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We administered severe acute respiratory syndrome coronavirus-2 viral-specific T cells (VSTs) under emergency investigational new drug applications to 6 immunocompromised patients with persistent coronavirus disease 2019 (COVID-19) and characterized clinical and virologic responses. Three patients had partial responses after failing other therapies but then died. Two patients completely recovered, but the role of VSTs in recovery was unclear due to concomitant use of other antivirals. One patient had not responded to 2 courses of remdesivir and experienced sustained recovery after VST administration. The use of VSTs in immunocompromised patients with persistent COVID-19 requires further study.

In this paper, we estimate the financial benefits that can result from effective sexual offender treatment. We base our estimates on both an earlier outcome evaluation of a prison-based sexual offe...

Treatment of individuals coinfected with hepatitis C virus (HCV) and human immunodeficiency virus (HIV) requires careful consideration of potential drug-drug interactions. We evaluated the pharmacokinetic interaction of the direct-acting antiviral agents elbasvir and grazoprevir coadministered with the nucleotide reverse transcriptase inhibitor tenofovir disoproxil fumarate (TDF). Three open-label, multidose studies in healthy adults were conducted. In the first study (N = 10), participants received TDF 300 mg once daily, elbasvir 50 mg once daily, and elbasvir coadministered with TDF. In the second study (N = 12), participants received TDF 300 mg once daily, grazoprevir 200 mg once daily, and grazoprevir coadministered with TDF. In the third study (N = 14), participants received TDF 300 mg once daily and TDF 300 mg coadministered with coformulated elbasvir/grazoprevir 50 mg/100 mg once daily. Pharmacokinetics and safety were evaluated. Following coadministration, the tenofovir area under the plasma concentration-time curve to 24 hours and maximum plasma concentration geometric mean ratios (90% confidence intervals) for tenofovir and coadministered drug(s) versus tenofovir were 1.3 (1.2, 1.5) and 1.5 (1.3, 1.6), respectively, when coadministered with elbasvir; 1.2 (1.1, 1.3) and 1.1 (1.0, 1.2), respectively, when coadministered with grazoprevir; and 1.3 (1.2, 1.4) and 1.1 (1.0, 1.4), respectively, when coadministered with the elbasvir/grazoprevir coformulation. TDF had minimal effect on elbasvir and grazoprevir pharmacokinetics. Elbasvir and/or grazoprevir coadministered with TDF resulted in no clinically meaningful tenofovir exposure increases and was generally well tolerated, with no deaths, serious adverse events (AEs), discontinuations due to AEs, or laboratory AEs reported. No dose adjustments for elbasvir/grazoprevir or TDF are needed for coadministration in HCV/HIV-coinfected people.

To describe the phase 1 and population pharmacokinetic investigations that support dosing recommendations for elbasvir/grazoprevir (EBR/GZR) in hepatitis C virus-infected people with advanced chronic kidney disease. This was an open-label, two-part, multiple-dose trial (MK-5172 PN050; NCT01937975) in 24 non–HCV-infected participants with end-stage renal disease (ESRD) or severe renal impairment who received once-daily EBR 50 mg and GZR 100 mg for 10 days. Population pharmacokinetic analyses from the phase 3 C-SURFER study (PN052, NCT02092350) were also conducted. When comparing haemodialysis (HD) and non-HD days in participants with ESRD, geometric mean ratios (GMRs) (90% confidence intervals [CIs]) for EBR and GZR AUC0–24 were 1.14 (1.08–1.21) and 0.97 (0.87–1.09). When comparing ESRD and healthy participants, GMRs (90% CIs) for EBR and GZR AUC0–24 were 0.99 (0.75–1.30) and 0.83 (0.56–1.22) on HD days, and 0.86 (0.65–1.14) and 0.85 (0.58–1.25) on non-HD days. GMRs (90% CIs) for AUC0–24 in participants with severe renal impairment relative to healthy controls were 1.65 (1.09–2.49) for GZR and 1.86 (1.38–2.51) for EBR. In population modelling of data from C-SURFER, absolute geometric means of steady-state EBR AUC0–24 were 2.78 and 3.07 μM*h (HD and non-HD recipients) and GZR AUC0–24 were 1.80 and 2.34 μM*h (HD and non-HD recipients). EBR/GZR represents an important treatment option for HCV infection in people with severe renal impairment and those with ESRD. No dosage adjustment of EBR/GZR is required in people with any degree of renal impairment, including those receiving dialysis.

Background Elbasvir/grazoprevir is a once-daily fixed-dose combination therapy for the treatment of chronic HCV infection, including HCV/HIV coinfection. Objectives To evaluate the pharmacokinetic interaction of elbasvir and grazoprevir with raltegravir or dolutegravir. Methods Three open-label trials in healthy adult participants were conducted. In the raltegravir trials, participants received a single dose of raltegravir 400 mg, a single dose of elbasvir 50 mg or grazoprevir 200 mg, and raltegravir with either elbasvir or grazoprevir. In the dolutegravir trial, participants received a single dose of dolutegravir 50 mg alone or co-administered with once-daily elbasvir 50 mg and grazoprevir 200 mg. Results The raltegravir AUC0-∞ geometric mean ratio (GMR) (90% CI) was 1.02 (0.81-1.27) with elbasvir and 1.43 (0.89-2.30) with grazoprevir. Dolutegravir AUC0-∞ GMR (90% CI) was 1.16 (1.00-1.34) with elbasvir and grazoprevir. The elbasvir AUC0-∞ GMR (90% CI) was 0.81 (0.57-1.17) with raltegravir and 0.98 (0.93-1.04) with dolutegravir. The grazoprevir AUC0-24 GMR (90% CI) was 0.89 (0.72-1.09) with raltegravir and 0.81 (0.67-0.97) with dolutegravir. Conclusions Elbasvir or grazoprevir co-administered with raltegravir or dolutegravir resulted in no clinically meaningful drug-drug interactions and was generally well tolerated. These results support the assertion that no dose adjustments for elbasvir, grazoprevir, raltegravir or dolutegravir are needed for co-administration in HCV/HIV-coinfected people.

This chapter begins with brief comments on the history of psychological treatment and then describes the principles upon which effective treatment relies. These empirically derived principles specify the approach to the allocation of resources according to each client’s risk to reoffend (the Risk principle), the issues that need to be targeted (the Needs principle), and the way in which treatment should be delivered (the Responsivity principle). The specific application of these principles in the treatment of sex offenders is then described. The limited evidence on the rate of entry into treatment and on treatment completion is outlined followed by a consideration of the inconsistencies in the application of these principles that is evident in the literature. Evidence supporting a limited number of treatment targets is noted followed by a consideration of the evidence on treatment effectiveness. Finally an alternative empirically-based treatment approach derived from the “positive psychology” literature is outlined followed by a review of the effectiveness of treatment.

We conducted two phase I trials to evaluate the pharmacokinetic interactions between elbasvir (EBR), grazoprevir (GZR), and methadone (MK-8742-P010 and MK-5172-P030) in non-hepatitis C virus (HCV)-infected participants on methadone maintenance therapy. Coadministration of EBR or GZR with methadone had no clinically meaningful effect on EBR, GZR, or methadone pharmacokinetics. The geometric mean ratios (GMRs) for R- and S-methadone AUC0-24 were 1.03 (90% confidence interval (CI), 0.92-1.15) and 1.09 (90% CI, 0.94-1.26) in the presence/absence of EBR; and 1.09 (90% CI, 1.02-1.17) and 1.23 (90% CI, 1.12-1.35) in the presence/absence of GZR. The GMRs for EBR and GZR AUC0-24 in participants receiving methadone relative to a healthy historical cohort not receiving methadone were 1.20 (90% CI, 0.94-1.53) and 1.03 (90% CI, 0.76-1.41), respectively. These results indicate that no dose adjustment is required for individuals with HCV infection receiving stable methadone therapy and the EBR/GZR fixed-dose regimen.

The aims of these phase I trials were to evaluate the pharmacokinetic interaction between elbasvir (EBR) or grazoprevir (GZR) and buprenorphine/naloxone (BUP/NAL). Trial 1 was a single-dose trial in healthy participants. Trial 2 was a multiple-dose trial in participants on BUP/NAL maintenance therapy. Coadministration of EBR or GZR with BUP/NAL had minimal effect on the pharmacokinetics of BUP/NAL, EBR, and GZR. The geometric mean ratios (GMRs (90% CI)) for BUP, norbuprenorphine, and NAL AUC0-∞ were 0.98 (0.89-1.08), 0.97 (0.86-1.09), and 0.88 (0.78-1.00) in the presence/absence of EBR; 0.98 (0.81-1.19), 1.13 (0.97-1.32), and 1.10 (0.82-1.47) in the presence/absence of GZR. The GMRs (90% CI) for EBR and GZR AUC0-∞ in the absence/presence of BUP/NAL were 1.22 (0.98-1.52) and 0.86 (0.63-1.18). In conclusion, no dose adjustment for BUP/NAL, EBR, or GZR is required for patients with HCV infection receiving EBR/GZR and BUP/NAL maintenance therapy.

Due to the relatively limited knowledge about female sexual offenders, treatment approaches and programs have been primarily based upon models developed for male perpetrators. Although male and female offenders share some common characteristics, there is increasing empirical evidence that many aspects of female sexual offending behaviors are separate and different from those of males. By integrating theoretical constructs from the current literature, this paper proposes a strength-based treatment approach utilizing a gendered paradigm of female sexual offending. In general, a gendered strength-based treatment model involves a collaborative process that builds upon positive skills and provides options to utilize those skills to fulfill unmet needs. This treatment process also considers the contextual nature of the female sexual offender's social functioning and the individual manifestations of her sexually assaultive behaviors.

Letermovir is a human cytomegalovirus terminase inhibitor for cytomegalovirus infection prophylaxis in hematopoietic stem cell transplant recipients. Posaconazole (POS), a substrate of glucuronosyltransferase and P-glycoprotein, and voriconazole (VRC), a substrate of CYP2C9/19, are commonly administered to transplant recipients. Because coadministration of these azoles with letermovir is expected, the effect of letermovir on exposure to these antifungals was investigated. Two trials were conducted in healthy female subjects 18 to 55 years of age. In trial 1, single-dose POS 300 mg was administered alone, followed by a 7-day washout; then letermovir 480 mg once daily was given for 14 days with POS 300 mg coadministered on day 14. In trial 2, on day 1 VRC 400 mg was given every 12 hours; on days 2 and 3, VRC 200 mg was given every 12 hours, and on day 4 VRC 200 mg. On days 5 to 8, letermovir 480 mg was given once daily. Days 9 to 12 repeated days 1 to 4 coadministered with letermovir 480 mg once daily. In both trials, blood samples were collected for the assessment of the pharmacokinetic profiles of the antifungals, and safety was assessed. The geometric mean ratios (90%CIs) for POS+letermovir/POS area under the curve and peak concentration were 0.98 (0.83, 1.17) and 1.11 (0.95, 1.29), respectively. Voriconazole+letermovir/VRC area under the curve and peak concentration geometric mean ratios were 0.56 (0.51, 0.62) and 0.61 (0.53, 0.71), respectively. All treatments were generally well tolerated. Letermovir did not affect POS pharmacokinetics to a clinically meaningful extent but decreased VRC exposure. These results suggest that letermovir may be a perpetrator of CYP2C9/19-mediated drug-drug interactions.

The combination of elbasvir and grazoprevir is approved for the treatment of hepatitis C virus genotype 1 or 4 infection. To evaluate the pharmacokinetics and safety of single-dose elbasvir 50 mg in participants with hepatic impairment. Participants with mild, moderate, or severe hepatic impairment and age-, sex-, and weight-matched healthy controls were enrolled in a 3-part, open-label, sequential-panel, single-dose pharmacokinetic study. Blood samples were collected to assess pharmacokinetics. Safety and tolerability were assessed throughout the study. Thirty-four participants were enrolled: eight with mild hepatic impairment, 11 with moderate hepatic impairment, seven with severe hepatic impairment, and eight healthy matched controls. Participants with mild, moderate, and severe hepatic impairment demonstrated a numeric, but not statistically significant, decrease in elbasvir exposure compared with controls, with a mean 39, 28, and 12% decrease in area under the concentration–time curve from time 0 extrapolated to infinity, as well as a 42, 31, and 42% decrease in maximum plasma concentration (C max), respectively. The observed median time to C max was similar in participants with hepatic impairment and controls. Single-dose administration of elbasvir was well tolerated. The pharmacokinetics of elbasvir after a single, oral 50-mg dose were not clinically meaningfully altered in non–HCV-infected participants with mild, moderate, or severe hepatic dysfunction. However, since elbasvir is currently available only as part of a fixed-dose combination with grazoprevir, the fixed-dose combination should not be administered to patients with moderate or severe hepatic impairment, due to the significantly increased plasma grazoprevir exposures in those populations.

Purpose The purpose of this paper is to note the basis for the emergence of strength-based approaches (SBA) to the treatment of sex offenders and point to Tony Ward’s Good Lives Model (GLM) as the impetus for these developments. Design/methodology/approach Next, the authors outline the elements of the GLM and of other SBAs. The features of various ways to evaluate treatment programs are discussed and this is followed by an examination of the evidence bearing on the value of the GLM and other SBAs. Findings The authors note that the effects of the GLM are limited to within treatment indices as, to date, there are no long-term outcome evaluations of the model on reducing recidivism. Indeed, there appears to be only one such study of an alternative SBA program. Originality/value The authors conclude that additional outcome studies are needed to evaluate the utility of the switch away from deficit-focused approaches to strength-based models of treatment.

The combination of the hepatitis C virus (HCV) nonstructural protein 5A (NS5A) inhibitor elbasvir and the NS3/4A protease inhibitor grazoprevir is a potent, once-daily therapy indicated for the treatment of chronic HCV infection in individuals coinfected with human immunodeficiency virus (HIV). We explored the pharmacokinetic interactions of elbasvir and grazoprevir with ritonavir and ritonavir-boosted HIV protease inhibitors in three phase 1 trials. Drug-drug interaction trials with healthy participants were conducted to evaluate the effect of ritonavir on the pharmacokinetics of grazoprevir (n = 10) and the potential two-way pharmacokinetic interactions of elbasvir (n = 30) or grazoprevir (n = 39) when coadministered with ritonavir-boosted atazanavir, lopinavir, or darunavir. Coadministration of ritonavir with grazoprevir increased grazoprevir exposure; the geometric mean ratio (GMR) for grazoprevir plus ritonavir versus grazoprevir alone area under the concentration-time curve from 0 to 24 h (AUC0-24) was 1.91 (90% confidence interval [CI]; 1.31 to 2.79). Grazoprevir exposure was markedly increased with coadministration of atazanavir-ritonavir, lopinavir-ritonavir, and darunavir-ritonavir, with GMRs for grazoprevir AUC0-24 of 10.58 (90% CI, 7.78 to 14.39), 12.86 (90% CI, 10.25 to 16.13), and 7.50 (90% CI, 5.92 to 9.51), respectively. Elbasvir exposure was increased with coadministration of atazanavir-ritonavir, lopinavir-ritonavir, and darunavir-ritonavir, with GMRs for elbasvir AUC0-24 of 4.76 (90% CI, 4.07 to 5.56), 3.71 (90% CI, 3.05 to 4.53), and 1.66 (90% CI, 1.35 to 2.05), respectively. Grazoprevir and elbasvir had little effect on atazanavir, lopinavir, and darunavir pharmacokinetics. Coadministration of elbasvir-grazoprevir with atazanavir-ritonavir, lopinavir-ritonavir, or darunavir-ritonavir is contraindicated, owing to an increase in grazoprevir exposure. Therefore, HIV treatment regimens without HIV protease inhibitors should be considered for HCV/HIV-coinfected individuals who are being treated with elbasvir-grazoprevir. ispartof: ANTIMICROBIAL AGENTS AND CHEMOTHERAPY vol:63 issue:4 ispartof: location:United States status: published

Letermovir (AIC246, MK-8228) is a human cytomegalovirus terminase inhibitor indicated for the prophylaxis of cytomegalovirus infection and disease in allogeneic hematopoietic stem cell transplant recipients that is also being investigated for use in other transplant settings. Many transplant patients receive immunosuppressant drugs, of which several have narrow therapeutic ranges. There is a potential for the coadministration of letermovir with these agents, and any potential effect on their pharmacokinetics (PK) must be understood. Five phase 1 trials were conducted in 73 healthy female participants to evaluate the effect of letermovir on the PK of cyclosporine, tacrolimus, sirolimus, and mycophenolic acid (active metabolite of mycophenolate mofetil [MMF]), as well as the effect of cyclosporine and MMF on letermovir PK. Safety and tolerability were also assessed. Coadministration of letermovir with cyclosporine, tacrolimus, and sirolimus resulted in 1.7-, 2.4-, and 3.4-fold increases in area under the plasma concentration-time curve and 1.1-, 1.6-, and 2.8-fold increases in maximum plasma concentration, respectively, of the immunosuppressants. Coadministration of letermovir and MMF had no meaningful effect on the PK of mycophenolic acid. Coadministration with cyclosporine increased letermovir area under the plasma concentration-time curve by 2.1-fold and maximum plasma concentration by 1.5-fold, while coadministration with MMF did not meaningfully affect the PK of letermovir. Given the increased exposures of cyclosporine, tacrolimus, and sirolimus, frequent monitoring of concentrations should be performed during administration and at discontinuation of letermovir, with dose adjustment as needed. These data support the reduction in clinical dosage of letermovir (to 240 mg) upon coadministration with cyclosporine.

In this chapter we review theories about the nature of empathy deficits in sex offenders, we consider what the evidence indicates regarding these proposed problems, and we review the ways in which these purported deficits have been addressed in treatment. Theorists differ in how they conceptualize empathy deficits among sex offenders, and some theorists have challenged the basis of this idea. Research has, for the most part, been based on the assumption that such deficits do exist. Research efforts have been, therefore, aimed at describing the extent of empathy deficits among sex offenders. However, it became apparent quite early that these deficits, in so far as they existed, were not toward all people or even toward all sexual abuse victims but rather only apparent when considering the offender’s own victim(s). Treatment has been directed at enhancing empathy either toward all people, toward all victims of sexual abuse, or only toward the offenders’ own victims. Contrary to the assumptions underlying these approaches, empathy deficits have not been shown to be criminogenic (i.e., predict reoffending) and yet evidence indicates that only criminogenic features should be the targets of treatment. To bolster this point, no one has yet shown that enhancing empathy reduces reoffending. We concluded that theoretical, research, and treatment efforts with sex offenders would be better directed at other more salient issues.

This article describes an evaluation of the effects of an early version (1991-2001) of Rockwood’s prison-based Cognitive Behavioral Therapy/Risk–Needs–Responsivity (CBT/RNR) sex offender program that had emerging elements of a strength-based approach. This program was implemented under contract to Correctional Service of Canada (CSC) and continued to evolve in response to emerging evidence until it closed in 2013. Thus, the program as evaluated here did not involve a fixed approach as did the comparison CSC program (hereafter referred to as SOTP). Long-term reoffense data, from Rockwood’s program ( n = 579), were compared with SOTP ( n = 625) and with a group of untreated men ( n = 107) sentenced for sex offenses. A modified brief actuarial risk scale (BARS-M) was used to control for baseline risk among the three groups, along with additional controls for age at release, victim type, and individual differences in the length of long-term follow-up period. Both treatment groups displayed lower rates of both sexual and violent reoffending when compared with the no-treatment offenders. Overall, the Rockwood program generated the lowest recidivism rates. The results demonstrate that prison-based sex offense–specific treatment can be effective. We discuss the strengths and limitations of the current design through the Collaborative Outcome Data Committee’s guidelines.

To examine the empirical bases underlying the diagnoses of the paraphilias. We address issues concerning the reliability of these diagnoses and their implications for etiology, treatment, and prognosis. Research on these issues with the paraphilias is quite limited except for those paraphilics whose interests lead them to sexually offend. Even among these clients, research has, for the most part, failed to distinguish those who meet criteria for a paraphilia from those who do not, thereby limiting the possibility of drawing firm conclusions regarding the value of a paraphilic diagnosis. Speculations regarding the etiology of the paraphilias are for the most part limited to those who sexually offend and these theories do not distinguish those who do, or do not, meet paraphilic criteria. Treatment of sex offenders, when effective, appears to have the same impact regardless of whether or not clients meet criteria for a paraphilia. In terms of prognosis, it was only among untreated child molesters that a paraphilic diagnosis (in this case “pedophilia”) predicted long-term outcome. In the face of these problems, we suggest a dimensional approach to diagnoses may represent an improvement over the current categorical model.

The goal of this paper is to provide a history of psychological theories, research, and treatment of male sex offenders from the onset of modern approaches that emerged in the 1960s up to the present time. The questions addressed in this paper primarily concern the reasons and justifications for the observed changes. Current conceptualizations of the motivations of sex offenders are quite comprehensive with a central focus on deficits in attachment and coping skills. Research now provides an empirical foundation for the issues to be addressed in treatment and for the manner in which treatment is delivered. Advances in theory and research have brought the field of sex offender treatment to the point where the empirical bases point to a structure that, if followed, seem likely to achieve the goal of reduced recidivism.

In correctional settings, a diagnosis of sexual sadism is likely to have negative consequences for the person thus assessed. Sexual sadists are typically considered high risk, non-eligible for parole, and difficult to treat. Hence, sexual sadists have good reasons to dissimulate or outright deny their sexual preference disorder. Methods have been developed to overcome the risk of faking; for example, the use of clinician ratings and the recording of physiological responses are potentially less prone to faking than are self-report measures. In the current chapter, we review the evidence for and against phallometric assessment, indirect measures, and structured clinician ratings. The Severe Sexual Sadism Scale (SeSaS)—its development, properties and definitions—is highlighted. This file-based screening can guide the diagnostic process in forensic cases in which sadism is suspected. Finally, the proper use of SeSaS is explained.

We conducted two phase I trials to evaluate the pharmacokinetic interactions between elbasvir (EBR), grazoprevir (GZR), and methadone (MK‐8742‐P010 and MK‐5172‐P030) in non‐hepatitis C virus (HCV)‐infected participants on methadone maintenance therapy. Coadministration of EBR or GZR with methadone had no clinically meaningful effect on EBR, GZR, or methadone pharmacokinetics. The geometric mean ratios (GMRs) for R‐ and S‐methadone AUC0‐24 were 1.03 (90% confidence interval (CI), 0.92–1.15) and 1.09 (90% CI, 0.94–1.26) in the presence/absence of EBR; and 1.09 (90% CI, 1.02–1.17) and 1.23 (90% CI, 1.12–1.35) in the presence/absence of GZR. The GMRs for EBR and GZR AUC0‐24 in participants receiving methadone relative to a healthy historical cohort not receiving methadone were 1.20 (90% CI, 0.94–1.53) and 1.03 (90% CI, 0.76–1.41), respectively. These results indicate that no dose adjustment is required for individuals with HCV infection receiving stable methadone therapy and the EBR/GZR fixed‐dose regimen.

Although denial takes many forms, in this review we have restricted our concerns to those sex offenders who claim to not have committed a sexual offense. We refer to these offenders as “categorical deniers”. The literature on the incidence of categorical denial, the characteristics of these offenders, and the many purposes denial seems to serve are all given consideration. We then examine the relationship of categorical denial to future risk taking into consideration the relationship of future risk to the meaning denial has for these men. Next we consider three different approaches treatment providers have taken to categorical deniers. These involve: 1) a decision to exclude them from treatment; 2) attempts to overcome denial (either by involving them in a pre-treatment program, or embedding them within a regular program); and 3) the provision of a program exclusively for deniers. Evidence for all of these approaches is limited and not yet impressive enough to allow for conclusions as to their value. Finally, we suggest that future studies include larger numbers of deniers and differentiate offender types.

This chapter provides our view of the most effective approaches to fully engaging sex offenders in treatment. It considers motivational strategies at various points in the treatment process and to consider an overall treatment approach that integrates motivation and engagement. In institutional settings, for example, in which the non-sex offender population is hostile towards sex offenders, interviews and treatment need to be conducted in a way that minimises the identification of potential participants. The chapter discusses the basic issues involved in being part of the group, such as the time and days the group runs, and emphasize the importance of confidentiality. It outlines the components of the treatment programme and why they are relevant to improving the participant's life. The chapter also outlines factors that we believe block motivation and yet are typically addressed in sex offender programmes. It addresses treatment facilitating factors such as therapeutic processes. The chapter concludes by considering the motivational value of a strength-based treatment approach.

This paper examines the utility of previous attempts to subcategorize child molesters. We argue that research based on these categorizations has resulted in confusion due to differences across studies concerning which offenders belong in each group. For example, there are no agreed-upon guidelines for identifying a child molester as an incest offender or as a ‘stranger’ offender. We examine research findings associated with previous attempts to subcategorize child molesters as well as the literature on modus operandi. From this, we conclude that current attempts to subcategorize child molesters are flawed. We propose that distinguishing child molesters according to new criteria – that is, whether or not they have been previously associated with their victim – should result in more productive research and provide a better guide for treatment and postdischarge supervision. In our terminology, nonaffiliative child molesters are those offenders who are truly strangers to their victims whereas affiliative chil...

This chapter addresses a range of factors that interfere with normative sexual functioning and that have been shown to characterize sex offenders. First, descriptions of features that are involved in healthy sexuality are described. These features are discussed as normative and include effective communication, mutual focus during sex, mutual self-disclosure regarding sexual needs, mutual and solitary masturbation, and, most importantly, information about activities during sex that facilitate mutual sexual pleasure. A description is provided of the normative male and female sexual arousal patterns and desire for sex, and also behaviours that facilitate mental satisfaction. Homosexual relations are presented as normative and as involving issues similar to heterosexual activities (e.g., expressions of love and affection, mutual respect and concern, communication). Sexual preoccupation is outlined and strategies for managing these excessive desires are noted. Finally deviant sexual interests are noted and strategies for changing these interests are described. Keywords: deviant interests; healthy sex; masturbatory reconditioning; sexual preoccupation; sexual response patterns

The present report offers a brief review of studies that have attempted to identify the features that distinguish offenders convicted of using the Internet to download or distribute sexual images of children. Most of these studies have simply examined child pornography Internet offenders (CPOs) and described their features while some, but few, studies have compared them with offenders who have directly contacted children for sexual purposes (CCMs). Overall existing research has suggested that, among other issues, CPOs appear to be socially anxious and emotionally lonely, and to also display obsessive and compulsive features. We report the early data from an ongoing study comparing CPOs and CCMs on these 3 features. The tentative results suggest that CPOs are more lonely and obsessive-compulsive than are CCMs, and that while social anxiety does not distinguish the two groups, the CPOs score in the range that meets diagnostic criteria for this problem.

Empathy has been linked to prosocial behaviour and a lack of empathy to a tendency to be aggressive, making research and theory on empathy in offenders a high priority. In this article, we briefly review the empathy concept and present the evolution of our view of empathy from a stage model to newer models examining issues related to breakdown of the empathy process. Empathy is presented as progressing through four stages: emotion recognition, perspective taking, emotional response, and reparative action. Research showing some support for this model of empathy and critiques are presented suggesting a need for a revised model which is then presented and discussed. Finally, a new model of a breakdown of the empathic process based on the early childhood experiences is presented and its implications for treatment are discussed.

This paper challenges accepted notions about the importance of cognitive distortions expressed by child molesters. First, we consider the role of excuse-making in a healthy life, and as a result question whether it is in the best interests of our clients to challenge their distortions. We examine the literature on eyewitness reports and the reconstructive nature of memory to call into question the value of requiring child molesters' reports of their offence to match the victim's account. Next we show that the evidence does not demonstrate convincingly that cognitive distortions are criminogenic. Furthermore, the responses of child molesters to measures of cognitive distortions indicate that they simply endorse less disagreement with the items than do others. However, we note that some of these distortions, while not criminogenic, may nevertheless interfere with the acquisition of skills for important treatment targets (e.g. relationships). We offer suggestions for the most effective way to elicit and change these distortions.

The present study examined the internal consistency and factorial structure of the Sexual Addiction Screening Test using samples not examined in previous psychometric research. The internal consistency of the items was high and analyses revealed that the majority of the variance (38.40%) could be accounted for by one factor. This single factor had clusters of items that were consistent with the essential features characteristic of sexual addiction. Taken together, these results support the psychometric integrity of the Sexual Addiction Screening Test and support previous and future studies conducted on this measure with sexual offenders and low socio-economic respondents.

This paper reviews the literature on therapeutic process specific to sexual offender treatment. The general clinical literature emphasises the importance of therapist style, the client's perceptions, the therapeutic alliance and cohesiveness. We highlight the importance of therapist characteristics, group cohesion and emotion in effective treatment of sexual offenders. Implications for programming and research are emphasised.

This paper reviews the literature addressing four process issues associated with the effectiveness of treatment for offenders: (1) Therapist characteristics; (2) Clients' perceptions of the therapist; (3) The therapeutic alliance; and (4) The group climate of treatment. The general clinical literature is briefly summarized and then these issues are examined in adult offenders and in juvenile offenders. Although there is a limited set of research articles on process issues in offender treatment it is possible to make some reasonably sound conclusions. Each of the four process features we appraised facilitates the attainment of treatment goals and they account for a greater proportion of the variance in the sought-after changes with treatment of offenders than do the procedures used to achieve these changes. This proportion of variance accounted for is significantly greater than is true in the treatment of nonoffending clients. Suggestions are offered for future research.

In my earlier paper (Marshall, 1993) I reviewed the evidence from the general literature on intimacy, attachment and loneliness with a view to seeing how well these features of human relationships ...

This paper considers the issues involved in the use of manuals to guide the treatment of sexual offenders. I identify problems in the use of manuals, particularly their failure to encourage satisfactorily the implementation of therapeutic skills, the restrictions they place upon the therapist's ability to address the responsivity principle, the limits to which manuals can accommodate changes as a result of new evidence and the suppression of innovation. I offer suggestions for an alternative set of strategies to ensure the integrity of treatment delivery while at the same time overcoming the problems associated with manualization.

In this paper we outline a model that integrates several issues that have been identified in the sexual offender literature but their relationships have not previously been specified. There is clear evidence that many sexual offenders suffer from low self-esteem, that most lack empathy for their victims, and that almost all have distorted perceptions and thoughts relevant to their offences. More recently shame and guilt have been identified in sexual offenders. Our model proposes that each of these issues is functionally related with each other, and may impede treatment progress, but the model suggests an approach based on evidence that should effectively overcome these obstacles to treatment.

This article describes a treatment program for sexual offenders that is a modification of cognitive-behavioral therapy (CBT) and that emphasizes a positive approach. Several issues that characterize most CBT programs for sexual offenders are challenged and alternatives are offered. The overall features of the positive approach are then described. Finally outcome evaluations of the effects of CBT programs are described and compared with the long-term outcome of the current positive program. This comparison suggested that the positive program is more effective than the traditional CBT approach.

Results on the prevalence of sexual addiction in incarcerated sexual offenders and socio-economically matched community samples are presented. The measure of sexual addiction was Carnes (1989) Sexual Addiction Screening Test (SAST). Observed rates of sexual addiction in the socio-economically matched community males was consistently higher than predicted by Carnes' estimates of prevalence in the general population, but lower than in incarcerated sexual offenders. No significant differences were found in the prevalence of problems with sexual addiction between those sexual offenders who offended against adults versus those who offended against children.

This case study describes a strategy for treating a sexual offender who categorically denies committing the offense. These offenders usually refuse to participate in treatment or are deemed ineligible or unsuitable for sexual offender treatment on the basis of their denial of responsibility. The treatment approach outlined in this case study reflects an adaptation of conventional sexual offender treatment such that the focus is on the problems in the offender's life that led to him or her to be in a position where he or she could be “accused” of an offense. This case study demonstrates how an offender who is categorically denying responsibility for his offending was therapeutically engaged in treatment. Treatment implications of this approach are discussed.

Fungal infections are increasing nationwide, paralleling increases in the number of immunosuppressed hosts. Most of the candida infections seen in the intensive care unit are likely due to iatrogenic factors such as hyperalimentation, catheters, broad-spectrum antibiotics, and postprocedure complications that are prevalent in intensive care unit patients. Delays in appropriate therapy are common and may compromise care. Fortunately, the recognition of several clinical syndromes in the intensive care unit that require specialized treatment can improve outcomes. The issue of antifungal prophylaxis has to be balanced against issues of resistance, and current guidelines are reviewed here for prophylactic use of fluconazole only in selected intensive care unit patients. Finally, several new antifungal agents are available to treat the emerging resistant fungi, with better toxic/therapeutic ratios than in the past. Thus, there are an increasing number of safer and more effective options for treating fungal infections in the intensive care unit.

The identification of offence-related cognition is a major target of most cognitive–behavioural treatment programmes for sexual offenders, and a number of measures are available for this purpose. This study assessed the psychometric properties of a brief measure of beliefs that support and justify child sexual abuse: the Sex With Children (SWCH) scale. Factor analysis revealed two distinct types of belief: that sex with children is harmless, and that children actively provoke adults into having sex with them. The SWCH was also found to have good internal consistency, test–retest reliability and concurrent validity. Child molesters scored significantly more highly on the SWCH than did rapists or non-offenders, and high-risk child molesters reported more entrenched offence-supportive beliefs than lower risk child molesters. A relationship was also observed between general offence-supportive beliefs as measured by SWCH and offence-specific cognitions ascribing responsibility or enjoyment to the offe...