Pharmacologic treatment of sex offenders with paraphilic disorder

The Effectiveness of Educational Interventions for Mental Health Professionals in Reducing Stigmatization Toward People with Pedophilia: A Meta-Analysis

Mental Health Professionals (MHP) often harbor strong negative attitudes toward people with a sexual attraction to children, hindering the provision of essential treatment. This reluctance stems from pervasive stigmatization, contributing to mental health issues among people with pedophilia and exacerbating risk factors associated with child sexual abuse. Limited research and small sample sizes in prior studies underscore the need to conduct a meta-analysis, examining the effectiveness of educational interventions as a tool for reducing stigmatization toward people with pedophilia in MHP. Eight studies meeting specific inclusion criteria were identified through a literature search. These criteria included (a) peer-reviewed empirical, (b) quantitative data, (c) a focus on attitudes toward people with pedophilia, (d) a sample of MHP that might come in contact with people with pedophilia (or the general public), (e) the intervention is educational, (f) the educational intervention is based on people with pedophilia, (g) pre- and post-test data, and (h) be written in English. Comparable variables within these studies encompassed dangerousness, social distance, intentionality, deviance, punitiveness, anger, sympathy, and motivation to treat. The intervention significantly improved perceptions of dangerousness (d = 0.65), social distance (d = 0.33), intentionality (d = 0.38), and punitiveness (d = 0.77). However, it showed non-significant effects on deviance (d = 0.22), anger (d = -0.22), sympathy (d = -0.12), and motivation to treat (d = -0.04). These findings indicate that educational interventions can reduce MHP stigmatization toward people with pedophilia, especially with contact-based and sufficiently prolonged interventions.

Development of a risk assessment tool for Japanese sex offenders: The Japanese Static-99

In Japan, sexual offending, especially paraphilic sexual offending, has become a major problem, and approximately 3000 people are arrested for frotteuristic and voyeuristic behavior each year. Considering the repetitive nature of such behaviors, determining the recidivism risk is imperative. Globally, Static-99 is one of the most widely used actuarial risk assessment tools to predict recidivism among sex offenders. However, sexual offending is largely influenced by social and cultural backgrounds, and whether risk factors identified in the West are applicable to other countries is unknown. Therefore, we developed a Japanese version of the Static-99 and examined its reliability and validity with 167 Japanese paraphilic sex offenders. The results showed good internal consistency (Cronbach's alpha coefficient = 0.88) and predictive accuracy (area under the curve = 0.76). The results indicate that the Japanese Static-99 can be used with Japanese sex offenders. Moreover, risk factors identified in the Western context are applicable to Japanese sex offenders despite the different nature and manifestations of their offending.

Portrait of an Exhibitionist

Exhibitionism has been viewed through many lenses, from the perspectives of sexual deviance, forensic psychiatry, psychopathology, psychological dynamics, feminism, behaviorism, and psychopharmacology. Starting from the description of one psychotherapy patient, the aim of this paper is to synthesize this disparate literature. The findings of the synthesis include an estimate of the lifetime male prevalence of exhibitionism, 2-4%, peaking in late adolescence. Insecure attachment, sexual abuse in childhood, substance abuse, and sexual dysfunction are acknowledged risk factors. Motives behind the act of genital exposure remain obscure, constructed of both sexual and non-sexual impulses. The usual response of women victims is alarm and disgust. Successful treatment relies on a strong therapeutic alliance with specific psychological and psychopharmacological interventions - comparative effectiveness not yet determined. In conclusion, precedents for exhibitionism vary. The frequency of the behavior usually wanes with age and, while exhibitionists may pose a risk to others, they usually do not. There is, as yet, no gold standard treatment; the recommendation for therapists is to respond to individual facets of the patient's circumstances and history.

The Effects of Acute Transcranial Direct Current Stimulation on Attentional Bias in Pedophilic Disorder: A Preregistered Pilot Study

OBJECTIVES

Individuals with pedophilic disorder (PD) experience personal and interpersonal difficulties and are at risk of sexually offending against children. As such, innovative and empirically validated treatments are needed. Recent studies have indicated that men who have sexually offended against children (SOC) with PD display an automatic attention bias for child-related stimuli as well as reduced activity in the dorsolateral prefrontal cortex (dlPFC), a brain area involved in cognitive control, including control over sexual arousal. In this preregistered pilot study, we are the first to investigate whether acutely increasing prefrontal activity could reduce the putative pedophilic attention bias.

MATERIALS AND METHODS

We delivered a single 20-min session of active anodal versus sham transcranial direct current stimulation (tDCS) over the left dlPFC to 16 SOC with PD and 16 matched healthy controls, while they performed a task requiring controlled attention to computer-generated images of clothed and nude children and adults. We collected responses unobtrusively by recording eye movements.

RESULTS

Our results did not support the presence of the expected automatic attention bias across outcome measures. Nonetheless, we found a response facilitation with child targets in patients and, unexpectedly, in controls, likely due to unwanted salience effects. Active versus sham tDCS reduced this bias across groups, as indicated by a significant group*condition interaction (p = 0.04). However, no attentional bias and no tDCS effects on attentional responses to child and adult images emerged following tDCS.

CONCLUSIONS

These results suggest enhanced cognitive control in response to salient stimuli during active tDCS. Thus, to assist future studies on neuromodulation in PD, we provide suggestions for design improvement.

Psychosexual history-taking in the 21st century: new terminology, new technology and new risks

Sexual and relationships difficulties are not uncommon among psychiatric patients. A presenting complaint of anxiety or depression may relate to an underlying sexual or relationship difficulty; commonly used psychotropic medications cause sexual side-effects that can have a significant impact quality of life, relationship maintenance and treatment adherence; patients may exhibit unusual or excessive sexual behaviours when acutely unwell, including risky use of apps to meet sexual partners and accessing online pornography in unsafe ways; patients may have used technology such as the internet to harm others or they may be victims of such harm; the internet and social media might even be influencing sexual expression, for example gender identity. Therefore, psychosexual history-taking remains a key competency for psychiatrists. They must also understand the new language used to describe sexuality, sexual behaviours and the use of social media, apps and so on to form relationships. This article outlines the key areas to consider in carrying out a structured psychosexual assessment. It also gives an overview of current sexual terminology, observed influences of the internet on sexuality and sexual behaviour, and its implications for mental health and potential sexual offending.

LEARNING OBJECTIVES

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DECLARATION OF INTEREST

None.

The pharmacologic treatment of problematic sexual interests, paraphilic disorders, and sexual preoccupation in adult men who have committed a sexual offence

This paper provides an international perspective on the use of medications to treat problematic sexual interests, paraphilic disorders, and sexual preoccupation in men who have committed a sexual offence. Experts from Canada, the Czech Republic (CR), Russia, the United Kingdom, and the United States met in Prague, CR in May 2017 to review and compare their treatment approaches. This report is a summary of their discussions, including empirical data from CR and Russia which have not previously been published in the English language. All participants agreed that continuing international collaboration would be very useful for the development of ethical international prescribing guidelines, as well as pooling data from studies on the efficacy and utility of pharmacological and other biological treatments for people who have committed sexual offences.

Gonadotrophin-releasing hormone agonist treatment for sexual offenders: A systematic review

BACKGROUND

Sexual offending is a significant international issue causing long-term consequences for victims, perpetrators and society.

AIMS

The purpose of this study was to review the existing research data assessing the efficacy of gonadotrophin-releasing hormone agonists for treating adult, male, sexual offenders.

METHOD

The method of this review involved the examination of studies involving participants prescribed at least one month of a gonadotrophin-releasing hormone agonist for the purposes of reducing sexual drive related to offending. The primary outcome measures were recidivism rates and sexual functioning. Secondary outcome measures included assessment of side effects and effects on interpersonal/psychiatric functioning. Studies in the English language that were dated 1969-2015 were included.

RESULTS

Twelve eligible studies (323 participants) were identified. A reduction in a variety of measures of sexual functioning and/or risk was found in all studies. Robust recidivism data was limited. Medication was rarely described as ineffectual. All studies reported side effects. Reduction in bone density and potential long-term reduction in fertility in some subjects were issues of concern.

CONCLUSION

Whilst identified studies showed promising results with respect to sexual functioning, challenges in performing randomised control trials in this subject group meant that included studies were methodologically limited. This review recommends that future research must be performed before the effectiveness and tolerability of gonadotrophin-releasing hormone agonists in this population can be confirmed.

The efficacy, safety and ethics of the use of testosterone-suppressing agents in the management of sex offending

PURPOSE OF REVIEW

The use of endocrine medications to reduce sexual offending recidivism is established and may involve clinicians from diverse specialities. The present review aims to outline relevant background information and note a Medical Ethics framework upon which to facilitate decision-making.

RECENT FINDINGS

There have been several systematic reviews in recent years. A number of problems with research in the area of the medical treatment of sex offenders have been highlighted. There remains scope for improvement in the research to answer a number of relevant clinical issues. Nonetheless, some very useful indicators of relevance to clinical practice have emerged.

SUMMARY

The use of medication to manage the risk of sex offending in males is appropriate under the right circumstances. These include, for example, hypersexuality with sexual deviance and psychological-treatment interfering sexual preoccupation.

The Biological Treatment of Paraphilic Disorders: an Updated Review

Paraphilic disorders are characterized by atypical sexual interests, fantasies, and behaviors that are subjectively distressing to patients or pose a risk of harm to others. By their very nature, some paraphilic disorders may predispose an individual to commit sexual offenses. The biological treatment of paraphilic disorders, then, is of paramount importance for psychiatry and society at large. Three categories of pharmacologic agents commonly used to treat paraphilic disorders are selective serotonin reuptake inhibitors, synthetic steroidal analogs, and gonadotropin-releasing hormone analogs. Each medication uses a different mechanism of action and has different effects on the physiological and psychological features of paraphilic disorders. In general, these medications have limited high-quality research to support their use. Despite this, some authors have proposed treatment algorithms for individuals with paraphilic disorders of varying severity. These guidelines offer clinicians potentially useful, rational approaches to assessing treatment need in individuals with paraphilic disorders. Recent neuroimaging research suggests that functional magnetic resonance imaging may offer further promise in effectively assessing paraphilic disorders to help direct treatment options.

The World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the treatment of adolescent sexual offenders with paraphilic disorders

The primary aim of these guidelines was to evaluate the role of pharmacological agents in the treatment of adolescents with paraphilic disorders who are also sexual offenders or at-risk of sexual offending. Psychotherapeutic and psychosocial treatments were also reviewed. Adolescents with paraphilic disorders specifically present a different therapeutic challenge as compared to adults. In part, the challenge relates to adolescents being in various stages of puberty and development, which may limit the use of certain pharmacological agents due to their potential side effects. In addition, most of the published treatment programmes have used cognitive behavioural interventions, family therapies and psychoeducational interventions. Psychological treatment is predicated in adolescents on the notion that sexually deviant behaviour can be controlled by the offender, and that more adaptive behaviours can be learned. The main purposes of these guidelines are to improve the quality of care and to aid physicians in their clinical decisions. These guidelines brought together different expert views and involved an extensive literature research. Each treatment recommendation was evaluated and discussed with respect to the strength of evidence for efficacy, safety, tolerability and feasibility. An algorithm is proposed for the treatment of paraphilic disorders in adolescent sexual offenders or those who are at risk.

Pharmacologic treatment of paraphilias

The treatment of paraphilias remains a challenge in the mental health field. Combined pharmacologic and psychotherapeutic treatment is associated with better efficacy. The gold standard treatment of severe paraphilias in adult males is antiandrogen treatment with cognitive behavioral therapy. Selective serotonin reuptake inhibitors have been used in mild types of paraphilia and in cases of sexual compulsions and juvenile paraphilias. Antiandrogen treatments seem to be effective in severe paraphilic subjects committing sexual offenses. In particular, gonadotropin-releasing hormone analogs have shown high efficacy working in a similar way to physical castration but being reversible at any time. Treatment recommendations, side effects, and contraindications are discussed.