enough to incorporate any adult involved with sexual activity with children yet still maintain clarity about diagnostic distinctions. In the present paper, we present data on a sample of adults who have engaged in sexual activity with children and have entered the criminal justice system because of such activity. To underscore the clinical rather than forensic nature of this report and because not all of these subjects necessarily meet DSM-IV-TR criteria for pedophilia, we will refer to our subjects as individuals with pedophilic behavior. Our ultimate goal is to contribute to a comprehensive understanding of pedophilic phenomena, which would hopefully support treatment options for a wider range of individuals with pedophilic inclinations and provide better protection for children and the public at large.

Relatedly, research into pedophilia is complicated by inherent limitations regarding sample selection and confounding variables. Because sexual activity between adults and children is illegal and socially taboo in most countries, pedophilic individuals run considerable legal and social risk by openly discussing their inclinations and behavior.

Consequently most research is performed on subjects already in the criminal justice system and is thus confounded by criminality, impulsivity, low SES and other traits associated with the performance and legal consequences of criminal behavior (4, 5). Nonetheless, there is sufficient consistency in the literature to support hypotheses about the psychological correlates of pedophilia.

The key psychological questions pertain to abnormalities of either motivation or inhibition. Impaired motivation has been linked to social anxiety or general interpersonal inhibitions, which make sexual activity with children appear less anxiety provoking or more accessible than such activity with age-appropriate partners (6-8). Additionally, the “abused abuser theory� suggests that pedophiles’ own childhood experiences of sexual abuse predispose them towards sexual attraction to children (9). Inhibitory factors include impulsivity, propensity towards cognitive distortions, and psychopathy.

Impulsivity impairs inhibition through failure to consider the negative consequences of pleasurable acts. Cognitive distortions allow individuals to distort the implications of their maladaptive behavior (10, 11), and psychopathy reduces inhibitions via inadequate concern for harm done to other people, in this case the child victims.

Within the literature, there are considerable data pointing to elevated levels of social anxiety, poor selfconfidence, and other personality traits which might inhibit appropriate sexual relations with adults (9, 12-15). In a study of 40 male pedophilic sex offenders, 43% met criteria for a Cluster C disorder according to the Structured Clinical Interview for DSM-IV Axis II Disorders (12). In a study of 36 patients with compulsive sexual behavior (29% of whom admitted to pedophilia), 19%, 17%, and 28% met Structured Interview for the DSM-III Personality Disorders (SIDP)/ SIDP-Revised criteria and 15%, 21%, and 15% met Personality Diagnostic Questionnaire (PDQ)/PDQRevised criteria for avoidant, obsessive-compulsive, and passive-aggressive disorders, respectively (13, 16).

Nonetheless, these traits are commonly found within the general, non-pedophilic population and thus are clearly not specific to pedophilia. Moreover, there is a question of the direction of causality, such that the presence of elevated traits related to social anxiety/ inhibition does not necessarily support a causative role in the motivation for pedophilic behavior. Narrative data from our own research revealed that some pedophiles turn to children in response to their impaired interpersonal skills while others described intense feelings of shame, low self esteem, and social avoidance as a result of their pedophilic urges.

The abused abuser theory purports that a history of sexual abuse predisposes individuals to pedophilic tendencies. This etiological hypothesis has robust support in the literature. While reports of elevated rates of childhood sexual abuse (CSA) in child molesters are highly consistent (17-19), the incidence reported varies considerably across studies, ranging from as low as 28.6% (20) to as high as 93% (21). Moreover, sexual offenders against children reported a higher rate of CSA than did sexual offenders against older age groups (17, 19, 22) and non-sexual offenders (19). As most of these findings derive from self-report data, we can question whether individuals in the criminal justice system might over-report such histories in an attempt to mitigate their sentences. In a large community sample, however, men with a history of multiple episodes of sexual abuse in their own childhood were almost 40 times more likely to report having engaged in sex with children aged 13 or younger as adults (0.2% vs. 7.7%) (23).

While there is strong evidence of an association between CSA and adult pedophilia, the mechanism behind this relationship is not clear. Proposed mecha281

Psychological Traits Subserving Aberrant Motivation or Inhibitory Failure in Pedophilic Behavior

nisms include a normalization of adult-child sex as well as identification with the aggressor, in which the victim identifies with the powerful aggressor in an attempt to mitigate the experience of helplessness (5, 9, 17). It is also possible that there are neurodevelopmental effects of CSA on sexual development. A growing body of literature documents the neurobiological effects of child trauma, for example on the hippocampus and the HPA axis (see 24 for a review). It is likewise conceivable that sexual trauma or premature sexual stimulation may have enduring effects on sexual neurodevelopment (6, 17).

Some evidence of the effect of early sexual experience on sexual brain-behavior relationships has come from rat studies (25). Nonetheless a substantial proportion of pedophilic subjects across studies do not report a history of CSA (5, 18-20, 22). It is possible that the variation in CSA histories among pedophilic samples reflects underlying heterogeneity among individuals with pedophilic behavior, as will be discussed below.

With regard to impulsivity, the literature is somewhat inconclusive. Pedophilia has been conceptualized as a disorder of impulse control (26-28) or impulsive aggression (28). Moreover, high levels of comorbid impulse control disorders have been documented in adult and juvenile pedophile samples (12, 29). However, we found no evidence of cognitive impulsivity on the Matching Familiar Figures Test or the Porteus Mazes (30). In an analysis drawn from the New York Sex Offenders Registry, sexual offenders against children were older and less likely to use force or a weapon than were offenders against either adolescents or adults, suggesting lower levels of impulsive aggression (31). Further, a very old but thorough study showed the vast majority of pedophilic acts (70-85%) to be premeditated rather than impulsive (32). These contradictory findings may also point to heterogeneity among pedophilic individuals.

There is robust evidence in the literature for a tendency towards cognitive distortions among pedophile samples. These mental manipulations serve to justify, minimize or normalize the pedophilic behavior (10, 11).

In fact the tendency towards distorted thinking may generalize to the entire personality, such that pedophiles may have elevated levels of schizotypal or other Cluster A personality disorder traits (13, 16, 33).

Elevated levels of psychopathic personality traits have also been widely documented in pedophilic samples (6, 12, 13, 28, 34). However, there is evidence of heterogeneity in this regard as well. For example, a sample of pedophilic priests had lower scores on the MMPI 282

psychopathic deviate scale compared to a sample of non-clerical pedophiles (5). We can speculate that those pedophiles who act on their urges would have greater levels of psychopathic traits than those who do not.

Thus the literature points to personality traits and/ or childhood histories putatively related to disordered motivation and impaired inhibition among pedophilic samples.

We will now present data from our research program comparing social inhibition, child sexual abuse histories, impulsivity, psychopathy and Cluster A personality traits in subjects with pedophilic behavior, healthy controls and individuals with opiate addiction. The first two traits are hypothesized to be associated with the motivation for pedophilic behavior, the last three with the failure to inhibit such behavior. Opiate addicted subjects were selected as a comparison group as we were interested in the notion of pedophilia as a behavioral addiction.

Subjects Our program comprised several separate studies (cf. 6, 18, 31, 34, 35). Data from two studies, Study 1 and Study 2, are presented here. The combined sample included 51 males with pedophilic behavior recruited from an outpatient clinic specializing in the treatment of sexual offenders, 53 subjects with opiate addiction recruited from a residential treatment center (69% males), and 84 healthy controls recruited from local media advertising (77% males). All subjects with pedophilic behavior admitted to committing and were charged for or convicted of a sexual offense against a child age 13 or younger when the subject was at least 18 years old or at least five years older than the child. Opiate addicted subjects in sustained remission were recruited from the SuCasa methadone to abstinence residential treatment program.

All opiate addicted subjects had at least a two-year history of opiate dependence, were abstinent from illicit substances, and had been detoxified from methadone for at least six months. We also administered a urine toxicology test to insure drug abstinence. Healthy controls were recruited from advertising in local New York City newspapers. Exclusion criteria for both the pedophilic group and controls included meeting DSM-IV criteria for a substance-use disorder within six months prior to the study. Exclusion criteria for both the opiate addicted group and controls included history of pedophilia or of sexual activity as an adult with anyone younger than 15, or with anyone at least five years younger than the subject

Lisa J. Cohen and Igor Galynker

when the subject was younger than 18. For all subjects any significant Axis I psychiatric disorder other than the index disorder (i.e., opiate addiction or pedophilia), such as Major Depressive Disorder with psychosis, recurrent psychotic disorders, Bipolar Disorder, Obsessive-Compulsive Disorder, or any disorder requiring hospitalization or disability leave, was an exclusion criterion. This study was approved by the Beth Israel Institutional Review Board and all subjects gave written informed consent.

Measures SCID II for DSM-IV (36). This widely used, semistructured clinical interview provides diagnoses for all DSM-IV axis II personality disorders. There is a 119-item screening questionnaire to be followed up by 119 sets of interview questions. According to the APA Handbook on Psychiatric Instruments (3), the reliability coefficients are comparable to those of other similar interviews. The three Cluster A personality disorders were used as measures of the propensity toward cognitive distortions as a personality trait. The Cluster C disorders were assessed as measures of personality traits related to social anxiety. Passive-Aggressive and Self-Defeating Personality Disorders were also included with these disorders as they had either been in Cluster C in DSM-III-R (PassiveAggressive) or otherwise involve some degree of self inhibition (Self-Defeating). To maximize sensitivity, the number of criteria for each diagnosis was analyzed rather than categorical diagnosis scores. Although interviewers were closely supervised by the first author (LJC), interrater reliability was not formally assessed.

Millon Clinical Multiaxial Inventory-II (37). This 175item questionnaire measures DSM-III-R personality disorders as well as several Axis I disorders and syndromes. Dimensional scales from the MCMI-II and a later edition, the MCMI-III, have been well correlated (r > 0.5) with related measures from the Symptom Checklist 90 - Revised (SCL-90-R) and the Minnesota Multiphasic Personality Inventory (MMPI) (38). Scale scores were calculated according to the scoring key in the MCMI-II manual (37). No corrections were used in scoring. Scales for Avoidant, Dependent, Obsessive-Compulsive, PassiveAggressive, and Self-Defeating personality disorders as well as a related axis I disorder (Anxiety Disorder) were used to assess traits related to social anxiety. As above, these personality disorders are referred to as Cluster C disorders. Additionally, MCMI Cluster A and Delusional Disorder scales and Antisocial Personality Disorder scales

were included as measures of propensity for cognitive distortions and psychopathy, respectively.

Temperament and Character Inventory (39). Adapted from the Tridimensional Personality Questionnaire, the 240-item Temperament and Character Inventory (TCI) assesses three dimensions of temperament and three dimensions of character. The internal consistency of the scales ranged from .76 to .87 for the temperament scales and .84 to .89 for the character scales. Principal component analysis identified seven factors accounting for 65% of the variance. The first six factors closely paralleled the rationally defined item loading of the six TCI scales. TCI Novelty Seeking was used as a measure of impulsivity, Dimensional Assessment of Personality ImpairmentQuestionnaire (DAPI-Q) (6, 40). The Dimensional Assessment of Personality Impairment-Questionnaire (DAPI-Q) is a 248-item questionnaire that measures personality impairment in 16 scales grouped into six function clusters: regulation of affect (3 scales), action (2 scales), cognition (2 scales), interpersonal function (4 scales), self-organization (3 scales), and societal function (2 scales). The DAPI-Q has been adapted from the Dimensional Assessment of Personality Impairment, a semi-structured interview (35, 40). Inter-item consistency for the questionnaire items ranged from 0.73 to 0.95 across scales. The DAPI scales differentiated three patient groups (subjects with depression, pedophilia or body dysmorphic disorder) from healthy controls and correlated strongly (r > .44) with matched MCMI-2 scales (35, 40, unpublished data). DAPI-Q Impulse control, Self Esteem, Societal Attitudes and Societal Behavior scales were used as measures of impulsivity, social inhibition and psychopathy, respectively.

Barratt Impulsivity Scale (BIS-11) (41). The BIS-11 is a widely used measure of impulsivity. It is a 30-item self-administered questionnaire with three subscales and a total score. Cronbach’s alphas ranged from .79 to .83 across several samples. The BIS-11 has been shown to distinguish impulsive aggressive from nonaggressive college students and prisoners from non-inmate controls (42). The total score was used for analysis.

Hare Psychopathy Checklist-Revised (43). PCL-R is a semistructured interview in which 20 items are rated by the clinician to assess psychopathic personality characteristics (factor 1) and socially deviant behaviors (factor 2). The PCL-R is a standard measure of antisocial personality pathology. Intra-class coefficients for reliability range from 0.73 to 0.95 across numerous samples.

The PCL-R has shown predictive validity regarding 283

Psychological Traits Subserving Aberrant Motivation or Inhibitory Failure in Pedophilic Behavior

recidivism after release from prison, construct validity via relations with other measures of psychopathy, and severity of criminal history (38). The factor 1, factor 2, and total scores were used for analysis. Although interviewers were closely supervised by the first author (LJC), inter-rater reliability was not formally assessed.

The Sexual History Questionnaire (18). A detailed 72-item self-report questionnaire assessing childhood sexual experiences, sexual interest, and pedophilic behavior was developed for this study. Sexual age preferences were assessed in a grid-format checklist, with three columns of the grid labeled “sexually attracted to,” “have had sexual encounters with,” and “have had legal trouble for sexual activity with.” The 10 rows included five categories of age groups for first girls and then boys, ranging from infancy through adulthood (18 years or more). Control subjects completed a shortened form, which collapsed the youngest age categories into one category of 12 years and younger. To increase the reliability of subjects’ reported sexual abuse history, childhood sexual history was assessed with multiple questions. At the beginning of the questionnaire, subjects are asked to list the age of their first sexual experience, with whom it occurred, and the age of their first partner. Later in the questionnaire, they are asked a series of questions such as: “When you were a child did any adult ever make sexual advances at you?” and “How old were you when it started?” They are also asked the number of people who made advances toward them, their gender, ages, and whether they were family members. Five primary variables were calculated from the SHQ. The first four variables were 1) age at youngest sexual contact, 2) age of partner at youngest sexual contact, 3) age difference between self and partner at first sexual contact, and 4) whether or not the subject experienced adult sexual advances as a child. The fifth primary variable was the percentage of subjects who reported their first sexual contact at or prior to the age of 13 with a partner who was at least five years older. This final variable was in keeping with the DSM-IV definition of pedophilia. Internal consistency was measured through correlating the key question about adult sexual advances experienced as a child, with the four other variables of interest. Correlations ranged from 0.60 to 0.88. Only variables 3, 4 and 5 are reported here.

The Child Trauma Questionnaire (44). A 28-item, self-report questionnaire, is used to assess five areas of childhood maltreatment: sexual, physical and emotional abuse, as well as physical and emotional neglect. Subjects are asked to rate whether each item is never, rarely, some284

times, often or very often true. This measure has been proven reliable and valid, with evidence of convergent and discriminant validity with structured trauma interviews, stability over time, and concordance with independent data (44). Only the sexual abuse scale is presented here.

Pedophilia Criteria Sheet. Developed for Study 2, this semi-structured interview includes both 32 questions and a narrative record of the subjects’ history of pedophilic behavior. Subjects are asked about age, sex and number of victims, number of acts and the specific circumstances of their sexual activity with children.

Statistical analysis All demographic variables that significantly differed across groups and correlated with the dependent variable in question were entered as covariates in group comparisons. MANCOVAs or ANCOVAs with simple contrasts for pairwise comparisons were used to compare continuous data across groups. Chi-square analysis was used to compare groups on categorical variables.

Binary logistic regression analysis was used for pairwise comparisons when there were three subject groups or when covariation for demographic variables was needed.

Results Demographic Data

Mean level of education was 12.5 ± 3.6 years for individuals with pedophilic behavior, 12.0 ± 2.6 for individuals with opiate addiction, and 15.4 ± 2.0 for controls.

Mean age was 38.6 ± 1.2 for pedophiles, 44.6 ± 6.4 for opiate addicts, and 33.8 ± 9.7 for controls. Individuals with pedophilic behavior were 16.7% African American, 35.4% Caucasian, 41.7% Hispanic, 4.2% Asian and 2.1% other. The ethnic distribution was 36.2%, 27.7%, 34%, 0% and 1% for opiate addicted subjects and 19.7%, 46.1%, 19.7%, 7.9% and 6.6% for healthy controls.

In Study 1 (n=21 individuals with pedophilic behavior, 24 healthy controls), groups did not differ as to education, ethnicity, age or gender. Therefore, none of the demographic variables were entered as covariates in subsequent analyses for Study 1. In Study 2 (n=29 individuals with pedophilic behavior, 53 individuals with opiate addiction, and 60 healthy controls), there were significant differences across groups for age, ethnicity, education and gender. As both sexual history and personality scores were significantly associated with education, and the SCID II Cluster A and Cluster C scores were significantly associated with

Lisa J. Cohen and Igor Galynker

both ethnicity and education, these demographic variables were entered as covariates in the relevant analyses.

Pedophilic Behavior Data on the first subset of pedophilic subjects (n=20) was drawn from the Sexual History Questionnaire. Regarding specific sexual acts, 90% admitted to sexual touching of a child aged 13 or younger, 75% to genital touching and 70% to non-genital touching (15% to non-genital touching only). Ninety percent admitted to legal trouble for sexual behavior with underage individuals, 70% for such behavior with children under 13, 30% with children under 10.

Eighty percent admitted to either legal trouble or sexual encounters with girls and 10% to both encounters and legal trouble with boys. As the self-report data was inconsistent (90% listed specific sexual acts with a child under 13 but only 50% admitted to “sexual encounters” with a child under 13), we developed a more detailed interview, the Pedophilia Criteria Sheet, for the second study.

In Study 2 (n=29), we utilized a semi-structured interview in order to gain a more fine grained assessment of subjects’ pedophilic behavior. The average age of youngest victim was 9.5 ± 3.2 years. The vast majority of subjects (86%) had only girl victims, 3% had only boy victims and 10% had both boys and girls. Fifty-five percent reported genital touching, 21% non-genital touching, and 24% non-touching offenses. Of the perpetrators with touching offenses, 41% reported 1 victim, 21% 1-5 victims, 3% 10-100 victims and 10% reported over 100 victims.

Opiate Addiction History The 51 subjects with opiate addiction reported 17.0 ± 10.3 (mean + s.d.) years of addiction, with a maximum of $129.30 ± $106.71 spent per day on their opiate addiction and 6.8 ± 7.5 years in methadone maintenance treatment before entering the SuCasa methadone to abstinence residential treatment program.

Potentially Motivating Traits Data comparing subject groups on potentially motivating traits is presented in Table 1. Specifically, Table 1 presents data both on personality traits related to social anxiety and on subjects’ own history of childhood sexual abuse.

Traits related to Social Anxiety. In Study 1 individuals with pedophilic behavior were compared with healthy controls on the MCMI anxiety disorder and five per-

sonality disorder scales (referred to herein as Cluster C).

Groups were also compared on the DAPI-Q Impairment of Self Esteem scale. The MCMI Cluster C scales were compared by MANOVA and the other scales by ANOVAs. The omnibus test for MCMI Cluster C disorders was statistically significant as were group differences on three of five scale scores (Passive-Aggressive, Self-Defeating and Avoidant). Groups also significantly differed on the MCMI Anxiety scale and the DAPI-Q Self Esteem scale.

In all cases, individuals with pedophilic behavior scored higher than controls (see Table 1).

The SCID II Cluster C results are drawn from Study 2. Although the omnibus test across the three subject groups (pedophilic, opiate addicted and controls) was not statistically significant, there were significant group differences for three out of five individual personality disorder scores, specifically Dependent, Passive-Aggressive and Depressive. By simple contrasts, both the pedophilic and opiate addicted group scored higher than controls on Dependent and the opiate addicted group scored higher than controls on Depressive (see Table 1).

History of Childhood Sexual Abuse (CSA). Results from three variables calculated from the Sexual History Questionnaire and the sexual abuse scale of the Childhood Trauma Questionnaire are also presented in Table 1. Fiftysix percent of the pedophilic group (n=27), 32% of the opiate addicted group and 6.6% of the controls admitted to experiencing adult sexual advances as children.

The pedophilic group reported a significantly higher incidence of adult sexual advances than either of the other two groups by binary logistic regression covarying for education (AOR=7.06 for P vs. C; 3.34 for P v. OA).

Likewise the pedophilic group was significantly more likely to state that their first sexual contact occurred at or before the age of 13 with a partner at least five years older (52.3% vs. 26.1% and 4.9%) (AOR=8.6 for P vs. C; AOR=3.9 for P vs. OA). Furthermore the mean age difference between self and first sexual partner was significantly higher for the pedophilic group than for the control group and marginally higher than the opiate addicted group (P=11.36 ± 11.5; OA=7.0 ± 11.4; C= 2.31 ± 7.8). Finally, the pedophilic group scored significantly higher than controls (but not opiate addicted individuals) on the CTQ sexual abuse scale (see Table 1).

Potentially Disinhibiting Traits Data comparing subject groups on potentially disinhibiting traits are presented in Table 2. Specifically Table 2 285

Psychological Traits Subserving Aberrant Motivation or Inhibitory Failure in Pedophilic Behavior

Table 1. Potentially Motivating Traits in Pedophiles, Healthy Controls and Opiate Addicts Motivating Traits Pedophiles (p)

Healthy Controls (c)

Opiate Addicts (oa)

Statistics

Traits Related to Social Anxiety

MCMI Cluster C

Hotellings T(5,38) = .341, p = .041

MCMI Avoidant

22.30 ± 16.6

10.38 ± 6.9

---

F(1,43) = 10.23, p = .003

MCMI Passive Aggressive

29.65 ± 17.0

17.25 ± 13.3

---

F(1,43) = 7.35, p = .010

MCMI Self Defeating

21.25 ± 16.4

8.92 ±.8.0

---

F(1,43) = 10.6, p = .002

MCMI Compulsive

37.35 ± 8.1

37.54 ± 7.1

---

NS

MCMI Dependent

27.1 ± 6.7

25.3 ± 5.9

---

NS

MCMI Anxiety Disorder

11.40 ± 12.0

3.25 ± 3.9

---

F(1.43) = 9.48, p = .004

DAPI Self Esteem

1.44 ± 1.1

0.57 ± 0.5

---

F(1,39) = 9.96, p = .003

SCID II Cluster C**

6.34 ± 4.9

2.67 ± 3.4

6.95 ± 5.9

Wilks' λ (10,136 = 0.86, p = .414

SCID II Avoidant

1.31 ± 1.4

0.63 ± 1.4

1.26 ± 1.7

NS

SCID II Dependent

0.79 ± 1.0

0.19 ± 0.4

1.00 ± 1.2

F(4,76) = 3.26, p = .016 OA>C, P>C#

SCID II Obs. Compuls

1.79 ± 1.8

0.89 ± 0.2

1.78 ± 1.3

NS

SCID II Passive Aggressive

1.17 ± 1.6

0.37 ± 0.6

1.09 ± 1.5

F(4,76) = 2.86, p = .029

SCID II Depressive

1.28 ± 1.6

0.59 ± 1.0

1.83 ± 1.6

F(4,76) = 2.79, p = .032 OA>C#

Sexual Advances as Child (SHQ)*a

27 (56.3%)

4 (6.6%)

8 (32%)

X2 = 32.3, p<.001 P > OA, C

<13, Partner > 5 yrs older (SHQ)*b

23 (52.3%)

3 (4.9%)

6 (26.1%)

X2 = 4.2, p = .040 P > OA, C

Age Difference with 1st Partner

11.36 + 11.5

2.31 + 7.8

7.00 + 11.4

F(3,117) = 13.8, p = .015 P>C, P> OA#

8.88 ± 5.9

5.97 ± 2.8

7.27 ± 5.5

F(5,92) = 2.95,p = .017 P > C

Abused Abuser

CTQ Sex Abuse Score*

c

#

* Covaried for education ** Covaried for education and ethnicity. Paired contrasts marginally significant at p<.1. a

Subject experienced adult sexual advances as a child.

b

Subject was aged 13 or younger and partner 5 or more years older at first sexual contact.

c

Age difference between subject and first sexual partner in years

presents data on impulsivity, propensity for cognitive distortions and psychopathy.

Impulsivity. Impulsivity was measured in Study 1 by the DAPI-Q Impairment of Impulse Control Scale and the TCI Novelty Seeking Scale and in Study 2 by the Barratt Impulsivity Scale (BIS). These data are presented in Table 2. There was a significant difference between the pedophilic group and controls on the DAPI Impulse Control scale but not on the TCI Novelty Seeking scale. Likewise the pedophilic group did not differ from controls on the BIS, although the opiate group scored significantly higher than either of the other two groups (see Table 2).

Propensity for Cognitive Distortions. Traits related to the propensity for cognitive distortions were measured by the MCMI Cluster A personality disorder scales along with the MCMI Delusional Disorder scale in Study 1 and by the SCID II Cluster A personality disorder scales in Study 286

2. The omnibus test for the MCMI scales was statistically significant and the pedophilic group scored significantly above controls on each of the individual scales. On the SCID II scales, the omnibus test was not statistically significant, but there was a significant group difference on the Paranoid scale and a marginally significant difference on the Schizoid scale. By simple contrasts, the pedophilic group scored marginally higher than controls on Paranoid and significantly higher on Schizoid scales (see Table 2).

Psychopathy. Psychopathy was assessed by the MCMI Antisocial Personality Disorder scale and the DAPI-Q Societal Attitudes and Behavior scales in Study 1 and by the Hare Psychopathy Checklist-Revised in Study 2.

The pedophilic group scored significantly higher than controls on both the MCMI and DAPI-Q scales. There were significant group differences on each of the PCL-R Attitudinal, Behavioral, and Total scores. Simple contrasts showed that both the pedophilic group and opiate

Lisa J. Cohen and Igor Galynker

Table 2. Potentially Disinhibiting Traits in Pedophiles, Healthy Controls, and Opiate Addicts Disinhibiting Traits Pedophiles (p)

Healthy Controls (c)

Opiate Addicts (oa)

Statistics

Impulsivity DAPI Impulse Control

1.37 ± 1.2*

0.59 ± 0.4

---

F(1,38)=8.23, p=.007

TCI Novelty Seeking

19.00 ± 4.1

17.50 ± 5.4

---

NS

BSI Total Score*

58.38 ± 12.7

57.75 ± 10.0

67.83 + 6.6

F(3,78)=5.3,p=.002 OA > P

Propensity for Cognitive Distortions Hotelling’s T (4,39)=.283, p=.041

MCMI Cluster A MCMI Schizotypal

20.90 ± 17.7

8.79 ± 6.3

---

F(1,43)=9.74, p=.003

MCMI Paranoid

30.90 ± 16.2

21.50 ± 12.9

---

F(1,43)=4.59, p=.038

MCMI Schizoid

20.55 ± 8.1

16.42 ± 5.1

---

F(1,43)=4.21, p=.046

MCMI Delusional D/O

15.20 ± 9.6

9.5 ± 5.8

---

F(1,43)=5.91, p=.019

SCID II Cluster A**

3.58 ± 3.2

1.33 ± 2.1

3.39 ± 2.9

Wilks' λ (6,140)=0.89, p=.235

SCID II Paranoid

1.48 ± 1.6

0.37 ± 0.9

1.65 ± 1.7

F(4,76)=5.08, p=.001 P > C#

SCID II Schizoid

1.00 ± 1.2

0.26 ± 0.7

0.78 ± 0.9

F(4,76)=2.37, p=.060 P > C

SCID II Schizotypal

1.10 ± 1.7

0.37 ± 0.8

1.65 ± 1.7

NS

Psychopathy MCMI Antisocial

34.75 ± 13.9

22.92 ± 12.3

---

F(1,42)=8.93, p=.005

DAPI Societal Attitudes

1.33 ± 1.0

0.80 ± 0.5

---

F(1,39)=4.74, p=.036

DAPI Societal Behavior

0.30 ± 0.3

0.07 ± 0.1

---

F(1,39)=12.33, p=.001

PCL-R Total* Score

11.15 ± 9.5

5.40 ± 5.6

16.08 ± 9.8

F(3,71)=8.4, p<.001 P,OA > C, OA > P

PCL-R Attitudinal*

4.62 ± 3.2

1.16 ± 1.6

4.54 ± 4.0

F(3,71)=6.79,p<.001 P, OA > C

PCL-R Behavioral*

5.62 ± 6.6

1.92 ± 2.5

8.79 ± 4.6

F(3,71)=7.40,p<.001 OA > P, C

* Covaried for education. ** Covaried for education and ethnicity. #Paired contrasts marginally significant at p<.1.

addicted group scored higher than controls on the Total and Attitudinal scores whereas only the opiate addicted group scored higher than controls on the Behavioral scale.

Moreover, opiate addicted individuals scored higher than the pedophilic group on the Behavioral scale (see Table 2).

Discussion This paper presented data from two studies conducted as part of a larger research program investigating behavioral and chemical addictions. The data presented here were collected in an attempt to examine whether characteristic psychological and historical traits could be identified that might shed light on factors contributing to either motivation for or failure to inhibit pedophilic urges. There was some evidence of elevations in each of these domains but the strength of the findings varied considerably. The strongest and most consistent findings were for the history of sexual abuse in childhood,

which distinguished the pedophilic group both from the opiate addicted group and controls, and for psychopathy. The findings of elevated traits related to a propensity for cognitive distortions relative to controls were also quite consistent and appeared specific to the pedophilic group vs. the opiate addicted group. The findings related to traits associated with social anxiety were less consistent and elevations in this domain were less distinguishable from those of the opiate addicted group.

This suggests that, while traits related to social anxiety may be elevated in some individuals with pedophilia, this is not a specific finding. Finally, only one out of the three impulsivity measures supported increased impulsivity in the pedophilic group relative to controls.

In fact, on the BSI, the opiate addicted group scored significantly higher than the pedophilic group. The elevation in the opiate addicted group compared to the pedophilic group on the behavioral but not attitudinal psychopathy score supports this finding, such that the 287

Psychological Traits Subserving Aberrant Motivation or Inhibitory Failure in Pedophilic Behavior

opiate addicted group appears in general to be more impulsive than the pedophilic group.

In general, our data is consistent with previous literature as was discussed above in the Introduction section (10, 12, 13, 17, 23, 33). Nonetheless, these data offer novel information. For one, the traits assessed here are collected together and synthesized into an integrated model of traits contributing either to aberrant motivation or inhibitory failure. Secondly, comparisons with a chemically addicted control group allow for assessment of the specificity of these findings. While perpetrators of sexual offences against children have been compared to non-sexual offenders and sexual offenders against adults (5, 17), there is little data comparing pedophilic individuals with non-forensic, clinical control groups.

Our data should be considered within the context of its limitations, however. Our samples were relatively small, our data relied on self-report and were not corroborated by criminal records, and although rating scales were closely supervised, we did not calculate inter-rater reliability coefficients. Further, although almost 60% of subjects in Study 2 reported more than one victim, subjects were not diagnosed by DSM-IV criteria for pedophilia. Finally, subjects with pedophilic behavior were recruited from an outpatient clinic specializing in the treatment of sex offenders and thus may differ from currently incarcerated sex offenders, from individuals with pedophilic behavior who have never been caught or those with pedophilic desire who have never acted on their urges. Nonetheless, our data is consistent with prior literature and contributes to a fuller understanding of the psychological traits potentially contributing to motivation for or the failure to inhibit pedophilic inclinations.

Heterogeneity in pedophilia Of particular interest, our data is consistent with prior research showing mixed findings for the degree of impulsivity among individuals with pedophilic behavior (12, 29, 32). Moreover, although elevated rates of childhood sexual abuse are one of the most robust findings in the literature, our data parallels many other studies in showing a high proportion of pedophilic subjects that deny any such history (17, 19, 22). One explanation for these discrepant findings is heterogeneity among pedophiles.

Many authors have written about this (1, 2, 45), but there is lack of consensus about the best means of categorizing subgroups. DSM-IV-TR lists subgroups according to sex of the victim, exclusivity of pedophilic desire and pres288

ence of incest (3). The DSM-V work group for pedophilia proposes subgroups based on age and sex of victim (46).

Perhaps a more useful distinction is between “true” or “opportunistic” pedophiles. Similar terms include fixated vs. regressed and preferential vs. situational pedophiles (1, 2, 45). A dimensional rather than categorical approach to this distinction has also been proposed (47). True pedophiles have a specific, ongoing sexual attraction to children, which persists relatively independent of context. In contrast, opportunistic pedophiles have less specific sexual attraction to pre-pubescent children and may turn to children for various situational reasons. The distinction between pedophilic and non-pedophilic child molesters falls in a similar vein (20, 48).

Although there is little data comparing true vs. opportunistic pedophiles, we can hypothesize how the traits putatively associated with deviant motivation and impaired inhibition may vary across the two groups. In short, true pedophiles should be strongly characterized by traits related to deviant motivation while opportunistic pedophiles would present significant inhibitory problems. As such, true pedophiles would have higher rates of CSA than opportunistic pedophiles who may in turn be more impulsive and psychopathic. Both might suffer from social anxiety but true pedophiles would be more characterized by cognitive distortions as pedophilic urges and behaviors are more central to their identity.

We also hypothesize that true pedophiles might show abnormalities in the amygdalar/temporal regions whereas opportunistic pedophiles might show abnormalities in the frontal regions. Table 3 presents hypothesized traits specific to each subgroup of pedophiles.

There is some support for these hypotheses in the literature. In fact, a study by Eher et al. (8) provides considerable support for this conceptualization.

Table 3.

Hypothesized Distinctions Between “True” and “Opportunistic” Pedophiles True

Opportunistic

Planful

Impulsive

+/- Psychopathy

Psychopathic

Cognitive Distortions/Cluster A Personality Pathology

Executive Dysfunction

+/- Social Anxiety

+/- Social Anxiety

Childhood Sexual Abuse History Amygdalar/Temporal Abnormalities

Frontal Abnormalities

Lisa J. Cohen and Igor Galynker

Classifying rapists and child molesters according to the Massachusetts Treatment Center rapist typology, “sexualized” sex offenders against either minors or adults were compared to “non-sexualized” rapists of adults. “Sexualized” sex offenders were motivated primarily by sexual concerns and often showed abnormal sexual arousal patterns. “Non-sexualized” sex offenders were motivated more by “aggression, hostility or vindictiveness.” The two groups of sexualized offenders were similar with regard to anxiety, depression, and aggression while the non-sexualized rapists had greater lifestyle impulsivity, more non-sexual offenses and more antisocial behavior as juveniles and adults. Further, Suchy and colleagues (48) found non-pedophilic child molesters to perform worse on tests of facial and vocal affect recognition than pedophilic child molesters. The authors interpreted this to imply greater levels of psychopathy in non-pedophilic child molesters compared to their pedophilic counterparts. Finally Freund et al.

(20) found a higher incidence of childhood sexual abuse in pedophilic vs. non-pedophilic child molesters.

Likewise, our own data comparing opiate addicted and pedophilic subjects are also consistent with the proposed distinctions between true and opportunistic pedophiles. Opiate addicted subjects, characterized by non-sexual, reward driven behavior, show higher levels of impulsivity, lesser incidence of childhood sexual abuse, and greater levels of psychopathic traits than subjects with pedophilic behavior, although this last difference seems largely attributable to behavioral disinhibition.

Our earlier PET study of 15 adult males with pedophilic behavior demonstrated abnormal activation in both frontal and temporal brain regions compared to healthy controls (6). As there is considerable evidence linking abnormal or hypoactive function in the frontal regions to impulsivity and behavioral disinhibition (49, 50), and reduced frontal function has been demonstrated in impulsive groups such as chemically addicted individuals (51), we can hypothesize that if opportunistic pedophiles are characterized by impulsivity, they would also show reduced frontal function.

The underlying neuropathology of pedophilic sexual desire, as distinct from impulsivity and psychopathy, is less understood although a 2007 study by Schiltz et al.

(52) showed decreased volume in the right amygdala in pedophilic offenders compared to controls on MRI. Amygdalar volume was not correlated with scores on the Hare Psychopathic Checklist but was inversely correlated with the exclusivity of pedophilic offenses, such

that offenders who committed sexual offenses against diverse age groups had higher amygdalar volumes.

All of the traits addressed in this paper, with the possible exception of psychopathy, have established treatments – either psychological, pharmacological or both (4, 34, 47). While many treatments for pedophilia include interventions designed to enhance social skills, combat cognitive distortions, control impulsivity, etc., coordination of such treatments into a comprehensive approach might prove highly beneficial. Moreover, interventions could be customized for each individual following a careful assessment of both inhibitory and motivating factors. In this way, treatments can be developed to address the commonalities among pedophiles without disregarding the oft-noted heterogeneity.

Acknowledgements We would like to acknowledge the contributions of Steven Frenda, Matthew Steinfeld, Cristina Nesci and Dr. Yuli Grebchenko.

Supported in part by Singer Grant 1480-410 and National Institute on Drug Abuse Grant #12273-01 to Dr. Galynker.

Contribution of Authors Dr. Cohen contributed to conceptual and study design, data collection, data analysis, manuscript preparation, editing and revision, and final approval.

Dr. Galynker contributed to conceptual and study design, data collection, staff supervision, manuscript editing, and final approval.

References 1. Prentky RA, Knight RA, Lee AFS. Child sexual molestation: Research issues. In: Bartol C, Bartol AM, editors. Current perspective in forensic psychology and criminal behavior, 2nd ed. Thousand Oaks: Sage, 2008: pp. 123-134.

2. Lanning KV. Child molesters: A behavioral analysis. [monograph on the Internet]. Alexandria: National Center for Missing & Exploited Children; 2001[cited 2009 April 6]. Available from: http://www.missingkids.com/ en_US/publications/NC70.pdf.

3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed., Text Revision. Washington, DC: American Psychiatric Press, 2000.

4. Seto MC. Pedophilia and sexual offending against children: Theory, assessment, and intervention. Washington, DC: American Psychological Association, 2008.

5. Haywood TW, Kravitz HM, Wasyliw OE, et al. Cycle of abuse and psychopathology in cleric and noncleric molesters of children and adolescents. Child Abuse Negl 1996; 20:1233-1243.

6. Cohen LJ, Nikiforov K, Gans S, Poznansky O, McGeoch P, Weaver C, et al. Hetrosexual male perpetrators of childhood sexual abuse: A preliminary neuropsychiatric model. Psychiatr Q 2002; 73:313-335.

7. Cohen LJ, Galynker II. Psychopathology and personality traits of pedophiles: Issues for diagnosis and treatment. Psychiatric Times 2009; 26: 25-30.

8. Eher R, Neuwirth W, Fruehwald S, Frottier P. Sexualization and lifestyle impulsivity: clinically valid discriminators in sexual offenders. Int J Offender Ther Comp Criminol 2003; 47:452-467.

9. Araji S, Finkelhor D. Explanations of pedophilia: Review of empirical research. Bull Am Acad Psychiatry Law 1985;13:17-37.

289

Psychological Traits Subserving Aberrant Motivation or Inhibitory Failure in Pedophilic Behavior

10. Haywood TW, Grossman LS. Denial of deviant sexual arousal and psychopathology in child molesters. Behav Ther 1994; 25:327-340.

11. Blumenthal S, Gudjonsson G, Burns J. Cognitive distortions and blame attribution in sex offenders against adults and children. Child Abuse Negl 1999;23:129-143.

12. Raymond NC, Coleman E, Ohlerking F, Christenson GA, Miner M. Psychiatric comorbidity in pedophilic sex offenders. Am J Psychiatry 1999;156:786-788.

13. Black DW, Kehrberg LLD, Flumerfelt DL, Schlosser SS. Characteristics of 36 subjects reporting compulsive sexual behavior. Am J Psychiatry 1997;154:243-249.

14. Wilson GD, Cox DN. Personality of paedophile club members. Pers Indiv Diff 1983;4:323-329.

15. Fisher D, Beech A, Browne A. Comparison of sex offenders to nonoffenders on selected psychological measures. Int J Offender Ther Comp Criminol 1999;43:473-491.

16. Black DW. The epidemiology and phenomenology of compulsive sexual behavior. CNS Spect 2000;5:26-35.

17. Freund K, Kuban M. The basis of the abused abuser theory of pedophilia: A further elaboration on an earlier study. Arch Sex Behav 1994;23:553-563.

18. Cohen LJ, McGeoch PG, Gans SW, Nikiforov K, Cullen K, Galynker II. Childhood sexual history of 20 male pedophiles vs. 24 male healthy control subjects. J Nerv Ment Dis 2002;190:757-766.

19. Dhawan S, Marshall WL. Sexual abuse histories of sexual offenders.

Sex Abuse 1996;8:7-15.

20. Freund K, Watson R, Dickey R. Does sexual abuse in childhood cause pedophilia: An exploratory study. Arch Sex Behav 1990;19:557-568.

21. Knopp F, Lackey L. Female sexual abusers: A summary of data from 44 treatment providers. Orwell, Vt.: Safer Society Program, 1987.

22. Seghorn TK, Prentky RA, Boucher RJ. Childhood sexual abuse in the lives of sexually aggressive offenders. J Am Acad Child Adolesc Psychiatry 1987;26:262-267.

23. Bagley C, Wood M, Young L. Victim to abuser: Mental health and behavioral sequels of child sexual abuse in a community survey of young adult males. Child Abuse Negl 1994;18:683-696.

24. Rick S, Douglas DH. Neurobiological effects of childhood abuse. J Psychosoc Nurs Ment Health Serv 2007;45:47-54.

25. Stark CP. Behavioral effects of stimulation of the medial amygdala in the male rat are modified by prior sexual experience. J Gen Psychol 2005; 132: 207-224.

26. Stein D, Black DW, Pienaar W. Sexual disorders not otherwise specified: Compulsive, addictive or impulsive? CNS Spectr 2000; 5:60-64.

27. Krueger RB, Kaplan MS. Behavioral and psychopharmacological treatment of the paraphilic and hypersexual disorders. J Psychiatr Pract 2002;8:21-32.

28. Kafka M. Sexual impulsivity. In Hollander E, Stein D, editors. Impulsivity and aggression. New York: John Wiley, 1995: pp. 201-228.

29. Galli V, McElroy SL, Soutullo CA, Kizer D, Raute N, Keck PE Jr, et al.

The psychiatric diagnoses of twenty-two adolescents who have sexually molested other children. Compr Psychiatry 1999;40:85-88.

30. Cohen LJ, Nesci C, Steinfeld M, Haeri S, Galynker I. Investigating the relationship between sexual and chemical addictions by comparing executive function in pedophiles, opiate addicts and healthy controls.

J Psychiatr Pract 2010;16:405-412.

31. Cohen LJ, Frenda S, Mojtabai R, Katsadakis K, Galynker I. Comparison of sexual offenders against children with sexual offenders against adolescents and adults: Data from the New York state sex offender registry. J Psychiatr Pract 2007; 13:373-384.

32. Gebhard PH, Gagnon JH, Pomeroy WB, Christenson CV. Sex offenders.

New York: Bantam Books, 1967.

290

33. Henderson MC, Kalichman SC. Sexually deviant behavior and schizotypy: A theoretical perspective with supportive data. Psychiatr Q 1990;61:273284.

34. Cohen LJ, Grebchenko YF, Steinfeld M, Frenda SJ, Galynker II. Comparison of personality traits in pedophiles, abstinent opiate addicts, and healthy controls: Considering pedophilia as an addictive behavior.

J Nerv Ment Dis 2008;196:829-837.

35. Cohen LJ, McGeoch P, Watras-Gans S, Acker S, Poznansky O, Cullen K, et al. Personality impairment in male pedophiles. J Clin Psychiatry 2002; 63:912-919.

36. 36.First MB, Gibbon M, Spitzer RL, Williams JBW, Benjamin LS. Userâ&#x20AC;&#x2122;s guide for the structured clinical interview for DSM-IV axis II personality disorders. Washington DC: American Psychiatric Press, 1995.

37. Millon T. Millon clinical multiaxial inventory-II: Manual for the MCMIII. 2nd ed. Minneapolis: National Computer Systems, 1987.

38. Kaye AL, Shea MT. Personality disorders, personality traits, and defense mechanisms. In: Task force for the handbook of psychiatric measures, editors. Handbook of Psychiatric Measures. Washington, DC: American Psychiatric Association, 2000: pp. 713-751.

39. Cloninger RC, Svrakic DM, Przybeck TR. A psychobiological model of temperament and character. Arch Gen Psychiatry 1993;50:975-990.

40. Cohen LJ, Kingston P, Bell A, Kwon J, Aronowitz B, Hollander E. Comorbid personality impairment in body dysmorphic disorder. Compr Psychiatry 2000;41:4-12.

41. Barratt ES, Stanford MS. Impulsiveness. In Costello CG, editor.

Personality characteristics of the personality disordered client. New York: Wiley, 1995: pp. 91-119.

42. Hollander E, Cohen LJ, Simon L. Impulse control disorder measures. In: Task force for the handbook of psychiatric measures, editors. Handbook of psychiatric measures. Washington, DC: American Psychiatric Association, 2000: pp.687-712.

43. Hare RD. The hare psychopathy checklist-revised manual. North Tonawanda, N.Y.: Multi-Health Systems, 1991.

44. Bernstein DP, Fink L, Handelsman L, Foote J, Lovejoy M, Wenzel K, et al. Initial reliability and validity of a new retrospective measure of child abuse and neglect. Am J Psychiatry 1994; 151:1132-1136.

45. McConaghy N. Paedophilia: A review of the evidence. Aust N Z J Psychiatry 1998;32:252-265.

46. American Psychiatric Association. DSM-5 Development. [homepage on the Internet]. Washington, DC: American Psychiatric Association; 2010 [updated 2010 February 2; cited 2010 October 12] Available from: http://www.dsm5.org/.

47. Maletzky BM. Factors associated with success and failure in the behavioral and cognitive treatment of sexual offenders. Sex Abuse J Res Treat 1993; 6:241-258.

48. Suchy Y, Whittaker WJ, Strassberg DS, Eastvold A. Facial and prosodic affect recognition among pedophilic and nonpedophilic criminal child molesters. Sex Abuse J Res Treat 2009; 21:93-110.

49. Oldham J, Hollander E, Skodol A. Impulsivity and compulsivity.

Washington DC: American Psychiatric Press, 1996.

50. Coccaro EF, Siever LJ, Klar HM, Maurer G, Cochrane K, Cooper TB, et al. Serotonergic studies in patients with affective and personality disorders: correlates with suicidal and impulsive aggressive behavior.

Arch Gen Psychiatry 1989;46:587-599.

51. Galynker I, Eisenberg D, Matochik JA, Gertmenian-King E, Cohen LJ, Kimes AS, et al. Cerebral metabolism and mood in remitted opiate dependence. Drug Alcohol Depend 2007; 90: 166-174.

52. Schiltz K, Witzel J, Northoff G, Zierhut K, Gubka U, Fellmann H, et al.

Brain Pathology in pedophilic offenders: Evidence of volume reduction in the right amygdala and related diencephalic structures. Arch Gen Psychiat 2007;64:737-746.

Isr J Psychiatry Relat Sci - Vol. 49 - No 4 (2012)

Cognitive-Behavioral Treatment of the Paraphilias Meg S. Kaplan, PhD, and Richard B. Krueger, MD Columbia University, College of Physicians & Surgeons, Department of Psychiatry, and Sexual Behavior Clinic, New York State Psychiatric Institute, New York, New York, U.S.A.

Abstract Background: Sexual offenders continue to occupy the public’s attention; a significant proportion of this population is diagnosed with paraphilias. Cognitivebehavioral treatment has been the mainstay of treatment for sex offenders and for the paraphilias for the past three decades. This article will review the history of cognitivebehavioral therapy, its techniques, and its efficacy.

Method: A literature review was conducted of PubMed and PsychInfo Databases.

Results: A significant literature exists describing cognitive-behavioral therapy and presenting outcome studies and meta-analyses evaluating its efficacy.

Limitations: This study is based on a literature review and influenced by the knowledge and biases of the authors.

Conclusions: Cognitive-behavioral therapy is the most prominent therapy for sexual offenders. Although reports from individual programs and meta-analyses support its efficacy, overall, the strength of the evidence base supporting this therapy is weak and much more empirical research is needed.

Background Public concern about sexual offenders has escalated.

A significant proportion of this population has been diagnosed with paraphilias (1). The essential features of

a paraphilia are “recurrent, intense, sexually arousing fantasies, sexual urges, or behaviors generally involving 1) nonhuman objects, 2) the suffering or humiliation of oneself or one’s partner, or 3) children or other nonconsenting persons that occur over a period of at least 6 months (Criterion A)” (2, p. 566). A reduction in sexual offending will depend on the ability of clinicians to identify the most effective treatments for this population. Currently the most widely recognized treatment for sexual offenders and paraphilias is cognitive-behavioral treatment, including relapse prevention (2-6). This article will review the theoretical base for cognitivebehavioral therapy, describe the specific techniques used, present information on efficacy, reviewing major reports from specific treatment programs and metaanalyses, and discuss limitations of the current evidence base. Suggestions for future directions will be offered.

Method A literature search was conducted on the non-pharmacological treatment of the paraphilias using PubMed and PsychInfo databases from the years 1990 through April of 2011. The non-pharmacological treatments emphasized cognitive-behavioral therapy and relapse prevention therapy. The PubMed search included any pertinent Cochrane Reviews. The search used search terms of “paraphilias,” “exhibitionism,” “voyeurism,” “frotteurism,” “sadism,” “masochism,” fetishism,” “transvestic fetishism,” “paraphilia-related disorder,” “paraphilic coercive disorder,” and “paraphilic rape.” In addition, the authors reviewed secondary references, textbooks, and textbook chapters. Relevant literature was selected and reviewed.

Address for Correspondence: Meg S. Kaplan, PhD, Sexual Behavior Clinic, New York State Psychiatric Institute, 1051 Riverside Drive, Unit #45, New York, New York 10032, U.S.A. msk2@columbia.edu The first author received travel support from Ferring, Inc. and was a consultant to the Paraphilias Subworkgroup of the Sexual Disorders Workgroup of DSM-5. The second author is on the Paraphilias Subworkgroup of the Sexual Disorders Workgroup of DSM-5 & on the World Health Organization International Classification of Disease Working Group on Sexual Disorders and Sexual Health.

291

Cognitive-Behavioral Treatment of the Paraphilias

Results History of Cognitive-Behavioral Therapy

In a recent review (5, 6) of behavioral and cognitive behavioral approaches to sexual offenders, Laws and Marshall concluded (p. 110): It is evident from this review of the history of sexual offender treatment that cognitive behavioral procedures have developed into a comprehensive approach that is widely shared and appears to be effective. The breadth of treatment targets has progressively increased and research has been implemented to evaluate the basis for these expanded targets. Theoretical and classification efforts have moved in harmony with both the expansion of treatment programs and the associated generation of research.

Social learning theory approaches have been cited as important contributing factors in the development and maintenance of paraphiliac sexual interest; the importance of conditioning is emphasized over intrapsychic processes (7). Behavior therapy interventions for this population were originally derived from Pavlov’s classical conditioning (8) and Skinner’s operant conditioning (9) and used to attempt to modify sexual preferences (10).

According to McGuire, Carlisle and Young (11), “The theoretical basis for such treatment, as for all behavior therapy, is that the symptom or behavior to be treated has been learned at some time in the past and can be changed by the learning of a new pattern of behavior” (p. 185).

Thus, the goal of treatment is to reduce inappropriate sexual arousal and increase appropriate arousal (12).

Prominence of Cognitive-Behavioral Therapy

The Safer Society Program, a non-profit organization in the United States dedicated to ending sexual abuse, has since the 1980s regularly conducted surveys of sex offender treatment programs in the United States and Canada.

These surveys clearly demonstrate that the predominant modality for treatment is cognitive-behavioral and relapse prevention therapy (13). For instance, in the most recent survey of 1,379 sexual abuser treatment programs from all 50 states (13), the District of Columbia, and nine Canadian Provinces during 2008, for community programs, 65.1% reported that cognitive-behavioral theory best described their program, followed by relapse prevention (14.8%), the good lives model (5.2%), multisystemic theory (3.1%), and risk-need-responsivity (3.1%). Other theoretical approaches (biomedical, family systems, harm reduction, psycho-dynamic, psycho-socio-educational, self-regulation, sexual addiction, sexual trauma, and 292

other) were reported by less than 2% of the programs.

Similar results were reported for residential programs and in earlier surveys. In Canada, 47.4% of adult community programs identified cognitive-behavioral treatment as their primary theory, 15.8% relapse prevention, 10.5% good lives, and 5.3% biomedical, multisystemic, psycho-socio-educational, risk-need-responsivity, and self-regulation. Among adult residential programs in Canada 50.0% identified cognitive-behavioral treatment as their main theory, 37.5% self-regulation, and 12.5% bio-medical. Thus, in North America, clearly cognitivebehavioral and relapse prevention modalities have been the predominate theory guiding treatment.

Description of Techniques

Decreasing Inappropriate Arousal

The principle treatment approach of behavior therapy for paraphilias is to eliminate the pattern of sexual arousal to deviant fantasy by assisting the patient with decreasing inappropriate sexual arousal. A variety of techniques that have been used have been reviewed by Marshall and Laws (5, 6, 14-16). Some of these will be described here: Covert Sensitization: This is a method that has been used effectively to disrupt fantasies and behaviors that are antecedent to the offending behavior. It pairs urges and feelings that lead an individual to engage in a deviant act with aversive images which reflect the adverse consequences of continuing with the deviant behavior (17, 18). This treatment is conducted by having the patient tape record the session in private. A therapist then reviews it and offers feedback in either individual or group sessions. This technique has been used successfully to treat exhibitionists (19, 20).

Satiation: Masturbatory satiation is a technique that is effective in decreasing deviant sexual arousal by making the deviant fantasy boring. This therapy consists of having the patient masturbate at home in private to non-deviant adult fantasies until ejaculation has occurred. Satiation works by pairing deviant sexual fantasies with the aversive task of masturbating for 55 minutes post orgasm. These sessions are audiotaped at home and brought to therapy sessions where tapes are reviewed and critiqued. Several studies have supported the value of this technique (12, 21-23).

Systematic Desensitization: This is a technique that aims at the decrease of maladaptive anxiety by pairing relaxation with imagined scenes depicting anxietyproducing situations (24).

Meg S. Kaplan and Richard B. Krueger

Enhancing Appropriate Sexual Arousal to Adult Partners

The second component of cognitive-behavioral treatment with individuals with paraphilias is to assist the patient with enhancing sexual interest and arousal to adult partners or to appropriate behavior with adult partners. There are a variety of techniques, some of which will be described here.

Orgasmic Reconditioning: Marquis (25) first described this procedure in which the client masturbates to orgasm while fantasizing about or watching normative sexual behavior with adults. Other clinicians later described similar techniques (26). According to Laws and Marshall (12), evidence is weak. Masturbatory satiation, previously described, is also used to replace deviant fantasy by pairing fantasies of consenting sex with peers with masturbation and ejaculation.

Fading: This is a technique which helps individuals shift their sexual fantasies from atypical to acceptable (27). It aims to change sexual fantasy and arousal towards more acceptable interests. The patient is asked to fantasize about atypical sexual stimuli and then gradually fade the fantasy to one involving more acceptable sexual activity.

It is also used to increase sexual interest in adults (27).

Kelly (28) reviewed behavioral procedures used to try and reorient sexual preferences of child molesters. He reported that 75% of programs employed behavioral techniques to suppress deviant sexual arousal, others used procedures to enhance appropriate sexual arousal and some used both. He concluded overall that these procedures were effective.

Other Components of Cognitive-Behavioral Treatment

Many early programs added other treatment components in order to help patients initiate and maintain appropriate social, sexual and intimate relationships (29-31). Marshall and Laws (5, 6) have written a comprehensive history of cognitive-behavioral approaches to treatment that describes all the components in detail.

The most widely used will be briefly described here.

Cognitive Restructuring: Behavior is influenced by cognitive processes and attitudes. This component of treatment targets cognitive distortions (17, 32, 33). An example of such a distortion is “Having sex with a child is a good way for an adult to teach the child about sex.”

Most individuals who engage in atypical sexual behaviors have developed permission-giving statements or rationalizations and hold irrational beliefs regarding their fantasies and behaviors. Many paraphiliacs change their

attitudes and beliefs to be consistent with their behaviors.

This results in cognitive distortions, misbeliefs, and a rationale to support their behavior. Treatment focuses on recognition of the offender’s own distortion.

Assertive Skills Training: Some paraphiliacs are unable to express positive or negative feelings, state what they want, or ask others to change their behavior.

Some are passive or aggressive. Techniques used include: modeling, rehearsal, and social feedback (17) Social Skills Training/Intimacy Deficits: Some paraphiliacs have deficits in establishing effective communication with adult partners. An example would be inappropriate questions of others in initiating conversations.

Role rehearsal is used to model appropriate interactions.

Sexual Education/Sexual Dysfunction Treatment: Some paraphiliacs lack knowledge of what is considered appropriate sexual behavior. Others have sexual problems that are in need of treatment, such as premature ejaculation or erectile dysfunction. A goal of this part of treatment is also to help the individual decide what the components of “healthy sexuality” would be (34).

Empathy: Often sexual offenders have deficits in empathy for their victims and little sensitivity to what their victims have experienced. One component of therapy is enhancement of empathy (35).

Personal Victimization: Research has shown that a large number of offenders have themselves been sexually abused (36) and that left untreated this may put them at greater risk to recidivate. Dealing with their own victimization is an important component of treatment for sex offenders (17, 37).

Relapse Prevention: Relapse prevention was first described by Marlatt (38) in his work with substance abusers. This was then extended to the treatment of sex offenders (39). The goals are to teach individuals how to anticipate and cope with relapse, to help identify high-risk situations and triggers, and to cope by using cognitive interventions and skills training.

Adjunctive Treatment: In response to criticism of the relapse prevention model, Ward and Hudson developed a “self-regulation” model of the offense process (40). This model is based upon setting goals and making decisions by integrating cognition, affect, and behavior (41). This approach is intended to augment and enhance cognitivebehavioral treatment. The Good Lives and Emotion SelfRegulation Models address the promotion of a good life and the management of risk. Treatment takes a positive approach rather than focusing on avoidance goals, and it is a humanistic and positive approach.

293

Cognitive-Behavioral Treatment of the Paraphilias

Multi-systemic Treatment is another modality which has been used with adolescents with inappropriate sexual behavior (42). Treatment addresses the needs of the family and other influences, such as school environment and peers.

Efficacy of Treatment

Evaluation of treatment effectiveness and recidivism has proven extremely difficult because of many factors.

Among these are methodological problems, underreporting of sexual crimes, sample variability, differences in treatment interventions, and differences in data analysis. However there have been several outcome studies of individual programs, as well as meta-analyses. We will focus on individual program outcome studies first.

Individual Programs

In 1988 Abel and his colleagues (43) conducted a study of outpatient sex offenders under a certificate of confidentiality and found that many offenders had multiple paraphilias and higher incidences of sexual offenses than had been found in other samples without the confidentiality certificate (44). This group also reported on a follow-up study of 192 sexual offenders treated in a 30 week cognitivebehavioral program (17, 43). At one-year post treatment, 12% had recidivated (according to self-report). A history of multiple offense types was the largest predictor of relapse.

In 1993 Maletzky reported on a retrospective study over 20 years of 4,381 pedophiles who had been treated in an outpatient program for an average of 23 months (45). Although recidivism was low initially, relapse rates continued to rise even 10 years after treatment. In 2002 Maletzky and Steinhauser reported on an expansion of the original database in a 25-year follow-up study of cognitive-behavioral therapy with 7,275 sexual offenders (46). They concluded that overall “the cognitivebehavioral techniques employed generated long lasting positive results by reducing recidivism & risk to the community” (p. 143). They reported that outcomes appeared to be better in child molesters and exhibitionists than in homosexual pedophiles and rapists.

Marques et al. in 2005 (47) reported on the results of a relapse prevention program with incarcerated sexual offenders. The study was randomized and compared reoffense rates among three groups: inpatient relapse prevention treatment and two untreated prison control groups. The results were disappointing: No significant differences were found among the three groups for both child molesters and rapists over an 8-year follow-up 294

period. However, of those who received relapse prevention treatment, individuals who met the program’s treatment goals had lower reoffense rates than those who did not.

Meta-analyses Relevant to Treatment Outcome

Furby et al. in 1989 (48) reviewed empirical studies of sex offender recidivism. They included 42 studies of treated and untreated sex offenders and cited many problems with methodological variability from study to study. They concluded that “There is as yet no evidence that clinical treatment reduces rates of sex offenses in general and no appropriate data for assessing whether it may be differentially effective for different types of offenders” (p. 27).

Hall (49) in 1995 conducted a meta-analysis of the treatment outcome literature and concluded that cognitive behavioral treatment was effective. Community based treatment showed better effects than institutional based treatment.

A more recent meta-analysis by Hanson and Bussière (3) summarized data from 43 studies (n=9,454) examining the effectiveness of psychological treatment for sex offenders. The sexual offense recidivism rate was lowest for the treatment groups (12.3%) than the comparison groups (16.8%). Cognitive-behavioral treatment (k=13) and systemic treatment (k=2) were associated with reductions in sexual recidivism (from 17.4 to 9.9%).

Older forms of treatment appeared to have little effect.

Lösel and Schmucker (4) in 2005 reported a metaanalysis performed on sex offender treatment from 69 studies (total N=22,181). Treated offenders showed 37% less sexual recidivism than controls. Of the treatments utilized, surgical castration and hormonal medication showed larger effects than psychosocial intervention. However, among the psychosocial interventions, cognitive-behavioral approaches revealed the most robust effect. Non-behavioral treatments did not demonstrate a significant impact.

The Cochrane Review (50) examined all randomized controlled trials for people with disorders of sexual preference and for convicted sex offenders. Using a comprehensive literature search strategy to locate treatment studies, 431 citations were identified; of these only three studies were included in the review. Nine studies were identified as awaiting assessment and the rest excluded for reasons that they were not randomized trials, interventions were not compatible with the review protocol, or the described trials on the same group of patients. One study, by Marques et al. (47, 51) has been mentioned.

The other, by McConaghy (52) found that anti-libidinal medication plus imaginal desensitization was no better

Meg S. Kaplan and Richard B. Krueger

than imaginal desensitization alone. A large pragmatic trial that investigated the value of group therapy for sex offenders was included (54); this study found no effect on recidivism at 10 years. The Review concluded (50, p. 2): It is disappointing to find that this area lacks a strong evidence base, particularly in light of the controversial nature of the treatment and the high levels of interest in the area. The relapse prevention programme did seem to have some effect on violent reoffending but large, well-conducted randomized trials of long duration are essential if the effectiveness or otherwise of these treatments is to be established.

Limitations The main limitation of this study is the fact that it is a literature review, which is influenced by the knowledge and biases of the authors. Additionally, treatment of sexual offenders has not had the funding, research base, or development of scientific studies that other areas of psychiatry have enjoyed. Most of the studies upon which the knowledge base of the treatment of sexual offenders is based are seriously flawed. Nevertheless, this article represents a comprehensive review of cognitive-behavioral therapy.

Conclusions Cognitive-behavioral therapy has been and continues to remain the predominate approach to the treatment of sex offenders and/or individuals with paraphilias. Its main treatment approach involves decreasing inappropriate sexual arousal through a variety of techniques, including covert sensitization, satiation, fading, and systematic desensitization. This approach also aims to enhance appropriate sexual arousal to adult partners through techniques such as orgasmic reconditioning or fading.

Other components of cognitive-behavioral treatment include cognitive restructuring, assertive skills training, social skills training, addressing intimacy deficits, sexual education, sexual dysfunction treatment, enhancing empathy, personal victimization, relapse prevention, and a variety of adjunctive treatments which have been developed through the years. Some individual programs utilizing cognitive-behavioral treatment have reported positive outcomes, but the best-designed study reported no clear benefit. An early influential meta-analysis by Furby (48) reported no discernable effect of treatment, but later meta-analyses reported positive effects of cognitive-behavioral treatment on recidivism. Overall,

however, the evidence base for cognitive-behavioral treatment is extremely limited and empirical research focusing on effective treatment for this population is critically needed.

References 1. Elwood RW, Doren DM, Thornton D. Diagnostic and risk profiles of men detained under Wisconsin's sexually violent person law. Int J Offender Ther Comp Criminol 2008; 54:1-10.

2. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. Text Revision. DSM-IV-TR. In: Association AP, editor. Diagnostic and Statistical Manual of Mental Disorders. Text Revision. DSM-IV-TR. 4th ed. Washington, DC: American Psychiatric Association, 2000: pp. 1-943.

3. Hanson RK, Gordon A, Harris AJR, Marques JK, Murphy W, Quinsey VL, et al. First report of the collaborative outcome data project on the effectiveness of psychological treatment for sex offenders. Sex Abuse 2002;14:169-194.

4. Lรถsel F, Schmucker M. The effectiveness of treatment for sexual offenders: A comprehensive meta-analysis. J Exp Criminol 2005;1:117-146.

5. Laws DR, Marshall WL. A brief history of behavioral and cognitive behavioral approaches to sexual offenders: Part 1. Early developments.

Sex Abuse 2003;15:75-92.

6. Marshall WL, Laws DR. A brief history of behavioral and cognitive behavioral approaches to sexual offender treatment: Part 2. The modern era. Sex Abuse 2003;15:93-120.

7. Abel GG, Blanchard EB, Jackson M. The role of fantasy in the treatment of sexual deviation. Arch Gen Psychiatry 1974;30:467-475.

8. Pavlov IP. The scientific investigation of the psychical faculties or processes in the higher animals. Science 1906;24:613-619.

9. Skinner BF. Science and human behavior. New York: Macmillan, 1953.

10. Quinsey VL. The assessment and treatment of child molesters: A review.

Can Psychol Rev 1977;18:204-220.

11. McGuire RJ, Carlisle JM, Young BG. Sexual deviations as conditioned behavior: A hypothesis. Behav Res Ther 1965;3:185-190.

12. Laws DR, Marshall WL. Masturbatory reconditioning with sexual deviates: An evaluative review. Adv Behav Res Ther 1991;13:13-25.

13. McGrath RJ, Cumming GF, Burchard BL, Zeoli S, Ellerby L. Current practices and emerging trends in sexual abuser management. The Safer Society 2009 North American Survey. Brandon, Vermont: The Safer Society Press, 2010.

14. Marshall WL, Barbaree HE. The reduction of deviant arousal. Satiation treatment for sexual aggressors. Crim Justice Behav 1978;5:294-303.

15. Krueger RB, Kaplan MS. The paraphilic and hypersexual disorders: An overview. J Psychiatr Pract 2001;7:391-403.

16. Krueger RB, Kaplan MS. Behavioral and psychopharmacological treatment of the paraphilic and hypersexual disorders. J Psychiatr Pract 2002;8:21-32.

17. Abel GG, Becker JV, Cunningham-Rathner J, Rouleau JL, Kaplan M, Reich J. The treatment of child molesters. Treatment Manual: The treatment of child molesters. Unpublished manual available from the Sexual Behavior Clinic, New York State Psychiatric Institute, New York, New York, 1984:1-106.

18. Barlow D, Leitenberg H, Agras W. Experimental control of sexual deviation through manipulation of the noxious scene in covert sensitization. J Abnorm Psychol 1969;74:596-601.

19. Maletsky B. Assisted covert sensitization. In: Cox DJ, Daitzman RJ, editors. Exhibitionism: Description, assessment, and treatment. New York, N.y.: Garland STPM, 1980: pp. 187-251.

20. Wolpe J. Psychotherapy by reciprocal inhibition. Stanford, California: Stanford University, 1958.

295

Cognitive-Behavioral Treatment of the Paraphilias

21. Hunter JA, Goodwin DW. The clinical utility of satiation therapy with juvenile sexual offenders: Variations and efficacy. Ann Sex Res 1992;5:71-80.

22. Johnston P, Hudson SM, Marshall WL. The effects of masturbatory reconditioning with nonfamilial child molesters. Behav Res Ther 1992;30:5.

23. Kaplan MS, Morales M, Becker JV. The impact of verbal satiation on adolescent sex offenders: A preliminary report. J Child Sex Abuse 1993;2:81-88.

24. Kraft T. A case of homosexuality treated by systematic desensitization.

Am J Psychother 1967; 21: 815-821.

25. Marquis JN. Orgasmic reconditioning: Changing sexual object choice through controlling masturbation fantasies. J Behav Ther Exp Psychiat ry 1970;1:263-271.

26. Maletzky BM. Orgasmic reconditioning. In: Bellack AS, Hersen M, editor. Dictionary of behaviour therapy techniques. New York: Pergamon, 1985: pp. 157-158.

27. Abel GG, Osborn CA. Behavioral therapy treatment for sex offenders.

In: Rosen I, editor. Sexual deviation. 3rd ed. Oxford: Oxford University, 1996: pp. 382-398.

28. Kelly RJ. Behavior re-orientation of pedophiliacs: Can it be done? Clin Psychol Rev 1982;2:387-408.

29. Abel GG, Becker JV, Skinner L. Behavioral approaches to the treatment of the violent person. In: Rother L, editor. Clnical treatment of the violent offender. Washingto, DC: NIMH, 1983: pp. 46-63.

30. Becker JV, Kaplan MS, Kavoussi R. Measuring the effectiveness of treatment for the aggressive adolescent sexual offender. In: Prentky RA, Quinsey VL, editors. Human sexual aggression: Current perspectives.

New York, N.Y.: New York Academy of Sciences, 1988: pp. 215-222.

31. Longo RE. Administering a comprehensive sexual aggressive treatment program in a maximum security setting. In: Greer JGS, Stuart JR, editors.

The sexual aggressor: Current perspectives on treatment. New York: Van Nostrand Reinhold, 1983: pp. 177-179.

32. Bumby KM. Assessing the cognitive distortions of child molesters and rapists: Development and validation of the MOLEST and RAPE scales.

Sex Abuse 1996;8:37-54.

33. Abel GG, Gore DK, Holland CL, Camp N, Becker JV, Rathner J. The measurement of the cognitive distortions of child molesters. Ann Sex Res 1989;2:135-153.

34. Kaplan MS, Becker J, Tenke C. Assessment of sexual knowledge and attitudes in an adolescent sex offender population. J Sex Educ Ther 1991;17:217-225.

35. Marshall WL, Hamilton K, Fernandez Y. Empathy deficits and cognitive distortions in child molesters. Sex Abuse 2001;13:123-130.

36. Araji S, Finkelhor D. Explanations of pedophilia: Review of empirical research. Bull Am Acad Psychiatry Law 1985;13:17-37.

296

37. Marshall WL, Serran GA, Cortoni FA. Childhood attachments, sexual abuse, and their relationship to adult coping in child molesters. Sex Abuse 2000;12:17-26.

38. Marlatt GA, Gordon JR. Relapse prevention. In: Marlatt GA, Gordon JR, editors. Relapse prevention. New York: Guildford, 1985: pp. 1-558.

39. Laws DR, Hudson SM, Ward T, editors. Remaking relapse prevention with sex offenders. A sourcebook. Thousands Oaks, California: Sage, 2000.

40. Ward T, Hudson SM, Keenan T. A self-regulation model of the sexual offense process. Sex Abuse 1998;10:141-157.

41. Yates PM, Prescott D, Ward T. Applying the good lives and self-regulation models to sex offender treatment: A practical guide for clinicians.

Brandon, Vermont: The Safer Society, 2010.

42. Borduin CM, Henggler SW, Blaske DM, Stein RJ. Multisystemic treatment of adolescent sexual offenders. Int J Offender Ther Comp Criminol 1990;34:105-113.

43. Abel GG, Mittelman M, Becker JV, Rathner J, Rouleau J-L. Predicting child molesters' response to treatment. In: Prentky RA, Quinsey VL, editors. Human sexual aggression: Current perspectives. New York, N.Y.: New York Academy of Sciences, 1988: pp. 223-234.

44. Abel GG, Becker JV, J. C-R, Mittelman M, Rouleau J-L. Multiple paraphilic diagnoses among sex offenders. Bull Am Acad Psychiatry Law 1988;16:153-168.

45. Maletzky BM. Factors associated with success and failure in the behavioral and cognitive treatment of sexual offenders. Ann Sex Res 1993;6:241-258.

46. Maletzky BM, Steinhauser C. A 25-year follow-up of cognitive/behavioral therapy with 7,275 sexual offenders. Behav Modif 2002;26:123-147.

47. Marques JK, Wiederanders M, Day DM, Nelson C, Van Ommeren A. Effects of a relapse prevention program on sexual recidivism: Final results from California's Sex Offender Treatment and Evaluation Project (SOTEP). Sex Abuse 2005;17:79-107.

48. Furby L, Weinrott MR, Blackshaw L. Sex offender recidivism: A review.

Psychol Bull 1989;105:3-30.

49. Nagayama Hall GC. Sexual offender recidivism revisited: A meta-analysis of recent treatment studies. J Consult Clin Psychol 1995;63:802-809.

50. White P, Bradley C, Ferriter M, Hatzipetrou L. Managements for people with disorders of sexual preference and for convicted sexual offenders.

The Cochrane Collaboration 2009; 1: 1-27.

51. Marques JK, Day DM, Nelson C, West MA. Effects of cognitive-behavoral treatment on sex offender recidivism. Crim Justice Behav 1994;21:28-54.

52. McConaghy N, Blaszczynski A, Kidson W. Treatment of sex offenders with imaginal desensitization and/or medroxyprogesterone. Acta Psychiatr Scand 1988;77:199-206.

53. Romero JW, L.M. Group psychotherapy and intensive probation supervision with sex offenders: a comparative study. Fed Probat 1983;47:36-42.

Isr J Psychiatry Relat Sci - Vol. 49 - No 4 (2012)

Pharmacological Treatment of Paraphilias Florence Thibaut , MD, PhD Psychiatric Department, University Hospital Ch. Nicolle, INSERM U 614, Rouen, France

Abstract Background: The psychiatrist’s main role is to provide care to the paraphilic patient and to reduce personal distress. However, in cases of paraphilia associated with sexual offences, reducing paraphilic behavior is critical in an approach to preventing sexual violence and reducing victimization. This review will focus on this specific population.

Method: We discuss the recently published recommendations for the treatment of paraphilias of the World Federation of Societies of Biological Psychiatry which were based on a review of the available literature about pharmacological treatment of paraphilias (1970-2010).

Results and Conclusion: Antiandrogens, and mostly GnRH analogues, significantly reduce the intensity and frequency of deviant sexual arousal and behavior, although informed consent is necessary in all cases. GnRH analogue treatment constitutes the most promising treatment for sex offenders at high risk of sexual violence, such as pedophiles or serial rapists. SSRIs remain an interesting option in adolescents, in patients with depressive or OCD disorders, or in mild paraphilias such as exhibitionism.

Pharmacological interventions should be part of a more comprehensive treatment plan including psychotherapy and, in most cases, behavior therapy.

Treatment of paraphilias began during the late nineteenth century at a similar time, though not directly connected, to the new concept of sexual deviance as a medical condition. Etiology of paraphilias remains

unclear despite years of research. Numerous psychological, developmental, environmental, genetic, and organic factors have been discussed, but none of the theories fully explains paraphilic behaviors. The causes are probably multifactorial, rendering treatment difficult. Recidivism of sex offences is a major concern in the treatment of paraphilias such as pedophilia.

Most people recognize that incarceration alone will not solve sexual violence. Indeed, treating the sexual offenders with a diagnosis of paraphilia is critical in an approach to preventing sexual violence and reducing victimization. This paper was intended to present and summarize pharmacological treatment of paraphilias and will focus on paraphilias associated with a risk of sexual offending such as pedophilia or exhibitionism.

Definition of Paraphilias According to the Diagnostic and Statistical Manual Disorder, Fourth Edition, Text Revision (DSM IV-TR) or to the International Classification of Mental Diseases (ICD 10th), paraphilias are defined as sexual disorders which are characterized by “recurrent, intense, sexually arousing fantasies, sexual urges or behaviors, generally involving (1) non-human objects, (2) the suffering or humiliation of oneself or one’s partner, or (3) children or other nonconsenting individuals, that occur over a period of 6 months” (criterion A), which “cause clinically significant distress or impairment in social, occupational, or other important areas of functioning” (criterion B). DSM IV-TR describes eight specific disorders of this type (exhibitionism, fetishism, frotteurism, pedophilia, sexual masochism, sexual sadism, voyeurism and transvestic fetishism) along with a residual category called “paraphilia not otherwise specified.”

Rape is not included in this classification, because it represents an heterogeneous behavior and an expression

Address for Correspondence: Prof. F. Thibaut, Psychiatric Dept., University Hospital Ch. Nicolle, 1 rue de Germont, 76031 Rouen, France florence.thibaut@chu-rouen.fr Potential conflict of interest: consultant for Debiopharm, Swiss

297

Pharmacological Treatment of Paraphilias

of aggression rather than a specific paraphilia. However, a small number of rapists may meet the criteria for having a paraphilia (e.g., exhibitionism or pedophilia, sexual sadism). Simply having paraphilia is not illegal, but acting in response to certain paraphilic urges may be illegal and, in some cases, subjects the person with paraphilia to severe sanctions. Conversely, not all sex offenders meet the criteria for a paraphilic disorder.

Some paraphilic subjects show evidence of comorbid major axis I mental illness which may require specific treatment, in most cases: affective disorders (3-95%), substance use disorders (8-85%), anxiety disorders (3-64%) and less often: schizophrenia or other psychotic disorders (1-16%) (1-4), dementia or other cognitive disorders (for review, 2). Attention deficit and hyperactivity disorders (ADHD) may also represent 36% of cases and eating disorders 10% of cases. Paraphilia may also be secondary to major axis I mental disorders (e.g., schizophrenia or manic episodes), in these cases, antipsychotic treatment and/or mood stabilizers are used as first line treatment. In cases of comorbid depressive or anxiety disorders, antidepressant treatment may be used as first line treatment or in combination with antiandrogen treatment if necessary.

Paraphilias may also occur within the context of axis II disorders, the prevalence of personality disorders may vary from 33 to 52% (among them antisocial personality disorder is the most frequently observed) (3-5). Heterogeneity of both the samples and the diagnosis criteria may have contributed to the discrepancies observed in terms of prevalence between the studies.

These personality disorders may be addressed with psychological therapies such as behavioral or cognitive treatments.

History of Treatments Surgical castration was first used in 1892 in Switzerland.

By the 1940s, some attempts had been made to treat paraphilias using oestrogens, but due to feminizing side-effects, this was supplanted in the 1960s by medications reducing testosterone levels (cyproterone acetate [CPA] is available in most countries, while in the U.S., medroxyprogesterone acetate [MPA] is the drug of choice). Unlike surgical castration, the effects of antilibido medication are reversible on discontinuation. A more recent and promising development in the treatment of paraphilias at high risk of sexual offending is the use of gonadotrophin hormone releasing 298

hormone (GnRH) agonists. These compounds reduce testosterone to very low levels and result in very low levels of recidivism.There is also emerging evidence for the use of selective serotonin reuptake inhibitors (SSRIs)A pharmacological approach is essential in the treatment of patients with severe paraphilias, but a psychotherapeutic context to the treatment is equally necessary (especially cognitive behavioral therapy).

Ethical Considerations Treatment for paraphilia should reduce or eliminate paraphilic fantasies and behaviors and decrease the level of distress of paraphilic subjects, permitting them to live a normal sexual life, it should not have significant side-effects and, most importantly, it should prevent the risk of acting out and victimization in case of pedophilia or exhibitionism, for example. The optimal treatment for paraphilias is currently unavailable and treatments already used decrease, in an unspecific manner, sexual arousal level and behavior. In the case of hormonal treatment, deviant but also non-deviant (if any) sexual behavior and fantasies are largely decreased in most subjects. An explanation of the sexual side effects associated with hormonal treatment and obtaining informed consent of the patient are considered by many authors a necessary prerequisite (2).

Paraphilic sex offenders referred for hormonal treatment are often the object of some external coercion, be it from a court decision or under the pressure of their family, employers or other involved persons. From an ethical point of view, the patient may be subjected to hormonal treatment only if all of the following conditions are met: • The person has a paraphilic disorder diagnosed by a psychiatrist after a careful psychiatric examination.

• The person’s condition represents a significant risk of serious harm to his health or to the physical or moral integrity of other persons.

• No less intrusive treatment means of providing care are available.

• The psychiatrist in charge of the patient agrees to inform the patient and receive his or her consent, to take the responsibility for the indication of the treatment and for the follow up including somatic aspects with the help of a consultant endocrinologist, if necessary.

In some cases, coerced treatment may be used in sex

Florence Thibaut

offenders with paraphilia. The decision to subject a sex offender to coerced treatment should be taken by a court or another competent body. The court or other competent body should: • Act in accordance with procedures provided by law based on the principle that the person concerned should be seen and consulted; • Not specify the content of the treatment (hormonal or not) but force the person to comply with the treatment plan negotiated with the psychiatrist; • The decision to subject this person to hormonal treatment must be taken by a psychiatrist with the requisite competence and experience and not by the judge, after examination of the person concerned and only after his or her informed consent has been obtained. While treatment may facilitate improvement and release or discharge, this may not be necessarily the case; • In some cases, failure of the offender to accept any kind of treatment could lead to sanctions by the court.

The Belgian Advisory Committee on Bioethics has published some guidelines in this field in 2006 (www. health.fgov.be/bioeth).

Methodological Limitations Most reports on the treatment of paraphilias are case reports or series. In general, controlled treatment efficacy studies in this field are extremely difficult to conduct for several reasons: those who suffer from paraphilia rarely seek treatment voluntarily; ethical considerations would not easily allow performing double-blind placebo-controlled studies in paraphilic subjects at risk of sex offending (such as pedophilic subjects or exhibitionists).

Methodological biases were observed in many studies. The small size of the samples and the short duration of follow up make statistical analyses in most of the studies difficult. The outcome measurements usually used, such as self reports of conventional and paraphilic sexual activity, are subjective and not always reliable.

Penile plethysmography (using audio or visual erotic stimuli videos including children, rapes or adults) may be used but, according to Marshall and Fernandez (6), many methodological flaws may limit the use of this technique. In contrast, Howes (7) reported that plethysmography may be used to assess the risk of

violence in incarcerated sex offenders. The comparison between studies is often difficult due to methodological differences between studies such as: heterogeneity of paraphilias included; different durations of follow up; different definitions of recidivism (sexual or non sexual offences); the presence or absence of previous offences and/or previous convictions which (if any) may increase the recidivism risk; the retrospective or prospective design of the study; outpatients or prisoners may be included which may interfere with treatment compliance and with the recidivism risk; and finally, in most cases, statistical analyses are not conducted due to small sample sizes and cross over designs.

This review, based on the published recommendations for the treatment of paraphilias of the World Federation of Societies of Biological Psychiatry (2), focused on pharmacological treatment of male adult paraphilic subjects at risk for sexual offending. Female sex offenders and female paraphilic subjects were excluded from this review.

Pharmacological Treatment Paraphilia is not a synonym for sex offender. Conversely, not all sex offenders suffer from a paraphilia. Paraphilic patients may only suffer from deviant sexual fantasies or urges and their deviant sexual behavior does not necessarily involve a non-consenting person or a child.

In these latter cases, treatment may open a possibility for prevention of acting out and victimization, thus reducing individual and social burden of this disease.

We will focus the review on these latter cases.

The primary aims of the treatment are: • To control paraphilic fantasies and behaviors (this will help to decrease the risk of sexual offences especially in cases of pedophilia or rape); • To decrease the level of distress of the paraphilic subject.

In addition to psychological and behavioral therapies, several pharmacological treatment options are available. The treatment choice will essentially depend on: • Th e patient’s previous medical history, • The patient’s compliance, • The intensity of paraphilic sexual fantasies and the risk of sexual violence.

In case of psychiatric comorbidities, pharmacological 299

Pharmacological Treatment of Paraphilias

and/or psychological treatment of these comorbidities must be used. Hormonal treatment may be coprescribed in case of lack of efficacy of adequate treatment of the psychiatric disease on deviant sexual behavior, in order to control paraphilic behavior. However, antiandrogen treatment may increase psychotic symptoms (8).

The evaluation of a subject with paraphilia must include demographic characteristics (including being in contact with children in case of pedophilia), information about deviant and non-deviant sexual behavior and fantasies (type, frequency of sexual activity and fantasies, presence or absence of sexual violence fantasies), past and current psychiatric history, history of previous sexual and non-sexual offences, past history of sexual or physical abuse, history of previous treatment of paraphilic behavior if any. The diagnosis of paraphilia includes: the number and type of paraphilias; comorbidity with axis 1 or axis 2 of the DSM classification (especially addictive disorders or personality disorders), if any; comorbidity with somatic diseases if any. Impulsivity and hypersexuality are also important to assess.

Some risk factors such as: comorbid psychiatric disorders, personality disorders, alcohol or substance abuse, type of paraphilia (pedophilia with sexual interest in boys), young age of onset of paraphilia, past history of sexual or physical abuse, previous history of sexual offences may increase the risk of recidivism. Some of these risk factors may be addressed during psychotherapy. Some scales, like Static-99, Rapid Risk Assessment for Sexual Offence Recidivism, Sex Offender Risk Appraisal Guide (SORAG), Sexual Violence Riskâ&#x20AC;&#x201C;20 and, more recently, Stable 2000 (using dynamic items) have been proposed to evaluate these risks (9-12). In meta-analyses all these instruments have shown a good predictive validity, supporting the utility and predictive validity of actuarial risk assessment complementary to treatment efforts to reduce risk (13). Static risk assessment tools that use historical or unchangeable risk variables (Static 99 or SORAG) are expected to be less accurate than dynamic tools in measuring risk changes despite their overall strong predictive validity (14).

Antiandrogens or GnRH analogues, if necessary, have to be prescribed by a physician after appropriate medical assessment and informed consent is required.

Meta-analyses and reviews concerning the efficacy of cognitive behavioral therapy for sex offenders with paraphilia indicate a modest reduction in recidivism (15), but this is doubted by studies with longer followup periods (16, 17). However, the other approaches 300

(insight-oriented treatment, therapeutic communities, other psychosocial programs) do not seem to reduce recidivism (18). Moreover, the longer the observation periods, the higher the recidivism rates, leaving the impression that the durability of psychological therapies is limited. Randomized controlled trials are needed.

No randomized controlled trials have documented the efficacy of psychotropic medications such as antidepressants, antipsychotics or mood stabilizers, in paraphilic behaviors. Concerning the use of antipsychotics and mood stabilizers, there are only anecdotal reports (for review see 2). In general their use is only recommended in case of psychiatric comorbidities treatment.

One double-blind non-controlled study comparing clomipramine and desipramine was conducted in a sample of 15 patients with different types of paraphilias.

Only 8 patients completed the study and both medications equally reduced the paraphilic symptoms (19).

The efficacy of SSRIs and clomipramine side effects have limited the use of clomipramine in the treatment of paraphilic disorders.

SSRIs

The rationale for their use in these indications is based on their sexual side effects (inhibitory) and on the similarities between OCD and some paraphilic behaviors. Despite the increasing clinical use of SSRIs for paraphilias and hypersexuality (for review see 20), double-blind controlled trials with these agents are still lacking.

Most of the available data are case reports and open or retrospective studies and a systematic review concerning the use of SSRIs in paraphilic subjects found only nine case series for analysis (21). The efficacy of SSRIs in the reduction of fantasies and paraphilic behaviors has previously been described for the treatment of pedophilia, exhibitionism, paraphilias in general, voyeurism and fetishism (for a review of studies: 24 case reports, 3 retrospective studies including 76 patients, 5 open studies including 141 patients - see 20). Pedophilia was clearly reported in 72 males and sexual sadism was reported in one case. The dosages may be increased up to the dosages usually used in OCD patients in case of lack or insufficiency of efficacy at 4th or 6th week. The maximal duration of follow up was 12 months but, in most cases, the duration was less than 3 months. Mostly fluoxetine (20-80 mg/d) and sertraline (100-200 mg/d), but also paroxetine and fluvoxamine (300 mg/d) have shown efficacy in

Florence Thibaut

reducing paraphilic sexual fantasies and behavior in these patients. Lack or insufficient therapeutic response to fluoxetine was described in one retrospective study concerning patients with paraphilias (22) and a case report concerning a patient with exhibitionism and one with sexual sadism (23).

Kafka and Prentky (24) used fluoxetine (30 mg/d-12 weeks) in ten patients with paraphilias and ten patients with hypersexual disorder and obtained a significant reduction in unconventional sexual behavior. Another trial obtained 70% remission of paraphilias (n=13) and paraphilia related disorders (n=11) after a two-stage treatment program of sertraline followed by fluoxetine (25). Fedoroff et al. (26) obtained almost 95% remission of symptoms in a treatment combining fluoxetine and psychotherapy versus psychotherapy alone (n=51). One trial noted a reduction in the total sexual outlet and the time spent in paraphilic behaviors with a combination of fluoxetine and methylphenidate (n=26) (27).

A 12-week open label dose titrated study of sertraline for the treatment of pedophilia (n=20) obtained reductions in sexual drive, sexual fantasies, and other sexual behaviors. These authors reported a reduction of sexual arousal patterns with suppression of deviant arousal, coupled with a maintenance or relative increase in nonpedophilic arousal in consenting sex with adults (28). A retrospective study concerning 25 patients treated with sertraline for pedophilia or other paraphilias found a significant decrease in paraphilic fantasies (29). Another study described 50% remission of paraphilic symptoms in an open label study using 100 mg of sertraline during a mean follow up of 17 weeks (27).

Efficacy of fluvoxamine has been described for the treatment of 16 patients with pedophilia (29).

Escitalopram was also useful for the treatment of one patient with transvestic fetishism (30).

Paraphilias usually start at adolescence and are limited to deviant fantasies related to masturbation between 12 and 18 years. SSRIs given at this stage could help to prevent acting out of deviant behaviors (31).

Taking into account clinical data, Bradford and Fedoroff (31) and Kafka (25), recommended SSRIs prescription in mild paraphilias especially in cases of exhibitionism, in juvenile subjects with paraphilia, or in cases that have comorbidity with OCD and/or depression. Though not formally approved, their off label use has become a standard of care.

However, controlled studies demonstrating efficacy are needed.

Antiandrogen treatment

Steroidal antiandrogens such as medroxyprogesterone acetate (MPA) or cyproterone acetate (CPA) have progestogenic activities in addition to their effects as antiandrogens, resulting in a decrease in circulating levels of both testosterone and dihydrotestosterone (DHT). These compounds interfere with the binding of DHT to androgen receptors and they have been shown to block the cellular uptake of androgens.

MPA Many paraphilic subjects received MPA treatment, although most studies were not controlled, and some biases were observed (32). Among the thirteen studies reported in Thibaut et al.â&#x20AC;&#x2122;s review (2 ), three were double blind cross over studies (comparing MPA and placebo) including 51 pedophiles and 8 sex offenders (33-35), nine were open studies and one was a retrospective study (275 sex offenders) (36). Reduction of sexual behavior and complete disappearance of deviant sexual behavior and fantasies were observed after one to two months in the majority of cases, in spite of maintained erectile function during plethysmography in some studies. In twelve cases, recidivism of deviant sexual behavior during MPA treatment was reported using different criteria. Some studies reported increased recidivism after MPA was stopped.

The re-offence rate for 334 individuals taking depot MPA was greater than with CPA, with a mean rate of 27% at the end of the follow-up (range 6 months to 13 years) as compared with 50% before treatment (37).

Money et al. (38), using MPA, reported no reduction in non-sexual crimes in sex offenders with antisocial behavior. McConaghy et al. (39) reported a lower efficacy of MPA in juveniles.

Severe side effects (pulmonary embolism, weight gain, diabetes mellitus, transient increased levels of hepatic enzymes, increased blood pressure, depressive disorders, Cushing syndrome or adrenal suppression, etc.) were observed with MPA. The benefit/risk ratio did not favor the use of MPA which was abandoned in Europe.

CPA Many subjects received CPA treatment but only a few studies were controlled, and some biases were observed.

Among the ten studies aimed to evaluate CPA treatment, two were double blind cross-over comparative studies (CPA vs ethinyl estradiol or MPA, 40, 41); two were double blind cross-over studies comparing CPA with placebo (42, 43); one was a single blind study, CPA 301

Pharmacological Treatment of Paraphilias

vs placebo (44); and five were open studies. In these comparative studies, CPA, ethinyl-estradiol and MPA showed similar efficacy and CPA was superior to placebo.

CPA (50 – 300 mg/day per os or i.m. 300 – 600 mg every 1 or 2 weeks) was associated with a significant decrease of self-reported sexual fantasies or activity and a disappearance of deviant sexual behavior in about 80 – 90% of cases within 4-12 weeks. The efficacy was maintained as long as the treatment was used and in some cases for up to 8 years.

Several studies examined the re-offence rates of individuals taking CPA. A mean rate of 6% was found at the end of the follow-up period (less than the rate observed with MPA), as compared with 85% before treatment, with a duration of follow up ranging from 2 months to 4.5 years. Many re-offences were committed by individuals who did not comply with therapy (37).

Plasma testosterone levels were moderately decreased and could not be used as a marker of compliance.

In addition, CPA has antiaggressive and anxiolytic properties that may be of interest in these populations.

CPA has shown positive but inconsistent results in the treatment of paraphilic subjects. In some countries, the oral form is the only form available and treatment compliance may be erratic. Because of a substantial number of side effects (in addition to those related to hypoandrogenism), including gynecomastia (20%, which is not always completely reversible), weight gain, depressive mood, thrombo-embolic phenomena and hepatocellular damage (severe cases < 1%), there was a need for other effective treatments with fewer side effects.

GnRH analogues

Gonadotrophin-releasing hormone (GnRH) analogues act initially at the level of the pituitary to stimulate LH release, resulting in a transient increase in serum testosterone levels (flare-up). After an initial stimulation, GnRH analogues cause rapid desensitization of GnRH receptors, resulting in reduction of LH and testosterone to castrate levels within 2 to 4 weeks. Two analogues of the gonadotrophin-releasing hormone were preferentially used in paraphilic subjects: triptorelin and leuprorelin. They were developed as 1- or 3-month formulations.

Triptorelin Two open prospective studies and one retrospective study using triptorelin 1-month formulation were performed in sex offenders or paraphilic subjects(45- 47).

302

In total, 75 male subjects (aged from 15 to 57 years) with paraphilia were included in two prospective open studies (n=41), two retrospective studies (n=30 + 3) and one case report. These subjects were receiving depot triptorelin for some months to 7 years (3.75 mg/month). During triptorelin treatment, no deviant sexual behavior was observed and no sexual offences were committed except in one case (45). One third of cases (13/41 cases) had previously received CPA without efficacy. No plethysmography was used. However, in all cases but one, triptorelin was successful and the deviant sexual behavior completely disappeared during GnRH analogue treatment.

In Czerny et al.’s study (48), similar efficacies were observed with CPA and triptorelin.

Leuprorelin Three open studies using leuprorelin (1- or 3-month formulations) were performed in patients with paraphilic behaviors (48-53).

Forty-five male subjects (20 to 61 years old) with paraphilias received leuprolide acetate; they were included in three prospective studies including a cross-over study (52) (28 cases), one naturalistic study comparing CPA and GNRH analogues (48) (58 cases, 11 with leuprorelin acetate) and 15 case reports. Maximal duration of follow up was 57 months (mean duration about 1 year).

In addition to the outcome measures used, such as self report of deviant and non-deviant sexual behavior and fantasies (type, frequency, intensity) or testosterone and LH levels, plethysmography was used in Schober et al.,s study (53). However, in one case report (54) the patient relapsed while treated with leuprorelin treatment and committed a sex offence.

In conclusion, there were no controlled studies, and some biases were observed. The efficacy observed in these open studies, though, was clear. In most cases, subjects were previously treated with psychotherapy or other antiandrogens such as CPA without efficacy. In most of the cases, CPA or flutamide were concurrently used for the first weeks of GnRH agonist in order to prevent the behavioral consequences of a flare-up effect and concurrent psychotherapy was used. Concomitantly to the rapid decrease of testosterone levels, a reduction of non-deviant sexual behavior was observed and deviant sexual fantasies disappeared with a maximal effect after 1 or 3 months in more than 90% of cases.

The duration of treatment and the conditions of treatment interruption remain controversial. For some patients, a life-long treatment may be necessary.

Florence Thibaut

Among the side effects observed with GnRHa, bone mineral loss is the most problematic side effect and needs to be carefully checked at least every two years and even more frequently in case of osteoporosis. Calcium and vitamin D or biphosphonates may be prescribed in the event of osteoporosis (for a review of these side effects see 2, 32). Decreased values of vertebral and femoral bone densities (0.95 and 0.8 g/cm³, respectively), without clinical signs but requiring medical supervision, were recorded during the third year of triptorelin treatment in one patient aged 27, among 6 cases in Thibaut et al.’s study (45) (normal ranges: 1.15 ± 0.15 and 0.9 ± 0.1 g/ cm³, respectively). In Rösler and Witztum study (47) two patients among 30 cases had progressive demineralization and were given oral calcium and vitamin D supplements after completing 24 months of triptorelin therapy. Hoogeveen and Van der Veer (55) reported bone demineralization in one patient aged 35 years after 37 months of triptorelin treatment in spite of biphosphonates and calcium treatment. Krueger and Kaplan (51) observed three cases of demineralization at 35 and 57 months respectively among 12 patients aged from 20 to 48, receiving leuprolide acetate. Czerny et al. (48) reported one case of bone mineral loss among 29 patients receiving GnRH analogues for a mean duration of 10 months. Dickey (56) observed demineralization after three years of leuprolide acetate treatment in a 28-year-old patient. Calcium and vitamin D were used. Grasswick and Bradford (57) focused their study on bone mineral survey and reported demineralization in 2/4 cases with CPA, 1/1 with leuprorelin and 2/2 with surgical castration, the follow-up duration was four years. patients may also complain of hot flushes, asthenia, nausea, weight gain (2–13%), transient pain or site reaction at the site of injection, decreased facial and body hair growth, blood pressure variations, decreased glucose tolerance, decreased testicular volume (4–20%), episodic painful ejaculation, diffuse muscular tenderness, sweating, depressive symptoms and finally mild gynecomastia (2-7%) (for review of their frequency of occurrence see 32, 48).

When properly administered, with an appropriate protocol in place to detect and treat side effects should they develop, GnRHa treatments constitute no more or less of a risk than most other forms of frequently prescribed pharmacological agents (58).

An algorithm which distinguishes six levels of treatment for different categories of paraphilias according to the severity of the paraphilia and the risk of sexual

violence was proposed (2) . Medical survey (including osteodensitometry at least every two years) is necessary during hormonal treatment (for detailed information, 2).

Until now, there have been no pharmacological studies conducted in sexual murderers, and in women, only few case reports have been described.

Hormonal agents cannot be easily used in the treatment of juvenile sex offenders with paraphilia owing to possible interference with the development of puberty.

In these subjects, behavioral therapy and SSRIs are the first choice treatment (for review, 59).

Duration of Treatment Paraphilia is a chronic disorder. According to the majority of authors, a minimal duration of treatment of three to five years for severe paraphilia with a high risk of sexual violence is necessary. Hormonal treatment must not be stopped abruptly. In case of mild paraphilia, a treatment of at least two years might be used, after which the patient must be carefully followed up following treatment stopping. Treatment must be resumed in case of recurrence of paraphilic sexual fantasies.

Conclusion In paraphilic subjects, pharmacological interventions should be part of a more comprehensive treatment plan including psychotherapy and, in most cases, behavior therapy (20, 60). In paraphilic subjects at high risk of victimization, pharmacological treatment should even be used as first line treatment. Not every sex offender with paraphilia is a candidate for hormonal treatment, even if it has the benefit of being reversible once discontinued. For paraphilias, characterized by intense and frequent deviant sexual desire and arousal, which highly predispose the patient to severe paraphilic behavior (such as pedophilia or serial rapes), a hormonal intervention may be needed.

Antiandrogens or GnRH analogues have to be prescribed by a physician, after appropriate medical assessment, and informed consent must be obtained. GnRH analogues reduce testosterone levels, more dramatically and more consistently, and produced less variable results in the treatment of paraphilic behaviors than MPA or CPA. GnRH analogue treatment probably constitutes the most promising treatment for sex offenders at high risk of sexual violence, such as pedophiles or serial rapists.

In contrast, SSRIs remains an interesting option in patients with depressive or OCD disorders, in mild 303

Pharmacological Treatment of Paraphilias

paraphilias such as exhibitionism or in juvenile paraphilic subjects.

Collaborative studies including large cohorts of well-defined paraphilic subjects with long durations of follow up are clearly needed.

Acknowledgements The author thanks Prof. Rösler for his valuable advice regarding this manuscript and Richard Medeiros, Medical Editor, Rouen University Hospital for editing the final manuscript.

References 1. Marshall WL. Diagnostic problems with sexual offenders In: Marshall WL, Fernandez YM, Marshall LE, Serran GA, editors. Sexual offender treatment: Controversial issues. Chichester: Wiley, 2006: pp. 33-43.

2. Thibaut F, Torres de la Barra F, Gordon H, Bradford JMW, Cosyns P, the WFSBP Task Force on Sexual Disorders. The World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for the Biological Treatment of Paraphilias. World J Biol Psychiatry 2010;11: 604-655.

3. Kafka MP, Prentky R. Attention-deficit/hyperactivity disorder in males with paraphilias and paraphilia-related disorders: A comorbidity study.

J Clin Psychiatry 1998,59: 388-396.

4. Dunsieth N, Nelson M, Brusman–Lovens L Holcomb JL, Beckman D, Welge JA, Roby D, Taylor P Jr, Soutullo CA, McElroy SL. Psychiatric and legal features of 113 men convicted of sexual offenses. J Clin Psychiatry 2004,65: 293-300.

5. Raymond N, Coleman E, Ohlerking F. Psychiatric comorbidity in pedophilic sex offenders. Am J Psychiatry 1999,156: 786-788.

6. Marshall WL, Fernandez YM. Phallometric testing with sexual offenders: Limits to its value. Clin Psychol Rev 2000,20: 807-822.

7. Howes RJ. Measurement of risk of sexual violence through phallometric testing. Leg Med (Tokyo) 2009, S1:368-369.

8. Thibaut F, Kuhn JM, Colonna L. A possible antiaggressive effect of cyproterone acetate. Br J Psychiatry 1991; 159: 298-299.

9. Hanson RK. The development of a brief actuarial risk scale for sexual offense recidivism (User Report No. 1997-04). In: DotSGo, editor.

Ottawa, 1997.

10. Boer DP, Hart SD, Kropp PR, Webster CD. Manual for the Sexual Violence Risk–20: Professional guidelines for assessing risk of sexual violence. Vancouver: The Mental Health Law & Policy Institute, 1997.

11. Hanson RK, Thornton D. Static-99: Improving actuarial risk assessments for sex offenders (User Report No. 1999-02). In: DotSGo, editor. Ottawa, 1999.

12. Quinsey VL, Harris GT, Rice ME, Cormier C. Violent offenders: Appraising and managing risk. Washington, DC: American Psychological Association, 2006.

13. Hanson RK, Morton-Bourgon KE. The accuracy of recidivism risk assessments for sexual offenders: A meta-analysis of 118 prediction studies. Psychol Assess 2009; 21: 1-21.

14. Olver ME, Wong SCP. A comparison of static and dynamic assessment of sexual offender risk and need in a treatment context. Criminal Justice and Behaviour 2011;38: 113-126.

15. Losel F, Schmucker M. The effectiveness of treatment for sexual offenders: A comprehensive meta-analysis. J Exp Criminol 2005;1: 117-146.

16. Kenworthy T, Adams CE, Bilby C, Brooks-Gordon B, Fenton M. Psychological interventions for those who have sexually offended or are at risk of offending. Cochrane Database Syst Rev 2004;3: CD 004858.

17. Maletzki BM, Steinhauser C. A 25-year follow-up of cognitive-behavioural therapy with 7,275 sexual offenders. Behav Modif 2002;26: 123-147.

18. Brooks-Gordon B, Bilby C, Wells H. A systematic review of psychological interventions for sexual offenders I. Randomised control trials. J Forensic

304

Psychiatry 2006;17: 442–466.

19. Kruesi MJ, Fine S, Valladares L, Phillips RA, Jr., Rapoport JL. Paraphilias: A double-blind crossover comparison of clomipramine versus desipramine. Arch Sex Behav 1992 ;21: 587-593.

20. Garcia F, Thibaut F. Current concepts in the pharmacotherapy of paraphilias. Drugs 2011;71:771-790.

21. Adi Y, Ashcroft D, Browne K, Beech A, Fry-Smith A, Hyde C. Clinical effectiveness and cost–consequences of selective serotonin reuptake inhibitors in the treatment of sex offenders, Health Technol Assess 2002;6:1-66.

22. Stein DJ, Hollander E, Anthony DT, Schneier FR, Fallon BA, Liebowitz MR, et al. Serotonergic medications for sexual obsessions, sexual addictions, and paraphilias. J Clin Psychiatry 1992;53: 267-271.

23. Casals-Ariet C, Cullen K. Exhibitionism treated with clomipramine.

Am J Psychiatry 1993;150: 1273-1274.

24. Kafka MP, Prentky R. Fluoxetine treatment of non-paraphilic sexual addictions and paraphilias in men. J Clin Psychiatry 1992;53: 351–358.

25. Kafka MP. Sertraline pharmacotherapy for paraphilias and paraphiliarelated disorders: An open trial. Ann Clin Psychiatry 1994;6: 189-195.

26. Fedoroff JP. Antiandrogens vs serotonergic medications in the treatment of sex offenders: A preliminary compliance study. Can J Hum Sexuality 1995;4: 111–123.

27. Kafka MP, Hennen J. Psychostimulant augmentation during treatment with selective serotonin reuptake inhibitors in men with paraphilias and paraphilia-related disorders: A case series. J Clin Psychiatry 2000;61: 664-670.

28. Bradford JM, Martindale JJ, Goldberg M, Greenberg D, Lane JG. Sertraline in the treatment of pedophilia: An open label study. New Research Program Abstracts, NR 441, APA Annual Meeting 1996, Miami, FL, 1996.

29. Greenberg DM, Bradford JM, Curry S, O'Rourke A. A comparison of treatment of paraphilias with three serotonin reuptake inhibitors: a retrospective study. Bull Am Acad Psychiatry Law 1996;24: 525-532.

30. Phahaj SK. Escitalopram treatment of transvestic fetishism: Case report.

German J Psychiatry 2004;7: 20-21.

31. Bradford J, Fedoroff P. Pharmacological treatment of the juvenile sex offender. In: Barbaree H, Marshall W, editors. The juvenile sex offender.

Second Edition. U.S.A.: Guilford, 2006: Chapter 16, pp. 358-382.

32. Guay DRP. Drug treatment of paraphilic and non paraphilic sexual disorders. Clin Ther 2009;31: 1-31.

33. Wincze JP, Bansal S, Malamud M. Effects of medroxyprogesterone acetate on subjective arousal, arousal to erotic stimulation, and nocturnal penile tumescence in male sex offenders. Arch Sex Behav 1986,15: 293-305.

34. Hucker S, Langevin R, Bain J. A double-blind trial of sex drive reducing medication in pedophiles. Ann Sex Res 1988, 1: 227-247.

35. Kiersch TA. Treatment of sex offenders with Depo Provera. Bull Am Acad Psychiatry Law 1990,18: 179-187.

36. Maletzky BM, Tolan A, McFarland B. The Oregon depo-Provera program: A five-year follow-up. Sex Abuse 2006,18: 206-316.

37. Meyer JW, Cole CM. Physical and chemical castration of sex offenders: A review. J Off Rehab 1997;25: 1–18.

38. Money J, Wiedeking C, Walker P, Migeon C, Meyer W, Borgaonkar D. 47, XYY and 46, XY males with antisocial and/or sex offending behaviour: antiandrogen therapy plus counselling. Psychoneuroendocrinology 1975,1: 165-178.

39. McConaghy N, Blaszczynski A, Armstrong MS. Resistance to treatment of adolescent sex offenders. Arch Sex Behav 1989,18: 97-107.

40. Bancroft J, Tennent G, Loucas K, Cass J. The control of deviant sexual behaviour by drugs. I. Behavioural changes following estrogens and antiandrogens. Br J Psychiatry 1974;125: 310-315.

41. Cooper AJ, Sandhu S, Losztyn S, Cernovsky Z. A double-blind placebo controlled trial of medroxyprogesterone acetate and cyproterone acetate with seven pedophiles. Can J Psychiatry 1992;37: 687-693.

Florence Thibaut

42. Cooper AJ. A placebo controlled trial of the antiandrogen cyproterone acetate in deviant hypersexuality. Compr Psychiatry 1981;22: 458-465.

43. Bradford JM, Pawlak A. Double-blind placebo crossover study of cyproterone acetate in the treatment of the paraphilias. Arch Sex Behav 1993;22: 383-402.

44. Cooper AJ, Cernovsky Z. The effects of cyproterone acetate on sleeping and waking penile erections in pedophiles: Possible implications for treatment. Can J Psychiatry 1992;37: 33-39.

45. Thibaut F, Cordier B, Kuhn JM. Effect of a long-lasting gonodatrophin hormone-releasing hormone agonist in six cases of severe male paraphilia.

Acta Psychiatr Scand 1993;87: 445-450.

46. Thibaut F, Cordier B, Kuhn J. Gonadotrophin hormone releasing hormone agonist in cases of severe paraphilia: A lifetime treatment?

Psychoneuroendocrinology 1996;21: 411-419.

47. Rรถsler A, Witztum E. Treatment of men with paraphilia with a longacting analogue of gonadotropin-releasing hormone. N Eng J Med 1998;338: 416-422.

48. Czerny JP, Briken P, Berner W. Antihormonal treatment of paraphilic patients in German forensic psychiatric clinics. Eur Psychiatry 2002;17: 104-106.

49. Briken P, Nika E, Berner W. Treatment of paraphilia with luteinizing hormone-releasing hormone agonists. J Sex Marital Ther 2001;27: 45-55.

50. Briken P. Pharmacotherapy of paraphilias with luteinizing hormonereleasing hormone agonists. Arch Gen Psychiatry 2002;59: 469-470.

51. Krueger RB, Kaplan MS. Depot-leuprolide acetate for treatment of paraphilias: A report of twelve cases. Arch Sex Behav 2001;30: 409-422.

52. Schober JM, Kuhn PJ, Kovacs PG, Earle JH, Byrne PM, Fries RA. Leuprolide acetate suppresses pedophilic urges and arousability. Arch Sex Behav 2005;34: 691-705.

53. Schober JM, Byrne P, Kuhn PJ. Leuprolide acetate is a familiar drug that may modify sex-offender behaviour: The urologist's role. BJU Int 2006;97: 684-686.

54. Briken P, Hill A, Berner W. A relapse in pedophilic sex offending and subsequent suicide attempt during luteinizing hormone-releasing hormone treatment. J Clin Psychiatry 2004,65: 1429.

55. Hoogeveen GH, Van Der Veer E. Side effects of pharmacotherapy on bone with long-acting gonadorelin agonist triptorelin for paraphilia. J Sex Med 2008,5: 626-630.

56. Dickey R. Case report: the management of bone demineralization associated with long term treatment of multiple paraphilias with long acting LHRH agonists. J Sex Marital Ther 2002,28: 207-210.

57. Grasswick LJ, Bradford JM. Osteoporosis associated with the treatment of paraphilias: A clinical review of seven case reports. J Forensic Sci 2003,48: 849-855.

58. Berlin F. Sex offender treatment and legislation. J Am Acad Psychiatry Law 2003;31: 510-513.

59. Gerardin P, Thibaut F. Epidemiology and treatment of juvenile sexual offending. Paediatric Drugs 2004;6: 79-91.

60. Hanson RK, Morton-Bourgon KE. The characteristics of persistent sexual offenders: A meta-analysis of recidivism studies. J Consult Clin Psychol 2005,73: 1154-1163.

List of reviewers for Israel Journal of Psychiatry, 2012 The Editors would like to thank the following for their contribution as reviewers of manuscripts during 2012 Henry Abramovitch

Silvana Fennig

Arturo Lerner

Joav Merrick

Gal Shoval

Alan Apter

Laurence French

Vladimir Lerner

David Miklowitz

Emi Shufman

Rachel Bachner-Melman

David Galameau

Andrea Letamendi

Chanoch Miodownik

Michael Silverman

Moshe Bensimon

Annette Gallant

Itzhak Levav

Piper Myers

Zahava Solomon

Oded Ben-Arush

Marc Gelkopf

Stephen Levine

Eitan Nahshoni

Eli Somer

Howard Berger

Lucas Giner

Dafna Levinson

Ora Nakash

Daniel Stein

Avi Bleich

Doron Gothelf

Alon Liberman

Shaul Navon

Elian Sommerfeld

Ehud Bodner

Michal Granot

Pesach Lichtenberg

Ross Norman

Jennifer Torr

Gabrielle Carlson

Ilanit Hasson-Ohayon

Gadi Lubin

Femi Oyebode

Tom Trauer

Efrat Dagan

Sol Jaworowski

Paul Lysaker

Torsten Passie

Anne-Marie Ulman

Adam Darnell

Sean Kidd

Iris Manor

Alan Pincus

Carol Veneziano

Giancarlo Dimaggio

Arad Kodesh

Saed Maree

Norman Relkin

Knut Wester

Zipi Dolev

Anatoly Kreinin

Cherie Marvel

Jamie Ringer

Zvi Zemishlany

Rimona Durst

Sefi Kronenberg

James Megna

Abraham Rudnick

Gadi Zerach

Adrienne Einarson

Ellen Leibenluft

Yuval Melamed

Michael Seto

Avner Elizur

Vadim Leibovitch

Shlomo Mendlovic

Leah Shelef

305

Isr J Psychiatry Relat Sci - Vol. 49 - No 4 (2012)

Double-blind, Controlled, Clinical Trial Planned in Germany to Investigate the Efficacy of Psychotherapy Combined with Triptorelin in Adult Male Patients with Severe Pedophilic Disorders: Presentation of the Study Protocol Peer Briken, MD,1 Wolfgang Berner, MD,2 and the P278 study group* 1

Institute for Sex Research and Forensic Psychiatry, Interdisciplinary Competence Centre for Sexual Health, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany 2 Psychotherapeutic Practice, Hamburg, Germany

ABSTRACT Background: The treatment of paraphilias, especially of pedophilia, centers upon cognitive-behavioral psychotherapy and pharmacologic interventions. Two open, uncontrolled clinical studies using the synthetic LHRH-agonist triptorelin suggested that, combined with psychotherapy, antiandrogen treatment reduced deviant sexual fantasies, urges, and behaviors in paraphilic patients. There is a need for further research using controlled, randomized trials to examine the effectiveness of sexual offender treatment including psychotherapeutic and pharmacologic interventions.

Objective: The aim of this pilot study is to evaluate the efficacy and tolerability of cognitive-behavioral psychotherapy together with intramuscular (IM) 3-monthly injections of triptorelin in adult men with severe pedophilia.

Study design and methods: In this multicenter, forensic psychiatric hospital-based, double-blind, controlled, parallel group phase IV trial conducted in Germany, convicted male sexual offenders aged ≥ 18 years with pedophilia, as defined by DSM-IV-TR criteria, will be randomized to receive study-specific psychotherapy together either with triptorelin or placebo for 12 months

(total of 4 injections). This is a pilot study, therefore exploratory data analyses will be carried out of three different target parameters: 1. Changes in psychosexual characteristics using the Multiphasic Sex Inventory (scale: sexual abuse of children) 2. Changes in the risk of violent sexual behavior using the Sexual Violence Risk-20 total score 3. Changes in serum testosterone concentration Treatment effects will be assessed by comparing baseline values with those at the final examination (month 12).

Limitations: The absence of real-life stimulants to test for actual recidivism limits possible findings.

The study will be conducted in agreement with the European GCP-guideline, all relevant legal requirements, and the legal framework for voluntary treatment of convicted sexual offenders in Germany.

BACKGROUND Considering the seriousness of some paraphilias, in particular pedophilia, which may result in severe consequences for the individual and can lead to sexually

Address for Correspondence: Prof. Dr. med. Peer Briken, Institute for Sex Research and Forensic Psychiatry, Interdisciplinary Competence Centre for Sexual Health, University Medical Centre Hamburg-Eppendorf, House W38, Martinistrasse 52, D – 20246, Hamburg, Germany briken@uke.uni-hamburg.de

306

Peer Briken et al.

offensive behavior with violation of established laws and unacceptable consequences for the young victims, there is an acute need for effective treatment. Currentlyavailable and ethically-acceptable treatment options include cognitive-behavioral, psychotherapy and treatment with antiandrogens as well as other medications, such as selective serotonin reuptake inhibitors (1, 2).

Data from randomized, controlled, clinical trials (RCTs) in men with severe paraphilias are still lacking. This can be explained by the difficulty in performing rigorous studies in the relevant patient population. Major reasons for the scarcity of data include legal impediments, ethical problems, and lack of reliable clinical endpoints; difficulties in standardizing sexually-deviant fantasies and behaviors; and difficulties in follow-up and reporting of endpoints which are criminal acts, such as sexual offences (1, 3).

Psychotherapy combined with antiandrogen medication in sex offenders is increasingly being used as a method to control paraphilic sexual urges, desires, and resultant behaviors (2). Since the implementation of luteinizing hormone-releasing hormone (LHRH)agonist therapy, especially for the treatment of severe paraphilias, the number of sex offenders voluntarily treated with antiandrogens in some German forensic psychiatric clinics has increased (4). Results of uncontrolled studies performed with LHRH-agonists support the potential efficacy of such approaches (1, 3, 5-8).

Most of the data have been generated with the longacting, synthetic analogues of LHRH, leuprorelin and triptorelin, which are generally delivered as depot injections on a 1-, 2-, 3-, or 6-monthly basis. These agents induce a transient rise in luteinizing hormone (LH) and follicle-stimulating hormone (FSH) release. This, in turn, elevates testosterone production (“flare up” phenomenon) transiently, beginning within approximately 2-3 days of the first injection and lasting through the first one or two weeks of therapy (9). As use continues, gonadotrope responsiveness to endogenous LHRH is suppressed. The result is reduced LH and FSH secretion and testosterone production such that testosterone serum concentrations fall to castration levels usually within 2-4 weeks of therapy initiation (9). One of the main advantages of LHRH agonists is the reversibility of their hormonal effect. Testosterone recovery, however, is highly variable among patients and the time for serum testosterone concentrations to increase above castrate levels is highly dependent on

the duration of androgen deprivation therapy (ADT) (10). Normalization is achieved in 73-100% of patients within six months of stopping ADT of ≤ one year in duration. However, normalization occurs in ≤ 18% of patients at six months after stopping ADT of three years duration. The period of attenuated serum testosterone concentrations in most patients who have received ADT for three years is approximately 18 months (10).

The most commonly observed adverse events (AEs) related to LHRH-agonist treatment are due to their hormonal effects.

In 2007, triptorelin received approval for “the reversible reduction of testosterone to castrate levels in order to decrease sexual drive in adult men with severe sexual deviations” in the European Union (11, 12). Approval for the drug in this indication is based on two open, uncontrolled studies (13-15). The first open-label trial in males with severe paraphilias, treated with triptorelin 3.75mg IM once monthly for up to seven years, showed that most patients (83%) responded with a cessation of deviant sexual behaviors and markedly reduced sexual fantasies/activities during the follow-up period (7 months to 7 years) (14, 15). In the other uncontrolled observational study, 30 “treatment-resistant” paraphilic outpatients were treated with monthly IM injections of 3.75mg of triptorelin and supportive psychotherapy for 8 to 42 months (13). The efficacy of therapy was evaluated by the Three Main Complaints Questionnaire and the Intensity of Sexual Desire and Symptoms Scale. No sexual offenses were committed during triptorelin therapy. The severity of paraphilia as measured by self-reports and serum testosterone concentrations decreased significantly. Six men stopped treatment after 8 to 10 months, three because of intolerable AEs, two emigrated, and one wanted to father a child. Adverse events occurring during treatment included erectile failure, hot flashes, and decrease in bone mineral density.

Professionals agree that there is a need for further research with randomized, controlled trials using appropriate sample sizes and standardized methodology to investigate the utility of pharmacotherapy, including LHRH-agonists, in paraphilias (1, 3). This proposed 12-month pilot study will be the first randomized and placebo-controlled study investigating the efficacy and tolerability of cognitive-behavioral psychotherapy with/ without antiandrogen treatment (3-monthly injections of triptorelin) in adult men with severe pedophilia.

The analyses will focus on objectively quantifiable 307

Efficacy of Psychotherapy Combined with Triptorelin in Patients with Severe Pedophilic Disorders

parameters which measure changes in psychosexual characteristics from baseline to the final visit.

METHODS Study Design

This is a multicenter, forensic psychiatric hospital-based, double-blind, placebo-controlled, parallel-group, phase IV trial in which convicted sexual offenders will be randomized to receive psychotherapy together with either triptorelin or placebo.

Ethical and Legal Considerations

This study will be in agreement with the European Good Clinical Practice (GCP) guideline (2005/28/EG), all relevant legal requirements, and the legal framework for voluntary antiandrogen treatment of convicted sexual offenders in Germany. The study has been planned by a national Advisory Board in cooperation with the sponsor (Dr. R. Pfleger GmbH, Bamberg, Germany).

Members of this board include professionals of forensic psychiatry, urology/andrology, osteology, biometrics, medical ethics, and a judge experienced in supervision of sex offenders. During the study, the Advisory Board will meet regularly and as required. A national independent Ethics Committee and national authorities will be asked to approve the study protocol, the patient’s information sheet, and the patient consent form before initiation of the study.

The study will be conducted in locked wards in about six German forensic psychiatric hospitals in accordance with the principles set out in the legal framework of the German Maßregelvollzug §63 Penal Code. All investigators will be psychiatrists experienced in treating patients with severe pedophilia. They will be trained in advance in all aspects of GCP and in performing all study-relevant procedures.

Eligible participants will be males aged ≥ 18 years with complete legal competence (Civil Code) exhibiting severe sexual behaviors which led to arrest by order of either judicial or administrative authorities and subsequent forensic commitment. They will have been sentenced to mandatory hospital treatment (German Maßregelvollzug) for psychiatric criminals intended to treat the offender and thus prevent subsequent reoffense.

If the investigator decides, on the basis of the study protocol, that an individual may be a potential study candidate an external forensic psychiatrist unaffiliated 308

with the study will assess the individual’s competence to consent to participate in the study. This independent psychiatrist will be experienced with treatment of sexual offenders and will be responsible for all study centers.

This psychiatrist will inform the offender about all relevant legal and medical aspects of this study, based on a study conversation guideline which will ensure that all individuals are provided with identical information. The potential participant will also receive a detailed information sheet about the benefits and risks of antiandrogen therapy. If he is willing to take part, the independent psychiatrist will then obtain his written consent to participate in this study and potentially receive antiandrogen therapy. The study consent will not be connected to any conditions for prematurely leaving forensic commitment (or avoiding further prosecution) or granting privileges from custody during the study. A second study-independent person at each center (e.g., a cleric) will act as ombudsperson for the patient in all relevant concerns.

Selection of Study Patients

Participants will be convicted males aged ≥ 18 years with pedophilia, as defined by DSM-IV-TR criteria (16), who are kept in institutions for mandatory treatment in forensic psychiatric hospitals. Eligibility criteria for the study will be determined by an experienced forensic psychiatrist. Results of physical and psychiatric examinations will provide information necessary to decide whether or not the potential patient fulfils all study inclusion criteria and does not meet any exclusion criteria.

Study Procedures and Assessments

After consenting to participate in the study, but before any trial-related procedures/assessments are performed, a medical and psychiatric history will be completed at the baseline visit (T0). all potential patients will undergo a physical examination and a number of laboratory parameters (blood chemistry including Prothrombin time [Quick value], serum testosterone, LH, FSH, prolactin, and sex hormone-binding globulin [SHBG]; urinalysis) will be measured. In order to maintain the blindness of the study, information about individual’s serum testosterone concentrations will be provided to the investigator only at the baseline visit. During the course of the study, serum testosterone concentrations will be directly reported to the responsible data monitor. Bone mineral density (BMD) of the proximal femur and the lumbal spine will be determined by dual-energy X-ray

Peer Briken et al.

absorptiometry at baseline and at final visit. Patients with pre-existing osteopenia (WHO criteria: T-score between -1.0 and -2.5 SD) will also be monitored by dual-energy X-ray absorptiometry for changes in BMD after 6 months. In order to describe the individual’s current and dynamic risk factors and sexual interests and behaviors, the following tests will be performed at the baseline visit: basic documentation including the Kinsey Scale (17, 18), and the STATIC-99 as a current risk-assessment tool (19); the Sexual Violence Risk20 (SVR-20) which includes dynamic risk factors (20, 21) will be performed at baseline and at final visit; the Multiphasic Sex Inventory (MSI) (22), a modification of the total sexual outcome (TSO) (23-25), and eye-tracking tests (26) will be carried out at baseline (preliminary tests) and at different visits during the course of the study. The German version of the Beck Depression Inventory Revision (BDI-II) for measuring the severity of depression will be applied at the baseline visit, after 3, 6, 9, and 12 months (27). Participants will be advised to refrain from smoking and alcohol use. All inclusion and exclusion criteria will be checked. Any signs and symptoms of potentially occurring AEs will be documented.

Fourteen days after the baseline visit T0 (visit T0+14), eye-tracking tests (visual orientation paradigm; mental rotation paradigm) will be performed. Again, all inclusion and exclusion criteria will be checked, serum testosterone concentrations will be measured, and signs and symptoms of potentially occurring AEs will be documented. Eligible patients at this time will randomly be assigned to one of the two therapy arms according to the randomization schedule and will receive the first psychotherapy session together with the study medication at the end of this visit.

Each patient will subsequently attend six visits (T1, T2, T3, T4, T5-14, T5) at 1, 3, 6, 9, 11.5, and 12 months after baseline visit T0+14 (in addition to the weekly psychotherapy sessions). The study will end for each patient at the final visit (T5) after 12 months. Follow-up treatment will be carried out according to the usual approach implemented at each clinic.

Study Treatments

All patients will receive cognitive-behavioral psychotherapy according to the study-specific manual in German, based on the Core Sex Offender Treatment Programme (SOTP), the Offending Behaviour Programme Unit, the SOTP Rolling Programme, and the explanations

set out in the manual “Treating Sexual Offenders” (28).

Study-related psychotherapy includes 13 thematic blocks, with each block consisting of a variable number of sessions. To be included in the evaluation of the study each patient will have to attend psychotherapy blocks 1-12 with a minimum of 28 and a maximum of 44 sessions.

Psychotherapy will be provided on a regular basis (one session per week; minimum duration: 40-50 minutes) over a period of 12 months by a psychiatrist/psychotherapist experienced in treating patients with pedophilia.

Each psychiatrist/psychotherapist involved in this study will be trained in advance to perform the study-related psychotherapy. Each will complete a checklist of the actual progress of the patient in the structured program, ensuring adequate quality and monitoring of psychotherapy.

One of the psychotherapists/psychiatrists who developed the psychotherapy manual will supervise and audit the treatment program every 2 to 3 months. Psychotherapy can be continued following the end of study.

At visit T0+14, drug therapy will start. Patients randomized to the test group will begin treatment with triptorelin (triptorelin embonate) suspension 11.25mg/2mL administered every 12 weeks as a single intramuscular injection for a period of 12 months (total of 4 injections). Patients randomized to the reference group will begin treatment with 2mL placebo suspension administered every 12 weeks as a single intramuscular injection for one year (total of 4 injections). Blinding will be achieved by packaging the test product (trademark: Salvacyl®, distributor: Dr. R. Pfleger, Bamberg; manufacturer: Ipsen Pharma Biotech, France) and the reference product (placebo suspension; manufactured

by Ipsen Pharma Biotech, France) in identical vials with identical printing (identical batch number) and supplied in identical folding boxes with identical labelling. Thus, the study medications (including packaging) will be indistinguishable. They will be kept in boxes labelled with the respective patient number as determined by the randomization procedure. Study medication and sealed emergency envelopes containing information for unblinding the study will be given to the investigators.

In order to minimize treatment-related bone loss, adequate calcium (1.000 mg/day) and vitamin D (1.000 IU/day) supplementation will be maintained according to recent recommendations (29).

Assessment of Efficacy

Changes in three target parameters will be used to assess therapeutic outcome: 309

Efficacy of Psychotherapy Combined with Triptorelin in Patients with Severe Pedophilic Disorders

1. Psychosexual characteristics using the MSI (in German), scale: sexual abuse of children (SMK) (22) 2. Risk of violent sexual behavior using the SVR-20 total score (in German) (20, 21) 3. Serum testosterone concentration (total testosterone) All instruments used for therapy assessment have been validated. Treatment effects will be assessed by comparing baseline values with those at the final examination (month 12).

Co-variables and all other variables will only be used to describe the patient population. The scales sexual compulsivity (SZ) and lying-scale regarding sexual abuse of children of the MSI (22) will be used as co-variables of the scale sexual abuse of children.

During the study, changes in total sexual outcome will be described using a modified version of the manual originated by Kafka (23-25). Two eye-tracking methods (Visual Orientation Paradigm, Mental Rotation) will be used to examine selective attention processes to sexual preferred stimuli before and after therapy (26).

A final judgement (low, moderate, or high) about the risk of future sexual violence will be made at the end of study by SVR-20 summary risk rating.

Assessment of Tolerability

The tolerability of treatment will be monitored throughout the study based on reported AEs and results of physical examination, BDI, routine laboratory measurements, urinalysis, and BMD examinations. Information on AEs will be collected by the investigator by questioning the patients, spontaneous reports and observation, and will be reported on the appropriate case report form (CRF) pages. Occurrence of any serious AE will lead to notification of the drug safety officer of the sponsor within 24 hours.

Statistical Analysis

This is a pilot study and, therefore, exploratory data analyses will be carried out. Nevertheless, data analyses will focus on defined therapeutically-relevant outcomes, i.e., the changes of psychosexual characteristics from baseline to final examination. Three different target parameters (see Assessment of Efficacy) will be evaluated in order to substantiate and elucidate the mechanisms underlying study results. All other variables will only be used to describe the patient population.

As valid information from RCTs is still lacking, a precise calculation of sample size is not possible.

Furthermore, there is only limited access to a restricted 310

pool of patients. Therefore, the ultimate sample size will be defined by the number of suitable patients present at the study centers.

Those individuals whose eligibility is confirmed will be randomly allocated to one of the two treatment arms in a 1:1 ratio stratified by center to rule out factors involving centers, investigators, and settings. The allocation schedule will be produced by persons who will not be involved in any subsequent aspect of the study.

Data will be analyzed by an intention-to-treat approach. All analyses will be performed and all tables, figures and data listings will be prepared using SAS version 9.2 or subsequent versions. Categorical variables will be presented as ratios and percentages. If the assumption of normal distribution for continuous variables of interest cannot be confirmed, the distribution will be described by the median, minimum and maximum and interquartile range. If variables are normally distributed (if required, after transformation) mean and standard deviation will also be calculated. Data summaries and listings will be separated by center and treatment group.

All patient data will be included in data listings. Further approaches to data analyses are still to be determined in detail by the final statistical analysis plan.

Quality Assurance

Quality assurance and quality control systems will be implemented and maintained using written standard operating procedures to ensure that the trial is conducted and data are generated, documented, analyzed, and reported in compliance with the study protocol, the GCP-rules, and other applicable regulatory requirements.

Monitoring will be performed by the sponsor or a representative of the sponsor. The monitor will get in touch with the study centers at regular intervals to request information on the progress of the study.

Dependent on patient recruitment the monitor will visit the study centers to check study procedures and to review study documents. The sponsor will supervise study progress and will organize internal and external audits of the study, as well as meetings of the Advisory Board at regular intervals.

DISCUSSION We are convinced that this pilot study will provide a platform for a critical debate of selected legal, ethical and methodological aspects. Some controversial points are emphasized in advance.

Peer Briken et al.

Several in-depth review articles have focused on the legal and ethical issues of antiandrogen pharmacotherapy in sex offenders with particular reference to the European Convention of Human Rights and the concept of human dignity (30-33). The design and methods of this study follow the recommendations of these articles. The legal requirements in Germany for antihormonal treatment of patients with severe sexual deviations, especially those regulating information to be provided and voluntary consent, are described in the German castration law (34). This law does not exclude convicted sexual offenders who are kept in institutions for hospital treatment enforcement (30). To what extent and under which conditions these sexual offenders can participate in clinical trials is currently under discussion (35, 36). In the present case this will be decided by the independent Ethics Committee and national authorities. The present trial protocol is explicit with regards to all aspects concerning genuinely independent study-related information and the voluntary decision-making of these patients.

The fact that the patients of this proposed study are to be treated in forensic psychiatric hospitals (the German Maßregelvollzug) complicates the treatment process both legally and scientifically. On the one hand in Germany this is the typical setting where antiandrogen medication is prescribed to patients with a high-risk for sexual offending related to a paraphilic disorder. On the other hand treatment has to be offered in a locked ward setting until the risk is reduced markedly. That means that risk has to be reduced before home leave steps are possible.

Antiandrogen treatment can be justified if it is medically and/or criminally necessary (30). Treatment has to be in the best interest of the offender to control his paraphilic thoughts and to decrease the risk for recidivism and, thus, in turn, to protect the general public.

Several uncontrolled studies with LHRH-analogues have suggested that testosterone suppression to castrate levels can reduce the sexual drive and urge in men with paraphilias (3, 5, 6, 13-15). Through this, it may be possible to also open a wider window for the success of concomitant psychological treatment approaches.

The first purpose of the present study is, therefore, to investigate the efficacy of cognitive-behavioral therapy in the management of males with pedophilia. All patients will receive intensive psychotherapy according to the study-specific manual. Through this, it can be guaranteed that all patients who have voluntarily

given their consent will be treated in a comparable manner. Attendance at psychotherapy sessions offers a real opportunity to each motivated sexual offender who truly desires to control his paraphilic behavior to have access to the currently most reliable risk management approach and through this to give the offender maximal help to effect a real change.

The second purpose of this study is to evaluate the efficacy of pharmacotherapy in addition to psychotherapy.

Proof of clinical efficacy and safety of a drug should be based on randomized, double-blind, controlled clinical studies. Therefore, patients in the trial will be randomly assigned to antiandrogen treatment and placebo reference groups. This means that only approximately half of the study population will be treated with the active drug. Moreover, a transient increase in the concentration of circulating testosterone can occur following the initial injection of triptorelin, which theoretically could be detrimental in terms of deviant sexual behaviors.

However, serum testosterone concentrations will subsequently decline dramatically over a reasonably short period of time and remain significantly lowered with repeated injections. Based on these facts, it is necessary to provide potentially effective risk management options (i.e., study-specific psychotherapy) to all patients. With view to the potential risk of recidivism and thus to the public’s safety, it is necessary to recruit the patients out of closed institutions for psychiatric criminals. Otherwise, it would be difficult to justify a controlled trial where only half of high-risk patients receive a verum medication. In Europe, no Ethics Committee, no (inter) national authority, no insurance, no sponsor and no court of law will allow or take responsibility for a clinical trial treating convicted high risk sexual offenders who will have the potential chance to abuse children or offend. However, treatment of incarcerated sexual offenders does not reflect a real-life situation in which patients in society have more difficulty in adherence as sexual stimuli are readily available. The present study will endeavor to assess sexual fantasy and urges and to imitate “sexual stimuli” present in the real world as far as possible using different approaches (i.e., presenting pictures of children and measuring attention processes with eye-tracking techniques; see under Methods). All researchers involved in the planning of this study realize the limitations of the trial. These comprise investigating a relatively small sample of sexual offenders without a “real” risk to reoffend due to the fact that they are in a forensic psychiatric hospital. Only indirect measure311

Efficacy of Psychotherapy Combined with Triptorelin in Patients with Severe Pedophilic Disorders

ments on one of the major risk factors for reoffending (â&#x20AC;&#x153;paraphiliaâ&#x20AC;?) will serve to assess efficacy. However, there is no other legal way to evaluate initial data, which can ethically be justified.

Beyond that, the use of a rigid approach to study procedures, implicit in a RCT design, should produce groups with similar patterns of offending and similar risk levels. Both groups will be compared statistically to validate their comparability.

Special care must be taken during the informed consent process in vulnerable populations such as prisoners.

Offenders must freely provide their informed consent, without external pressure or coercion or any suggestion that participation will affect the length of time or quality of the mandatory forensic psychiatric hospital treatment (30-32). Therefore, an external psychiatrist unaffiliated with the study will fully inform each eligible individual regarding all aspects of the study and assess whether or not he truly understands what he is consenting to, including all possible risks, including failure of therapy, and side effects (30-32). When considering potential side effects, it should be stressed that antiandrogens must be given continuously, perhaps for years or even a lifetime in order to prevent relapse.

As seen with other LHRH-agonists or after surgical castration, the most commonly observed adverse effects related to triptorelin treatment are due to testosterone suppression and, apart from hypogonadism with decreased libido and erectile dysfunction, include hot flashes, an increased risk of developing a metabolic syndrome, manifested by changes in glucose and lipid metabolism, as well as diabetes mellitus; and a small increased risk of cardiovascular mortality and depression (11, 12, 37, 38). The long-term use of synthetic LHRH-agonists may also be associated with increased bone loss and may lead to osteoporosis (WHO criteria: T-score <-2.5 SD) and elevated risk of bone fracture (13, 14, 38-40). Effective and safe management of patients undergoing ADT must therefore include careful monitoring for AEs and their prevention (if possible) and treatment (37). Information on AEs will be collected regularly throughout the proposed study. A limitation of the study is that blinding could be broken by the observation of AEs (e.g., hot flashes). However, there is no solution for this problem since for legal reasons the investigating physician has to be the one who also monitors the AEs. In order to prevent treatment-related bone loss, lifestyle modification including smoking cessation, moderation of 312

alcohol consumption and regular weight bearing exercise will be recommended and are of additional benefit for the patients. Adequate dietary calcium and vitamin D supplementation will also be provided. According to the recommendations of Briken et al. (3), physical examinations of each participant and laboratory as well as BMD screening tests at baseline and regularly throughout the study are included in the study protocol.

The rigorous validation of all possible legal and methodological aspects in this pilot study is essential to minimize the risk of failure and biased results, and, thus, provide the first controlled data on the efficacy and tolerability of psychotherapy combined with antiandrogen treatment, in terms of reduction in paraphilic urges and interests as well as in risk assessment measures, in patients with severe pedophilia. The planned pilot study will be an initial, but important step in ADT treatment research of sex offenders.

Acknowledgments The study was planned by the principle investigator (first author) and the advisory board (the second author is part of the advisory board) together with the Dr. R Pfleger GmbH. The study is sponsored by Dr. R. Pfleger GmbH, Germany, with financial and pharmaceutical contribution of Beaufour Ipsen Pharma, France. We would like to thank Dr. rer. nat. Petra Schwantes, Biomedical Services [www.biomedicalservices.eu], who provided medical writing services on behalf of Dr. R. Pfleger GmbH. The manuscript was drafted in close collaboration with authors, the statistician (member of the Advisory Board) and the sponsor.

References 1. Guay DRP. Drug treatment of paraphilic and nonpharaphilic sexual disorders. Clin Ther 2009; 31: 1-31.

2. Briken P, Kafka MP. Pharmacological treatments for paraphilic patients and sexual offenders. Curr Opin Psychiatry 2007; 20: 609-613.

3. Briken P, Hill A, Berner W. Pharmacotherapy of paraphilias with longacting agonists of luteinizing hormone-releasing hormone: a systematic review. J Clin Psychiatry 2003; 64: 890-897.

4. Briken P, Welzel K, Habermann N, Hill A, Berner W. Antiandrogenic pharmacotherapy of sexual offenders and home leave steps in the forensic psychiatric hospital Berlin. Psychiat Prax 2009; 36: 232-237.

5. Bussmann H, Finger P. Anti-androgenic treatment of sex-offenders in the forensic psychiatric hospital of Berlin. Forens Psychiatr Psychol Kriminol 2009; 3: 129-140.

6. Czerny JP, Briken P, Berner W. Antihormonal treatment of paraphilic patients in German forensic psychiatric clinics. Eur Psychiatry 2002; 17: 104-106.

7. Briken P, Nika E, Berner W. Treatment of paraphilia with luteinizing hormone-releasing hormone agonists. J Sex Marital Ther 2001; 27: 45-55.

8. Krueger RB, Kaplan MS. Depot-leuprolide acetate for treatment of paraphilias: A report of twelve cases. Arch Sex Behav 2001; 30: 409-422.

9. Heidenreich A, Bolla M, Joniau S, et al. Guidelines on prostate cancer.

European Association of Urology, 2010.

10. Tombal B, Stainier A. Hormone therapy in the management of prostate cancer. Eur Urol Rev 2010; 5(2): 22-6.

11. LĂ kemedelsverket (Medical Products Agency). Public Assessment Report. Scientic discussion, Moapar, 11.25mg powder and solvent

Peer Briken et al.

for suspension for injection (triptorelin embonate). SE/H/663/01/ MR, 2006-10-13. http://www.lakemedelsverket.se/SPC_PIL/Pdf/par/ Moapar%2011%2C25%20mg%20powd%20and%20solvent%20for%20 susp%20for%20injection.pdf 12. Làkemedelsverket (Medical Products Agency). SmPC Moapar 11.25mg.

2008. http://www.lakemedelsverket.se/SPC_PIL/Pdf/enhumspc/ Moapar%2011.25%20mg%20powd.%20and%20solvent%20for%20 susp.%20for%20injection%20ENG.pdf 13. Roِsler A, Witztum E. Treatment of men with paraphilia with a longacting analogue of gonadotropin-releasing hormone. N Engl J Med 1998; 338: 416-422.

14. Thibaut F, Cordier B, Kuhn JM. Effect of a long-lasting gonadotrophin hormone-releasing hormone agonist in six cases of severe male paraphilia.

Acta Psychiatr Scand 1993; 87: 445-450.

15. Thibaut F, Cordier B, Kuhn JM. Gonadotrophin hormone releasing hormone agonist in cases of severe paraphilia: A lifetime treatment?

Psychoneuroendocrinology 1996; 21: 411-419.

16. Saß H, Wittchen HU, Zaudig M, Houben I. Diagnostisches und Statistisches Manual Psychischer Stِrungen – Textrevision – DSM-IVTR. German translation of: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision.

Washington, DC, American Psychiatric Association, 2000. HogrefeVerlag GmbH & Co KG, Gِottingen, 2003.

17. The Kinsey Institute. Kinsey’s Heterosexual-Homosexual Rating Scale. http://www.kinseyinstitute.org/research/ak-hhscale.html 18. Kinsey A, Pomeroy WR, Martin CE. Sexual behavior in the human male.

Philadelphia, Penn.: W.B. Saunders; Bloomington: Indiana Press, 1953.

19. Rettenberger M, Eher R. Actuarial assessment of sex offender recidivism risk: A validation of the German version of the STATIC-99. Sexual Offender Treatment 2006; 1(3).

20. Müller-Isberner R, Gonzalez Cabeza S, Eucker S. Die Vorhersage sexueller Gewalttaten mit dem SVR-20. German version of: Boer DP, Hart SD, Kropp PR, Webster CD. Manual for the Sexual Violence Risk-20. Mental Health, Law, and Policy Institute Simon Fraser University, Burnaby, B.C., Canada, 1997. Institut für Forensische Psychiatrie Haina, 2000.

21. Rettenberger M, Hucker SJ, Boer DP, Eher R. The reliability and validity of the Sexual Violence Risk-20 (SVR-20): An international review. Sexual Offender Treatment 2009; 4(2).

22. Deegener G. Multiphasic Sex Inventory (MSI). Fragebogen zur Erfassung psychosexueller Merkmale bei Sexualt‫ن‬tern, Handbuch. Hogrefe-Verlag, Gِottingen 1996.

23. Kafka MP, Hennen J. Hypersexual desire in males: Are males with paraphilias different from males with paraphilia-related disorders?

Sexual Abuse 2003; 15: 307-321.

24. Kafka MP. Hypersexual disorder: A proposed diagnosis for DSM-V. Arch Sex Behav 2009. DOI 10.1007/s10508-009-9574-7.

25. Fuchs A, Turner D, Briken P. Anleitung zur Anwendung des Sexual Outlet Inventory durch Fachleute für psychische Gesundheit. German version of: Kafka MP. Sexual Outlet Inventory. Unpublished manuscript.

Hamburg, 2010.

26. Müller JL. Eye-tracking studies: Description of the test procedure and individual tests. Manual for the Clinical Study P278, Dr. R. Pfleger GmbH, 2010.

27. Hautzinger M, Keller F, Kühner C. BDI-II Beck Depressions-Inventar Revision, Manual. German translation of: Beck AT, Steer RA, Brown GK. BDI-II Beck Depression Inventory Revision. Pearson Assessment & Information GmbH, Frankfurt, 2009.

28. Fuchs, Briken P, Berner W. Studie P278. Leitfaden für die Einzeltherapie.

2010.

29. Kasperk C. Das Osteoporoserisiko der antiandrogenen Therapie des Mannes. Forens Psychiatr Psychol Kriminol 2010; 4: S22-S26.

30. Koller M. Antiandrogen treatment – relapse prevention or assault. R & P 2008; 26: 187-199.

31. Rainey B, Harrison K. Pharmacotherapy and human rights in sexual offenders: Best of friends or unlikely bedfellows? Sexual Offender Treatment 2008; 3(2).

32. Harrison K. Legal and ethical issues when using antiandrogenic pharmacotherapy with sex offenders. Sexual Offender Treatment 2008; 3(2).

33. Elger BS. Research involving prisoners: Consensus and controversies in international and European regulations. Bioethics 2008; 22: 224-238.

34. Bundesministerium der Justiz. Gesetz über die freiwillige Kastration und andere Behandlungsmethoden (KastrG). Stand: 17.12.2008.

35. Duttge G. Striktes Verbot der Arzneimittelprüfung an zwangsweise Untergebrachten (§ 40 I S. 3 Nr. 4 AMG)?In: Ahrens HJ, et al. (eds).

Medizin und Haftung. Berlin, Heidelberg: Springer Verlag, 2009.

36. Spranger TM. Fremdnützige Forschung an Einwillungsunf‫ن‬higen, Bioethik und klinische Arzneimittelprüfung. MedR 2001; 5: 238-247.

37. Giltay EJ, Gooren LJG. Potential side effects of androgen deprivation treatment in sex offenders. J Am Acad Psychiatry Law 2009; 37: 53-58.

38. Berlin FS. Commentary: risk/benefit ratio of androgen deprivation treatment for sex offenders. J Am Acad Psychiatry Law 2009; 37: 59-62.

39. Grasswick LJ, Bradford JMW. Osteoporosis associated with the treatment of paraphilias: A clinical review of seven case reports. J Forensic Sci 2003; 48: 849-855.

40. Hoogeveen J, Van der Veer E. Side effects of pharmacotherapy on bone with long-acting gonadorelin agonist triptorelin for paraphilia. J Sex Med 2008; 5: 626-630.

313

Book Reviews

Book reviews It's Not All in Your Head: Anxiety, Depression, Mood Swings and Multiple Sclerosis

diminishing the standards and value of this book. I came away uncertain as to recommending this book to my patients. Will they act as Dr. Farrell says: “…(after finishing the book) Head straight to your computer or to your phone and take some action right now.” Will they sigh and say: “another ‘American’ feel-good book…”

I really do not know.

Yoram Barak

Patricia Farrell, PhD, Demos Health, New York, 2011 Paperback: 221 pages, includes index. Price: $16.95

Bat Yam

ISBN 978-1-932603-95-8

T

he opening paragraph of this book, titled: “Multiple Sclerosis Made Simple,” begins with the following nearly poetic description of the pathophysiology of the complicated immunological impairment in multiple sclerosis: “…the process (disease) is thought to be caused by an attack of the body’s immune system on the delicate covering on nerves and areas of the brain related to mood, memory, judgment, concentration and movement.”

Due disclosure is herein required. I have been working as a psychiatric consultant for Israel’s Multiple Sclerosis Center at the Sheba Medical Center for over 20 years. I do not like light banter when it comes to this devastating chronic disease. Dr. Farrell writes with commitment and passion about living with the comorbid anxiety and depression that frequently complicate multiple sclerosis. Nevertheless her style made it very difficult for me to stay neutral as I read this book. The author often berates the physicians mentioned for doing a bad job of diagnosis and management. She also dispenses advice that as a trained psychiatrist I find hard to accept. An example pops up in the opening paragraphs of the book’s preface: “I believe that if you wish to take several tests to get an ‘official’ diagnosis of depression and/or anxiety, this can be accomplished quite easily on the Internet.”

The book is divided into nine major parts: MS made simple, the body-mind connection, riding the rollercoaster of MS, the “ugly twins” of depression and anxiety, learning to help yourself, handling guilt and maintaining resilience, maximizing memory to combat depression, coping strategies for everyday and the future is bright. Each part has its mix of solid data and encouraging advice together with truisms that are in fact 314

Rekindling the Spirit: Creativity, Passion and the Prevention of Burnout in the Medical Profession Stanley Rabin, Benyamin Maoz, Yuval Shorer and Andre Matalon Ramot Publishing, Tel Aviv University, 2010, 174 pages ISBN: 978-965-274-459-3.

W

hat are the components that contribute to the optimal functioning of health care professionals who persist in the face of difficulties? For doctors like me in daily practice it was gratifying to discover in this attractive book whose elements can enhance the level of my job satisfaction and reduce burnout.

Medical professionals have in the past paid little attention to the promotion of optimal mental health.

However, over the past years there has been a substantial effort to attend to matters such as how to cope with burnout. The rate of burnout among physicians is considered to be high and it is a critical issue for healthcare delivery, as burnout can lead to decreased work performance and poorer treatment outcomes. High levels of exhaustion can cause less humanistic attitudes toward patients, and physicians who are satisfied with their careers are likely to provide better treatment.

The first chapters of this book are dedicated to general concepts that can contribute to better understanding of phenomena such as burnout in health care services. The second part is more specific and includes practical suggestions to improve creativity in health systems by using methods like an integrative approach and home visits.

The book lights up several areas that can contribute from one side to a better encounter with the patient and from the other side can foster the doctor’s resilience.

With assistance from passion, humanistic attitude, humor and creativity even the worst nemesis of the

Book Reviews

patient-doctor encounter, the infamous computer, can be seen in a creative way as a mode to promote integrative psychosocial care.

The authors come from different disciplines: psychology, family medicine, psychotherapy and psychiatry, and the integration of these disciplines contribute to the book’s holistic viewpoint. I believe this book can be helpful for specific sectors of doctors and health care

workers who have an interest and want to expand their knowledge in the biopsychosocial model.

The book is full of clinical examples and I myself enjoyed reading it and look forward to taking advantage of some of the concepts and methods in my clinical practice.

Assaf Shelef Bat Yam

PSYCHIATRIA POLSKA VOLUME XLVI ISSUE 6 - November-December 2012 CONTENT 933 > Dysfunctional meta-cognitive beliefs and anxiety, depression and self-esteem among healthy subjects with hallucinatory-like experiences. Gawęda Ł et al

1029 > Psychiatric manifestations of autoimmune

951 > The comparison of self image before and after the

1043 > The role of oxytocin and vasopressin in central

psychotic crisis – the analysis of schizophrenic patients’ narration. Chądzyńska M, et al

961 > Are deficits of working memory and executive functions more severe in adolescent schizophrenic patients than in adult schizophrenic patients? Hintze B. 975 > The association of quality of life with mental status and sociodemographic data in schizophrenic patients

Badura-Brzoza K, et al

985 > Physicians’ opinion on the use of perazine in the

treatment of mental disorders – results of the Delphi consensus study. Adamowski T, Kiejna A.

995 > A new role of people suffering from mental illnesses in treatment and recovery.

Cechnicki A, Liberadzka A.

1007 > Sense of humour in patients with depression –

diseases – diagnostic and therapeutic problems.

Celińska-Löwenhoff M, Musiał J.

nervous system activity and mental disorders

Wójciak P, et al

1053 > Seeking the aetiology of autistic spectrum disorder. Part 1: structural neuroimaging. Bryńska A.

1061 > Seeking the aetiology of autistic spectrum

disorder. Part 2: functional neuroimaging. Bryńska A.

1073 > Faces affect recognition in schizophrenia.

Prochwicz K, Różycka J.

1089 > The use of RHLB battery for the evaluation of the lingualand social skills among psychiatric patients – case study. Talarowska M, et al 1099 > Psychotic symptoms and cognitive impairment in neurosarcoidosis. Case report and review of literature

Gaweł M, et al

review. Braniecka A, et al

1019 > Comorbidity and characteristic of obsessivecompulsive symptoms in anorexia nervosa.

Błachno M, Bryńska A.

315

‫החוק מתייחס לחולה נפש במשמעות של חולה פסיכוטי (לפי הפרשנות‬ ‫המשפטית)‪ ,‬ובמחלת האנורקסיה אין מחשבות שווא או שמיעת קולות‬ ‫במובן הפורמלי‪ ,‬אך מדובר במצב של חוסר יכולת שיפוט קיצונית‪,‬‬ ‫המובילה לסכנת חיים – משקל נמוך של החולה גורם לשיבוש מערכות‬ ‫הגוף‪ ,‬במיוחד של המוח‪ ,‬ומסכן את חייה‪ ,‬ואילו היא‪ ,‬עקב הפרעה נפשית‬ ‫חמורה אשר במצבים קיצוניים אלו דינה כדין מחלת נפש‪ ,‬מסרבת לאכול‬ ‫מפחד שתשמין‪ ,‬ללא שיקול דעת והבנה לגבי סיכון החיים‪.‬‬ ‫לדעתנו במצבים חריגים ומסכני חיים אלו‪ ,‬שאינם רבים‪ ,‬יש צורך באשפוז‬ ‫כפוי בהתאם לחוק לטיפול בחולי נפש‪ .‬הדבר דומה לאשפוז כפוי של‬ ‫חולה אבדני הסובל מדיכאון מג'ורי‪ .‬אשפוז כפוי בהתאם לחוק לטיפול‬ ‫בחולי נפש ייתן מענה לפרק זמן קצר לצורך הצלת חיים‪ .‬החוק לטיפול‬ ‫בחולי נפש ניתן לאכיפה ובעל מנגנוני בקרה ופיקוח מובנים‪ .‬הפסיכיאטר‬ ‫המחוזי‪ ,‬בהתאם לחוק‪ ,‬יקבע את מקום הטיפול‪ .‬לדעתנו‪ ,‬יש לתת עדיפות‬ ‫לטיפול ביחידות ייעודיות בבית חולים כללי‪ ,‬ויש להיערך לכך ביחידות‬ ‫אלו ולאפשר אשפוז בתנאי מחלקה פעילה סגורה‪ .‬אשפוז כפוי יכול‬ ‫לאפשר עלייה מתונה וחוזרת במשקל‪ ,‬והדבר יכול לתרום להצלת חיים‪.‬‬ ‫שינוי חקיקה‪:‬‬ ‫שינוי חקיקה הוא החלטה של הציבור‪ ,‬כפי שבאה לידי ביטוי בכנסת‪.‬‬ ‫לדעתנו אין צורך בתיקון החוק באופן ספציפי על פי אבחנה מסוימת‪,‬‬ ‫אלא יש ליישם את החוק הקיים גם על חולות אנורקסיה נרבוזה הנמצאות‬ ‫בסכנת חיים‪ ,‬כפי שפירטנו‪.‬‬ ‫סיכום‪:‬‬ ‫במרבית המקרים של אנורקסיה נרבוזה די בתכנית טיפול מובנית היטב‪,‬‬ ‫המופקדת בידי צוות רב־מקצועי הבקי בטיפול בהפרעות אכילה ונמצאת‬ ‫בפיקוח של רופא מומחה‪.‬‬ ‫במסגרת טיפולית כזו אפשר לזהות אם ומתי יש צורך במעבר מטיפול‬ ‫במרפאה לאשפוז במחלקה ייעודית בבית חולים כללי‪ .‬הניסיון מלמד‬

‫כי רק במקצת המקרים יש צורך באשפוז פסיכיאטרי כפוי‪.‬‬ ‫יש לציין כי אפשרות של טיפול כפוי באנורקסיה קיימת בכמה מדינות‬ ‫(‪ .)7,6‬הטיפול ייקבע בהתאם לעיקרון "בחירת המסגרת המגבילה פחות"‬ ‫(‪ .)Least restrictive environment‬יש לציין כי מיטות המיועדות לטיפול‬ ‫בהפרעות אכילה קיימות כיום בבתי חולים כלליים ומוגדרות כמיטות‬ ‫פסיכיאטריות (הפרעות אכילה)‪ ,‬אך אין בהם אגף סגור‪.‬‬ ‫אנו ממליצים כי עיקר הטיפול יתמקד ביחידות ייעודיות לכך במסגרת‬ ‫בית החולים הכללי‪ ,‬אשר צריך להיערך גם לטיפול כפוי‪ .‬דברים אלה‬ ‫נכונים גם לגבי צעירות מעל גיל ‪.15‬‬

‫ביבליוגרפיה‪:‬‬

‫‪1. Sadock BJ, Sadock VA. Kaplan and Sadock›s synopsis of‬‬ ‫‪psychiatry: Behavioral sciences/clinical psychiatry (10th ed.).‬‬ ‫‪Philadelphia: Lippincott Williams & Wilkins, 2007.‬‬ ‫‪2. Melamed Y, Mester R, Margolin J, Kalian M. Involuntary‬‬ ‫;‪treatment of anorexia nervosa. Int J Law Psychiatry 2003‬‬

‫‪26(6):617-626.‬‬

‫]‪3. Israel Patient's rights act of 1996. [Hebrew‬‬ ‫]‪4. Israel Legal capacity and guardianship law 1962. [Hebrew‬‬ ‫]‪5. Israel Treatment of the mentally ill law of 1991. [Hebrew‬‬ ‫‪6. Ramsay R, Ward A, Treasure J, Russell GF. Compulsory‬‬ ‫‪treatment in anorexia nervosa. Short-term benefits and long‬‬‫‪term mortality. Br J Psychiatry 1999;175: 147-153.‬‬ ‫‪7. Norrington A, Stanley R, Tremlett M, Birrell G. Medical‬‬ ‫‪management of acute severe anorexia nervosa. Arch Dis Child‬‬ ‫‪Educ Pract Ed 2012; 97:48–54.‬‬

‫איגוד הפסיכיאטריה בישראל‪ :‬ההסתדרות הרפואית ‪ -‬המועצה המדעית ‪Israeli Psychiatric Association -‬‬

‫יו"ר‪ :‬פרופ' משה קוטלר ‪president: Prof. M. Kotler /‬‬ ‫‪Moshe.kotler@beerness.health.gov.il‬‬ ‫מזכיר כללי‪ :‬ד"ר טל ברגמן לוי ‪Secretary General: Dr. T. Bergman–Levy /‬‬ ‫‪Tal.Bergman–Levy@beerness.health.gov.il‬‬ ‫גזבר‪ :‬ד"ר שמואל הירשמן ‪Treasurer: Dr. S. Hirschmann /‬‬ ‫‪shmuelhirschmann@yahoo.com‬‬

‫מרכז לבריאות הנפש באר יעקב‬

‫‪Beer Yaacov Mental Health Center‬‬

‫ ת‪.‬ד‪ 1 .‬באר יעקב‬ ‫‪Beer Yaacov Mental Health Center, P.O.B 1 ,‬‬ ‫‪Beer Yaacov, Israel, 70350‬‬

‫יו"ר נבחר‪ :‬פרופ' חיים בלמקר ‪President Elect: Prof. H. Belmaker /‬‬ ‫‪belmaker@bgu.ac.il‬‬ ‫יו"ר יוצא‪ :‬פרופ' זאב קפלן ‪President Emeritus: Prof. Z. Kaplan /‬‬ ‫‪Zeev.kaplan@pbsh.health.gov.il‬‬

‫‪316‬‬

‫נייר עמדה‪ :‬הטיפול באנורקסיה נרבוזה במצב מסכן חיים‬ ‫מחברים‪:‬‬ ‫ •ד"ר אלכסנדר גרינשפון‪ ,‬יו"ר ועדת החוקה באיגוד הפסיכיאטריה‪ ,‬יו"ר‬ ‫סניף חיפה וצפון‪ ,‬מנהל בית חולים שער מנשה ולשעבר ראש שירותי‬ ‫ברה"נ (‪.)2006–2001‬‬ ‫ •ד"ר טל ברגמן־לוי‪ ,‬בי"ח באר יעקב ‪ -‬נס ציונה‪ ,‬מזכירת איגוד הפסיכיאטריה‪.‬‬ ‫ •ד"ר איגור ברש‪ ,‬מנהל המערך הקליני‪ ,‬ברה"ן‪ ,‬משרד הבריאות‪.‬‬ ‫ •ד"ר איתן גור‪ ,‬מנהל מחלקת הפרעות אכילה‪ ,‬תה"ש‪.‬‬ ‫ •פרופ' יובל מלמד‪ ,‬יו"ר נבחר של איגוד הפסיכיאטריה המשפטית‪ ,‬סגן‬ ‫מנהל בית חולים לב השרון‪.‬‬ ‫ •ד"ר יעקוב פולאקביץ‪ ,‬יו"ר נבחר איגוד הפסיכיאטריה לילדים ונוער‪,‬‬ ‫מנהל בית חולים טירת כרמל ולשעבר ראש שירותי ברה"נ (‪.)2009–2006‬‬ ‫רקע‪:‬‬ ‫אנורקסיה נרבוזה היא הפרעה נפשית קשה‪ ,‬ואחוז התמותה ממנה גבוה‪:‬‬ ‫‪ 18%–7%‬לפי מחקרים שונים (‪ .)1‬רוב הסובלות מהמחלה הן נשים‪ .‬רובן‬ ‫מטופלות באופן אמבולטורי‪ ,‬וחלקן זקוקות לטיפול במסגרת אשפוז‪.‬‬ ‫אנורקסיה עלולה להוביל למצב של סכנת חיים‪ ,‬ולמרות זאת חלק‬ ‫מהחולות אינן מסכימות לקבל טיפול כלשהו‪ .‬במקרים אלו עולה השאלה‬ ‫של טיפול בכפייה לצורך הצלת חיים ובכך דן נייר עמדה זה‪.‬‬ ‫יש לציין כי בכל טיפול בחולה אנורקטית יש מרכיב מסוים של כפייה‪,‬‬ ‫שכן האנורקטית מיזמתה אינה מסוגלת לוותר על המחלה‪ .‬אנו דנים‬ ‫כאן במצבים של סכנת חיים‪.‬‬ ‫מאפייני המחלה‪:‬‬ ‫איבוד היכולת לשמור על משקל מינימלי ביחס לגובה ולגיל (פחות‬ ‫מ־‪ 85%‬מהמשקל המצופה)‪ ,‬פחד עז מעלייה במשקל‪ ,‬הפרעה בתדמית‬ ‫הגוף ואמנוריאה‪.‬‬ ‫תת סוגים של המחלה‪:‬‬ ‫‪Restrictive, Binge-eating/purging type‬‬

‫סיבוכים רפואיים‪:‬‬ ‫ •‪Cachexia‬‬

‫ •אבדן מסת שריר הלב‪ ,‬הארכת ‪ ,QT‬הפרעות בקצב הלב‪ ,‬מוות פתאומי‬ ‫ •עצירות‪ ,‬כאב בטן‬ ‫ •רמות ‪ LH‬ו־‪ FSH‬נמוכות‪ ,‬הפסקת מחזור‬ ‫ •לויקופניה‬ ‫ •אוסטאופורוזיס‬ ‫מהלך המחלה‪:‬‬ ‫כ־‪ 25%‬מהחולות מחלימות לחלוטין‪ .‬אצל כ־‪ 50%‬חל שיפור משמעותי‬ ‫והן שבות לתפקוד תקין‪ 25% .‬מהחולות ממשיכות לסבול מתת משקל‬ ‫ומתפקוד לקוי‪ ,‬וחלקן עלולות למות מהמחלה בהמשך‪.‬‬ ‫אפשרויות הטיפול‪:‬‬ ‫ •טיפול בהסכמה‪ :‬האפשרות המועדפת היא טיפול בהסכמה‪ ,‬גם במצבים‬ ‫קשים‪ ,‬וזאת בהסתמך על האמביוולנטיות של החולה ביחס למחלתה‬ ‫וגיוסה לתהליך הטיפול‪ .‬רוב המטופלות נמצאות בטיפול אמבולטורי‬ ‫(לרוב במרפאות המתמחות בתחום)‪ .‬בעת הצורך‪ ,‬אפשר בדרך זו להגיע‬ ‫גם להסכמה לאשפוז‪ ,‬באמצעות הבניית טיפול בשלבים פרוגרסיביים‪.‬‬ ‫האשפוז במחלקה ייחודית מוצג כאחד השלבים שאליו מגיעים אם‬ ‫‪317‬‬

‫כשלו מאמצי טיפול מקדימים‪.‬‬ ‫ •טיפול בכפייה‪ :‬טיפול בכפייה עולה על הפרק במצבים שבהם נשקפת‬ ‫לחולה סכנת חיים‪ .‬מטרת הטיפול הכפוי היא הצלת חיים‪ ,‬והוא ניתן‬ ‫לפרק זמן קצר יחסית עד שהסכנה חולפת‪ .‬מדובר כיום בקבוצה קטנה‬ ‫של חולות‪ ,‬כ־‪ 30–20‬חולות סרבניות טיפול‪ ,‬הנמצאות בסכנה גופנית‬ ‫חמורה‪ .‬רובן שוקלות בין ‪ 20‬ל־‪ 30‬ק"ג וסובלות מפעילות לב אטית‬ ‫עד הפסקה פתאומית של פעימות הלב (מברדיקארדיה)‪ ,‬מירידה‬ ‫דראסטית של חום הגוף (היפותרמיה)‪ ,‬מהפרעות אלקטרוליטיות‪,‬‬ ‫מאנמיה (חוסר ברזל בדם)‪ ,‬מבצקות כתוצאה מהיפואלבולינמיה‬ ‫(חוסר חלבון) ומעוד בעיות גופניות רבות שעלולות לגרום למוות‪.‬‬ ‫הטיפול מתמקד במתן מזון ונוזלים‪ ,‬באיזון אלקטרוליטים‪ ,‬בשיפור‬ ‫חום הגוף וכדומה‪ .‬טיפול בהפרעה הבסיסית ושאיפה לריפוי מצריכים‪,‬‬ ‫לדעתנו‪ ,‬הסכמה לטיפול ממושך יותר‪ .‬טיפול זה יכול להינתן גם בהמשך‬ ‫לטיפול כפוי‪ ,‬שיתרום לאיזון המצב הגופני ויוביל לשיפור יכולת‬ ‫החשיבה‪ ,‬אם תתעורר תובנה לגבי המחלה ותינתן הסכמה לטיפול‪.‬‬ ‫להבנתנו‪ ,‬האפשרויות לטיפול כפוי בהתאם לחוק הן כדלקמן (‪:)2‬‬ ‫חוק זכויות החולה (‪)3‬‬ ‫חוק זכויות החולה סעיף ‪ 15‬אמור לתת פתרון לטיפול כפוי בבית חולים‬ ‫כללי‪ .‬חוק זה מאפשר כפיית טיפול לפי החלטת ועדת האתיקה של‬ ‫בית החולים או לפי החלטת רופא (שלושה רופאים אם ניתן) במצבים‬ ‫של סכנת חיים מיידית‪ .‬הוא מאפשר מתן נוזלים ותיקון אלקטרוליטים‬ ‫במקרים דחופים‪ .‬בפועל הוא מאפשר לרופא לפעול בחדר המיון באופן‬ ‫דחוף גם בלי לקבל את הסכמת החולה במצבים של שינוי הכרה (למשל‬ ‫להחדיר עירוי וכדומה)‪ ,‬מבלי שיואשם בתקיפה‪.‬‬ ‫לחוק זה אין כל מנגנוני אכיפה והוא אינו מאפשר לטפל בחולה שאינו‬ ‫נמצא בבית החולים‪ .‬הוא גם אינו מאפשר כפיית טיפול על חולה שמסרב‬ ‫אקטיבית לטיפול‪ .‬החוק אינו נותן מענה לצורך הממושך של חולות‬ ‫אנורקסיה בטיפול ואף לא לטיפול בהן במקרים של סכנה מיידית‪,‬‬ ‫שכן הטיפול מצריך כמה ימים‪ ,‬ופרוצדורה חד־פעמית אינה מספיקה‬ ‫במקרים אלו‪.‬‬ ‫טיפול כפוי בהחלטת אפוטרופוס‪:‬‬ ‫הפגם העיקרי אצל חולות אנורקסיה הוא היכולת שלהן לקבל החלטה‬ ‫מושכלת (‪ )competence‬לגבי הצורך בטיפול ובתזונה‪.‬‬ ‫לפיכך התגבש בשנים האחרונות הפתרון של מינוי אפוטרופוס על ידי‬ ‫בית המשפט‪ ,‬אשר יחליט בנושאי האשפוז‪ .‬בדרך־כלל ממנה בית המשפט‬ ‫קרוב משפחה כאפוטרופוס לנושא‪ ,‬לרוב הורה‪ .‬אין זה פתרון אידיאלי‪.‬‬ ‫הורה אינו יכול להתמודד עם הלחץ של הבת החולה‪ ,‬ולדעת שהוא‪,‬‬ ‫כביכול‪ ,‬גורם לה להיקשר‪ ,‬להיות מוזנת על ידי זונדה וכו'‪ .‬לא ברור גם‬ ‫איך ניתן ליישם זאת כאשר יש צורך להזין בכפייה‪ ,‬על ידי הגבלה למיטה‪,‬‬ ‫סגירת דלת המחלקה וכדומה‪ .‬נוסף לכך‪ ,‬סוג זה של אשפוז הוא "אשפוז‬ ‫כפוי על ידי אפוטרופוס"‪ ,‬ומבחינה פרוצדוראלית הוא נרשם כאשפוז‬ ‫בהסכמה ואינו עובר את הבקרה הקיימת באשפוז הכפוי הפסיכיאטרי‬ ‫(ייצוג על ידי עו"ד‪ ,‬ועדה פסיכיאטרית ובית משפט)‪ .‬חוק זה גם לא נותן‬ ‫מענה להבאה של מטופלת לבית חולים (‪.)4‬‬ ‫החוק לטיפול בחולי נפש (‪)5‬‬ ‫לדעתנו‪ ,‬במצבים מסכני חיים שפורטו לעיל‪ ,‬יש להפעיל את החוק‬ ‫לטיפול בחולי נפש‪ ,‬עקב חוסר יכולת השיפוט של החולות ותפיסת‬ ‫הגוף המעוותת שאפשר לפרשה כמחשבות שווא סומאטיות ‪.‬אמנם‬

‫האינטנסיביות של התעוררות ושל התנהגות מינית חריגה‪ .‬טיפול‬ ‫באנלוגים כאלה הוא הטיפול המבטיח ביותר כיום לעברייני‬ ‫מין עם מסוכנות גבוהה כמו פדופילים ואנסים סדרתיים‪ ,‬אולם‬ ‫יש צורך בקבלת "הסכמה מדעת" לטיפול במקרים אלה‪ .‬טיפול‬ ‫ב–‪ SSRI‬נשאר אופציה מעניינת לטיפול במתבגרים ובמטופלים‬ ‫הלוקים גם בדיכאון ובהפרעות כפייתיות או בפרפיליות קלות‬ ‫כמו חשפנות‪.‬‬ ‫התערבות פרמקולוגית צריכה להיות חלק מתכנית טיפול מקיפה‪,‬‬ ‫הכוללת פסיכותרפיה וברוב המקרים גם טיפול התנהגותי‪.‬‬ ‫ניסוי קליני כפול־סמיות מבוקר מתוכנן בגרמניה‬ ‫לבחינת היעילות של פסיכותרפיה משולבת‬ ‫עם טריפטורלין בקרב גברים בוגרים הסובלים‬ ‫מפדופיליה חמורה‪ :‬פרוטוקול הניסוי‬ ‫פ‪ .‬בריקן‪ ,‬וו‪ .‬ברנר וקבוצת ‪ ,P278‬המבורג‪ ,‬גרמניה‬

‫רקע‪ :‬הטיפול בפרפיליה‪ ,‬ובמיוחד בפדופיליה‪ ,‬מתמקד בפסיכותרפיה‬ ‫קוגניטיבית–התנהגותית ובהתערבויות פרמקולוגיות‪ .‬שני מחקרים‬ ‫קליניים לא מבוקרים שבהם השתמשו ב– ‪LHRH - agonist‬‬ ‫‪ triptorelin‬סינתטי‪ ,‬הצביעו על כך שבשילוב עם טיפול פסיכותרפי‪,‬‬ ‫תרופות אנטיאנדרוגניות מפחיתות פנטזיות מיניות‪ ,‬התנהגויות‬ ‫ודחפים סוטים אצל מטופלים פרפיליים‪ .‬יש צורך במחקרים נוספים‬ ‫מבוקרים ואקראיים על מנת לבדוק את יעילות הטיפול בעברייני‬ ‫מין‪ ,‬לרבות התערבות פסיכותרפית ופרמקולוגית‪.‬‬ ‫מטרות‪ :‬מטרת מחקר חלוץ זה היא להעריך את היעילות ואת‬ ‫הנסבלות של פסיכותרפיה קוגניטיבית־התנהגותית בשילוב עם ‪3‬‬ ‫חודשי זריקות תוך–שריריות של טריפטורלין בקרב גברים בוגרים‬ ‫הסובלים מפדופיליה חמורה‪.‬‬ ‫תכנון ושיטות‪ :‬בניסוי רב–מרכזי שלב ‪ IV‬מבוסס אגף סגור (טיפול‬ ‫פסיכיאטרי–משפטי בבית חולים)‪ ,‬כפול–סמיות ומבוקר בקרב‬ ‫קבוצות מקבילות שנערך בגרמניה‪ ,‬עברייני מין מורשעים בני‬ ‫‪ 18‬או יותר הסובלים מפדופיליה על פי תבחיני ‪,DSM-IV-TR‬‬ ‫ייבחרו באקראי לקבלת פסיכותרפיה ספציפית למחקר יחד עם‬ ‫טריפטורלין או אינבו במשך ‪ 12‬חודשים (סה"כ ‪ 4‬זריקות)‪ .‬זהו‬ ‫מחקר ניסיוני‪ ,‬לכן ייערכו ניתוחי חקר נתונים של שלושה משתני‬ ‫יעד שונים‪:‬‬ ‫ •שינויים במאפיינים פסיכו–סקסואליים על ידי שימוש במדריך‬ ‫‪( Multiphasic Sex Inventory‬סולם‪ :‬התעללות מינית בילדים)‪.‬‬ ‫ •שינויים בסיכון להתנהגות מינית אלימה על ידי שימוש ב–‪Sexual‬‬ ‫‪ Violent Risk-20‬תוצאה כוללת‪.‬‬ ‫ •שינויים בריכוז נסיוב טסטוסטורון‪.‬‬ ‫כל הפרמטרים מתמקדים בהערכת תוצאות הטיפול על ידי השוואה‬ ‫בין ערכי קו ההתחלה לערכים בבדיקה הסופית לאחר ‪ 12‬חודשים‪.‬‬ ‫המחקר ייערך בהתאם להנחיות האירופיות לתנאים קליניים‬

‫נאותים (‪ )GCP‬ולכל דרישות החוק לגבי טיפול מרצון בעברייני‬ ‫מין מורשעים בגרמניה‪.‬‬ ‫הערכת מסוגלותם של חולי סכיזופרניה כרונית‬ ‫לתת הסכמה מדעת להשתתפות בניסויים קליניים‪:‬‬ ‫השימוש ב־‪MacArthur Competence Assessment Tool‬‬ ‫‪for Clinical Research1‬נ(‪)MacCAT-CR‬‬ ‫מ‪ .‬לינדר‪ ,‬ל‪ .‬לב־ארי‪ ,‬ר‪ .‬קורס וי‪ .‬מלמד‪ ,‬ישראל‬ ‫תקציר בעברית של המאמר‬ ‫(המאמר המקורי פורסם ב־‪IMAJ‬נ‪)14:470-474 ;2012‬‬

‫רקע‪ :‬שמירה על זכויות החולה מחייבת חתימה על הסכמה‬ ‫מדעת של נבדקים פוטנציאליים להשתתפות במחקר רפואי‪ .‬ה־‬ ‫‪MacArthur Competence Assessment Tool for Clinical Research‬‬

‫(‪ )MacCAT-CR‬נמצא בשימוש נרחב בחו"ל לבדיקת היכולת של‬ ‫נבדקים לתת את הסכמתם להשתתף במחקר‪.‬‬ ‫מטרות‪ :‬בדיקת היעילות של התרגום העברי של הכלי (‪)MacCAT-CR‬‬ ‫בהערכת יכולתם של חולי סכיזופרניה כרונית לתת הסכמה מדעת‬ ‫להשתתף בניסויים קליניים‪.‬‬ ‫שיטות‪ :‬התרגום של ‪ MacCAT-CR‬נבדק על ידי בחינת יכולתם של‬ ‫חולי סכיזופרניה כרונית לתת הסכמה מדעת להשתתף בניסויים‬ ‫קליניים‪ .‬נעשה שימוש בכלי ההערכה הניורוקוגניטיביים הבאים‪:‬‬ ‫‪ )ACE) Addenbrooke's Cognitive Examination‬ו־ ‪Frontal‬‬ ‫‪Assessment Battery‬נ(‪ )FAB‬ובנוסף התקבלה חוות דעתו של‬ ‫הרופא המטפל‪.‬‬ ‫תוצאות‪ :‬במחקר השתתפו ‪ 21‬חולים‪ .‬הניקוד הממוצע ב־‪MacCAT-CR‬‬ ‫היה ‪( 10.57±12‬טווח ‪ )32-0‬ממוצע ניקוד ה־‪ FAB‬היה ‪4.77±9.9‬‬ ‫(טווח ‪ ,)18–1‬ממוצע ‪ ACE‬היה ‪( 16.6±59.14‬טווח ‪ )86-27‬וממוצע‬ ‫הערכת הרופא היה ‪( 1.18±5.24‬טווח ‪.)7-3‬‬ ‫מסקנות‪ :‬הגרסה העברית של ‪ MacCAT-CR‬סייעה לזיהוי חולים‬ ‫המסוגלים לתת הסכמה מדעת להשתתפות במחקר‪ .‬חולים שניקוד‬ ‫‪ FAB‬שלהם היה גבוה מ־‪ 12‬או שווה לו‪ ,‬נטו להצליח יותר בגרסה‬ ‫העברית של ‪ ,MacCAT-CR‬ובכך מאושרת למעשה היעילות של‬ ‫הגרסה העברית שלו‪ .‬במהלך תהליך הסינון לניסויים הקליניים‪,‬‬ ‫ייתכן שיהיה מעשי יותר לתת את ה־‪ MacCAT-CR‬רק לנבדקים‬ ‫שהשיגו ניקוד של ‪ 12‬או יותר בשאלון ‪ FAB‬המקוצר‪.‬‬ ‫*תרגום שאלון ‪ MacCAT-CR‬באישור ההוצאה לאור ‪Professional‬‬ ‫‪ Resource Exchange, Inc‬לשימוש שאינו מסחרי לעידוד המחקר‬

‫בארץ‪ ,‬מופיע באתר האיגוד‪.‬‬ ‫‪Appelbaum P, Grisso T. The MacArthur Competence Assessment‬‬ ‫‪Tool for Clinical Research (MacCAT-CR). Sarasota, FL: Profes‬‬‫‪sional Resource Press, 2001.‬‬

‫‪1‬‬

‫‪318‬‬

‫עברו הערכה פסיכולוגית מקיפה שכללה ריאיון קליני נרחב‬ ‫ומבחנים פסיכולוגיים (בנדר‪ ,‬רורשאך ו־‪ .)TAT‬סקר זה התמקד‬ ‫בקבוצה של ‪ 46‬פדופילים מהמגזר החרדי‪ .‬ניתוחי שכיחות נערכו‬ ‫על מנת להעריך את שיעור היסטוריית הטראומה בילדות והפגיעות‬ ‫האורגניות בקבוצה ייחודית זאת‪.‬‬ ‫תוצאות‪ :‬בהתבסס על דיווח עצמי משולב במידע מאמת מגורמים‬ ‫חיצוניים (הורים וגורמים חינוכיים ורפואיים)‪ ,‬נמצא כי ‪82%‬‬ ‫מהמשתתפים היו קרבנות לפגיעה מינית בילדות ו–‪ 87%‬סבלו‬ ‫מסוג כלשהו של פגיעות אורגנית (הפרעת למידה‪ ,‬הפרעת קשב‪,‬‬ ‫קשיי ויסות וכדומה)‪.‬‬ ‫מגבלות‪ :‬ההשפעה של גודל המדגם ושל היותו "מדגם נוחות" על‬ ‫יכולת ההכללה נדונה בדיון‪.‬‬ ‫מסקנות‪ :‬מהסקר עולה כי במדגם שלפנינו‪ ,‬אצל הפדופיל החרדי‬ ‫נמצאה שכיחות גבוהה של טראומה מינית בילדות וביטויים‬ ‫של פגיעות אורגנית‪ .‬ממצאים אלה ניכרים יותר מהממצאים‬ ‫הקיימים בספרות‪ ,‬ויש צורך במחקרים נוספים על מנת להבין‬ ‫את הגורמים לכך‪.‬‬ ‫קרבן ותוקף‪ :‬חוויות טראומתיות כגורמי‬ ‫סיכון להתנהגות של התעללות מינית‬ ‫ל‪.‬א‪ .‬רסמוסן‪ ,‬סן־דיאגו‪ ,‬ארה"ב‬

‫המודל "מקורבן לתוקף" מנסה להסביר כיצד קורבן של פגיעה‬ ‫מינית הופך לפוגע מיני‪ .‬המודל משייך התנהגות מינית פוגענית‬ ‫למחזור הניתן לניבוי של עיוותים קוגניטיביים והתנהגויות של‬ ‫הרס עצמי ופגיעות מיניות‪.‬‬ ‫שילוב של שני מודלים אקולוגיים "הערכת תהליך תוצאות של‬ ‫טראומה" ו"מיפוי אהבה משפחתית"‪ ,‬יכול אולי לספק הסבר‬ ‫מקיף לגורמים העיקריים המובילים להתנהגות תוקפנית מינית‬ ‫של בני נוער‪.‬‬ ‫תיאור מקרה מדגים את תהליך תוצאות הטראומה של קורבן וגם‬ ‫של תוקף‪ ,‬ומצביע על גורמים הגנתיים התורמים להתמודדות עם‬ ‫טראומה ולהחלמה ממנה‪.‬‬

‫בילדות‪ ,‬של מאפיינים פסיכופתיים ושל כאלה המתייחסים לנטייה‬ ‫לעיוותים קוגניטיביים בקבוצת הפדופילים לעומת קבוצת הביקורת‬ ‫הבריאה‪.‬‬ ‫השוואת קבוצת המכורים לקבוצת הפדופילים העלתה שיעור‬ ‫גבוה של פגיעות מיניות בילדות‪ ,‬יותר מאפיינים סכיזואידיים‬ ‫ופחות נטיות אימפולסיביות והתנהגות פסיכופתית אצל הנבדקים‬ ‫הסובלים מפדופיליה‪ .‬הציון של קבוצת הפדופילים היה גבוה בכמה‬ ‫מדדים של חרדה חברתית מזה של קבוצת הביקורת‪ ,‬ולא נבדל‬ ‫מהציון של קבוצת המכורים‪.‬‬ ‫מגבלות‪ :‬המדידות היו מבוססות על דיווח עצמי‪ ,‬ובמשתנים‬ ‫הדמוגרפיים הייתה שונות רבה‪.‬‬ ‫מסקנות‪ :‬אצל מטופלים הסובלים מהתנהגות פדופילית ניתן לראות‬ ‫בבירור מאפיינים אישיותיים וכאלה הקשורים להיסטוריה שלהם‪,‬‬ ‫הנוגעים הן לבעייתיות בריסון דחפים והן לגורמים מוטיבציוניים‪.‬‬ ‫טיפול קוגניטיבי־התנהגותי בפרפיליות‬ ‫מ‪.‬ס‪ .‬קפלן ור‪.‬ב‪ .‬קרוגר‪ ,‬ניו יורק‪ ,‬ארה"ב‬

‫רקע‪ :‬עברייני מין ממשיכים להיות במרכז תשומת הלב הציבורית‪,‬‬ ‫ושיעור משמעותי מהאוכלוסייה מאובחן כסובל מפרפיליות שונות‪.‬‬ ‫טיפול קוגניטיבי־התנהגותי הוא אחד מכלי הטיפול המרכזיים‬ ‫בעברייני מין ובפרפיליות‪ .‬המאמר סוקר את ההיסטוריה של‬ ‫שימוש בכלי טיפול זה‪ ,‬מבחינת ההיבטים הטכניים והיעילות‪.‬‬ ‫שיטה‪ :‬סקירת הספרות נערכה בעזרת שני מאגרי מידע (‪PubMed‬‬ ‫ו–‪)PsychInfo‬‬ ‫תוצאות‪ :‬נמצאה ספרות רבה שבה מתואר הטיפול הקוגניטיבי־‬ ‫התנהגותי ומוצגים מחקרי תוצאה ומטה־אנליזות שבוחנים את‬ ‫יעילותו‪.‬‬ ‫מגבלות‪ :‬סקר זה מבוסס על סקירת הספרות ומושפע מהידע‬ ‫ומההטיות של עורכיו‪.‬‬ ‫מסקנות‪ :‬הטיפול הקוגניטיבי־התנהגותי הוא השכיח ביותר בטיפול‬ ‫בעברייני מין‪ .‬אף כי תוצאות של תכניות טיפול פרטניות ומטה־‬ ‫אנליזה תומכות ביעילותו‪ ,‬נראה כי באופן כללי העדויות התומכות‬ ‫בטיפול זה אינן חזקות‪ ,‬ויש צורך במחקר אמפירי נוסף כדי לבססו‪.‬‬

‫זיהוי מאפיינים פסיכולוגיים המסייעים‬ ‫למוטיבציה חריגה או לכישלון בריסון‬ ‫דחפים בהתנהגות פדופילית‬

‫פ‪ .‬תיבו‪ ,‬רואן‪ ,‬צרפת‬

‫רקע‪ :‬המאמר מציג מידע מתכנית מחקר שבדקה מאפיינים‬ ‫אישיותיים או גורמים בילדות שיכולים לתרום למוטיבציה או‬ ‫לכישלון בריסון דחפים להתנהגות פדופילית‪.‬‬ ‫שיטה‪ :‬המדגם כלל ‪ 51‬גברים שנראתה אצלם התנהגות פדופילית‪,‬‬ ‫‪ 53‬מתמכרים לאופיאטים (‪ 69%‬מהם גברים) ו–‪ 84‬בריאים (‪77%‬‬ ‫גברים) ששימשו כקבוצת ביקורת‪ .‬ההשוואה בין הקבוצות כללה‬ ‫מאפיינים אישיותיים של חרדה חברתית‪ ,‬עכבות‪ ,‬אימפולסיביות‬ ‫ונטיות לעיוותים קוגניטיביים ופסיכופתיה‪ .‬כל אלה נבחנו בהתייחס‬ ‫לשכיחות של פגיעות מיניות בילדות‪.‬‬ ‫תוצאות‪ :‬התוצאות תומכות בהיארעות מוגברת של פגיעות מיניות‬

‫רקע‪ :‬תפקידו העיקרי של הפסיכיאטר הוא לטפל במטופלים הלוקים‬ ‫בפרפיליה ולהקטין את המצוקה שממנה סובל המטופל‪ .‬במקרים של‬ ‫פרפיליה הקשורים בפגיעות מיניות‪ ,‬הפחתת ההתנהגות הפרפילית‬ ‫היא קריטית להפחתת האלימות המינית ולמניעת ויקטימיזציה‪.‬‬ ‫סקירה זו מתמקדת באוכלוסייה ייחודית זאת‪.‬‬ ‫שיטה‪ :‬נדונו ההמלצות לגבי טיפול בפרפיליה שפורסמו לא מכבר‬ ‫על ידי ‪World Federation of Societies of Biological Psychiatry‬‬ ‫המבוססות על סקירת הספרות הקיימת לגבי הטיפול הפרמקולוגי‬ ‫בפרפיליה (‪.)2010-1970‬‬ ‫תוצאות ומסקנה‪ :‬תרופות אנטי־אנדרוגיניות‪ ,‬ובמיוחד אנלוגים‬ ‫של ‪ ,GnRH‬מפחיתים בצורה משמעותית את התדירות ואת‬

‫ל‪.‬ג'‪.‬כהן וא‪.‬גלינקר‪ ,‬ניו יורק‪ ,‬ארה"ב‬

‫‪319‬‬

‫טיפול פרמקולוגי בפרפיליות‬

‫כתב עת ישראלי‬ ‫לפסיכיאטריה‬

‫‪israel journal of‬‬

‫‪psychiatry‬‬ ‫כרך ‪ ,49‬מס' ‪2012 ,4‬‬

‫רקע‪ :‬ה־‪ DSM-5‬עובר רביזיה מאז ‪ 1999‬ועומד להתפרסם בשנת‬ ‫‪ .2013‬מאמר זה סוקר את השינויים המוצעים לפראפיליות‪.‬‬ ‫שיטה‪ :‬המידע הנסקר נלקח ממאגרי מידע כמו פבמד ופסיכאינפו‪,‬‬ ‫אתר ה־‪ DSM-5‬ומקורות נוספים‪.‬‬ ‫תוצאות‪ :‬פדופיליה‪ ,‬הפרעת היפרסקסואליות והפרעת פראפילית‬ ‫בכפייה (‪ )coercive‬הן אבחנות חדשות מוצעות‪ .‬לפראפיליות‬ ‫מוקדש פרק נפרד ב־‪ DSM-5‬ומוצעת בו הבחנה בין פראפיליות‬ ‫לבין הפרעות פראפיליות‪ .‬מספר הקרבנות הוכנס כמשתנה לאבחנה‬ ‫של פראפיליות‪ ,‬הכוללת קורבנות ורמיסה‪ ,‬ומדדי חומרה הוספו‬ ‫לכל הפראפיליות‪.‬‬ ‫טרנסווסטיזם (‪ )Transvestic disorder‬יכול להיות מאובחן הן בקרב‬ ‫גברים הן בקרב נשים‪ .‬נקבע כי הפרעה פטישיסטית כוללת גם‬ ‫פארטיאליזם (הפרעה שבה יש משיכה מינית לחלקי גוף שונים)‪,‬‬ ‫והפרעה מזוכיסטית כוללת גם ‪( Asphyxiophilia‬הפרעה נדירה‬ ‫שבה מושג גירוי מיני על ידי חנק ויצירת אנוקסיה)‪.‬‬ ‫מגבלות‪ :‬סקירה זאת מתבססת על סקירת הספרות ומושפעת‬ ‫מהידע ומדעותיהם של המחברים‪.‬‬ ‫מסקנות‪ :‬הפרק על הפרעות פראפיליות ב־‪ DSM-5‬יהיה שונה‬ ‫משמעותית מה־‪.DSM-IV-TR‬‬

‫בעזרת כלי הערכה מתוקפים‪.‬‬ ‫תוצאות‪ :‬הפרעות הקשורות בדיכאון חד־קטבי ודו–קטבי‪ ,‬בחרדה‬ ‫חברתית‪ ,‬בהפרעה בקשב וריכוז וכן מצבים אחרים הקשורים‬ ‫להפרעות התפתחותיות בילדות (פיגור שכלי‪" ,‬תסמונת העובר‬ ‫האלכוהולית" ותסמונת אספרגר) הן הפרעות הקשורות‬ ‫לציר ‪ I‬והמדווחות כקשורות להפרעות בדחף מיני‪ .‬ההפרעות‬ ‫הפסיכיאטריות של ציר ‪ I‬הנזכרות לעיל מופיעות בדרך כלל בתקופת‬ ‫הילדות או ההתבגרות‪ ,‬התקופה שבה מופיעות גם ההפרעות‬ ‫הפרפיליות‪ .‬שימוש לרעה באלכוהול היה שכיח בין הפוגעים‬ ‫הפרפילים והאלכוהול היה גורם נוסף משחרר עכבות‪ .‬המחקר‬ ‫מראה שלטיפול פרמקולוגי הניתן בו–זמנית להפרעות בציר ‪I‬‬ ‫ולתחלואה כפולה הקשורה אליהן‪ ,‬אפקט מתון‪ ,‬אך הוא תומך‬ ‫בממצא שטיפול כזה יכול למתן התנהגות פרפילית‪.‬‬ ‫מגבלות‪ :‬סקירה זו אורגנה באופן המדגיש את הממצאים החיוביים‪.‬‬ ‫המחקרים שנסקרו היו שונים מבחינת המדגמים‪ ,‬מבחינת המערך‬ ‫המחקרי שלהם ומבחינת המתודולוגיות האבחנתיות ומהימנותן‪.‬‬ ‫הספרות שנסקרה הייתה בינונית בגודלה והמדגמים היו כאמור‬ ‫קטנים‪.‬‬ ‫מסקנות‪ :‬תת־קבוצה של זכרים עם אבחנות בציר ‪ I‬של הפרעות‬ ‫במצב רוח‪ ,‬חרדה חברתית‪ ,‬התמכרויות‪ ,‬הפרעת קשב וריכוז‬ ‫והפרעות התפתחותיות נוספות יכולה לסבול גם מהתנהגות חסרת‬ ‫עכבות ותוקפנית המתבטאת כפרפיליה‪ .‬לגבי טיפול פרמקולוגי‬ ‫שניתן להפרעות בציר ‪ I‬והתחלואה הכפולה הקשורה אליהן‬ ‫ולפרפיליות‪ ,‬דווח שטיפול כזה יכול להקל על שני סוגי ההפרעות‪,‬‬ ‫אולם בשלב זה יש להתייחס למידע זה כאל מידע מקדמי‪.‬‬

‫הפרעות פסיכיאטריות בציר ‪ I‬של ה־‪,DSM‬‬ ‫פגיעות מיניות פרפיליות וההשלכות‬ ‫לגבי טיפול פרמקולוגי‬

‫היסטוריה של פגיעה מינית ושל פגיעות‬ ‫אורגניות ב"מדגם נוחות" של ‪46‬‬ ‫גברים פדופילים מהמגזר החרדי‬

‫תקצירים‬ ‫הפרעות פראפיליות‬

‫ב־‪DSM-5‬‬

‫ר‪.‬ב‪.‬קרוגר‪ ,‬מ‪.‬ס‪.‬קפלן‪ ,‬ניו יורק‪ ,‬ארה"ב‬

‫מ‪ .‬קפקא‪ ,‬בוסטון‪ ,‬ארה"ב‬

‫א‪ .‬ויצטום‪ ,‬נ‪ .‬דאי‪ ,‬א‪ .‬דאי־גבאי וא‪ .‬רסלר‪ ,‬באר שבע‬

‫רקע‪ :‬הפרעות פסיכופתולוגיות לפי ציר ‪ ,I‬שאינן בעלות אופי‬ ‫מיני‪ ,‬במיוחד אם הן קשורות לאימפולסיביות‪ ,‬צריכות להילקח‬ ‫בחשבון בהערכה של טיפול בהפרעות בדחף המיני‪.‬‬ ‫שיטות‪ :‬סקירת ספרות במדליין בוצעה תוך שימוש בצירוף‬ ‫המונחים הבאים‪" :‬פוגע מיני"‪" ,‬פרפיליה"‪" ,‬ציר ‪ "I‬ו"תחלואה‬ ‫כפולה"‪ ,‬וכן במונחים של הפרעות פרפיליות פרטניות נוספות‬ ‫כמו "חשפנות"‪" ,‬חככנות"‪" ,‬מציצנות" "סדיזם מיני" ו"פדופיליה"‬ ‫ביחד עם "ציר ‪ "I‬ו"תחלואה כפולה"‪ .‬נסקרו ‪ 18‬מאמרים רלבנטיים‬ ‫ופריטי ספרות נוספים שהשתמשו בהם במתודולוגיה מתאימה‪,‬‬ ‫כדי לאשר פסיכופתולוגיה של ציר ‪ I‬או אבחנות ייחודיות אחרות‪,‬‬ ‫שאינן נכללות בדרך כלל בראיונות אבחנתיים מובנים‪ ,‬אך הושגו‬

‫רקע‪ :‬בשנים האחרונות החלו להצטבר עדויות הקושרות פדופיליה‬ ‫להיסטוריה של פגיעה מינית בעבר ולתחלואה כפולה בבעיות‬ ‫אורגניות‪ .‬במהלך מחקר שהתמקד בטיפול בפדופילים‪ ,‬עברו‬ ‫המשתתפים הערכה קלינית ופסיכו–דיאגנוסטית‪ .‬תת קבוצה‬ ‫חשובה במסגרת המחקר הייתה קבוצה של גברים פדופילים מהמגזר‬ ‫החרדי‪ ,‬שהגיעו למחקר שלא דרך המערכת המשפטית‪ .‬בעזרת‬ ‫הערכה פסיכיאטרית‪ ,‬מבחנים פסיכולוגיים ואנמנזה קלינית נבדקו‬ ‫בתת־קבוצה מיוחדת זאת שיעורי ההיסטוריה של טראומה בילדות‬ ‫ושל פגיעות אורגנית‪.‬‬ ‫שיטות‪ :‬סקר זה היה חלק ממחקר גדול שבחן את היעילות של‬ ‫זריקות דקאפפטיל בטיפול בפדופיליה‪ .‬כל המשתתפים במחקר‬ ‫‪320‬‬