Characteristics of paraphilics in Turkey: A retrospective study—20 years

IJLP-01194; No of Pages 9 International Journal of Law and Psychiatry xxx (2016) xxx–xxx

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International Journal of Law and Psychiatry

Characteristics of paraphilics in Turkey: A retrospective study—20 years☆ Şafak Taktak a,⁎, Ebru Yılmaz b, Oguz Karamustafalıoglu c, Ayla Ünsal d a

Psychiatry and Forensic Medicine Departments, Ahi Evran University Education and Research Hospital, Turkey Forensic Medicine Department, Forensic Medicine Institution, Istanbul, Turkey c Uskudar University, Psychology Department, Turkey d Nursing Department, School of Health, Ahi Evran University, Turkey b

a r t i c l e

i n f o

Article history: Received 28 April 2016 Accepted 2 May 2016 Available online xxxx Keywords: Paraphilia Forensic psychiatry Forensic medicine Turkey

a b s t r a c t Objective: This study is carried out to research the frequency of occurrence and the characteristics of paraphilic cases in Turkey and forensic aspects of them and to explain forensic psychiatric studies of people show paraphilic actions and assess them from legal aspects. Method: This research is done by studying a total of 101,208 cases who were sent to Istanbul Forensic Medicine Institute (FMI) by the judicial organs of 4th Specialization Board between 1984 and 2004 to decide whether they show paraphilic actions or not. When choosing the cases of pedophilic actions, incest incidents were excluded and 307 incidents were taken into assessment. Results: The male subjects are 97.4%, 39.7% of them are 19–29 years old, 10% of them are over age 60, 59% of the subjects are single, 36.5% of them are unemployed, 71.7% of the incidents have no physical disorder. The subjects who were imprisoned before were 20.2% and 22.1% of them had undergone psychiatric treatment before the incident. Twenty separate diagnosis are determined by the FMI for the subjects. There were mental retardation, schizophrenia and various personality disorders on the top the diagnosis list. The paraphilia type of the incidents are pedophilia (60.3%), exhibitionism (8.1%), pedophilia and exhibitionism (7.5%) and fetishism (5.9%). It was determined that there were more than one paraphilia type in 40 incidents (13%). FMI decided that 54.7% of them have criminal responsibility, 25.1% of them have no criminal responsibility, and 20.2% of them have reduced criminal responsibility. Conclusion: There were 20 separate type of diagnosis for the incidents. It is understood that paraphilic incidents do not seek for help although they have the symptoms of disorder and they are exposed to psychiatric assessment only when they face a criminal inquiry. This suggests that there are more paraphilic incidents in the society than what we encounter. © 2016 Elsevier Ltd. All rights reserved.

1. Introduction In Turkey, there is no reliable and comprehensive epidemiological research on the frequency of occurrence of the paraphilic cases in society. The social reaction to this kind of sexual disorders prevents the application for treatment except for the criminal and administrative obligations. Thus it is difficult to know the frequency of occurrence. The existing paraphilic cases are limited to those who applied to the health institutions by the force of family and environment, more rarely per se or enforced by law. This research is carried out to determine the forensic psychiatric studies of people who show paraphilic actions. Moreover, this study is considered to be important as it has revealed a 20-year screening and it covers all of Turkey. ☆ Apart from this article was presented at the 49th Congress of National Psychiatry, İzmir, Turkey, September 24–28, 2013. ⁎ Corresponding author. Tel.: +90 505 403 79 67. E-mail address: [email protected] (Ş. Taktak).

In Çitici's (2004) study, less than 50% of sexual assaults have been reported, in which 5%–10% of them reverberate to the judicial authorities, and because of this, little is known about sexual assaults. In this study, of all the 101,208 case files in which criminal responsibility is requested, paraphilic actions are only found in 307 cases. The purpose of the forensic psychiatric assessment is to investigate whether the perversive action which occurs during the crime is the result of a mental disorder which affects people's control over their movements and intentional functions. M'Naughten defined the rules for circumstances in which the perpetrator will not be penalized due to the unknowing nature, the character and the results of the action or being unaware of the unfair and destructive character of the action. Despite the lack of academic infrastructure, the M'Naughten rules are adopted in the Anglo-American culture and asking for severe cognitive deficits. This rule was flexed a bit with the judgment of the 1954 Durham trial. Accordingly, if the actions result from a person's mental illness or weakness, the perpetrator cannot be held responsible for the crime. In 1959, the Durham Rule was softened more with legal

http://dx.doi.org/10.1016/j.ijlp.2016.05.004 0160-2527/© 2016 Elsevier Ltd. All rights reserved.

Please cite this article as: Taktak, Ş., et al., Characteristics of paraphilics in Turkey: A retrospective study—20years, International Journal of Law and Psychiatry (2016), http://dx.doi.org/10.1016/j.ijlp.2016.05.004

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Ş. Taktak et al. / International Journal of Law and Psychiatry xxx (2016) xxx–xxx

regulations in England. Regulations have been made to prevent psychotic patients to be punished even if they have the ability to understand the causes and the consequences of the crime. The American Law Institute Rules (1962) has added the individuals' basic capacity and the ability to judge the criminal responsibility criteria as well as the lack of understanding and becoming aware of the causes and the consequences of the action which the M'Naughten rules mentioned before (Soysal, 2005, 2015). Sex is an integral part of the basic needs of an individual. However, some people cannot get satisfaction from ordinary sexual relationship; instead they prefer unusual sexual behavior and objects. They are referred to as paraphilics in psychiatric terminology. The term paraphilia was first introduced into DSM-III to replace the DSM-II term sexual deviation “because it correctly emphasizes that the deviation (para-) lies in that to which the person is attracted (philia)”. The number and taxonomy of paraphilia are under debate; one source lists 549 types of paraphilia (Aggrawal, 2009; Kalra, Tandon, & Sathyanarayana Rao, 2014; Oğuz & Uygur, 2005). Although paraphilia has been used to refer to disorders of atypical sexual arousal up through DSM-IV-TR, no term was available in DSMIV-TR to indicate no pathological, atypical sexual interests. In contrast, DSM-5 redefines the term paraphilia so that it now refers to a persistent, intense, atypical sexual arousal pattern, independent of whether it causes any distress or impairment which by itself, would not be considered disordered (First, 2011). DSM-5, as did its predecessor DSM-IV-TR, includes eight specific paraphilic disorders: voyeurism, exhibitionism, frotteurism, sexual masochism, sexual sadism, pedophilia, fetishism, and transvestia. These eight disorders were selected for DSM-5 as they are relatively common, and some of them involve behaviors that are classified as criminal offenses because of their noxiousness and potential for harm to others. However, the range of stimuli that can form the basis of a persistent and intense sexual arousal pattern is potentially limitless, and some of these patterns can undoubtedly lead to negative consequences in some individuals (Beech & Harkins, 2012; First, 2011; Wakefield, 2011). In ICD-10, perversive (paraphilia) behaviors as a primary symptom of sexual selection disorder are defined as ego-dystonic. The only sexual expressions of continuous perversive actions are simultaneously going along with the active sexual life and they are hard to control during the relationship conflicts and are difficult to supervise. These behaviors have a structure that makes them preferable to genital sexuality with a partner. Perversive behaviors are classified by the quality of the action and the urge descriptively. Besides that they should also be classified by the frequency and intensity of the action, the role they play in psychic organization and their relationship with ego (Geyran & Uygur, 1996; Geyran, Özdemir, & Uygur, 1994). In studies it is stated that 10%–20% of the children under the age of eighteen suffered from sexual assault, and 20% of the women are the targets of exhibitionists and voyeur. Although there has been a significant increase in the paraphilia prevalence, there is no method to determine the true prevalence. One of the reasons for this situation is due to its confidential nature the paraphilic action cannot be seen in the statistics as this happens with the mutual consent of the adults (sexual masochism and sadism) (Erdoğan, 2010; Geyran et al., 1994; Gülçat, 1998; İncesu, 2004). There is an academic discussion between the people who think that paraphilia is close to obsessive compulsive disorder and the people who think that paraphilia is close to the impulse control disorder group. In obsessive compulsive disorder, in order to sedate temporarily or satisfy (not sexual satisfaction) the anxiety which is increased by the obsessions, mental or motor compulsion execution is needed. In impulse control disorders, although it is known that the rise of mental impulse with fierceness is wicked or harmful, the regret following the short satisfaction after this action is typical. In general, the paraphilia is believed to have originated from psychosocial and organic factors. The etiology of paraphilia is not

known exactly as in most behavioral disorders' multifactorial features are seen to take place in the etiology (Casanova, Mannheim, & Kruesi, 2002; Kaplan & Sadock, 2005; McManus et al, 2013; Oztürk, 2002). In personality psychopathology, perversive reaction may arise in the life crisis or in its periods in which coping and adapting abilities are challenged. Psychoanalytic studies argue that perversive activities can be shown in subconscious conflicts. In this type of personality organization, the perversive symptom is joined by the structure since the earliest periods of the development and has a feature that holds the personality organization together. To assess the perversive action psychodynamically, the interaction between the personality structure and the “perversive sexual activity” must be understood (Ertekin, Özayhan, Eren, & Ertekin, 2013; Gülçat, 1998; Oğuz & Uygur, 2005). The most argued cases in classical perversion literature are the cases in which the show up of the perversive symptoms like the formation of neurotic symptoms can be observed. In this context perversive symptom is a pathological defense mechanism experienced as experiences that are isolated from the whole personality and directed to control the urge. It can show the periodicity and the iterativeness features. It is seen to be in evident contrast with the personality dimensions which are foreign elements of the personality. These symptoms are unfamiliar to ego and bitter experiences. In another group of cases which is much more rarely seen, perversive symptomatology is integrated into the self-concept. These cases are expressed as “perversive character structures”. In these cases, perversive symptom is like a connection that holds together psychic structure that is fragmentary in nature. There is no any other coping strategy than “nonperversive compensatory”. Since the typical perversive desires, urges and actions infested all areas of personality more or less, they are defined as positive life experiences. Against such behaviors that affect people's social role and the relationship with the environment, they can try to impose themselves and their behaviors on others by showing extreme defensive attitude and denial response (Gabbard, 2000; Geyran & Uygur, 1996; Geyran et al., 1994; Gülçat, 1998; Oğuz & Uygur, 2005). Paraphilia is generally seen in a relationship with the borderline personality organization. Some of the cases that are on the borderline level are close to neurotic and some are close to psychotic level. If high level integration is involved, perversion is intended for sexual functionality, and sexual potency is achieved by fantasies not by actions. In the lower levels, the role of perversion protects the ego boundaries and find a way out to aggression besides providing sexual functioning. Because of the fragmentary nature of the personality structure the impulse neurosis accompanied by perversive symptomatology show serious deficiencies and passivity in almost every part of life in which impulse is concentrated. Due to the lack of productive compensating defense mechanisms, destructive–disruptive actions are common attitudes. It is difficult to separate perversive elements in personality structure than nonperversive elements. These kinds of people generally show polymorphic perversive actions. The perversive actions mostly seen among sex offenders are generally in this group (Geyran & Uygur, 1996; Geyran et al., 1994; Gülçat, 1998). Perversive actions may occur due to organic brain damage or major psychosis. “Impulsivity and the deterioration of the judging” are among the personality changes described in the organic brain syndrome. Just a few literature prognosticate that temporal lobe abnormalities are observed more in the EEG tracings of the people who show perversive behavior (Alkhalil, Tanvir, Alkhalil, & Lowenthal, 2004; Oğuz & Uygur, 2005). People with mental disability can have substantial problems in achieving an ordinary sexual relationship and can deviate from the ordinary way and try to find alternative ways to satisfy themselves. This derailing leads to perversion. As in all segments of society, there are some individuals who are mentally retarded or of borderlinenormal intelligence who engage in aggression with a sexual content (Swanson & Garwick, 1990).

Please cite this article as: Taktak, Ş., et al., Characteristics of paraphilics in Turkey: A retrospective study—20years, International Journal of Law and Psychiatry (2016), http://dx.doi.org/10.1016/j.ijlp.2016.05.004

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In the Turkish Criminal Law, judgments concerning the sexual assaults are edited considering that they damage the morals and moral values of the society and the family system. The Turkish Criminal Law and the institutions and the physicians giving expertise service have been under the influence of the western rules. Trends forming the idea that there is an absence of the criminal responsibility which affects the control and the judgment of the person has been dominant. It is possible to describe this trend and tradition as flexible implementation of the M'Naughten rules (Soysal, 2015; Uygur, 2014). Aforementioned mental disorder as defined by law indicates that there must be a loss of capacity in the cognition–comprehension–perception–evaluation and behavior because of a mental disorder. The causal connection and relationship between the capacity loss resulting from mental disorder and the criminal action must be indicated clearly and directly. There is a medical opinion that the freedom of mind and movement is removed or impaired significantly as a result of the mental disorder which disrupts the cognition–comprehension–evaluation capacity of a person. In these cases the mental illness that disrupts the cognition–comprehension and evaluation capacity also causes the capacity loss in voluntary functions. The insistent request and impulse resulting from mental disorder affects the voluntary functions significantly. Even though there is no loss in cognition and comprehension capacity, there is loss in the ability to control the behaviors appropriate to the law and the freedom of movement (Geyran & Uygur, 1996; Geyran et al., 1994). Several mental disorders organize the wishes and choices leading to the crime. All people have wishes. Only some turn their wishes into criminal actions. The factors such as the characters, mood, intoxication, psychic stress and overloading situations just before the criminal history, the character and the severity of the punishment for the crime, the culture and the characteristics of the sub-groups determine whether the crime will be committed or not. The mental illness causing the insistent urge and action in perversive cases stems from the person himself. In cases like these, the only foundation that a clinician can form is the decision on determining a life story that is compatible with similar wishes, urges and the fantasies (Uygur, 2014). Perversions in the form of voluntary incompetence are not the nosological entities occurring depending on a single phenomenon. It is quite difficult and disputable to show that the case was affected by the persistent nature of the urges, desires and fantasies or the people who have committed such crimes act just to satisfy their personal needs (a form of voluntary behavior) (Geyran & Uygur, 1996). A growing impulsive tension (depending on the intensity of the underlying psychodynamic conflict and anxiety) during the action is described in a group of perversion cases. And after the crime, there is a feeling of a moral guilt. In a group of cases in which growing impulsive tension brings forth the perversive action which is a motif of the criminal action, the ability to control and organize the behavior (self-control) is thought to be damaged (Geyran et al., 1994). In another group of perversion cases which accept and defense perversive sexual preferences as they are natural (perversive character structures), the choices do not affect the self-control, and no conflict or tension happens. Judgments and moral values in such cases are inadequate. Their actions are harmless. Preferences do not create difficulties in voluntary functions in perversive characters, who show similar characteristics to personality disorders. Their treatment resistance is high. Similarly in our law, it is indicated that the perpetrators who have mental problems like personality disorder have full criminal responsibility (Gülçat, 1998). As a result in impulse control disorders which may pervade all parts of life and in the sub level personality organizations (anti-social, narcissistic, borderline) in which the character that holds fragmented personality organization of the perversive symptom together can be shown; it is considered as a medical opinion that the identified perversive behaviors cannot remove the criminal responsibility. To form the basis of the decision, it is necessary to show that action emerges for the first time due to the compelling and persistent nature of the impulses and the

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repetitive nature of the actions which can be observed during the fantasies and self-saturation process since the earliest childhood or the weakening impulse control and incompetence depending on any psychic strain and overloading during the course of ordinary life. The guilt and remorse are felt after the discharge of the impulse which creates a sense of tension and distress. The experts who state that the criminal responsibility is affected, have a responsibility to propose a regulation to the treatment of the perpetrator as well. The aim is not only to punish the perpetrator for the action that harms the general moralities of the society, but also to remove the possibility of the repetition of the action via treatment and by doing so the society will be protected and the perpetrator will be reintroduced to the society (Soysal, 2012). In forensic psychiatry practices, the main issue of the expert is not whether the perpetrator will be punished or not. A psychiatry expert sets his/her main aim to evaluate the state of mind by protecting his/ her position beyond the criminal law. In these cases expert also evaluates the possibility of the utilization of the perversion case to whom he/she propose a treatment. The perpetrator as in the defendant position must be informed with the results of the expert's decision and the alternatives and the responsibility he/she takes during the treatment, the quality of the treatment, the failure of the treatment and the legal equivalents for the recurrence (Gülçat, 1998). It is not possible to say that almost all aggressive sexual behaviors originate from a paraphilic motivation. Although considered to be rare, paraphilia cases have socio-cultural authenticity which is interesting in psychiatric and social aspects. These cases cause abnormal sexual behaviors. Paraphilia is in the field of forensic psychiatry which deals with a variety of unusual crimes and antisocial behaviors. Conducting forensic psychiatric examination of paraphilia is important for understanding the underlying properties of sexual crimes, the determination of criminal motivation, social risk and the detection of protective factors (Lehne & Money, 2003; Oral, 1999; Oncü, Türkcan, Canbek, Yeşilbursa, & Uygur, 2009). The statistics show that mentally retarded people mostly stand trial due to the sexual assault. 83 of the 307 cases have mental retardation and 65 of these mentally retarded people show pedophilic actions. In forensic psychiatric assessment, the person with the possibility of facing punishment may try to escape from criminal responsibility by imitating mentally retarded people. In forensic psychiatric examination, the cases are handled in many ways. For this, the person's criminal history, the mental state of this person before and after the action also has to be examined in depth. The main purpose of this is to investigate whether the criminal act is the result of a mental disorder which has the control over his/her movements. The concept of criminal responsibility in the historical process is assessed in two different ways as narrow and broad (Shah, 1986). The cause and effect relationship between the behavior and the illness of the person can only be assessed by supporting it with the content of the file. In forensic psychiatric assessment, the person with the possibility of facing punishment may try to escape from criminal responsibility by imitating mental illness. To reach the truth, the statements of the witness and the perpetrator and other information about the background of the case should be evaluated together (Ey et al., 1989; Freund & Seto, 1998; Lehne & Money, 2003; Meloy, 2000).

2. Method This research is done by studying a total of 101,208 cases that were sent to Istanbul Forensic Medicine Institute by the judicial organs of the 4th Specialization Board between 1984 and 2004 whether they show paraphilic actions or not. When choosing the cases of pedophilia actions, incest incidents were excluded and 307 incidents were taken into assessment. A total of 307 paraphilic incidents who are over 18 years old and committed the same crime with the same characteristics twice are assessed.

Please cite this article as: Taktak, Ş., et al., Characteristics of paraphilics in Turkey: A retrospective study—20years, International Journal of Law and Psychiatry (2016), http://dx.doi.org/10.1016/j.ijlp.2016.05.004

Ş. Taktak et al. / International Journal of Law and Psychiatry xxx (2016) xxx–xxx

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The 4th Specialization Board which is connected to the ministry of justice and founded with a special act, functions as a legal expert which assesses the cases related to the forensic psychiatry from all 7 regions of Turkey. The specialization board consists of psychiatry, forensic and neurology experts and presents scientific and technical opinions about the determination of the legal competence with the reasons to remove criminal responsibility and reduce criminal responsibility and the determination of mania level for the drug users. As cases tend to minimize their problems or try to mislead the doctor, the legal investigation files which include all the necessary information related to the crime (statements of the witnesses, victims, police, friends, perpetrator and family members, marriage and military info, criminal records, available medical documents, crime scene investigation reports) are sent to the 4th Specialization Board. Some cases are kept in the Observation Specialization Department for 3 weeks and physical examination, various psychometric tests, neurological examination, EEG, tomography and magnetic imaging are done to make a decision. If the proofs and statements are inadequate, social observation is made and consultations on family members and acquaintances are done. The documents related to the crime may be wanted to be brought to the board via judicial authorities. To satisfy judicial authorities whether the person has a mental illness or weakness must be indicated. Although there is no obligation to comply with the classification system like DSM, ICD, findings and symptoms helping to diagnose must be reported to enlighten other medical evaluations and protection and treatment processes. Although the diagnoses are made based on both systems changing from time to time and assessments are carried out according to these diagnoses. The retrospectively analyzed judicial reports show sociodemographic characteristics (sex, age, place, marital status, employment, education, being a parent, economical status, having physical disorder, military status, substance addiction, suicidal before incident and psychiatric treatment) and psychiatric status of the incidents are evaluated in accordance with the diagnosis and criminal responsibility decisions of the 4th Specialization Board. The data are assessed by computers. 3. Results Of all the 101,028 cases from judicial authorities, only 307 cases are related to paraphilic actions. 97.4% of the incidents are male; 39.7% of them are 19–29 years old, 25.1% of them are primary school graduates, 59% of them are single, 59.6% of them have no children, 36.5% of them are unemployed, only 1.6% of them have much income than their expenses, 71.7% of them have no physical disorder, 16.3% of them have addiction(cigarette/alcohol/drugs either of them or combination of them), 30% of them live in the Marmara Region, only 2.3% did suicidal actions before the incident and 22.1% of them had undergone a psychiatric treatment (Table 1). It is determined that 33.6% of the incidents show paraphilic actions for 0–5 years. 15% of the incidents show paraphilic action for 20 years and more. We do not have information of the duration of the paraphilic action for 27.7% of them. 33.6% of them show rape actions, 30.6% of them show public indecency and 19.2% of them show molestation behaviors. 94.8% of the incidents have victims. The victims are mostly women (51.8%) and their ages are 6–10 (38.4%) and 0–5 (31.3%). 47.9% of the victims are strangers and 44.1% of them are acquaintances. 43% of the victims were fooled and 21.2% of them were forced. The incidents happened mainly in an open field (36.5%) and physical violence was used (63.8%). 79.5% of the cases are revealed as a result of denunciations, while 20.5% of them are a result of getting caught. In 17% of the cases, substance use was determined to be in effect. 26.1% of the cases had previously committed other crimes and 20.2% had been previously imprisoned (Table 2). The psychiatric diagnosis of cases before the incident and the type of paraphilia is given in Table 3. Accordingly, it is determined that the cases had 12 psychiatric diagnosis before the incidents. These are

mostly mental retardation (83, 27%), psychotic disorder (28, 9.1%), personality disorders (24, 7.8%), affective disorders (5, 1.6%), and neurotic disorders (4, 1.3%). 48.5% of the cases have no prior psychiatric diagnosis and have no application for psychiatric treatment. The paraphilia types of the cases are mostly pedophilia (185, 60.3%), exhibitionism (25, 8.1%), pedophilia + exhibitionism (23, 7.5%), fetishism (18, 5.9%), phone scatology (15, 4.9%), necrophilia (7, 2.25%), transvestic fetishism (5, 1.6%), and gerontophilia (4, 1.3%), and 3 cases have pedophilia + exhibitionism + fetishism triad paraphilic behaviors and it is determined that they have no diagnosis before the incident (Table 3). 20 kinds of diagnosis are determined by the FMI 4th Specialization Board to the incidents: Low debility (28, 9.1%), schizophrenia (26, 8.4%), and intelligence level between the up imbecility and down debility (18, 5.9%), imbecility (13, 4.2%), up imbecility (13, 4.2%), up debility (10, 3.3%), fetishism and impulse control disorder (8, 2.7%), fetishism (8, 2.7%), organic brain syndrome (8, 2.7%), and antisocial personality disorder (7, 2.7%) are on the top of these diagnosis. 49.5% of them have no psychiatric diagnosis (Table 4). Respectively, 168 (54.7%) cases have criminal responsibility, 77 (25.1%) cases have no criminal responsibility and 62 (20.2%) cases have reduced criminal responsibility (among these 45 (14.6%) cases got minimum, and 17 (5.5%) cases got maximum sentence reduction). These decisions are given by the FMI 4th Specialization Board. Most of the criminals who got sentence reduction have been diagnosed as down debilitating (Table 4). 4. Discussion Although paraphilia is rarely seen, a major part of the society faces this kind of action because of the repetitive and persistent nature of the paraphilic actions. Only very few of the cases reverberate to the judicial authorities due to psychosociocultural, legislative regulations or unknown reasons. It is not possible to say that all aggressive sexual behaviors originate from paraphilic motivation but it may still give an opinion about the frequency of the paraphilic actions (Guay, 2009; İncesu, 2004; Langstrom & Seto, 2006; Valença, Meyer, Freire, Mendlowicz, & Nardi, 2015). Paraphilia studies are generally carried out on men as paraphilia cases generally involve men (Abel, Jordan, Hand, Holland, & Phipps, 2001; Kafka & Hennen, 1999, Kafka & Hennen, 2003; Price, Kafka, Commons, Gutheil, & Simpson, 2002). All paraphilics are regarded as men but women have been also reported (Fedoroff, Fishell, & Fedoroff, 1999; Gayford, 1997; Twohig & Furnham, 1998). In this study, very few of the cases 2.6% are women. In the literature in paraphilia the male/female ratio is 30/1. In this research the male /female ratio is 37/ 1. Of all 8 women who show paraphilic behaviors, 3 of them have pedophilia, 2 of them have pedophilia, exhibitionism and personality disorder, 2 of them have phone scatology and one has exhibitionism and psychotic disorder. Although the sample is tiny, it suggests that female paraphilia should be considered in a wide spectrum in terms of diversity. Sexual masochism is more common in female paraphilia and the percentage of the observation behavior is 4% (First, 2014). In our study it is considered that it may not reverberate to the judicial authorities due to the cultural reasons. Puberty includes important psychic changes aiming to gain genital and orgasmic functioning accompanied by biological structural changes and forming the personality organization. Paraphilia cases mostly begin at childhood or adolescence, but they are more descriptive and expressive during late adolescence and adulthood (Gayford, 1997). Paraphilic activities range between the ages of 13 and 26, and they continue during the active sexual life and develop (Czerny, Briken, & Berner, 2002; Gayford, 1997; Gelder, Lopez-Ibor, & Andreasen, 2003; Leue, Borchard, & Hoyer, 2004; Oral, 1999; Price et al., 2002). In this study, consistent with the literature, the number of the cases found in a period with the active sexual life like adolescence and adulthood is higher. Most cases of paraphilia in the literature as in this study, are

Please cite this article as: Taktak, Ş., et al., Characteristics of paraphilics in Turkey: A retrospective study—20years, International Journal of Law and Psychiatry (2016), http://dx.doi.org/10.1016/j.ijlp.2016.05.004

Ş. Taktak et al. / International Journal of Law and Psychiatry xxx (2016) xxx–xxx

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Table 1 Socio-demographic features of the cases (N = 307). Socio-demographic features

N (%)

Socio-demographic features

N (%)

Socio-demographic features

N (%)

Gender

Male Female

299 (97.4) 8 (2.6)

Having children

183 (59.6) 37 (12.1) 87 (28.3)

Job status

112 (36.5) 105 (34.2) 90 (29.3)

Age (min: 11–max: 67)

11–18 19–29 30–39 40–49 50–59 60–67 Single Married Divorced Unknown

64 (20.8) 122 (39.7) 69 (22.5) 29 (9.4) 13 (4.2) 10 (3.3) 181 (59.0) 34 (11.1) 19 (6.2) 79 (23.8

Education

Unemployed Employed Unknown No Yes Unknown

Unknown No Yes

243 (79.2) 57 (18.5) 7 (2.3)

Marmara Central Anatolia Aegean Black sea Mediterranean Southeast Anatolia Eastern Anatolia

92 (30.0) 66 (21.5) 47 (15.3) 40 (13.0) 30 (9.8) 16 (5.2) 16 (5.2)

Addiction

Marital status

Region

Economic status

Yes No Unknown Illiterate or dropout Primary school graduate High school graduate Collage graduate Unknown Less income than expenses Equal income to expenses More income than expenses Unknown Unknown No Alcohol Drug More than one cigarette

single or married for a year (Kafka & Hennen, 1999; Kafka & Hennen, 2003; Valença et al., 2015). In this study, it is identified that the majority of incidents have no children (59.6%). This is expected as the majority of incidents were single. Similar to the experiences in puberty, perversive actions can be observed due to the inability to control the urge and stress during aging process in which biological and psychic fluctuations reemerge. 10 cases are over 60 years old in which our study supports this. In some studies that are trying to bring clarity to the socio-cultural and social structuring of sexual aggression, it has been reported that the majority of patients have low educational level, unemployed, and have middle or lower income levels (Gölge, 2005; Kafka & Hennen, 2003; Okumuş, 1994; Price et al., 2002; Valença et al., 2015). The mentioned results of this study are supporting the literature indications. The data in this study, is composed of data from all parts of Turkey which consists of seven geographical regions. The region where the data is

Having physical disorder 47 (15.3) 77 (25.1) 8 (2.6) 16 (5.2) 159 (51.8) 70 (22.8) 79 (25.7) 5 (1.6) 153 (49.8) 228 (74.3) 29 (9.4) 24 (7.8) 14 (4.6) 11 (3.6) 1 (0.3)

220 (71.7) 61 (19.9) 26 (8.5)

Suicide attempt before the incident

Psychiatric treatment before the incident No Yes

239 (77.9) 68 (22.1)

collected is in the Marmara Region in which Istanbul having the largest population in Turkey. Furthermore, these findings show partly compliance with Çitici's works on pedophiles. 19.9% of the cases have physical illness that complies with Çitici's (2004) findings. Few studies on this subject have been found in the literature. Being physically patient can be as much facilitating as it can be prohibitive to show paraphilia behavior and to prove itself in different ways. Therefore, extensive studies on the subject are required to be undertaken (Langstrom & Seto, 2006). The identifications of health problems associated with paraphilia are of theoretical interest because it may provide clues about etiology, of which we know very little. For example, a finding that individuals with paraphilic behaviors are significantly more likely to have concurrent mental disorders would suggest that common neurodevelopmental or environmental stressors might contribute to other disorders (Langstrom & Seto, 2006). Finding psychiatric co-morbidity may also have clinical relevance because the pharmacological treatment

Table 2 Paraphilic features of the cases (N = 307). Paraphilic features Years of paraphilic actions

Victim

Gender of the victim

Rapprochement Style to the victim

N (%)

Paraphilic features Paraphilia type

0–5 6–10 11–15 16–20 20 and over Unknown Yes No Female Male Both genders No gender Unknown Deceiving By force Unknown Suddenly No victim Friendship By calling Stealthy

103 (33.6) 24 (7.8) 24 (7.8) 25 (8.1) 46 (15.0) 85 (27.7) 291 (94.8) 16 (5.2)

Age of the victim

159 (51.8) 93 (30.3) 18 (5.9) 21 (6.8) 16 (5.2)

132 (43.0) 65 (21.2) 37 (12.1) 26 (8.5) 16 (5.2) 13 (4.2) 11 (3.6) 7 (2.3)

Rape Public indecency Molestation Killing by raping Theft Acting publicly shameless Rape and theft 0–5 6–10 11–18 18 and over 60 and over No victim

The degree of familiarity of the victim with the paraphilia case

Stranger Acquaintance No victim Unknown

Criminal records

Yes No Unknown

N (%)

Paraphilic features

103 (33.6) 94 (30.6) 59 (19.2) 27 (8.8) 14 (4.6) 8 (2.6) 2 (0.7) 96 (31.3) 118 (38.4) 20 (6.5) 53 (17.2) 4 (1.3) 16 (5.2)

The place of the incident

Manifestation of the incident Physical violence The effect of the addiction

Psychiatric treatment before the Incident 147 (47.9) 138 (44.1) 16 (5.6) 6 (2.4) 80 (26.1) 68 (22.1) 159 (51.8)

N (%) Open field Strange structure, school or work place The house of the paraphilia case Another house Unknown Denunciation In the act Yes No Yes No Unknown

112 (36.5) 88 (28.7) 60 (19.5) 36 (11.7) 11 (3.6) 244 (79.5) 63 (20.5) 196 (63.8) 111 (36.2) 63 (20.5) 49 (17.0) 195 (63.5)

No Yes 239 (77.9) 68 (22.1)

Been in prison

No Yes Unknown

91 (29.6) 62 (20.2) 154 (50.2)

Please cite this article as: Taktak, Ş., et al., Characteristics of paraphilics in Turkey: A retrospective study—20years, International Journal of Law and Psychiatry (2016), http://dx.doi.org/10.1016/j.ijlp.2016.05.004

Ş. Taktak et al. / International Journal of Law and Psychiatry xxx (2016) xxx–xxx

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Table 3 Psychiatric diagnoses before the incident and paraphilia type of the cases (N = 307). Paraphilia type of the cases Psychiatric diagnoses before the incident Mental retard. Psychotic disorders Personal disorders Affective disorders Neurotic disorders Paraphilias Dementia Obsessive com. dis. Exitation syndrome Reactive disorder MildMRet + atipic. psyc. Conduct disorder No diagnosis Total

P

E

P+E F

PS 0 0

N TF G P + Z + P V Fr V + F T P + N P + V G + F Z + E E+F 1 0 1 0 2 0 0 0 0 1 1 0 0 1 0 0 0 1 2 0 2 1 0 0 1

P+ E + N F + K TOTAL E+V 1 1 0 83 0 0 0 28

65 11

7 5

3 3

0 1

12

3

4

0

0

0

0

2

1

0

1

1

0

0

1

0

3

0

0

0

0

0 0 0

0 1 2

1 0 1

0 0 0

0 0 0

0 0 0

2

0

0

0

0

0

0

1

0

1

0

o

1

0

0

90 6 7 185 25 23

1

0

0

1

0

1

0 0

1

1

0

0

0

0

24

0

0

0

0

0

0 0

0

0

0

0

0

0

5

0

0

0

0

0

0

0 0

0

0

0

0

0

0

4

1 0 0

0 0 0

0 0 0

0 1 0

0 0 0

0 1 0

0 0 0

0 0 0 0 0 0

0 0 0

0 0 0

0 0 0

0 0 0

0 0 0

1 0 0

3 3 3

0

0

0

0

0

0

0

0

0 0

0

0

0

0

0

0

2

0

0

0

0

0

0

0

0

0

0 0

0

0

0

0

0

0

1

0

0

0

0

0

0

0

0

0

0

0 0

0

0

0

0

0

0

1

0

0

0

0

0

0

0

0

0

0

0 0

0

0

0

0

0

0

1

16 14 5 18 15 7

4 5

2 4

3 3

0 3

1 3

0 3

1 2

0 0 2 2

0 2

0 1

0 1

0 1

0 1

0 1

149 307

P: pedophilia, E: exhibitionism, F: fetishism, Fr: frottorism, PS: phone scatology, N: necrophilia, TF: transvestic fetishism, G: gerontophilia, Z: zoophilia, V: voyeurism, T: toucherism, K: kleptomania.

addressing co-morbid DSM Axis I conditions might ameliorate some of the problems associated with paraphilia (Kafka & Hennen, 2000). Kafka and Hennen (1999) stated in their study that 30% of the cases have the psychiatric history. In this study the cases' psychiatric story level is higher than that of Kafka and Hennen's study (51.5%) (Table 3). It is identified that only 22.1% of the cases had received treatment. In half of the cases, the failure to implement treatment may have led to exhibit paraphilic behavior (Table 1). One of the reasons for this is that after the diagnosis, which involves various degrees of severity of mental retardation and psychotic disorder, treatment is generally not

chosen as a solution. As the military service is compulsory in Turkey, this made it easy to detect the cases with mental retardation. The statistics show that mentally retarded people mostly stand trial due to sexual assault (Soysal, 2005). In this study 27% of the cases are mentally retarded people and 78% of these mentally retarded people show pedophilic actions. It is known that the intelligence level is lower in psychotic patients, which increases the tendency of a crime and especially violent actions (Soysal, 2012). Our cases had especially chosen children who are 6–10 years old and unable to defend themselves. It is considered that 36.1% of the cases (mental retardation and psychotic disorder)

Table 4 The decisions of criminal responsibility and psychiatric diagnoses given by the 4th FMB Specialized Board (N = 307). The psychiatric diagnoses given by the 4th FMB Specialized Board

N (%)

The decisions of criminal responsibility by the 4th FMB Specialized Board (N = 307) Criminal responsibility (N = 168)

No Down debilitating Schizophrenia A level of intelligence between up imbecility and down debilitating Imbecility Up imbecility Up debilitating Fetishist (ejaculate) + impulse control disorder Fetishist Organic brain syndrome Antisocial personality disorder OCD + fetishist Necrophilia Excitation syndrome Pedophilia Exhibitionism + OCD Shoe fetishism + kleptomania Sexual compulsive disorder Up debilitating (the psychotic episode) Paranoid personality on the edge of psychosis Epilepsy + psychotic disorders

152 (49.5) 28 (9.1) 26 (8.4) 18 (5.9) 13 (4.2) 13 (4.2) 10 (3.3) 8 (2.7) 8 (2.7) 8 (2.7) 7 (2.2) 3 (1.0) 3 (1.0) 3 (1.0) 1 (0.3) 1 (0.3) 1 (0.3) 1 (0.3) 1 (0.3) 1 (0.3) 1 (0.3)

152 0 0 0 0 0 7 0 0 0 7 0 1 0 1 0 0 0 0 0 0

No criminal responsibility (N = 77)

0 0 26 10 13 11 0 1 0 8 0 0 2 3 0 1 0 0 1 0 1

Reduced criminal responsibility (N = 62) minimum (N = 45)

maximum (N = 17)

0 28 0 0 0 0 3 0 8 0 0 3 0 0 0 0 1 1 0 1 0

0 0 0 8 0 2 0 7 0 0 0 0 0 0 0 0 0 0 0 0 0

Please cite this article as: Taktak, Ş., et al., Characteristics of paraphilics in Turkey: A retrospective study—20years, International Journal of Law and Psychiatry (2016), http://dx.doi.org/10.1016/j.ijlp.2016.05.004

Ş. Taktak et al. / International Journal of Law and Psychiatry xxx (2016) xxx–xxx

who applied to medical authorities before the incident were not treated properly and this leads to the reduction in impulse control in social competence and causes them to show paraphilic behavior. It has been seen that only 3 cases were diagnosed as paraphilia regarding the psychiatric diagnosis before the incident. One of the reasons for this is that paraphilic behaviors are not considered as an issue of complaint but as an act of pleasure and it might be thought to be misunderstood or not to be understood at all. Another reason might be that impulse control disorder reports, which include paraphilia being turned into a medical board report, are not a requirement as in mental illnesses (psychosis, mental retardation, dementia and other cognitive disorders) in Turkish laws (Soysal, 2015). It has been seen that the 4th Specialization Board has diagnosed 25 cases which are sent by forensic authorities after the incident as paraphilia, 20 of them as fetishism, and 3 of them as necrophilia. The reason why most of them are fetishism may result from the reason that the offensive weapon is an evincible, tangible object. The reason why paraphilia diagnosis was not made by the concerning specialization board although paraphilic actions are present in the investigation files might be the prevention from removal of the criminal responsibility or the stigmatization of the person. The unusual sexual behavior of the people may cause difficulties in custody or unnecessary treatment attempts. For some people getting rid of the punishments from the society and the law might mean encouragement to show more perversive behaviors. In a total of 77 cases in which criminal responsibility is removed, most are mentally retarded at various levels (imbecility is the most), with the second most frequent case being schizophrenia and the third being organic brain syndrome. One of the 4 cases who have no criminal responsibility is diagnosed as exhibitionism + severe obsessive compulsive disorder, one is diagnosed as ejaculation fetishism with impulse control disorder, and two others are diagnosed as necrophilia, one of which is also diagnosed as schizophrenia and the other as comorbid with mental retardation. These 4 cases have psychiatric illnesses accompanying paraphilia and they suffer from these illnesses for a long time. There had been treatment attempts and they repeat this action many times but did not commit another crime. No crime was committed under the influence of any drugs. There was no physical contact with living victims, and the ejaculation fetishist case even took the consent of the victim and gave money to the victim (Taktak, Karakuş and Eke, 2015).”” It has been seen that 62 cases were granted diminished criminal responsibility. 45 of them were granted minimum and 17 of them were granted maximum diminished criminal responsibility. 41 of these cases have mental retardation at various levels. 8 of them have only fetishism, the other seven have fetishism and impulse control disorder, three of them have fetishism and obsessive compulsive disorder and one has shoe fetishism and kleptomania (Taktak, Karakuş, Kaplan & Eke, 2015). It has been found out that like the paraphilic cases that have no criminal responsibility, these cases also had suffered from these illnesses for a long time, had repeated this action many times, had undergone a treatment, had troubles because of these illnesses, had lost the people around and had remorse after the action and convinced the psychiatry board. In Çitici's (2004) study it is stated that 75% of the sexual aggressors to children have no mental disorder and they got no sentence reduction. In our study of 185 cases that are pedophilic, 90 cases had no diagnosis before the incident. Sentence reduction had been applied only to the people who had mental illness accompanied by paraphilia. 65 of these cases were diagnosed as mental retardation. Only one case was diagnosed as pedophilia and no sentence reduction was applied to this case. It might be told that the reason why no sentence reduction is applied to pedophilic cases is to protect the most valuable asset of the society which is the “children” and the necessity to punish the criminal action against children and avoiding social reaction (Erdoğan, 2010). It has been seen that the specialized board granted diminished criminal responsibility and were more tolerant.

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It has been seen in the studies that personality disorder which is the third psychiatric diagnosis has been seen frequently among the paraphilic cases. In our study 24 cases were diagnosed as personality disorder before the incident. Pedophilic individuals are known to be self-enclosed, psychopathic psychosexual and have limited social contact and immature personality traits (Hall, 2007). It is considered that the patients use paraphilic actions to overtower sexually and patients at the psychotic edge use it to prevent the disintegration of self (Erdoğan, 2010; Gülçat, 1998). Pedophilia may be the most common among paraphilia as it comes over to legal proceeding more and its limits can be drawn clearly (Erdoğan, 2010). In our study 60.3% of the cases show pedophilic behavior. In a study conducted in North America on 3270 men with paraphilia behavior, child aggression (61.5%) is the most common case (Murray, 2000). In another study; it was observed that 19% of the diagnoses are pedophilia, 11% of them involve raping adult women, and exhibitionism is in 12% of them; 5% of them invove voyeurs, 5% of them are Frottee, and few of them involve minor perversion behaviors (Gölge, 2005). In psychiatric practice, masochism, sadism and fetishism are the most encountered paraphilia. It has been said that pedophilia, voyeurism and exhibitionism are the most common ones as they have clinical treatment because of their criminal features (Kaplan & Sadock, 2005). It is quite possible to see the coexistence of multiple paraphilia behavior in a paraphilic person (Heil, Ahlmeyer, & Simons, 2003; Karamustafalıoğlu, 2007; Oral, 1999). 40 cases (13%) show multiple paraphilia and the most seen association show pedophilia and exhibitionism association (23 cases). In Çitici's (2004) study, as in this study rape is in the first place of the crime and carnal rape has been reported to be in second place. Okumuş's (1994) work also shows that the crime rate for rape is 57%. In the literature it has been reported that in most paraphilia cases there have been victims (Meloy, 2000; Okumuş, 1994). Only 16 cases have no victims and 7 of them are necrophilia. It is stated that the cases in Geyran and Uygur's (1996) article showed paraphilia behavior toward female victims. In many studies (Gölge, 2005; Okumuş, 1994) as in this study, most of the victims are women. Only 30 (3%) of the victims are men in our study. In Murray's (2000) study, it has been reported that pedophilias prefer children under the age of 12 and especially girls between the ages of 8 and 10. In Gölge's (2005) study, he found out that there is a high level of child victims from 10 to 14 years old. In Çitici's (2004) study, the majority of the victims of pedophilia were determined to be in the 0–5 age group. In the literature it was emphasized that some frottoris actions for victims in this age group, rather than the actual rape, generally remain in the carnal rape stage and behaviors like lap friction can emerge (Oral, 1999). In this study the levels of stranger victims (47.9%) or acquaintances (44.1%) are very close to each other. In Gölge's (2005) study, it is reported that most of the victims are acquaintances. Due to the variety and the nature of paraphilia actions depending on the type of action it is expected that the relationship to the victims can vary. Therefore, the degree of relationship in pedophilic actions can show no compliance with the degree of relationship in exhibitionistic action. In Çitici's (2004) study, it has been reported that the act of deceiving is the most commonly used method for children. Murray (2000) mentioned in his study that the aggressors approach by tricking little kids. In this study, 60 (3%) of the paraphilic cases involve pedophilia (Table 3) and the age group of the victims of pedophilia is 0–10 years. These findings are consistent with the findings of both studies. In Gölge's (2005) study, it is stated that aggressors often preferred victims' or an acquaintance's home or workplace. This study found out that the cases occurred mostly in open terrain although some cases occurred at homes and in workplaces. In Çitici's (2004) study, more than half of the sexual assault incidents were reported with the presence of physical violence. In this research like the aforementioned studies, it has been reported that 63.8% of patients used physical violence. In this study the majority of the cases

Please cite this article as: Taktak, Ş., et al., Characteristics of paraphilics in Turkey: A retrospective study—20years, International Journal of Law and Psychiatry (2016), http://dx.doi.org/10.1016/j.ijlp.2016.05.004

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were reported first and after that they were caught in act like in Çitici's (2004) study. The view that sexual assaults are committed more with the effect of alcohol is similar to the findings of Gölge's (2005) and Çitici's (2004) studies. Alcohol is detected in only 24 (7.8%) cases. Moreover there is no history of drug abuse in most of the cases. 29 of the 79 paraphilic cases do not use any kind of drugs. 49 cases have history of alcohol or other drug use. In this study, 26.1% of the cases had previously committed other criminal offenses and 20.2% had previously been in prison. In a study conducted with sex offenders it was found out that 22% of the perpetrators had criminal records (Çitici, 2004). Aslan's (2003) study on sexual assault convicts indicates that 26% of cases had old conviction. In addition to this, Gölge (2005) found out that sexual aggressors had high levels of general criminal history and sexual assault. Gölge found out that 1/4 of the cases have a history of suicide attempt and those findings are close to the findings of this study. Criminal responsibility (54.7%), reduced criminal responsibility (20.2%), and no criminal responsibility (25.1%) decisions are given by the FMI 4th Specialized Board (Table 4). Of the 62 cases who have reduced criminal responsibility, the punishment for 45 has been reduced to the minimum extent while that for17 has been reduced to the maximum extent. Various assessments are made for different cases, so each case has its own degree of severity. In this case the capability of examination and observation and experience of the clinician, are expected to be well developed. There is a variety of pharmacological and psychological treatments for paraphilic perpetrators. Despite some case reports of a reduction of some sexual behaviors psychotropic drugs showed very poor evidence of effective treatment for paraphilic behaviors (McManus, Rainbow, & Alison, 2013). 5. Strength and limitation In the criminal law before 2005 in which this study was carried out, it had been decided that the people who do not have the competence to judge mentally and control the behaviors due to mental illness and weakness are found to have no criminal responsibility. In the other article of this law, maximum (1/2) and minimum (1/3) sentence reduction had been administered to people who have issues which remove mental faculties not completely but significantly. Because of this law in 2005, patients who are affected to the maximum are included to the patient group under an article of the prior law and patients who are affected to the minimum are granted less sentence reduction (1/6) In the criminal responsibility application of the prior law, preservation and treatment were not included. It is decided that on the condition that the length of the punishment is the same, it can be used as a security precaution specific to mental patients. As the change in the article of the law may change the reduced criminal responsibility and naturally it may change the treatments, this study included only the cases before 2005. Soysal (2015) stated that there is no adequate experience and articles of the Turkish Psychiatry Society on the treatment process, which became available after 2005 for the impulse control disorders. We consider that when there is sufficient data, another study should be carried on for the cases after 2005. Moreover it is not possible to mention observations for the paraphilia therapy as there is no regulation in the psychiatric treatment during the sentence duration of some cases in which the sentence reduction was applied according to the law before 2005. 6. Conclusion As can be seen from the research, findings on paraphilia are found within forensic psychiatric examinations. The most conspicuous characteristics of the paraphilic cases are that of all 307 cases, 298 are male, 220 have no physical disorder, 291 have victims, 167 have criminal responsibility, and 196 used physical violence. The most common type of paraphilia is pedophilia.

When it comes to criminal acts, forensic psychiatric evaluation is an act specific process that determines a person's psychopathology during criminal acts while trying to reach a decision on criminal responsibility. Especially when it comes to pedophilic acts, repetitiveness of paraphilic behavior is frightening. Moreover pedophilia, as seen in this study is one of the most common types of paraphilia. Besides the protective studies about this disorder, more information should be obtained. As the theories of etiology show, today's victim can be tomorrow's offender. In forensic psychiatry, for cases who may harm people, things and even themselves, forensic psychiatry units look for psychosis, mood disorders, mental retardation and dementia, and if these are found, it is reported that they do not have criminal responsibility. The assessment that there is no criminal responsibility is not right in the paraphilic cases except from mental disability and diseases in which the moral elements of the crime do not occur which is also called “mens rea”. However in selected cases in which disorder is seen solely, paraphilic behaviors come to the fore and there is no antisocial personality disorder, it may be right to assess these actions as reduced criminal responsibility. The paraphilics desiring to seize the feeling of pleasure at a time when the sexual hormones are at the peak even for a moment are like the anthropologists looking for a bone to reach their origin. The child who wants to be a competent adult or the people who are facing with mental problems may look in to the past to solve the problems they cannot solve at present or especially to get rid of the troublesome circumstances. It is observed that to get rid of the pain due to inability to find the object that he/she is seeking, he/she enjoys the object that he has at the moment or alters the object. Some of them, if they cannot find the object, just try to enjoy the path, and some tries to dig deeper and even sacrifices so many things for that. The research on any criminal behavior disorder against public order will deepen the knowledge on the subject. Thus, information will be provided for the prevention of crime. As these cases come within the scope of forensic psychiatry, reasonable achievements for the public interest can be achieved by developing multidisciplinary approaches as a result of the data obtained in forensic psychiatric examination of the cases. We think that the new criminal law will help the paraphilic cases seeking treatment by implementing the special security precautions for the mental patients for the partial or complete period of sentence. Conflict of interest The authors declare that they have no conflicts of interest concerning this article. We think that the new criminal law will help the paraphilia cases seeking treatment by implementing the special security precautions for the mental patients for the partial or complete period of sentence. Acknowledgment We would like to thank Professor Doctor Gökhan Oral and Barış Karaaslan for their kind support in this work. References Abel, G. G., Jordan, A., Hand, C. G., Holland, L. A., & Phipps, A. (2001). Classification models of child molesters utilizing the Abel Assessment for sexual interest. Child Abuse & Neglect, 25 (703-18.4). Aggrawal, Anil (2009). Forensic and medico-legal aspects of sexual crimes and unusual sexual practices. Boca Raton: CRC Press1-4200-4308-0. Alkhalil, C., Tanvir, F., Alkhalil, B., & Lowenthal, D. T. (2004, May–Jun). Treatment of sexual disinhibition in dementia: Case reports and review of the literature. American Journal of Therapeutics, 11(3), 231–235. Aslan, M. (2003). Irza geçme suçu nedeniyle Türkiye cezaevlerinde bulunan mahkumların profili. İstanbul: Istanbul Üniversitesi Adli Tıp Enstitüsü, Yüksek Lisans Tezi. Beech, A. R., & Harkins, L. (2012). DSM-IV paraphilia: Descriptions, demographics and treatment interventions. Aggression and Violent Behavior, 17, 527–539. Casanova, M. F., Mannheim, G., & Kruesi, M. (2002). Hippocampal pathology in two mentally ill paraphiliacs. Psychiatry Research, 115, 79–89.

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Please cite this article as: Taktak, Ş., et al., Characteristics of paraphilics in Turkey: A retrospective study—20years, International Journal of Law and Psychiatry (2016), http://dx.doi.org/10.1016/j.ijlp.2016.05.004