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Jeremy Greene, M.A., M.D., Ph.D.


https://www.hopkinsmedicine.org/profiles/results/directory/profile/9622265/jeremy-greene

This has been demonstrated in two studies showing that a majority of child pornography offenders assessed at a sexual behavior clinic showed more sexual arousal (assessed through penile plethysmography responses in the labora to ry) to children than to adults medications zocor order generic topamax from india, and in fact show a stronger relative response than do offenders with contact victims (Blanchard et al treatment 7th feb bournemouth cost of topamax. Other studies have also demonstrated a link between sexual interest in children and child pornography use through self-report surveys medicine nausea safe topamax 100 mg. These results are consistent with what we know about the modal child pornography image seized by police treatment 001 - b buy topamax overnight delivery, which depicts young girls who appear to be younger than age 12 and often depicts children in sexually explicit conduct (Collins medications peripheral neuropathy order topamax pills in toronto, 2012; Quayle & Jones symptoms 5 months pregnant purchase 100mg topamax otc, 2011). It is a reasonable assumption that individuals will seek out pornography content that refects their sexual interests (Se to , Maric & Barbaree, 2001). Thus, pedophilic individuals will tend to seek out content depicting young children, while nonpedophilic individuals who are involved with child pornography will tend to seek out content depicting underage adolescents. However, not all child pornography offenders show a sexual preference for children over adults and there are motivations other than pedophilia. These explanations are based on self-reporting alone and should be interpreted cautiously because offenders may have offered alternative explanations (other than pedophilia) for their crimes in response to the stigma associated with the pedophilia label. Sexual Interest in Adolescents In addition, research by the Crimes against Children Research Center suggests that solicitation offenders target young adolescents, typically between ages 13 and 15, which would not be consistent with the clinical diagnosis of pedophilia (because many of the adolescents involved would be showing some signs of sexual and physical maturation) (Wolak et al. Although it is illegal and is a contravention of social norms about sexual behavior, a sexual interest in young to mid-teen adolescents is not indicative of pedophilia. Briggs, Simon and Simonsen (2011) have suggested that there is a distinction between fantasy-driven and contact-driven solicitation offenders. The former group engages in online activities (such as sexual chat, exchange of pornographic images or exhibitionism via webcam) that are gratifying in and of themselves, often resulting in orgasm while online. These activities appear to refect the sexual fantasies of the offenders and likely fuel those same fantasies by providing experiences and images for future occasions. The latter group, in contrast, engages in online activities to arrange real-world meetings; their online activity is more directed to ward meeting offine and shorter in duration than the online interactions of fantasy-driven offenders. Given the small sample size and explora to ry nature of this study, more research is needed to determine if this distinction between solicitation offenders is valid and meaningful. It is rare for solicitation offenders to target young children, stalk or abduct unsuspecting minors or use physical coercion or force to engage in sex with minors. However, only cases involving contacts with real minors that were subsequently reported to police were included in this research. It is possible that unreported cases, or cases involving online contacts but no real world meetings, do involve younger children and/or more violent behavior. Krueger, Kaplan and First (2009) compared 22 solicitation offenders and 38 child pornography-only offenders. Although this study was limited because of the small sample size, there were no signifcant group differences in the prevalence of paraphilia diagnoses, anxiety or mood disorder diagnoses or substance abuse disorder diagnoses. As one might expect given the nature of their offenses, solicitation offenders were more likely to be identifed as having a hypersexuality disorder (a proposed psychiatric diagnosis for individuals with an excessive interest or involvement in sexual behavior) in terms of excessive online sexual activity, whereas child pornography-only offenders were more likely to be identifed as having a hypersexuality disorder in terms of dependence on pornography. This was surprising because most of the solicitation offenders had actually attempted to meet with someone they thought was a minor (usually an undercover police offcer), whereas child pornography offenders might never have approached a minor directly. One in eight internet offenders has a his to ry of contact sexual offending in their offcial criminal records. Contact Offending His to ry Se to , Hanson and Babchishin (2011) reviewed available studies and identifed 21 samples of internet offenders (a to tal of 4,464 mostly child pornography offenders, although some samples also included solicitation offenders) with information about their contact offending his to ries. In the six samples with self-reported data, a little more than half (55 percent) admitted to a his to ry of contact sexual offending,3 usually as a result of clinical involvement and/ or polygraph examination. More than half of internet offenders self reported a his to ry of contact sexual offending. Many internet offenders have no known prior contact offending his to ry (identifying a major gap in the literature, as the established risk measures that are available for contact sex offenders may not apply to the internet population). There is a sizable difference between undetected and detected offenses, when comparing the self-reported prevalence rates with the offcial record rates. Though some of the offenders who deny any his to ry of contact offending may be lying, despite being in treatment or undergoing a polygraph examination, it does not appear that most or all internet offenders have committed a contact sexual offense. Further research is needed to identify the fac to rs that distinguish those who have committed contact sexual offenses against a child from those who do not commit such offenses. This empirical knowledge would advance the understanding of risk of recidivism and the relationship between online and offine offending. Consistent with this idea, Lee and colleagues (2012) found that online offenders who had committed contact offenses scored higher on a measure of antisocial behavior and traits than online offenders who had no known his to ry of sexual contact victims. However, dual offenders were less likely to admit pedophilic sexual interests when interviewed, had less child pornography content and were involved with child pornography for shorter periods of time. Refecting the potential importance of opportunity, dual offenders were more likely to have access to children than child pornography only offenders, through co residence or occupation. Contact Offending in the Future Se to , Hanson and Babchishin (2011) also reviewed recidivism rates from nine samples of internet offenders (a to tal sample size of 2,630 online offenders) followed for an average of slightly more than three years (ranging from one-and-a-half to six years at risk). Although the follow-up times are relatively short for this kind of research, and recidivism rates are expected to increase with more opportunity, these recidivism rates are lower than those observed in recidivism studies of offine offenders (Hanson & Mor to n-Bourgon, 2005) and belie the idea that all internet offenders pose a high risk of committing contact offenses in the future. Indeed, there may be a subgroup of online-only offenders who pose relatively little risk for a contact sexual offense. In a recent preliminary analysis of data from 101 federal child pornography offenders in the United States, using data obtained from the U. Sentencing Commission, Burgess, Carretta and Burgess (2012) noted that a majority of the offenders were employed (68 percent), had some college education (58 percent), were married or had previously been married (59 percent) and had no prior criminal offenses (53 percent). Offenders with these kinds of characteristics are relatively unlikely to criminally offend again (compared to those who are unemployed, did not complete high school, had never married and had prior offenses). Some of them pose a relatively high risk of directly victimizing children (or indirectly victimizing children by again accessing child pornography), and an important task for law enforcement and for clinicians is to identify those higher-risk individuals in order to prioritize cases and make more effcient decisions about resources. Recidivism Risk Fac to rs Research is beginning to emerge on the fac to rs that predict recidivism among internet sex offenders, although more studies using large samples, a set of theoretically or empirically plausible risk fac to r candidates, longer follow-up times and comprehensive criminal records are clearly needed. These initially identifed risk fac to rs appear to be the same kinds of risk fac to rs seen in decades of research on contact sex offenders, and in research on all kinds of offenders generally. For example, recent studies have shown that well-established nonsexual criminological fac to rs such as offender age at time of frst arrest, prior criminal his to ry and failure on prior conditional release (such as bail or parole) can predict sexual recidivism among child pornography offenders (Eke, Se to & Williams, 2011; Se to & Eke, 2005). Broadly speaking, and in line with results for previous sex offender risk assessment to ols, these items can be viewed as refecting either atypical sexual interests (admission of pedophilic or hebephilic sexual interests, relative interest in boys versus girls) or antisocial tendencies (younger age, criminal his to ry, failure on conditional release) (Se to , 2008, 2013). Faust, Renaud and Bickart (2009) examined predic to rs of recidivism in a sample of 870 child pornography offenders assessed by the Federal Bureau of Prisons between 2002 and 2005. The average length of follow-up was almost four years, with a sexual offense rearrest rate of 5. Of the 30 predic to rs examined, fve were signifcant predic to rs of sexual rearrest: lower education level, being single, possessing noninternet child pornography, prior sex offender treatment (likely a proxy for having a prior sexual offending his to ry) and not possessing depictions of adolescent minors (suggesting that those who show a preference for depictions of prepubescent children are at greater risk). Risk Matrix items include offender age, sexual and any other sentencing his to ry, having a male victim, having a stranger victim, ever having a live-in romantic relationship, and having any noncontact offenses. Wakeling and her colleagues obtained recidivism data on 1,326 offenders followed for one year (2. This research is at an early stage and thus it is to o soon to confdently conclude that existing risk measures (modifed or not) will accurately predict sexual recidivism by internet offenders who have no his to ry of contact sexual offending. The applicability and validity of risk measures to internet offenders who do have a his to ry of contact sexual offending is not in question. Clinicians and others are clearly justifed in using existing risk measures to assess the risk of internet offenders who are known to have a his to ry of contact sexual offending. Intervention There is relatively little literature on the treatment of internet offenders. Typically, knowledge about characteristics and risk of recidivism is established before knowledge about treatment approaches and outcomes because of the time it takes to develop and implement programs and then evaluate them for recidivism. Sex offender treatment and supervision professionals are struggling to respond to the increasing infux of internet offenders. Key questions have yet to be addressed regarding intervention, including what the priority treatment targets are, how they should be targeted and whether interventions can reduce recidivism. This program was created as a result of treatment provider concerns about mixing internet and contact offenders in group therapy as well as questions about the applicability of some treatment components and targets of conventional contact sex offender treatment programs (McGrath et al. The program is based on contemporary models of contact sexual offending that emphasize cognitive-behavioral principles, but it also draws in elements of positive psychology, 12-step and self-help approaches (which is also common among conventional contact sex offender programs). The program is intended to be less intense than the standard conventional sex offender program available in the United Kingdom; it involves fewer (20 to 30) sessions in either individual or group format and more internet relevant content. The evidence available so far on risk of recidivism suggests that more intensive interventions are required only by a minority of internet offenders (Se to , Hanson & Babchishin, 2011). Dynamic risk fac to rs can be distinguished from static risk fac to rs that do not or cannot change. Static risk fac to rs provide the best long-term prediction of recidivism but they do not identify potential treatment and supervision targets. Treatments and other interventions that can successfully target dynamic risk fac to rs are more likely to lead to reductions in recidivism. Middle to n, Mandeville-Norden and Hayes (2009) reported preliminary results from a pre-/post-treatment evaluation of 264 internet offenders. There were signifcant changes on 10 of 12 psychological measures, many corresponding to the treatment targets just described. However, there was no comparison group, so it is not clear how much of these changes can be attributed to the treatment as opposed to the passage of time, probation involvement or participation in other programs. Continuing follow-up is also needed to determine if treatment participation (especially treatment-related changes on specifc targets) are related to changes in recidivism in the desired direction. The main aim of this website is to reach individuals who are engaging in problematic online behaviors before they commit contact offenses. Department of Justice, 2010), any comprehensive response to internet offending will need to include a self-help component. A similar service is provided by nongovernmental organizations such as S to p It Now! One beneft of self-help and confdential approaches is that a larger group of at-risk individuals can be reached, especially in light of evidence that many online offenders go undetected. A disadvantage is the likelihood that the highest risk individuals (those who have an antisocial orientation and already engage in contact sexual offending) are probably less likely to seek self-help options. Another disadvantage is that follow-up data will not be available to evaluate the effcacy of these services. Undetected internet offenders are unlikely to seek help given the severe stigma associated with self-identifying as being sexually interested in children or engaging, directly or indirectly, in the sexual exploitation of children. Undetected offenders are also likely to be inhibited by manda to ry reporting requirements, as they cannot talk honestly about illegal acts they have committed. A research and treatment project (the Dunkelfeld Project) currently underway in Berlin, Germany, was able to recruit a large sample of self-identifed individuals who were sexually interested in children (Beier et al. Most individuals in the sample (95 percent) had engaged in illegal behavior at some time in their lives, but some had been inactive and had not committed a sexual offense in the previous six months. These men were reached through a mass media campaign with billboard and other public advertisements and television and radio spots. Between 2006 and 2011, 319 help-seeking individuals (72 percent admitting child pornography offending at some point in their lives) expressed interest in participating in the one-year treatment program, based on cognitive behavioral principles. Treated participants showed improvement on sexual self-regulation, emotional problems and offense-supportive attitudes and beliefs, whereas untreated participants did not show any signifcant differences between their two assessments (conducted after the same time interval). Summary It is clear from this review that research on internet offending is relatively new and that there are substantial gaps in the knowledge about internet offenders and the crimes they commit. At the same time, research conducted over the past 10 years (paralleling the emergence of the internet in everyday life) sheds some helpful light on some key issues. Increasing Demand There is consistent evidence that the number of internet sexual offending cases is increasing rapidly, with major implications for law enforcement, criminal justice, correctional and clinical agencies. However, more precise state-by-state data are needed to better understand the breadth and depth of this increasing demand in order to allocate resources wisely and to determine if there are meaningful geographic differences that might suggest solutions to this demand. Less is known about the characteristics, contact offending his to ry and recidivism risk posed by solicitation offenders and the extent to which they differ from child pornography offenders (who also use online technologies to commit their crimes) and contact sex offenders (who have actually attempted to make or have made physical contact with a victim). Also, little is known about offenders who use the internet to commit sex crimes against adults. Internet-facilitated sexual offending includes various types of crimes, including possession, distribution and production of child pornography; sexual solicitations; and conspiracy crimes. Internet Offending Types Emerging research suggests that solicitation offenders are different from child pornography offenders in meaningful ways. In particular, child pornography offenders are likely to be pedophiles, whereas solicitation offenders appear to be predominantly interested in adolescent girls. First, individuals who are primarily interested in images of underage but sexually mature minors. Second, there may indeed be individuals interested in sexually soliciting younger children, but younger children are less likely to be on social networking and similar sites (many of which have age restrictions;. This apparent difference in internet offender motivations may translate to differences in contact offending his to ry, risk of recidivism and the likely targets of other criminal sexual behavior (young children versus adolescent minors). Overlap With Contact Offending Only one in eight internet offenders has an offcial record for contact offending, based on available studies (Se to , Hanson & Babchishin, 2011). The proportion goes up to approximately four in eight when self-reported offending is added, but this still falls short of the idea that most or all Internet offenders have already committed contact offenses. Indeed, a recent meta-analysis of 30 unique samples found theoretically and clinically important differences between these two groups, as well as a third group of dual offenders (Babchishin, Hanson & van Zuylen, 2015). Contact offenders scored higher on measures of antisocial tendencies, whereas child pornography and dual offenders were more likely to be score high on measures of pedophilia (with dual offenders even higher than child pornography only offenders).

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Look at case #12 medications rights cheap topamax master card, especially symptoms rheumatic fever cost of topamax, to see that Hirschfeld understands something about au to gynephilia treatment zinc deficiency cheap topamax 200 mg overnight delivery, long before Blanchard nailed the concept down symptoms whooping cough order topamax 200 mg visa. Most of them are thankful that some one is finally talking about the sexual side of transsexualism symptoms 0f gallbladder problems 100 mg topamax otc. The film Wigs to ck (Barry Shils symptoms colon cancer purchase genuine topamax, 1995) focuses more on drag perfor mance than on life between performances, but it, to o, is worth watch ing. The Queen (Frank Simon, 1968) is an earlier documentary of a drag contest that has several very funny moments along with some poignant ones. She also has sections on other relevant issues, such as voice feminization and outcome research. Debasish Basu Professor of Psychiatry, Drug De-addiction & Treatment Centre, Department of Psychiatry, Postgraduate Institute of Medical Education & Research, Chandigarh-160012, India. No part of this publication may be reproduced, s to red in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, pho to copying, digital, recording or otherwise, without the prior permission of the publishers. Balhara | Kaustav Chakraborty Prabhat Chand | Anju Dhawan | Shubh Mohan Singh | B. Hospital, Kalyani West Bengal University of Health Sciences, West Bengal drkaustav2003@yahoo. Medical College and Associated Groups Hospitals, Bikaner (Rajasthan) shrigopalgoyal@gmail. This is a rich and updated source of knowledge and skills, comprehensive in its width as well as depth of coverage. However, a need was felt to produce an evidence-based synopsis of the previous exhaustive reference book, targeted directly for the practitioners and students, for an easy checking and implementation. Despite the lack of rigorous evidence in some of these areas, the eminent authors of this book have done their best by highlighting the emergent gravity of the problems, collating the updated evidence to the extent possible, and making recommendations for practice concordant with the current state of knowledge and expertise. Drug addiction is an important psychosocial problem from time immemorial and is found amongst all cultures and civilizations across the world throughout his to ry. Drug addiction causes immense human distress and unfortunately there is no part of the world that is free from it. Millions of people all over the world are leading very miserable and pathetic lives. The drug abuse is a complex phenomenon with involvement of social, cultural, biological, geographical, his to rical and economic aspects. All of us know that there are innumerable varieties of drugs which are abused but most commonly used include alcohol, nicotine, cannabis, opioids, inhalants, and benzodiazepines. Newer psychoactive substances have been emerging on the Indian scene, some of them old but used more often in India lately (like cocaine), and others are so new that they are not even mentioned in the legal statu to ry schedules of controlled drugs. Patients with co occurring psychiatric disorders and drug addictions are seen and recognized more frequently. It is difficult to treat these conditions, firstly because these are newer entities and challenges in the Indian scenario and secondly because strong evidence base is often lacking. Indian Psychiatric Society is happy to involve in bringing out the latest developments in the field of addictions and I am sure the handbook will be very useful to experienced clinicians, young postgraduates and serious researchers. Of course such a dream would not have been reality but for the support extended by Dr. In addition, the composition of our continuing medical education will continue to change, with increasing numbers and shares of the population coming from communities of color. In this publication we use experimental clinical projection techniques to capture the impact of these changes on the size and ethnic composition of medical education to the members of each state, each zone, and nationally the Indian Psychiatric Society as a whole. First and foremost among them were authors who played critical roles at several steps along the way to publication. Debasish Basu who designed and produced the layout and graphics; who edited the text and helped proof the data; who built the interactive to ol providing readers with cus to mizable data and graphics for our Society; and we also like to design in the web environment for the online version of the publication. We would also like to thank those individuals who gave of their time and expertise in serving on the technicalities over the past few months. Finally, our thanks go to all the senior members for their generous support of the preparation, publication, and dissemination of this edition. Rao, and grateful to all Council Members for helping and cooperating us to run the Publication Committee at ease. It was a comprehensive book running in to 531 pages, with a masterly compendium of references and updated knowledge crystallized in to practical recommendations. It synthesized all the practice-relevant information necessary for the assessment and management of common substance use disorders and dual diagnosis. They have provided the clinicians with updated and evidence-based guidelines for assessment and management of substance use disorders, and others with a comprehensive compendium of updated knowledge that can be a rich resource for academic purposes of teaching, learning, and research. Four broad changes have been noted in the landscape of addictive disorders in India of late. They co-opted additional contribu to rs, not below the rank of a Senior Resident in psychiatry and working in the area of addictive disorders. In the process of development, we were guided by: (a) an extensive review of the relevant literature, including Indian data wherever available in published and retrievable form; (b) pre-existing recent guidelines in this area; (c) an awareness of the local needs and priorities whenever applicable. Thus, these chapters have been artificially carved out more out of practical necessities than for any basic underlying principles, except for the fact that these do cover the newer and emerging substances of use and their patterns of use in India. This has been covered in the next chapter in this book keeping in view its rising importance both in the popular media as well in the clinical and scientific circles. One chapter in this Section focuses on dual diagnosis psychotic disorders while the other focuses on non-psychotic disorders. These summary points and recommendations come with the grading of evidence and strength as mentioned in the Appendix of this chapter. Each chapter is subdivided in to several sections and sub-sections, which are numbered hierarchically in a numerical-point scheme (1, 1. Special attention has been paid to locate and highlight Indian studies and the applicability of the recommendations to the Indian situation. Certain special populations or situations have also been mentioned at the end of each chapter if available. Finally, along with pharmacological therapies, a conscious emphasis has been placed on non pharmacological (psychosocial, cognitive and behavioural) interventions as well, to the extent possible. They should benefit from the Executive Summary and Key Recommendations to be applied in their clinical practice. Whoever is further interested can look up the relevant literature cited in the text as and when needed. The secondary, but very important, audiences include, among others, medical teachers, postgraduate students, and researchers. We had to necessarily prioritize the content and coverage of the areas, and, in this process, some sections might have been missed. Another important limitation has to be kept in mind while interpreting the recommendations made in this book. Perhaps the situation may change by the time a later edition of this book is published. This statement does not reduce the value of this book but rather puts in proper perspective. Committee to advise the Public Health Service on Clinical Practice Guidelines, Institute of Medicine. The target users of the guideline the primary target users of these guidelines are practicing clinicians (especially psychiatrists but also non-psychiatric medical doc to rs and even non-medical professionals working in the area of addictions). The secondary, but very important, target users include medical teachers, postgraduate students, researchers and policy makers at various levels. The methods for formulating the this guideline is based on the synthesis and recommendations interpretation of available evidence obtained from studies across the world, especially in light of the Indian context, rating them on strength of evidence and combining this strength with the perceived importance and relevance in the Indian context to finally arrive at specific key recommendations as well as identifying current areas of uncertainty where applicable. The health benefits, side effects, and risks Yes have been considered in formulating the recommendations There is an explicit link between the Yes. Further, it has been clearly pointed out recommendations and the supporting where no specific recommendations can be evidence made at this time because of lack of supporting evidence of acceptable quality. Rather, major principles are recommended, which have to be applied along with clinical judgment in individual circumstances. The guideline provides advice and/or to ols on Yes, usually but not in very instance. The guideline describes facilita to rs and this issue has not been specifically addressed barriers to its application. An edi to rial close on the heels of this proclamation in the Lancet, cautioned that the over-medicalisation of addiction could have its downsides. Whatever the position, there is general agreement that being addicted is really like being in a maze, with confusing signals emitted both from within the individual (from biological predisposition and temperament) as well as from external fac to rs (family, 3 society and other aspects of the environment). An understanding of vulnerability, effect of substances on the body and mind, effective medical and psychosocial interventions, family support and follow-up support are all important for restitution and recovery. Who can better balance the science and art of addiction management than the psychiatrist! We saw persons with alcohol dependence and treated them with disulfiram and psycho-social interventions. We saw nicotine dependence, but did precious little except giving half-hearted advice to quit smoking. In fact, change has been the only constant in the area of addiction and its management. We are increasingly encountering sedative/hypnotic dependence, 5 particularly benzodiazepine dependence in clinical practice. Many young people are brought to treatment settings with inhalant misuse and dependence. The use of ketamine has been reported 6 nearly two decades ago and continues to be prevalent. We have learnt that licit drugs like nicotine and alcohol are associated with greater public health problems in comparison to illicit drugs whose supply is more strongly controlled. There is now a national to bacco control programme and to bacco cessation clinics and treatments are becoming more readily available in hospitals and practice settings. The scenario has moved beyond chemical addictions to various kinds of behavioural addictions. Gender and substance use is another area that is garnering greater attention, with more women being brought for the treatment of addiction, narrowing gender ratios, all underscoring the need to develop gender-sensitive treatment 11 approaches. We are recognising the need to look at addiction on a developmental continuum, 12 from the foetal effects of maternal substance use, to the growing problem of 13 substance use among the elderly. Cases of substance use are often complex to manage with both physical and psychiatric co-morbidities. The successful management of addiction includes not just the management of craving and relapse, but the effective management of co-morbidities. Therapeutic nihilism is still very prevalent and many psychiatrists are hesitant, if not loath to treat persons with addiction. A large part of this nihilism stems from a lack of skills as to how to approach such persons and lack of a collaborative approach with the patient. Addiction is recognised as a chronic, relapsing condition, with outcome rates 14 similar to other chronic diseases and planned follow-up and aftercare yields 15 better treatment retention and outcome.

The author argued that the following fac to rs must be evaluated when examining the extent of the situation: clinical diagnosis and abuse his to ry symptoms breast cancer buy 100 mg topamax overnight delivery, quality of treatment and response to treatment medicine hat lodge generic topamax 200 mg on line, aftercare program treatments cheap topamax 100 mg free shipping, availability of supervision and ministry not involving minors treatment jellyfish sting discount topamax 200 mg with amex, a considered waiting period treatment nail fungus buy cheap topamax online, and various other pas to ral considerations medicine images 200 mg topamax mastercard. In discussing suicide amongst priests, Rossetti asserted that the most difficult time is right after the perpetra to r has been confronted because they become overwhelmed. It is at this point that they must be supported and interventions must be provided. While the majority of priests do not commit suicide when confronted with allegations of abuse, this may be due in part to their faith. The last two chapters of the book included a discussion of suggested reforms in addressing the issue of cleric abuse. Bless me father for I have sinned: Perspectives on sexual abuse committed by Roman Catholic priests (pp. Sipe posits four problems that hinder the development of a program of prevention of sexual abuse in the Church. The first problem was the lack of screening methods to eliminate sex offenders from entering the clergy. The problem with this is that while some individuals may have a his to ry of offending prior to joining the seminary, many begin acting out once they have entered the institution. Third, certain elements of Church doctrine facilitated the creation of a pro-offending environment. Finally, the clergy was lacking in professional ethical standards regarding sexuality. This article argued that state laws which mandate the reporting of child abuse should be used as a to ol in clergy sexual abuse cases in order to s to p Church officials from denying the incidents. The issue of celibacy as a cause of sexual abuse is discussed in conjunction with the theory that those entering the seminary are already underdeveloped. If implemented, there would be no conflict with the First Amendment because as set forth in Forest Hills Early Learning Ctr. In regards to the Church, a reasonable belief that the child had been molested may be sufficient grounds to report the incident. Under the Child Abuse Prevention and Treatment Act, the reporters of the abuse are allowed immunity whereas failure to alert the authorities may result in criminal procedures. While one may potentially sue the Catholic Church concerning their failure to report the abuse, the doctrine of charitable immunity forbids lawsuits against charities (this also includes Churches). It informed the clergy of the responsibility to report, myths concerning domestic violence/sexual abuse, and the consequences of failure to report these issues. The author recommended that if there is a child in the parish who is suspected of being a victim of abuse, the parishioner should try to develop a rapport with the child and assess the situation before reporting it. The article also contains a discussion concerning the affect of sexual abuse on the victim as well as the process involved in removing the child from the home. It is stressed that as long as one makes a report in good faith the person will be protected from civil litigation. While the 1995 article outlined the various reasons why the courts have been unwilling to institute a complaint on the basis of clergy malpractice, the authors argued that the current trend appears to be to award on the basis of a breach of fiduciary duty. However, courts have been willing to evaluate the secular nature of a situation and award on the basis of professional malpractice, as was the finding in the present case. Even though it is stated that the relationship between cleric and parishioner is not a fiduciary one, much is involved in proving that it is. The authors contend that in order to establish the presence of a fiduciary relationship it has to be illustrated that the individual is acting in a manner that would allow them to gain influence over the person and gain their trust. Based upon the 1995 research conducted by the authors, it was concluded that while there is no complaint of clergy malpractice for fear of implicating the First Amendment, the complaint of breach of fiduciary duty may prove successful in prosecuting the clergy. In the present case, the New Jersey Supreme Court also viewed the breach of fiduciary duty was a more appropriate complaint than clergy malpractice. This article reviewed various cases and examined the justifications given by the courts in not expanding malpractice theory to wards clergy counselors who sexually abuse their clients. The allegation of clergy malpractice is problematic in legal proceedings due to the lack of precedents in this area. The courts also argue that a clergy malpractice to rt would in fact be redundant since sexual misconduct with a patient already violates the law. Courts have also cited a conflict with the First Amendment and the mishandling of transference as reasons why clergy malpractice should not be pursued. Many of these cases also claimed intentional infliction of emotional distress, which is problematic to establish and prove intent. Fraud is sometimes claimed against sexually abusive clergy but the courts are reluctant to shy away from the traditional definition of this to rt, which involves commercial transactions. Vicarious liability is another frequent claim made against the Church, but it was often rejected by lower courts because no complaint was left after granting a motion for 136 summary judgment in favor of the individual judgment. The authors suggested specific legal means of prosecuting sexually abusive clergy counselors that do not implicate the First Amendment. This article sought to place the issue of clergy sexual misconduct in a framework, which equated the exploitation to that of father/daughter incest. Blanchard has isolated several variables, which are similar to both situations and include the issues of power, trust, authority, intellectual and educational differences, idealization, and vulnerability. The article provided a brief discussion about how social attitudes influence the treatment of the cleric and provides an outline for an intervention strategy. This article presented a review of the his to rical precedents to the problem of sexual abuse of children by clergy as well as the impact of clericalism on the psychological and emotional development of the victims. In combating these claims, the Church has minimized the extent of the abuse by first denying its existence. During this crisis, Doyle discussed the various claims that the Church made in order to deal with the problem of sexual abuse. First, they claimed to not have unders to od the nature of child sexual abuse until recently when it was no longer regarded as a moral lapse made right through penance. This came in to conflict with Church Canon, which to ok steps to ensure the moral and spiritual protection of the congregation in situations that include the solicitation for sexual favors by priests hearing confession and sexual the abuse of minors (Code of Canon Law, 1917, 1983). Doyle examined Church doctrine dating back to the middle ages in which the issue of sexual misconduct was first brought to light. In his citation of Body of Canon Law, the author points out that in the section concerning penance (De Poenitentia), Gratian asserts that clerics who engage in sexual abuse should be subjected to the same punishment as lay people and should be excommunicated from the Church. Pope Pius V issued Horrendum, which stated that priests who abuse are deprived of all offices, benefits, and privileges. These clerics would also be degraded, and turned over to a Church tribunal for further punishment. The unpublished work by Baars & Terruwe (1971) revealed that 20-25% of the priests had serious psychiatric difficulties while 60-70% suffered from emotional immaturity. They concluded that some of the priests experienced psychological disturbances that developed in childhood while others developed difficulties while in the seminary. These results are consistent with the findings of Kennedy (1972), which concluded that 6% of priests were psychologically and emotionally developed, 29% were still developing, 57% were underdeveloped, and 8% were maldeveloped. Those who were underdeveloped were more comfortable with teenagers, had few friends their own age, and used intellectualization as a coping device. Despite these studies, sexual abuse and dysfunction were still viewed as a sin having resulted from social 137 disorganization and moral decay. Doyle contends that the official Church has refused to acknowledge the structure of the Catholic Church as a cause of sexual abuse. Doyle cited speeches from the pope at various gatherings (an address to the Irish Bishops 1999, World Youth Day, 1993) that fail to acknowledge the responsibility of the Church. As a result, a decree from the Congregation for the Doctrine of the Faith outlined a new and secret process for investigating clergy abuse. Gilbert Gauthe in Louisiana, claims of sexual abuse were handled by the Bishop in private. Doyle also discussed the different meanings of Church and how it shaped the response to wards victims of sexual abuse. By shifting focus and painting the Church as the victim, it served to minimize and abuse the victim further. A discussion of clericalism is included in order to help the reader understand its impact on the victim. The victim is susceptible to clergy abuse because along with having authority by way of being older, he is a familiar authority figure. Part of the seduction process involves a secret and special relationship that traps the victim. The author discussed the Myth of Complicity, which is where the victim is somehow led to believe that the abuse is normal behavior and not a violation. The fact that the abuser is a trusted person as well as the extreme reaction of the community also affects the trauma bond. The authors asserted their concern over the use of terminology and clinical data cited by Rossetti. The failure to distinguish the types of child molesters and the neglectful attention paid to the published data raises concerns. One particular criticism concerns the recidivism data for Saint Luke Institute, in which Rossetti neglected to acknowledge that child molesters lie, minimize, and dis to rt the truth. The authors also raised the question of the lack of credible data concerning the characteristics of clergy offenders. The authors concluded that it is to o early in the stages of research and treatment to assert that any of these findings are conclusive. Nineteen percent of those surveyed admitted to having extramarital affairs and 15% admitted that they had sought counseling for this reason. Fifty-five percent of the pas to rs said they had no close friends or family members with which they could discuss their problems. This article argued that the Church does not know how to reach out to victims of sexual abuse within the parish. Educating members of the Church concerning the signs of sexual abuse may make it less challenging to help these victims. The author also called for pas to rs to receive training in counseling skills so that they can better comfort their parishioners. The Church community is also called upon to be supportive and patient with the victim. This article reviewed the literature pertaining to clergy offenders and the his to ry of molestation in the Catholic Church through examination of various Church documents. Isley asserted that the problem of sexual abuse in the Church has been present for years and that contrary to the claims of the Church, it is not a recent phenomenon. In the Middle Ages the practice of child oblation was instituted by the Benedictine Order where parents would send their male children to the monastery until they were 15 years old. While Church treatise still condemned sexual misconduct, the victim and the abusive monk were both subjected to penance. This was publicly condemned in the eleventh century document Book of Gomorrah written by Fr. The Church has claimed that in light of these accusations they have been unfairly portrayed in the media and that they were lacking in knowledge concerning sex offender recidivism. Isley pointed out that a claim of ignorance concerning sex offender risk fac to rs and recidivism rates is unwarranted because the field was ripe with literature concerning these issues at the height of the abuse scandal. As of 1990, two thousand cases were pending in the state courts, but the judicial system has been reluctant to prosecute such cases and they are often dismissed on procedural grounds. Despite public outcry, some Church officials such as Philip Jenkins claimed that the situation has been blown out of proportion and that the Church is in fact the victim of various interests groups with private agendas. The studies that are available suffer from methodological problems and must be interpreted with caution.

Diseases

Once a pattern of repetitive and intense use develops medications with sulfa buy topamax online from canada, individuals with alcohol use disorder may devote substantial periods of time to obtaining and consuming alcoholic beverages symptoms 38 weeks pregnant buy topamax 100 mg. Craving for alcohol is indicated by a strong desire to drink that makes it difficult to think of anything else and that often results in the onset of drinking symptoms schizophrenia discount topamax on line. Associated Features Supporting Diagnosis Alcohol use disorder is often associated with problems similar to those associated with other substances medicine wheel images order generic topamax line. Alcohol may be used to alleviate the unwanted effects of these other substances or to substitute for them when they are not available medicine misuse definition buy cheap topamax on-line. Symp to ms of conduct problems symptoms after hysterectomy order topamax without a prescription, depression, anxiety, and insomnia frequently accompany heavy drinking and sometimes precede it. Gastrointestinal effects include gastritis, s to mach or duodenal ulcers, and, in about 15% of individuals who use alcohol heavily, liver cirrhosis and/or pancreatitis. There is also an increased rate of cancer of the esophagus, s to mach, and other parts of the gastrointestinal tract. These fac to rs, along with marked increases in levels of triglycerides and low-density lipoprotein cholesterol, contribute to an elevated risk of heart disease. Peripheral neuropathy may be evidenced by muscular weakness, paresthesias, and decreased peripheral sensation. These effects are related to the direct effects of alcohol or of trauma and to vitamin deficiencies (particularly of the B vitamins, including thiamine). In the United States, the 12-month prevalence of alcohol use disorder is estimated to be 4. Twelve-month prevalence of alcohol use disorder among adults decreases in middle age, being greatest among individuals 18 to 29-years-old (16. In contrast, among adults, the 12-month prevalence of alcohol use disorder is clearly greater among Native Americans and Alaska Natives (12. Development and Course the first episode of alcohol in to xication is likely to occur during the mid-teens. Alcohol related problems that do not meet full criteria for a use disorder or isolated problems may occur prior to age 20years, but the age at onset of an alcohol use disorder with two or more of the criteria clustered to gether peaks in the late teens or early to mid 20s. The first evidence of withdrawal is not likely to appear until after many other aspects of an alcohol use disorder have developed. Alcohol use disorder has a variable course that is characterized by periods of remission and relapse. A decision to s to p drinking, often in response to a crisis, is likely to be followed by a period of weeks or more of abstinence, which is often followed by limited periods of controlled or nonproblematic drinking. However, once alcohol intake resumes, it is highly likely that consumption will rapidly escalate and that severe problems will once again develop. Among adolescents, conduct disorder and repeated antisocial behavior often co-occur with alcohol and w^ith other substance-related disorders. These changes can cause older people to develop more severe in to xication and subsequent problems at lower levels of consumption. Alcohol-related problems in older people are also especially likely to be associated with other medical complications. Alcohol use disorder runs in families, with 40%-60% of the variance of risk explained by genetic influences. The rate of this condition is three to four times higher in close relatives of individuals with alcohol use disorder, with values highest for individuals with a greater number of affected relatives, closer genetic relationships to the affected person, and higher severity of the alcohol-related problems in those relatives. A significantly higher rate of alcohol use disorders exists in the monozygotic twin than in the dizygotic twin of an individual with the condition. A three to fourfold increase in risk has been observed in children of individuals with alcohol use disorder, even when these children were given up for adoption at birth and raised by adoptive parents who did not have the disorder. Recent advances in our understanding of genes that operate through intermediate characteristics (or phenotypes) to affect the risk of alcohol use disorder can help to identify individuals who might be at particularly low or high risk for alcohol use disorder. Among the low-risk phenotypes are the acute alcohol-related skin flush (seen most prominently in Asians). In general, high levels of impulsivity are associated with an earlier onset and more severe alcohol use disorder. In the United States, 80% of adults (age 18 years and older) have consumed alcohol at some time in their lives, and 65% are current drinkers (last 12 months). When consuming alcohol, individuals with these gene variations can experience a flushed face and palpitations, reactions that can be so severe as to limit or preclude future alcohol consumption and diminish the risk for alcohol use disorder. These gene variations are seen in as many as 40% of Japanese, Chinese, Korean, and related groups worldwide and are related to lower risks for the disorder. Despite small variations regarding individual criterion items, the diagnostic criteria perform equally well across most race/ethnicity groups. G ender-Related Diagnostic issues Males have higher rates of drinking and related disorders than females. However, because females generally weigh less than males, have more fat and less water in their bodies, and metabolize less alcohol in their esophagus and s to mach, they are likely to develop higher blood alcohol levels per drink than males. Diagnostic iViaricers Individuals whose heavier drinking places them at elevated risk for alcohol use disorder can be identified both through standardized questionnaires and by elevations in blood test results likely to be seen with regular heavier drinking. These measures do not establish a diagnosis of an alcohol-related disorder but can be useful in highlighting individuals for whom more information should be gathered. Other potential markers of heavy drinking that are more nonspecific for alcohol but can help the clinician think of the possible effects of alcohol include elevations in blood levels or lipids. Additional diagnostic markers relate to signs and symp to ms that reflect the consequences often associated with persistent heavy drinking. Other physical signs of heavy drinking include tremor, unsteady gait, insomnia, and erectile dysfunction. Functional Consequences of Alcohol Use Disorder the diagnostic features of alcohol use disorder highlight major areas of life functioning likely to be impaired. These include driving and operating machinery, school and work, interpersonal relationships and communication, and health. Rates are elevated in homeless individuals, perhaps reflecting a downward spiral in social and occupational functioning, although most individuals with alcohol use disorder continue to live with their families and function within their jobs. Severe alcohol use disorder, especially in individuals with antisocial personality disorder, is associated with the commission of criminal acts, including homicide. Unanticipated alcohol withdrawal in hospitalized individuals for whom a diagnosis of alcohol use disorder has been overlooked can add to the risks and costs of hospitalization and to time spent in the hospital. While most drinkers sometimes consume enough alcohol to feel in to xicated, only a minority (less than 20%) ever develop alcohol use disorder. Therefore, drinking, even daily, in low doses and occasional in to xication do not by themselves make this diagnosis. The signs and symp to ms of alcohol use disorder are similar to those seen in sedative, hypnotic, or anxiolytic use disorder. Alcohol use disorder, along with other substance use disorders, is seen in the majority of individuals with antisocial personality and preexisting conduct disorder. Comorbidity Bipolar disorders, schizophrenia, and antisocial personality disorder are associated with a markedly increased rate of alcohol use disorder, and several anxiety and depressive disorders may relate to alcohol use disorder as well. Severe, repeated alcohol in to xication may also suppress immune mechanisms and predispose individuals to infections and increase the risk for cancers. One (or more) of the following signs or symp to ms developing during, or shortly after, alcohol use: 1. The signs or symp to ms are not attributable to another medical condition and are not better explained by another mental disorder, including in to xication with another substance. Associated Features Supporting Diagnosis Alcohol in to xication is sometimes associated with amnesia for the events that occurred during the course of the in to xication ("blackouts"). This phenomenon may be related to the presence of a high blood alcohol level and, perhaps, to the rapidity with which this level is reached. During even mild alcohol in to xication, different symp to ms are likely to be observed at different time points. Evidence of mild in to xication with alcohol can be seen in most individuals after approximately two drinks (each standard drink is approximately 10-12 grams of ethanol and raises the blood alcohol concentration approximately 20mg/ dL). Early in the drinking period, when blood alcohol levels are rising, symp to ms often include talkativeness, a sensation of well-being, and a bright, expansive mood. The duration of in to xication depends on how much alcohol was consumed over what period of time. Signs and symp to ms of in to xication are likely to be more intense when the blood alcohol level is rising than when it is falling. There appears to be an increased rate of suicidal behavior, as well as of completed suicide, among persons in to xicated by alcohol.

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