Different Roles, Same Goals: Preventing Sexual Abuse 2016 ATSA Conference Thursday November 3 3:30 PM - 5:00 PM T-37

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1 T-37 Understanding and Treating Hypersexuality and Hypersexual Disorder Symposium Chair: Drew A. Kingston, Ph.D., C.Psych, Royal Ottawa Health Care Group In this symposium, hypersexuality is considered a dimensional measure of sexual interest and motivation that includes the frequency, intensity, and time consumed by sexual behaviors. Hypersexual Disorder is a putative non-paraphilic syndrome characterized by hypersexuality, accompanied by the use of sex in response to dysphoric mood, continued sexual risk-taking, and volitional impairment in association with adverse consequences and/or personal distress. Diagnostic criteria for Hypersexual Disorder were proposed but ultimately rejected for inclusion in the DSM-5 (American Psychiatric Association, 2013). Nevertheless, features subsumed within this construct are highly relevant to both the initiation and maintenance of sexually aggressive behavior. Despite this importance, the literature has been characterized by a number of problems, such as a relative lack of empirical research as compared to clinical anecdotes and opinions, overreliance on clinical samples, lack of comparison groups, and a tendency to reflexively assume pathological underpinnings. Some of these problems were noted decades ago (Coleman, 1986; Orford, 1978) and there has been little progress made toward resolving many of these issues. The three presentations that this symposium comprises are organized in a sequential manner and emphasis is placed on (1) the latent structure and theoretical/explanatory models of hypersexuality and sexual offending (Kingston); (2) hypersexuality and its covariation with other constructs related to sexual aggression (Knight & Graham); and (3) effective treatment approaches with sexual offenders presenting with non-paraphilic hypersexuality (Marshall). Defining and Conceptualizing Hypersexuality in Sexual Offenders Drew A. Kingston, Ph.D., C.Psych, Royal Ottawa Health Care Group Non-paraphilic hypersexuality is a controversial concept and there is considerable disagreement about the extent to which excessive sexual behavior constitutes a discriminable disorder. Nevertheless, hypersexuality is a key component in the initiation and maintenance of sexual aggression, and it has been identified as a psychologically meaningful risk factor in sexual offenders. Although the paraphilic disorders and their association with hypersexuality and sexual offending have received a fair bit of empirical

2 attention, far less attention has been devoted to a second set of conditions characterized by non-paraphilic hypersexuality. Several descriptors have been used when describing this phenomenon (e.g., paraphilia-related disorder, sexual addiction, and sexual preoccupation) and although some authors highlight subtle distinctions between these terms, typically they are used inconsistently and sometimes inappropriately. In addition to this descriptive diversity, the literature has been plagued by a lack of empirical research, leading to reliance on clinical and anecdotal experience. This has undoubtedly contributed to a general lack of understanding about non-paraphilic hypersexuality including how best to define and conceptualize the construct. As noted earlier, this symposium is structured in a sequential manner. In this initial presentation, I will focus on historical and current definitions and conceptual models of non-paraphilic hypersexuality. Explanatory models and evidence regarding the underlying latent structure of the construct will be discussed with emphasis placed on implications for understanding, assessing, and treating sexual offenders presenting with hypersexuality. Importantly, theoretical discussions are augmented by recent evidence obtained from multivariate analyses (e.g, Taxometrics) conducted with several independent and distinct samples, including two non-offending samples of University students (n = 840) and community participants (n = 611) and a large clinical sample of sexual offenders (n = 553). Learning Goals and Objectives: Provide an operational definition of hypersexuality and hypersexual disorder with particular relevance to sexual offending populations. Critically discuss current pathophysiological models of hypersexual disorder. Present recent evidence examining the underlying latent structure of hypersexuality Present new research derived from distinct clinical and community based samples. Discuss implications for assessing and treating hypersexuality and hypersexual disorder in sexual offenders. Covariates and Latent Structure of Hypersexuality: Implications for Assessment and Treatment Raymond A. Knight, Ph.D., Brandeis University Franklyn J. Graham, M.S., Brandeis University Hypersexuality has been identified as a key component in sexual coercion and sexual recidivism (Kingston & Bradford, 2013; Knight & Cerce, 1999) and should therefore constitute a dynamic target for the treatment and management of sex offenders (Andrews & Bonta, 2006). Consequently, it is important both to maximize its assessment accuracy by exploring the parameters of its dimensional latent structure and to study the theoretical and practical position of this construct within the nomological network of domains related

3 to the etiology of sexual offending. This talk focuses on the examination of its latent structure and on its covariation with self-centered impulsivity. First, as illustrated in the first presentation, hypersexuality has been found in multiple forensic and non-forensic samples to be distributed as a dimension. Item Response theory will be used to explore whether the hypersexuality dimension can be assessed as a probabilistic Guttman scale, which has many advantages for clinical evaluation. It will be argued that a logistic scale starting from normal sexual fantasy and behavioral frequency, progressing through sexual preoccupation to sex interfering with one s routine, and ending in loss of control over sex, appears to be a consistent cross-sample scale that allows the assessment of sexualization in both non-deviant and deviant samples. The advantages of this scale for clinical evaluation will be illustrated. Second, in multiple studies various aspects of sexual drive and fantasy have been found to covary substantially with the Machiavellian, callous, narcissistic, and impulsive components of psychopathy (e.g., Baughman, Jonason, Veselka, & Vernon, 2014; Carter, Campbell, & Muncer, 2014; Kastner & Sellbom, 2012; Knight & Sims-Knight, 2004; LeBreton, Baysinger, Abbey, & Jacques-Tiura, 2013). This has been labeled the Self- Centered Impulsivity factor (ScI; Lilienfeld & Widows, 2005). In the Multidimensonal Inventory of Development, Sex, and Aggression (the MIDSA) the Callous-Manipulativeness (CM) latent trait, which comprises Conning-Superficial Charm, Impulsivity, Hostility toward Women, and Lack of Perspective Taking (see MIDSA, 2011 for scale descriptions), measures this ScI construct and has also been found to covary with the latent trait Hypersexuality in all etiological structural equation models (SEM) generated with MIDSA data (e.g., Knight & Sims-Knight, 2003, 2004, 2011). We argue that the involvement of incentive neurocircuitry in both CM/ScI and hypersexuality constructs (Buckholtz et al., 2010a, 2010b; Bjork, Chen, & Hommer, 2012; Stoléru, Fonteille, Cornélis, Joyal, & Moulier, 2012) may account in part for the high covariation found between these constructs. We argue further one must differentiate between two forms of impulsivity--the risk-taking, reward-sensation seeking, secondary-information ignoring type and emotionally dysregulated, over-threat responding disinhibition, because only the former is related to incentive neurocircuitry. We present an explanatory model of the CM/hypersexuality covariation that integrates findings from Sternberg (2008), Burt (2012), and Newman and Baskin-Sommers (2011) with recent data on biological and neurological correlates of psychopathy. In addition, SEM etiological analyses suggest that CM mediates the relation between developmental antecedents and hypersexuality, but hypersexuality does not completely mediate the same for CM. The consequences of these analyses will be discussed. Learning Goals and Objectives: Show the clinical utility of the probabilistic Guttman structure of hypersexuality. Explore hypersexuality s relation to CM/ScI. Provide evidence for potential neural mechanisms that covary with hypersexuality and CM/ScI. Discuss the importance of differentiating the risk-taking, reward-sensation seeking,

4 secondary-information ignoring type of impulsivity from emotionally dysregulated, over-threat responding disinhibition Explore the implications of the models presented and of the dimensional nature of the constructs they comprise for assessment and treatment. Treatment Approaches with Sexual Offenders Presenting with Non-Paraphilic Hypersexuality Liam E. Marshall, Ph.D., Waypoint Centre for Mental Health Care Research has demonstrated problematic sexual behaviours and desires as measured by the Sexual Addiction Screening Test (SAST, Carnes, 1989) to be a greater problem for sexual offenders than community comparison groups. This approach to examining non-paraphilic Hypersexual disorder has been found to be correlated with: attachment problems, maladaptive schemas, shame and guilt, sexual desires and beliefs about sexual behaviours, and coping, in particular using sex to cope (Marshall & Marshall, 2002, 2006, 2010; Marshall, Marshall, Moulden, & Serran, 2008). We and others (e.g., Hanson & Harris, 2000) have shown that more than a third of incarcerated sexual offenders experience problems with hypersexual desires and behaviors. However, little is known about the effect of treatment on this problematic sexual behavior and in particular, among incarcerated sexual offenders. This presentation examines extant empirical literature on approaches to treatment of hypersexuality and hypersexual disorder and its relevance for incarcerated sexual offenders. This paper will outline the methods described in the literature and used in our treatment programs, for sexual offenders presenting with non-paraphilic (and paraphilic) hypersexuality and report on outcome, where available. Results suggest a positive impact on sexual recidivism in sexual offenders with hypersexual disorder and other hypersexual behavior problems. Implications of these findings for the assessment, management, and treatment of sexual offenders with problematic hypersexuality will be discussed. Learning Goals and Objectives: Understand criminogenic and other issues correlated with hypersexuality Review a developmental path model of the acquisition of hypersexual problems in sex offenders Describe existing approaches to dealing with hypersexuality in sex offenders Understand the importance of a positive approach to treatment of problematic hypersexuality Examine evidence on outcome to decide on an approach to treating problematic hypersexuality as it relates to sexual offending

5 References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. Andrews, D. A., & Bonta, J. L. (2006). The psychology of criminal conduct (4 th ed.). Cincinnati, OH: Anderson. Baughman, H. M., Jonason, P. K., Veselka, L., & Vernon, P. A. (2014). Four shades of sexual fantasies linked to the Dark Triad. Personality and Individual Differences, 67, Bjork, J. M., Chen, G., & Hommer, D. W. (2012). Psychopathic tendencies and mesolimbic recruitment by cues for instrumental and passively obtained rewards. Biological Psychology, 89, Buckholtz, J. W., Treadway, M. T., Cowan, R. L., Woodward, N. D., Benning, S. D., Li, R., et al (2010a). Mesolimbic dopamine reward system hypersensitivity in individuals with psychopathic traits. Nature Neuroscience, 13, Buckholtz, J. W., Treadway, M. T., Cowan, R. L., Woodward, N. D., Li, R., Ansari, M., et al (2010b). Dopaminergic network differences in human impulsivity. Science, 329, 532. Burt, S. A. (2012). How do we optimally conceptualize the heterogeneity within antisocial behavior? An argument for aggressive versus non-aggressive behavioral dimensions. Clinical Psychology Review, 32, Carnes, P. (1989). Contrary to love: Helping the sexual addict. Minneapolis, MN: CompCare. Carter, G. L., Campbell, A. C., & Muncer, S. (2014). The dark triad personality: Attractiveness to women. Personality and Individual Differences, 56, Coleman, E. (1987). Sexual compulsivity: Definition, etiology, and treatment considerations. Journal of Chemical Dependency Treatment, 1, Hanson, R. K., & Harris, A. J. R. (2000). Where should we intervene? Dynamic predictors of sex offence recidivism. Criminal Justice and Behavior, 21, Kastner, R. M., & Sellbom, M. (2012). Hypersexuality in college students: The role of psychopathy. Personality and Individual Differences, 53, Kingston, D. A., & Bradford, J. M. (2013). Hypersexuality and recidivism among sexual offenders. Sexual Addiction & Compulsivity, 20, Kingston, D. A., & Firestone, P. (2008). Problematic hypersexuality: A review of conceptualization and diagnosis. Sexual Addiction and Compulsivity: The Journal of Treatment and Prevention, 15, Knight, R. A., & Cerce, D. D. (1999). Validation and revision of the Multidimensional Assessment of Sex and Aggression. Psychologica Belgica, 39, Knight, R. A., & Sims Knight, J. E. (2003). The developmental antecedents of sexual coercion against women: Testing alternative hypotheses with structural equation modeling. In R. A. Prentky, E. Janus, & M. Seto (Eds.), Sexual coercion: Understanding and management (pp ). New York: New York Academy of Sciences. Knight, R. A., & Sims-Knight, J. E. (2004). Testing an etiological model for male juvenile sexual offending against females. Journal of Child Sexual Abuse, 13, Knight, R. A., & Sims-Knight, J. E. (2011). Risk factors for sexual violence. In J. W. White, M. P. Koss, & A. E. Kazdin (Eds.), Violence against women and children, Volume 1:

6 Mapping the terrain (pp ). Washington, DC: American Psychological Association. Långström, N., & Hanson, R. K. (2006). High rates of sexual behavior in the general population: Correlates and predictors. Archives of Sexual Behavior, 35, LeBreton, J. M., Baysinger, M. A., Abbey, A., & Jacques-Tiura, A. J. (2013). The relative importance of psychopathy-related traits in predicting impersonal sex and hostile masculinity. Personality and Individual Differences, 55, Lilienfeld, S. O., & Widows, M. R. (2005). Psychological assessment inventory-revised (PPI- R). Lutz, FL: Psychological Assessment Resources. Marshall, L. E., & Marshall, W. L. (2006). Sexual addiction in incarcerated sexual offenders. Sexual Addiction and Compulsivity, 13, Marshall, L. E., Marshall, W. L., Moulden, H. M., & Serran, G. (2008). The prevalence of sexual addiction in incarcerated sexual offenders and matched community nonoffenders. Sexual Addiction and Compulsivity, 15, MIDSA clinical manual. (2011). Bend, OR: Augur Enterprises. Retrieved January 26, 2014, from Newman, J. P., & Baskin-Sommers, A. R. (2011). Early selective attention abnormalities in psychopathy: Implications for self-regulation. In M. Poser (Ed). Cognitive Neuroscience of Attention (pp ). Guilford Press: New York. Orford, J. (1978). Hypersexuality: Implications for a theory of dependence. British Journal of Addiction, 73, Steinberg, L. (2008). A social neuroscience perspective on adolescent risk-taking. Developmental Review, 28, Stoléru, S., Fonteille, V., Cornélis, C., Joyal, C., & Moulier V. (2012). Functional neuroimaging studies of sexual arousal and orgasm in healthy men and women: A review and meta-analysis. Neuroscience and Biobehavioral Reviews, 36, doi: /j.neubiorev