Psychotic and sexually deviant

Alish et al⁴ found that pedophilia was not necessarily linked to psychotic behavior or antisocial personality features when comparing pedophilia rates in individuals with or without schizophrenia. In a sample of 22 adolescent males who sexually molested a child at least once, axis I morbidity was common, and 55% met criteria for bipolar disorder.⁸

Few experts in paraphilias

A patient who endorses deviant sexual fantasies should be evaluated by a mental health professional with specialized training in paraphilias. Although paraphilias are not recognized as a subspecialty in psychiatry, diagnosing and treating patients with a paraphilia requires additional training. There is a scarcity of psychiatrists trained to evaluate and treat patients with paraphilias.

Sexual evaluation. Evaluating a patient who presents with problematic sexual behaviors includes performing a comprehensive psychiatric history with a focus on sexual history. A psychosexual history is distinct from general psychiatric evaluations because of the level of detail regarding a sexual history (Table 3). In addition to the clinical interview, objective testing to determine sexual interests may be useful in some patients (Table 4).⁹

Actuarial tools—risk assessment instruments based on statistically significant risk factors—are valid tools for determining the risk of sexual reoffending. There are several validated actuarial tools in the assessment of sex offender recidivism, such as the Static-99R,¹⁰ Stable-2007,¹¹ and the Sex Offender Risk Appraisal Guide.¹² However, these tools are used for sex offenders, and would not be used for individuals who have not committed a sex offense, such as Mr. P.

Table 3

Psychosexual evaluation

Aspect of evaluation	Measures
Sexual behavior history	History of sexual abuse Childhood exposure to sex Masturbation history Preferred sexual partners Kinsey Scale
Sexual addiction or compulsion	Total Sexual Outlet measure Amount of time in sexual fantasy Financial, legal, or social cost of sexual behavior Prior treatment of sexual behavior
Sexual interests	Sex, age, and number of partner(s) Review of criteria for all paraphilias (exposing, voyeurism, cross-dressing, sadistic or masochistic interests)

Table 4

Objective testing to determine sexual interests

Test	Results
Penile plethysmograph	Measures penis circumference with a mercury-in-rubber strain gauge. Used clinically by measuring circumferential changes in the penis while the patient is listening to audio or video stimuli of various sexual vignettes
Abel Assessment for Sexual Interests-3	An objective method for evaluating deviant sexual interest uses noninvasive means to achieve objective measures of sexual interest. The subject’s visual response time is measured while viewing images of males and females of varying age. Visual reaction time is correlated with sexual interests
Source: Reference 9

Conducting a psychosexual evaluation in a psychiatric hospital is limited by the confounding presentation of active major mental illness, medications, and medico-legal implications. A valid psychosexual history cannot be obtained when the patient is unable to participate in a meaningful historical report. Mr. P’s attention difficulties and psychosis interfered with his ability to answer questions in a reliable, consistent manner. A psychosexual history should be reserved for when a patient is no longer presenting with significant symptoms of major mental illness.

Medicolegal aspects of a psychosexual evaluation may include mandated reporting, confidentiality, and documentation. Mental health professionals are mandated to report to law enforcement or child welfare agencies when they observe or suspect physical, sexual, or other types of abuse in vulnerable populations such as children. In psychosexual evaluations, the evaluator is legally required to report if a patient discloses current sexual behavior with a child with a plan to continue to engage in the behavior. In Mr. P’s case, there was no duty to report because although he described viewing child pornography and had a sexual interest in prepubescent individuals, he did not report a history of engaging in handson sexual behaviors with children or impulses to do so. When an individual has engaged in sexual contact with a prepubescent individual, reporting is not mandated unless the individual continues to engage in sexual behavior with a minor. Mental health professionals are not responsible for calling the police or alerting authorities after a crime has been committed.

The commission of a crime is not an exception to confidentiality. If a clinician reports a patient’s criminal activity to the authorities without the patient’s consent, he or she has breached confidentiality. It is unknown whether Mr. P and his psychotherapist had a discussion about the legal consequences of his viewing child pornography. No legislation requires clinicians to report patients who view child pornography.