Die Behandlung paraphiler Störungen mit GnRH-Agonisten unter besonderer Berücksichtigung ethischer und rechtlicher Aspekte

Current guidelines recommend the use of antiandrogenic medication in addition to psychotherapeutic procedures in the treatment of patients and sexual offenders with severe paraphilic disorders and a high to very high risk of committing severe sexual offences. This article provides an overview about the current state of research concerning the effectiveness and possible side effects of antiandrogens and discusses the legal and ethical basis of using antiandrogens in the therapy of paraphilic disorders with a focus on gonadotropin-releasing hormone (GnRH) agonists. Meanwhile, a great deal of empirical evidence exists with respect to the effectiveness of GnRH agonists for lowering paraphilic sexual fantasies and behaviors; however, GnRH agonist treatment also still has a risk of mild to severe undesired side effects, e.?g. hypertension, hyperlipidemia, liver damage, bone demineralization and depression. Nevertheless, in German forensic psychiatric institutions a not insignificant proportion of patients are treated with antiandrogens and furthermore, in the last few years treatment with GnRH agonists has become more important. In Germany, GnRH agonists can only be used on a voluntary basis; however, in some European countries and North American states legal statutes for compulsory treatment also exist. This is clearly contrary to the recommendations of current international guidelines. In light of the fact that GnRH agonist treatment could violate basic human rights, the need for an ethically sound approach is even more important in the decision for therapy with GnRH agonists. This article provides some proposals for a treatment approach that is in line with current ethical and legal requirements.     

Understanding Intimate Partner Sexual Assaults: Findings from Sexual Assault Kits

ABSTRACT

In 2013, Cuyahoga County, Ohio, began DNA testing and investigating nearly 5000 previously unsubmitted sexual assault kits (SAKs) from 1993 through 2009. We examined case files from a sample of SAKs that were tested but not previously adjudicated (n = 429). More than 10% (n = 45) involved victims who reported to police that a former or current intimate partner sexually assaulted them. This article integrates the available data on the offenders, the victims, the initial investigation, and the specifics of the assaults to provide a more complete understanding of intimate partner sexual assault (IPSA). More than one-third of the IPSA offenders were serial sex offenders; that is, the offenders sexually assaulted an intimate partner and another person(s). Comparing IPSAs to all other sexual assaults, IPSAs more frequently involved bodily force, less frequently involved a weapon, and IPSA investigations were more frequently closed because (1) the victims stated they lied or the police doubted the victims and (2) the victims declined to prosecute. The most common sequencing of events was a demand for sex by the offender followed by a verbal refusal by the victim and the use of bodily force in the sexual assault. The findings, however, indicate a great deal of variation in the sequencing of events surrounding the sexual assault, with over 25% involving no physical confrontation before or after the sexual assault and no demands for sex. Unsubmitted SAK data provide a unique window into understanding the understudied and underreported issue of IPSA.     

Development and Refinement of a Targeted Sexual Risk Reduction Intervention for Women With a History of Childhood Sexual Abuse

Childhood sexual abuse (CSA) is associated with sexual risk behavior in adulthood. Traditional sexual risk reduction interventions do not meet the unique needs of women who have been sexually abused. In the current paper, we describe the four-stage process we followed to develop and refine a targeted sexual risk reduction intervention for this population. First, initial quantitative work revealed that the intervention should address how maladaptive thoughts related to traumatic sexualization, trust, powerlessness, and guilt/shame (traumagenic dynamics constructs) influence current sexual behavior. Second, qualitative interviews with 10 women who reported a history of CSA (M age = 34 years; 90% African American) as well as current sexual risk behavior provided support for targeting maladaptive thoughts associated with these traumagenic dynamics constructs. Third, based on the qualitative and quantitative results, we developed a 5-session, group-delivered intervention to address the maladaptive thoughts that occurred as a result of CSA, as well as the cognitive-behavioral determinants of sexual risk behavior. This intervention drew heavily on cognitive behavioral techniques to address cognitions associated with CSA and the links between these cognitions and current sexual risk behavior. Techniques from trauma-based therapies, as well as motivational techniques, were also incorporated into the intervention. Finally, we refined the intervention with 24 women (M age = 33 years; 79% African American), and assessed feasibility and acceptability. These women reported high levels of satisfaction with the intervention. The resultant intervention is currently being evaluated in a small, randomized controlled trial.     

A comparison of five-factor personality dimensions in males with sexual dysfunction and males with paraphilia.

We compared personality profiles of men with sexual dysfunction (n = 51) to those of age-matched men with a primary diagnosis of paraphilia (n = 51) employing the NEO Personality Inventory (NEO-PI), a measure of the five-factor model. Preliminary analyses in a large sample of patients in a sexual behaviors consultation unit supported the reliability and factorial validity of the NEO-PI for this population. Analysis of variance showed significant differences between the dysfunctional and the paraphilic groups on two of the five NEO-PI domains, Neuroticism (N) and Agreeableness (A). The group personality profile of the sexually dysfunctional men was comparable to the normative sample of the NEO-PI, except for a slight elevation in N. By contrast, men with paraphilia had a personality profile marked by high N, low A, and low Conscientiousness (C). Treatment implications of the average personality profile of the sexual dysfunction group and the distinctive personality profile of paraphilic men are discussed.     

Associations Between Proactive and Reactive Aggression and Risky Sexual Behavior Among Emerging Adults

This study examined associations between proactive and reactive aggression and types of risky sexual behavior. Additionally, gender was examined as a moderator of these associations. The sample included emerging adults (N = 232; male = 132) ranging from 18 to 25 years of age. Of the overall sample, 155 individuals (53.5% male) reported engaging in sexual intercourse. Proactive, but not reactive, aggression was uniquely associated with 4 types of risky sexual behavior (i.e., ever engaging in sexual intercourse, number of lifetime sexual partners, number of partners within past 3 months, and frequency of contraception use). Further, associations with number of sexual partners were strongest when levels of reactive aggression were low. With regard to gender differences, proactive aggression was associated with lower likelihood of contraception use in males. Gender also moderated the association between reactive aggression and number of lifetime sexual partners. Implications and future directions are discussed.     

Psychopathie,antisoziale Persönlichkeitsstörung und Sexualdelinquenz

In today’s field of forensic psychiatry, psychopathy is seen as a subtype of antisocial personality disorder and includes manipulative behavior, egocentric and arrogant characteristics, high-risk behavior as well as a lack of empathy. Empirical data on the prevalence of psychopathy and antisocial personality disorder among offenders greatly vary depending on the study design and the composition of the sampled population. Offenders who committed both violent and sex offenses seem to have antisocial traits with a higher probability than offenders who committed only violent or only sex offenses. In the context of criminal responsibility and risk assessment for sex offenders, antisocial and psychopathic traits have a negative impact on the prediction of recidivism. Many study results, even though not all, additionally indicate that the combination of psychopathic traits and sexual deviance (i.?e. for example a paraphilic disorder such as sexual sadism) in sex offenders may be associated with a particularly high risk to reoffend. Due to the specific interpersonal characteristics (e.?g., dominant, provocative behavior, exaggerated self-esteem), therapeutic treatment of sex offenders with antisocial and psychopathic traits is often difficult. The regular supervision by the therapist is considered to be crucial to avoid harmful relationship dynamics or distorted perception of the therapist.     

The relationship between conformity to gender norms,sexual orientation,and gender identity for sexual minorities

The current study examined how dimensions of masculinity and femininity were expressed for sexual minorities. Cluster analysis was used to determine the number of latent classes for conformity to masculine and feminine norms for sexual minorities. A four-class solution was the best fit to the data. Cluster 1 (labeled Relating to others through equality and caring, n = 41) was characterized by low dominance and power over women and high involvement with kids and have nice relationships norms. Cluster 2 (labeled Relating to others through avoidance and misogyny, n = 38) was characterized by low risk-taking and have nice relationships and high power over women and disdain for homosexuality. Cluster 3 (labeled Relating to others through power, n = 34) was characterized by high winning, pursuit of status, and appearance and low modesty. Cluster 4 (labeled Relating to others through sex, n = 27) was characterized by low involvement in romantic relationships and sexual fidelity while endorsing high playboy attitudes. Results indicate that conforming to gender norms tends to follow categories of interpersonal beliefs and behaviors rather than being based in gender identity or sexual orientation. Implications of the results for future research and clinical practice are examined.     

Body Image Satisfaction and Involvement in Risky Sexual Behaviors Among University Students

This study examined the impact of body image satisfaction on university students’ (N = 465) involvement in risky sexual behaviors. A valid and reliable survey instrument was designed and administered to students in their classrooms at a Midwestern university. Of 465 participants, 53.8 % reported having low levels of body image satisfaction and 78.9 % indicated they had engaged in sexual intercourse during their lifetime. Of the sexually active students, 80 % have had sexual intercourse without the use of a condom, 76 % have had sexual intercourse while intoxicated, and 21 % have had sexual intercourse following illegal drug use. Students who had high body image satisfaction were significantly more likely to have ever engaged in sexual intercourse. These results should be considered when developing and implementing sexual education efforts for university students. Future studies should seek to identify specific strategies to increase body image satisfaction and decrease risky sexual behaviors among this high-risk population.     

Becoming the victim: Beyond sadism in serial sexual murderers

The behavior and characteristics of sexually sadistic serial murderers have been described primarily in relation to their paraphilic arousal to the control and torture of their victims. Sadistic sexual murderers who demonstrate both sadism and masochism have been described, but less is known about this type of offender. This article will review a number of hypotheses proposed to explain these behaviors. Next, the authors describe two cases demonstrating a separate phenomenon in which the offender assumes the identity of the victim that has been tortured to enhance his sexual gratification. It is proposed that these cases represent a grandiose form of sadism in which the offender extends his control of the victim beyond life and death. This form of sadism will be distinguished from sadomasochism, and its possible implications will be discussed.     

Let's talk openly about sex: Sexual communication,self-esteem and efficacy as correlates of sexual well-being

Drawing from theories of sexual development, the aim of this study was investigate whether sexual well-being was more positive when youth reported more frequent and better quality sex-related communication, and greater sexual subjectivity (sexual body esteem and pleasure self-efficacy). Sexual well-being was measured with reference to partnered behaviour, including safe-sex behavioural competence, sexual assertiveness, and emotional reactions. Young adults (N = 209; 61% female) aged 17–21 completed questionnaires. While also considering age, gender, romantic status and coital experience in regression analyses, participants higher in competence reported more frequent communication with mothers in high school, and current higher quality communication with mothers and friends. Participants reported more positive emotions related to sex when they had better quality communication with their friends. Associations of sexual subjectivity with greater sexual well-being were found, and small indirect effects were found between retrospectively reported communication frequency and sexual well-being via pleasure self-efficacy.     

Overcoming Empathy-Induced Partiality: Two Rules of Thumb

Young sexual minority men might cope with early stigma by strongly investing in achievement-related success. Sexual minority men (n = 136) reported deriving their self-worth from academics (d = 0.33), appearance (d = 0.33), and competition (d = 0.35) more so than heterosexual men (n = 56). Length of early sexual orientation concealment predicted investment in these domains (β = 0.19, 0.22, 0.24) and an objective measure of stigma predicted the degree to which young sexual minority men sought self-worth through competition (β = 0.26). A nine-day experience sampling approach confirmed that investment in achievement-related domains exacts negative health consequences for young sexual minority men.     

How Gendered Attitudes Relate to Women’s and Men’s Sexual Behaviors and Beliefs

This study examines associations between endorsement of a sexual double standard, gender role attitudes, and sexual behaviors and beliefs. First year university students in the northeastern United States (N = 434; 52 % female; 33 % Black, 29 % Latino, 39 % White; ages 17–19) participated during their first year of college. Endorsement of a sexual double standard was associated with more conventionally gender-stereotyped sexual behaviors and beliefs, specifically, more sexual partners and fewer perceived barriers to condom use for young men, and more perceived barriers to condom use for young women. Women who were more conventional about men’s roles in society tended to use condoms less, whereas women who were more conventional about women’s roles tended to use condoms more. Men who were more conventional about men’s roles tended to have fewer sexual partners. Findings suggest the importance of examining gender’s role in sexual behaviors and beliefs by assessing multiple gendered attitudes, rather than simply considering biological sex.     

The admissibility of other specified paraphilic disorder (non-consent) in sexually violent predator proceedings

Following the advent of sexually violent predator (SVP) legislation in the early 1990s, forensic evaluators began to apply diagnostic labels related to a paraphilic interest in rape as a mental condition predisposing individuals convicted of sexual offenses to recidivate. The most recent iteration of the concept, other specified paraphilic disorder (non-consent) (OSPD (non-consent)), is a commonly utilized diagnostic entity in SVP proceedings. Research on paraphilic interest in coercive sex has failed to define a valid methodology or set of criteria to make a diagnosis of OSPD (non-consent) and has repeatedly demonstrated that the diagnostic construct has poor interrater reliability. The state of the science pertaining to OSPD (non-consent) thus raises serious concerns regarding its admissibility in SVP proceedings. Indeed, there are recent cases in which courts have deemed it inadmissible. The forensic expert involved in SVP proceedings should understand admissibility concerns related to OSPD (non-consent) and how to address them in court.     

The Influence of Early Experiences and Adult Attachment on the Exhibition of the Sexual Double Standard

The sexual double standard is the phenomenon whereby men and women are judged differently for the same sexual behavior. The purpose of the present study was to investigate the potential relationship between life history theory, attachment theory and the sexual double standard. Life history theory posits that one’s upbringing (e.g., quality of early relationship with one’s parents) may have implications for one’s future mating strategies, especially for women. Furthermore, adult attachment orientation often influences individuals’ feelings toward sexual behavior. To address the relationship between these variables, we had participants complete questionnaires regarding their early relationships with their parents and their current attachment regarding romantic partners. Participants then evaluated a target individual who reported having 1 or 12 sexual partners (N = 154). Results showed that female participants’ early relationships with their parents and their current attachment avoidance predicted their exhibition of the double standard. Results are discussed in the context of theoretical and empirical implications.     

Adolescent Sexting and Risky Sexual Behaviours in Zimbabwe: A Cross-Sectional Study

This study measured the relationship between sexting and risky sexual practices among school-going adolescents (N = 502, 53.8% female). Correlates of sexting to consistent condom use, age at sexual debut, transactional sex, intergenerational sex and multiple sexual partners were calculated. Prevalence of sexting was 13%, with boys twice more likely to have sent a sext compared to girls. Significant associations existed between sexting and sexual intercourse (95% CI 2.57–7.82), multiple lifetime sexual partners (95% CI 2.48–10.746) and intergenerational sex (95% CI 1.06–4.9). Condom use was significantly higher among girls (p < 0.001). Interventions targeting adolescents are likely to have higher impact if they address harmful effects of sexting.     

Condom Use Among South African University Students in the Province of KwaZulu-Natal

South Africa has one of the highest HIV infection rates in the world, with young people particularly affected. Condoms are an effective preventative method against HIV among sexually active adults. This study assessed the level of condom usage among university students in South Africa and their attitudes towards condom usage, negotiation efficacy and confidence in condom usage. It was a cross-sectional study conducted amongst South African university students living at the university residences. Students were randomly selected and required to complete a self-administered questionnaire. The mean age of participants (n?=?441) was 22.7?±?4.3 years. The mean age of sexual debut was 17.7?±?3.0 years with 1.4?±?1.47 (range 0–13) current partners. Less than half of the students used a condom at sexual debut and only 28.5% used condoms during recent sexual activity. Those students who used a condom at first sexual intercourse had marginally more positive attitudes about condom usage than those who did not do so (p?=?0.056). Students with a single current partner had more positive attitudes about condom usage than those with multiple current partners (p?=?0.021). Only 32.5% (n?=?127) of the students were very confident in using condoms. Similarly, only 33.0% (n?=?130) of the participants felt that they could definitely negotiate condom use with their partners. We conclude that condom use among South African students is low and that they lack the confidence to use condoms. We recommend that programmes to step up condom use must also incorporate educational interventions on usage.     

Effects of cognitive-behavioural therapy on anxiety,depression and condom use in people with HIV in Mexico City: a pilot study

Anxiety and depression in people living with HIV (PLWH) are negatively associated with healthy sexual behaviours. We pilot-tested a Cognitive-Behavioural Therapy (CBT)-based intervention to reduce anxiety and depression, aimed to increase serostatus disclosure to sexual partners, quality of sexual life (QoSL) and condom use. The study had a single-case experimental design (AB) with follow-up measures. Eleven PLWH with moderate/severe anxiety/depression received six-module CBT intervention delivered in ten one-hour individual weekly sessions. Anxiety, depression, consistent/correct condom use and QoSL were measured. Depression and anxiety decreased after the intervention (depression baseline [BL] Mdn = 21, final [F] Mdn = 3, z = -2.934, p = .003; anxiety BL Mdn = 30, F Mdn = 4, z = -2.941, p = .003). QoSL improved (BL Mdn = 28, F Mdn = 13, z = -2.625, p = .009), along with participants’ ability to use condoms (57.14 vs.100, z = -2.937, p = .003). Effect size was large, changes were maintained at follow-up measurements. The CBT intervention had positive effects in reducing anxiety and depression, which could facilitate the acquisition of healthy sexual behaviours. Further studies are important to clarify the benefits of targeting emotional variables to improve wellbeing and prevention behaviours in PLWH.