Steps towards international standardization in the assessment and treatment of problematic sexual interests and behaviours

Clinicians and researchers alike have long stressed the need for a standardized approach to the assessment of people with problematic sexual interests, particularly regarding the use of penile plethysmography (PPG) (Fedoroff, Kuban, & Bradford, 2009; Fernandez, 2009; Marshall, 2014; Murphy et al., 2015a). Despite the continued call for standardization, few improvements have been made over the years. Significant challenges exist regarding implementation of standardization, both locally and internationally. The establishment of standardized assessment protocols and procedures across multiple labs enhances practical utility, decreases variability, inter-rater discrepancies, and provides the foundation for a more homogeneous comparison between competing sides in legal cases. Without a unified approach, each lab introduces significant variation between assessment protocols, including types of equipment, stimuli, data analysis, and interpretation (Murphy et al., 2015a). This makes comparison and generalizations of outcomes between labs and across countries difficult.

In response to this problem, The Royal’s Sexual Behaviours Clinic in Ottawa, Canada, and the Medical University of South Carolina’s Sexual Behaviours Clinic and Lab in Charleston, South Carolina, United States (US), established a team to undertake joint clinical research projects including multi-site standardization. Members of both clinics have jointly presented extensively throughout North America and Europe. These international presentations reviewed each clinic’s innovative work in the areas of assessment and treatment of problematic sexual interests and behaviours, as well as the need for standardization between labs. Ongoing joint clinical research included improvement of the stimuli used in PPG (Burke & Murphy, 2017; Murphy & Fedoroff, 2017; Murphy, Ranger, Stewart, Dwyer, & Fedoroff, 2015b), sharing of specialized stimuli, alternative measures of sexual arousal, including simultaneous PPG and Functional MRI (fMRI) (Dwyer et al., 2016, 2017), and the assessment of forensic female populations with Vaginal Photoplethysmography (VPP) (Knack, Murphy, Ranger, Meston, & Fedoroff, 2015). In doing so, the team has taken steps to address concerns about the lack of standardization through activities such as education, clinical research, technical guidelines, and the linking up of clinical assessment labs.

In the summer of 2015, a small group of sexual behaviour clinicians were gathered around the poster session at an international sex research conference. In the group were professionals from Canada, the US, and the Czech Republic (CR)—all of whom work in the areas of forensic psychiatry and sexology. There was discussion of our ongoing attempts to create a unified system of assessment and what steps we should be considering to internationalize the process. From this emerged the idea of hosting an international consensus meeting to bring together experts in the areas of both assessment and treatment of individuals with problematic sexual interests and behaviours. The idea was to not only provide a platform for information sharing, but also to develop a process of ongoing international collaboration that would facilitate multisite standardization. After 2 years of planning, the dream was realized.

The first international consensus meeting took place in Prague, Czech Republic in May 2017. The host site was the Laboratory of Evolutionary Sexology at the National Institute for Mental Health. The countries that were represented included: Canada, CR, Russia, the UK, and the US. Delegates at the conference included at least two representatives from each of the participating countries; an expert on assessment and an expert on treatment. Each day of the 3-day meeting had a specific theme: assessment, treatment, and steps towards the future. Each day included an allotted time for general discussion of the theme of the day and a comparison of practices and practical applications between sites.

The first day reviewed assessment protocols in which a representative from each country presented on the work being done in their clinics and labs. Clinical practices and research initiatives were addressed. Each speaker provided materials outlining the psychological and physiological measures used within the lab and (if applicable) how their findings were used for clinical and legal assessments. The assessment protocols, methods of analysis, and interpretation were discussed. The specific test stimuli used in PPG assessments were also reviewed.

The second day focused on treatment options used within each location. Presenters reviewed the types of clientele seen and the types of treatment used, including psychological and pharmacological interventions. There was much discussion of barriers to treatment, including funding issues, access to medications, and the variability of treatment approaches between programmes. This led to dialogue about the varying perspectives around the treatability of paraphilias and Paraphilic Disorders.

The final day permitted reflection and discussion about what had been learned from the meeting, in order to establish an outline of the next steps in facilitating best practices, and multi-site standardization. One of the shortfalls of many conferences or courses is that, after the information sharing is done, little or no time is designated for discussion of how to best utilize newly-acquired knowledge to advance the field. However, at this conference, ways in which different countries could continue to work together toward common goals were addressed, while also recognizing that variation in each country’s approaches to these populations necessarily imposes some barriers to international collaboration. As expected, some joint initiatives were deemed more viable than others, depending on the populations served within the clinics, and the theoretical frameworks on which the clinic was based.

A number of positive outcomes and collaborative efforts have emerged from the 3-day international consensus meeting, with new projects emerging regularly. The team at the Laboratory of Evolutionary Sexology in CR has recently completed a replication of the Canadian/American study done on combined use of PPG and fMRI. Within this study, stimuli scripts routinely used in Canada’s SBC lab were translated and recorded into the Czech language (Klapilová, Wells, Dwyer, & Murphy, 2017). This was the first time in the history of PPG use in CR that audio had been used. Historically, labs in CR have relied exclusively on visual modes of stimuli. Due to the success of that project, in the future, audio stimuli will likely be used in studies within the sexology lab. Members of this lab have also developed mobile avatar stimuli that, once standardized in CR, will be tested for replication on Canadian and American populations. Both stimuli modalities are part of broader initiatives intended to identify the ideal PPG stimuli for international use.

Attendees representing Russia came from the Laboratory of Forensic Sexology at the Serbsky National Medical Research Centre for Psychiatry and Narcology. Joint publications about the work done in respective labs have also been published, in Russian, elsewhere (Fedoroff, Murphy, & Ly, 2018; Kamenskov, Murphy & Kuptsova, 2018; Murphy & Fedoroff, 2017). As a result of information exchanged about psychological and physiologic measures used in other assessment labs, their team has adopted some of the measures routinely used in the SBC in Canada. Following the consensus meeting, other site visits occurred to facilitate ongoing collaborations. The Russian team visited Ottawa, Canada to present at The Royal’s Risk & Recovery Conference and the Ottawa team has attended the Serbsky three times to present at joint workshops and courses. Rooted within these collaborative efforts, the Serbsky has begun to develop a treatment program for Paraphilic Disorders. In May 2019, the Serbsky hosted experts from Canada, Germany, and the UK for a 2-day training course focusing exclusively on the treatment of Paraphilic Disorders and PPG as a measure of treatment effect. This course has set the foundation for the development of a psychotherapeutic treatment program for the first time in the Serbsky Institute, which has historically focused on assessment and pharmacologic treatment only. During the meeting, it was formally announced that for the first time in Russian history, the Serbsky will be implementing PPG for assessment of pedophilic interests and will be linking their assessment lab with the SBC lab in Ottawa, Canada. This is an incredible milestone in the ongoing efforts towards multi-site standardization.

The development of this special issue emerged directly from the presentations and conversations that were shared during the international consensus meeting. In this issue, the authors (mainly attendees of the meeting) review the topics of assessment, treatment, and prevention among the populations they serve. Readers will notice significant differences in the process of assessment and treatment are approached internationally. We recommend assessing each approach not from the perspective of ‘is it right or wrong’, but rather from the perspective of considering how each approach adds to our collective ability to enhance what we are doing in our own clinics and labs. At the same time, we hope readers will also consider the benefits of standardizing at least some of the assessment and treatment paradigms in order to make it possible to pool data and generalize findings.

The initial consensus meeting not only highlighted the importance of establishing universal standards for assessment, but also set the foundation for ongoing development of evidence-based protocols and procedures in labs across multiple international sites with continued information sharing.

The process of developing original clinical research collaborations, which will provide the foundation for creating multi-site assessment protocols, is ongoing. Plans are undeway for the development of a second international consensus meeting which will build on the progress made in the first meeting, and include new intentional partners for further improvement of this ongoing initiative. After all, if researchers and clinicians cannot interact collegially and collaboratively about sex, we are all in trouble. Fortunately, the articles in this special journal issue prove it can be done, and we thank all the contributors for leading the way.

Acknowledgements

A very special thank you to Drs. Kateŗina Klapilová and Gregg Dwyer for their dedication and hard work towards the development of the international consensus meeting.

Disclosure statement

The authors report no conflicts of interest.