Onset, Maintaining Risk Factors, and Treatment of Sexually Maladaptive Behaviors: Introduction to Sex Offender Assessmen

1. Onset, Maintaining Risk Factors, and Treatment of Sexually Maladaptive Behaviors: Introduction to Sex Offender Assessment and Treatment Gerry D. Blasingame, MA Licensed Marriage & Family Therapist

2. How Do Problematic Sex Behaviors Develop? Gerry D. Blasingame, MA Licensed Marriage & Family Therapist

3. How Do Problematic Sex Behaviors Develop? • Neuroanatomy • Reinforcement structures • Androgenization • Psychosocial enhancements • Psychosocial impairments

4. Gerry D. Blasingame, MA, LMFT http://www.childtrauma.org/images/neuroarcheology2.jpg

5. Neuroanatomy & Development • Human sex differences have varied origins. • Human fetus brains are bimorphic • Human fetus gonads are bimorphic • X and Y chromosomes carry different amounts of genetic materials and lead to different outcomes

6. Neuroanatomy & Development • Chromosomal errors have varied expressions • Adaptive differences can be traced to activation and/or levels of suppression of chromosomal expressions and genomic imprinting (Arnold, Xu, Grisham, Chen, Kim, & Itoh, 2004)

7. Sex and Gender • Sex • genetic sex - chromosomes • anatomical sex - internal and external genitalia • sexual identity - one’s identity as male or female Gerry D. Blasingame, MA, LMFT

8. Sex and Gender • Gender • social meaning attached to being male or female • gender identity - sense of being male or female • gender role - expectations about how a male or female should behave Gerry D. Blasingame, MA, LMFT

9. Normal Prenatal Development: Genetics • Chromosomes • each human cell contains 46 chromosomes, occurring in pairs • 23 pairs of chromosomes • 22 autosomes (determines e.g., hair color) • 23rd pair are the sex chromosomes • male: XY • female: XX Gerry D. Blasingame, MA, LMFT

10. Normal Prenatal Development: Genetics Gerry D. Blasingame, MA, LMFT

11. Normal Prenatal Development: Genetics • Gamete cells: • male: sperm - contains “X” or “Y” • female: ovum - contains an “X” • “Y” chromosome contains less genetic material than “X” chromosome Gerry D. Blasingame, MA, LMFT

12. Normal Prenatal Development:Internal & External Genitalia • Undifferentiated stage: • 0-7 weeks gestation • male and female external genitals the same • urogenital fold • genital groove • genital tubercle • labioscrotal swelling • male and female internal genitalia the same - undifferentiated sex glands….dimorphic Gerry D. Blasingame, MA, LMFT

13. Normal Prenatal Development:Internal & External Genitalia • Sexual differentiation: Gonadal development • 8 weeks gestation • Y chromosome synthesis of H-Y antigen • Male: H-Y antigen causes undifferentiated sex glands to develop into testes • Female: lack of H-Y antigen causes undifferentiated sex glands to develop into ovaries Gerry D. Blasingame, MA, LMFT

14. http://www.flyfishingdevon.co.uk/salmon/year1/psy128psychosexual_differentiation/sexdiff.htmhttp://www.flyfishingdevon.co.uk/salmon/year1/psy128psychosexual_differentiation/sexdiff.htm

15. http://www.flyfishingdevon.co.uk/salmon/year1/psy128psychosexual_differentiation/sexdiff.htmhttp://www.flyfishingdevon.co.uk/salmon/year1/psy128psychosexual_differentiation/sexdiff.htm

16. Normal Prenatal Development:The Brain • Sexual differentiation: • Male: • Testosterone secreted into the blood reaches the brain • testosterone converted to estradiol and dihydrotestosterone in the brain • estradiol masculinizes the brain, making permanent changes • Female: • alpha-fetoprotein binds to estradiol • prevents estradiol from entering the brain • protects female brains from being masculinized by estradiol Gerry D. Blasingame, MA, LMFT

17. Normal Prenatal Development: The Brain • Prenatal hormone exposure fundamentally organizes the brain: • Sexual/Reproductive Behaviors: • development of the hypothalamus (sexual orientation) • Problem Solving • Aggression • Rough-and-tumble play • Hormone exposure seems to involve a critical period - exposure outside the critical period does not have the same impact on brain organization Gerry D. Blasingame, MA, LMFT

18. Errors in chromosomal expression and/or hormone-based processes contribute to variances in the sexual and social self-expression of individuals.

19. Female brains not exposed to androgens prenatally typically leads to heterosexual female behavior in adulthood. • Genetic females with a condition known as Congenital Adrenal Hyperplasia are exposed to high amounts of androgens pre and post- natally, and often develop bi-sexual or homosexual behaviors in adulthood. (Carlson, 2007) • Women with CAH may have enlarged clitorises, to the extent that some parents have been recommended to raise them as males or surgically alter them.

20. In genetic males with a condition known as Androgen Insensitivity Syndrome, the person will also develop as a female with a shallow vagina. (Carlson, 2007) • These males do not develop homosexual or bisexual orientations, suggesting the absence of androgen receptors prevents the masculinizing and defeminizing effects of androgens on a persons’ sexual interests.

21. Additional studies have identified that high stress mothers, during pregnancy, are more likely to procreate homosexual males. • The high stress levels would interfere with the androgenization processes and may contribute to development of a smaller sexually dimorphic nucleus of the preoptic area. (the latter is typically larger in males than females but is reduced in homosexual males) (Carlson, 2007)

22. How do problematic sex behaviors develop? • Reinforcement structures within the brain

23. Reinforcement Structures • Puberty has its onset when the hypothalamus secretes gonadatropin-releasing hormones that then stimulate the production and release of two gonadotropic hormones by the anterior pituitary gland. (Carlson, 2007) • Hypothalamic changes have typical onset at age ten with gradual changes as the person moves towards puberty. • These promote sexual maturation

24. Reinforcement Structures • Puberty has its onset when the hypothalamus secretes gonadatropin-releasing hormones that then stimulate the production and release of two gonadotropic hormones by the anterior pituitary gland. (Carlson, 2007) • Hypothalamic changes have typical onset at age ten with gradual changes as the person moves towards puberty. • These promote sexual maturation

25. A number of brain structures are responsible for sexual behaviors. Androgens are responsible for dimorphisms in the brain. • In males, sexual behavior is significantly managed by the medial pre-optic area (MPA), located next to the hypothalamus. • The sexually dimorphic nucleus of the MPA is several times larger in males than females, influenced by the amount of androgen exposure prenatally.

26. http://www.niaaa.nih.gov/NR/rdonlyres/01DAE108-9B80-4672-A497-1E53A7ED5EF4/0/211p67.gifhttp://www.niaaa.nih.gov/NR/rdonlyres/01DAE108-9B80-4672-A497-1E53A7ED5EF4/0/211p67.gif Gerry D. Blasingame, MA, LMFT

27. Copulation increases the production of FOS proteins and that makes certain brain sections very happy… • Impairment of the MPA reduces sexual behavior while injecting testosterone into the MPA restores such behavior. (Carlson, 2007)

28. http://www.becomehealthynow.com/popups/pit_hypothalamus.htm Gerry D. Blasingame, MA, LMFT

29. http://www.scholarpedia.org/wiki/images/9/9d/Hypo_pit.jpg Gerry D. Blasingame, MA, LMFT

30. The hypothalamic-pituitary-gonadal axis. The hypothalamus produces luteinizing hormone releasing hormone (LHRH), which is released to the pituitary gland. In response to the LHRH signal, the pituitary gland produces luteinizing hormone (LH) and follicle-stimulating hormone (FSH). In males, LH stimulates testosterone production and FSH is important to sperm maturation. Testosterone circulates in the blood back to the hypothalamic-pituitary unit and regulates the further production and secretion of LHRH and LH. • http://pubs.niaaa.nih.gov/publications/arh25-4/254images/283Fig1.gif Gerry D. Blasingame, MA, LMFT

31. Other Brain Regions • The ventral tegmentum and sublenticular extended amygdala of the basal forebrain are involved in the appraisal of beautiful faces. (Senior, 2003) • Facial features signal sexual fertility and readiness for reproductive activity; facial features indicate levels of psychosexual and psychosocial maturity.

32. Other Brain Regions • Responses to facial attractiveness is also associated with the brain regions involved with reinforcement and pleasure, e.g. the hypothalamus and amygdala.

33. Other Brain Regions • Pleasure and reinforcement from orgasm are likely generated from several locations in the brain. • These include the ventral tegmental area, areas of the midbrain, several thalamic nuclei, the lateral putamen and the cerebellum.

34. Other Brain Regions • Orgasm leads to decreased activity in the amygdala, which is involved in defensive behavior and negative emotions such as fear and anxiety. (could this contribute to sexual behavior as a coping mechanism?) • The amygdala is loaded with testosterone receptors. • The hippocampus is loaded with estrogen receptors

35. Development • The process of sexual discovery begins prior to the obvious signs of puberty. • The increases in secretion of sex related hormones at sensitive periods of development facilitate the sexual discovery process. (Quinsey, 2003) • Errors during this periods could lead to reinforcement of maladaptive behaviors.

36. development • Adolescents process more information through the amygdala and limbic system while adults process more information through the prefrontal cortex and upper brain. • This may explain the adolescents higher level of novelty seeking associated with puberty, i.e. risk taking and increased priority for social interaction.

37. development • The transition to adulthood involves increased use of the frontal lobes with its increased integration of the widely distributed brain circuitry. • Faster connections for top down modulation • More efficient neural processing • The connections between brain regions appear to be as critical as the regions themselves.

38. Neuroanatomy and neurodevelopment applied to development of pedophilia and other paraphilic disorders….?

39. There appear to be a number of potential neuroanatomical and/or neurodevelopmental anomalies that can occur, contributing differentially to the development of the mental disorder known as pedophilia and related paraphilias.

40. A number of brain regions are involved in perception and response to sexual stimuli in normal, non-pedophilic males. (Arnow, Desmond, Banner, Glover, Solomon, Polan, Lue, & Atlas, 2002) • These include the left caudate and putamen, right middle occipital/middle temporal gyri, bilateral cingulated gyrus, and right sensorimotor and premotor regions, when subjects were watching video clips of adult erotic stimuli.

41. In an fMRI study, the paralimbic and limbic areas are found to differentially participate in managing sexual responses in different phases of the sexual arousal cycle. (Miyagawa, Tsujimuar, Fujita, Matsuoka, Takahashi, Takao, Takade, Matsumiya, Osaki, Takasawa, Oku, Hatazawa, Kaneko, & Okuyama, 2007) • During the plateau phase subcortical activation was recorded in the right ventral putamen, as well as significant increase in cerebral blood flow to the left hypothalamus. The right anterior cingulate and left insula were activated during the excitation phase, but not during plateau.

42. The onset of paraphilic interest in children appears to be in childhood for many men. (Freund & Kuban, 1993) In a retrospective study, males with pedophilia were more likely to recall early sexual interest in seeing children nude but not adults. • Most males interested in same-age adult females outgrew any such child-oriented sexual interests by adolescence, suggesting that to be a time when normal-interested males would self-terminate sexual interest in some categories, establishing sexual preferences at puberty.

43. There is a growing body of research findings that strongly suggest a neurogenesis of the paraphilic tendencies that unfold over time. (Rahman & Symeonides, 2008) • It is suggested that developmental instabilities and maternal immunity may play a role in sexual deviation. • Having failed a grade in school or being enrolled in special education were found to be common among pedophilic and hebephilic offenders compared to offenders who sexually abused adults. (Cantor, Kuban, Blak, Klassen, Dickey, & Blanchard, 2006)

44. These concepts imply there may be an interface of psychosocial factors with neuroanatomical and/or neurodevelopmental sensitive periods causing differential responses to either or both factors presumed to contribute to developing sexual deviance.

45. Another study found that lower intellectual functioning was correlated with a diagnosis of pedophilia. Blanchard et al (1999) found that the presence of lowered intellectual capacities decreased the likelihood of exclusive sexual interest in girls. • They also found that maternal age at birth of the child increased the likelihood of exclusive sexual interest in boys. • When both of these characteristics were present there was a greater likelihood of sexual interest in boys; when only one was present that likelihood decreased.

46. Males with pedophilia were measured with reduced activation of the hypothalamus, periaqueductal gray matter, and dorsolateral prefrontal cortex while viewing erotic stimuli. • These were different results than their non-pedophilic male counterparts. There was also alteration of emotional processing associated with the amygdala-hippocampal formation and dorsomedial prefrontal cortex.

47. These data suggest that males with pedophilia lack sufficient connections between these brain regions that play critical parts in sexual arousal and activity. • This may explain some aspects of their inability to become aroused when viewing adult appropriate stimuli. (Walter, Witzel, Wiebking, Gubka, Rotte, Schiltz, Bermpohl, Templemann, Bogerts, Heinze, & Northhoff, 2007)

48. These data indicate that males with pedophilia do not have significant activation of the hypothalamus when viewing adult stimuli and suggests an inaccurate pairing of age-appropriate stimuli with the normal reinforcement mechanisms. • This is further supported by data regarding measured sexual arousal while viewing child-focused stimuli, via penile plethysmography or viewing time measures. (Abel, Huffman, Warberg, & Holland, 1998)

49. Insufficient self-control of sexual interest and arousal appears to be an outcome of inadequate activation of the prefrontal cortex, along with dyscontrol of other impulses. • Further, under-activation of the hippocampal-amygdala complex indicates that persons with pedophilia are less in tune with the emotional aspects of sexuality and social relationships and assertiveness. (Walter et al, 2007)

50. These data imply a neural basis may underlie a lack of self-regulation, non-responsiveness to age-typical sexual interest in adults, and allows for immature sexual interests in children to persist beyond childhood.