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Sauter J, Lingenti LM, Rettenberger M, Turner D, Briken P, Voß T. The impact of testosterone-lowering medication on recidivism in individuals convicted of sexual offenses. DIALOGUES IN CLINICAL NEUROSCIENCE 2024; 26:28-37. [PMID: 38837043 PMCID: PMC11155425 DOI: 10.1080/19585969.2024.2359923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 05/21/2024] [Indexed: 06/06/2024]
Abstract
INTRODUCTION Treatment of individuals who have committed sexual offences with Testosterone-Lowering Medication (TLM) is a comparatively intrusive kind of intervention, which regularly takes place in coercive contexts. Thus, the question of efficacy, but also the question of who should be treated, when and for how long, are of great importance. METHODS Recidivism rates of TLM-treated high-risk individuals (+TLM; n = 54) were compared with high-risk individuals treated with psychotherapy only in the same forensic outpatient clinic (-TLM; n = 79). RESULTS Group differences suggested a higher initial risk of + TLM (e.g. higher ris-assessment, previous convictions). Despite the increased risk, after an average time at risk of six years, +TLM recidivated significantly less often and significantly later than - TLM (27.8% vs. 51.9%). Such an effect was also found for violent (1.9% vs. 15.2%), but not for sexual (5.6% vs. 10.1%) and serious recidivism (5.6% vs. 10.1%), which could be explained partly by the small number of cases. In the course of treatment, TLM proved to be a significant variable for a positive process, whereas a high risk-assessment score indicated a rather negative course. In total, n = 19 individuals had stopped their TLM treatment, of these 31.6% recidivated. CONCLUSION The results support the efficacy of TLM, particularly in the group of high-risk offenders.
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Affiliation(s)
- Julia Sauter
- Department of Psychology, University of Kassel, Kassel, Germany
| | - Laura M. Lingenti
- Institute of Health, Institute of Forensic Psychiatry, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
- Faculty of Psychology and Neuroscience (FPN), Maastricht University, Maastricht, The Netherlands
| | - Martin Rettenberger
- Department of Psychology, Johannes Gutenberg-University (JGU), Mainz, Germany
- Centre for Criminology, Kriminologische Zentralstelle (KrimZ), Wiesbaden, Germany
| | - 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
| | - Tatjana Voß
- Institute of Health, Institute of Forensic Psychiatry, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
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Lievesley R, Swaby H, Winder B, Norman C, Hocken K. "One a Day Keeps the Prison Away": Understanding the Experiences of Individuals Convicted of Sexual Offences Receiving Anti-Androgens for the Treatment of Problematic Sexual Arousal. ARCHIVES OF SEXUAL BEHAVIOR 2024; 53:2141-2158. [PMID: 38594464 PMCID: PMC11176105 DOI: 10.1007/s10508-024-02847-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 02/22/2024] [Accepted: 02/23/2024] [Indexed: 04/11/2024]
Abstract
Problematic sexual arousal (PSA) is an umbrella term to describe a range of clinical presentations related to excessive sexual thinking (e.g., sexual preoccupation) and sexual behavior (e.g., hypersexuality). Although such concepts are known to affect sexual recidivism among individuals convicted of sexual offences, PSA is not routinely or directly targeted in offending behavior programs in England and Wales. However, in recent years, there have been moves to incorporate pharmacological interventions for addressing this among people with sexual offence histories. Although some work to understand the experiences of those taking SSRI medication for this purpose has emerged, little is known about the experiences of service users taking anti-androgen medication. In this study, we interviewed all individuals in prison taking anti-androgens for the treatment of problematic sexual arousal following convictions for sexual offences in England at the time of data collection (N = 10). Using a phenomenologically oriented thematic analysis, we established themes pertaining to "Differing needs: Motivations for treatment," "Medication as a risk management strategy," and how the medication helped the men in their pursuit of "Discovering a 'new me'." This work contributes important knowledge to inform the development of ethical and effective prescribing of anti-androgen medication with this population and offer recommendations for both future research and the development of clinical practice.
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Affiliation(s)
- Rebecca Lievesley
- NTU Psychology, School of Social Sciences, Nottingham Trent University, 50 Shakespeare Street, Nottingham, NG1 4FQ, UK.
| | - Helen Swaby
- NTU Psychology, School of Social Sciences, Nottingham Trent University, 50 Shakespeare Street, Nottingham, NG1 4FQ, UK
| | - Belinda Winder
- NTU Psychology, School of Social Sciences, Nottingham Trent University, 50 Shakespeare Street, Nottingham, NG1 4FQ, UK
| | - Christine Norman
- NTU Psychology, School of Social Sciences, Nottingham Trent University, 50 Shakespeare Street, Nottingham, NG1 4FQ, UK
| | - Kerensa Hocken
- Midlands Psychology Services, His Majesty's Prison and Probation Service, Nottingham, UK
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Barceló-Soler A, García-Campayo J, Araya R, Doukani A, Gili M, García-Palacios A, Mayoral F, Montero-Marin J. Working alliance in low-intensity internet-based cognitive behavioral therapy for depression in primary care in Spain: A qualitative study. Front Psychol 2023; 14:1024966. [PMID: 37063543 PMCID: PMC10090318 DOI: 10.3389/fpsyg.2023.1024966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 03/07/2023] [Indexed: 03/31/2023] Open
Abstract
Introduction Psychotherapies delivered via the Internet have been promoted as an alternative for improving access to psychological treatments. A conceptual working alliance model of blended (i.e., traditional face-to-face consultation combined with Internet-delivered psychotherapy) cognitive-behavioral therapy (b-CBT) for depression has been developed in the UK. However, little is known about how this important therapeutic process, namely the working alliance (WA), is developed and maintained in Internet-delivered cognitive-behavioral therapy without face-to-face consultation (i-CBT). The aim of this study was to evaluate the validity of the WA model of b-CBT in Spanish patients with depression receiving i-CBT. Methods Forty-one patients suffering from mild-moderate depression were interviewed to assess their experiences of an i-CBT program. Interviews were conducted with participants who received a self-guided application (n = 9), and low-intensity support (n = 10). Three group interviews were also conducted with patients who either did not start the program (n = 8) or did not complete it (n = 6), and with patients who did complete it (n = 8). Results Qualitative thematic content analysis was performed using the constant comparative method, which revealed four main themes: "bond," "goals," "task," and "usability heuristics," all consistent with the existing literature. However, a new subcategory emerged, called "anonymity," which may highlight the social stigma that mental illness still has in the Spanish context. Conclusion Results suggest that the development and maintenance of the WA through i-CBT could offer a better experience of the therapeutic process and improve the clinical impact. Clinical Trial Registration Clinicaltrials.gov, identifier: NCT01611818.
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Affiliation(s)
- Alberto Barceló-Soler
- Navarra Medical Research Institute (IdiSNA), Pamplona, Spain
- Institute of Health Research of Aragon (IIS Aragon), Zaragoza, Spain
| | - Javier García-Campayo
- Institute of Health Research of Aragon (IIS Aragon), Zaragoza, Spain
- Department of Psychiatry, University of Zaragoza, Zaragoza, Spain
| | | | - Asmae Doukani
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Margalida Gili
- Department of Psychology, University of the Balearic Islands, Palma, Spain
| | - Azucena García-Palacios
- Department of Basic and Clinical Psychology and Psychobiology, Universitat Jaume I, Castelló de la Plana, Spain
- CIBER Fisiopatología Obesidad y Nutrición (CIBERObn), Instituto Salud Carlos III, Madrid, Spain
| | | | - Jesus Montero-Marin
- Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, United Kingdom
- Teaching, Research and Innovation Unit, Parc Sanitari Sant Joan de Déu, Sant Boi de Llobregat, Spain
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBER Epidemiology and Public Health—CIBERESP), Madrid, Spain
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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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Sauter J, Rettenberger M, Briken P, Turner D. Survey on the Prescription Patterns of Pharmacological Agents in Individuals Who Have Committed Sexual Offenses During Forensic Outpatient Treatment in Germany: How Many Discontinue Testosterone Lowering Medication Under Parole? J Sex Med 2022; 19:1147-1155. [PMID: 35624071 DOI: 10.1016/j.jsxm.2022.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 04/01/2022] [Accepted: 04/13/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND The number of individuals who sexually offended, and who are continued to be treated with pharmacological agents to reduce sex drive after their release from prison or forensic psychiatry, are not known. Furthermore, figures on the number of those who stop their sexdrive supressing antiandrogen treatment in the outpatient setting are unknown as well. This is of central importance though as it might be associated with an increased risk of recidivism. AIM To assess prescription patterns as well as adherence to pharmacological treatment in outpatient clinics in Germany for individuals who have sexually offended and were released from prison or forensic psychiatric hospital. METHODS A self-constructed online survey assessing the pharmacological treatment modalities was sent by e-mail to n = 103 forensic outpatient clinics in Germany. Thirty-three (32.0%) completed the questionnaire and reported about 834 patients. OUTCOMES Prevalence of the use of different pharmacological agents in the treatment of individuals convicted for sexual offenses as well as the number of patients who have discontinued testosterone-lowering medication (TLM). RESULTS Among all institutions, 22.4% (n = 187) of individuals received pharmacological treatment, with 40.1% receiving gonadotropin-releasing-hormone-agonists, 26.2% antipsychotics, 24.6% selective serotonin reuptake inhibitors, 6.4% cyproterone acetate, and 2.7% a combination of gonadotropin-releasing-hormone-agonists and cyproterone acetate. A significant positive correlation was found between the number of patients released from a forensic-psychiatric hospital and the number of patients treated with TLM. Within 1 year 8.6% (n = 16) stopped their TLM during or at the end of the supervision period, most of them against treatment providers advice. CLINICAL IMPLICATIONS Substantial regional differences indicate uncertainties regarding the prescription of pharmacological agents for outpatients who have committed sexual offences in Germany. The discontinuiation of TLM within the first year of treatment against treatment providers advise in a substantial proportion of patients could be associated with a serious risk for reoffending. STRENGTHS & LIMITATIONS The present survey captures prevalences of the pharmacotherapy in forensic aftercare facilities for individuals who have offended sexually, and is the first to record the number of discontinuations. This is a cross-sectional survey covering only 1 country, but includes a large number of individuals. CONCLUSION Even though the number of treated individuals has increased in prisons, the majority of pharmacological treatment is still provided by forensic hospitals, which then translates into the outpatient setting. The number of those who stop taking such medication is a highly relevant topic for both forensic treatment providers and legal decision makers Sauter J, Rettenberger M, Briken P, et al. Survey on the Prescription Patterns of Pharmacological Agents in Individuals Who Have Committed Sexual Offenses During Forensic Outpatient Treatment in Germany: How Many Discontinue Testosterone Lowering Medication Under Parole?. J Sex Med 2022;19:1147-1155.
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Affiliation(s)
- Julia Sauter
- Department of Psychology, University of Kassel, Kassel, Germany; Department of Psychology, Johannes Gutenberg-University (JGU), Mainz, Germany.
| | - Martin Rettenberger
- Department of Psychology, Johannes Gutenberg-University (JGU), Mainz, Germany; Centre for Criminology (Kriminologische Zentralstelle - KrimZ), Wiesbaden, Germany
| | - Peer Briken
- Institute for Sex Research, Sexual Medicine and Forensic Psychiatry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Daniel Turner
- Department of Psychiatry and Psychotherapy, University Medical Center Mainz, Mainz, Germany
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De Landtsheer A, Bekaert L, David K, Marcq P, Jeandarme I, Decallonne B, Antonio L, Vanderschueren D. The impact of androgen deprivation therapy on bone mineral density in men treated for paraphilic disorder: A retrospective cohort study. Andrology 2021; 10:545-550. [PMID: 34914863 DOI: 10.1111/andr.13142] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Revised: 11/30/2021] [Accepted: 12/10/2021] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
| | - Lieslinde Bekaert
- Department of Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - Karel David
- Department of Endocrinology, University Hospitals Leuven, Leuven, Belgium.,Department of Clinical and Experimental Medicine, KU Leuven, Laboratory of Clinical and Experimental Endocrinology, Leuven, Belgium
| | - Philippe Marcq
- Department of Endocrinology, University Hospitals Leuven, Leuven, Belgium
| | | | - Brigitte Decallonne
- Department of Endocrinology, University Hospitals Leuven, Leuven, Belgium.,Department of Clinical and Experimental Medicine, KU Leuven, Laboratory of Clinical and Experimental Endocrinology, Leuven, Belgium
| | - Leen Antonio
- Department of Endocrinology, University Hospitals Leuven, Leuven, Belgium.,Department of Clinical and Experimental Medicine, KU Leuven, Laboratory of Clinical and Experimental Endocrinology, Leuven, Belgium
| | - Dirk Vanderschueren
- Department of Endocrinology, University Hospitals Leuven, Leuven, Belgium.,Department of Clinical and Experimental Medicine, KU Leuven, Laboratory of Clinical and Experimental Endocrinology, Leuven, Belgium
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Masson S, Medam T, Raibon E, Fontaine C, Levy X. Double-Blind, Placebo-Controlled Trial of Cyproterone Acetate to Prevent Flare-Up Effect on Dogs Implanted With Deslorelin. Front Vet Sci 2021; 8:714154. [PMID: 34660758 PMCID: PMC8511793 DOI: 10.3389/fvets.2021.714154] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 08/30/2021] [Indexed: 11/13/2022] Open
Abstract
Deslorelin slow-released implants are registered in Europe for the reversible suppression of fertility in male dogs. After administration, a time-limited increase in sex hormones concentration and related behavioral problems may be observed. The aim of this work was to assess whether cyproterone acetate, a synthetic progestogen, can prevent this flare-up effect. Eighteen privately-owned entire male dogs were enrolled in this double-blind, placebo-controlled, randomized clinical trial. All subjects received a 4.7 mg deslorelin implant by SC route and 1-3 capsules containing either cyproterone acetate 2 mg/kg (N = 9) or a placebo (N = 9), by oral route BID for 14 days, depending on the dog's weight. The dogs were followed for 28 days. An increase in the blood testosterone concentration was observed in respectively 9/9 and 7/9 dogs of the control and cyproterone groups (p = 0.47). However, a worsening of the sex hormone related problems (i.e., urinary marking, mounting, aggressiveness toward other dogs and/or escape) was only observed in the placebo group, in 56 or 66% of the dogs as measured by respectively the veterinarian and the owners. Our study suggests that cyproterone acetate is effective and safe to supress the deslorelin induced behavioral flare-up effect, but not the rise in testosterone.
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Affiliation(s)
| | | | | | | | - Xavier Levy
- Centre de Reproduction des Carnivores du Sud-Ouest (CRECS), L'isle Jourdain, France
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New Insights Into Extended Steroid Hormone Profiles in Transwomen in a Multi-Center Setting in Germany. J Sex Med 2021; 18:1807-1817. [PMID: 37057498 DOI: 10.1016/j.jsxm.2021.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 06/07/2021] [Accepted: 08/09/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Little information is available on steroid hormone profiles in transwomen on the day of gender affirming surgery (GAS) after gender affirming hormone therapy (GAHT). AIM We compared extended serum steroid hormone profiles of 77 transwomen with 3 different treatment regimens in order to get more insight on how GAHT changes the hormone system. METHODS Samples were obtained from 3 independent clinics. Individuals in clinic A (n = 13) and B (n = 51) discontinued GAHT 4-6 weeks and 2 weeks before GAS, individuals in clinic C (n = 13) continued treatment. Testicular tissue, blood samples and questionnaires on age, weight, height, and medication use were received from each patient. Steroid hormones were measured by liquid chromatography-tandem mass spectrometry (LC-MS/MS), 6 sex hormones were determined by immunofluorometric assays, and ELISA. Spermatogenesis was scored using the Bergman/Kliesch score. OUTCOMES Participants were not different with regard to age, BMI, treatment duration, and dosage. Feminized blood serum levels with low LH, low FSH and low testosterone, however, were achieved in persons taking GAHT until GAS. Significantly reduced cortisone levels were seen after stopping GAHT before GAS. RESULTS GAHT had marked effects on the sex-steroid profile in each person. Factor analysis provided a model explaining 78% of the variance and interdependency of sex steroid levels. Stopping treatment was inversely associated with intactness of the corticosteroid-axis with adrenal steroidogenesis as well as it was inversely associated with pituitary-gonadal hormone production. CLINICAL IMPLICATIONS Transwomen generally did not have elevated cortisone levels but differed significantly depending on and when GAHT was stopped. STRENGTHS & LIMITATIONS This is the first study examining the steroid hormone profiles of transgender persons on the day of GAS in a multi-center setting. Additional studies (including follow ups before and after GAS and stress questionnaires) will be necessary to assess these conflicting results about the possible psychological impact on persons undergoing GAS to improve care. CONCLUSION Concerning feminized blood serum levels, continued GAHT seems the better alternative, however stopping treatment 4-6 weeks prior to surgery was associated with reduced cortisone levels. Schneider F, Wistuba J, Holterhus P-M, et al. New Insights Into Extended Steroid Hormone Profiles in Transwomen in a Multi-Center Setting in Germany. J Sex Med 2021;18:1807-1817.
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Abstract
Androgens are potent drugs requiring prescription for valid medical indications but are misused for invalid, unproven, or off-label reasons as well as being abused without prescription for illicit nonmedical application for performance or image enhancement. Following discovery and first clinical application of testosterone in the 1930s, commercialization of testosterone and synthetic androgens proliferated in the decades after World War II. It remains among the oldest marketed drugs in therapeutic use, yet after 8 decades of clinical use, the sole unequivocal indication for testosterone remains in replacement therapy for pathological hypogonadism, organic disorders of the male reproductive system. Nevertheless, wider claims assert unproven, unsafe, or implausible benefits for testosterone, mostly representing wishful thinking about rejuvenation. Over recent decades, this created an epidemic of testosterone misuse involving prescription as a revitalizing tonic for anti-aging, sexual dysfunction and/or obesity, where efficacy and safety remains unproven and doubtful. Androgen abuse originated during the Cold War as an epidemic of androgen doping among elite athletes for performance enhancement before the 1980s when it crossed over into the general community to become an endemic variant of drug abuse in sufficiently affluent communities that support an illicit drug industry geared to bodybuilding and aiming to create a hypermasculine body physique and image. This review focuses on the misuse of testosterone, defined as prescribing without valid clinical indications, and abuse of testosterone or synthetic androgens (androgen abuse), defined as the illicit use of androgens without prescription or valid indications, typically by athletes, bodybuilders and others for image-oriented, cosmetic, or occupational reasons.
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Affiliation(s)
- David J Handelsman
- ANZAC Research Institute, University of Sydney, Sydney, Australia.,Andrology Department, Concord Hospital, Sydney, Australia
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10
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Sauter J, Turner D, Briken P, Rettenberger M. Testosterone-Lowering Medication and Its Association With Recidivism Risk in Individuals Convicted of Sexual Offenses. SEXUAL ABUSE : A JOURNAL OF RESEARCH AND TREATMENT 2021; 33:475-500. [PMID: 32167420 PMCID: PMC8072038 DOI: 10.1177/1079063220910723] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
For a particular subgroup of individuals with severe paraphilic disorders and a high risk of sexual recidivism, the combination of sex drive-reducing medications and psychotherapy is a promising treatment approach. The present quasi-experimental study aims at comparing differences in clinical characteristics and dynamic risk factors between persons receiving (+TLM, n = 38) versus not receiving (-TLM, n = 22) testosterone-lowering medications (TLMs). Individuals receiving TLM were more frequently diagnosed with paraphilic disorders. Neither the criminal history nor average risk scores differed between the two groups. In the +TLM, Stable-2007 scores showed a stronger decrease after TLM treatment was started. This accounted especially for the general and sexual self-regulation subscales. Individual variations in risk, however, were not predicted by TLM but were significantly related to treatment duration and Psychopathy Checklist-Revised (PCL-R) Factor I. Paraphilic patients with problems in self-regulatory abilities seem to profit most from pharmacological sex drive-reducing treatment. Furthermore, therapists seem to underestimate deviant sexual fantasies in medicated patients.
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Affiliation(s)
- Julia Sauter
- Charité–Universitätsmedizin Berlin, Germany
- Johannes Gutenberg-University Mainz, Germany
| | - Daniel Turner
- University Medical Center Mainz, Germany
- University Medical Center Hamburg-Eppendorf, Germany
| | - Peer Briken
- University Medical Center Hamburg-Eppendorf, Germany
| | - Martin Rettenberger
- Johannes Gutenberg-University Mainz, Germany
- Kriminologische Zentralstelle, Wiesbaden, Germany
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11
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Boons L, Jeandarme I, Vervaeke G. Androgen Deprivation Therapy in Pedophilic Disorder: Exploring the Physical, Psychological, and Sexual Effects From a Patient's Perspective. J Sex Med 2021; 18:353-362. [PMID: 33468446 DOI: 10.1016/j.jsxm.2020.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 11/30/2020] [Accepted: 12/02/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND The use of androgen deprivation therapy (ADT) shows promising results in the treatment of paraphilic disorders. Although the side effects of ADT can be intrusive, there is no research into the experiences of patients with pedophilic disorder themselves. AIM This research aims to explore the psychological, physical, and sexual experiences of ADT from the perspective of sex offenders diagnosed with pedophilic disorder. METHODS Twelve semistructured in-depth interviews with male adults diagnosed with pedophilic disorder were conducted using a phenomenological approach. Six of the 12 respondents were on luteinizing hormone-releasing hormone agonists and the remaining on anti-androgens. Half of each group were inpatients, and the other half outpatients. The respondents were recruited in collaboration with one psychiatric hospital. The data were analyzed with help of a qualitative software application NVivo. OUTCOMES The respondents described experiences on the use of ADT on a physical, psychological, and sexual level. RESULTS The most prominent physical side effects mentioned were bone loss, weight gain, and breast formation. The respondents generally described a positive influence of the medication on their well-being. They felt more relaxed and experienced a reduction in frequency and intensity of sexual fantasies, anger, and aggressive feelings in general. In addition, all the respondents noticed a lower frequency of sexual contact and masturbation. Most of the participants experienced the use of ADT as a mandatory decision made by the treating psychiatrist. CLINICAL IMPLICATIONS This study recommends informing patients and their loved ones on the potential side effects of ADT. Furthermore, training forensic counselors on potential side effects of ADT and methods to alleviate them can promote the dissemination of information and will encourage the informed consent procedure. STRENGTHS & LIMITATIONS This is the first qualitative study about the experiences of ADT in men diagnosed with pedophilic disorder in Belgium. Future studies should include more than one treatment center. CONCLUSION The majority of the participants had a positive attitude towards ADT in general. Boons L, Jeandarme I, Vervaeke G. Androgen Deprivation Therapy in Pedophilic Disorder: Exploring the Physical, Psychological, and Sexual Effects From a Patient's Perspective. J Sex Med 2021;18:353-362.
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Affiliation(s)
- Lena Boons
- Department of Criminal Law and Criminology, KU Leuven, Leuven, Belgium.
| | - Inge Jeandarme
- Department of Criminal Law and Criminology, KU Leuven, Leuven, Belgium
| | - Geert Vervaeke
- Department of Criminal Law and Criminology, KU Leuven, Leuven, Belgium
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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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Ly T, Fedoroff JP, Briken P. A narrative review of research on clinical responses to the problem of sexual offenses in the last decade. BEHAVIORAL SCIENCES & THE LAW 2020; 38:117-134. [PMID: 32026512 DOI: 10.1002/bsl.2448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Revised: 12/14/2019] [Accepted: 12/17/2019] [Indexed: 06/10/2023]
Abstract
Research on the treatment and programs for people who have committed sexual offenses has greatly increased in the past decade. The aim of this review is to discuss research that has been published over that period (2010-2019) that is relevant for treatment providers. The articles included in this review were found through PsycINFO and PubMed (Medline) using the keywords "treatment or therapy" and "sex offen*". The inclusion criteria were publications that discuss treatment of persons who have committed sexual offenses (written in the English language only). Any articles that examined only special populations were excluded, such as those that examined persons who committed sexual offenses who were female, had intellectual disabilities, deafness, juveniles, etc., because these groups will likely have needs and responsivity factors that differ from the "average" natal-born male sex offender. Results showed that several meta-analyses indicate that treatment is effective in reducing sexual recidivism. The most frequently used treatment for sex offenders is cognitive behavioral therapy, which is often provided in conjunction with pharmacological treatment to reduce sexual impulsivity and/or sex drive. This review is limited to the specific key search terms. The findings of this review support the use of treatment and a community reintegration approach when treating persons who have committed sexual crimes to prevent sexual recidivism.
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Affiliation(s)
- Thanh Ly
- Forensic Research Unit at the Institute of Mental Health Research, Royal Ottawa Mental Health Care Group, Ottawa, Ontario, Canada
| | - J Paul Fedoroff
- Sexual Behaviours Clinic at the Royal Ottawa Mental Health Care Group, Institute of Mental Health Research, University of Ottawa, Ottawa, Ontario, Canada
| | - Peer Briken
- Institute for Sex Research, Sexual Medicine and Forensic Psychiatry, University Medical-Centre Hamburg-Eppendorf, Hamburg, Germany
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Turner D, Petermann J, Harrison K, Krueger R, Briken P. Pharmacological treatment of patients with paraphilic disorders and risk of sexual offending: An international perspective. World J Biol Psychiatry 2019; 20:616-625. [PMID: 29057702 DOI: 10.1080/15622975.2017.1395069] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
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.
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Affiliation(s)
- Daniel Turner
- Institute for Sex Research and Forensic Psychiatry, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.,Department of Psychiatry and Psychotherapy, University Medical Centre Mainz, Johannes Gutenberg University Mainz, Mainz, Germany
| | - Julius Petermann
- Institute for Sex Research and Forensic Psychiatry, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | | | - Richard Krueger
- College of Physicians and Surgeons, Department of Psychiatry, Columbia University, New York, NY, USA
| | - Peer Briken
- Institute for Sex Research and Forensic Psychiatry, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
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[Standards for treatment in forensic committment according to § 63 and § 64 of the German criminal code : Interdisciplinary task force of the DGPPN]. DER NERVENARZT 2019; 88:1-29. [PMID: 28776213 DOI: 10.1007/s00115-017-0382-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
People who have been convicted of a crime due to a severe mental disorder and continue to be dangerous as a result of this disorder may be placed in a forensic psychiatric facility for improvement and safeguarding according to § 63 and § 64 of the German Criminal Code (StGB). In Germany, approximately 9000 patients are treated in clinics for forensic psychiatry and psychotherapy on the basis of § 63 of the StGB and in withdrawal centers on the basis of § 64 StGB. The laws for treatment of patients in forensic commitment are passed by the individual States, with the result that even the basic conditions differ in the individual States. While minimum requirements have already been published for the preparation of expert opinions on liability and legal prognosis, consensus standards for the treatment in forensic psychiatry have not yet been published. Against this background, in 2014 the German Society for Psychiatry and Psychotherapy, Psychosomatics and Neurology (DGPPN) commissioned an interdisciplinary task force to develop professional standards for treatment in forensic psychiatry. Legal, ethical, structural, therapeutic and prognostic standards for forensic psychiatric treatment should be described according to the current state of science. After 3 years of work the results of the interdisciplinary working group were presented in early 2017 and approved by the board of the DGPPN. The standards for the treatment in the forensic psychiatric commitment aim to initiate a discussion in order to standardize the treatment conditions and to establish evidence-based recommendations.
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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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Sauter J, Stasch J, Klemke K, Emmerling A, Voß T. Das Absetzen antiandrogener Medikation im ambulanten Setting. FORENSISCHE PSYCHIATRIE PSYCHOLOGIE KRIMINOLOGIE 2018. [DOI: 10.1007/s11757-018-0498-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
In Germany, depending on a sexual offender's culpability and the severity of the offence, he/she can be placed either in the forensic-psychiatric or the correctional system. Numbers related to the pharmacological treatment of sexual offenders for the correctional system are missing so far. In sexual offenders, the pharmacological treatment of paraphilic disorders is of special importance. The present study aimed at assessing the prevalence of pharmacological sexual offender treatment in German outpatient treatment centers supervising mainly clients from the correctional sector. An online questionnaire was sent to 112 outpatient treatment centers and 21 provided data relevant for the present study. The included institutions reported about a total of 813 sexual offenders, of whom 200 (24.6%) were treated with pharmacological agents, most frequently antipsychotics (14.8%) and selective-serotonin-reuptake-inhibitors (7.1%). Of the total sample, 26.7% of sexual offenders were diagnosed with a paraphilic - mainly with a pedophilic - disorder. Only 2% were treated with androgen-deprivation therapy. Compared with forensic-psychiatric institutions, only a minority of sexual offenders are treated with medication specifically addressing paraphilic symptomatology. However, the prevalence of paraphilic disorders found in the present study suggests that pharmacological treatment of paraphilic fantasies and behaviors could be of great importance in the correctional sector as well.
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Müller JL, Saimeh N, Briken P, Eucker S, Hoffmann K, Koller M, Wolf T, Dudeck M, Hartl C, Jakovljevic AK, Klein V, Knecht G, Müller-Isberner R, Muysers J, Schiltz K, Seifert D, Simon A, Steinböck H, Stuckmann W, Weissbeck W, Wiesemann C, Zeidler R. Standards für die Behandlung im Maßregelvollzug nach §§ 63 und 64 StGB. FORENSISCHE PSYCHIATRIE, PSYCHOLOGIE, KRIMINOLOGIE 2018. [DOI: 10.1007/s11757-017-0445-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Wong JS, Gravel J. Do Sex Offenders Have Higher Levels of Testosterone? Results From a Meta-Analysis. SEXUAL ABUSE : A JOURNAL OF RESEARCH AND TREATMENT 2018; 30:147-168. [PMID: 27000267 DOI: 10.1177/1079063216637857] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
The purpose of the current study is to review the available scientific evidence on the relationship between testosterone and sexual aggression. A systematic search for all primary studies comparing basal testosterone levels in sex offenders and non-sex offenders was undertaken across 20 electronic databases using an explicit search strategy and inclusion/exclusion criteria. A total of seven studies were identified and 11 effect sizes were computed; effects were pooled using both fixed and random effects meta-analysis models. Although individual study findings present a mix of results wherein sex offenders have higher or lower baseline levels of testosterone than non-sex offenders, pooled results indicate no overall difference between groups. Moderators of the analyses suggest possibly lower rates of testosterone in child molesters than controls; however, results are dependent on study weighting. Limitations, policy implications with respect to chemical castration laws, and future directions for research are discussed.
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Rix K. Pharmacological interventions for sex offenders: A poor evidence base to guide practice. BJPSYCH ADVANCES 2017. [DOI: 10.1192/apt.bp.116.016923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
SummaryAlthough a significant proportion of prisoners and patients in secure hospitals are sex offenders and victim surveys reveal a high level of hidden sexual victimisation, the authors of this Cochrane review found only very limited support for pharmacological intervention with sex offenders. Given the nature and extent of the problem of sexual offending and the promise shown by new drugs, there is a need for clinical scientists, lawyers and ethicists to rise to the challenge of ascertaining the effectiveness and safety of drugs which are being used to treat sex offenders, some involuntarily, without the evidence base to justify confidence as to their effectiveness and safety.
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Lewis A, Grubin D, Ross CC, Das M. Gonadotrophin-releasing hormone agonist treatment for sexual offenders: A systematic review. J Psychopharmacol 2017; 31:1281-1293. [PMID: 28661259 DOI: 10.1177/0269881117714048] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
| | - Don Grubin
- 2 Newcastle University, Newcastle upon Tyne, UK
| | | | - Mrigendra Das
- 3 Broadmoor Hospital, Crowthorne, UK.,4 Top End Mental Health Service, Darwin, Australia
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Schneider F, Kliesch S, Schlatt S, Neuhaus N. Andrology of male-to-female transsexuals: influence of cross-sex hormone therapy on testicular function. Andrology 2017; 5:873-880. [DOI: 10.1111/andr.12405] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 06/12/2017] [Accepted: 06/27/2017] [Indexed: 12/24/2022]
Affiliation(s)
- F. Schneider
- Center of Reproductive Medicine and Andrology; Institute of Reproductive and Regenerative Medicine; Muenster Germany
- Department of Clinical Andrology; Center of Reproductive Medicine and Andrology; Muenster Germany
| | - S. Kliesch
- Department of Clinical Andrology; Center of Reproductive Medicine and Andrology; Muenster Germany
| | - S. Schlatt
- Center of Reproductive Medicine and Andrology; Institute of Reproductive and Regenerative Medicine; Muenster Germany
| | - N. Neuhaus
- Center of Reproductive Medicine and Andrology; Institute of Reproductive and Regenerative Medicine; Muenster Germany
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Stationäre Krankenhausbehandlungen ausgewählter sexueller Störungen. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2017; 60:987-998. [DOI: 10.1007/s00103-017-2592-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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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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Petersen TS, Kragh K. Should violent offenders be forced to undergo neurotechnological treatment? A critical discussion of the 'freedom of thought' objection. JOURNAL OF MEDICAL ETHICS 2017; 43:30-34. [PMID: 27845682 DOI: 10.1136/medethics-2016-103492] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Revised: 10/18/2016] [Accepted: 10/28/2016] [Indexed: 06/06/2023]
Abstract
In this paper we examine one reason for rejecting the view that violent offenders should be forced to undergo neurotechnological treatments (NTs) involving such therapies as psychoactive medication to curb violent behaviour. The reason is based on the concern that forced treatment violates the offender's right to freedom of thought. We argue that this objection can be challenged. First, we present some specifications of what a right to freedom of thought might mean. We focus on the recently published views of Jared Craig, and Jan Cristopher Bublitz and Reinhard Merkel. Second, we argue that forcing violent offenders to undergo certain kinds of NTs may not violate the offender's right to freedom of thought as that right is specified by Craig, and Bublitz and Merkel. Third, even if non-consensual NT is used in a way that does violate freedom of thought, such use can be difficult to abandon without inconsistency. For if one is not an abolitionist, and therefore accepts traditional state punishments for violent offenders like imprisonment-which, the evidence shows, often violate the offender's right to freedom of thought-then, it is argued, one will have reason to accept that violent offenders can legitimately be forced to undergo NT even if doing so denies them the right to freedom of thought.
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Affiliation(s)
| | - Kristian Kragh
- Department of Communication and Arts, Roskilde University, Roskilde, Denmark
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The Use of Testosterone/Cortisol Ratio in Response to Acute Stress as an Indicator of Propensity to Anger in Informal Caregivers. SPANISH JOURNAL OF PSYCHOLOGY 2016; 19:E48. [PMID: 27641230 DOI: 10.1017/sjp.2016.62] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Caring for an offspring diagnosed with a psychological chronic disorder is used in research as a model of chronic stress. Indeed, it is usually associated with disturbances in the salivary cortisol (Csal) levels of the caregiver. An imbalance between salivary testosterone (Tsal) and Csal levels is a marker of proneness to social aggression. Given this, we aimed to establish whether the salivary testosterone/cortisol (Tsal/Csal) ratio response to acute stress could be employed as a marker of proneness to anger in informal caregivers of offspring with autism spectrum (ASD). Tsal/Csal ratio and anger responses to a set of different cognitive tasks as well as anger trait and expression were compared in these informal caregivers and controls. Caregivers, particularly those of offspring with ASD, had higher Tsal/Csal ratios than controls in response to acute stress, concretely after the stress in the case of fathers (p = .05) and before stress when analyzing mothers (p = .05). Moreover, ASD fathers and mothers obtained higher magnitude of the T/C ratio response to stress (p = .03 and p =.04, respectively), anger state (p = .02 and p = .02, respectively) and expression scores (p = .05 and p = .05, respectively) than controls. Finally, high Tsal/Csal ratio levels and response to stress were significantly associated with high anger feelings increases (p .05, respectively) and expression (p .05, respectively) in caregivers.
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Khan O, Mashru A. The efficacy, safety and ethics of the use of testosterone-suppressing agents in the management of sex offending. Curr Opin Endocrinol Diabetes Obes 2016; 23:271-8. [PMID: 27032060 DOI: 10.1097/med.0000000000000257] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
PURPOSE OF REVIEW The use of endocrine medications to reduce sexual offending recidivism is established and may involve clinicians from diverse specialities. The present review aims to outline relevant background information and note a Medical Ethics framework upon which to facilitate decision-making. RECENT FINDINGS There have been several systematic reviews in recent years. A number of problems with research in the area of the medical treatment of sex offenders have been highlighted. There remains scope for improvement in the research to answer a number of relevant clinical issues. Nonetheless, some very useful indicators of relevance to clinical practice have emerged. SUMMARY The use of medication to manage the risk of sex offending in males is appropriate under the right circumstances. These include, for example, hypersexuality with sexual deviance and psychological-treatment interfering sexual preoccupation.
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Affiliation(s)
- Omer Khan
- aChadwick Lodge, Milton Keynes bThe Wells Road Center, Nottingham, UK
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Voß T, Klemke K, Schneider-Njepel V, Kröber HL. Wenn ja, wie lange? – Dauer antiandrogener Behandlung von Sexualstraftätern mit paraphilen Störungen. FORENSISCHE PSYCHIATRIE PSYCHOLOGIE KRIMINOLOGIE 2015. [DOI: 10.1007/s11757-015-0346-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Khan O, Ferriter M, Huband N, Powney MJ, Dennis JA, Duggan C. Pharmacological interventions for those who have sexually offended or are at risk of offending. Cochrane Database Syst Rev 2015; 2015:CD007989. [PMID: 25692326 PMCID: PMC6544815 DOI: 10.1002/14651858.cd007989.pub2] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Sexual offending is a serious social problem, a public health issue, and a major challenge for social policy. Victim surveys indicate high incidence and prevalence levels and it is accepted that there is a high proportion of hidden sexual victimisation. Surveys report high levels of psychiatric morbidity in survivors of sexual offences.Biological treatments of sex offenders include antilibidinal medication, comprising hormonal drugs that have a testosterone-suppressing effect, and non-hormonal drugs that affect libido through other mechanisms. The three main classes of testosterone-suppressing drugs in current use are progestogens, antiandrogens, and gonadotropin-releasing hormone (GnRH) analogues. Medications that affect libido through other means include antipsychotics and serotonergic antidepressants (SSRIs). OBJECTIVES To evaluate the effects of pharmacological interventions on target sexual behaviour for people who have been convicted or are at risk of sexual offending. SEARCH METHODS We searched CENTRAL (2014, Issue 7), Ovid MEDLINE, EMBASE, and 15 other databases in July 2014. We also searched two trials registers and requested details of unidentified, unpublished, or ongoing studies from investigators and other experts. SELECTION CRITERIA Prospective controlled trials of antilibidinal medications taken by individuals for the purpose of preventing sexual offences, where the comparator group received a placebo, no treatment, or 'standard care', including psychological treatment. DATA COLLECTION AND ANALYSIS Pairs of authors, working independently, selected studies, extracted data, and assessed the risk of bias of included studies. We contacted study authors for additional information, including details of methods and outcome data. MAIN RESULTS We included seven studies with a total of 138 participants, with data available for 123. Sample sizes ranged from 9 to 37. Judgements for categories of risk of bias varied: concerns were greatest regarding allocation concealment, blinding of outcome assessors, and incomplete outcome data (dropout rates in the five community-based studies ranged from 3% to 54% and results were usually analysed on a per protocol basis).Participant characteristics in the seven studies were heterogeneous, but the vast majority had convictions for sexual offences, ranging from exhibitionism to rape and child molestation.Six studies examined the effectiveness of three testosterone-suppressing drugs: cyproterone acetate (CPA), ethinyl oestradiol (EO), and medroxyprogesterone acetate (MPA); a seventh evaluated two antipsychotics (benperidol and chlorpromazine). Five studies were placebo-controlled; in two, MPA was administered as an adjunctive treatment to a psychological therapy (assertiveness training or imaginal desensitisation). Meta-analysis was not possible due to heterogeneity of interventions, comparators, study designs, and other issues. The quality of the evidence overall was poor. In addition to methodological issues, much evidence was indirect. PRIMARY OUTCOME recividism. Two studies reported recidivism rates formally. One trial of intramuscular MPA plus imaginal desensitisation (ID) found no reports of recividism at two-year follow-up for the intervention group (n = 10 versus one relapse within the group treated by ID alone). A three-armed trial of oral MPA, alone or in combination with psychological treatment, reported a 20% rate of recidivism amongst those in the combined treatment arm (n = 15) and 50% of those in the psychological treatment only group (n = 12). Notably, all those in the 'oral MPA only' arm of this study (n = 5) dropped out immediately, despite treatment being court mandated.Two studies did not report recidivism rates as they both took place in one secure psychiatric facility from which no participant was discharged during the study, whilst another three studies did not appear directly to measure recividism but rather abnormal sexual activity alone. SECONDARY OUTCOMES The included studies report a variety of secondary outcomes. Results suggest that the frequency of self reported deviant sexual fantasies may be reduced by testosterone-suppressing drugs, but not the deviancy itself (three studies). Where measured, hormonal levels, particularly levels of testosterone, tended to correlate with measures of sexual activity and with anxiety (two studies). One study measured anxiety formally; one study measured anger or aggression. Adverse events: Six studies provided information on adverse events. No study tested the effects of testosterone-suppressing drugs beyond six to eight months and the cross-over design of some studies may obscure matters (given the 'rebound effect' of some hormonal treatments). Considerable weight gain was reported in two trials of oral MPA and CPA. Side effects of intramuscular MPA led to discontinuation in some participants after three to five injections (the nature of these side effects was not described). Notable increases in depression and excess salivation were reported in one trial of oral MPA. The most severe side effects (extra-pyramidal movement disorders and drowsiness) were reported in a trial of antipsychotic medication for the 12 participants in the study. No deaths or suicide attempts were reported in any study. The latter is important given the association between antilibidinal hormonal medication and mood changes. AUTHORS' CONCLUSIONS We found only seven small trials (all published more than 20 years ago) that examined the effects of a limited number of drugs. Investigators reported issues around acceptance and adherence to treatment. We found no studies of the newer drugs currently in use, particularly SSRIs or GnRH analogues. Although there were some encouraging findings in this review, their limitations do not allow firm conclusions to be drawn regarding pharmacological intervention as an effective intervention for reducing sexual offending.The tolerability, even of the testosterone-suppressing drugs, was uncertain given that all studies were small (and therefore underpowered to assess adverse effects) and of limited duration, which is not consistent with current routine clinical practice. Further research is required before it is demonstrated that their administration reduces sexual recidivism and that tolerability is maintained.It is a concern that, despite treatment being mandated in many jurisdictions, evidence for the effectiveness of pharmacological interventions is so sparse and that no RCTs appear to have been published in two decades. New studies are therefore needed and should include trials with larger sample sizes, of longer duration, evaluating newer medications, and with results stratified according to category of sexual offenders. It is important that data are collected on the characteristics of those who refuse and those who drop out, as well as those who complete treatment.
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Affiliation(s)
- Omer Khan
- The Priory GroupChadwick Lodge, Chadwick DriveEaglestoneMilton KeynesBuckinghamshireUKMK6 5LS
| | - Michael Ferriter
- Nottinghamshire Healthcare NHS TrustForensic DivisionThe Clair Chilvers CentreRampton HospitalWoodbeckNottinghamshireUKDN22 0PD
| | - Nick Huband
- University of NottinghamInstitute of Mental HealthTriumph RoadNottinghamUKNG7 2TU
| | - Melanie J Powney
- The University of ManchesterDepartment of Clinical Psychology2nd Floor, Zochonis BuildingBrunswick StreetManchesterUKM13 9PL
| | - Jane A Dennis
- Queen's University Belfastc/o Cochrane Developmental, Psychosocial and Learning Problems GroupICCR6 College ParkBelfastUK
| | - Conor Duggan
- University of NottinghamInstitute of Mental HealthTriumph RoadNottinghamUKNG7 2TU
- Partnerships in Care2 Imperial PlaceMaxwell RoadBorehamwoodHertfordshireUKWD6 1JN
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Schneider F, Neuhaus N, Wistuba J, Zitzmann M, Heß J, Mahler D, van Ahlen H, Schlatt S, Kliesch S. Testicular Functions and Clinical Characterization of Patients with Gender Dysphoria (GD) Undergoing Sex Reassignment Surgery (SRS). J Sex Med 2015; 12:2190-200. [DOI: 10.1111/jsm.13022] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Abstract
PURPOSE OF REVIEW The recent implementation of the Diagnostic and Statistical Manual of Mental Disorders, fifth edition introduced some important changes in the conceptualization of hypersexuality and paraphilic disorders. The destigmatization of nonnormative sexual behaviors could be viewed as positive, However, other changes are more controversial. In order to stimulate new research approaches and provide mental healthcare providers with appropriate treatment regimes, validated assessment and treatment methods are needed. The purpose of this article is to review the studies published between January 2013 and July 2014 that aimed at assessing the psychometric properties of the currently applied assessment instruments and treatment approaches for hypersexuality and hypersexual disorders or paraphilias and paraphilic disorder. RECENT FINDINGS Currently existing instruments can validly assess hypersexual behaviors in different populations (e.g. college students, gay and bisexual men, and patients with neurodegenerative disorders) and cultural backgrounds (e.g. Germany, Spain, and USA). Concerning the assessment of paraphilias, it was shown that combining different assessment methods show a better performance in distinguishing between patients with paraphilias and control groups. In addition to psychotherapeutic treatment, pharmacological agents aiming at a reduction of serum testosterone levels are used for hypersexual behaviors as well as paraphilic disorders. SUMMARY Although the currently applied assessment and treatment methods seem to perform quite well, more research about the assessment and evidence-based treatment is needed. This would help to overcome the existing unresolved issues concerning the conceptualization of hypersexual and paraphilic disorders.
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Turner D, Basdekis-Jozsa R, Dekker A, Briken P. Which factors influence the appropriateness of testosterone-lowering medications for sex offenders? A survey among clinicians from German forensic-psychiatric institutions. World J Biol Psychiatry 2014; 15:472-8. [PMID: 24219802 DOI: 10.3109/15622975.2013.839052] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES Although testosterone-lowering medications (TLM) are a frequently used addition to psychotherapy in sex offender treatment, discord still seems to exist amongst clinicians as to in which cases administering TLM is justified. The depo-Provera scale (DPS), which was published by Maletzky and Field (Aggress Violent Behav 2003;8:391), assesses the appropriateness of TLM administration in sex offender treatment. METHODS The DPS was sent to all forensic psychiatric institutions in Germany. The clinical directors of these institutions were asked to rate the importance of each item of the DPS on a six-point Likert scale. RESULTS Twenty-nine clinicians participated. The most important reason selected for the prescription of TLM for sex offender treatment was a "history of sexual offender treatment failure". The least important item was "deviant sexual interest, by plethysmograph or Abel Screen" (neither plethysmograph nor Abel Screen is used in Germany). CONCLUSIONS Clinicians' attitudes towards the DPS correspond to the suggestions made in the current WSFBF-guidelines for the pharmacological treatment of sex offenders (Thibaut et al. 2010 ; World J Biol Psychiatry 11:604-655). Use of the DPS could therefore contribute to a more structured approach towards helping clinicians come to a decision about whether or not to treat a sex offender with TLM.
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Affiliation(s)
- Daniel Turner
- Institute for Sex Research and Forensic Psychiatry, University Medical Center Hamburg-Eppendorf , Hamburg , Germany
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Koo KC, Ahn JH, Hong SJ, Lee JW, Chung BH. Effects of Chemical Castration on Sex Offenders in Relation to the Kinetics of Serum Testosterone Recovery: Implications for Dosing Schedule. J Sex Med 2014; 11:1316-24. [DOI: 10.1111/jsm.12492] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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