Dr Rajan DarjeeConsultant Forensic Psychiatrist

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

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

Three basic assumptions:1. The effects of any stimulation depends

ultimately on neurobiological characteristics.

2. Neurobiological inhibition of sexual response is an adaptive pattern, preventing distracting effects of sexual arousal and appetite when sexual activity would be disadvantageous or dangerous.

3. Individuals vary in their propensity for both sexual excitation and sexual inhibition.

Sexual development Sexual differentiation (anatomical) Gender identity Sexual interests, arousal, preference Sexual relationships Sexual identity

1. Problems of reduced interest or response2. Problems with gender or sexual identity3. Problematic sexual behaviour

Sexual attraction Sexual desire Sexual interest Sexual arousal Sexual behaviour Sexual fantasy Sexual preference Sexual urge

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

Development: childhood, adolescence, adulthood

Range of sexual interests No interest vs. some interest vs. strong

interest vs. preference State vs. trait Dimensional vs. categorical

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

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

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

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

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

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

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

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

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)

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

Overtly present in: SA07 SARN RSVP SVR-20 SORAG

By proxy in: RM 2000 Static 99

RISK FACTORS Historic/static Stable dynamic/dispositional Acute/precipitating

PROTECTIVE Internal External

History from the individual Reports from other people Observation of behaviour Use of sexually stimulating

materials/media Self-report questionnaires ‘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

Sexual Sadism Scale (SESAS; Nitschket et al. 2012)

Screenig Scale for Pedophilic Interests (Seeto

1. Sexually aroused during offence

2. Exercises power/control/domination

3. Torture/cruelty4. Humiliating/

degrading5. Sexual mutilation

6. Non-sexual mutilation

7. Gratuitous violence8. Inserts objects9. Ritualistic acts10. Abducts or confines11. Keeps trophies

PART 21. Pre-plans offence2. Cruelty/torture of

other persons or animals

3. Evidence of sexual arousal by sadistic acts/fantasies

SUMMARY EVALUATION

Empirical assessmentPart 1 score 4-11 =

probably sexual sadism

Summary assessmentPart 1 & 2 and any other

material:Sexual sadist Y or N

1. Boy victim (2)2. Unrelated child victim (1)3. More than one child victim (1)4. Victim under 11 years old (1)

Only count victims if aged 13 or younger Score of 4 or 5 indicates likely

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

OFFENCEOFFENCE

Static factors

Stable dynamic factors

Acute dynamic factors

Triggers

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

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

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

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

1. Identify for whom you are working2. Facilitate disclosure3. Establish what the problem is4. Why is the person seeking help now5. Avoid one-sided treatment plans6. Intervene quickly7. Be persistent8. Series of ‘experiments’9. Be inclusive and collaborative10. Be optimistic