working with MEN with DEVIANT SEXUAL INTERESTS

1. working with MEN with DEVIANT SEXUAL INTERESTS Dr Rajan Darjee Consultant Forensic Psychiatrist

5. Models of human sexuality • Sexual strategy theory • Evolutionary psychology • Sexual scripting theory • Cultural, interpersonal, intrapsychic • The big picture • Neurobiological, developmental, psychological, social, cultural, population factors • Dual control model • Balance between excitatory and inhibitory neurobiological systems

6. The Dual Control model (Bancroft & Janssen 2000) Whether sexual response and arousal occurs in a particular individual, in a particular situation, is ultimately determined by the balance of two systems in an individual’s brain, the sexual activation or excitation system and the sexual inhibition system, each of which has a neurobiological substrate

7. The Dual Control model (Bancroft & Janssen 2000) Three basic assumptions: • The effects of any stimulation depends ultimately on neurobiological characteristics. • Neurobiological inhibitionof sexual response is an adaptive pattern, preventing distracting effects of sexual arousal and appetite when sexual activity would be disadvantageous or dangerous. • Individuals varyin their propensity for both sexual excitation and sexual inhibition.

8. The Psychosomatic Circle of Sex (Bancroft 2009)

9. Human sexuality • Sexual development • Sexual differentiation (anatomical) • Gender identity • Sexual interests, arousal, preference • Sexual relationships • Sexual identity

10. Types of sexual problems • Problems of reduced interest or response • Problems with gender or sexual identity • Problematic sexual behaviour

11. Sexual interests etc. - TERMINOLOGY • Sexual attraction • Sexual desire • Sexual interest • Sexual arousal • Sexual behaviour • Sexual fantasy • Sexual preference • Sexual urge

12. Sexual fantasy • Is use of sexual fantasy different between offenders and non-offenders? • Role of sexual fantasy: • Enhancement of positive mood state • Coping with negative mood state • Enhance sexual arousal • Escape from reality • Rehearsing sexual behaviour • Fantasy shapes and is shaped by behaviour and experience • Range of arousing fantasies / stimuli

16. Sexual interests • Development: childhood, adolescence, adulthood • Range of sexual interests • No interest vs. some interest vs. strong interest vs. preference • State vs. trait • Dimensional vs. categorical

17. Adolescence • In males there appears to be a critical period of sexual development around puberty, when sexual arousal to certain stimuli becomes an established pattern • This is determined neurobiologically • But maintenance depends on subsequent psycho-sexual experience/development, abnormal learning

18. Neurobiology of sexual orientation • Prenatal androgen exposure • Fraternal birth order: mother producing antibodies to male-specific antigens in male foetuses • Non-right handedness • Structural findings: • Interstitial nucleus of the hypothalamus and suprachiasmatic nucleus • Hemispheric volume symmetry • Anterior commisure • Functional findings • Effects of pheromones • Functional cerebral asymmetry • Response to visual sexual stimuli

19. Neurobiological studies of sex offenders • Neuro-imaging • Temporal lobe abnormalities • ? Frontal • ? Amygdala / other subcortical areas • Functional imaging studies emerging • Neuropsychology • Executive function • Intelligence, memory, handedness • Emotional intelligence • Brain injury and sexually inappropriate behaviour • Genetics • Klinefelter’s syndrome • Endocrine • Testosterone • Neurotransmitters • 5-HT

20. Structural imaging studies in paedophilia Becerra-García, JA (2011) Magnetic Resonance Techniques in Study of Sexual Stimuli Processing in Paedophilia. In Neuroimaging for Clinicians (Ed. Peres JFP) InTech

21. Functional imaging studies in paedophilia Becerra-García, JA (2011) Magnetic Resonance Techniques in Study of Sexual Stimuli Processing in Paedophilia. In Neuroimaging for Clinicians (Ed. Peres JFP) InTech

22. Sexual interests interact with other factors • Role of other factors in development and maintenance of deviant interests • Role of other factors in precipitating experiencing deviant interests • Role of other factors in precipitating acting on deviant interests

24. Paraphilia DSM-IV TR CRITERION A • Recurrent, intense sexually arousing fantasies, sexual urges or behaviors • Generally involving • Nonhuman objects, or • Suffering/humiliation of oneself or one’s partner, or • Children or other nonconsenting persons • Occurring over a period of 6 months CRITERION B • Cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

25. Paraphilias DSM-5PARAPHILIA (A) vs PARAPHILIA DISORDER (A & B) • A. Over a period of at least 6 months, recurrent and intense sexual arousal from_________ as manifested by fantasies, urges or behaviors. • B. The person has clinically significant distress or impairment in important areas of functioning or has sought sexual stimulation from ___ or more unsuspecting strangers on separate occasions. • C. Exclusionary criteria (when applicable) • Specifiers – Eg. course and remission – Eg. non-exclusive behavioral manifestations

26. Types of paraphilia DSM IV TR DSM 5 • Exhibitionism • Fetishism • Frotteurism • Pedophilia • Sexual masochism • Sexual sadism • Transvestic fetishism • Voyeurism • Paraphilia not otherwise specified (e.g. necrophilia, zoophilia) Changes: • Pedohebephilic disorder • Paraphilic coercive disorder • Hypersexual disorder (nonparaphilic but associated disorder)

27. Kafka, M.P. (2008) Neurobiological processes and comorbidity in sexual deviance. In ‘Sexual Deviance – theory, assessment, and treatment’ (Eds. Laws, D.r. & O’Donohue, W. T.). Guildford Press, New York.

28. Rates of paraphilias in sexual offenders

29. Deviant sexual interests as a risk factor for sexual recidivism • Important risk factor for sexual recidivism (many studies and several meta-analyses) • Particularly sexual interest in children (PPG, SSPI) • ?Interest in sexual violence • ?Sexual sadism • ?Other paraphilias

30. Deviant sexual interests in risk assessment instruments • Overtly present in: • SA07 • SARN • RSVP • SVR-20 • SORAG • By proxy in: • RM 2000 • Static 99

31. Risk and protective factors for sexual recidivism RISK FACTORS • Historic/static • Stable dynamic/dispositional • Acute/precipitating PROTECTIVE • Internal • External

32. ASSESSMENT • History from the individual • Reports from other people • Observation of behaviour • Use of sexually stimulating materials/media • Self-report questionnaires • ‘Objective’ measures

33. ‘Objective’ measures • Penile plethysmography (PPG) • Viewing time measures • Choice reaction time • Implicit association tests • Rapid serial presentation test • Stroop tests • Startle probe refelex • Objective behavioural scales

34. Objective behavioural scales • Sexual Sadism Scale (SESAS; Nitschket et al. 2012) • Screenig Scale for Pedophilic Interests (Seeto

35. Sexual sadism scale (SESAS) • Sexually aroused during offence • Exercises power/control/domination • Torture/cruelty • Humiliating/degrading • Sexual mutilation 6. Non-sexual mutilation 7. Gratuitous violence 8. Inserts objects 9. Ritualistic acts 10. Abducts or confines 11. Keeps trophies

36. Sexual sadism scale (SESAS) contd. PART 2 • Pre-plans offence • Cruelty/torture of other persons or animals • Evidence of sexual arousal by sadistic acts/fantasies SUMMARY EVALUATION Empirical assessment Part 1 score 4-11 = probably sexual sadism Summary assessment Part 1 & 2 and any other material: Sexual sadist Y or N

37. Screening Scale for Pedophilic Interests (SSPI) • Boy victim (2) • Unrelated child victim (1) • More than one child victim (1) • Victim under 11 years old (1) • Only count victims if aged 13 or younger • Score of 4 or 5 indicates likely

38. Polygraph: facilitating honesty? • Evidence that voluntary and mandatory post-conviction polygraph testing facilitate disclosure of sexual interests and treatment • Mandatory testing has been introduced and evaluated in England and Wales • Recent case studies from Broadmoor Hospital

39. Formulation Staticfactors Stable dynamic factors Acute dynamic factors Triggers OFFENCE

42. Paedophilia • Many child sexual offenders do not have a persistent sexual preference for children • Internet offenders> extra-familial contact offenders > intra-familial offenders • Most men who offend against older teenage girls are no paedophilic • Some paedophiles are only aroused by pre-pubescent children, but most are not • Up to 10-20% of males show some sexual interest in children

43. Sexual interest in children in ‘normal young men’ (Briere and Runtz 1989)

44. Sexual sadism • Problems with definition and assessment • ‘Sadomasochism’ vs. ‘criminal sexual sadism’ • Very few rapists are sexually sadistic (<5%) • A significant number of sexual murderers (about 30-40%) are sexually sadistic • Most repeat sexual murderers are sexually sadistic (90%) • Sexual sadism + serious contact offending = extreme caution required • In some countries long-acting anti-libidinals by injection are seen as a necessary treatment

45. Internet offenders • Men who use child pornography have high rates of paedophilia (higher than other child sex offenders) • Is this a group who despite deviant interests are less likely to commit contact offences? • Extreme pornography – new legislation regarding images/videos depicting bestiality, sadism and/or necrophilia

46. Working with men with deviant sexual interests – General points • Interviews and your reaction • Only problem if functionally related to offending • Addressing other factors and facilitating health sexual relationships and functioning will deal with it in many/most cases • How to choose intervention approaches • Range and course of deviant interests • Motivation • Formulation • What does he want to achieve • Timing

47. Principles of intervention (Federoff 2009) • Identify for whom you are working • Facilitate disclosure • Establish what the problem is • Why is the person seeking help now • Avoid one-sided treatment plans • Intervene quickly • Be persistent • Series of ‘experiments’ • Be inclusive and collaborative • Be optimistic

49. Medication and healthy sexual functioningSildenafil (Viagra)