2014-17: Sexual preoccupation in sex offenders (Call 2014-17)

Sexual preoccupation is a recognised risk factor for new sexual criminal behaviour among sex offenders. This risk factor requires a lot of research because little is known about the origin of sexual preoccupation, and how it can be measured accurately. There are several different terms, with small differences and large similarities, to describe sexual preoccupation. On the one hand, there is the excessive sexual urge/activity, and on the other hand, the suffering of the patient. The regular mental health care focusses on the suffering, and as little as possible judgement is made about how much sex is too much.  But in the forensic setting, excessive sexual activity is more important, because it is an important risk factor for sexual recidivism. In the risk assessment instrument Stable-2007, sexual preoccupation is measured by behavioural criteria: having sex or masturbating four or more times a week is considered a sign of sexual preoccupation, especially if the sexual activities are impersonal. In clinical practice, sexual preoccupation often goes hand in hand with sexual coping, in which sex is used as the main way of regulating emotions.

An incentive-motivational model describes sexual preoccupation in terms of 'liking', 'wanting' and (dis)inhibition, in which learning effects play a role. Persons with sexual preoccupation can be triggered by many different stimuli (liking), can show a quick and intense tendency to act when sensing sexual stimuli (wanting) and may be unable to suppress this tendency (inhibition). The problem can be exacerbated by 'incentive sensitisation', in which the wanting system becomes hyperreactive to sexual stimuli and creates a strongly increased urge to act that is not accompanied by a similar appreciation of the stimulus (liking). This mechanism is the essence of addiction and has been described for many forms of addictive behaviour. It is, therefore, quite possible to describe sexual preoccupation as an addiction.

There are several self-report questionnaires available for the assessment of sexual preoccupation, of which the Hypersexual Behavior Inventory (HBI19) is the most useful in this report. An Approach-Avoidance task (AAT) is examined for its usefulness in the assessment of sexual preoccupation. An AAT uses reaction times to determine whether there is a tendency to approach certain stimuli (Wiers et al., 2009). Subjects are asked to (digitally) push certain images away or to pull them towards themselves. For alcoholics, for example, it appears that they attract images containing alcohol relatively faster than images of soft drinks: they tend towards alcohol. For this study, an AAT with sexual content was created, to measure the approach tendency towards sexual stimuli.

The usual treatment for sexual preoccupation focuses primarily on strengthening the inhibition through cognitive behavioural therapy. In severe cases, medication is also prescribed that primarily influences the tendency to act. Retraining through an AAT (Wiers, Rinck, Kordts, Houben, & Strack, 2010) will be researched for a possible contribution to reducing the tendency towards sexual stimulation. In the assessment AAT, images with different content must be randomly pushed away or pulled closer to measure what is easiest for the subject. In a training AAT, specific images (e.g. with sexual content) must be systematically pushed away, to train the test subject in an avoidance reaction.

The results show that sexual preoccupation among male forensic patients at De Waag, being treated for sexual misconduct, occurs significantly more often than among a sample of men from the general population. In one subgroup of forensic patients, sexual preoccupation seems to be associated with some tendency towards sexual stimulation, while another subgroup shows some tendency towards avoidance of sexual stimuli. Further research will have to reveal the difference between these two groups.

In forensic patients with a tendency to approach, this tendency decreases after training. Although more research is needed, it seems that assessment and training using an AAT could be useful for some forensic patients, in addition to the existing treatment.

Executive Party

De Forensische Zorgspecialisten