Assessment methods and management of hypersexuality and paraphilic disorders

The World Federation of Societies of Biological Psychiatry guidelines on the assessment and pharmacological treatment of compulsive sexual behaviour disorder

OBJECTIVES

The current guidelines aim to evaluate the role of pharmacological agents in the treatment of patients with compulsive sexual behaviour disorder (CSBD). They are intended for use in clinical practice by clinicians who treat patients with CSBD.

METHODS

An extensive literature search was conducted using the English-language-literature indexed on PubMed and Google Scholar without time limit, supplemented by other sources, including published reviews.

RESULTS

Each treatment recommendation was evaluated with respect to the strength of evidence for its efficacy, safety, tolerability, and feasibility. Psychoeducation and psychotherapy are first-choice treatments and should always be conducted. The type of medication recommended depended mainly on the intensity of CSBD and comorbid sexual and psychiatric disorders. There are few randomised controlled trials. Although no medications carry formal indications for CSBD, selective-serotonin-reuptake-inhibitors and naltrexone currently constitute the most relevant pharmacological treatments for the treatment of CSBD. In cases of CSBD with comorbid paraphilic disorders, hormonal agents may be indicated, and one should refer to previously published guidelines on the treatment of adults with paraphilic disorders. Specific recommendations are also proposed in case of chemsex behaviour associated with CSBD.

CONCLUSIONS

An algorithm is proposed with different levels of treatment for different categories of patients with CSBD.

Off-label Uses of Selective Serotonin Reuptake Inhibitors (SSRIs)

Psychiatric drugs have primacy for off-label prescribing. Among those, selective serotonin reuptake inhibitors (SSRIs) are highly versatile and, therefore, widely prescribed. Moreover, they are commonly considered as having a better safety profile compared to other antidepressants. Thus, when it comes to off-label prescribing, SSRIs rank among the top positions. In this review, we present the state of the art of off-label applications of selective serotonin reuptake inhibitors, ranging from migraine prophylaxis to SARS-CoV-2 antiviral properties. Research on SSRIs provided significant evidence in the treatment of premature ejaculation, both with the on-label dapoxetine 30 mg and the off-label paroxetine 20 mg. However, other than a serotoninergic syndrome, serious conditions like increased bleeding rates, hyponatremia, hepatoxicity, and post-SSRIs sexual dysfunctions, are consistently more prominent when using such compounds. These insidious side effects might be frequently underestimated during common clinical practice, especially by nonpsychiatrists. Thus, some points must be addressed when using SSRIs. Among these, a psychiatric evaluation before every administration that falls outside the regulatory agencies-approved guidelines has to be considered mandatory. For these reasons, we aim with the present article to identify the risks of inappropriate uses and to advocate the need to actively boost research encouraging future clinical trials on this topic.

Attention-Deficit/Hyperactivity Disorder (ADHD), antisociality and delinquent behavior over the lifespan

Attention-Deficit/Hyperactivity Disorder (ADHD) is closely linked to the development of conduct problems during socialization in early life and to an increased risk for antisocial activities and delinquency over the lifespan. The interaction between ADHD and common comorbid disorders like substance use disorders as well as changing environmental conditions could mediate the course of antisocial and delinquent behavior with increasing age. However, this complex interaction is only partially understood so far. This review presents current knowledge about the association of ADHD with antisociality and the development of delinquent behavior. Thereby, the relationships between ADHD, conduct disorder and antisocial personality disorder in offenders are discussed, as well as the impact of comorbid psychiatric disorders and psychosocial conditions on offending behavior. Also, treatment studies in offender populations with ADHD are presented. Although our understanding of the role of ADHD in the development of criminal behavior has substantially improved during the last two decades, more research is needed to further elucidate the mechanisms generating unfavorable outcomes and to engender adequate treatment strategies for this population at risk. Moreover, more attention is needed on children with conduct problems in order to avoid antisocial or delinquent behaviors over the lifespan.

Pharmacological treatment of patients with paraphilic disorders and risk of sexual offending: An international perspective

Objectives: The present study aims to evaluate existing policy and practice relating to the use of pharmacological treatments with patients suffering from paraphilic disorders who are at risk of committing further sexual offences.Methods: A systematic literature search was conducted to document current legal policies across 26 different countries. In addition, a questionnaire assessing the practice of pharmacological treatment was sent to practitioners involved in the treatment of patients with paraphilic disorders.Results: Legal policies concerning the preconditions of using pharmacological treatments differ considerably between countries, and for most jurisdictions do not exist. Drawing on the responses of 178 practitioners, pharmacological agents are a useful addition to psychotherapeutic interventions, especially with those patients classified as medium or high risk for sexually violent behaviours. It would appear that most patients are medically examined, are informed of the risks and possible side effects before treatment commences and are also obliged to sign a consent form.Conclusions: Although pharmacological agents can be seen as an intrusion into a patients' sexual self determination, results indicate that ethical and clinical standards are being met in the majority of cases. However, further promotion of current WFSBP treatment guidelines would help to standardise practice across North American and European countries.

Treatment of Paraphilic Disorders in Sexual Offenders or Men With a Risk of Sexual Offending With Luteinizing Hormone-Releasing Hormone Agonists: An Updated Systematic Review

BACKGROUND

Different pharmacologic agents are used in the treatment of paraphilic disorders in sexual offenders or men with a risk of sexual offending, with luteinizing hormone-releasing hormone (LHRH) agonists being the agents introduced more recently to treatment regimens.

AIM

To summarize the relevant literature concerning LHRH agonist treatment of paraphilic disorders in sexual offenders and update the previously published systematic review by Briken et al (J Clin Psychiatry 2003;64:890-897).

METHODS

The PubMed and Google Scholar databases were searched for literature published from January 2003 through October 2017 using the following key words: LHRH agonists, GnRH agonists, antiandrogens AND paraphilia, pedophilia, sex offenders.

OUTCOMES

Evaluation of the effectiveness and side effects of LHRH agonist treatment of paraphilic disorders in sexual offenders.

RESULTS

After screening for duplicates and applying specific selection criteria, the search yielded 24 eligible studies reporting on a sample of 256 patients. There is increasing evidence that LHRH agonists are more effective than steroidal antiandrogens in lowering paraphilic sexual thoughts and behaviors. Current research also is based on methods that might be less susceptible to faking (eg, eye-tracking, brain imaging, and viewing-time measures). Side effects occurring most frequently are fatigue, hot flashes, depressive mood, weight gain, high blood pressure, diabetes, gynecomastia, loss of erectile function, and loss of bone mineral density.

CLINICAL IMPLICATIONS

Although LHRH agonists seem to be the most effective drugs in the treatment of paraphilic fantasies and behaviors, they should be reserved for patients with a paraphilic disorder and the highest risk of sexual offending because of their extensive side effects.

STRENGTHS AND LIMITATIONS

This systematic review considers all types of research on LHRH agonist treatment in patients with paraphilic disorders, thereby providing a complete overview of the current state of research. However, most studies are case reports or observational studies and randomized controlled clinical trials have not been conducted or published.

CONCLUSIONS

LHRH agonists are a useful treatment when combined with psychotherapy in patients with a paraphilic disorder and the highest risk of sexual offending. However, throughout treatment, close monitoring of side effects is needed and ethical concerns must always be kept in mind. Turner D, Briken P. Treatment of Paraphilic Disorders in Sexual Offenders or Men With a Risk of Sexual Offending With Luteinizing Hormone-Releasing Hormone Agonists: An Updated Systematic Review. J Sex Med 2018;15:77-93.

Sexual Compulsivity among Indonesian College Students

The objective of this study is to describe the sexual compulsivity of Indonesian college students. We used a cross-sectional design and recruited 301 college students in Universitas Indonesia. Data were collected using the modified Sexual Compulsivity Scale (SCS) instrument. These findings show that Indonesian students have lower sexual compulsivity scale (mean: 11.39 ± 4.21). Male students have significantly higher SCS score than female students (p = 0.000). Working students were also found to have a higher SCS score than those who did not work (p = 0.039). Further studies on sexual compulsivity among young adults in Indonesia are deemed necessary to give more understanding about sexual compulsivity. These findings provide basic information to design a sexual counseling method for improving the sexual health of young adults.

Are There Any Biomarkers for Pedophilia and Sexual Child Abuse? A Review

The use of biomarkers in medicine is a common and valuable approach in several clinical fields. Understanding the relationship between measurable biological processes and clinical outcomes not only is indispensable in the face of understanding physiological processes in healthy as well as in diseased organisms but also for understanding and evaluating treatment effects. Therefore, also in the context of forensic psychiatry, biomarkers and their potentially beneficial effects are of growing interest. The objective of this review is to examine if there are biomarkers that may serve as a tool to support diagnostic process, treatment evaluation, and risk assessment of pedophilic individuals and child sexual offenders. In the first part, we present an overview of the current neurobiological, as well as physiological and psychophysiological approaches to characterize pedophilia and child sexual offending. Secondly, we discuss and evaluate the impact of these approaches on the development of biomarkers for diagnosis, therapy, and risk assessment in pedophilic subjects and child sexual offenders. We conclude that a lot of research has already enhanced our neurobiological knowledge about pedophilia and child sexual offending. Although there surely exist promising parameters and approaches, in our view currently none of these is ready yet to serve as a clinically applicable diagnostic, response, or predictive biomarker for pedophilia and child sexual offending. Therefore, further work remains to be done. The development of a composite diagnostic biomarker to assess deviant sexual interest, combining several measures like functional magnetic resonance imaging, electroencephalogram, eye tracking, and behavioral approaches seems to be most promising. A valid and reliable measurement of deviant sexual interest, insensitive to manipulations could significantly support clinical diagnostic process. Similarly, regarding therapy evaluation and risk assessment, a composite biomarker to assess inhibitory control functions seems to be promising. Furthermore, the application of the Research Domain Criteria-approach, a new approach for investigating and classifying mental disorders, offers the possibility to take research to a new level.

Sexuality in autism: hypersexual and paraphilic behavior in women and men with high-functioning autism spectrum disorder

Like nonaffected adults, individuals with autism spectrum disorders (ASDs) show the entire range of sexual behaviors. However, due to the core symptoms of the disorder spectrum, including deficits in social skills, sensory hypo- and hypersensitivities, and repetitive behaviors, some ASD individuals might develop quantitatively above-average or nonnormative sexual behaviors and interests. After reviewing the relevant literature on sexuality in high-functioning ASD individuals, we present novel findings on the frequency of normal sexual behaviors and those about the assessment of hypersexual and paraphilic fantasies and behaviors in ASD individuals from our own study. Individuals with ASD seem to have more hypersexual and paraphilic fantasies and behaviors than general-population studies suggest. However, this inconsistency is mainly driven by the observations for male participants with ASD. This could be due to the fact that women with ASD are usually more socially adapted and show less ASD symptomatology. The peculiarities in sexual behaviors in ASD patients should be considered both for sexual education and in therapeutic approaches.

Innovations, Reviews and Proposals on the DSM-5: the Case of Sexual Dysfunctions, Gender Dysphoria and Paraphilic Disorders

Human behaviours have different meanings according to the historical moment and context. In this article sexual behaviours are taken as a category in order to analyse how psychiatric nosology is structured, as manifested in texts such as the DSM-5. The development of these diagnostic manuals are tools that are far from being free of subjectivities and interference of elements of power, expressed in the way health, illness, mental health, and mental disorders, are assumed; in short, the normal and pathological. Each new diagnosis, or even its elimination, and the recomposing of the different diagnostic criteria, especially in the field of sexual behaviour, present visions of how individual and collective human life is conceived, as well as an expression of accurate attempts to control human sexualities through the medicalisation of behaviour, coupled with moral, religious, and even legal considerations. Categories such as gender dysphoria, paraphilia or paraphilic disorders are examples of how the limits intended to establish a biomedical perspective are also incomplete and imprecise. These violate individual and social construction of sexualities and the conception of mental health, showing persistent difficulties and controversies that are evident in the way psychiatric classifications are made.

Similar mechanisms of traumatic rectal injuries in patients who had anal sex with animals to those who were butt-fisted by human sexual partner

Sexual pleasure comes in various forms of physical play, for many it involves stimulation of the vagina, while the anus for others; some enjoy both. A recent report by Cappelletti et al.¹ shows a meta-analysis of cases describing anal trauma due to sexual fisting in human partners. This clinical article reports four cases of males diagnosed with zoophilia, and who received anal sex from animals, resulting in injuries. Surgical and psychiatric evaluations are summarized. Unusual etiology of sexual activity with animals caused peri-anal trauma in men who engaged in anal sex with dogs and farm animals. Injuries to patients who receive anal sex from animals are mechanistically similar to fisting-induced rectal damage. Among zoophiles, the mode of harm occurs through blood-engorged, interlocked penis that causes tissue lacerations upon retraction from an anus. In people experimenting with fisting, repetitive stretching within anal canal and of external sphincter causes the internal injuries. The mode of physical stimulation explains the extent of injuries in fisters vs. zoophiles: in fisting, the pressure applied by hand is controllable proximally around and within anal sphincter, while penetration by the animal penis is unpredictable and occurs within the proximal anal canal. Forensically, the findings presented in this article describe a significant mechanism of injury in fisters versus passive zoophiles. These descriptions may aid in clinically differentiating pleasurable and pathological rectal stimulation.

Paraphilic Thoughts, Behaviors and Sex Addiction in a Sample of Persons Who Use Drugs: A Cross-Sectional Study

OBJECTIVE

The aim of this study was to evaluate the prevalence of paraphilic thoughts/behaviors (including paraphilic disorders) with and without sexual addiction and sexual-related conditions in a sample of substance disorder patients.

METHODS

This was a cross-sectional study of substance-dependent individuals who sought outpatient treatment in São Paulo, Brazil. Data included sociodemographic information, drug of choice, responses to questions about sexual behavior, and to the following standardized questionnaires: (a) Sexual Addiction Screening Test, and (b) Childhood Trauma Questionnaire.

RESULTS

The sample comprised 134 persons who use drug, predominantly men (76.1%), 39.6% were aged between 18 and 29 years, and 54.9% were single. Most were persons who use polydrug, 73.9% were alcohol and cocaine users, 63.4% marijuana users, 81.1% tobacco users, and 5.2% steroid users. Prevalence of paraphilic thoughts/behaviors (including paraphilic disorders) with and without sexual addiction was 47%. The HPV/herpes and hepatitis B rates were 7.9% (P = 0.021) and 6.3% (P = 0.046) respectively. Paraphilic and nonparaphilic thoughts/behaviors were associated to the presence of childhood physical neglect (odds ratios [OR] = 4.7, 95% confidence interval [CI] 1.0 to 21.9), low educational level (OR = 7.2, 95% CI 1.4 to 36), heterosexuality (OR = 3.8, 95% CI 1.1 to 12.8) and youth (age 18 to 20 years) (OR = 5.6, 95% CI 1.4 to 11.8).

CONCLUSIONS

The high prevalence of paraphilic thoughts/behaviors with or without sex addiction in persons who use drugs may be related to the experience of physical and emotional neglect during childhood and this possibility should routinely be investigated in clinical practice.

Hypersexuality in Psychiatric Conditions Observer-Rated Scale (HIPCORS): Evaluation of Reliability and Validity

Hypersexual behavior is not uncommon in psychiatric presentations. Most available scales that measure hypersexual behavior are self-rated, often containing sexually explicit questions, unsuitable for use in mentally unwell people. Lack of a clinically suitable instrument may have resulted in underdetection and under-researching of hypersexuality in people with mental disorders, with potential to cause significant consequences for themselves and those around them, including family members, coclients, and clinicians. To address this need, we developed the Hypersexuality in Psychiatric Conditions Observer-Rated Scale (HIPCORS), a rater-rated, nonintrusive tool, designed for use in mentally unwell people. It has been shown to be a reliable and valid instrument.

Neurobiological Basis of Hypersexuality

Until now, hypersexuality has not found entry into the common diagnostic classification systems. However it is a frequently discussed phenomenon consisting of excessive sexual appetite that is maladaptive for the individual. Initial studies investigated the neurobiological underpinnings of hypersexuality, but current literature is still insufficient to draw unequivocal conclusions. In the present review, we summarize and discuss findings from various perspectives: neuroimaging and lesion studies, studies on other neurological disorders that are sometimes accompanied by hypersexuality, neuropharmacological evidence, genetic as well as animal studies. Taken together, the evidence seems to imply that alterations in the frontal lobe, amygdala, hippocampus, hypothalamus, septum, and brain regions that process reward play a prominent role in the emergence of hypersexuality. Genetic studies and neuropharmacological treatment approaches point at an involvement of the dopaminergic system.

INSTRUMENTS OF HIGH RISK SEXUAL BEHAVIOR ASSESSMENT: A SYSTEMATIC REVIEW

BACKGROUND

Sexual behavior is a complex activity affecting all aspects of human's life. Risky sexual behaviors impose negative outcomes on family, relationships and health. Unsafe sex is the second most leading cause of disability adjusted life years worldwide. Valid and reliable tools for assessment of risky sexual behaviors are necessary for implementing preventive measures.

METHODS

we searched Medline and the Cochrane Library of Systematic Reviews, with the keywords of "risky sexual behavior assessment", "sexual risk assessment", "high risk sexual behavior", "sexual risk taking". By reviewing references of the articles, some complementary studies were added.

RESULTS

Assessment can be performed by questionnaire or non-questionnaire instruments. Questionnaires vary depending on their target population, evaluation of risky sexual behavior as a whole or focusing on an associated risk factor. In order to avoid usual biases in self reports, objective biomarker assessment of unprotected sex are employed. These markers include prostate specific antigen, chromosome Y DNA and Seminogelin.

CONCLUSION

Risky sexual behavior can be assessed by various subjective and objective methods. While self-reports are more feasible, objective methods offer a higher degree of reliability. Further studies for finding more feasible methods of using biomarkers are recommended.

Deep brain stimulation to reduce sexual drive

To date there are few treatment options to reduce high sexual drive or sexual urges in paraphilic patients with a risk for sexual offending. Pharmacological therapy aims to reduce sexual drive by lowering testosterone at the cost of severe side effects. We hypothesize that high sexual drive could also be reduced with deep brain stimulation (DBS) of circuits that generate sexual drive. This approach would help to avoid systemic side effects of antiandrogenic drug therapies. So far the best investigated target to reduce sexual drive is the ventromedial hypothalamus, which was lesioned unilaterally and bilaterally by stereotaxic interventions in paraphilic patients in the 1970s. Here, we discuss DBS as a treatment strategy in patients with severe paraphilic disorders with a serious risk of sexual offending. There are profound ethical and practical issues associated with DBS treatment of paraphilic patients that must be solved before considering such a treatment approach.

Paraphilias

PURPOSE OF REVIEW

The concept of paraphilia still carries an 'unwanted burden' of sexual norms because the pathologization of some sexual practices as paraphilic disorders is still based on the assumption that normal sexuality should be genitally organized with the aim of reproduction. The aim of this review is to give an impression of the ongoing discussion about the changes introduced with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) and the results of recent research in this area.

RECENT FINDINGS

The release of DSM-5 in the spring of 2013 introduced a distinction between paraphilias and paraphilic disorders, implying a destigmatization of consenting adults engaging in unusual sexual behaviour. According to DSM-5 diagnostic criteria, paedophilic disorder is the only paraphilic disorder without an 'in remission' and an 'in a controlled environment' specifier. Today, antiandrogen treatment is offered to sex offenders in many countries as an additional treatment strategy alongside psychotherapy.

SUMMARY

The introduction of DSM-5 offers the possibility to distinguish between paraphilia and paraphilic disorders. The aetiology of paraphilias is still unknown. Paraphilias are much more common in men than in women, but the reasons for this difference remain unknown. So far there is no clear consent on the best therapeutic approach for a paraphilic disorder.