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Murugesh V, Ritting M, Salem S, Aalam SMM, Garcia J, Chattha AJ, Zhao Y, Knapp DJHF, Kalthur G, Granberg CF, Kannan N. Puberty Blocker and Aging Impact on Testicular Cell States and Function. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.03.23.586441. [PMID: 38585884 PMCID: PMC10996503 DOI: 10.1101/2024.03.23.586441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
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.
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Affiliation(s)
- Varshini Murugesh
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Megan Ritting
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Salem Salem
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | | | - Joaquin Garcia
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Asma J Chattha
- Department of Pediatrics, Mayo Clinic, Rochester, MN, USA
| | - Yulian Zhao
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN, USA
| | - David JHF Knapp
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
- Institut de Recherche en Immunologie et Cancérologie, and Département de Pathologie et Biologie Cellulaire, Université de Montréal, Montreal, QC, Canada
- Senior authors
| | - Guruprasad Kalthur
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
- Division of Reproductive Biology, Department of Reproductive Science, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, India
- Senior authors
| | | | - Nagarajan Kannan
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
- Mayo Clinic Comprehensive Cancer Center, Mayo Clinic, Rochester, MN, USA
- Center for Regenerative Biotherapeutics, Mayo Clinic, Rochester, MN, USA
- Senior authors
- Lead contact
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Turner D, Briken P, Grubbs J, Malandain L, Mestre-Bach G, Potenza MN, Thibaut F. The World Federation of Societies of Biological Psychiatry guidelines on the assessment and pharmacological treatment of compulsive sexual behaviour disorder. DIALOGUES IN CLINICAL NEUROSCIENCE 2022; 24:10-69. [PMID: 37522807 PMCID: PMC10408697 DOI: 10.1080/19585969.2022.2134739] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 09/18/2022] [Accepted: 10/03/2022] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- Daniel Turner
- Department of Psychiatry and Psychotherapy, University Medical Center Mainz, Mainz, Germany
| | - Peer Briken
- Institute for Sex Research, Sexual Medicine, and Forensic Psychiatry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Joshua Grubbs
- Department of Psychology, Bowling Green State University, Bowling Green, OH, USA
| | - Leo Malandain
- Department of Psychiatry and Addictive Disorders, University Hospital Cochin (site Tarnier) AP-HP, Paris, France
| | - Gemma Mestre-Bach
- Facultad de Ciencias de la Salud, Universidad Internacional de La Rioja, La Rioja, Spain
| | - Marc N. Potenza
- Departments of Psychiatry and Neuroscience and Child Study Center, Yale School of Medicine, New Haven, CT, USA
- Connecticut Mental Health Center, New Haven, CT, USA
- Connecticut Council on Problem Gambling, Wethersfield, CT, USA
- Wu Tsai Institute, Yale University, New Haven, CT, USA
| | - Florence Thibaut
- Department of Psychiatry and Addictive Disorders, University Hospital Cochin (site Tarnier) AP-HP, Paris, France
- INSERM U1266, Institute of Psychiatry and Neurosciences, University of Paris Cité, Paris, France
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Thibaut F, Cosyns P, Fedoroff JP, Briken P, Goethals K, Bradford JMW. The World Federation of Societies of Biological Psychiatry (WFSBP) 2020 guidelines for the pharmacological treatment of paraphilic disorders. World J Biol Psychiatry 2020; 21:412-490. [PMID: 32452729 DOI: 10.1080/15622975.2020.1744723] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
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.
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Affiliation(s)
- Florence Thibaut
- Department of Psychiatry and Addictive Disorders, University Hospital Cochin, University of Paris, INSERM U1266, Institute of Psychiatry and Neurosciences, Paris, France
| | - Paul Cosyns
- Collaborative Antwerp Psychiatric Research Institute (CAPRI), University of Antwerp, Antwerp, Belgium
| | - John Paul Fedoroff
- Division of Forensic Psychiatry, The Royal Institute of Mental Health Research, University of Ottawa, Ottawa, ON, Canada
| | - Peer Briken
- Institute for Sex Research, Sexual Medicine and Forensic Psychiatry, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Kris Goethals
- Collaborative Antwerp Psychiatric Research Institute (CAPRI), University of Antwerp and University Forensic Centre, Antwerp University Hospital, Antwerp, Belgium
| | - John M W Bradford
- The Royal Institute of Mental Health Research, University of Ottawa, McMaster University, Ottawa & Hamilton, ON, Canada
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A Case of Paraphilia with Osteoporosis and Administered with Depot Leuprorelin. ACTA ACUST UNITED AC 2019; 55:medicina55100705. [PMID: 31635190 PMCID: PMC6843497 DOI: 10.3390/medicina55100705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 10/07/2019] [Accepted: 10/17/2019] [Indexed: 11/17/2022]
Abstract
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.
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Briken P, Turner D, Thibaut F, Bradford J, Cosyns P, Tozdan S. Validation of the Change or Stop Testosterone-Lowering Medication (COSTLow) Scale Using the Delphi Method Among Clinical Experts. JOURNAL OF SEX & MARITAL THERAPY 2018; 45:148-158. [PMID: 30040595 DOI: 10.1080/0092623x.2018.1491910] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 06/15/2018] [Accepted: 06/19/2018] [Indexed: 06/08/2023]
Abstract
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.
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Affiliation(s)
- Peer Briken
- a Institute for Sex Research and Forensic Psychiatry, University Medical Center Hamburg-Eppendorf , Hamburg , Germany
| | - Daniel Turner
- a Institute for Sex Research and Forensic Psychiatry, University Medical Center Hamburg-Eppendorf , Hamburg , Germany
- b Department of Psychiatry , University Medical Center Mainz , Mainz , Germany
| | - Florence Thibaut
- c Centre of Psychiatry and Neurosciences, Faculty of Medicine Paris Descartes, University Hospital Cochin (site Tarnier) , Paris , France
| | - John Bradford
- d Institute of Mental Health Research , Ottawa , Canada
| | - Paul Cosyns
- e Collaborative Antwerp Psychiatric Research Institute, University Forensic Centre , Antwerp , Belgium
| | - Safiye Tozdan
- a Institute for Sex Research and Forensic Psychiatry, University Medical Center Hamburg-Eppendorf , Hamburg , Germany
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6
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Choi JH, Lee JW, Lee JK, Jang S, Yoo M, Lee DB, Hong JW, Noh IS, Lim MH. Therapeutic Effects of Leuprorelin (Leuprolide Acetate) in Sexual Offenders with Paraphilia. J Korean Med Sci 2018; 33:e231. [PMID: 30190656 PMCID: PMC6125314 DOI: 10.3346/jkms.2018.33.e231] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 06/14/2018] [Indexed: 11/20/2022] Open
Abstract
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.
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Affiliation(s)
- Jong Hyuk Choi
- Department of Psychiatry, National Forensic Hospital, Gongju, Korea
| | - Jae Woo Lee
- Department of Psychiatry, National Forensic Hospital, Bugok, Korea
| | - Jang Kyu Lee
- Sex Offenders and Treatment Center, National Forensic Hospital, Gongju, Korea
| | - Soyeong Jang
- Department of Psychiatry, National Forensic Hospital, Gongju, Korea
| | - Mi Yoo
- Department of Psychiatry, National Forensic Hospital, Gongju, Korea
| | - Dae-bo Lee
- Department of Psychiatry, National Forensic Hospital, Gongju, Korea
| | - Jeong-Won Hong
- National Institution of Probation and Parole Office, Chuncheon, Korea
| | - Il Suk Noh
- National Institution of Probation and Parole Office, Cheonan, Korea
| | - Myung Ho Lim
- Department of Psychology and Psychotherapy, College of Health Science, Dankook University, Cheonan, Korea
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Briken P, Müller JL, Berner W, Bödeker RH, Vollmann J, Kasperk C, Koller M. Vom Scheitern einer Studie in Maßregelvollzugskrankenhäusern. DER NERVENARZT 2017; 88:480-485. [DOI: 10.1007/s00115-017-0301-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Abstract
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.
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Affiliation(s)
- Brian J Holoyda
- Department of Psychiatry and Behavioral Sciences, University of California, Davis School of Medicine, 2230 Stockton Blvd., Sacramento, CA, 95817, USA.
| | - Denise C Kellaher
- Department of Psychiatry and Behavioral Sciences, University of California, Davis School of Medicine, 2230 Stockton Blvd., Sacramento, CA, 95817, USA.
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9
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Shin MS, Chung KJ, Ko IG, Kim SH, Jin JJ, Kim SE, Lee JM, Ji ES, Kim TW, Cho HS, Kim CH, Cho YS, Kim CJ, Kim KH. Effects of surgical and chemical castration on spatial learning ability in relation to cell proliferation and apoptosis in hippocampus. Int Urol Nephrol 2016; 48:517-27. [PMID: 26781653 DOI: 10.1007/s11255-015-1200-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Accepted: 12/23/2015] [Indexed: 11/28/2022]
Abstract
PURPOSE Chemical castration using luteinizing hormone-releasing hormone agonists and/or anti-androgens is an alternative to surgical castration. Goserelin and bicalutamide are representative drugs used for chemical castration. The effects of chemical castration on sexual functions are well documented; however, the possibility that chemical castration might induce undesirable effects on brain functions has been raised. We investigated the effects of chemical castration and surgical castration on spatial learning ability in relation to cell proliferation and apoptosis in hippocampus. METHODS Bilateral orchiectomy was performed for surgical castration, and chemical castration was induced by treatment with goserelin or bicalutamide for 28 days. To find out the effects of goserelin and bicalutamide with those of orchiectomy on the spatial learning ability, radial eight-arm maze test was performed. To find out the effects of goserelin and bicalutamide with those of orchiectomy in relation to cell proliferation and apoptosis in the hippocampus, terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling staining, and immunohistochemistry for 5-bromo-2'-deoxyuridine, doublecortin, and caspase-3 were performed. Western blot for brain-derived neurotrophic factor, tyrosine kinase receptor B, Bax, and Bcl-2 in the hippocampus was also performed. RESULTS Orchiectomy caused deterioration of spatial learning ability with suppression of cell proliferation and enhancement of apoptosis in the hippocampus. However, treatment with goserelin and bicalutamide had no effect on spatial learning ability. Cell proliferation and apoptosis were not altered by treatment with goserelin and bicalutamide either. CONCLUSIONS Surgical castration causes deterioration of spatial learning ability, while chemical castration does not impair spatial learning ability. We should find out further mechanisms affect to the relationship between androgen level and neurogenesis and neuronal apoptosis.
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Affiliation(s)
- Mal-Soon Shin
- Department of Physiology, College of Medicine, Kyung Hee University, Dongdaemun-gu, Seoul, 130-701, Republic of Korea
| | - Kyung Jin Chung
- Department of Urology, Gachon University Gil Medical Center, Gachon University School of Medicine, Incheon, 405-760, Republic of Korea
| | - Il-Gyu Ko
- Department of Physiology, College of Medicine, Kyung Hee University, Dongdaemun-gu, Seoul, 130-701, Republic of Korea
| | - Sang-Hoon Kim
- Department of Physiology, College of Medicine, Kyung Hee University, Dongdaemun-gu, Seoul, 130-701, Republic of Korea
| | - Jun-Jang Jin
- Department of Physiology, College of Medicine, Kyung Hee University, Dongdaemun-gu, Seoul, 130-701, Republic of Korea
| | - Sung-Eun Kim
- Department of Physiology, College of Medicine, Kyung Hee University, Dongdaemun-gu, Seoul, 130-701, Republic of Korea
| | - Jae-Min Lee
- Department of Physiology, College of Medicine, Kyung Hee University, Dongdaemun-gu, Seoul, 130-701, Republic of Korea
| | - Eun-Sang Ji
- Department of Physiology, College of Medicine, Kyung Hee University, Dongdaemun-gu, Seoul, 130-701, Republic of Korea
| | - Tae-Woon Kim
- Department of Physiology, College of Medicine, Kyung Hee University, Dongdaemun-gu, Seoul, 130-701, Republic of Korea
| | - Han-Sam Cho
- Department of Physiology, College of Medicine, Kyung Hee University, Dongdaemun-gu, Seoul, 130-701, Republic of Korea
| | - Chang Hee Kim
- Department of Urology, Gachon University Gil Medical Center, Gachon University School of Medicine, Incheon, 405-760, Republic of Korea
| | - Young-Sam Cho
- Department of Urology, School of Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University, Jongro-gu, Seoul, 110-746, Republic of Korea
| | - Chang-Ju Kim
- Department of Physiology, College of Medicine, Kyung Hee University, Dongdaemun-gu, Seoul, 130-701, Republic of Korea
| | - Khae-Hawn Kim
- Department of Urology, Gachon University Gil Medical Center, Gachon University School of Medicine, Incheon, 405-760, Republic of Korea.
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10
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Nair M. Pharmacotherapy for Sexual Offenders. SEXUAL OFFENDING 2016. [DOI: 10.1007/978-1-4939-2416-5_32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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11
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Thibaut F, Bradford JMW, Briken P, De La Barra F, Häßler F, Cosyns P. The World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the treatment of adolescent sexual offenders with paraphilic disorders. World J Biol Psychiatry 2015; 17:2-38. [PMID: 26595752 PMCID: PMC4743592 DOI: 10.3109/15622975.2015.1085598] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 08/18/2015] [Indexed: 01/12/2023]
Abstract
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.
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Affiliation(s)
- Florence Thibaut
- University Hospital Cochin, Faculty of Medicine Paris Descartes, INSERM U 894 CPN,
Paris,
France
| | - John M. W. Bradford
- University of Ottawa, Institute of Mental Health Research, Division of Forensic Psychiatry, Queen’s University, Clinical Director, Forensic Treatment Unit, Brockville Mental Health Centre, Royal Ottawa Health Care Group,
Brockville,
Ontario,
Canada
| | - Peer Briken
- Institute for Sex Research and Forensic Psychiatry, Center for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf,
Hamburg,
Germany
| | - Flora De La Barra
- East Psychiatry and Mental Health Department, University of Chile,
Clinica Las Condes,
Chile
| | - Frank Häßler
- Clinic for Child and Adolescent Psychiatry, University of Medicine of Rostock,
Rostock,
Germany
| | - Paul Cosyns
- University Forensic Centre (University Hospital of Antwerp),
Belgium
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12
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Park WS, Kim KM, Jung YW, Lim MH. A case of mental retardation with paraphilia treated with depot leuprorelin. J Korean Med Sci 2014; 29:1320-4. [PMID: 25246754 PMCID: PMC4168189 DOI: 10.3346/jkms.2014.29.9.1320] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2013] [Accepted: 02/10/2014] [Indexed: 11/20/2022] Open
Abstract
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.
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Affiliation(s)
- Woo Sung Park
- Department of Pediatrics, College of Medicine, Dankook University, Cheonan, Korea
| | - Kyung Min Kim
- Department of Psychiatry, College of Medicine, Dankook University, Cheonan, Korea
| | - Yong Woo Jung
- Department of Pharmacy, College of Pharmacy, Korea University, Sejong, Korea
| | - Myung Ho Lim
- Department of Psychology, College of Social Science, Dankook University, Cheonan, Korea
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13
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Assumpção AA, Garcia FD, Garcia HD, Bradford JMW, Thibaut F. Pharmacologic treatment of paraphilias. Psychiatr Clin North Am 2014; 37:173-81. [PMID: 24877704 DOI: 10.1016/j.psc.2014.03.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Alessandra Almeida Assumpção
- Department of Psychiatry, INCT-Medicina Molecular, Universidade Federal de Minas Gerais, Avenida Alfredo Balena, 190 Sala 240, Belo Horizonte, Minas Gerais, 30130-100, Brazil
| | - Frederico Duarte Garcia
- Department of Psychiatry, INCT-Medicina Molecular, Universidade Federal de Minas Gerais, Avenida Alfredo Balena, 190 Sala 240, Belo Horizonte, Minas Gerais, 30130-100, Brazil; INSERM U1073, Rouen University Hospital, Rouen University, 22 Boulevard Gambetta, Rouen Cx 76183, France.
| | - Heloise Delavenne Garcia
- Department of Psychiatry, INCT-Medicina Molecular, Universidade Federal de Minas Gerais, Avenida Alfredo Balena, 190 Sala 240, Belo Horizonte, Minas Gerais, 30130-100, Brazil; INSERM U1073, Rouen University Hospital, Rouen University, 22 Boulevard Gambetta, Rouen Cx 76183, France
| | - John M W Bradford
- Institute of Mental Health Research, Brockville Mental Health Centre, University of Ottawa, 1804 Highway 2 East, Brockville, Ontario K6V 5W7, Canada
| | - Florence Thibaut
- Psychiatry and Addictive Disorders, University Hospital Cochin-Tarnier, 89 rue d'Assas, 75006 Paris, France; Department of Psychiatry and Addictive Disorders, Faculté de Médecine Paris V Descartes, 75000 Paris, France; INSERM U894, Centre des Neurosciences, 2 ter rue d'Alesia, 75000 Paris, France
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Garcia FD, Delavenne HG, Assumpção ADFA, Thibaut F. Pharmacologic treatment of sex offenders with paraphilic disorder. Curr Psychiatry Rep 2013; 15:356. [PMID: 23572328 DOI: 10.1007/s11920-013-0356-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
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.
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Affiliation(s)
- Frederico Duarte Garcia
- Department of Psychiatry, INCT - de Medicina Molecular, Faculdade de Medicina, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Brazil
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Jordan K, Fromberger P, Stolpmann G, Müller JL. The Role of Testosterone in Sexuality and Paraphilia—A Neurobiological Approach. Part II: Testosterone and Paraphilia. J Sex Med 2011; 8:3008-29. [DOI: 10.1111/j.1743-6109.2011.02393.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
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.
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Affiliation(s)
- Frederico D Garcia
- ADEN Laboratory EA4311, Rouen University Hospital, Biomedical Research Institute, IFR 23, Rouen, France
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Thibaut F, De La Barra F, Gordon H, Cosyns P, Bradford JMW. The World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the biological treatment of paraphilias. World J Biol Psychiatry 2010; 11:604-55. [PMID: 20459370 DOI: 10.3109/15622971003671628] [Citation(s) in RCA: 124] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
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.
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Affiliation(s)
- Florence Thibaut
- Faculty of Medicine, Rouen University Hospital Ch. Nicolle, University of Rouen, Rouen, France.
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Guay DR. Drug treatment of paraphilic and nonparaphilic sexual disorders. Clin Ther 2009; 31:1-31. [DOI: 10.1016/j.clinthera.2009.01.009] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2008] [Indexed: 10/21/2022]
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Abstract
In a meta-analysis on controlled outcomes evaluations of 22,000 sex offenders, Losel and Schmucker found 80 comparisons between treatment and control groups. The recidivism rate averaged 19% in treated groups, and 27% in controls. Most other reviews reported a lower rate of sexual recidivism in treated sexual offenders. Of 2039 citations in this study (including literature in five languages), 60 studies held independent comparisons. Problematic issues included the control groups; various hormonal, surgical, cognitive behavioral, and psychotherapeutic treatments; and sample sizes. In the 80 studies compared after the year 2000, 32% were reported after 2000, 45% originated in the United States, 45% were reported in journals, and 36% were unpublished. Treatment characteristics showed a significant lack of pharmacologic treatment (7.5%), whereas use cognitive and classical behavioral therapy was 64%. In 68% of the studies, no information was available on the integrity of the treatment implementation; 36% of the treatment settings were outpatient only, 31% were prison settings, and 12% were mixed settings (prison, hospital, and outpatient). Integrating research interpretations is complicated by the heterogeneity of sex offenders, with only 56% being adult men and 17.5% adolescents. Offense types reported included 74% child molestation, 48% incest, and 30% exhibitionism. Pedophilia was not singled out. Follow-up periods varied from 12 months to greater than 84 months. The definition of recidivism ran the gamut from arrest (24%), conviction (30%), charges (19%), and no indication (16%). Results were difficult to interpret because of the methodological problems with this type of study. Overall, a positive outcome was noted with sex offender treatment. Cognitive-behavioral and hormonal treatment were the most promising. Voluntary treatment led to a slightly better outcome than mandatory participation. When accounting for a low base rate of sexual recidivism, the reduction was 37%, which included psychological and medical modes of treatment. Which treatments will reduce recidivism rates in sex offenders is extremely difficult to conclude. Some treatment effects are determined from small studies; however, recidivism rates may be based on different criteria. Larger studies tend to be published more frequently than small studies, negative results may be less likely to be reported in published studies, and differences in mandatory versus voluntary treatment may occur. Clearly more high-quality outcome studies are needed to determine which treatments work best for which individuals. One size is unlikely to fit all. However, pharmacologic intervention, although not always the perfect choice, has improved and will continue to advance the treatment of paraphilic, nonparaphilic, and compulsive sexual behaviors.
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Gordon H. The treatment of paraphilias: an historical perspective. CRIMINAL BEHAVIOUR AND MENTAL HEALTH : CBMH 2008; 18:79-87. [PMID: 18383202 DOI: 10.1002/cbm.687] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
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Abstract
The present report is a review of all 554 papers published on Medline on pedophilia. The first discussion is the history of the disorder from ancient Greece to the present time, especially the influence of the liberal country of the Netherlands, the North American Man-Boy Love Association, and the sexual crisis in the Catholic Church. One important question is the relationship between homosexual pedophilia and adult homosexuality. Evidence for and against this relationship is presented. Next discussed are the characteristics of the victim and the long lasting serious effects of sexual abuse. Laboratory correlations are included, especially phallometric tests in order to objectively measure the physical responses to sexual stimuli. Electrophysiological and radiographic tests are also mentioned, including electroencephalography, computed tomography, magnetic resonance imaging, and positron emission tomography scans. An important section is the characterization of pedophiles with emphasis on their frequent previous sexual abuse, their past, their present, and their anticipated future. The final topic is treatment of this disorder with surgery, medication, behavioral therapy and the combination of medication and behavioral therapy.
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Affiliation(s)
- John R Hughes
- Department of Neurology, University of Illinois Medical Center, Chicago 60612, USA.
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KAFKA MARTINP. The Monoamine Hypothesis for the Pathophysiology of Paraphilic Disorders: An Update. Ann N Y Acad Sci 2006. [DOI: 10.1111/j.1749-6632.2003.tb07295.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Pharmacogenomics as an Aspect of Molecular Autopsy for Forensic Pathology/Toxicology: Does GenotypingCYP 2D6Serve as an Adjunct for Certifying Methadone Toxicity? J Forensic Sci 2003. [DOI: 10.1520/jfs2002392] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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AmpFℓSTR® Profiler Plus™ Short Tandem Repeat DNA Analysis of Casework Samples, Mixture Samples, and Nonhuman DNA Samples Amplified under Reduced PCR Volume Conditions (25 µL). J Forensic Sci 2003. [DOI: 10.1520/jfs2002188] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Hill A, Briken P, Kraus C, Strohm K, Berner W. Differential pharmacological treatment of paraphilias and sex offenders. INTERNATIONAL JOURNAL OF OFFENDER THERAPY AND COMPARATIVE CRIMINOLOGY 2003; 47:407-421. [PMID: 12971182 DOI: 10.1177/0306624x03253847] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
This article gives an overview of current pharmacological treatment of paraphilias and sex offenders focusing on the situation in Germany. Information about selective serotonin reuptake inhibitors (SSRI) is followed by data about established antihormonal substances (cyproterone acetate/CPA, and medroxyprogesterone acetate/MPA), as well as a more detailed account on luteinizing hormone-releasing hormone agonists (LHRH agonists). The results of open, uncontrolled clinical studies with SSRIs (n = 16) and LHRH agonists (n = 11) in paraphilic outpatients confirm the positive effects of these substances. A survey about the use of CPA and LHRH agonists in forensic hospitals in Germany shows that half of the patients treated with any kind of (anti-) hormonal agents received an LHRH agonist. The authors present a protocol on side effects, contraindications, and monitoring of CPA and LHRH agonists and develop an algorithm for differential pharmacotherapy of paraphilias.
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Affiliation(s)
- Andreas Hill
- Klinik fuer Psychiatrie und Psychotherapie, Abteilung für Sexualforschung und Forensik, Universitaetsklinikum Hamburg Eppendorf, Hamburg D-20246, Germany
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Osteoporosis Associated with the Treatment of Paraphilias: A Clinical Review of Seven Case Reports. J Forensic Sci 2003. [DOI: 10.1520/jfs2002089] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Schwartz BK. Overview of rehabilitative efforts in understanding and managing sexually coercive behaviors. Ann N Y Acad Sci 2003; 989:360-83; discussion 441-5. [PMID: 12839912 DOI: 10.1111/j.1749-6632.2003.tb07319.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
In reviewing approaches to rehabilitative efforts in understanding and managing sexually coercive behaviors within the past two decades, one is struck by the development of two totally divergent paths. In 1971, there were a few civil commitment programs operated by mental health departments-most notably were the Sexual Psychopath Program at Western State Hospital in Fort Steilacoom, Washington, and the Massachusetts Treatment Center for Sexually Dangerous Persons. There were a few programs in prisons started by therapists who were interested in this population but given little recognition and even fewer resources. Additionally there were a handful of community-based programs including the J.J. Peters Institute in Philadelphia and PASO (Positive Approaches to Sex Offenders) in Albuquerque, New Mexico. Today there are thousands of specialized sexual offender treatment programs treating sexual abusers of every age, gender, ethnicity, and with a wide range of comorbid conditions. They are treated in the community, prisons, mental hospitals, residential facilities, and private practices. There is an international organization, a specialized research journal, and a specialized branch of the Department of Justice, the Center for Sex Offender Management. This chapter will provide an overview of the developments in the field, primarily covering the last 25 years. It will look at the evolution of theoretical approaches, the development of specialized approaches for subpopulations, significant landmarks, and possible future trends.
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Saleh FM, Berlin FS. Sex hormones, neurotransmitters, and psychopharmacological treatments in men with paraphilic disorders. JOURNAL OF CHILD SEXUAL ABUSE 2003; 12:233-253. [PMID: 15308453 DOI: 10.1300/j070v12n03_09] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
Paraphilic disorders are psychiatric syndromes primarily characterized by deviant sexual thoughts, cravings, urges, and/or behaviors. Paraphilic men may engage in inappropriate sexual behaviors when cravings for socially unacceptable sexual acts become overpowering. These often chronic disorders may not only cause emotional distress and social embarrassment to the afflicted patient but also to the targets of their paraphilic focus. The primary objective of this article is to examine and review data on the efficacy and tolerability of the testosterone-lowering agents medroxprogesterone acetate, cyproterone acetate, and leuprolide acetate. The secondary goal is to review data on less conventional and more innovative pharmacological treatments, particularly the serotonin-specific reuptake inhibitors.
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Affiliation(s)
- Fabian M Saleh
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Krueger RB, Kaplan MS. Behavioral and psychopharmacological treatment of the paraphilic and hypersexual disorders. J Psychiatr Pract 2002; 8:21-32. [PMID: 15985851 DOI: 10.1097/00131746-200201000-00004] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Richard B Krueger
- Columbia University College of Physicians and Surgeons, New York State Psychiatric Institute, NY 10032-2695, USA
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Bradford JM. The neurobiology, neuropharmacology, and pharmacological treatment of the paraphilias and compulsive sexual behaviour. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2001; 46:26-34. [PMID: 11221487 DOI: 10.1177/070674370104600104] [Citation(s) in RCA: 125] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
There has been increasing interest in the treatment of sexual disorders in recent years. Sexual disorders are classified in DSM-IV as sexual dysfunctions, paraphilias, and gender identity disorders. The sexual dysfunctions are nondeviant or nonparaphillic. The sexual dysfunction disorders should include "hyperactive sexual desire disorder" under sexual desire disorders. Further, there should be a specifier for paraphilias of "with hypersexuality" or "without hypersexuality." There is still incomplete understanding of the neurobiology of sexual disorders although functional neuroanatomy and neoropharmcological research has exposed the neurotransmitters, receptors, and hormones that are involved in sexual desire. Various pharmacological agents including serotonin reuptake inhibitors, antiandrogens, LHRH agonists, and others have been documented as reducing sexual desire. An algorithm for the use of these drugs in the treatment of the paraphilias as well nonparaphilic hypersexuality is outlined. The modes of action, dosages, aims of treatment, and usual methods of prescribing these agents is reviewed in this article. Some future directions of research in pharmacological treatment is also discussed.
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Affiliation(s)
- J M Bradford
- Division of Forensic Psychiatry, University of Ottawa, Ontario.
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Briken P, Nika E, Berner W. Treatment of paraphilia with luteinizing hormone-releasing hormone agonists. JOURNAL OF SEX & MARITAL THERAPY 2001; 27:45-55. [PMID: 11224953 DOI: 10.1080/00926230152035840] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
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.
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Affiliation(s)
- P Briken
- Department of Sexology, Clinic of Psychiatry & Psychotherapy of the University of Hamburg, Martinistrasse 25, 20246 Hamburg, Germany
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Reilly DR, Delva NJ, Hudson RW. Protocols for the use of cyproterone, medroxyprogesterone, and leuprolide in the treatment of paraphilia. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2000; 45:559-63. [PMID: 10986575 DOI: 10.1177/070674370004500608] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To propose a protocol for minimizing medical complications associated with the use of cyproterone, medroxyprogesterone, and depot leuprolide to treat paraphilia. METHOD Review of the relevant literature. RESULTS Certain patient populations should not be treated with these medications, and medical complications associated with each can be detected early and avoided. CONCLUSIONS For each drug, a series of screening tests prior to use and scheduled testing during use can minimize potential medical complications.
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Abstract
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.
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Affiliation(s)
- A Rösler
- Department of Endocrinology, Hadassah University Hospital, P.O. Box 12000, il-91120 Jerusalem, Israel.
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Balon R. Pharmacological treatment of paraphilias with a focus on antidepressants. JOURNAL OF SEX & MARITAL THERAPY 1998; 24:241-254. [PMID: 9805285 DOI: 10.1080/00926239808403960] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
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.
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Affiliation(s)
- R Balon
- Department of Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine, Detroit, Michigan, USA.
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Rösler A, Witztum E. Treatment of men with paraphilia with a long-acting analogue of gonadotropin-releasing hormone. N Engl J Med 1998; 338:416-22. [PMID: 9459644 DOI: 10.1056/nejm199802123380702] [Citation(s) in RCA: 165] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- A Rösler
- Department of Endocrinology and Metabolism, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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Thibaut F, Cordier B, Kuhn JM. Gonadotrophin hormone releasing hormone agonist in cases of severe paraphilia: a lifetime treatment? Psychoneuroendocrinology 1996; 21:411-9. [PMID: 8844879 DOI: 10.1016/0306-4530(96)00004-2] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Six patients with severe paraphilia were treated with a long-acting gonadotrophin hormone releasing hormone analogue (GnRH-a). In five cases, the antiandrogen treatment ended their deviant sexual behaviour and markedly decreased their sexual fantasies and activities without significant side-effects. The beneficial effects of this treatment were maintained for 7 years in the patient where there was the longest follow-up. Two patients abruptly withdrew front their antiandrogen treatment at the end of the first and third year, respectively. Both relapsed within 8-10 weeks. One of them asked for resumption of antiandrogen treatment. In another case, in order to phase out antiandrogen treatment, testosterone (T) was added to the GnRH-a. In spite of normal T levels, and of resumption of normal sexual activities and deviant fantasies, deviant sexual behaviour did not return. A smoother phasing out of GnRH-a treatment is thought to be better than an abrupt withdrawal. However, the duration of antiandrogen treatment necessary to ensure a complete disappearance of deviant sexual behaviour remains uncertain, but is at least 4 years.
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Affiliation(s)
- F Thibaut
- Department of Pschiatry, University of Rouen, France
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