Gonadotrophin hormone releasing hormone agonist in cases of severe paraphilia: a lifetime treatment?

Puberty Blocker and Aging Impact on Testicular Cell States and Function

Spermatogonial stem cell (SSC) acquisition of meiotogenetic state during puberty to produce genetically diverse gametes is blocked by drugs collectively referred as 'puberty blocker' (PB). Investigating the impact of PB on juvenile SSC state and function is challenging due to limited tissue access and clinical data. Herein, we report largest clinically annotated juvenile testicular biorepository with all children with gender dysphoria on chronic PB treatment highlighting shift in pediatric patient demography in US. At the tissue level, we report mild-to-severe sex gland atrophy in PB treated children. We developed most extensive integrated single-cell RNA dataset to date (>100K single cells; 25 patients), merging both public and novel (52 month PB-treated) datasets, alongside innovative computational approach tailed for germ cells and evaluated the impact of PB and aging on SSC. We report novel constitutional ranges for each testicular cell type across the entire age spectrum, distinct effects of treatments on prepubertal vs adult SSC, presence of spermatogenic epithelial cells exhibiting post-meiotic-state, irrespective of age, puberty status, or PB treatment. Further, we defined distinct effects of PB and aging on testicular cell lineage composition, and SSC meiotogenetic state and function. Using single cell data from prepubertal and young adult, we were able to accurately predict sexual maturity based both on overall cell type proportions, as well as on gene expression patterns within each major cell type. Applying these models to a PB-treated patient that they appeared pre-pubertal across the entire tissue. This combined with the noted gland atrophy and abnormalities from the histology data raise a potential concern regarding the complete 'reversibility' and reproductive fitness of SSC. The biorepository, data, and research approach presented in this study provide unique opportunity to explore the impact of PB on testicular reproductive health.

Risk Factors for Sexual Offenses Committed by Men With or Without a Low IQ: An Exploratory Study

Although risk factors associated with offending and recidivism are relatively well-established for mainstream sexual offenses, much less is known about men with a low IQ who have sexually offended (MIQSO), let alone those with forensic involvement. In this exploratory study, 137 convicted for the commission of at least one sexual offense and found not criminally responsible because a mental disorder were recruited in a maximum-security hospital. They were all assessed with the SORAG (static risk factors) and the RSVP (dynamic risk factors). Compared with MIQSO (N = 76), men with an average or higher IQ who have sexually offended (MSO, N = 61) obtained significantly higher scores on static factors related with general delinquency (histories of alcohol abuse, non-violent criminality, violent criminality, and sexual offense) and dynamic factors related with sexual delinquency, paraphilia, and recidivism (chronicity, psychological coercion, escalation, sexual deviance, and substance abuse). In contrast, MIQSO obtained significantly higher scores on major mental illness, problems with planning and problems with self-awareness. Logistic regressions revealed that both the SORAG and RSVP were useful to predict group membership. It is concluded that risk factors related with general and sexual delinquency better describe offenses committed by MSO, whereas risk factors related with mental disorder, lack of insight and contextual impulsivity better describe offenses committed by MIQSO.

The impact of androgen deprivation therapy on bone mineral density in men treated for paraphilic disorder: A retrospective cohort study

BACKGROUND

Guidelines suggest treating men with paraphilic disorder with androgen-deprivation therapy (ADT). However, little evidence is available about the long-term impact on bone loss and how to manage this adverse event.

OBJECTIVES

The aim of this study is to assess the impact of ADT on bone mineral density (BMD) in men treated for paraphilic disorder with the androgen receptor blocker cyproterone acetate (CPA) and/or GnRH agonist triptoreline (GnRHa) and to evaluate the effect of treatment with bisphosphonates.

METHODS

Baseline and follow-up dual-energy X-ray absorptiometry scan (DXA-scan) data (lumbar and femoral T-scores) were retrospectively extracted from electronic medical files of paraphilic men who received CPA and/or GnRHa.

RESULTS

A total of 53 patients with a mean age of 39.1 years (range 17.5-74.6) were included. Lumbar (-0.39 ± 0.17, Mean ± SEM, p = 0.046), femoral neck (-0.34 ± 0.09, p = 0.002) and total femur (-0.33 ± 0.12, p = 0.014) T-scores decreased significantly in the CPA-only group (n = 13) during a mean follow-up of 6.0 ± 5.3 years. In the GnRHa group (n = 29), T-scores at all sites decreased significantly over 6.6 ± 4.4 years (lumbar: -0.55 ± 0.12, p < 0.001, femoral neck: -0.53 ± 0.09, total femur: -0.44 ± 0.09, p < 0.001). In the group, who received bisphosphonates (n = 11), no significant T-score change was observed (lumbar: -0.25 ± 0.14, p = 0.106, femoral neck -0.15 ± 0.17, p = 0.402, total femur -0.25 ± 0.14, p = 0.106) during 5.0 ± 2.8 years of follow-up.

DISCUSSION AND CONCLUSION

Following a mean duration of 6 years of ADT, we observed a significant decline in BMD of approximately half a standard deviation in T-score at lumbar and femoral site. Although the number of patients who received bisphosphonates was limited, this treatment seems to have a positive stabilizing effect on bone density.

The World Federation of Societies of Biological Psychiatry (WFSBP) 2020 guidelines for the pharmacological treatment of paraphilic disorders

Objectives: The primary aim of these guidelines is to evaluate the role of pharmacological agents in the treatment and management of patients with paraphilic disorders, with a focus on the treatment of adult males. Because such treatments are not delivered in isolation, the role of specific psychotherapeutic interventions is also briefly covered. These guidelines are intended for use in clinical practice by clinicians who diagnose and treat patients, including sexual offenders, with paraphilic disorders. The aim of these guidelines is to bring together different views on the appropriate treatment of paraphilic disorders from experts representing different countries in order to aid physicians in clinical decisions and to improve the quality of care.Methods: An extensive literature search was conducted using the English-language-literature indexed on MEDLINE/PubMed (1990-2018 for SSRIs) (1969-2018 for hormonal treatments), supplemented by other sources, including published reviews.Results: Each treatment recommendation was evaluated and discussed with respect to the strength of evidence for its efficacy, safety, tolerability, and feasibility. The type of medication used depends on the severity of the paraphilic disorder and the respective risk of behaviour endangering others. GnRH analogue treatment constitutes the most relevant treatment for patients with severe paraphilic disorders.Conclusions: An algorithm is proposed with different levels of treatment for different categories of paraphilic disorders accompanied by different risk levels.

A Case of Paraphilia with Osteoporosis and Administered with Depot Leuprorelin

Paraphilia is a complex psychological and psychiatric disorder that has been difficult to treat. Leuprorelin has been used as one of the therapeutic methods for paraphilia. Leuprorelin administration could change insulin resistance and accelerate bone loss. The case study in this work was a 59-year-old man who visited a hospital with the chief complaints of frotteuristic behaviors in public places, a continuous increase in sexual desire, and sexual molestation behavior that started in 2007. We injected leuprorelin (3.6 mg) intramuscularly every month for this patient with paraphilia and comorbidities of osteoporosis and hyperthyroidism. The clinical global impression (CGI), Sex Addiction Screening Test (SAST), Wilson Sex Fantasy Questionnaire (WSFQ), physical examination, and laboratory tests were performed. After 12 months of leuprorelin injection for paraphilia, we found a significant improvement in abnormal sexual behavior/desire without aggravation of osteoporosis/hyperthyroidism. Gonadotrophin-Releasing Hormone (GnRH) analogs could be used as alternative or supplementary treatment methods for paraphilia with osteoporosis/hyperthyroidism.

Validation of the Change or Stop Testosterone-Lowering Medication (COSTLow) Scale Using the Delphi Method Among Clinical Experts

Guidelines for pharmacological treatment of patients with paraphilic disorders have been developed by a working group of the World Federation of Societies of Biological Psychiatry (Thibaut et al., 2010 ). With an increasing duration of experience and number of treated patients as well as aging patients, change of or withdrawal from testosterone-lowering medications (TLM) has become an important issue. The current study aimed to assess the quality of a structured professional judgment procedure that helps switching or discontinuing TLM in patients with paraphilic disorders. We used the Delphi method to estimate the quality of 10 factors originally proposed by the authors. A total of 30 experts participated in the first stage; 18 experts participated in the second stage. The experts' assessment resulted in an instrument of 15 factors that can be used to structure the process of changing or discontinuing TLM. These factors can be grouped into five broader categories: age and duration of treatment; therapeutic alliance; psychopathology and risk factors; motivation; and compliance and level of control. The developed COSTLow-R Scale provides an instrument that can be used to structure the process of changing or discontinuing TLM in patients with severe paraphilic disorders.

Therapeutic Effects of Leuprorelin (Leuprolide Acetate) in Sexual Offenders with Paraphilia

BACKGROUND

This study examined the clinical effects of leuprolide acetate in sexual offenders with paraphilic disorders evaluated by means of objective psychiatric assessment.

METHODS

The subjects of this study were seven sexual offenders who were being treated by means of an injection for sexual impulse control by a court order. They had been diagnosed with paraphilia by a psychiatrist based on the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) and had been put on probation by the Ministry of Justice between January 2016 and December 2016.

RESULTS

After twelve months, we observed significant improvement in symptoms, as decrease of abnormal sexual interest and activity, sexual fantasy, Clinical Global Impression-Severity (CGI-S), and Clinical Global Impression-Impulsivity (GCI-I). There were a mild feminization of the body shape, feelings of fatigue, and mild hot flushes. No other adverse effect was reported.

CONCLUSION

These results suggested that the clinical effects of leuprolide acetate in sexual offenders might be an effective treatment and safety strategy.

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 Development of In Vivo Measures to Assess the Impact of Sex-Drive Reducing Medications in an Offender with an Intellectual Disability

The ability to adequately evaluate medications in the treatment of paraphilias has been limited by reliance upon self-report as a measure of effectiveness over periods of time that may be too short to detect reoffending. One solution to this shortcoming is the development of valid, long-term, stable assessment measures. The purpose of this case study was to analyze the effects of Prozac and Provera on an array of behaviors germane to the successful treatment of paraphilias, including: (a) sexual arousal in the laboratory and natural environment, (b) sexual thoughts (deviant and nondeviant) accompanied by arousal in the natural environment, and (c) overt actions in the community associated with increased risk of reoffending over a 31-month period for an exhibitionist with an intellectual disability. Despite the ineffectiveness of the medications, the measures demonstrated long-term, differentiated significant clinical responding; further underscored the importance of assessing deviant sexual arousal and adherence to relapse-prevention procedures in the natural environment; and provided a new methodology to assess sexual preoccupations and sexual arousal. Use of these in vivo measures raises questions regarding their potential to improve the predictability of risk assessments, and serve as an aide in the analysis of whether a treatment procedure is effective for an individual.

A Systematic Review of Behavioral Health Interventions for Sex Offenders With Intellectual Disabilities

This article reviews evaluation studies of programs designed to treat sex offenders with intellectual and developmental disabilities (IDD) published in peer-reviewed journals between 1994 and 2014. The design of this study is mirrored after PRISMA (Preferred Reporting of Items for Systematic Reviews and Meta-Analyses) recommendations for conducting a systematic literature review. The study design, study setting, characteristics of participants, type of treatment, and intervention procedures comprise areas of focus for evaluating the implementation of treatment programs. Therapeutic outcomes include changes in attitudes consistent with sex offending, victim empathy, sexual knowledge, cognitive distortions, and problem sexual behaviors. Eighteen treatment evaluation studies were identified from the United States, the United Kingdom, Australia, and New Zealand. Cognitive-behavioral treatments were the most commonly delivered treatment modality to sex offenders with IDD. Other less common treatments were dialectical behavioral therapy, problem solving therapy, mindfulness, and relapse prevention. No randomized controlled trials were identified. The most common designs were multiple case studies and pre- and post-treatment assessments with no control and repeated measures follow-up. Small sample sizes, no control groups, and wide variation in treatment length and follow-up time complicate the qualitative synthesis of study findings. Short follow-up times introduce the potential for bias in conclusions surrounding treatment efficacy for many of the studies reviewed in this analysis. The overall quality of studies examining treatments for sex offenders with IDD is poor and requires further development before rendering firm conclusions about the effectiveness of interventions for this population.

A case of mental retardation with paraphilia treated with depot leuprorelin

Paraphilia is a psychiatric disease that has been difficult to cure. However, recently developed therapeutic methods hold promise. The patient was a 20-yr-old male with chief complaints of continuous masturbation, genital exposure, and aggressive behavior that started 2 yr ago. We administered leuprorelin 3.6 mg intramuscular injection per month, a depot gonadotrophin-releasing hormone analogue, to this patient who a severe mentally retardation with paraphilia. The clinical global impression (CGI)-severity, CGI-improvement and aberrant behavior checklist were performed. After one month, we observed significant improvement in symptoms, such as decreases of abnormal sexual behavior and sexual desire. The GnRH analogues are suggested to be used as an alternative or supplementary therapeutic method for sexual offenders after clinical studies.

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.

Pharmacologic treatment of sex offenders with paraphilic disorder

Sexual offending is both a social and a public health issue. Evidence demonstrates that a combination of pharmacological and psychotherapeutic approaches may reduce or even eliminate deviant sexual behavior in sex offenders with paraphilic disorders. In this article, we will review pharmacological treatment options for sex offenders with paraphilias. Both serotonin selective reuptake inhibitors (SSRIs) and antiandrogen treatments have been used with reported success in decreasing recidivism. SSRIs have been used in mild types of paraphilias and juvenile paraphilias. Antiandrogen treatments seem to be effective in severe sex offenders with paraphilic disorders in order to reduce victimization. Combined pharmacological and psychotherapeutic treatment is associated with better efficacy. Imaging studies may improve the knowledge of paraphilic disorders and the mechanisms of action of current treatments. In spite of existing evidence, there is a need for independent, large-scale and good quality studies assessing the long-term efficacy and tolerance of treatments.

Psychological interventions for adults who have sexually offended or are at risk of offending

BACKGROUND

Sexual offending is a legal construct that overlaps, but is not entirely congruent with, clinical constructs of disorders of sexual preference. Sexual offending is both a social and a public health issue. Victim surveys illustrate high incidence and prevalence levels, and it is commonly accepted that there is considerable hidden sexual victimisation. There are significant levels of psychiatric morbidity in survivors of sexual offences.Psychological interventions are generally based on behavioural or psychodynamic theories.Behavioural interventions fall into two main groups: those based on traditional classical conditioning and/or operant learning theory and those based on cognitive behavioural approaches. Approaches may overlap. Interventions associated with traditional classical and operant learning theory are referred to as behaviour modification or behaviour therapy, and focus explicitly on changing behaviour by administering a stimulus and measuring its effect on overt behaviour. Within sex offender treatment, examples include aversion therapy, covert sensitisation or olfactory conditioning. Cognitive behavioural therapies are intended to change internal processes - thoughts, beliefs, emotions, physiological arousal - alongside changing overt behaviour, such as social skills or coping behaviours. They may involve establishing links between offenders' thoughts, feelings and actions about offending behaviour; correction of offenders' misperceptions, irrational beliefs and reasoning biases associated with their offending; teaching offenders to monitor their own thoughts, feelings and behaviours associated with offending; and promoting alternative ways of coping with deviant sexual thoughts and desires.Psychodynamic interventions share a common root in psychoanalytic theory. This posits that sexual offending arises through an imbalance of the three components of mind: the id, the ego and the superego, with sexual offenders having temperamental imbalance of a powerful id (increased sexual impulses and libido) and a weak superego (a low level of moral probation), which are also impacted by early environment.This updates a previous Cochrane review but is based on a new protocol.

OBJECTIVES

To assess the effects of psychological interventions on those who have sexually offended or are at risk of offending.

SEARCH METHODS

In September 2010 we searched: CENTRAL, MEDLINE, Allied and Complementary Medicine (AMED), Applied Social Sciences Index and Abstracts (ASSIA), Biosis Previews, CINAHL, COPAC, Dissertation Abstracts, EMBASE, International Bibliography of the Social Sciences (IBSS), ISI Proceedings, Science Citation Index Expanded (SCI), Social Sciences Citation Index (SSCI), National Criminal Justice Reference Service Abstracts Database, PsycINFO, OpenSIGLE, Social Care Online, Sociological Abstracts, UK Clinical Research Network Portfolio Database and ZETOC. We contacted numerous experts in the field.

SELECTION CRITERIA

Randomised trials comparing psychological intervention with standard care or another psychological therapy given to adults treated in institutional or community settings for sexual behaviours that have resulted in conviction or caution for sexual offences, or who are seeking treatment voluntarily for behaviours classified as illegal.

DATA COLLECTION AND ANALYSIS

At least two authors, working independently, selected studies, extracted data and assessed the studies' risk of bias. We contacted study authors for additional information including details of methods and outcome data.

MAIN RESULTS

We included ten studies involving data from 944 adults, all male.Five trials involved primarily cognitive behavioural interventions (CBT) (n = 664). Of these, four compared CBT with no treatment or wait list control, and one compared CBT with standard care. Only one study collected data on the primary outcome. The largest study (n = 484) involved the most complex intervention versus no treatment. Long-term outcome data are reported for groups in which the mean years 'at risk' in the community are similar (8.3 years for treatment (n = 259) compared to 8.4 in the control group (n = 225)). There was no difference between these groups in terms of the risk of reoffending as measured by reconviction for sexual offences (risk ratio (RR) 1.10; 95% CI 0.78 to 1.56).Four trials (n = 70) compared one behavioural programme with an alternative behavioural programme or with wait list control. No meta-analysis was possible for this comparison. For two studies (both cross-over, n = 29) no disaggregated data were available. The remaining two behavioural studies compared imaginal desensitisation with either covert sensitisation or as part of adjunctive drug therapy (n = 20 and 21, respectively). In these two studies, results for the primary outcome (being 'charged with anomalous behaviour') were encouraging, with only one new charge for the treated groups over one year in the former study, and in the latter study, only one new charge (in the drug-only group) over two years.One study compared psychodynamic intervention with probation. Results for this study (n = 231) indicate a slight trend in favour of the control group (probation) over the intervention (group therapy) in terms of sexual offending as measured by rearrest (RR 1.87; 95% CI 0.78 to 4.47) at 10-year follow-up.Data for adverse events, 'sexually anomalous urges' and for secondary outcomes thought to be 'dynamic' risk factors for reoffending, including anger and cognitive distortions, were limited.

AUTHORS' CONCLUSIONS

The inescapable conclusion of this review is the need for further randomised controlled trials. While we recognise that randomisation is considered by some to be unethical or politically unacceptable (both of which are based on the faulty premise that the experimental treatment is superior to the control - this being the point of the trial to begin with), without such evidence, the area will fail to progress. Not only could this result in the continued use of ineffective (and potentially harmful) interventions, but it also means that society is lured into a false sense of security in the belief that once the individual has been treated, their risk of reoffending is reduced. Current available evidence does not support this belief. Future trials should concentrate on minimising risk of bias, maximising quality of reporting and including follow-up for a minimum of five years 'at risk' in the community.

WITHDRAWN: Managements for people with disorders of sexual preference and for convicted sexual offenders

This review has been withdrawn (Issue 9, 2012) as it is no longer current and is to be superseded by two new reviews.

The editorial group responsible for this previously published document have withdrawn it from publication.

Androgen deprivation therapy of self-identifying, help-seeking pedophiles in the Dunkelfeld

Androgen deprivation therapy (ADT) is considered an effective strategy in sexual offender treatment. However, the evidence base concerning its effects on sexual arousal control is limited. Past research has focused almost exclusively on men in forensic contexts. The present retrospective observational study provided data on ADT in a sample of self-identifying, help-seeking pedohebephilic men applying for a one-year group therapy program. Factors possibly influencing the readiness to take up or discontinue ADT were presented. Effects of a combination of ADT and group psychotherapy program on changes in paraphilic sexual behavior and associated psychological factors were examined. The proportion of men having taken up ADT was rather small (n=15). Greater awareness of potentially risky situations to commit child sexual offenses and self-rated uncontrollability of sexual urges were identified as characterizing men resorting to ADT. Additionally, these men were initially more open to include medical treatment. Examination of the effects of ADT and psychotherapy was limited to a sample of six men providing complete data sets. Descriptive data demonstrated a reduction of paraphilic sexual behaviors, an increase of risk-awareness and self-efficacy, and a decrease of offense-supportive cognitions and self-esteem. The present study underlined the importance of careful education and monitoring of self-identifying, help-seeking pedohebephilic patients interested in ADT concerning the effects and side effects of the treatment in a clinical context.

Current concepts in the pharmacotherapy of paraphilias

Concerns about paraphilia and its treatment have grown in the past few years. Although the aetiology of paraphilia disorder is still not completely understood, pharmacological treatments have been proposed for this disorder. Paraphilias are a major burden for patients and society; nevertheless, only a few individuals with paraphilias voluntarily seek treatment. Antidepressants have been used in the treatment of certain types of mild (e.g. exhibitionism) and juvenile paraphilias. Antilibidinal hormonal treatments, such as steroidal antiandrogens and gonadotrophin-releasing hormone (GnRH) analogues, have also been studied and they seem to be effective in paraphilic disorders, although caution should be taken in the prescription of these treatments in order to avoid or minimize adverse effects and the risk of victimization. The combination of psychotherapy and pharmacological therapy is associated with better efficacy compared with either treatment as monotherapy. Paraphilia is a chronic disorder and a minimal duration of treatment of 3-5 years is highly recommended for severe paraphilia with a high risk of sexual violence. In conclusion, this review of the literature provides suggestive evidence that paraphilias are well characterized disorders marked by pathological dimensions. Although further research is necessary to confirm treatment efficacy and to improve our knowledge of long-term tolerance, available data on the use of selective serotonin reuptake inhibitors, steroidal antiandrogens and GnRH analogues strongly suggest the efficacy of these treatments for paraphilic disorders.

The World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the biological treatment of paraphilias

OBJECTIVES

The primary aim of these guidelines was to evaluate the role of pharmacological agents in the treatment and management of paraphilia, with a focus on the treatment of adults males. Because such treatments are not delivered in isolation, the role of specific psychosocial and psychotherapeutic interventions was also briefly covered. These guidelines are intended for use in clinical practice by clinicians who diagnose and treat patients with paraphilia. The aim of these guidelines is to improve the quality of care and to aid physicians in clinical decisions.

METHODS

The aim of these guidelines was to bring together different views on the appropriate treatment of paraphilias from experts representing different continents. To achieve this aim, an extensive literature search was conducted using the English language literature indexed on MEDLINE/PubMed (1990-2009 for SSRIs) (1969-2009 for antiandrogen treatments), supplemented by other sources, including published reviews.

RESULTS

Each treatment recommendation was evaluated and discussed with respect to the strength of evidence for its efficacy, safety, tolerability and feasibility.

CONCLUSIONS

An algorithm was proposed with six levels of treatment for different categories of paraphilias.

Pharmacological management of inappropriate sexual behaviours: a review of its evidence, rationale and scope in relation to men with intellectual disabilities

BACKGROUND

The management of inappropriate sexual behaviours (ISB) including sexual offending is difficult, especially when the person treated has intellectual disabilities (ID). Psychological therapies are the accepted first line of treatment. Pharmacological treatments have also been advocated, particularly for people who have committed serious sexual offences. There is limited information on available drugs and evidence of their efficacy in the treatment of ISBs, in particular for people with ID.

METHODS

A literature search of electronic databases was undertaken. Pharmaceutical companies were contacted for unpublished information. Trials that included people with ID were systematically reviewed for the benefits and outcome in that population.

RESULTS

Androgen depleting drugs (cyproterone acetate, medroxyprogesterone acetate and luteinising hormone releasing hormone agonists) and psychotropic drugs (serotonin specific reuptake inhibitors and antipsychotics) are the two major categories of medications used in the treatment of ISBs. The majority of studies identified were open trials and most relied on self-report measures. Trials that included people with ID were few in number. Most trials indicated beneficial effects including reduction in sexually deviant fantasies and behaviours.

CONCLUSION

The quality of evidence base for the use of pharmacological agents in the treatment of ISBs is inadequate to justify their use in routine clinical practice. If used, they should only be a part of a comprehensive treatment programme and closely monitored. In addition, there are several clinical, ethical and legal issues to be addressed before considering pharmacological treatment of ISBs in people with ID.

WITHDRAWN: Psychological interventions for those who have sexually offended or are at risk of offending

BACKGROUND

Sexual offending is both a social problem and a public health issue. To date, no positive treatment effects have been found in quasi-experimental institutional treatment programmes.

OBJECTIVES

To evaluate effects of psychological interventions on target sexual acts, urges or thoughts for people who have been convicted, or cautioned, for sexual offences.

SEARCH STRATEGY

33 electronic databases including the Cochrane Controlled Trials Register (Issue 4, 2002) were searched. Relevant authors and organisations were contacted for additional data.

SELECTION CRITERIA

Randomised controlled trials (RCTs) involving adults treated in institutional or community settings for sexual behaviours that have resulted in conviction or caution for sexual offences, or offences or violent behaviours with a sexual element. Behavioural, cognitive-behavioural, psychodynamic, and psychoanalytic therapies were compared with each other, drug treatment, or standard care.

DATA COLLECTION AND ANALYSIS

Independent assessors selected and assessed studies and extracted data. Data were excluded where more than 50% of participants were lost to follow-up. For binary outcomes, standard estimations of risk ratio (RR) and their 95% confidence intervals (CI) were calculated. Where possible, number-needed-to-treat or harm statistics (NNT, NNH) and their 95% CIs were calculated.

MAIN RESULTS

We included nine RCTs with over 500 male offenders, 231 of whom have been followed up for a decade. Cognitive behavioural therapy (CBT) in groups may reduce re-offence at one year for child molesters when compared with standard care (n=155, 1 RCT, RR any sexual/violent crime - 0.41 CI 0.2 to 0.82, NNT 6 CI 3 to 20). However, when CBT was compared with a trans-theoretical counselling group therapy the former may have increased poor attitudes to treatment (corrected n=38, 1 RCT, RR 2.8 CI 1.26 to 6.22, NNH 2 CI 1 to 5). The largest trial compared broadly psychodynamic group therapy with no treatment for 231 men guilty of paedophilia, exhibitionism or sexual assault. Re-arrest over ten years was greater for those allocated to group therapy (result not statistically significant [n=231, 1 RCT, RR 1.87 CI 0.78 to 4.47]).

AUTHORS' CONCLUSIONS

Limited data make recommendations difficult. One study suggests that a cognitive approach results in a decline in re-offending after one year. Another large study shows no benefit for group therapy and suggests the potential for harm at ten years. The ethics of providing this still-experimental treatment to a vulnerable and potentially dangerous group of people outside of a well-designed evaluative study are debatable. This review proves such studies are possible.

Interventions for learning disabled sex offenders

BACKGROUND

The management of sex offenders is a major public concern. Behavioural and pharmacological interventions have been used for many years and more recently cognitive behavioural based interventions have become popular around the world. Programmes designed for the general population have been modified for those sex offenders with learning disability, to address their cognitive deficits. The efficacy of these modified programmes is unclear.

OBJECTIVES

To determine the efficacy of interventions with learning disabled sex offenders.

SEARCH STRATEGY

The reviewers searched the Cochrane Library 2006 (Issue 1), MEDLINE (1966 to Sept 2006), Embase (1980 to September 2006), CINAHL (1982 to September 2006), PsycINFO (1872 to September 2006), Biological Abstracts (1980 to September 2006).

SELECTION CRITERIA

All randomised controlled trials comparing an intervention for learning disabled sex offenders to any other, or no intervention.

DATA COLLECTION AND ANALYSIS

Data were independently extracted.

MAIN RESULTS

No randomised controlled trial was identified.

AUTHORS' CONCLUSIONS

Using the methods described the reviewers found no randomised controlled trial evidence to guide the use of interventions for learning disabled sex offenders. Until the urgent need for randomised controlled trials is met, clinical practice will continue to be guided by either extrapolation of evidence from randomised controlled trials involving sex offenders without learning disability or non-randomised trial evidence of interventions for the learning disabled sex offender.

Epidemiology and treatment of juvenile sexual offending

The juvenile sex offender is defined as a youth who commits any sexual act with a person of any age against the victim's will, or in an aggressive, exploitative, or threatening manner. The term 'child molester' refers to those who choose only, or primarily, child victims. In this article, we mostly focus on adolescents aged between 13 and 18 years. To reduce sex crimes and the risk of adolescent sexual re-offending, effective treatment strategies have to be implemented for adolescent sexual offenders. Supervision and treatment recommendations for juvenile sex offenders initially emerged from the literature on adult sex offenders. Treatment must include behavioral therapy, family therapy, and psychosocial interventions. Pharmacotherapy is not always a first-line treatment. Antidepressants (especially selective serotonin reuptake inhibitors) offer promise in the treatment of adolescent sexual offending but further controlled studies are needed. In some rare situations, however, especially when severe paraphilic behaviors (such as pedophilia) are present, an hormonal intervention such as cyproterone acetate treatment may be needed.

Psychological interventions for those who have sexually offended or are at risk of offending

BACKGROUND

Sexual offending is both a social problem and a public health issue. To date, no positive treatment effects have been found in quasi-experimental institutional treatment programmes.

OBJECTIVES

To evaluate effects of psychological interventions on target sexual acts, urges or thoughts for people who have been convicted, or cautioned, for sexual offences.

SEARCH STRATEGY

33 electronic databases including the Cochrane Controlled Trials Register (Issue 4, 2002) were searched. Relevant authors and organisations were contacted for additional data.

SELECTION CRITERIA

Randomised controlled trials (RCTs) involving adults treated in institutional or community settings for sexual behaviours that have resulted in conviction or caution for sexual offences, or offences or violent behaviours with a sexual element. Behavioural, cognitive-behavioural, psychodynamic, and psychoanalytic therapies were compared with each other, drug treatment, or standard care.

DATA COLLECTION AND ANALYSIS

Independent assessors selected and assessed studies and extracted data. Data were excluded where more than 50% of participants were lost to follow-up. For binary outcomes, standard estimations of risk ratio (RR) and their 95% confidence intervals (CI) were calculated. Where possible, number-needed-to-treat or harm statistics (NNT, NNH) and their 95% CIs were calculated.

MAIN RESULTS

We included nine RCTs with over 500 male offenders, 231 of whom have been followed up for a decade. Cognitive behavioural therapy (CBT) in groups may reduce re-offence at one year for child molesters when compared with standard care (n=155, 1 RCT, RR any sexual/violent crime - 0.41 CI 0.2 to 0.82, NNT 6 CI 3 to 20). However, when CBT was compared with a trans-theoretical counselling group therapy the former may have increased poor attitudes to treatment (corrected n=38, 1 RCT, RR 2.8 CI 1.26 to 6.22, NNH 2 CI 1 to 5). The largest trial compared broadly psychodynamic group therapy with no treatment for 231 men guilty of paedophilia, exhibitionism or sexual assault. Re-arrest over ten years was greater for those allocated to group therapy (result not statistically significant [n=231, 1 RCT, RR 1.87 CI 0.78 to 4.47]).

REVIEWERS' CONCLUSIONS

Limited data make recommendations difficult. One study suggests that a cognitive approach results in a decline in re-offending after one year. Another large study shows no benefit for group therapy and suggests the potential for harm at ten years. The ethics of providing this still-experimental treatment to a vulnerable and potentially dangerous group of people outside of a well-designed evaluative study are debatable. This review proves such studies are possible.

Acute neuroendocrine response to sexual stimulation in sexual offenders

BACKGROUND

Several pharmacotherapeutic approaches have confirmed the influence of neuroendocrine parameters on sexual desire, function, and fantasies in men; however, the relevance of acute neuroendocrine changes in mediating heightened sexual drive remains unknown. We recently demonstrated that plasma prolactin substantially increases following orgasm in healthy men, suggesting a feedback mechanism for peripheral prolactin in the control of acute sexual arousal. Because prolactin appears to play a regulatory role in acute sexual drive, we initiated this study to see whether sexual offenders with a high sexual drive have a different neuroendocrine response to sexual arousal. This study compares the prolactin response to orgasm of sexual offenders with high sexual drive and that of healthy subjects with average sexual drive.

METHODS

From a subject pool of 150 inpatients held because of sexual crimes, we recruited 10 volunteers, based on their high sexual drive according to an intensive, semistructured clinical interview. We defined sexual drive by a short refractory period and strong sexualization, or a high frequency of sexual stimulation. We analyzed the acute psychoneuroendocrine response to sexual arousal and orgasm continuously before, during, and after masturbation-induced orgasm in patients and control subjects.

RESULTS

Sexual offenders demonstrated higher sexual desire (P < 0.001) and function (P < 0.001) and a more positively perceived refractory period (P < 0.05). Both groups displayed a prolonged, significant increase in prolactin plasma levels after orgasm (P < 0.001). Sexual offenders did not differ from control subjects in neuroendocrine response to sexual arousal and orgasm.

CONCLUSIONS

These data demonstrate that sexual offenders with a high sexual drive do not differ from control subjects in the postorgasmic neuroendocrine response, particularly in prolactin release. This study confirms that factors other than peripheral hormones influence deviant sexual behaviour.

Multiplex versus multiple taxonomy of paraphilia: case example

Several different paraphilias are presently diagnosed in some individuals whereas a more parsimonious taxonomy would be that of one multiplex paraphilia. A multiplex paraphilia may be expressed by variations of content at different times in an individual's life or in different situations. The present case example shows the unfolding of a multiplex paraphilia over a lifetime. At age 7 the subject was dressed in public as a girl wearing a diaper as a humiliation for bed-wetting. This experience had 3 paraphilic components that were separately manifested at different times in his life: fetishistic transvestism, pedophilic incest, and infantilism. A multiplex paraphilia taxonomy may lead to improved identification of etiology, prognosis, and treatment of paraphilia.

Antihormonal treatment of paraphilic patients in German forensic psychiatric clinics

The aim of this study was to investigate which antihormonal treatment strategies are used in German forensic psychiatric institutions. Forensic clinics were asked about the number of treated patients. Four hundred seventy-four patients were committed for sex offences; 12% received either CPA (n = 29) or LHRH- agonists (n = 29). Differences in efficacy were small. Several side effects confirm the importance of a protocol for minimizing medical complications.

Behavioral and psychopharmacological treatment of the paraphilic and hypersexual disorders

In this article, the second of a two-part series, the authors present information on the clinical assessment of individuals with paraphilias and hypersexual disorders. They review ethical considerations in the assessment and treatment of individuals with paraphilias. The role of interview and subjective and objective instruments in the assessment of individuals with paraphilias and hypersexual disorders is discussed. The authors discuss the use of penile plethysmography or phallometry, polygraphy, and viewing time assessments. Risk assessment of sexual offenders is reviewed. The authors then discuss behavioral, environmental, and psychopharmacological treatments for paraphilias and hypersexual disorders. Cognitive-behavioral therapy appears to be the most effective nonpharmacological strategy. The authors describe cognitive-behavioral techniques for decreasing and/or controlling sexual urges (e.g., satiation, covert sensitization, fading, cognitive restructuring, victim empathy therapy) as well as methods for enhancing appropriate sexual interest and arousal (e.g., social skills training, assertiveness skills training, sex education, couples therapy). The authors also discuss the role of relapse prevention therapy and 12-step programs, as well as other nonbiological therapies such as surveillance networks. The importance of providing appropriate treatment for comorbid conditions (e.g., depression, substance abuse or dependence) is stressed. The authors then review psychopharmacological treatments, including serotonin reuptake inhibitors (SRIs) and antiandrogens, in particular, the use of gonadotropin-releasing hormone (GNRH) agonists. SRIs have been studied in these disorders in an uncontrolled way and appear promising. Earlier antiandrogens (e.g., estrogen, progesterone, and cyproterone acetate) have demonstrated efficacy in the treatment of paraphilias. The newer GNRH agonists have the advantage over the earlier treatments of being available in long-acting depot formulations and having fewer side effects. Preliminary studies and case reports with these agents appear promising. Further study of both the SRIs and GNRH agonists in these disorders is needed. The article concludes with a treatment algorithm, in which the authors suggest beginning with less restrictive treatments (e.g., behavioral or verbal therapies), if possible, and moving to more restrictive alternatives (e.g., biological therapies, institutionalization) as needed. A guide for clinicians and patients about where and how to find appropriate clinicians and treatment resources in the United States is provided.

Interventions for learning disabled sex offenders

BACKGROUND

The management of sex offenders is a major public concern. Behavioural and pharmacological interventions have been used for many years and more recently cognitive behavioural based interventions have become popular around the world. Programmes designed for the general population have been modified for those sex offenders with learning disability, to address their cognitive deficits. The efficacy of these modified programmes is unclear.

OBJECTIVES

To determine the efficacy of interventions with learning disabled sex offenders.

SEARCH STRATEGY

The reviewers searched electronically EMBASE, PsycINFO, Medline, Cinahl, Cochrane Library, SPECTR, National Clearinghouse on Child Abuse and Neglect Information and National Criminal Justice Reference Service and Biological Abstracts.

SELECTION CRITERIA

All randomised controlled trials comparing an intervention for learning disabled sex offenders to any other, or no intervention.

DATA COLLECTION AND ANALYSIS

Data were independently extracted.

MAIN RESULTS

No randomised controlled trial was identified.

REVIEWER'S CONCLUSIONS

Using the methods described the reviewers found no randomised controlled trial evidence to guide the use of interventions for learning disabled sex offenders. Until the urgent need for randomised controlled trials is met, clinical practice will continue to be guided by either extrapolation of evidence from randomised controlled trials involving sex offenders without learning disability or non-randomised trial evidence of interventions for the learning disabled sex offender.

Treatment of paraphilia with luteinizing hormone-releasing hormone agonists

Up to now there have been no published results of therapy of paraphilia (for example, pedophilia or sadism) and sexual aggressive impulsiveness with luteinizing hormone-releasing hormone (LHRH) agonists in the German-speaking countries. After a short introduction about physiologic features and the present state of investigations in treatment of paraphilia with LHRH agonists we describe 11 patients who were treated with the LHRH agonist Leuprolide Acetate over a period of 12 months. The patients showed no tendency toward sexually aggressive behavior and reported an evident reduction of penile erection, ejaculation, masturbation, sexually deviant impulsiveness, and fantasies. One patient died from suicide. In combination with other treatments, LHRH Agonists seem to be a very promising alternative to cyproterone acetate and its possible carcinogene effects.

Pharmacotherapy of paraphilias in the next millennium

Paraphilias are psychiatric disorders of abnormal sexual behavior whose prevalence has markedly increased during the last decade. Treatment modalities currently used fall into three categories: surgical castration, psychotherapy, and pharmacotherapy. The pharmacological interventions consist of antiandrogens that either completely reduce testosterone secretion and/or antagonize the action of testosterone at the level of the receptor, and psychotropic drugs, namely antidepressants. Cyproterone and medroxyprogesterone acetates are the two antiandrogens more commonly used. They are only effective in relatively high doses, but have a substantial number of severe side effects which has considerably limited their use. Psychotropic drugs may be effective solely in men with a definite obsessive-compulsive disorder component. Because of the erratic results and lack of permanent eradication of the paraphilic manifestations their use in paraphilias is highly controversial. Long-acting gonadotropin-releasing hormone (GnRH) agonist analogues are the most potent antiandrogens, and selectively abolish testosterone secretion in a totally reversible fashion. They are administered parenterally once every 1 to 3 months, and have the fewest side effects. Long-acting GnRH analogues, together with psychotherapy, are highly effective in controlling selected paraphilias (pedophilia, exhibitionism, and voyeurism), and are the most promising mode of therapy in the next millennium. There is an urgent need for good methodological research; carefully designed double-blind controlled studies with a large number of subjects in order to validate or not the use of the various pharmacotherapies.

Managements for people with disorders of sexual preference and for convicted sexual offenders

BACKGROUND

The reviewers recognise that it may be thought that convicted sex offenders and those with disorders of sexual preference are quite different groups. In combining them within this review we have taken the view that legal process alone should not define the population. Illegal behaviours in one jurisdiction may not be considered so in others. Studies of those who are convicted of sexual offending describe reconviction rates for sexual offences of up to 40-60%. It would seem important to know if there are interventions that might reduce this high rate of re-offending. This review examines antilibidinal management of those who have been convicted of sexual offences or who have disorders of sexual preference.

OBJECTIVES

To determine the effectiveness of a range of management techniques to assist people who have disorders of sexual preference and those who have been convicted of sexual offences.

SEARCH STRATEGY

Biological Abstracts, the Cochrane Schizophrenia Group Register of Trials, The Cochrane Library, EMBASE, MEDLINE, and PsychLIT were searched. Further references were sought from published trials and their authors. Relevant pharmaceutical manufacturers were contacted.

SELECTION CRITERIA

All relevant randomised controlled trials.

DATA COLLECTION AND ANALYSIS

Reviewers evaluated data independently and analysed on an intention-to-treat basis. Data were extracted for short and medium term outcomes.

MAIN RESULTS

A single trial (McConaghy 1988) found the effect of antilibidinal medication (medroxyprogesterone acetate) plus imaginal desensitisation was no better than imaginal desensitisation for problematic/anomalous sexual behaviour and desire. A relapse prevention programme was trialed by Marques (Marques 1994) and participants were followed up for an average of 3 years. What data there are suggest that although there is no discernable effect on the outcome of sex offending (OR 0.76 CI 0. 26-2.28) those treated with response prevention do have less non-sexual violent offences (OR 0.3, CI 0.1-0.89, NNT 10 CI 5-85). In addition those committing both sexual and violent offences also declined in the response prevention group (OR 0.14 CI 0.02-0.98, NNT 20 CI 10-437). A large pragmatic trial investigated the value of group therapy for sex offenders (Romero 1983). This study finds no effect on recidivism at ten years.

REVIEWER'S CONCLUSIONS

It is disappointing to find that this area lacks a strong evidence base, particularly in light of the controversial nature of the treatment and the high levels of interest in the area. The relapse prevention programme did seem to have some effect on violent reoffending but large, well-conducted randomised trials of long duration are essential if the effectiveness or otherwise of these treatments are to be established.

An exploration of child sexual abusers' sexual fantasies before and after treatment

Although there is a substantial literature looking at the relationship between deviant sexual fantasies and child sexual abuse, there is scant previous work that focuses upon the actual content of such fantasies. The present study looks at child sexual abusers' deviant fantasies both pre- and postintervention. Using both qualitative and quantitative methodologies, a description of the frequency and content of, and triggers for, child sexual abusers' deviant fantasies is reported both pre- and postintervention. The implications of this information for subsequent intervention programs is explored.

Pharmacological treatment of paraphilias with a focus on antidepressants

This article reviews the advances in pharmacotherapy of paraphilias. Antiandrogen hormones, phenothiazines, and lithium therapy of paraphilias is briefly reviewed. Pharmacotherapy of paraphilias with serotonergic drugs such as fluoxetine, clomipramine, sertraline, and fluvoxamine is reviewed in detail. In addition, the use of buspirone hydrochloride in paraphilias is discussed. The final focus of the article is on the etiologic theories of paraphilias and some practical advice for the pharmacotherapy and management of paraphilias.

Treatment of men with paraphilia with a long-acting analogue of gonadotropin-releasing hormone

BACKGROUND

Men with deviant sexual behavior, or paraphilia, are usually treated with psychotherapy, antidepressant drugs, progestins, and antiandrogens, but these treatments are often ineffective. Selective inhibition of pituitary-gonadal function with a long-acting agonist analogue of gonadotropin-releasing hormone may abolish the deviant sexual behavior by reducing testosterone secretion.

METHODS

In an uncontrolled observational study, we treated 30 men (mean age, 32 years) with severe long-standing paraphilia (25 with pedophilia and 5 with other types of abnormal behavior) with monthly injections of 3.75 mg of triptorelin and supportive psychotherapy for 8 to 42 months. The efficacy of therapy was evaluated monthly by the Intensity of Sexual Desire and Symptoms Scale and yearly by the Three Main Complaints questionnaire.

RESULTS

All the men had a decrease in the number of deviant sexual fantasies and desires, from a mean (+/-SD) of 48+/-10 per week before therapy to zero during therapy (P<0.001), and a decrease in the number of incidents of abnormal sexual behavior (from 5+/-2 per month to zero, P<0.001) while receiving triptorelin. These effects were evident after 3 to 10 months of therapy (P<0.001) and persisted in all 24 men who continued therapy for at least 1 year. The men's mean serum testosterone concentration fell from 545+/-196 ng per deciliter (18.9+/-6.8 nmol per liter) before therapy to 23+/-14 ng per deciliter (0.8+/-0.5 nmol per liter, P<0.001) after 42 months of triptorelin. The main side effects were erectile failure, hot flashes, and decrease in bone mineral density in some men.

CONCLUSIONS

Continuous administration of triptorelin, a long-acting agonist analogue of gonadotropin-releasing hormone, together with supportive psychotherapy, may be an effective treatment for men with severe paraphilia.